Observations and impressions of the Canadian health care system.

The United States government, in its desire to deliver broad health care coverage to its citizens, has looked to several of the established socialized health care systems for direction. There are definitely good points in each system, and the Canadian system, in particular, has done quite well in providing services within a limited federal budget. On the other hand, the unlimited access to care has led to increased demands for health care services, overperformance of services, and excessive utilization of facilities. There are major technological constraints now emerging and the fiscal integrity of the system is shaky. There is a notable decrease in research and voluntary faculty participation at university levels. Financial constraints are becoming more severe and it appears that demand vis-a-vis the resources available will soon force stringent readjustments in Canadian health care delivery and funding. Health care plan administrators concede that unless more dollars are invested in the system, the current level of health care delivery cannot be maintained.     

A framework for cultural competence in health care organizations

Increased racial and ethnic diversity in the United States brings challenges and opportunities for health care organizations to provide culturally competent services that effectively meet the needs of diverse populations. The need to provide more culturally competent care is essential to reducing and eliminating health disparities among minorities. By removing barriers to cultural competence and placing a stronger emphasis on culture in health care, health care organizations will be better able to address the unique health care needs of minorities. Organizations should assess cultural differences, gain greater cultural knowledge, and provide cultural competence training to deliver high-quality services. This article develops a framework to guide health care organizations as they focus on establishing culturally competent strategies and implementing best practices aimed to improve quality of care and achieve better outcomes for minority populations.     

CEO's challenge: balance fiscal solvency, service to poor

Competitive practices and the prospective payment system are among factors challenging Catholic health care facilities' commitment to serve the poor and elderly and to provide individualized care. To concentrate their mission on services to the marginated and thus alienate other payer groups through inability to compete in either services or price is fiscal suicide. Sponsors and CEOs of Catholic facilities are exploring creative solutions to this dilemma: Revising the mission statement. The facility may restate its goals--e.g., to provide an "adequate" level of care and technology, rather than "the best care possible;" Changing delivery methods to focus on outreach services, ambulatory care centers, surgicenters, etc.; Finding new ways of providing charity care through endowment, trust, foundation, and unrelated business income. Corporate restructuring to generate income and protect the facility's asset base is being widely studied. Because many congregations sponsor several institutions, Catholic health facilities are well positioned to enter multi-institutional systems and participate in networking as a means to save money and to market services. Catholic health care facilities must form a nationwide system of influence in the growing public policy debate about access to and rationing of health care. Before these issues are resolved; Catholic facilities will continue to feel pressure to provide services beyond their means. The chief executive officer has four particular tasks during this period: To use an entrepreneurial approach to generate funds to support the facility's mission activity; To guide the board of trustees to accept multi-institutional arrangements; To raise legislators' and citizens' awareness of the institution's fiscal challenges; To motivate the institution's staff to provide individualized, compassionate care in spite of the depersonalizing effects of DRGs.(ABSTRACT TRUNCATED AT 250 WORDS)     

The nonprofit sector's response to the AIDS epidemic: community-based services in San Francisco.

Community-based organizations in San Francisco have played a key role in providing social support services and public health information to those affected by acquired immune deficiency syndrome (AIDS). These services have helped minimize the economic impact of the epidemic by reducing the level and expense of hospitalization of AIDS patients. During fiscal year 1984-85, the three largest community-based groups in San Francisco provided more than 80,000 hours of social support and counseling services, responded to over 30,000 telephone inquiries and letters, and distributed nearly 250,000 pieces of literature. Home-based hospice care was provided to 165 AIDS patients at an average cost per day of $94 per patient. Community-based organizations require a significant level of funding from government and private sources. Local government in San Francisco has provided 62 per cent of the revenues for these groups. At the same time, they are not viable without a steady stream of volunteer labor. More than 130,000 hours were donated this past year. There are intrinsic limits to the current dependency on unpaid labor and contributions made by private charity and local government which will eventually require increased support and intervention at the state and federal levels.     

New models of women's health care

A consideration of contemporary U.S. women's health status, causes of morbidity and mortality, and the progress of the women's health care movement prompts a reconsideration of traditional health care models. New models must deliver comprehensive services, invite participation of clients, offer a choice of healers, incorporate new sites for delivery of services, and transcend the boundaries of traditional medicine. Although consumer demand and cost effectiveness may ease the birth of these models, their acceptance by traditional professionals and fiscal and business management will be influential in their survival.     

Health care reform and the paradox of efficiency: "writing in" culture.

Widespread global migration is occurring at the same time that health care delivery systems in Western nations are undergoing major restructuring. The call for health care to be more efficient, economical, and responsive to diverse cultural populations has come from several sectors, including governments and researchers. This has led to policies to address perceived deficiencies in health care services. The authors draw on their research at health care institutions in a western Canadian city to probe, first, how the concept of culture is interpreted within organizations; and second, how culture is "written into health systems" as they undergo restructuring. Meanings and interpretations of culture are not transparent; moreover, "writing in" culture is not simply a matter of health care providers learning about their clients' "belief systems" and being sensitive to these beliefs. Belief systems and people's experiences of the care they receive are negotiated within highly complex "organizational cultures," located in broader macroeconomic and political structures, and discourses that shape how health care systems are organized. The authors consider whether current discourses on cost containment are in competition with providing equitable health care services to diverse client populations.     

How health care organizations are using data on patients' race and ethnicity to improve quality of care

Context: Racial and ethnic disparities in the quality of health care are well documented in the U.S. health care system. Reducing these disparities requires action by health care organizations. Collecting accurate data from patients about their race and ethnicity is an essential first step for health care organizations to take such action, but these data are not systematically collected and used for quality improvement purposes in the United States. This study explores the challenges encountered by health care organizations that attempted to collect and use these data to reduce disparities. Methods: Purposive sampling was used to identify eight health care organizations that collected race and ethnicity data to measure and reduce disparities in the quality and outcomes of health care. Staff, including senior managers and data analysts, were interviewed at each site, using a semi‐structured interview format about the following themes: the challenges of collecting and collating accurate data from patients, how organizations defined a disparity and analyzed data, and the impact and uses of their findings. Findings: To collect accurate self‐reported data on race and ethnicity from patients, most organizations had upgraded or modified their IT systems to capture data and trained staff to collect and input these data from patients. By stratifying nationally validated indicators of quality for hospitals and ambulatory care by race and ethnicity, most organizations had then used these data to identify disparities in the quality of care. In this process, organizations were taking different approaches to defining and measuring disparities. Through these various methods, all organizations had found some disparities, and some had invested in interventions designed to address them, such as extra staff, extended hours, or services in new locations. Conclusion: If policymakers wish to hold health care organizations accountable for disparities in the quality of the care they deliver, common standards will be needed for organizations’ data measurement, analysis, and use to guide systematic analysis and robust investment in potential solutions to reduce and eliminate disparities.     

Hub-and-spokes regionalization. The teaching hospital should be the hub of its healthcare market

To remain viable, teaching hospitals must be horizontally and vertically integrated, multilevel healthcare delivery systems. Such integration is needed for a teaching hospital to remain the hub of its urban or rural regional healthcare market and to generate sufficient fiscal resources to support its medical education programs, research activities, quality of care, and innovative technology. Teaching hospital trustees, physicians, and managers must evaluate an increasing number of alternatives to improve quality of patient care, maximize educational and research opportunities, and increase revenues. These options include merging with community hospitals and improving relationships between community physicians and teaching hospitals and their full-time clinical faculty. To ensure long-term viability, teaching hospitals may need to use an approach that concurrently employs a hub-and-spokes arrangement, a horizontal and vertical diversification, and a multilevel healthcare delivery system configuration.     

A journal of community. Catholic healthcare providers' presence is necessary to sustain a values-based system

Catholic healthcare leaders must use all their will and creative imagination to find a way to maintain a significant Catholic presence in healthcare. Catholic healthcare leaders across the nation are acquiring, consolidating, and merging hospitals; forming alliances and networks of integrated services; and bringing together Catholic healthcare systems on a regional and local basis. The next few years are critical for Catholic sponsors of healthcare services. The unique challenge is to pursue the development of a Catholic network that would include a wide range of health, mental health, home care, long-term care, social, and housing services. The key ingredient to making networks happen will be leadership, and I think CHA and sponsors rightly emphasize the need for continuing leadership formation and development of trustees and executives in Catholic healthcare. A united effort by Catholic healthcare providers could have a penetrating influence on the overall development of healthcare in this nation. Now is the time to exercise imaginative leadership; to reach out to the existing Catholic and community-based providers of health and human services; and to create networks that can provide a continuum of accessible, high-quality, values-based, and cost-efficient services.     

Quality improvement to guide the new health system

While there are many areas, such as intensive care treatment and pain management, where great gains in quality improvement can be made, the greatest strides will come as the leaders and trustees in health care organizations begin to create "the industrial revolution" in their organizations by creating cultures of quality. Stephen Shortell recommends the following list of things board members can do to improve quality in their organizations.     

Sense of place, organizational context and the strategic management of publicly funded hospitals

An era of managerialism in health care delivery systems is now well ensconced throughout the nations of the OECD. This development has occurred, in large part, as a response to funding pressures in institutionally based health care delivery imposed by principal third party insurers. In the case of publicly funded hospitals, the more traditional concerns for stewardship and appeasement of professional groups is being replaced by a greater emphasis on cost consciousness and corporate-style leadership as these organizations seek to reposition themselves in new funding and regulatory environments. While institutional theory and strategic management perspectives help illuminate these issues, this paper argues that a place-based perspective is also needed to understand the changes currently underway in health care delivery and publicly funded human services more generally. This is illustrated with reference to developments in the strategic management of public hospitals in the province of Ontario. Evidence from a survey of senior administrators of public hospitals, distributed at the height of these policy reform initiatives, is examined to shed light on local level management responses to changing policy and fiscal pressures. The data suggest that the latest policy directions in the province of Ontario will 'encourage' hospital executives in particular community settings to steer their organizations in very unfamiliar directions. The findings suggest a need for greater attention to context and setting in health services research and policy.     

How the United States exports managed care to developing countries.

As their expansion slows in the United States, managed care organizations will continue to enter new markets abroad. Investors view the opening of managed care in Latin America as a lucrative business opportunity. As public-sector services and social security funds are cut back, privatized, and reorganized under managed care, with the support of international lending agencies such as the World Bank, the effects of these reforms on access to preventive and curative services will hold great importance throughout the developing world. Many groups in Latin America are working on alternative projects that defend health as a public good, and similar movements have begun in Africa and Asia. Increasingly, this organizing is being recognized not only as part of a class struggle but also as part of a struggle against economic imperialism--which has now taken on the new appearance of rescuing less developed countries from rising health care costs and inefficient bureaucracies through the imposition of neoliberal managed-care solutions exported from the United States.     

The transition to regional networks. Changes in reimbursement and approaches to care favor cooperative arrangements among providers

As costs escalate and the delivery system becomes more fragmented, organizations throughout the United States have begun to call for basic reform of the healthcare system. Several national organizations, including the American Hospital Association and the Catholic Health Association, have presented working proposals advocating coordinated regional healthcare delivery systems. The proposed networks would provide a full continuum of services from prevention through aftercare and long-term care, and from primary through tertiary care. In the past few years, providers themselves have begun to see the value of cooperative efforts. Collaborative ventures such as group purchasing and sharing mobile equipment have increased as hospitals look for ways to reduce costs and control overhead. Mergers and affiliations are also becoming more common. As they develop, different networks will allow for various kinds of interrelationships among components. In general, these systems will provide high-volume, low-cost services at a number of sites and low-volume, high-cost services at a central location. Secondary and tertiary campuses will focus increasingly on specialty care, and as volume increases at primary campuses, secondary and tertiary organizations will establish more primary affiliations. To make the transition from a competitive to a cooperative healthcare delivery system, providers will have to reexamine their mission and values and, in many cases, refocus their vision of the future.     

Leadership and Quality of Working Life in Home Health Care

Home health care has undergone startling changes in the past decade and, in the process, become a strategically important ingredient of health care delivery. However, the question remains whether home health care organizations can deliver the benefits anticipated for integrated care delivery systems. The answer to this question depends to a great extent on whether home health care organizations build vibrant, visionary leadership capable of transforming organizations and motivating staff to deliver high quality and low cost services. This paper examines a case study of transformational leadership as it relates to the quality of working life for nurses, homemakers, and staff. The findings indicate that leader behavior is strongly associated with homemakers', and to a lesser extent staff members', job satisfaction, job involvement, and propensity to remain with the organization. These job attitudes have been shown to be related to higher job performance. The implications for leadership in home health agencies are discussed.     

Comparisons of medical technology in Canadian, German, and U.S. Hospitals

One strategy proposed to constrain our health costs is to regulate the acquisition of and to centralize the availability of tertiary care services. American hospitals provide significantly more sophisticated equipment per million persons than is available either in Canada or Germany in six of seven expensive medical technologies studied (radiation therapy being the exception). The regionalization of tertiary care resources should be stimulated by the fiscal incentives inherent in managed care and capitated payment, additional shortfalls in Medicare and Medicaid reimbursement, and hospitals, physicians, and insurance companies' organizing health networks. These trends could eventually force an increasing number of community hospitals to eliminate their expensive sophisticated services.     

Legal issues in contracting with HMOs. 1

The Health Maintenance Organization Act of 1973 established a 5-year $325 million program of federal assistance to aid in the planning and organization of HMOs. The Act also required employers to offer their employees the alternative of an HMO membership to existing health benefits plans. Health Maintenance Organizations are defined by the following characteristics: 1) they are total health care delivery systems; 2) they consist of a voluntarily enrolled population; 3) agreed-upon services are provided by a prearranged and prepaid fee; and 4) the organizations bear the risk of providing the services for the prearranged fee. HMOs differ from existing health care delivery systems in that the system is closed, i.e., physicians and referral services are limited to those participating in the organization. HMOs must have a 1/3 consumer membership on their policy-making boards. Most also have physician representation on the boards. There exists a financial incentive to reducing the use of hospital services. HMOs are required to provide all services, including abortion and sterilization, but a hospital which takes care in negotiating its contract with the HMO will be exempt from having to do so.     

The relevance of the U.S. experience to the reforms in the British National Health Service: the case of General Practitioner Fund Holding

This article presents a discussion of the relevance of the U.S. experience in general, and health maintenance organizations in particular, to the reforms advocated by the current Conservative government in the general practitioner services of the British National Health Service. The author analyzes empirical information relevant to the assumptions made by the Conservative reformers that (1) the HMO type of practice is better able to respond to people's needs than are current general practitioner arrangements; (2) entrepreneurship in medicine is good for patients; (3) market-based primary care is more efficient than the nonmarket system in the United Kingdom; and (4) the expansion and strengthening of the private sector is an efficient and equitable means of encouraging competition and raising revenues. All of these assumptions are questioned.     

Work ethics and CQI

CQI is a management paradigm adopted by many health care organizations. This paradigm can be helpful as health care organizations respond to the ethical demands created by the workplace, particularly respect for empowerment of the worker, shared levels of power, subsidiarity, collegiality, and the production of goods and services that meet the needs of the community served. An analysis of the workplace reveals other ethical questions that require the attention of managers, owners, and trustees. Some of these are not addressed by the CQI paradigm.     

Quality Improvement in Healthcare Delivery Utilizing the Patient-Centered Medical Home Model

Despite the fact that the United States dedicates so much of its resources to healthcare, the current healthcare delivery system still faces significant quality challenges. The lack of effective communication and coordination of care services across the continuum of care poses disadvantages for those requiring long-term management of their chronic conditions. This is why the new transformation in healthcare known as the patient-centered medical home (PCMH) can help restore confidence in our population that the healthcare services they receive is of the utmost quality and will effectively enhance their quality of life. Healthcare using the PCMH model is delivered with the patient at the center of the transformation and by reinvigorating primary care. The PCMH model strives to deliver effective quality care while attempting to reduce costs. In order to relieve some of our healthcare system distresses, organizations can modify their delivery of care to be patient centered. Enhanced coordination of services, better provider access, self-management, and a team-based approach to care represent some of the key principles of the PCMH model. Patients that can most benefit are those that require long-term management of their conditions such as chronic disease and behavioral health patient populations. The PCMH is a feasible option for delivery reform as pilot studies have documented successful outcomes. Controversy about the lack of a medical neighborhood has created concern about the overall sustainability of the medical home. The medical home can stand independently and continuously provide enhanced care services as a movement toward higher quality care while organizations and government policy assess what types of incentives to put into place for the full collaboration and coordination of care in the healthcare system.     

Financial management services in consumer-directed programs

Shifting from an agency-based model of personal assistance services to consumer direction has important consequences for both recipients and workers. In consumer direction, recipients assume the responsibilities of employing their attendants--for both self-directing their supportive services and being responsible for numerous fiscal responsibilities. Many states have eased these fiscal responsibilities among recipients in publicly financed personal care programs by using Financial Management Services (also known as fiscal intermediaries). This article introduces the major types of Financial Management Services organizations used by Medicaid consumer-directed personal care programs, and examines the extent to which the varied approaches can and do serve the needs of both recipients and workers. Despite the expansion of consumer-directed programs and the accompanying emergence of Financial Management Services, these organizations have not been extensively studied or evaluated. The paper concludes with a discussion of the challenges, opportunities, and policy implications of the current practice; and suggests directions for future research.