The WAMI Rural Hospital Project. Part 3: Building health care leadership in rural communities.

The WAMI Rural Hospital Project (RHP) intervention combined aspects of community development, strategic planning and organizational development to address the leadership issues in six Northwest rural hospitals. Hospitals and physicians, other community health care providers and local townspeople were involved in this intervention, which was accomplished in three phases. In the first phase, extensive information about organizational effectiveness was collected at each site. Phase two consisted of 30 hours of education for the physician, board, and hospital administrator community representatives covering management, hospital board governance, and scope of service planning. In the third phase, each community worked with a facilitator to complete a strategic plan and to resolve conflicts addressed in the management analyses. The results of the evaluation demonstrated that the greatest change noted among RHP hospitals was improvement in the effectiveness of their governing boards. All boards adopted some or all of the project's model governance plan and had successfully completed considerable portions of their strategic plans by 1989. Teamwork among the management triad (hospital, board, and medical staff) was also substantially improved. Other improvements included the development of marketing plans for the three hospitals that did not initially have them and more effective use of outside consultants. The project had less impact on improving the functioning of the medical chief of staff, although this was not a primary target of the intervention. There was also relatively less community interest in joining regional health care associations. The authors conclude that an intervention program tailored to address specific community needs and clearly identified leadership deficiencies can have a positive effect on rural health care systems.     

Hospital system works to ensure risk management, quality of care

A health care corporation that includes several hospitals and other related health services conducts a wide variety of institutional and corporate activities and programs of risk management and quality assurance. Some of these efforts include board review of medical staff organization and privileges, medical and nursing audits, patient care evaluation, a risk manager and steering committee, patient education, equipment maintenance, and safety programs.     

The quality-value proposition in health care

Powerful forces are converging in US health care to finally cause recognition of the inherently logical relationship between quality and money. The forces, or marketplace "drivers," which are converging to compel recognition of the relationship between cost and quality are: (1) the increasing costs of care; (2) the recurrence of another medical malpractice crisis; and (3) the recognition inside and outside of health care that quality is inconsistent and unacceptable. It is apparent that hospital administrators, financial officers, board members, and medical staff leadership do not routinely do two things: (1) relate quality to finance; and (2) appreciate the intra-hospital structural problems that impede quality attainment. This article discusses these factors and offers a positive method for re-structuring quality efforts and focusing the hospital and its medical staff on quality. The simple but compelling thesis of the authors is that health care must immediately engage in the transformation to making quality of medical care the fundamental business strategy of the organization.     

Implementing meaningful CME as an essential component in a community hospital quality assurance plan.

The pursuit of high-quality patient care within a community hospital highlights the tenuous relationship between the hospital board and administration on one side and the voluntary medical staff on the other. Craddick describes the need to monitor and improve patient management, the commitment of physicians and administrators to high quality care, and the unfortunate failure of most hospital programs to go beyond paper exercises designed to satisfy the Joint Commission of Accreditation of Hospitals (JCAH). The American College of Surgeons summarizes current methods of monitoring the quality of patient care, and gives four examples of successful programs. The JCAH Manual sets standards for hospitals and medical staffs to achieve. However, thus far no one has described how a hospital's medical staff, board, and administration join forces to implement a comprehensive quality assurance program. This paper presents the experience of one community hospital in dealing with this problem over a two-year period.     

Causes and Consequences of Rural Small Hospital Closures from the Perspectives of Mayors

Mayors of rural towns whose small general hospitals closed between 1980 and 1988 were surveyed. Only hospitals that were the sole hospitals in their towns and that had not reopened were included in the survey. Of the 132 hospitals meeting these criteria, 130 (98.5%) of the mayors of their communities responded to the survey. The typical study hospital had 31 beds, with an average daily census of 12. Three fourths of the hospital closures were in the North-Central and South census regions. Half of the hospital closures were for hospitals that were 20 miles or more from another hospital. Mayors attributed the closure of their hospitals primarily to governmental reimbursement policies, poor hospital management and lack of physicians. To a lesser extent, they also implicated competition from other hospitals, reputation for poor quality care, lack of provider teamwork, and inadequate hospital board leadership. Respondents reported they had little warning that their hospitals were in imminent danger of closing. Warnings of six months or less were reported by 49 percent of the mayors; only 33 percent of mayors of towns with for-profit hospitals reported having more than six months warning. Of the 132 hospital buildings that closed, only 38 percent were not in use in some capacity in the summer of 1989. Most were being utilized as some form of health care facility such as an ambulatory clinic, nursing home, or emergency room. More than three fourths of the mayors felt access to medical care had deteriorated in their communities after hospital closure, with a disproportionate impact on the elderly and poor. Nearly three fourths of the mayors also perceived that the health status of the community was worse because of the hospital closure, and more than 90 percent felt it had substantially impaired the community's economy.     

CEO turnover in rural northwest hospitals

This study examines rates of and reasons for turnover among administrators from 148 rural hospitals in four northwestern states. Data were obtained from a survey of CEOs who left their positions between 1987 and 1990 and from a survey of board members from those same hospitals. During the study period, 85 CEO turnovers occurred at 78 hospitals. High-turnover hospitals were generally smaller than those facilities with fewer turnovers. The annual rate of CEO turnover was 15 percent in 1988 and 16 percent in 1989. The reasons for turnover most often cited by those in their positions for less than four years were due to: seeking a better position elsewhere, an unstable health care system, conflict with hospital board members or with medical staff, and inadequate salary. High levels of self-reported job satisfaction and job performance by turnover CEOs contrasted to the much lower performance evaluations reported by hospital board members. Nearly three out of four board members indicated they would not rehire their departed CEOs. CEOs perceived their professional weaknesses to center on deficiencies in leadership and financial skills as well as problems with physician, hospital board, and community relations.     

民营医院医疗风险致因分析与防范

目的 通过对2家大型民营医院风险信息进行收集和分析,探索出有效的防范措施,以减少医疗风险带来的损失,维护医患双方的共同利益.方法运用SPSS 17.0统计软件,对2家民营医院2005-2009年医疗纠纷、医疗意外和投诉资料信息进行统计学分析.结果因民营医院诊疗环境的复杂性,增加了医疗风险致因和防范的难度.其复杂性体现在卫生技术人员梯队构建不合理;依法执业意识薄弱,存在非法或跨范围执业;全民保健和维权法律意识的增强,提升了患者就医的期望值等种种供需矛盾的存在,体现出民营医院的不成熟的经营模式.有效的风险防范措施,要从实际出发,不断改进和完善医疗风险控制体系.结论民营医院在医疗风险防范措施上应从这几方面考虑：建立健全医疗风险监测、预警和追溯机制,制定医疗风险防范预案和奖惩制度;健全医院管理体制,引用高端卫生技术人员,合理组建人才梯队;重点科室、关键环节及时检测;贯彻落实医疗安全管理制度和防范措施;提高医务人员风险防范意识,实施三不放过,即：事实经过不放过、经验教训总结不放过、当事人认识不清不放过.     

Appointment and reappointment of doctors in Canadian hospitals

Summary The mechanisms are described by which medical staff are selected and reviewed in an average Canadian hospital. Unlike the United Kingdom, all clinical appointments have a defined term and the onus is upon the incumbent to indicate his suitability for continued appointment. Ultimate legal responsibility for the administrative and medical management of hospitals is that of a lay representative board which delegates authority to doctors nominated by their peers. Thus, the credentials committee is held responsible for the initial investigation and subsequent annual monitoring of all doctors with respect to professional and personal suitability to practise. It is suggested that, despite the differences in provision of health care in Canada, some of these concepts might be worthy of discussion in the United Kingdom. Formerly representative for the Canadian Council on Hospital Accreditation; now Registrar in Community Medicine.     

How can we keep patients with dementia safe in our acute hospitals? A review of challenges and solutions

Maintaining patient safety in acute hospitals is a global health challenge. Traditionally, patient safety measures have been concentrated on critical care and surgical patients. In this review the medical literature was reviewed over the last ten years on aspects of patient safety specifically related to patients with dementia. Patients with dementia do badly in hospital with frequent adverse events resulting in the geriatric syndromes of falls, delirium and loss of function with increased length of stay and increased mortality. Contributory factors include inadequate assessment and treatment, inappropriate intervention, discrimination, low staff levels and lack of staff training. Unfortunately there is no one simple solution to this problem, but what is needed is a multifactorial, multilevel approach at the seven levels of care – patient, task, staff, team, environment, organisation and institution.Improving safety and quality of care for patients with dementia in acute hospitals will benefit all patients and is an urgent priority for the NHS.     

Can managers empower nurse‐midwives to improve maternal health care? A comparison of two resource‐poor hospitals in Tanzania

Maternal mortality is very high in Tanzania. Competent hospital care is key to improving maternal outcomes, but there is a crisis of availability and performance of health workers in maternal care. This article uses interviews with managers, nurse‐midwives, and women who had given birth in two hospitals providing virtually all the emergency maternal care in one Tanzania city. It contrasts women's experience in the two hospitals, and analyses interconnections with nurse‐midwives' and managers' experiences of working conditions. The conceptual literature on nurse empowerment identifies some key explanatory variables for these contrasts. Staff experienced less frustration and constraint in one of the hospitals; had more access to structurally empowering resources; and experienced greater congruence between job commitment and working culture, resulting in better work engagement. Conversely, nurse‐midwives in the other hospital were constrained by supply shortages and recurrent lack of support. Contrasting management styles and their impacts demonstrate that even in severely resource‐constrained environments, there is room for management to empower staff to improve maternal care. Empowering management practices include participatory management, supportive supervision, better incentives, and clear leadership concerning ward culture. Structural constraints beyond the capacity of health facility managers must however also be addressed. © 2015 The Authors. International Journal of Health Planning and Management published by John Wiley & Sons, Ltd.     

Completing the Maternal Care Team: OB/GYN Expertise at Rural District Hospitals in Ghana,a Qualitative Study

Introduction To provide a qualitative perspective on the changes that occurred after newly placed OB/GYNs began working at district hospitals in Ashanti, Ghana. Methods Structured interviews of healthcare professionals were conducted at eight district hospitals located throughout the Ashanti district of Ghana, four with and four without a full-time OB/GYN on staff. Individuals interviewed include: medical superintendents, medical officers, district hospital administrators, OB/GYNs (where applicable), and nurse-midwives. Interviews were transcribed verbatim and content analysis was performed to identify common themes. Characteristics quotes were identified to illustrate principal interview themes. Quotes were verified in context by researchers for accuracy. Results Interviews with providers revealed four areas most impacted by an OB/GYN’s leadership and expertise at district hospitals: patient referral patterns, obstetric protocol and training, facility management and organization, and hospital reputation. Discussion OB/GYNs are uniquely positioned to add clinical capacity and care quality to established maternal care teams at district hospitals–empowering district hospitals as reliable care centers throughout rural Ghana for women’s health. Coordinated efforts between government, donors and OBGYN training institutions to provide complete obstetric teams is the next step to achieve the global goal of eliminating preventable maternal mortality by 2030.     

Total quality management: an implementation strategy for excellence in the medical record department

Trustees do not seem to agree on how quality accountability will be accomplished, but they are starting to agree that procedures to establish quality accountability are necessary. They also agree that leadership from the board level, coupled with a firm resolve to monitor quality, will ensure that hospitals provide high-quality care and services to their most important and influential customers: patients. The manufacturing industry has provided the health care industry with the benefit of its experiences with continuous quality improvement, including the pitfalls. It is both exciting and challenging to learn the philosophies of total quality management and build a customized strategy for excellence, especially in medical record departments. As a customer of numerous processes throughout the health care organization and a supplier of products and services as well, the MRD represents a common thread throughout the organization, often linking people and departments together. A medical record professional who is working in a health care organization whose executives believe in TQM can expect great things in the decade ahead.     

Quality management in Malaysian public health care

PURPOSE: The main aim of the study is to provide an empirical analysis of quality management practice among Malaysian Ministry of Health hospital employees, ranging from medical specialists to health attendants. DESIGN/METHODOLOGY/APPROACH: Self-administered questionnaires collected data and cluster sampling used to select hospitals, while stratified random sampling selected employee respondents. The research was limited to peninsular Malaysian public health care. FINDINGS: A total of 23 public hospitals participated in the survey, including the National Referral Centre, which is based in Hospital Kuala Lumpur. Eight quality management practices were identified in Malaysian public hospitals: continuous improvement, strategic planning, quality assurance, teamwork, leadership and management commitment, employee involvement and training, management by fact, and supplier partnership. Support for quality management was found to be lowest among the physicians. ORIGINALITY/VALUE: The article fills a lacuna in the health care quality management empirical research literature. The main recommendation is for the Malaysian Ministry of Health to gamer physicians' support in its quality endeavours.     

Hospital adaptation to risk-bearing: managerial implications of changes in purchaser-provider contracting

A number of countries have adopted contracting reforms in which hospitals are placed at financial risk. This risk has stimulated a number of adaptive strategies to achieve organizational success. This paper presents a model of six forms of contracting relationships and reviews the adaptation strategies observed in three health systems: the USA, England and the Netherlands. These strategies include service diversification, improved management information systems, the employment of marketing and contract managers, the use of clinical pathways, case management and concurrent/retrospective review of hospital stays, quality management and quality assurance programs, pre-admission authorization, discharge planning, and physician profiling and participation in management. These adaptive strategies have three implications for managers: increased 'partnering', with purchasers, collaboration with medical staff, and assumption of managed care roles. Two groups of institutions are at risk from the changes in hospital contracting: university teaching hospitals and inner-city hospitals serving socially deprived populations. The paper ends with implications for the education of hospital managers and research on hospital management and adaptation to contracting.     

浅析基层医院医患纠纷的原因及防范

近年来,基层医院医患纠纷逐年增多,通过1999²013年在基层工作实践体会,发现基层医院医患纠纷发生的原因多个方面:基层医院改革和管理不成熟,医务人员技术水平、沟通、服务不到位,医院内部不团结、缺乏自我保护意识;患者对医疗服务期望值过高、依从性差、经济条件差并法制观念薄弱;以及社会、媒体等方面的原因。对此,应当加强基层医院的内部管理、提高医务人员综合素质、加强医患沟通、增强自我保护意识,树立基层医院良好的形象,才能有效缓解医患关系的紧张,构建和谐的医疗环境。     

Promoting clinical involvement in hospital quality improvement efforts: the effects of top management, board, and physician leadership.

STUDY QUESTION: An examination of the effects of top management, board, and physician leadership for quality on the extent of clinical involvement in hospital CQI/TQM efforts. DATA SOURCES: A sample of 2,193 acute care community hospitals, created by merging data from a 1989 national survey on hospital governance and a 1993 national survey on hospital quality improvement efforts. STUDY DESIGN: Hypotheses were tested using Heckman's two-stage modeling approach. Four dimensions of clinical involvement in CQI/TQM were examined: physician participation in formal QI training, physician participation in QI teams, clinical departments with formally organized QA/QI project teams, and clinical conditions and procedures for which quality of care data are used by formally organized QA/QI project teams. Leadership measures included CEO involvement in CQI/TQM, board quality monitoring, board activity in quality improvement, active-staff physician involvement in governance, and physician-at-large involvement in governance. Relevant control variables were included in the analysis. PRINCIPAL FINDINGS: Measures of top management leadership for quality and board leadership for quality showed significant, positive relationships with measures of clinical involvement in CQI/TQM. Active-staff physician involvement in governance showed positive, significant relationships with clinical involvement measures, while physician-at-large involvement in governance showed significant, negative relationships. CONCLUSIONS: Study results suggest that leadership from the top promotes clinical involvement in CQI/TQM. Further, results indicate that leadership for quality in healthcare settings may issue from several sources, including managers, boards, and physician leaders.     

医学装备质量控制体制建立对提高医疗质量影响的探讨

目的：建立医学装备质量控制体制,消除设备安全隐患。方法：解剖当前医院医学装备质量控制的现状,提出医学装备质量控制体制建立的初步路径。结果：通过医学装备质量控制体制建立,改变医院重使用,重购买,忽视医学装备质量控制的传统模式。结论：医学装备质量控制体制的建立,对提高医疗质量管理水平具有重要的意义。     

Correlates of hospital leadership team effectiveness: results of a national survey of board chairmen

To examine hospital leadership team effectiveness, analyses the responses of 540 randomly sampled board chairmen of US hospitals. Reports findings regarding board chairmen's evaluation of their hospitals' productive outputs and of the adequacy of their communications with the CEO and medical staff president (MSP) in their hospitals. Notes that over one-quarter of board chairmen found communications with the MSP to be only sometimes productive and notes means whereby positive communications are promoted. Offers suggestions for board chairmen recruitment.     

提高病案首页数据采集质量

病案首页是医院质量管理的重要原始资料。对影响病案首页数据采集质量的因素从人员与管理两方面进行了分析,指出通过加强培训,提高医务人员数据采集质量意识;依托病案全程动态质量监控网络,加强数据源管理;调动医务人员参与信息管理的积极性等措施,可有效提高病案首页数据采集质量。     

基于SWOT模型分析下天津市医联体模式实施现状及对策研究

目的:结合我国医疗卫生现状及相关政策分析天津市开展医联体工作的实施现状,为医联体模式在天津市全面开展提供理论依据,对医疗卫生服务体系整体格局平衡具有现实的指导意义。方法:目的性选取天津市16个建立医联体的三级医院和基层医疗机构的20名人员进行半结构式访谈,采用Colaizzi内容分析法将资料整理分析,应用SWOT模型,归纳总结出天津市医联体模式在实施过程中的优势、劣势、机遇和挑战。结果:天津市开展医联体的优势包括提高基层医生医务能力,应用信息网络搭建沟通平台,提升社区整体水平;劣势包括基层医生工作繁多、压力大、积极性不高,药品管理制度限制患者基层就医,医保制度限制医联体运行;机遇包括医联体建设有国家政策支持,设立专人专岗从事医联体工作;挑战包括基层缺乏吸引人才的机制、区域发展不平衡、缺乏统一管理。结论:天津市医联体模式在实施过程中应加强用经济激励医务人员积极性、建立医联体统一管理制度、完善相关医保政策和药品管理制度,维持医疗卫生服务体系整体格局平衡,促进天津市医联体的全面开展。