Combined Effects of Iranian Heavy Crude Oil and Bacterial Challenge (Streptococcus iniae) on Biotransformation and Innate Immune Responses in Rockfish (Sebastes schlegeli)

To clarify the effects of spilled crude oil on fish bacterial disease resistance, rockfish (Sebastes schlegeli) were exposed to Iranian Heavy crude oil (IHCO) and Streptomyces iniae in combination. Hepatic biotransformation enzymes (ethoxyresorufin O-de-ethylase, glutathione-S-transferase) and plasma biochemical parameters (glutamic oxaloacetic transaminase, glutamic pyruvic transaminase and glucose) in fish exposed to IHCO were not significantly different from those in unexposed fish. The level of biliary 1-OH-pyrene and cytochrome P4501A mRNA expression increased in a dose-dependent manner with IHCO exposure. The interferon stimulated gene 15, interleukin-1beta and cathepsin L were increased significantly in the liver in IHCO-exposed fish, but not dose-dependently, but the granulocyte colony stimulating factor was not related to IHCO exposure. The percentage mortality in fish following a single exposure to S. iniae was positively correlated with IHCO exposure concentration. We concluded that IHCO exposure exacerbates fish mortality following environmental bacterial infection.     

Managing health care organizations: where professionalism meets complexity science

This article examines the intersection of professionalism and complexity science as a source of new insights for improving the health care industry from both a clinical and business point of view. Viewing health care organizations as professional complex adaptive systems suggests eight leadership tasks for addressing the circumstances that engulf health care. Managers who adopt this view will be able to create new levers for positive movement in their organizations.     

In health care reform, who cares for the community?

Health care reform has again focused the issues of ownership and mission of organizations in the health care field. Some believe that universal entitlement will eventually make both charitable patient care and the nonprofit form of organization obsolete. Others believe that special treatment of nonprofit organizations does not depend on charity at all; rather that the nonprofit form has social value in and of itself. The authors reflect a different point of view. They suggest that with reform, community benefit as the modern expression of a charitable mission will become ever more important in achieving the nation's health care goals. They believe that nonprofit organizations will continue to be entitled to special treatment only if their missions and programs extend beyond care of patients and entitled populations to focus also on care of communities. Any health organization's investment in disciplined community initiatives encompasses all the people in targeted communities, including those served by competing organizations. Without tax exemption, an organization committed to community care initiatives will be at a competitive disadvantage under the proposed community rated capitation payment system. Rather than abandoning the community benefit standard for tax exemption, health care reform calls for more systematic management of community care initiatives by nonprofit organizations and also of tax-exemption eligibility by the IRS.     

Organization and financing of British primary care groups and trusts: observations through the prism of US managed care

There are many parallels between the UK's new primary care commissioning organizations and the managed care organizations and integrated delivery systems that have evolved in the USA over the last three decades. Those building primary care groups and trusts (PCG/Ts) can learn from the American experience with health maintenance organizations and other similar entities. These lessons should also be relevant to those in other countries interested in establishing innovative primary care led organizations within the broader structure of a socialized health care system. Following an overview of US managed care and an update of the progress of the UK's PCG/Ts, we go on to suggest how new consortia of PCG/Ts might be developed and how budgets and provider incentives could be structured. This international comparison suggests that the resources needed to support the development of effective PCG/Ts will be considerable, as will the need to maintain organizational flexibility. If primary care organizations are to thrive, it will be essential to develop truly integrated budgets for primary and secondary care.     

Can managed health care help manage health care-associated infections?

Managed-care organizations have a unique opportunity, still largely unrealized, to collaborate with health-care providers and epidemiologists to prevent health care-associated infections. Several attributes make these organizations logical collaborators for infection control programs: they have responsibility for defined populations of enrollees and for their overall health, including preventive care; they possess unique data resources about their members and their care; and they are able to make systemwide changes in care. Health care-associated infections merit the attention and effort of managed-care organizations because these infections are common, incur substantial illness and costs, and can be effectively prevented by using methods that are unevenly applied in different health-care settings. Both national and local discussions will be required to enable the most effective and efficient collaborations between managed care organizations and health-care epidemiologists. It will be important to articulate clear goals and standards that can be readily understood and widely adopted.     

Kaiser Permanente: integrating around a care delivery model

The risk-adjusted payment model mandated for Medicare + Choice organizations by the Balanced Budget Act of 1997 has significant implications for health care organizations that offer the Medicare + Choice program. Chronic medical conditions in the ambulatory care setting will become the focus of data capture, requiring significant retooling of ambulatory care operations. Health care organizations in California currently do not have the capital available to invest in the information management tools that will be required. Private practitioners continue not to have the technology and expertise to capture the data needed to run the model. Nevertheless, the risk-adjusted payment model presents the potential to better integrate care delivery around the continuum of health care needs of the population.     

Complementary and alternative medicine: opportunities and challenges

Complementary and alternative medicine (CAM) has emerged as a significant sector within the health care industry as patient demand has increased, as the number and diversity of providers has grown, and as more providers deliver evidence-based CAM modalities to patients. The challenges confronting health care organizations that offer CAM are both similar and dissimilar to organizations that do not offer CAM. The unique challenges will be described in a way to provide academics and health care finance practitioners with a plan to address these challenges which range from lack of third-party coverage to lack of knowledge about financing CAM among patients and providers. Not only will the unique challenges be described but the distinctive opportunities to finance CAM will be highlighted. These opportunities will be discussed from both a financial perspective and innovation perspective with the aim of providing academics and health care financial practitioners with a rationale to offer CAM to patients and get compensated for providing these services.     

The leadership and executive potential of physicians in an era of managed care systems

The emergence of managed care signals a need for an expanded role for physicians. Physician executives, trained in management, have the potential to become champions of clinical integrity, negotiators with patient agent organizations, public interpreters of hospital performance data, consultants to the profession, and designers of health care systems. Nonclinically trained administrators have been slow to recognize the unique skills and perspective that physicians bring to the managerial suite. The clash of professional and managerial cultures has often been perceived as precluding a strong working alliance between physician and nonphysician executives. As hospital margins are threatened, decision protocols must not be designed to incorporate teams of leaders who are able to overcome the managerial/clinical divide. The management of this interface will demand the attention of both administration and boards and may require the establishment of new structures in health care organizations.     

Network integration. A new vision for Catholic healthcare systems in the 1990s

The 1990s will be the decade of network integration for many of the nation's healthcare organizations. Catholic healthcare systems will have to refocus on local and regional healthcare delivery. To succeed in local and regional markets, the systems will have to offer various levels of care through numerous types of providers, share services among facilities, cooperate with secular organizations, and build stronger affiliations with local parishes. Managing this change (from offering fragmented healthcare services to offering integrated services) will be a major challenge facing organizations in the decade ahead. They must develop a clearly articulated vision to provide stability during this time of rapid change. To meet the challenges of the 1990s, Catholic healthcare systems will have to determine the types of functional sharing that will be beneficial at the local level, divest and transfer sponsorship of facilities that burden the system's mission, and expand the activities of the laity.     

Perceptions of management development in selected hospitals

Today health care executives are managing organizations that are complex and require a higher degree of financial management, medical knowledge, and general business skills. The skills and academic background required to manage health care facilities have been debated by practitioners and academicians over the years. This study will examine executives' perceptions of management development activities in their organizations. To assess these perceptions, an eight-item questionnaire was mailed to 587 executives. Forty-two percent were returned. The data showed that a majority of the respondents indicated that the management development programs in their organizations were well received and that the morale of managers had improved. The pressures and challenges facing health care organizations will require managers and executives to make use of a wide range of skills if they are to be successful.     

Carrot and stick: state mechanisms to influence private provider behavior

The behavior of private sector health care providers will depend critically on the environment within which they operate. A bewildering array of possible regulatory and incentive setting structures exist. Most developing countries have the basic legislation for regulation, but there are frequently difficulties in enforcing such controls. While process aspects of quality of care regulation are often the responsibility of professional organizations, these organizations may have limited incentives to be active in ensuring high quality medical car.e There has been less experience with the use of incentives to encourage appropriate behavior amongst private providers: this appears a promising area for further work. Above all, adequate information is essential both for the enforcement of regulations and the application of incentive mechanisms.     

Those conversion blues.

With the ever-increasing market penetration of capitated payment systems throughout health care markets, average payment rates for health services have dropped correspondingly. At the same time, the added competitive pressures from managed care organizations have served to increase the demand for new capital investment in information systems, lower cost facilities, and innovative modes for delivering all types of health care services. As a result, many nonprofit health care organizations have converted, or have attempted to convert, to for-profit status in an effort to gain access to the public equity capital markets. As hospitals, Blue Cross and Blue Shield organizations, and other nonprofit health care organizations across the U.S. seek to convert to for-profit status, they are finding the path is not easy. Access to capital, operating efficiencies, and the need to accelerate movement into new markets are offset by public benefit obligations, potential private inurement, and significant political cost issues. The bottom line is whether the conversion will be structured to both protect the public interest and allow the health care organization the flexibility and access to capital it needs in order to continue as a viable, competitive organization into the next millennium.     

对我国医院重组的初步研究

医院重组策略是提高卫生资源使用效率的重要途径之一。目前我国医院重组主要分为协作经营型、连锁经营型、兼并经营型三类，重组中的纽带主要有：资产、管理资源、除管理以外的资源（人才、技术、品牌）等。我国医院重组的经营行为日趋成熟，但在如改革目标、法律保障体系、管理机制和内部人等方面仍存在一定的障碍。卫生行政部门和医疗机构应当根据医院重组特生和操作方式的不同，而采取相适宜的运作思路。我国医院的重组经营具有着较大的发展空间，它对今后发展形成国家新型医疗保健体系将产生深远影响。     

Planning for successful outcomes in the new millennium

The complexity of the health care environment will increase in the next millennium. Organizations must adopt an approach of selecting outcomes management solutions that are focused on data capture, analysis, and comparative reviews and reporting. They must decisively and creatively implement, in a phased approach, integrated solutions from existing robust systems, while considering future systems targeted for implementation. Outcomes management solutions must be integrated with the organization's information systems strategic plan. The successful organization must be able to turn business-critical data into information that supports both business and clinical decision-making activities. In short, health care organizations will have to become information-driven.     

Competencies for health management practice: a practitioner's perspective

The current health care environment will require executive leadership with a new set of management competencies to effectively lead and manage the various components of a restructured health care delivery system. The traditional management skills of planning, organizing, directing, controlling, and staffing resources will remain relevant, but the true measure of professional success will be the development of conceptual skills. This means the ability to look at the health care enterprise as a whole, and recognize how changes in the environment shape your strategic mission, goals, and objectives. The successful health care leader will have a demonstrated ability to apply these conceptual skills to the development of information systems and integrated networks that position their organization to accept capitated risks. This paper examines the United States and Canadian health care systems from the perspective of both the more traditional hospital and the emerging medical care organizations. New importance of the team approach to leadership and management and all that entails is stressed.     

Improving hospital performance: issues in assessing the impact of TQM activities

Despite numerous published reports of the need for TQM activities in health care organizations and their widespread diffusion within the health care industry, whether they make a difference remains an unresolved issue. In this article, we discuss the major reasons why the impacts of TQM should be assessed, what needs to be measured during assessment activities, and significant methodological issues that can confound the evaluation of TQM effects. An audit framework is described that can be used to depict the types of effects that TQM may have on the performance of health care organizations. Assessment guidelines are offered that will hopefully benefit the future efforts of institutional managers and health services researchers in their attempts to determine whether TQM activities do in fact make a significant difference.     

Large Employers That Have Lived Through Transformation Say Payment Reform Alone Won't Cut Costs And Reengineer Care

As payment reform in health care gathers momentum, employers, as major payers, endorse the effort to move away from volume-driven payment to incentivizing and rewarding the delivery of better health care at lower cost. In this commentary we discuss large employers' perspectives on three particular challenges that payment reform alone, as important as it is, may not be sufficient to address: high health care prices, inefficient and complex systems, and an outdated work environment ill designed to meet the pressing goals of better health care at lower cost. We believe that policies that support health care organizations in redesigning work processes will be essential to reducing prices and simplifying interactions in care delivery. We also believe that health care organizations will need to redesign their compensation systems to align their employees' pay with improvements in performance. To that end, we describe the major transformation that IBM underwent in the 1990s to position itself to compete in a radically changed computer marketplace. We also offer several policy recommendations to support health care organizations in making the necessary changes.     

An exploratory investigation of hospice marketing: How are palliative care providers marketing their services?

ABSTRACT

Hospice and palliative care is a recent, but fast growing, industry in healthcare. Demographics suggest that hospice care will only increase. The purpose of this article is to examine strategic marketing initiatives hospice organizations currently employ. Data were collected at a hospice regional conference, capturing opinions from hospice organizations located in North and South Carolina. The results show that many hospice organizations do not have a dedicated marketing staff person, have a limited marketing budget, do not fully utilize all strategic planning tools, and have yet to differentiate themselves via branding. Implications of these findings for hospice providers are discussed.     

Integrating performance measure data into the Joint Commission accreditation process

This article describes the Joint Commission's implementation plans, experience, and results to date of incorporating performance measurement data into the accreditation process. These plans have evolved in response to changes in the health care environment, feedback from accredited organizations, and both technical and political obstacles encountered. During the late 1980s, the Joint Commission developed a national performance measurement system, the IMSystem, to incorporate information about the process and outcomes of care into the accreditation process. In 1995, the ORYX initiative was introduced to offer health care organizations significant flexibility in selecting a measurement system and measures while promoting organizational self-improvement and accountability. Recently, the plans have evolved to incorporate standardized core measures that are known to be valid and reliable. These initiatives have moved the field much closer to the day when quality assessment will reflect a comprehensive view of organizational performance, based, in part, on performance measurement data.