Strategic responses by hospitals to increased financial risk in the 1980s.

OBJECTIVE. This research addresses the following types of responses by hospitals to increased financial risk: (a) increases in prices to privately insured patients (testing separately the effects of risk from the effects of "cost-shifting" that depends on level of Medicare payment in relation to case mix-adjusted cost); (b) changes in service mix offered and selectivity in acceptance of patients to reduce risk; and (c) efforts to reduce variation in resource use for those patients admitted. DATA SOURCES. The database includes a national panel of over 400 hospitals providing information from patient discharge abstracts, hospital financial reports, and county level information over the period 1980-1987. STUDY DESIGN. Econometric methods suitable to panel data are implemented, with tests for pooling, hospital-specific fixed effects, and possible problems of selection bias. PRINCIPAL FINDINGS. The prices paid by private insurers to a particular hospital were affected by the changes in risk imposed by Medicare prospective payment, the generosity of Medicare payment, state rate regulation, and ability of the hospital to bear risk. The risk-weighted measure of case mix did not respond to changes in payment policy, but other variables reflecting the management of care after admission to reduce risk did change in the predicted directions. CONCLUSIONS. Some of the findings in this article are relevant to current Medicare policies that involve risk-sharing, for instance, special allowances for "outlier" patients with unusually high cost, and for sole community hospitals. The first type of allowance appears successful in preserving access to care, while the second type is not well justified by the findings. State rate regulation programs were associated not only with lower hospital prices but also with less risk reduction behavior by hospitals. The design of regulation as a sort of risk-pooling arrangement across payers and hospitals may be attractive to hospitals and help explain their support for regulation is some states.     

Total quality in acute care hospitals: guidelines for hospital managers

Quality improvement can not focus exclusively on peer review and the scientific evaluation of medical care processes. These essential elements have to be complemented with a focus on individual patient needs and preferences. Only then will hospitals create the competitive advantage needed to survive in an increasingly market-driven hospital industry. Hospital managers can identify these patients' needs by 'living the patient experience' and should then set the hospital's quality objectives according to its target patients and their needs. Excellent quality program design, however, is not sufficient. Successful implementation of a quality improvement program further requires fundamental changes in pivotal jobholders' behavior and mindset and in the supporting organizational design elements.     

Specialty hospitals: the challenge of the 1980s

Specialty care institutions will face many concerns during the remainder of this decade. Increased intermediary and community education, establishing reliable benchmarks, understanding and dealing with a competitive marketplace, and establishing improved professional productivity are some of the major challenges.     

Making an impact on the hospital environment to improve quality care

All hospitals and health systems in the country face the same problem: What do they do with the millions of tons of waste they generate each year? This issue of The Quality Letter for Healthcare Leaders reveals what a number of award-winning organizations and individuals are doing to make a difference in the healthcare environment through new and innovative ways while impacting the lives of patients, employees, community members, and future generations. Their methods include eliminating the use of products containing mercury, recycling to creating new consumer products, and reviewing the hazards of pharmaceutical disposal.     

The NHS as an agent of change: creating a smoke-free environment in hospital.

In 1985 a Health Circular (HC(85)22)1 asked all District Health Authorities (DHAs) to draw up written policies which would establish non-smoking as normal practice on health service premises and for health service staff. Two years later, a survey of all 191 English Health Authorities assessed progress. Results of the survey indicate a high degree of compliance with the primary goal of each DHA. However, few DHAs gave a policy which contained explicit guidelines on implementation and monitoring procedures. This might have had considerable impact on commitment to smoke-free provision in hospitals.     

Performance of major teaching hospitals during the 1990s: adapting to turbulent times

A panel design was used to analyze changes in performance variables related to profitability, volume, and efficiency in a national sample of major teaching hospitals from 1990 to 1999. After steady increases beginning in 1990, the average total margin ratio peaked in 1996 and by 1999 it declined by almost 50 percent. Average operating margins were negative every year. Major teaching hospitals responded to financial pressures by expanding outpatient activity, reducing length of stay, downsizing inpatient capacity, and increasing labor productivity. Membership in multi-hospital systems increased by over 70 percent through the 1990s. Increases in average real cost per adjusted admission peaked in 1994 and fell by 6 percent from 1994 to 1999.     

Social workers respond to the AIDS epidemic in an acute care hospital

Acquired immune deficiency syndrome (AIDS) has had dramatic effects on hospital staff, particularly social workers. However, little documentation exists of how hospitals and their social work departments have responded to the myriad needs of people with human immunodeficiency virus-related conditions. Patterns of social work service delivery to 152 persons with AIDS at St. Luke's-Roosevelt Hospital Center in New York City were reviewed. Gaps were identified; in particular, social workers provided services to only 40 percent of the identified persons with AIDS. The need for staff education and training, dedicated resources for services to persons with AIDS, and increased out-of-hospital services are discussed.     

Association of job-related stress factors with psychological and somatic symptoms among Japanese hospital nurses: effect of departmental environment in acute care hospitals

The present study examined degrees of job-related stress factors as well as mental and physical symptoms among Japanese hospital nurses in various departments, and clarified associations of departments and job-related stress factors with those symptoms. A self-administered anonymous questionnaire was distributed to 1,882 full-time nurses at four acute care hospitals in Japan. The survey included demographic factors, and the Brief Job Stress Questionnaire. Among 1,599 nurses who completed all items relevant to the present study, we analyzed data from 1,551 female nurses. The results show that working in operating rooms was associated with fatigue, that working in intensive care units (ICU) was associated with anxiety, and that working in surgery and internal medicine was associated with anxiety and depression independently of demographic factors and job-related stress factors. The physical and mental health of nurses might affect their time off, quality of nursing care and patient satisfaction in acute care hospitals. Therefore, job-related stress factors should be minimized, to improve the physical and mental health of nurses, considering unique departmental demands.     

Predicting length of stay in an acute care hospital: the role of psychosocial problems.

In an acute care hospital, a major performance indicator is patient length of stay. This study, in a large university teaching acute care hospital in Canada, examined the effect of psychosocial problems on length of stay, controlling for patient demographics and medical condition. Average days stay for Diagnostic Related Groups (DRGs) was used as a proxy variable for severity of medical condition, and the Person-in-Environment (PIE) classification system was used to measure psychosocial problems. Data were collected on a sample of 160 patients; 78 in psychiatry and 82 in medical/surgical wards. In a regression analysis, the severity of the patient's psychosocial problem was a more significant predictor of length of stay than the DRG variable. The identification of psychosocial problems and their severity add an important and complementary dimension to research into the effectiveness of social workers in reducing length of stay. Workers found clients had significantly more problems related to their social role functioning than problems in the environment.