A strategic approach for managing conflict in hospitals: responding to the Joint Commission leadership standard, Part 1

BACKGROUND: The Joint Commission's leadership standard for conflict management in hospitals, LD.02.04.01, states, "The hospital manages conflict between leadership groups to protect the quality and safety of care." This standard is one of numerous standards and alerts issued by The Joint Commission that address conflict and communication. They underscore the significant impact of relational dynamics on patient safety and quality of care and the critical need for a strategic approach to conflict in health care organizations. Whether leadership conflicts openly threaten a major disruption of hospital operations or whether unresolved conflicts lurk beneath the surface of daily interactions, unaddressed conflict can undermine a hospital's efforts to ensure safe, high-quality patient care. DEVELOPING A STRATEGIC APPROACH TO CONFLICT MANAGEMENT: How leaders manage organizational conflict has a significant impact on achieving strategic objectives. Aligning conflict management approaches with quality and safety goals is the first step in adopting a strategic approach to conflict management. A strategic approach goes beyond reducing costs of litigation or improving grievance processes--it integrates a collaborative mind-set and individual conflict competency with nonadversarial processes. UNDERTAKING A CONFLICT ASSESSMENT: Conflict assessment should determine how conflicts are handled among the leaders at the hospital, the degree of conflict competence already present among the leaders, where the most significant conflicts occur, and how leaders think a conflict management system might work for them. CONCLUSIONS: Strategically aligning a conflict management approach that addresses conflict among leadership groups as a means of protecting the quality and safety of patient care is at the heart of LD.02.04.01.     

An exploration of the leadership attributes and methods associated with successful lean system deployments in acute care hospitals

The lean system has been shown to be a viable and sustainable solution for the growing number of cost, quality, and efficiency issues in the health care industry. While there is a growing body of evidence to support the outcomes that can be achieved as a result of the successful application of the lean system in hospital organizations, there is not a complete understanding of the leadership attributes and methods that are necessary to achieve successful widespread mobilization and sustainment. This study was an exploration of leadership and its relevant association with successful lean system deployments in acute care hospitals. This research employed an exploratory qualitative research design encompassing a research questionnaire and telephonic interviews of 25 health care leaders in 8 hospital organizations across the United States. The results from this study identified the need to have a strong combination of personal characteristics, learned behaviors, strategies, tools, and tactics that evolved into a starting adaptable framework for health care leaders to leverage when starting their own transformational change journeys using the lean system. Health care leaders could utilize the outcomes reported in this study as a conduit to enhance the effective deployment, widespread adoption, and sustainment of the lean system in practice.     

New research alliances in the era of managed care

BACKGROUND: The rise of managed behavioral health care in the United States was accompanied by reductions in costs, which has shifted the policy debate from concerns about rising costs to questions of universal access, mental health benefits at parity with medical benefits and quality of care. To meet these new challenges, managed care organizations, the purchasers of health care and academic services researchers must work together in new ways. AIMS OF THE STUDY: This paper discusses collaborative efforts between a for-profit managed care firm, academia and purchasers of health care coverage to study parity for mental health and substance abuse and how this effort has become part of a research strategy to inform policy. Historical, strategic and methodological issues are presented. METHODS: Case Study. RESULTS: Although the benefits from cooperative research are substantial, there are severe hurdles. Managed care organizations often have data that could answer pressing policy questions, yet these data are rarely used by researchers because it is difficult to obtain access and because analyzing the data requires computing facilities and skills that are not common in health services research. In turn, managed care organizations can learn how to design and implement more informative data systems that eventually lead to more cost-effective care, but there often are more immediately pressing business considerations and sometimes resistance to outside scrutiny. Important features that made this cooperation successful include strong support from the senior management in the company, including complete access to their extensive databases, and established funding for a managed care research center by the National Institute of Mental Health. CONCLUSION: This paper illustrates the potential of collaborative research. New research challenges, such as the linkages between quality and cost-effectiveness in actual practice settings, can only be met successfully if we build alliances among payors, managed care companies and academic researchers.     

Physician organization in California: crisis and opportunity.

Many of the 250 physician organizations that provide care to California's sixteen million health maintenance organization enrollees are in a state of crisis, squeezed between constrained revenues, rising practice costs, and consumer sentiment that favors unconstrained choice over integrated delivery. Medical groups and independent practice associations are retrenching to their core geographic areas, reducing capitation for drug benefits and hospital services, and abandoning dreams of displacing health plans. Consolidation is accelerating in some areas, as medical groups join with hospitals to extract higher payment rates from insurers and employers. The conjunction of consumerism and premium inflation creates new opportunities for organizations that truly can manage health care, but the challenges roiling California's medical groups may preclude meaningful efforts to seize the initiative.     

Knowledge sharing networks related to hospital quality measurement and reporting

BACKGROUND: With the growing momentum toward hospital quality reporting by public payers, hospitals face increasing pressures to improve their medical record documentation and administrative data coding performance. The literature on "professional complex systems" has put forth various strategies for improving the performance of professional organizations. In doing so, it has emphasized the importance of creating effective structures for knowledge sharing and organizational learning. This study integrates knowledge networks and professional organizations literatures to develop hypotheses related to knowledge sharing network effectiveness in professional organizations. PURPOSE: Correspondingly, this study explores the relationship between the organizational knowledge sharing structure related to quality and hospital coding performance related to quality. Simultaneously, this study seeks to identify other organizational characteristics associated with coding for quality measurement. The purpose is to identify strategies not only for improving hospital coding performance but also for the organization to adapt to the changing environment. METHODS: An exploratory and comparative research design is used. The sample is composed of four hospitals, two showing "good-coding" performance for quality measurement and two showing "poor-coding" performance. Interviews and surveys are conducted with administrators and staff in the quality, medical staff, and coding subgroups in each facility. Survey data are subjected to social network analysis to examine knowledge sharing structures. FINDINGS AND IMPLICATIONS: This study finds that good-coding performance is systematically associated with a knowledge sharing network structure rich in brokerage and hierarchy (with leaders connecting different professional subgroups to each other and to the external environment) rather than in density (where everyone is directly connected to everyone else). From a health care management perspective, this study suggests that to improve hospital coding performance, senior administrators must undertake proactive and unceasing efforts to coordinate knowledge exchange across physician and coding subgroups and connect these subgroups with the changing external environment.     

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.     

Hospitals and health professional education: contemporary challenges

Both the role of hospitals in health professionals education and hospital's needs in terms of professionals for health care and hospital management are changing as health systems move towards quality, comprehensiveness, efficiency and costs control. The article intends to analyze dilemmas and challenges in each of these fields, acknowledging hospitals' complexity, their critical role on healthcare delivery and their deep involvement in the hegemonic orientation for health education and practice.     

Hospital responses to pay-for-performance incentives.

Not-for-profit hospitals are complex organizations and, therefore, may face unique challenges in responding to financial incentives for quality. In this research, we explore the types of behavioural changes made by not-for-profit Michigan hospitals in response to a pay-for-performance system for quality. We also identify factors that motivate or facilitate changes in effort. We apply a conceptual framework based on agency theory to motivate our research questions. Using data derived from structured interviews and surveys administered to 86 hospitals participating in a pay-for-performance system, we compare hospitals reporting and not reporting behavioural changes. Separate analyses are performed for hospitals reporting structure-related changes and hospitals reporting process-related changes. Our findings confirm that hospitals respond to incentive payments; however, our findings also reveal that hospital responses are not universal. Rather, involvement by boards of trustees, willingness to exert leverage with physicians, and financial and competitive motivations are all associated with hospitals' behavioural responses to incentives. Results of this research will help inform payers and hospital managers considering the use of incentives about the nature of hospitals' responses.     

The strategic management of organizational knowledge exchange related to hospital quality measurement and reporting

CONTEXT/PURPOSE: With the growing momentum toward hospital quality measurement and reporting by public and private health care payers, hospitals face increasing pressures to improve their medical record documentation and administrative data coding accuracy. This study explores the relationship between the organizational knowledge-sharing structure related to quality and hospital coding accuracy for quality measurement. Simultaneously, this study seeks to identify other leadership/management characteristics associated with coding for quality measurement. THEORY AND METHODS: Drawing upon complexity theory, the literature on "professional complex systems" has put forth various strategies for managing change and turnaround in professional organizations. In so doing, it has emphasized the importance of knowledge creation and organizational learning through interdisciplinary networks. This study integrates complexity, network structure, and "subgoals" theories to develop a framework for knowledge-sharing network effectiveness in professional complex systems. This framework is used to design an exploratory and comparative research study. The sample consists of 4 hospitals, 2 showing "good coding" accuracy for quality measurement and 2 showing "poor coding" accuracy. Interviews and surveys are conducted with administrators and staff in the quality, medical staff, and coding subgroups in each facility. FINDINGS AND IMPLICATIONS: Findings of this study indicate that good coding performance is systematically associated with a knowledge-sharing network structure rich in brokerage and hierarchy (with leaders connecting different professional subgroups to each other and to the external environment), rather than in density (where everyone is directly connected to everyone else). It also implies that for the hospital organization to adapt to the changing environment of quality transparency, senior leaders must undertake proactive and unceasing efforts to coordinate knowledge exchange across physician and coding subgroups and connect these subgroups with the changing external environment.     

Hospital–Community Partnerships: Facilitating Communication for Population Health on Columbus’ South Side

Previous studies have focused on the role anchor institutions play in community development. However, less attention has been directed to how hospitals can effectively partner with community-organizations and residents as part of population health efforts. This article examines community views of one initiative developed by a major American children’s hospital in partnership with local community organizations. The data for this study come from 35 in-depth interviews with local residents from the neighborhood adjacent to the hospital and two interviews with hospital administrators. Our findings suggest that the contexts in which hospitals and other non-profit corporations operate pose unique challenges to effective communication. In particular, hospitals and community organizations may think differently about the merits and nature of open communication. Especially when acting as anchor institutions working beyond their formal medical expertise, hospitals may struggle to communicate the scope and goals of their non-medical work in the community.     

Understanding benchmarking

In order to meet the challenges facing health care today, organizations are turning to new approaches. Benchmarking is one such approach. Benchmarking is externally driven, encouraging organizations to look outside their own walls to learn from others and achieve exemplar performance. Organizations can benchmark within their own systems, against competitors, against "best-in-class" companies in the same general industry and against "best-in-class" companies in different industries. A four-step approach to benchmarking includes planning, collecting information, analyzing results and adapting and improving. A benchmarking study team composed of the process owner and other users of the process conducts the study. Application of benchmarking to healthcare materiel management is particularly appropriate, since many materiel management processes occur in other industries and, therefore, best practices outside the healthcare industry may be adapted. The practice, through growing in other industries, is still very new in health care.     

Economic Effects of the Outmigration of Obstetric Services in a Rural County

Obstetrical health care resources have been declining in rural areas since 1980, resulting in reduced prenatal care that can result in higher medical costs. Loss of health care services is known to have negative economic consequences for rural communities. This article illustrates how hospitals and other providers of medical services can be used as vehicles for local economic development. Provision of medical services is an important component of the economic base of all communities and especially of small rural communities with hospitals. When a community loses medical services to another community, it loses both direct and indirect economic benefits. The research presented here analyzes the economic effects of outmigration of obstetric services from a rural "perimeter" community in Wyoming. The combined direct and indirect economic losses are shown to be significant. Annual revenue losses to the local hospital were estimated as high as 12 percent. It is important to make explicit the economic losses that result from reductions in health care. Such research, combined with knowledge of negative health and social factors can provide community leaders with additional motivation to find solutions to declining health care in rural areas.     

Developing Tomorrow's Integrated Community Health Systems: A Leadership Challenge for Public Health and Primary Care

As the nation's health system moves away from earlier models to one grounded in population health and market-based systems of care, new challenges arise for public health professionals, primary care practitioners, health plan and institutional managers, and community leaders. Among the challenges are the need to develop creative concepts of organization and accountability and to assure that dynamic, system-oriented structures support the new kind of leadership that is required. Developing tomorrow's integrated community health systems will challenge the leadership skills and integrative abilities of public health professionals, primary care practitioners, and managers. These leaders and their new organizations must, in turn, assume increased accountability for improving community health.     

The looming health care crisis. Fact or myth?

Health care literature succinctly describes the challenges faced by hospitals today: shortages of skilled workers, escalating costs, government regulations, shortfalls in revenue, and similar concerns. To assess the relative importance that hospitals attach to these challenges, as perceived by hospital HR managers, a nationwide survey of 400 randomly selected HR managers was conducted. These HR directors were asked to rank-order various hospital concerns, assess the success their employers have achieved in dealing with such problems, and predict the difficulty of recruiting and retaining qualified workers in various job categories throughout this decade. In contrast to hospital CEOs, who regard financial concerns as their top priority, hospital HR managers rank shortages of skilled workers first. These HR managers anticipate continued difficulty in recruiting and retaining RNs, pharmacists, anesthetists, and some therapists and technicians throughout this decade.     

Towards an organization with a memory: exploring the organizational generation of adverse events in health care.

The role of organizational factors in the generation of adverse events, and the manner in which such factors can also inhibit an organization's abilities to learn, have become important agenda items within health care. The government report 'An organization with a memory' highlighted many of the problems facing health care and suggested changes that need to be made if the sector is to learn effective lessons and prevent adverse events from occurring. This paper seeks to examine some of these organizational factors in more detail and suggests issues that managers need to consider as part of their wider strategies for the prevention and management of risk. The paper sets out five core elements that are held to be importance in shaping the manner in which the potential for risk is incubated within organizations. Although the paper focuses its attention on health care, the points made have validity across the public sector and into private sector organizations.     

Meaning in motivation: does your organization need an inner life?

Leaders of health care organizations are increasingly interested in ways to attract, retain, and gain commitment from their employees. This interest is created in part because high turnover rates and the lack of commitment negatively affect the provision of care and the bottom line in their organizations. In a quality and cost conscious health care environment, health care managers need to find solutions for these difficult issues; solutions that are effective, efficient and sustainable. What can be done? This article reviews, amplifies, and extends work that has been done in the area of "meaningfulness of work" in the context of employee retention and commitment. It begins with an exploration of the problems caused by lack of employee engagement and commitment including their impact on quality and costs. It then summarizes both the theoretical and applied research in the area of meaning and work. It also introduces the basic principles of Viktor Frankl's logotherapy (Frankl, 1998) as a foundation for encouraging the integration of meaning and work. The seminal work by Pattakos (2004) is used to demonstrate how Frankl's principles can be applied to healthcare work settings. Finally, the article provides suggestions for increasing employee commitment and engagement through identifying meaning and purpose in work.     

Isomorphic pressures, institutional strategies, and knowledge creation in the health care sector

BACKGROUND: Health care organizations are facing surprisingly complex challenges, including new treatment and diagnostic technologies, ongoing pressures for health care institutional reform, the emergence of new organizational governance structures, and knowledge creation for the health care system. To maintain legitimacy in demanding environments, organizations tend to copy practices of similar organizations, which lead to isomorphism, and to use internal strategies to accommodate changes. A concern is that a poor fit between isomorphic pressures and internal strategies can interfere with developmental processes, such as knowledge creation. PURPOSES: The purposes of this article are to, first, develop a set of propositions, based on institutional theory, as a theoretical framework that might explain the influence of isomorphic pressures on institutional processes through which knowledge is created within the health care sector and, second, propose that a good fit between isomorphic pressures factors and health care organizations' institutional strategic choices will enhance the health care organizations' ability to create knowledge. METHOD: To develop a theoretical framework, we developed a set of propositions based on literature pertaining to the institutional theory perspective of isomorphic pressures and the response of health care organizations to isomorphic pressures. FINDINGS: Institutional theory perspectives of isomorphic pressures and institutional strategies may provide a new understanding for health care organizations seeking effective knowledge creation strategies within institutional environment of health care sector. PRACTICE IMPLICATIONS: First, the ability to identify three forces for isomorphic change is critical for managers. Second, the importance of a contingency approach by health care managers can lead to strategies tailoring to cope with uncertainties facing their organizations.     

Automated,wireless, continuous,intelligent, and noninvasive systems for risk management and performance improvement in vital signs monitoring

Few health professionals need to stay up‐to‐date on as many different problems and solutions as risk managers do. Consequently, a single solution that resolves several problems at once is really helpful for job performance, especially when it doesn't require duplicating effort in multiple areas. This article summarizes current literature about one such technology that helps risk managers address 3 of today's biggest challenges for healthcare delivery organizations: reducing costs, improving quality, and preventing harm across the continuum of clinical care; ensuring valid and reliable data for healthcare clinical and managerial decision makers; and adopting technologies that improve the medical marketplace.