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.     

我国医院质量管理现状——基于五省调研

本研究通过对5个省开展实地调研,发现我国三级医院、县级医院、民营医院之间医疗质量管理的发展水平有很大差距。三级医院的质量管理体系最为健全;县级医院由于人力资源匮乏和运营压力而无力完善薄弱的质量管理体系;民营医院的医疗质量管理水平则呈现两极分化的趋势。其中存在的具体问题包括:省级质量监管机构监管能力薄弱,运行缺乏保障;医院内部质量管理组织架构不完善,专业质管人员缺乏,人员培训不足;医院信息化发展程度不均衡,信息共享不足。针对上述问题,本文建议:提升第三方监管机构的隶属层次,加强对质控中心的运行保障;完善县级医院、民营医院内部质量管理组织架构,保障人员配置,加大经费投入,开展全员质量管理培训;制定医院信息化建设的基本框架,加强对县级医院、民营医院信息化建设的经费补贴,尽快颁布全国统一的疾病编码,促进医院信息共享。     

工作嵌入、组织承诺对儿科医务人员工作绩效影响的路径分析

目的:探讨儿科医务人员工作嵌入、组织承诺与工作绩效的关系,为医院管理者提高儿科医务人员的工作绩效提供参考。方法:采用分层随机抽样的方法,对某市三级甲等儿童医院194名医务人员进行问卷调查。结果:儿科医务人员的工作绩效得分为(141.38±13.77)分,路径分析结果显示组织承诺对工作绩效有直接正向影响,工作嵌入对工作绩效既有直接又有间接正向影响。结论:医院管理者应“以人为本”,给予儿科医务人员充分的组织支持,使儿科医务人员保持稳定且较高的工作绩效水平。     

Hospital performance: competing or shared values?

OBJECTIVE: To find out which are the emerging views on hospital performance and to analyze how these views vary among hospital stakeholders. METHODS: Study setting: Three hospital stakeholder groups (physicians, caregivers, and administrative staff) in a large Paris teaching hospital. Study design: A case study combining a qualitative (interviews of 80 key hospital stakeholders and a survey of hospital staff), and a quantitative analysis (a questionnaire composed of 4 theoretical dimensions, 13 sub-dimensions, 66 items) with triangulation of the results. RESULTS: Hospital stakeholders assign greatest importance to the human relations dimension, i.e., organizational climate (professional and public service values) and quality of work life. These values attract a high degree of consensus among stakeholders (no statistical difference between physicians, caregivers and administrative staff). CONCLUSIONS: Our findings challenge the mainstream view that competing values underlie hospital performance. Currently, views are to some extent shared among different stakeholder groups. A reason for this could be the need to form a more united front in the face of recent reforms. This common emphasis on professional and public service values could be the basis for formulating management priorities in teaching hospitals in order to improve performance.     

Is your hospital safe? Disruptive behavior and workplace bullying

The author defines disruptive behavior; distinguishes among disruptive, impaired, and incompetent behavior; describes the prevalence of disruptive behavior; and identifies some recommendations to prevent and resolve disruptive behavior in hospitals. The proactive prevention and management of workplace bullying have implications on managing costs, quality, and satisfaction in hospitals among patients, families, staff, and physicians. The author describes an evidence-based framework and recommends that hospital administrators use it to design an organizational approach to promoting a work environment that is psychologically and physiologically safe and that enables staff to focus on delivering high-quality, cost-effective, and satisfying care.     

Conflict management in public university hospitals in Turkey: a pilot study

By nature, hospitals are extremely complex organizations, combining many different professional groups within an intricate administrative structure. Conflicts therefore expectedly arise between individuals, groups, and departments. It is in the interest of health care administrators to periodically assess the major factors giving rise to these conflicts. In this study, a questionnaire designed to measure sources of conflict in the workplace was completed by 204 staff members at Gazi University Hospital. Of the participants, 30.9% were physicians, and 12.5% were administrators at various levels; 61.5% were female, and 38.5% were male. In terms of work experience, 52.6% of participants had worked less than 5 years at the hospital. The results of the study show that educational differences among the hospital staff were a major barrier to good communication and information flow between groups. Professionals in the same specialties experienced fewer conflicts. Another source of conflict was that resource allocation was considered unfair across departments. Although the hospital management provided an ombudsman for staff concerns, staff rarely resorted to the ombudsman because of the stigma associated with complaining. A lack of opportunity for career advancement was mentioned by 52% of the participants as a source of conflict. At present, job performance and rewards are not closely related in public university hospitals in Turkey because promotions and pay raises are strictly limited by law. Bureaucracy was also perceived to be a source of conflict, with 48.4% of participants saying that their performance was less than optimal because of the presence of multiple supervisors. This pilot study suggests that in Turkey, legislative reform is needed to give public university hospitals more flexibility regarding work incentives, open-door policies at the administrative level, and social interactions to improve teamwork among hospital staff.     

医务人员人格特质对知识共享绩效的影响

目的分析医务人员不同人格特质对知识共享绩效的影响。方法以五大人格理论为基础,提出研究假设,采取问卷调查方式,对各层级医护人员进行调查,以检验各项假设是否成立。结果医务人员的亲和性与开放性人格特质对医院知识共享具有正向支持（P＜0.05）,与知识共享绩效具有相关性（P＜0.05）,并且其通过知识共享间接影响知识共享绩效。结论医院应重视医务人员人格特质差异,改进人员选拔与考核机制,制定医务人员职业发展体系,营造支持知识共享的组织氛围,以提高知识共享绩效。     

A baseline study of communication networks related to evidence-based infection prevention practices in an intensive care unit

This study seeks to gain a baseline understanding of the communication network structure, content of communication, and outcomes in a medical intensive care unit experiencing higher-than-expected central line blood stream infection (CLBSI) rates. The communication network structure refers to the direction and frequency of communication on evidence-based CLBSI prevention practices across various professional subgroups and hierarchical levels in the unit, including medical faculty, nurses, residents, students, unit managers, and hospital administrators. The content of communication refers to the type of knowledge (ie, tacit vs explicit knowledge) exchanged on CLBSI prevention practices. Outcomes include (1) compliance with CLBSI prevention practices and (2) hospital-acquired CLBSI rates in the unit. Data on communication network structure and content of communication are collected using communication logs completed weekly for 4 weeks, by individual participants in each professional subgroup and hierarchical level. Outcomes are collected weekly through chart (medical record) review. Study results indicate a sparse communication network structure with minimal interaction across professional subgroups and hierarchical levels. They also indicate that primarily explicit knowledge on general infection topics is being exchanged as against tacit knowledge on specific infection prevention practices. Unit outcomes are poor, with the central line bundle score at zero during all 4 weeks. The study represents an original attempt at developing methods for measuring the communication network structure related to evidence-based infection prevention practices at the unit level. It lays a foundation for testing hypotheses related to effective communication network structures for hospital infection prevention in a larger study. More significantly, the study lays a foundation for generating concrete and context-sensitive strategies for organizational learning and improvement in the context of evidence-based practices. Such insight is critical from the perspective of evidence-based health care management.     

Family medicine practice performance and knowledge management

BACKGROUND: Knowledge management (KM) is the process by which people in organizations find, share, and develop knowledge for action. KM affects performance by influencing work relationships to enhance learning and decision making. PURPOSE: To identify how family medicine practices exhibit KM. METHODOLOGY: A model and a template of KM concepts were derived from a comprehensive organizational literature review. Two higher and two lower performing family medicine practices were purposefully selected from existing comparative case studies based on prevention delivery rates and innovation. Interviews, fieldnotes of operations, and clinical encounters were coded independently using the template. Face-to-face discussions resolved coding differences. FINDINGS: All practices had processes and tools for finding, sharing, and developing knowledge; however, KM overall was limited despite implementation of expensive technologies like an electronic medical record. Where present, KM processes and tools were used by individuals but not integrated throughout the organization. Loss of information was prominent, and finding knowledge was underdeveloped. The use of technical tools and developing knowledge by reconfiguration and measurement were particularly limited. Socially related tools, such as face-to-face-communication for sharing and developing knowledge, were more developed. As in other organizations, tool use was tailored for specific outcomes and leveraged by other organizational capacities. PRACTICE IMPLICATIONS: Differences in KM occur within family practices and between family practices and other organizations and may have implications for improving practice performance. Understanding interaction patterns of work relationships and KM may explain why costly technical or externally imposed "one size fits all" practice organizational interventions have had mixed results and limited sustainability.     

Success factors in hospital network performance: evidence from Korea.

Collaborative networks have become a common organizational strategy to deal with uncertain and dynamic environments. Like their counterparts in the USA, Korean hospitals are establishing cooperative relationships with one another, with varying performance results. This paper analyses some of the sources of variation in hospital network performance and identifies some of the possible success factors. The study finds that the quality of cooperation and information sharing between network partners are critical. The paper concludes with a discussion of the implications for researchers and practitioners.     

医院管理者对医院感染管理工作人员任职条件认识程度调查

目的了解内蒙古自治区各医院管理者对医院感染管理工作人员任职条件的认识程度。方法应用统一的调查表,对内蒙古自治区173所医院的医院管理者关于医院感染管理工作人员任职条件进行调查。结果445名医院管理者中,认为医院感染管理科工作人员应具备预防医学、临床医学、护理学专业背景的比率最高,分别占20.09%、19.89%、18.05%。对于医院感染管理科主任,认为其应具备高级职称者占58.20%,应具备本科以上学历者占89.44%,应在医院工作2～5年者占43.37%。认为医院感染管理科主任应具备的最重要的能力为业务能力和管理能力,分别占34.92%和30.93%。结论医院管理者对医院感染管理工作人员的任职条件倾向于业务能力强,具备一定的管理能力,以及具有多学科背景的复合型人才。     

军队医院护理人员战伤救护知识调查分析

目的：了解军队医院护理人员掌握战伤救护知识的现状,探讨在军队医院进行战伤救护培训的必要性和方法。方法：对4所军队医院222名军人护士进行问卷调查。结果：222名军人护士中,不同学历、不同职称者对战伤救护知识的掌握无显著差异,平均分均在5分以下,掌握较差。结论：对军队医院护士应从思想教育、强化战备意识着手,从基础救护知识学习训练抓起,不断地学习高新技术知识和技能,开展平战结合的训练模式,以提高军队医院护理队伍整体的备战素质。     

The American Hospital Quest for Quality Prize

Improving the quality and safety of health care requires dedicated leadership and the involvement of everyone who affects care within an organization, from trustees and administrators to physicians, nurses and frontline staff. To honor organizations that have made exceptional improvements in quality and patient safety, the American Hospital Association, along with McKesson Corp. and McKesson Foundation, established The American Hospital Quest for Quality Prize: honoring leadership and innovation in patient care quality, safety and commitment. The award recognizes hospitals and health systems that have created measurable and sustainable quality and patient safety programs. Among other things, the organization must have a blame-free work environment and systems in place to help identify actual and potential adverse events and solutions to improve them. As the winner of the inaugural Quest for Quality Prize, Missouri Baptist Medical Center, Town and Country, Mo., received $75,000 to further its safety and quality efforts. Two finalists--Children's Hospitals and Clinics, Minneapolis/St. Paul, Minn., and Fairview Hospital, Great Barrington, Mass.--each received a $12,500 award. A Citation of Merit was presented to Brigham and Women's Hospital, Boston.     

Building customer capital through knowledge management processes in the health care context

BACKGROUND: Customer capital is a value generated and an asset developed from customer relationships. Successfully managing these relationships is enhanced by knowledge management (KM) infrastructure that captures and transfers customer-related knowledge. The execution of such a system relies on the vision and determination of the top management team (TMT). The health care industry in today's knowledge economy encounters similar challenges of consumerism as its business sector. Developing customer capital is critical for hospitals to remain competitive in the market. PURPOSES: This study aims to provide taxonomy for cultivating market-based organizational learning that leads to building of customer capital and attaining desirable financial performance in health care. With the advancement of technology, the KM system plays an important moderating role in the entire process. METHODOLOGY/APPROACH: The customer capital issue has not been fully explored either in the business or the health care industry. The exploratory nature of such a pursuit calls for a qualitative approach. This study examines the proposed taxonomy with the case hospital. The lessons learned also are reflected with three US-based health networks. FINDINGS: The TMT incorporated the knowledge process of conceptualization and transformation in their organizational mission. The market-oriented learning approach promoted by TMT helps with the accumulation and sharing of knowledge that prepares the hospital for the dynamics in the marketplace. Their key knowledge advancement relies on both the professional arena and the feedback of customers. The institutionalization of the KM system and organizational culture expands the hospital's customer capital. PRACTICE IMPLICATIONS: The implication is twofold: (1) the TMT is imperative for the success of building customer capital through KM process; and (2) the team effort should be enhanced with a learning culture and sharing spirit, in particular, active nurse participation in decision making and frontline staff's role in providing a delightfully surprising patient experience.     

Inpatient nursing case management as a strategy for rural hospitals: a case study.

Increasingly, hospitals are facing the dual challenges of cost containment and a nursing shortage. These challenges are especially problematic for rural hospitals where nursing staff must be recruited and quality standards maintained within the financial limitations of lower DRG reimbursement rates when compared with urban centers. Therefore, it has become necessary for rural administrators to find new approaches to maximizing the utilization of available nursing staff. Experts have proposed that one solution to the nursing shortage is redesigning the work of RNs to more fully utilize the knowledge and skill of nurses. Nursing case management--a system in which the registered nurse (RN) assesses patient needs, develops a plan of care, procures and coordinates needed resources, and provides ongoing evaluation of care--is one strategy for redesigning nursing roles which offers potential financial benefits to hospitals. Through daily coordination and evaluation of patient care activities, nursing case managers can ensure cost effective allocation of organizational resources and facilitate early discharge planning. This article includes a case study of a rural hospital that introduced the nursing case management system, the hospital's steps of planning and implementation, and examples of forms associated with the system.     

The newest miracle drug: quality circles in hospitals

In recent years, a number of hospitals throughout the United States have been exploring the use of Japanese-style quality circles to reduce their operating expenses, improve productivity, and enhance the quality of work life for hospital employees. This article examines the organizational climate necessary for quality circles, methods used to implement quality circles, and management's role in guiding and responding to circle activities. Ideas for building and maintaining staff support are presented along with a cost/benefit analysis of quality circle programs. The author concludes that quality circles are most successful in hospitals where they are part of a larger organizational development effort. When administrators believe in their employees' ability to contribute to the institution and are willing to invest necessary time and resources in employee education and the measurement of quality circle achievements, quality circles can produce creative solutions to perplexing institutional problems.     

System-Level Factors Affecting Clinicians’ Perceptions and Use of Interpreter Services in California Public Hospitals

Professional language interpreters are skilled in the nuances of interpretation and are less likely to make errors of clinical significance but clinicians infrequently use them. We examine system-level factors that may shape clinicians’ perceptions and use of professional interpreters. Exploratory qualitative study in 12 California public hospitals. We conducted in-person key informant interviews with hospital leadership, clinical staff, and administrative staff. Five emergent themes highlight system-level factors that may influence clinicians’ perceptions and use of professional interpreters in hospitals: (1) organization-wide commitment to improving language access for LEP patients; (2) organizational investment in remote interpreter technologies to increase language access; (3)training clinicians on how to access and work with interpreters; (4) hospital supports the training and certification of bilingual staff to serve as interpreters to expand in-person, on-site, interpreter capacity; and (5)organizational investment in readily accessible telephonic interpretation. Multiple system-level factors underlie clinicians’ use of professional interpreters. Interventions that target these factors could improve language services for patients with limited English proficiency.     

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.     

医院团队知识共享影响因素的编码研究

医院是典型的知识密集型组织。研究以医院科室为研究对象,运用质性研究的方法,将焦点小组访谈记录整理成的质性资料进行内容分析,采用编码技术,通过开放性编码、主轴编码和选择性编码3个有序的后建式编码步骤,并经编码的一致性检验,最终识别出医院团队知识共享的主要影响因素,并识别出团队性激励和组织支持感两个特殊的关键因素。研究成果丰富了知识共享领域的理论研究。     

The changing managerial role of physician executives

A survey of tasks performed by a sample of 517 physician executives from the AMA Masterfile was carried out to determine the role played by this group of administrators in health care organizations. In contrast to the findings of previous studies, physician executives appear to have responsibilities in general management as well as clinical management and do not focus primarily on physician and medical staff issues. No significant differences were found among respondents from hospitals, government, academic organizations, group practices/HMOs, and physician executives who spend more than 90 percent of their time in administration. Tasks identified as important for the future but not currently being done were primarily in the category of external activities such as "changing regulations and legislation" and "communicating goals to the public." These results identify an important boundary-spanning role for physician executives in balancing managerial and professional issues of cost, quality, and access in health care organizations. The implications of these findings for the educational needs of physician executives are discussed.