US hospital engagement in cross-sector partnerships for population health improvement in socioeconomically distressed counties.

OBJECTIVES: This study identifies the internal characteristics of hospitals located in counties with poor socioeconomic conditions that develop collaborative partnerships with a wide range of community organizations, including non-health organizations. STUDY DESIGN: Cross-sectional study that conducted Chi-square and logistic regression analyses. METHODS: Chi-square tests and logistic regression analyses were performed in this cross-sectional research to identify the internal hospital characteristics associated with non-health sector partnership development for hospitals located in U.S. counties in the worst quartile of performance across three socioeconomic conditions. The 2015 American Hospital Association Population Health Survey provided data on hospitals' collaborative arrangements and internal characteristics, including hospital size, teaching status, ownership type, and system affiliation (n = 1,238). The 2014 County Health Rankings were used to identify counties in the worst quartile of performance on educational attainment, unemployment, and child poverty. RESULTS: Chi-square analyses show that larger hospitals, teaching hospitals, hospitals that belong to a system, and not-for profit hospitals are significantly and positively correlated with non-health sector collaborative partnerships across one or more of the county indicators of poor socioeconomic conditions. Logistic regression results show that the only significant internal hospital characteristic associated with such partnerships is hospital size, in counties with poor educational attainment and those with high child poverty. CONCLUSION: Larger hospitals are more likely to have the resources and strategic perspectives to address community health in counties with poor socioeconomic conditions.

The impact of center accreditation on hematopoietic cell transplantation (HCT).

There are two voluntary center-accrediting organizations in the USA, the Foundation for the Accreditation of Cellular Therapy (FACT) and core Clinical Trial Network (CTN) certification, that are thought to improve and ensure hematopoietic cell transplantation (HCT) center quality care and certify clinical excellence. We sought to observe whether there are differences in outcomes between HLA-matched and -mismatched HCT by CTN and FACT status. Using the 2008-2010 Center for International Blood & Marrow Transplant Research data we created three center categories: non-FACT centers (24 centers), FACT-only certified centers (106 centers) and FACT and core clinical trial network (FACT/CTN) certified centers (32 centers). We identified patient characteristics within these centers and the relationship between FACT certification and survival. Our cohort consisted of 12 993 transplants conducted in 162 centers. After adjusting for patient and center characteristics we found that FACT/CTN centers had consistently superior results relative to non-FACT and FACT-only centers (P<0.05) especially for more complex HCT. However, non-FACT centers were comparable to FACT-only centers for matched related and unrelated patients. Although FACT status is an important standard of quality control that begins to define improved OS, our results indicate that FACT status alone is not an indicator for superior outcomes.

Factors underlying organizational change in local health care markets, 1982-1995.

This article examines the association between characteristics of local health care market areas in 1982 and the penetration of new organizational forms in those markets in 1995. The Northeast and South exhibit less organizational form development than the West. Local markets with higher population size and greater density of specialty physicians in 1982 are associated with greater proportions of the markets being covered by a wide variety of organizational forms in 1995.

Diversity in health administration doctoral education: alternative scenarios for the future.

Doctoral programs in health administration are characterized by extreme diversity in focus, format, content, and market. The observed diversity reflects two key structural attributes of health administration as a doctoral field of study: 1) its multidisciplinary base, and 2) its small size. These attributes leave doctoral programs vulnerable to a host of external pressures. The field lacks structure and organizing principles at the national or international level, and students, employers, and other stakeholders suffer some damaging consequences. Pressures from the institutional environment are weak and splintered (among the constituent disciplines of health administration), while the technical environment (economic forces such as competition for students and research funding) produces a powerful set of incentives that shape the form and substance of health administration doctoral education. As alternatives to the current hybrid nature of the field, two additional future scenarios are considered: Integration with Health Services Research, and Integration with Business Administration. The future of health administration doctoral education is interdependent with 1) the continued differentiation of health administration as a master's field of study; 2) trends in research funding; and 3) economies in the delivery of small-scale or individually customized doctoral education. At the least, programs and students currently would benefit from more information classifying program breadth and goals and reporting outcomes; more adequate information on careers and placement; and a modicum of workforce planning.

Benchmarking organ procurement organizations: a national study.

OBJECTIVE: An exploratory examination of the technical efficiency of organ procurement organizations (OPOs) relative to optimal patterns of production in the population of OPOs in the United States. DATA SOURCES: A composite data set with the OPO as the unit of analysis, constructed from a 1995 national survey of OPOs (n = 64), plus secondary data from the Association of Organ Procurement Organizations and the United Network for Organ Sharing. STUDY DESIGN: The study uses data envelopment analysis (DEA) to evaluate the technical efficiency of all OPOs. PRINCIPAL FINDINGS: Overall, six of the 22 larger OPOs (27 percent) are classified as inefficient, while 23 of the 42 smaller OPOs (55 percent) are classified as inefficient. Efficient OPOs recover significantly more kidneys and extrarenal organs; have higher operating expenses; and have more referrals, donors, extrarenal transplants, and kidney transplants. The quantities of hospital development personnel and other personnel, and formalization of hospital development activities in both small and large OPOs, do not significantly differ. CONCLUSIONS: Indications that larger OPOs are able to operate more efficiently relative to their peers suggest that smaller OPOs are more likely to benefit from technical assistance. More detailed information on the activities of OPO staff would help pinpoint activities that can increase OPO efficiency and referrals, and potentially improve outcomes for large numbers of patients awaiting transplants.

Hospital-physician relationships in the integrated delivery system: an ethical analysis.

The need to compete for managed care contracts is causing hospitals and physicians to dramatically change how they do business with each other. Most significant is the formation of integrated delivery health-care systems. The emergence of these systems creates an enhanced need for physicians and administrators to better understand what the other actually does. This article examines the new health-care marketplace from both perspectives and how integrated delivery systems affect individual and community patient care, and it offers guidelines for effective hospital-physician relationships within integrated delivery systems.

Strategic adaptation of US rural hospitals during an era of limited financial resources: a longitudinal study, 1983 to 1993.

This research investigated the competing effects of environmental and organizational pressures on rural hospitals' revenue-enhancing and cost-containment strategies from 1993 to 1993. In general, organizational pressures (multihospital system membership and non-government control) exerted more influence than environmental ones. Also, strategies generally were sustained over time and were particularly interdependent with hospitals' maintenance of staffed beds. Strategies did respond to environmental pressures, however, with revenue enhancement associated with local market competition and munificence, and cost containment associated with pressures from Medicare reimbursement.

Hospital development and the performance of organ procurement organizations.

With more than 56,000 patients on the national waiting list for organ transplants and relatively little growth in the number of donors, organ procurement organizations now recognize the need to aggressively market their services and the range of donor procurement opportunities to hospital personnel. This study examines the types and levels of hospital development activities being conducted by organ procurement organizations, the characteristics of organ procurement organizations that are more involved in hospital development, and the relationship between hospital development and organ procurement. Results from a national survey indicate that, as of the mid-1990s, organ procurement organizations had not made major investments in hospital development despite an increased recognition of the importance of these activities. Organ procurement organizations whose directors were more committed to hospital development exhibited higher levels of hospital development activity. Efforts to formalize hospital development activities through the establishment of a hospital development department and evaluation standards were associated with more organs procured per donor.

Hospital response to the implementation of prospective payment.

This research examined the competing effects of regulatory intensity (Prospective Payment System) and inertial pressure on US hospitals' cost of medical materials, shifting of services from inpatient to outpatient settings, size of the administrative component, and use of new technology. Among the expected findings, regulatory intensity was associated with reduced medical material costs, less new technology and a greater administrative component. Inertial pressures were associated with higher medical material costs, more new technology and less shifting of services from inpatient to outpatient settings. It was concluded that US hospitals respond to regulatory pressures within the context of strong inertial forces. The stronger the inertial forces, the less dramatic a hospital's response to regulatory pressures is likely to be.

Nursing entrepreneurship in an era of chaos and complexity.

To adapt to a workplace characterized by chaos and complexity, individual nurses and the profession as a whole must position themselves in a more entrepreneurial stance. We describe the forces in the health care environment that present opportunities for nursing entrepreneurship. Skills and personality traits that promote entrepreneurship are discussed with suggestions for positioning the nursing profession and individual nurses as proactive innovators to satisfy the needs of the new health care marketplace.

How does Catholic hospital sponsorship affect services provided?

Catholic hospitals maintain a significant presence in delivering hospital services in the United States, but little is known about the ways they differ from other ownership forms in similar market environments. This paper analyzes characteristics of Catholic, other private nonprofit, and investor-owned hospitals in metropolitan areas of the United States to identify the extent to which Catholic hospitals differ from other ownership types on three dimensions of mission-driven identity--access, stigmatized, and compassionate care services. Based on 1993 data, Catholic hospitals offered more compassionate care services than other private nonprofit hospitals, and more compassionate care and stigmatized services than investor-owned hospitals, controlling for four market and six organizational characteristics. The results may help Catholic hospitals differentiate their services and help justify their tax-exempt status.

Profession building in the new health care system.

To further the goals of greater legitimacy and power, it is necessary for nursing to abandon many of the profession building strategies it has pursued in the past. We describe the traditional framework for profession building in nursing and some reasons it is no longer effective. In contrast, a contemporary framework for profession building in nursing is presented. Because nursing, like other complex adaptive systems, is strongly anchored by its past trajectory, it will require considerable energy and resources to make the transition.

Building departmental influence in health care organizations.

This article has outlined several steps to follow in assessing and building department influence at the top management levels of health care organizations. Identifying and contributing to resolving the organization's key areas of uncertainty are strategies that have improved the influence of many departments in recent years. Individual strategies, such as developing one's expertise and sharing that expertise with other departments and top management (an example of the "involvement" technique), also are being used daily by effective department managers. Decentralized management, which entails the assignment of greater responsibilities to middle managers, is increasingly popular in health care organizations. This trend will no doubt facilitate the building of departmental influence in organizational decision making. However, the steps outlined in this article can be implemented whether or not top management endorses a decentralized management style. In a critical sense, departmental influence is too important to be left to top management. It is up to department managers to exert their influence for the good of their employees, the organization as a whole, and their own careers.

Birth order in small multihospital systems.

The strategic behaviors of small multihospital systems have received little attention in the literature despite the fact that small systems are the predominant scale among multihospital systems. This study examines one important aspect of small-system strategic behaviors: the birth-order or evolutionary patterns of hospital acquisition. The evolutionary patterns of acquisition are compared across three strategic model types studied elsewhere: local market, investment, and historical. Using data obtained from a variety of sources, local market model systems are found, in the sequence of acquisition, to be significantly different from the other two model types in terms of relative distances of acquisitions from the initiating or parent hospital, the sizes of acquisition hospitals, the complexity of those hospitals, and the likelihood that the acquisitions are located in rural areas. Differences between parents and acquisitions are also significant, as hypothesized, for the market model system types, although they are not generally significant for the other two model types. The findings suggest that the market model represents an important strategic form that may have important implications for the restructuring of hospital markets.

Policy and research on health manpower regulation: never too late to deregulate?

Research on health manpower regulation has reached a consistent conclusion for the last two decades that is likely to carry into the 1990s: deregulate. Research has progressed in recent years, however, and research in the 1990s will be quite different from that of the past two decades. While the battle cry "never too late to deregulate" will continue to be heard, the "easy" targets, those markets with the least extensive or least important information asymmetry, have already been attacked. What is (or should be) finally emerging in the 1990s is a more challenging appraisal of health manpower regulation, one that recognizes greater complexity in health care markets and consumer preferences than has been recognized in past research. Lessons for the 1990s include the need to recognize, accept, and study information asymmetry and its consequences, and to more closely analyze the hypothesis that occupational interest groups, while meeting their self-interest, also may be serving the commonwealth. Such a reorientation leads us to ask different questions of regulation in future research, all directing attention to the informational attributes of markets: (1) How much information asymmetry exists in different health care markets, and how important is it? In which information-asymmetric markets is manpower regulation most likely to benefit consumers? (2) How can information asymmetry between consumers and providers be reduced, thereby facilitating deregulation? (3) How many regulations, of what type, are consumers willing to eliminate, for what benefits? Simplistic policy recommendations are less likely with this new orientation, and there is a great deal of interesting research awaiting health services researchers.

Quasi firms: strategic interorganizational forms in the health care industry.

In response to significant political, governmental, and socioeconomic changes affecting the health care industry, health care organizations are forming a wide variety of loosely coupled interorganizational arrangements. In this article, loosely coupled forms are classified according to the extent to which they are designed to achieve strategic purposes. The quasi firm is defined as a loosely coupled arrangement created to achieve long-lasting and important strategic purposes. Mechanisms that are needed to ensure the continuity of quasi firms are explored, and an agenda for further research is given.

Strategic orientations of small multihospital systems.

Strategic behaviors of organizations can be classified along two dimensions--growth orientations, or patterns of evolution over time, and action orientations, or strategic aggressiveness in undertaking a particular growth orientation. We create measures of growth and action orientations for small multihospital systems and test the validity of the growth and action orientation typologies, using data from a sample of small multihospital systems. Growth and action orientations do appear to exist independently of each other, and they are related to the ownership status of the systems. Not-for-profit and church-other systems exhibit similar strategic orientations, unlike those of Catholic and investor-owned systems.