Changes in the structure, composition, and activity of hospital governing boards, 1989-1997: evidence from two national surveys.

Hospital governance arrangements affect institutional policymaking and strategic decisions and can vary by such organizational attributes as ownership type/control, size, and system membership. A comparison of two national surveys shows how hospital governing boards changed in response to organizational and environmental pressures between 1989 and 1997. The magnitude and direction of changes in (1) board structure, composition, and selection; (2) CEO-board relations; and (3) board activity, evaluation, and compensation are examined for the population of hospitals and for different categories of hospitals. The findings suggest that hospital boards are engaging in selective rather than wholesale change to meet the simultaneous demands of a competitive market and traditional institutional orientations to community, the disenfranchised, and philanthropic service. Results also suggest parallel increases in collaboration between boards and CEOs and in board scrutiny of CEOs.

The effects of reengineering: fad or competitive factor?

Healthcare organizations have often participated in managerial innovations that have promised to revolutionize their operations (e.g., management by objectives, quality circles, total quality management, and reengineering). Historically, such managerial innovations began with a few devout adherents, snowballed into widespread acceptance, and then faded as their popularity waned. This cycle of managerial adoption generally has been complicated by a lack of a consistent, clear definition of the innovation and little or no evaluation of its organizational effects. This article examines a current managerial innovation, reengineering, that after widespread adoption has now begun to fall out of favor with many executives. A clear, practical definition of reengineering is first offered, followed by an evaluation of the effect of reengineering on competitive hospital costs. Finally, factors that influence the results of reengineering are explored. Overall, reengineering did not statistically improve a hospital's cost position; however, we suggest that providing clear and consistent feedback, codifying the reengineering process, and involving executives in core changes are key means for improving reengineering outcomes. Specific examples of how these factors may be used to facilitate reengineering are provided. Reengineering may still be beneficial if it is properly implemented.

Layers of leadership. The challenges of collaborative governance.

If your goal is the health of a population, you can't do it alone. But working with partners requires special skills, not the least which is the ability to share control and put trust in others--in other words, collaborative governance. Here's some guidance for getting to this next level.

Community experiments in action: developing community-defined models for reconfiguring health care delivery.

In the United States, health system change occurs as the interaction of politics and policies is played out and pushed forward by individuals and organizations taking action in their local communities and markets. This article provides context and descriptive information about a model of local health care reform that is being tested in twenty-five communities around the nation. We introduce a value-based model of community-responsive health system change, the Community Care Network (CCN) Vision. We briefly describe a national demonstration program that is testing this model between January 1996 and the end of 1998. We offer several ways of looking at the local and regional multisectoral partnerships that are attempting to demonstrate the CCN vision. We look at their composition, the kinds of actions in which they are engaged, several example challenges and responses to them, and we give several examples of schools becoming part of the health system of last resort. Finally, we present some early ideas on how the local actions described here may influence (and be influenced by) the political and policy contexts in which they occur.

Conditions affecting rural hospital specialization, conversion, and closure: a case-based analysis of threat and change.

The purpose of this analysis is to increase understanding of how and why rural hospitals change, with an eye toward the relevance of these questions to overall access and quality in the rural community. This study reports the threats that precipitated three major classes of organizational change (specialization, conversion, and closure) in 16 rural hospital cases. The authors identify the types and levels of threat faced by the case hospitals and examine how different threat situations may lead toward different classes of change. Conversions and closures typically seem to result from moderate- or high-threat situations. Specializations seem to result from low- or moderate-threat situations.

Hospital reorganization after merger.

Major organizational changes among hospitals, like system affiliation, merger, and closure, would seem to offer substantial opportunities for hospitals and health systems to be strategic in the local reconfiguration of health services. This report presents the results of a unique survey on what happened to hospitals after mergers occurring between 1983 and 1988, inclusive. Building on an ongoing verification process of the American Hospital Association, surviving institutions from all 74 mergers that occurred during the study frame were surveyed in the fall of 1991. Responses were received from 60 of the 74 mergers (81%), regarding the primary, postmerger use of the hospitals involved. Topics surveyed included the premerger competition between the hospitals and in their environment, and what happened to the hospitals after their mergers. Mergers frequently served to convert acute, inpatient capacity to other functions, with less than half of acquired hospitals continuing acute services after merger. In the context of health care reform, mergers may offer an expeditious way locally to restructure health services. Evidence on the postmerger uses of hospitals and about the reasons given for merger suggests that mergers may reflect two general strategies: elimination of direct acute competitors or expansion of acute care networks.