The role of collegiality in academic review, promotion, and tenure.

Review, promotion, and tenure (RPT) processes at universities typically assess candidates along three dimensions: research, teaching, and service. In recent years, some have argued for the inclusion of a controversial fourth criterion: collegiality. While collegiality plays a role in the morale and effectiveness of academic departments, it is amorphic and difficult to assess, and could be misused to stifle dissent or enforce homogeneity. Despite this, some institutions have opted to include this additional element in their RPT documents and processes, but it is unknown the extent of this practice and how it varies across institution type and disciplinary units. This study is based on two sets of data: survey data collected as part of a project that explored the publishing decisions of faculty and how these related to perceived importance in RPT processes, and 864 RPT documents collected from 129 universities from the United States and Canada. We analysed these RPT documents to determine the degree to which collegiality and related terms are mentioned, if they are defined, and if and how they may be assessed during the RPT process. Results show that when collegiality and related terms appear in these documents they are most often just briefly mentioned. It is less common for collegiality and related terms to be defined or assessed in RPT documents. Although the terms are mentioned across all types of institutions, there is a statistically significant difference in how prevalent they are at each. Collegiality is more commonly mentioned in the documents of doctoral research-focused universities (60%), than of master's universities and colleges (31%) or baccalaureate colleges (15%). Results from the accompanying survey of faculty also support this finding: individuals from R-Types were more likely to perceive collegiality to be a factor in their RPT processes. We conclude that collegiality likely plays an important role in RPT processes, whether it is explicitly acknowledged in policies and guidelines or not, and point to several strategies in how it might be best incorporated in the assessment of academic careers.

Improving the measurement of health system output growth.

National income accounting practice is to weight health service activities by their cost so that they can be aggregated into an output index. Quality changes are ignored. We propose an 'ideal' value weighted output index in which the value attached to each output reflects its contribution to health outcomes and other characteristics valued by patients. Calculation of the index for the health system as a whole is currently infeasible because of a lack of data, especially on health outcomes. We demonstrate alternative ways of combining health outcome data with existing information on post-treatment survival, life expectancy and waiting times to construct quality adjusted cost weighted and health outcome weighted indices for a small set of hospital activities for which there are health outcome data.

The effects of expanding patient choice of provider on waiting times: evidence from a policy experiment.

Long waiting times for inpatient treatment in the UK National Health Service have been a source of popular and political concern, and therefore a target for policy initiatives. In the London Patient Choice Project, patients at risk of breaching inpatient waiting time targets were offered the choice of an alternative hospital with a guaranteed shorter wait. This paper develops a simple theoretical model of the effect of greater patient choice on waiting times. It then uses a difference in difference econometric methodology to estimate the impact of the London choice project on ophthalmology waiting times. In line with the model predictions, the project led to shorter average waiting times in the London region and a convergence in waiting times amongst London hospitals.

The role of competition in health care: a Western European perspective.

The Federal Trade Commission and Department of Justice 2004 report Improving Health Care: A Dose of Competition expresses a clear allegiance to competition as the organizing principle for health care. In Europe, by contrast, the key organizing principle of health care systems is solidarity. Solidarity means that all have access to health care based on medical needs, regardless of ability to pay. This is not to say that competition is not important in Europe, but competition must take place within the context of solidarity. This article critiques the report from a European perspective, describes the role of competition in Europe (focusing in particular on European Union law), and suggests that the United States could learn from the European perspective.

What's the evidence that NICE guidance has been implemented? Results from a national evaluation using time series analysis, audit of patients' notes, and interviews.

OBJECTIVES: To assess the extent and pattern of implementation of guidance issued by the National Institute for Clinical Excellence (NICE). DESIGN: Interrupted time series analysis, review of case notes, survey, and interviews. SETTING: Acute and primary care trusts in England and Wales. PARTICIPANTS: All primary care prescribing, hospital pharmacies; a random sample of 20 acute trusts, 17 mental health trusts, and 21 primary care trusts; and senior clinicians and managers from five acute trusts. MAIN OUTCOME MEASURES: Rates of prescribing and use of procedures and medical devices relative to evidence based guidance. RESULTS: 6308 usable patient audit forms were returned. Implementation of NICE guidance varied by trust and by topic. Prescribing of some taxanes for cancer (P < 0.002) and orlistat for obesity (P < 0.001) significantly increased in line with guidance. Prescribing of drugs for Alzheimer's disease and prophylactic extraction of wisdom teeth showed trends consistent with, but not obviously a consequence of, the guidance. Prescribing practice often did not accord with the details of the guidance. No change was apparent in the use of hearing aids, hip prostheses, implantable cardioverter defibrillators, laparoscopic hernia repair, and laparoscopic colorectal cancer surgery after NICE guidance had been issued. CONCLUSIONS: Implementation of NICE guidance has been variable. Guidance seems more likely to be adopted when there is strong professional support, a stable and convincing evidence base, and no increased or unfunded costs, in organisations that have established good systems for tracking guidance implementation and where the professionals involved are not isolated. Guidance needs to be clear and reflect the clinical context.

Is patient choice an effective mechanism to reduce waiting times?

In many countries, patient choice is a routine part of the normal healthcare system. However, many choice initiatives in secondary care are part of policies aimed at reducing waiting times. This article provides evidence on the effectiveness of patient choice as a mechanism to reduce waiting times within a metropolitan area. The London Patient Choice Project was a large-scale pilot offering patients on hospital waiting lists a choice of alternative hospitals with shorter waiting times. A total of 22 500 patients were offered choice and 15 000 accepted. The acceptance rate of 66% was very high by international standards. In this article we address two questions. First, did the introduction of choice significantly reduce waiting times in London relative to the rest of the country where there was no choice? Second, how were the waiting times of London patients not offered choice affected by the choice regime? We examine the evidence on these issues for one specialty, orthopaedics. A difference-in-difference analysis is used to compare waiting times for hospitals within London before and after the introduction of choice. Although there was a small but significant reduction in waiting times in London relative to other areas where there was no patient choice, the main effect of the choice regime was to produce convergence of mean waiting times within London. Convergence was achieved by bringing down waiting times at the hospitals with high waiting times to the levels that prevailed in hospitals with low waiting times. This represented a clear improvement in equity of access, an important objective of the English National Health Service.

Variation in unit costs of hospitals in the English National Health Service.

OBJECTIVES: In England, the Department of Health places high priority on reducing the variation in unit costs of National Health Service (NHS) hospitals. Efficiency targets are set for hospitals to create incentives for relatively high cost hospitals to reduce their costs and shift performance closer to that of their lower cost counterparts. We examine empirically the dispersion in unit costs to assess the extent of variation in the productivity of hospitals and trends over time. METHODS: We use econometric panel data techniques on data from 235 NHS acute hospital trusts over a six-year period, 1994/95 to 1999/00, supplemented with information from semi-structured interviews with key individuals in hospitals and purchasing bodies. RESULTS: There appears to have been no reduction in variation during this period. Relative unit costs for individual trusts also appear stable, with little movement from relatively high cost to low cost. Judging from limited quantitative evidence outside health care, the variation in costs between NHS hospitals may be comparatively low. CONCLUSIONS: Given all the other aspects of hospital performance that government is seeking to change, reduction in the dispersion of unit costs per se should not be a major policy objective. It is far more important to examine variation in quality-adjusted unit costs.

Hospital efficiency targets.

Cost-efficiency targets, used to encourage downward pressure on hospital unit costs, have been employed within the UK NHS for many years. There has been considerable speculation that these targets create incentives to reduce beds and increase occupancy rates at the expense of holding spare capacity to accommodate fluctuations in emergency admissions. This research used panel data for the period 1994/1995-1999/2000, supplemented by a series of semi-structured interviews, to explore the strategies Trusts employ to reduce unit costs. No relationship could be found between published targets and changes in unit costs, nor that targets were successful in reducing the dispersion of unit costs over time. Interviews revealed that efficiency gains required of Trusts, usually dictated by the local health economy, often bore no correspondence to the national or regional published targets. Results further indicated that contrary to prior speculation, Trusts divide into two distinct groups, those with high occupancy rates and those with a high proportion of free beds to accommodate emergencies, with Trust characteristics displaying stability over time. A pressing need for future work is the development of measures to encourage efficiency that take account of quality improvement.