The role of performance referents in health services organizations.

Health care executives rely on a variety of information sources to evaluate organizational performance. This is because outcomes take on meaning only when compared to referents, or standards of comparison. Although performance referents are widely acknowledged to be important, consideration of their relevance to health services management has been minimal. To address this need, we draw on organizational theories and observations from health services organizations to describe the use of performance referents and to provide insights about the possible effects of performance referent selection on strategic choices and performance.

Coordination of care: stage one in assessing rural managed care.

This article provides a framework for assessing the role of managed care in optimizing the mix of services to advance the health of rural populations. Mindful of limited organizational and financial resources in many rural areas, such assessments must carefully weigh the contribution of these resources to effective management of care. The framework presented emphasizes the different populations and different health conditions that a variety of care coordinators may address more or less effectively. Attention to issues having to do with organizational architecture and financial accountability of managed care should flow from prior to consideration of care management.

Electronic medical records: are physicians ready?

The use of electronic medical records (EMR) in healthcare organizations will require substantial changes in the way physicians and their staff provide patient care. This study is the first part of a larger study assessing factors that influence successful implementation of EMR in ambulatory care settings. The purposes of this study were to identify specific attitudes or factors that should be targeted before implementating an EMR project, and demonstrate empirical support for a model of perceived usefulness of EMR. We found that computer experience, computer anxiety, and perceptions of organizational support predict the degree to which physicians and mid-level practitioners view the EMR effort positively. Strategies for the successful management of EMR implementation include engaging the physicians and practitioners in computer activities prior to implementation and providing strong organizational support before and during the redesign effort. Acceptance of EMR by physicians and their support staff is essential if computerization is to be successful, yet anecdotal reports of resistance and negative attitudes are frequently reported. Empirical studies indicate that physicians have not yet embraced this technology. As part of strategic planning and deployment of a computerized patient record, attitudes of end-users must be assessed. Using an integrative framework from the job design literature and management information sciences, we propose that multiple factors influence attitudes toward EMR, offer a conceptual model of end-user acceptance, and present findings from an empirical test of our model.

The influence of governmental policy on community health partnerships and community care networks: an analysis of three cases.

This is a comparative analysis of hospitals' efforts in three communities to pursue collaborative ventures to advance community health. The events occurred over a two-year period characterized by increasing market competition and national debate about comprehensive health care financing reform. The study objectives are to better understand factors that contributed to the initiation of the collaborative efforts, and factors that sustained, hindered, or thwarted these efforts. The study explores how the collaborative ventures in these three communities fared in the face of multiple and conflicting policies and the simultaneous creation of larger, competing health systems. A number of concluding generalizations address the impact of interorganizational dynamics and public policy initiatives on community health partnerships.

Advancing community health through community health partnerships.

Improving a community's health is a key goal of health services organizations. Effectively pursuing that goal requires health services organizations to create partnerships with other organizations to help identify community health needs and to create and carry out programs that bring together community members and needed health services. Drawing on community systems concepts and a recent study of community health partnership efforts in three cities, this article provides a framework for such partnerships. Types of partnerships described include: Community action partnerships, in which the partnership forms to address a specific problem or pursue a specific opportunity. Community organization partnerships, in which a set of organizations in a similar service sector agree to collaborate for mutually agreed upon goals; and Community development partnerships, in which a partnership attempts to increase participation by people and organizations in collaborative activities that advance the community on multiple fronts or that contribute to community assets and services in multiple areas. The article also describes how the pressures to create large integrated delivery systems can affect creation of partnerships to improve community health. Increasingly, healthcare leaders are being held accountable for the health of communities they serve. When creating partnerships for community health and carrying out health-improvement activities, leaders should be aware of and respond to four key dimensions of accountability: political accountability, commercial accountability, clinical/patient accountability, and community accountability.

Pre- and post-control model research on end-users' satisfaction with an electronic medical record: preliminary results.

This study reports early results of a project that addresses the process of computerizing medical records in multiple ambulatory care sites of a health system. The study focuses on end-user attitudes before, during, and after implementation, through the use of questionnaires, interviews, and participant observation. Knowledge about end-user attitudes prior to computerization may contribute to planning for the training and implementation process. Tailoring these processes to meet the varying needs of user groups may result in a higher level of functional use of the system and less stress to the persons involved in its use. One implementation plan may not work for all sites when there are differences in size of the clinic, work flow patterns prior to implementation, and computer experience among personnel. Preliminary analysis of post-installation questionnaires and interviews six months after the installation point to a number of areas that might be usefully addressed in future installation efforts.

Do the right thing. When it comes to your community, do you know what that is? Roundtable discussion.

What is the health care organization's responsibility to maintaining a healthy community, and how does the board fit into that role? Has the field's understandable fixation on costs and the penetration of managed care into most markets affected that role? Leaders of both for-profit and not-for-profit organizations often believe that they are fulfilling their community obligations as long as they provide uncompensated care to the indigent and the uninsured. But is that really being accountable to the community? And if it's not, then what is community accountability? The American Hospital Association's Division of Trustee Leadership and Trustee magazine posed these questions to 13 health care and community leaders last December. Their different perspectives provide for some surprising answers.

Understanding hospital referrals to home health agencies.

Using resource dependency theory and transaction-cost economics theory, we examined the simultaneous effects of a vertical integration strategy and environmental complexity on home health agency (HHA) referrals by hospitals. Discharge data for calendar year 1990 from 61 Pennsylvania hospitals were analyzed. Using hospital ownership of home health agencies and urban versus rural location as the primary independent variables, a logistic regression model calculated the probability of HHA referral, after controlling for long-term care beds and patient characteristics. Results showed that HHA ownership was a significant predictor of home health referrals for both rural and urban hospitals, although the effect was greater for urban hospitals. These results suggest that hospitals are actively using referrals to home healthcare in response to environmental pressures. As these pressures increase, hospitals will benefit from tight linkages with home health providers.

Linkage strategies of rural hospitals--independent hospital, local health system, and/or externally linked facility.

Strategies associated with ownership or management of a range of health service facilities, service sharing, and other coordination activities are important to the viability of many rural hospitals. This article articulates a set of linkage strategies employed by rural hospitals. Such strategies and their environmental and organizational correlates are assessed in a sample of 46 rural Pennsylvania hospitals.

Validation of a nutritional screen in children with respiratory syncytial virus admitted to an intensive care complex.

OBJECTIVE: We sought to validate a nutritional screen that was easy to perform and accurate in identifying pediatric patients at risk for adverse clinical outcomes based on their nutritional status. METHODS: Twenty-five consecutive patients admitted to our pediatric intensive care complex between July 1992 and July 1993 with a primary diagnosis of respiratory syncytial virus infection were evaluated. Nutritional screen parameters included historical (disease and condition), growth (anthropometrics), and laboratory (hemoglobin, lymphocyte count, and albumin) data. Outcome measures included days in the hospital, days of mechanical ventilation, days not fed enterally, and days receiving oxygen. RESULTS: Regression analysis indicated that a score of 5 or less signified a low risk of adverse outcome and a score of greater than 5 signified a high risk. Eleven of 25 patients had low scores, and 14 of 25 had high scores. All outcome measures differed significantly between the low- and high-risk groups: median number of days in the hospital, 7 and 13.5, respectively; median number of days of ventilation, 0 and 8.5, respectively; median number of days without enteral feeding, 3 and 8.5, respectively; and median number of days receiving oxygen, 4 and 20, respectively. CONCLUSIONS: Our nutritional screen identifies patients in the pediatric intensive care complex with respiratory syncytial virus at increased risk for adverse outcome. This screen may be useful in identifying pediatric patients at risk for adverse clinical outcomes from other medical diagnoses.

Dimensions of accountability for not-for-profit hospitals and health systems.

This article examines four dimensions of accountability as they apply to not-for-profit hospitals and health systems: political accountability, particularly relating to the retention of tax-exempt status; commercial accountability associated with the nonprofit hospital's role of selling low cost and high value health services to a variety of commercial payers; community accountability in terms of addressing community health and other social needs, and clinical/patient accountability in terms of access and quality outcomes.

Health care markets as interorganizational fields: a conceptual perspective.

This paper examines the interorganizational (IO) field approach to the study of local health care markets. An IO field conceptualization focuses attention on organizational behavior and interorganizational relations among providers and purchasers and other health care organizations relevant to the field. This perspective is suitable for guiding evaluations of the multiple effects of pro-competition or regulative interventions on health care markets.

Sales force development in health services organizations; a boundary spanning perspective.

Sales force development is of growing importance to HSOs in their increasingly competitive and heterogenous health care markets. There is always some danger that, under such circumstances, strategies new to HSOs will be adopted without sufficient attention to how they function and how they might best be integrated into the organization's overall mission. The sales force is becoming an important part of administration in the modern HSO. Ensuring that sales personnel effectively meet the needs of clients and of all relevant units of their HSO calls for attention to a number of concerns raised in organization-environment theory. Concepts from the literature on organizational boundaries and boundary spanning used here organize and illuminate major issues in sales force development. The approach taken is one which underscores the importance of these issues, illustrates some possible responses, and encourages HSO administrators to reflect on organizational implications of sales force development. The perspective offered provides a base for more detailed design considerations in planning and implementing a sales force.

A micro-computer based approach to curriculum evaluation.

The wide range of content appropriate to graduate study in health administration calls for an effective means to analyze the structure and content of the graduate program curriculum. This article presents a curriculum analysis matrix approach to curriculum evaluation. The matrix approach uses spreadsheet software to carry the analysis through several iterations, involving faculty throughout the process. A case illustration is presented. This approach is deemed relevant to accreditation self-studies and to any other periodic curriculum reviews.