An international constant: The crucial role of policy competence in the effective strategic management of health services organizations.

In view of the pervasive impact of government policies on health services organizations worldwide, policy competence is an increasingly important element in the successful strategic management of these organizations. This article discusses a conceptual perspective of policy competence, including three intertwined components of this competence. Firstly, policy competence is built upon understanding the government policies that affect health services organizations, as well as understanding the process by which such policies are made and the forces that can affect the process and its outcomes. Secondly, policy competence helps strategic managers anticipate and lead responses of health services organizations to the opportunities and threats emanating from their policy environments. Finally, policy competence assists strategic managers to participate effectively in shaping the policy environments of health services organizations to the benefit of these organizations.

Managerial competence at senior levels of integrated delivery systems.

The advent of integrated delivery systems (IDSs) in the healthcare industry has changed much about the work involved in running many healthcare organizations. As a result of these changes, senior healthcare managers in IDSs need different skills and knowledge (competencies) than managers of other healthcare systems. The work of managers is changed by the shift to more organizational integration in the healthcare industry because they become responsible for coordinated continuation of services, accountable for the overall health status of the populations they serve, and involved in more complex organizational structures. The article identifies six distinct managerial competencies--conceptual, technical managerial/clinical, interpersonal/collaborative, political, commercial, and governance--and describes how they relate to an IDS senior manager's successful work performance. The implications of these competencies are considered for practicing senior managers in IDSs, as well as those who aspire to such positions, and those who help educate them.

Managerial roles in contemporary hospital departments.

The emergence of managed care and more integrated healthcare delivery systems brings new challenges to managers in hospital departments. Managers can effectively respond to these challenges by assuming three roles--those of strategist, designer, and leader--described in the following article.

The divergence of federal and state policies on the charitable tax exemption of nonprofit hospitals.

Nonprofit hospitals have traditionally enjoyed charitable exemption from real estate taxes because they provide specific social benefits. However, in the past three decades, major health policy changes at the federal level--most significantly, implementation of the Medicare and Medicaid programs--have weakened this rationale. Federal tax regulations during this period have changed in ways that complement these federal health programs and the accompanying federal interests in encouraging efficiency and performance uniformity among hospitals. States and local governments, however, have different interests, and these may favor a strict set of tax exemption standards that disregard efficiency and elevate the importance of a measurable level of charitable service. Their divergent policies rest on a fundamental value judgment about whether nonprofit hospital care is intrinsically charitable or not. Increasingly, this judgment may be forced upon state courts and legislation by local governments seeking new tax revenues through the elimination of hospitals' exemption from real estate taxes.

Organizational leadership in hospitals.

Hospitals face very dynamic environments and must meet diverse needs in the communities they serve and respond to multiple expectations imposed by their stakeholders. Coupled with these variables, the fact that leadership in these organizations is a shared phenomenon makes organizational leadership in them very complicated. An integrative overview of the organizational leadership role of CEOs in hospitals is presented, and determinants of success in playing this role are discussed.

An integrated model for continuous quality improvement and productivity improvement in health services organizations.

The health services paradigm with respect to quality has shifted to that of conformance to requirements (the absence of defects) and fitness for use (meeting customer expectations and needs). This article presents an integrated model of continuous quality improvement (CQI) (often referred to as total quality management) and productivity improvement for health services organizations. It incorporates input-output theory and focuses on the CQI challenge--"How can we be certain that we do the right things right the first time, every time?" The twin pillars of CQI are presented. Achievement of both will result in productivity improvement and enhancement of the health services organization's competitive position.

A cost-containment agenda for academic health centers.

Many people, particularly the business leaders and legislators who must find ways to pay most of the nation's health care bill, consider current and projected rates of health expenditure growth a serious problem. Effective solutions to this intractable problem have thus far eluded policymakers. The problem has complex and intertwined roots; its amelioration will require action by many players in the health sector. Academic health centers (AHCs), as the breeding ground for so much of the technological and organizational base of medical care and as the training ground for so many of the professionals in the health sector, bear some of the responsibility for the rate of health expenditure growth. Thus, they have a clear responsibility to help develop an effective response to this vexatious challenge. Three specific recommendations for steps the leaders of AHCs can take to assist in slowing the rate of growth in health care expenditures form the basis for this article.

Interorganizational linkages in the health sector.

A key element in the success of organizations in the health sector is the maintenance of effective interorganizational linkages with interdependent organizations. A conceptual framework is posited of three general classes of mechanisms through which these linkages are managed.

American health policy in the year 2000.

While predictions of future health policy in the United States cannot be fully prescient, they can be informed by two important relationships. The most consequential of these is that policy is inevitably developed to achieve policy objectives. If future objectives are known, predictions of policy prescriptions to achieve them can be more rational. Secondly, since future policy is likely to build incrementally upon past policy, a grasp of the evolutionary path of the nation's health policy can enlighten projections. These relationships are used to predict a possible scenario of health policy in the United States through the 1990s. Health policy in the year 2000 is predicted to be barely distinguishable from that of the present. An admixture of regulatory and market-based policies are predicted to continue to be used as policymakers seek simultaneous achievement of access, quality, and cost-effectiveness objectives.

The ethical imperative in health services governance and management.

Increasingly, administrative and biomedical ethical issues affect decision making in health services organizations. Although the ethics of biomedical decision making affect governance and management, this article is limited to administrative ethics: fiduciary duty, conflicts of interest, confidential information, resource allocation, and consent. Those who govern and manage health services organizations face an ethical imperative: They are moral agents with an independent duty to protect patients and further their interests. This duty is separate from any existing between care givers--such as physicians--and patients. It may complement other relationships, but it is always present. This imperative will become more difficult to attain. The potential conflict between economic and patient interests lies close to the surface in the patient care relationship, and maintaining it undoubtedly will be exacerbated by competitive pressures. The ethical implications of this conflict for those who govern and manage health services organizations are enormous.

Design and behavioral strategies for cost containment and quality assurance.

The design and behavioral strategies for cost containment and quality assurance in hospitals are related closely to similar issues in larger organizations. Using a taxonomy developed by Georgopoulos it is possible to develop a research outline examining design and behavioral strategies. The most important determinant of the shape and direction of these strategies in the VA medical care system appears to be its environmental constraints. For each of the seven categories presented by Georgopoulos, the nature of the VA is discussed and specific research questions are proposed. The seven categories include adaptation, allocation, coordination, integration, strain, output, and maintenance.

Health care delivery: delivery prospers in diversity.

The health care delivery literature of 1979 evaluated HMOs and long-term, ambulatory, and home care, glanced at the hospice movement, and found that variety is here to stay.

A conceptual framework for understanding the multihospital arrangement strategy.

Participation in a multihospital arrangement is part of a strategy adopted by many hospital managers in an effort to achieve a higher level of organizational stability than is available to them when their organizations remain completely autonomous and independent.