Improving the Effectiveness of Root Cause Analysis in Hospitals.

Improving patient safety within hospitals has become a major focal point for administrative and clinical action. Root Cause Analysis (RCA) is an analytical tool used by hospitals in quality improvement and patient safety efforts. While hospitals have widely embraced RCA, the effectiveness of the RCA process has been questioned in recent years. Based on a literature review and feedback from practicing administrators, this paper identifies current barriers to the effectiveness of the RCA process, and suggests actions to overcome them. A more effective RCA process will enable hospitals to establish a safer and more trustworthy care environment for patients.

Organizational Factors Associated With Quality Perinatal Care.

Perinatal care has been recognized as an integral part of ensuring quality health care in hospitals, and the focus on perinatal care quality is increasing. The previous hospital literature has focused much attention on measuring and improving quality of care generally, but recently there has been a call for a more comprehensive approach to measuring quality in the perinatal care setting. The perinatal literature is limited in addressing the association between organizational factors and perinatal quality. Using chart audit data for more than 10 000 maternity patients, we used multiple regression analysis to examine the association of organizational factors and perinatal quality of care. Findings show that ownership, setting (location), and hospital policy on infant feeding were statistically significant. Findings suggest that it is important that hospital boards and leaders develop and implement organizational policies to enhance perinatal quality of care.

Going Beyond Compliance: A Strategic Framework for Promoting Information Security in Hospitals.

In the past decade, public and private organizations have experienced a significant and alarming rise in the number of data breaches. Across all sectors, there seems to be no safe haven for the protection of information. In the health care industry, the trend is even worse. Information security is at an unbelievable low point, and it is unlikely that government oversight can fix this issue. Health care organizations have ramped up their approaches to addressing the problem; however, these initiatives are often incremental rather than transformational. Hospitals need an overall organization-wide strategy to prevent breaches from occurring and to minimize effects if they do occur. This article provides an analysis of the literature related to health information security and offers a suggested strategy for hospital administrators to follow in order to create a more secure environment for patient health information.

Hospital Acquisitions Before Healthcare Reform.

The hospital industry has experienced increased consolidation in the past 20 years. Since 2010, in particular, there has been a large rise in the number of hospital acquisitions, and observers have suggested this is due in part to the expected impact of federal healthcare reform legislation. This article reports on a study undertaken to identify the market, management, and financial factors affecting acute care, community hospitals acquired between 2010 and 2012. We identified 77 such hospitals and compared them to other acute care facilities. To assess how different factors were associated with acquisitions, the study used multiple logistic regressions whereby market factors were included first, followed by management and financial factors. Study findings show that acquired hospitals were located in markets with lower rates of preferred provider organization (PPO) penetration compared with nonacquired hospitals. Occupancy rate was found to be inversely related to acquisition rate; however, case-mix index was significantly and positively related to a hospital's being acquired. Financial factors negatively associated with a hospital's being acquired included age of plant and cash flow margin. In contrast to the findings from earlier studies of hospital acquisitions, our results showed that acquired hospitals possessed newer assets. However, similar to the findings of other studies, the cash flow margin of acquired hospitals was lower than that of nonacquired facilities.

Early Careerist Interest and Participation in Health Care Leadership Development Programs.

Health care organizations are increasingly embracing leadership development programs. These programs include a variety of specific activities, such as formally structured leadership development, as well as mentoring, personal development and coaching, 360-degree feedback, and job enlargement, in order to increase the leadership skills of managers and high-potential staff. However, there is a lack of information on how early careerists in health care management view these programs and the degree to which they participate. This article reports on a study undertaken to determine how early careerists working in health care organizations view leadership development programs and their participation in such programs offered by their employers. Study findings are based on a survey of 126 early careerists who are graduates of an undergraduate health services administration program. We found varying levels of interest and participation in specific leadership development activities. In addition, we found that respondents with graduate degrees and those with higher compensation were more likely to participate in selected leadership development program activities. Implications of study findings for health care organizations and early careerists in the offering of, and participation in, leadership development programs are discussed.

A profile of hospitals with leadership development programs.

Community hospitals face increasing organizational and environmental complexities that challenge effective leadership. Hospitals are embracing leadership development programs in efforts to ensure leadership talent. While prior literature has described the intent and availability of these programs, the characteristics and performance of hospitals having such programs and their associated market characteristics have not been fully addressed. This article identifies significant differences in organizational, operational, performance, and market factors that are associated with hospitals offering a leadership development program, compared with those hospitals lacking such a program. The authors used American Hospital Association Survey data for 2008, the Area Resource File, and Centers for Medicare & Medicaid data to identify hospitals with and without leadership development programs and analyzed the differences for a number of organizational, operational, performance, and market variables. Findings indicate that hospitals having leadership development programs were large-bed-size facilities, had not-for-profit ownership, were system affiliated, were located in metropolitan statistical areas, and were teaching affiliated facilities. These hospitals also generated higher patient discharges, had higher occupancy, and had a longer average length of stay, compared with hospitals without such programs. In addition, these hospitals had higher net patient revenue per adjusted discharge and higher total profit margins relative to the comparison group.

Hospital compliance with a state unfunded mandate: the case of California's Earthquake Safety Law.

Abstract In recent years, community hospitals have experienced heightened regulation with many unfunded mandates. The authors assessed the market, organizational, operational, and financial characteristics of general acute care hospitals in California that have a main acute care hospital building that is noncompliant with state requirements and at risk of major structural collapse from earthquakes. Using California hospital data from 2007 to 2009, and employing logistic regression analysis, the authors found that hospitals having buildings that are at the highest risk of collapse are located in larger population markets, possess smaller market share, have a higher percentage of Medicaid patients, and have less liquidity.

The impact of HCA's 2006 leveraged buyout on hospital performance.

Leveraged buyout (LBO) arrangements are a reorganization strategy whereby a firm assumes a substantial amount of debt to buy back its publicly held stock to become privately held. LBOs offer a firm several advantages and have the potential to increase efficiency. In the past 20 years, several healthcare firms have engaged in LBOs, but the literature on performance changes in healthcare organizations as a result of an LBO is limited. In this article, we report on a study that examined the performance of Hospital Corporation of America (HCA) hospitals before and after the LBO that was initiated in 2006. We used data from the Medicare Hospital Cost Report Information System and analyzed data from 130 HCA hospitals and 490 comparison hospitals. Findings show that HCA hospitals reduced expenses and their number of full-time equivalents (FTEs) relative to local competitor hospitals. HCA hospitals' cash-flow-margin ratio was substantially higher when adjusted for its local competing hospitals at the beginning of the LBO as well as at end of the LBO. When compared to local hospitals, HCA hospitals had a significant decrease in their capital investment in fixed assets from 2006 to 2009. These findings underscore the effectiveness of HCA's management strategies to repay debt and increase the value of the company, and they are informative for healthcare firms and their managers who are considering LBOs.

Organizational and market factors associated with leadership development programs in hospitals: a national study.

Effective leadership in hospitals is widely recognized as the key to organizational performance. Clinical, financial, and operational performance is increasingly being linked to the leadership practices of hospital managers. Moreover, effective leadership has been described as a means to achieve competitive advantage. Recent environmental forces, including reimbursement changes and increased competition, have prompted many hospitals to focus on building leadership competencies to successfully address these challenges. Using the resource dependence theory as our conceptual framework, we present results from a national study of hospitals examining the association of organizational and market factors with the provision of leadership development program activities, including the presence of a leadership development program, a diversity plan, a program for succession planning, and career development resources. The data are taken from the American Hospital Association's (AHA) 2008 Survey of Hospitals, the Area Resource File, and the Centers for Medicare & Medicaid Services. The results of multilevel logistic regressions of each leadership development program activity on organizational and market factors indicate that hospital size, system and network affiliation, and accreditation are significantly and positively associated with all leadership development program activities. The market factors significantly associated with all leadership development activities include a positive odds ratio for metropolitan statistical area location and a negative odds ratio for the percentage of the hospital's service area population that is female and minority. For-profit hospitals are less likely to provide leadership development program activities. Additional findings are presented, and the implications for hospital management are discussed.

Interest in long-term care among health services administration students.

The aging of the population has created increased opportunities for health administrators in long-term care. This study consisted of a cross-sectional survey of 68 undergraduate health services administration students to explore factors related to interest in a career in long-term care administration. One third expressed interest working in the field. Experience in long-term care settings, quality of contact with unrelated older adults, satisfaction working with the elderly, and confidence in the ability to work in the field were positively associated with interest in long-term care administration. The findings have important implications for experiential learning in health administration programs.

Analysis of cash flow in academic medical centers in the United States.

PURPOSE: To examine cash flow margins in academic medical centers (AMCs; i.e., teaching hospitals) in an effort both to determine any significant differences in a set of operational and financial factors known to influence cash flow for high- and low-cash-flow AMCs and to discuss how these findings affect AMC operations. METHOD: The authors sampled the Medicare cost report data of 103 AMCs for fiscal years 2005, 2006, and 2007, and then they applied the t test to test for significant mean differences between the two cash flow groups across operational and financial variables (e.g., case mix, operating margin). RESULTS: Compared with low-cash-flow AMCs, high-cash-flow AMCs were larger-bed-size facilities, treated cases of greater complexity, generated higher net patient revenue per adjusted discharge, served a significantly lower percentage of Medicaid patients, had significantly higher average operating profit margins and cash flow margin ratios, possessed a higher number of days of cash on hand, and collected their receivables more quickly. CONCLUSIONS: Study findings imply that high-cash-flow AMCs were earning higher cash flow returns than low-cash-flow AMCs, which may be because high-cash-flow AMCs generate higher patient revenues while serving fewer lower-paying Medicaid patients.

HealthSouth's inpatient rehabilitation facilities: how does their performance compare with other for-profit and nonprofit inpatient rehabilitation facilities?

OBJECTIVES: To assess the financial and operational differences in freestanding inpatient rehabilitation facilities (IRFs) that are operated by HealthSouth Corporation relative to other for-profit and nonprofit system-affiliated ownership groups. Since 2003, when it faced fraud charges and financial penalties, HealthSouth has experienced new management and refocused its business strategy. Because HealthSouth is the largest provider of freestanding IRF services, it is important to understand how their performance may differ relative to other ownership groups. DESIGN: We used the Mann-Whitney U test to assess differences in median values for financial and operational variables of HealthSouth-owned IRFs compared with other for-profit system IRFs and nonprofit system IRFs. SETTING: System-affiliated freestanding IRFs in the United States. PARTICIPANTS: Sixty-four HealthSouth IRFs, 18 nonprofit system-affiliated IRFs, and 18 for-profit system-affiliated IRFs. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Net patient revenue per adjusted discharge, operating expense per adjusted discharge, salary expense per full-time equivalent, and cash flow margin. RESULTS: HealthSouth IRFs had significantly lower net patient revenue per adjusted discharge and operating expense per adjusted discharge; however, its cash flow margin was significantly higher than other comparison groups. HealthSouth IRFs treated a higher case mix of patients relative to these comparison groups. CONCLUSIONS: The financial and operating performance of HealthSouth IRFs is stronger than other ownership groups. Strong cash flow will enable HealthSouth to pay down long-term debt.

Understanding and managing organizational change: implications for public health management.

Managing organizational change has become a significant responsibility of managers. Managing the change process within public health organizations is important because appropriately and systematically managing change is linked to improved organizational performance. However, change is difficult and the change process poses formidable challenges for managers. Managers themselves face increased pressure to respond to environmental influences and provide the necessary leadership to their organizations in the change process. In fact, managing organizational change has become a key competency for healthcare managers. This article addresses the important topic of organizational change in public health organizations. It provides a conceptual foundation for understanding organizational change and its relationship to healthcare organizational performance, and then discusses the types and nature of change, using some examples and evidence from those organizations that have successfully managed change. A framework for guiding public health managers in the change management process is provided. The article concludes with suggested management competencies to establish a change-oriented organization with the culture and capacity for change.

Performance of freestanding inpatient rehabilitation hospitals before and after the rehabilitation prospective payment system.

BACKGROUND: Inpatient rehabilitation hospitals provide important services to patients to restore physical and cognitive functioning. Historically, these hospitals have been reimbursed by Medicare under a cost-based system; but in 2002, Medicare implemented a rehabilitation prospective payment system (PPS). Despite the implementation of a PPS for rehabilitation, there is limited published research that addresses the operating and financial performance of these hospitals. PURPOSE: We examined operating and financial performance in the pre- and post-PPS periods for for-profit and nonprofit freestanding inpatient rehabilitation hospitals to test for pre- and post-PPS differences within the ownership groups. METHODS: We identified freestanding inpatient rehabilitation hospitals from the Centers for Medicare and Medicaid Services Health Care Cost Report Information System database for the first two fiscal years under PPS. We excluded facilities that had fiscal years less than 270 days, facilities with missing data, and government facilities. We computed average values for performance variables for the facilities in the two consecutive fiscal years post-PPS. For the pre-PPS period, we collected data on these same facilities and, once facilities with missing data and fiscal years less than 270 days were excluded, computed average values for the two consecutive fiscal years pre-PPS. Our final sample of 140 inpatient rehabilitation facilities was composed of 44 nonprofit hospitals and 96 for-profit hospitals both pre- and post-PPS. We utilized a pairwise comparison test (t-test comparison) to measure the significance of differences on each performance variable between pre- and post-PPS periods within each ownership group. FINDINGS: Findings show that both nonprofit and for-profit freestanding inpatient rehabilitation hospitals reduced length of stay, increased discharges, and increased profitability. Within the for-profit ownership group, the percentage of Medicare discharges increased and operating expense per adjusted discharge decreased. PRACTICE IMPLICATIONS: Findings suggest that managers of these hospitals have adapted their administrative practices to conform with the financial incentives of the rehabilitation PPS. Managers must continue to control costs, increase discharges, and reduce length of stay to remain financially viable under the rehabilitation PPS.

Health care professionals' perceptions and knowledge of infection control practices in a community hospital.

As hospital-acquired infections increase, it is essential that infection control practitioners and hospital administrators have an understanding of the perceptions and knowledge of health care providers as they relate to infection control practices. This article describes the use of the Health Belief Model, a theory-based model used to predict health-related behaviors, in assessing hospital clinical professionals' perceptions and knowledge of infection control practices and summarizes findings from an exploratory study conducted in a community hospital. A total of 130 providers within a hospital setting completed a 51-item survey instrument. The scores for the 6 Health Belief Model constructs show variation, with perceived severity, perceived benefits, and self-efficacy rated higher than perceived susceptibility and cues to action. Knowledge on hand hygiene practices was limited. Providers did not identify any perceived barriers or possible cues to action to increase the likelihood of engaging in proper infection control practices. The constructs of perceived susceptibility and cues to action show a need for improvement by determining appropriate cues for this workforce and addressing susceptibility of workers. These findings can be used by administrators and infection control practitioners to develop and disseminate educational and other interventions to increase compliance with infection control protocols.

The relationship of financial and mission factors to the level of uncompensated care provided in California hospitals.

Community hospitals in the United States have experienced a substantial rise in the burden of uncompensated care over the past few years. Debate continues, however, about whether hospitals, especially private not-for-profits, are providing sufficient levels of uncompensated care. Increased scrutiny regarding uncompensated care and the community benefit of not-for-profit hospitals may be fueled in part by the growing profitability of community hospitals. This study assesses how and whether a hospital's financial performance, mission characteristics, or other significant factors influence its provision of uncompensated care. The study sample consists of 193 short-term, private, acute care community hospitals in California. Results from multivariate regression suggest that free cash flow is positively associated with the provision of uncompensated care in not-for-profit hospitals, whereas a higher level of debt is related to a lower level of uncompensated care. Ownership type (for-profit versus private not-for-profit) does not make a significant difference in the provision of uncompensated care, and overall levels of uncompensated care in the local market are positively associated with a hospital's level of uncompensated care.

High-performance teams for current and future physician leaders: an introduction.

The scope of patient management increasingly crosses the defined lines of multiple medical specialties and services to meet patient needs. Concurrently, many hospitals and health-care systems have adapted new multidisciplinary team structures that provide patient-centric care as opposed to the more traditional discipline-centered delivery of care. As health care continues to evolve, the use of teams becomes even more critical in allowing interdependence between multiple disciplines to provide excellent care delivery and ongoing patient management. The use of teams permeates the health-care industry (and has done so for many years), but confusion about the structure, role, and use of teams contributes to limited effectiveness. The health-care industry's underuse of the fundamentals of corporate teamwork has, in part, created ineffective team leadership at the physician level. As the first in a series of documents on teamwork, this article is intended to introduce the reader to the rudiments of team theory and to present an introduction to a model of teamwork. The role of current and future physician leaders in ensuring team effectiveness is emphasized in this discussion. By educating health-care professionals on the foundations of high-performance teamwork, we hope to accomplish two main goals. The first goal is to help create a common and systematic taxonomy that physician leaders and institutional management can agree on and refer to concerning the development of high-performance health-care teams. The second goal is to stimulate the development of future physician leaders who use proven teamwork principles as a powerful modality to achieve efficient and optimal patient care. Most importantly, we wish to emphasize that health care, both philosophically and practically, is delivered best through high-performance teams. For such teams to perform properly, the organizational environment must support the team concept tangibly. In concert, we believe the best manner in which to cultivate knowledge and performance of the health-care organizational mission and goals is by using such teams.

The early career progress of baccalaureate healthcare management students.

Programs in healthcare management are increasingly asked to demonstrate program outcomes by identifying graduates working in the profession of healthcare management. In particular, standards under AUPHA's certification process for undergraduate programs require that programs identify programmatic and educational outcomes. However, little is known about the career track of undergraduate healthcare management graduates. This paper describes management roles and settings for the graduates of a baccalaureate program in healthcare management, and presents salary and career progression information obtained from a recent alumni survey. Findings and implications are important to highlight the success of program graduates, and support the value of undergraduate programs in healthcare management.

Operational and financial performance of newly established hospices.

The objective of the study was to examine the financial and operating performance of newly established, free- standing hospices relative to existing, freestanding hospices. A nonparametric median test was used to compare the median values of operating and financial performance measures between newly established hospices and existing hospices. Operating and financial data were measured for the 2 groups using cost report data from the Centers for Medicare and Medicaid Services. The authors sampled 44 new, freestanding hospices and selected 312 freestanding existing hospices and analyzed their data over 2 years from 2002 to 2003. The study found that 91% of these new hospices were owned by for-profit organizations and were located in the southern region of the United States. New hospices served fewer patients; however, they had a longer length of stay compared to existing hospices. They offered fewer imaging services and radiation therapy services. New hospices generated significantly higher revenue but incurred significantly higher expenses. The results suggest that longer lengths of stay allow these newer hospices to increase revenue and improve overall profitability.

Fundamentals of service lines and the necessity of physician leaders.

In the demanding and unpredictable environment of the health care industry, hospitals and health systems continue to search for ways to improve the efficiency and quality of care provision and, thus, thrive. Service line organization in health care, a concept that was popularized in the past, has recently experienced a resurgence, spanning the gamut from small community hospitals to large academic medical centers. The modern service line has transformed into an organizational tool that provides hospitals and health systems with a novel approach to achieve the goals of efficient and effective care. Physician leaders can play an integral role in the management of service lines, using a combination of management skills and clinical expertise to provide the oversight and direction necessary for assuring excellence in clinical care and value in its delivery. This article presents an overview of service line structure, implementation, implications, and the role of the physician-leader.