Looking good or doing better? Patterns of decoupling in the implementation of clinical directorates.

BACKGROUND: The interest toward hospital restructuring has risen significantly in recent years. In spite of its potential benefits, often organizational restructuring in health care produces unexpected consequences. Extant research suggests that institutional theory provides a powerful theoretical lens through which hospital restructuring can be described and explained. According to this perspective, the effectiveness of change is strongly related to the extent to which innovative arrangements, tools, or practices are adopted and implemented within hospitals. Whenever these new arrangements require a substantial modification of internal processes and practices, resistance to implementation emerges and organizational change is likely to become neutralized. PURPOSE: This study analyzes how hospital organizations engage in decoupling by adopting but not implementing a new organizational model named clinical directorate. METHODOLOGY: We collected primary data on the diffusion of the clinical directorate model, which was mandated by law in the Italian National Health Service to improve hospital services. We surveyed the adoption and implementation of the clinical directorate model by monitoring the presence of clinical governance tools (measures for the quality improvement of hospital services) within single directorates. In particular, we compared hospitals that adopted the model before (early adopters) or after (later adopters) the mandate was introduced. FINDINGS: Hospitals were engaged in decoupling by adopting the new arrangement but not implementing internal practices and tools for quality improvement. The introduction of the law significantly affected the decoupling, with late-adopter hospitals being less likely to implement the adopted model. PRACTICE IMPLICATIONS: The present research shows that changes in quality improvement processes may vary in relation to policy makers' interventions aimed at boosting the adoption of new hospital arrangements. Hospital administrators need to be aware and identify the institutional changes that might be driven by law to be able to react consistently with expectations of policymakers.

The politics of local hospital reform: a case study of hospital reorganization following the 2002 Norwegian hospital reform.

BACKGROUND: The Norwegian hospital reform of 2002 was an attempt to make restructuring of hospitals easier by removing politicians from the decision-making processes. To facilitate changes seen as necessary but politically difficult, the central state took over ownership of the hospitals and stripped the county politicians of what had been their main responsibility for decades. This meant that decisions regarding hospital structure and organization were now being taken by professional administrators and not by politically elected representatives. The question raised here is whether this has had any effect on the speed of restructuring of the hospital sector. METHOD: The empirical part is a case study of the restructuring process in Innlandet Hospital Trust (IHT), which was one of the largest enterprise established after the hospital reform and where the vision for restructuring was clearly set. Different sources of qualitative data are used in the analysis. These include interviews with key actors, observational data and document studies. RESULTS: The analysis demonstrates how the new professional leaders at first acted in accordance with the intentions of the hospital reform, but soon chose to avoid the more ambitious plans for restructuring the hospital structure and in fact reintroduced local politics into the decision-making process. The analysis further illustrates how local networks and engagement of political representatives from all levels of government complicated the decision-making process surrounding local structural reforms. Local political representatives teamed up with other actors and created powerful networks. At the same time, national politicians had incentives to involve themselves in the processes as supporters of the status quo. CONCLUSION: Because of the incentives that faced political actors and the controversial nature of major hospital reforms, the removal of local politicians and the centralization of ownership did not necessarily facilitate reforms in the hospital structure. Keeping politics at an arm's length may simply be unrealistic and further complicate the politics of local hospital reforms.

Narratives of change and reform processes: global and local transactions in French psychiatric hospital reform after the Second World War.

As with the rest of biomedicine, psychiatry has, since the Second World War, developed under the strong influence of the transnational accumulation of a whole series of practices and knowledge. Anthropology has taught us to pay attention to the transactions between local-level actors and those operating at the global level in the construction of this new world of medicine. This article examines the role played by the recommendations of the WHO Expert Committee of Mental Health in the reform of the French mental health system during the 1950s. Rooted in the experience of practitioners and administrators participating in the process of reforming local psychiatric systems, the recommendations of the WHO Expert Committee developed a new vision of regulating psychiatry, based on professionalism and an idea of a normativity of the doctor-patient relation. This article shows how, by mobilizing the WHO reports' recommendations, French administrators and doctors succeeded in creating a typically French object: "the psychiatric sector", founded on elaborating a new mandate for the psychiatric profession. The article thus questions the deinstitutionalization model as an explanation of transformations of the structure of the French psychiatry system in the post-war period.

The economics of hospital reform from hierarchical to market-based incentives.

Heavy investment over the past 30 years has made the hospital sector the largest expenditure category of the health system in most developed and developing countries. In most countries hospitals remain a critical link to health care, providing both advanced and basic care for the population. Often, they are the provider 'of last resort' for the poor and critically ill. This article provides insights into recent hospital reforms undertaken throughout the world, with an emphasis on organisational changes such as increased management autonomy, corporatisation, and privatisation. It provides some insights about these popular reform modalities from a review of the literature, reform experiences in other sectors and empirical evidence from hospital sector itself. The material presented tries to answer three questions: (a) what problems did this type of reform try to address; (b) what are the core elements of their design, implementation and evaluation; and, (c) is there any evidence that this type of reform is successful in addressing problems for which they were intended? While this paper focuses on issues related to the design of the reforms, the paper also reports the findings from a larger study that examined the implementation and evaluation of such reforms so that they will be available to countries that are considering venturing down this reform path.

Making claims. A hospital that's still in the insurance business has drawn the ire of a private rival, with the legality of hidden payments at issue.

Antitrust experts are turning their attention to a pending lawsuit in Ohio, where competition between a third-party administrator and a hospital-owned rival has spilled into state court. The antitrust case may show how far a hospital can penetrate the local health insurance market without breaking the law. "Competition is the lifeblood of trade," says John Cusack, left, an antitrust lawyer who is defending the hospital in the case.

Lessons from New Zealand for England's NHS Foundation Trusts.

The legislation to devolve responsibility for the management and operation of England's top-performing NHS hospitals to community-owned NHS Foundation Trusts raises several issues relating to the challenges posed to governance structures by private non-profit ownership and control of assets used to provide government-financed services. Building upon the lessons learned from devolution of public hospital governance in New Zealand to boards at arm's-length from central control during the 1990s, this paper analyses the English NHS hospital changes. Whilst local political accountability and competition between hospitals indicate that the English reforms may be more successful in meeting patients' needs more efficiently than the New Zealand reforms, the English proposals may be compromised by the ability of staff to become members of Trusts, boards bearing risks of decisions outside their control whilst simultaneously being insulated from the consequences of their decisions by a 'soft budget constraint', and conflicts of interest as boards simultaneously act as agents of both central regulators and local beneficiaries.

[Outpatient hand surgery--possibilities and limitations]. / Ambulante und kurzzeitstationäre Handchirurgie. Möglichkeiten und Grenzen.

On January 1st 2004, a new contract between the government, health insurance services, and hospitals was inaugurated in Germany. The aim of the contract is to decrease costs for surgical therapies by abolishing or at least minimizing hospitalization of patients. Hand surgery is widely affected by the new contract, since a very large part of surgical therapies for the hand was declared to be compulsory outdoor and another major part to be preferable outdoor. The surgeon may decide whether a patient needs inpatient or outpatient treatment but has to justify his decision. Hospitals and surgical clinics are both allowed to offer outpatient hand surgery and get the same payment under the same regulations. For most hospitals, structural changes will be necessary to offer outpatient surgery without financial loss. In our experience a personal and regular contact between patient and surgeon is most necessary for the best surgical result. Many of the compulsory outpatient operations in hand surgery can be done sufficiently and at high standard. This may not be the case for the second group to be handled not compulsory outdoor. The new contract allows hospitals to offer postoperative care for only 14 days, whereas many specific hand surgical procedures will need the surgeon's control and care for a much longer time. On the other hand, clinics and general practitioners have strict limitations for the prescription of hand therapies. We believe that the quality of hand surgery is highly dependent on sufficient postoperative treatment. If the postoperative care is neglected or restricted, secondary costs such as sick leave will increase.

The hospital board at risk and the need to restructure the relationship with the medical staff: bylaws, peer review and related solutions.

This article argues that the current structure of the hospital governing board and medical staff relationship does not support and promote quality and patient-centered care. The fundamental flaw in the current structure is the interdependent, yet independent and discordant relationships between hospital governing boards and medical staffs. These relationships are described as cultures and fit into three types of "silos": organizational (the "structural silo"); professional (the "professional silo", including the "culture of blame"); and the fragmented quality information silo (the "informational silo"). While case law, statutory requirements and regulatory expectations clearly state that governing boards are ultimately responsible for quality of patient care, governing boards delegate these functions to medical staff without having sufficient information to measure and monitor quality. As a result, problems manifest because of these failures of oversight and compliance. Dramatic lapses in quality occur due to overuse, underuse, and misuse of healthcare services. Furthermore, the challenges and opportunities from improved quality and patient safety, as a strategic business driver, cannot be seized until the underlying structural flaws are understood and addressed. This article proposes that solutions become apparent when the various health care constituencies are educated about these cultural impacts and when multidisciplinary bodies, with board leadership and direct authority, integrate and consider quality information.

Courts and health policy: judicial policy making and publicly funded health care in Canada.

The 1982 Canadian Charter of Rights and Freedoms provided political actors with the opportunity to make rights-based challenges to public policy decisions. Two challenges launched by providers and consumers of health care illuminate the impact of judicial review on health care policy and the institutional capacity of courts to formulate policy in this field. The significant impact of rights-based claims on cross-jurisdictional policy differences in a federal regime is noted.