Future public health delivery models for Native American tribes.

BACKGROUND: More and more Native American tribes are assuming control of their own public health care delivery systems by contracting the functions of the Indian Health Service (IHS) through the provisions of P.L. (public law) 93-638, the Indian Self-Determination and Education Assistance Act. In doing this, some Native American tribes are making decisions to create or plan their own departments of public health. In Arizona, the Gila River Indian Community has already established its own department of public health and the Navajo Nation is in the planning stages of establishing its own department of public health. METHODS AND RESULTS: This paper proposes three public health organizational delivery models to meet the public health needs of small, medium, and large Native American tribes. Information for these models was derived from interviews with officials associated with the Arizona Department of Health Services and leaders of Native American tribes. These models progress in size and complexity as we move from small to medium to large tribes. CONCLUSIONS: (a) service delivery should focus on both preventative and curative services; (b) services should be developed with input from the underserved population; (c) members of underserved populations should be trained to provide service to their communities; (d) one model of health service delivery will not be appropriate for all underserved populations; and (e) different models are required to respond to differing cultures, populations, and geographic locations.

Do HMO penetration and hospital competition impact quality of hospital care?

This study examines the impact of HMO penetration and competition on hospital markets. A modified structure-conduct-performance paradigm was applied to the health care industry in order to investigate the impact of HMO penetration and competition on risk-adjusted hospital mortality rates (i.e. quality of hospital care). Secondary data for 1957 acute care hospitals in the USA from the 1991 American Hospital Association's Annual Survey of Hospitals were used. The outcome variables were risk-adjusted mortality rates in 1991. Predictor variables were market characteristics (i.e. managed care penetration and hospital competition). Control variables were environmental, patient, and institutional characteristics. Associations between predictor and outcome variables were investigated using statistical regression techniques. Hospital competition had a negative relationship with risk-adjusted mortality rates (a negative indicator of quality of care). HMO penetration, hospital competition, and an interaction effect of HMO penetration and competition were not found to have significant effects on risk-adjusted mortality rates. These findings suggest that when faced with intense competition, hospitals may respond in ways associated with reducing their mortality rates.

Measuring organizational performance in the hospital industry: an exploratory comparison of objective and subjective methods.

One of the major challenges facing health services management researchers is the measurement of various aspects of organizational performance. This challenge is exacerbated by a reluctance of many healthcare organizations to share data with researchers because of a fear of competitor access to these data. Even where objective, reliable and valid measures of organizational performance are available, typically they are available only in aggregate form, rather than for individual organizations. In response to these constraints, researchers have used subjective measures of performance often based on the perception of key executives. This research compares the subjective perceptions of hospital executives to the objective financial performance data of 60 hospitals. While the correlations between the subjective and objective measures vary, return of assets (ROA) and operating margin are the most valid subjective financial measures of hospital performance. Implications for future research are discussed.

The future of doctoral education in health administration and policy.

Doctoral education in health administration and policy has exhibited stagnation over the past decade in terms of enrollment, graduates, curricula, etc. However, this apparent overall stagnation masks some significant changes that should accelerate in the years ahead. This paper examines the current challenges for doctoral programs in health administration and policy in terms of program orientation, program content, student profiles, and the job market. Given these challenges, predictions are made concerning future enrollment growth in various types of doctoral programs over the next ten years. Finally, recommendations concerning program orientation, program content, student profiles, and the job market are provided overall and by program type. The two most important recommendations that apply across-the-board are to update data on doctoral education and to seek foundation support for a fundamental reassessment of doctoral education for the twenty-first century.

Creating customer-focused health care organizations.

Most health care organizations are operating under an "old paradigm" wherein the needs of physicians and third party payers drive the organization. In the current hypercompetitive health care markets, executives need to focus more directly on their increasingly assertive and knowledgeable patient customers. This article describes practices of the best guest-services organizations that may be transferable to health services organizations. It also proposes ten principles that constitute the "new paradigm."

Creating a healing environment: the importance of the service setting in the new consumer-oriented healthcare system.

Over the last ten years, the healthcare industry has recognized that the physical environment is a valuable resource that can and does affect all of its customers. Although most service organizations give some thought to setting, its importance to the service experience has been most thoroughly understood by those who view and treat their customers as guests, that is, the guest service industry. An excellent healing environment will reinforce excellent clinical quality, but an inferior environment can detract from fine clinical care. One of the most important principles learned by the guest service industry is to provide the setting customers expect. Another is to create an environment that meets or exceeds customer needs for safety, security, support, competence, physical comfort, and psychological comfort. This article provides a detailed discussion of how such an environment can be created in healthcare facilities drawing from the experience of the best guest service organizations.

Does system membership enhance financial performance in hospitals?

While hospitals continue to join multi-institutional systems, empirical data on the benefits of system membership are ambiguous. This study examines the same 166 Florida hospitals in 1986 and 1992. System membership, in general, did not enhance financial returns (measured by operating margin, total margin, and return on assets) for the pooled data or for either year. In fact, a significant negative relationship is noted in 1986. However, when only hospitals affiliated with national systems (in this study, American Medical International, Hospital Corporation of America, or Humana) are analyzed, a positive statistically significant association is found for two of the above three profitability indicators for both the pooled data and for 1986. However, there was no statistically significant impact noted for 1992. Reasons for the apparent discrepancy in the impact of national versus local/regional systems on hospital financial performance and the apparent declining ability of national systems to generate above-average returns are explored.

Attitudes of organized labor officials toward health care issues: an exploratory survey of Alabama labor officials.

Delegates to the Alabama AFL-CIO Convention were surveyed concerning their attitudes toward their health benefits and various options for health care reform. Most are satisfied with their current health care coverage, but dissatisfied with its high costs. Participants attribute the high costs to providers' pricing policies and insurance companies' overhead.

Transformation of an academic medical center: lessons learned from restructuring and downsizing.

This article reviews management literature on health care transformation and describes the processes, including restructuring, job redesign, and downsizing, involved in one academic medical center's experience. The article concludes with lessons learned at each of the stages of the transformation process: planning, implementation, and process continuation. Managerial implications for similar transformation efforts in other health care organizations are suggested.

A framework for doctoral education in health administration and policy.

The fundamental building block upon which the whole edifice of education for health services administration rests is doctoral education. Programs can be no better than the quantity and quality of doctoral graduates available to them. In turn, these graduates can be no better than the programs in which they were trained. The purpose of the present paper is to propose a framework for analyzing five different types of doctoral programs in health services administration and policy. First, five models of doctoral education in health services administration and policy are proposed and described. Second, the advantages and disadvantages of each of these models are described fro the viewpoint of the producer. Third, the most appropriate matches of program types and customer orientations are outlined. The basic premise of the paper is that the employers of doctoral graduates occupy (implicitly or explicitly) a limited set of market niches. No single doctoral program can meet the needs of all potential employers. Nor should the potential employer expect that all program types will produce graduates equally capable of meeting their needs.

Developing an outcomes report card for hospitals: a case study and implementation guidelines.

Except for a few state mandates and dominant business coalitions in selected markets, the provider report card initiative is a voluntary response to a perceived public desire for performance data on healthcare providers. This study uses a detailed investigation of a single "typical" case to collect information about one hospital's decision processes and the operational activities required to develop a report card for communicating clinical outcomes and financial indicators to its external stakeholders. Three research questions are addressed: How did the organization identify who its key stakeholders for outcomes information were? How were the stakeholders' outcomes information needs determined? What were the stakeholders' information needs and preferred reporting formats? The research findings are reported as a case study. A general model for developing and implementing a report card for public dissemination is proposed. Crucial steps include: Hospital leaders should define the intent of the report card and identify key performance domains. Stakeholders' needs, desires, and intended use of the information should be explored when determining the format of the report card. External validation of the information presented should be obtained. The report should be made available through several mediums including direct mailing, print media, and the Internet. Usefulness of the information included in the report card should be continually evaluated. The outcomes report card can be useful to organizations and their stakeholders in many ways. They provide information about clinical outcomes, cost-effectiveness, and organizational performance in an era when healthcare organizations are competing for marketshare and consumers are demanding to be informed about their healthcare providers.

Methods of measuring patient satisfaction in health care organizations.

Patient perceptions of the quality of services provided is a key factor (along with cost effectiveness) in determining a health care organization's competitive advantage and survival. This article examines the advantages, disadvantages, and problems associated with nine different methods of measuring patient satisfaction with service quality. The appropriateness of each of these techniques under different organizational conditions is also discussed. The article concludes with guidelines for measurement of patient satisfaction and implementation of managerial follow-up.

Measuring patient satisfaction in healthcare organizations: qualitative and quantitative approaches.

Patient perceptions of the quality of services provided are a key factor in determining a healthcare organization's competitive advantage and survival. This article examines the advantages, disadvantages, and problems associated with nine different qualitative and quantitative methods of measuring patient satisfaction with service quality and concludes with guidelines for measurement of patient satisfaction and implementation of managerial follow-up.

Strategic choices for medical group practices.

This is the sixth in a series of articles (1) describing how to identify, assess, diagnose and strategically manage key medical group practice (MGP) stakeholders and (2) interpreting the results from the Facing the Uncertain Future (FUF) study. This article continues (from the previous article in this series) the discussion of the vital strategic stakeholder management process of choosing the most effective strategies for key stake holders based on two strategic priorities: reducing stakeholders potential for threat and enhancing their potential for cooperation. From this critical strategic priority-setting process. strategies are classified as either involving, collaborating, defending, or monitoring. Using data from the FUF project, four medical group practice (MCP) stakeholders are analyzed. These are the integrated delivery system/network (lDS/N) itself as well as its components: physicians, hospitals and managed care organizations (MCOs). The FUF project's MGP executive respondents believe these four stakeholders will be some of the most important MGP stakeholders in the year 2000. The FUF study was conducted jointly between the Center for Research in Ambulatory Health Care Administration (CRAHCA), the research and development arm of the Medical Group Management Association (MGMA), Englewood. Colo., and The Institute for Management and Leadership Research (IMLR). College of Business Administration at Texas Tech University, Lubbock, Texas. MGMA s American College of Medical Practice Executives (ACMPE), faculty of Texas Tech University's Ph.D. and M.BA programs in Health Organization Management (HOM), and faculty from the University of Alabama at Birmingham collaborated on the project. Abbott Laboratories. Abbott Park. Ill., provided funding for the FUF project The administration of Round One was completed in the fall of 1994. The administration of Round Two was completed in the summer of 1995. Selected Round One (i.e.. health care experts) and Round Two (i.e., MGP executives) results have previously been presented in educational programs and publications.

The role and impact of multiskilled health practitioners in the health services industry.

The utilization of multiskilled health practitioners (MSHPs) is one method of enhancing employee productivity and cost effectiveness of health services delivery. This article reviews the trend toward increasing specialization of health personnel in this century as well as its limitations and the potential of the MSHP to enhance productivity. Then research on factors that inhibit or facilitate adoption of the concept, the effectiveness of the concept, and implementation strategies that impact effectiveness are presented. The article concludes with guidelines and future challenges for health care executives, public policymakers, and researchers as regards implementation of the multiskilled concept.

The impact of flooding on the delivery of hospital services in the southeastern United States.

A survey and three case studies were conducted of hospitals in Alabama, Georgia, and Florida affected by flooding in July 1994. Our findings suggest that the existence or quality of hospital or community plans for disaster did not seem related to the effect of the flood or the hospitals' response to flooding. Recommendations for preparation and problem avoidance in future flood disasters are provided.

Determinants of maternal mortality in rural China.

A case-control study of maternal mortality was conducted in selected rural areas of two provinces in China: Henan province, which has a relatively lower socio-economic status and higher maternal mortality rates, and Jiangsu province with higher socio-economic status and lower maternal mortality rates. The major cause of maternal mortality in the two provinces was postpartum hemorrhage and the largest proportion of deaths occurred on the road between the women's home and the health care facility. Results indicate that the expectant mother's socio-economic status, knowledge of maternal care, and the nature and level of maternal care provided all influence rural maternal death rates. However, socio-economic factors were only significant predictors of mortality in the poorer province. Implications for health policy and future research are discussed.

The problematic fit of diagnosis and strategy for medical group stakeholders--including IDS/Ns.

This article extends stakeholder management theory using data from 270 medical practice executives to identify key stakeholders and determine the "fit" between stakeholder diagnosis and stakeholder management strategy. Four optimal and 12 suboptimal situations are identified.