Better information for the board.

Healthcare managers are making quicker, riskier decisions in an increasingly competitive and regulated environment. Questions have been raised regarding the accountability and performance of boards of these organizations, as board members are not always selected based on their competencies to guide such decisions. Adapting mission and strategy and monitoring organizational performance require information that boards get mostly from management. The purpose of this study was to examine the information that boards regularly get to carry out their functions. I obtained board documents from four not-for-profit hospitals and health systems in different boroughs of New York City. At each institution, I conducted one-hour interviews with at least three board members and three top managers. I also attended at least one board or executive committee meeting and one additional meeting, usually of the finance committee. Principal findings were that the boards get too much data, the same data that management gets, and little comparative data on performance of similar benchmarked organizations. Board members and managers are satisfied with the information that board members get and have no plans to improve their system of shaping, or the quality of, information. Key recommendations to boards and managers are: (1) boards must take greater responsibility for identifying the information that they get and how they wish to get it, (2) managers must ensure that measurable objectives are developed, against which organizational performance can be evaluated, (3) boards must get information that is targeted and shaped to better fit board functions, (4) managers must develop information sets for main service lines, (5) boards must get information on the expectations and satisfaction levels of key stakeholders, (6) boards must get better and more focused information on performance of benchmarked institutions, and (7) boards must get less hospital operating data on a monthly basis.

Evidence-based management.

Healthcare Providers are having to make quicker, riskier decisions in a competitive and regulated environment. Leaders often make these decisions with the advice of management consultants; however, top management generally lacks adequate internal support to rigorously evaluate strategic interventions or consultant recommendations and to learn from industry-wide best practices. In fact, healthcare providers generally underinvest in management support, both in evaluating best practices within the organization and in learning from past strategic interventions. The creation of evidence-based management cooperatives might be a means to change this trend.

Implementing Medicaid managed care: the New York City story.

Across the nation, public officials are encouraging or requiring Medicaid beneficiaries to enroll in managed care. In this article, we report on a study of the implementation of Medicaid managed care in New York City. Several findings are clear. First, government officials need to treat health plans as partners rather than adversaries; in New York, the relationship between the state and the plans is far too adversarial. Second, effective managed care requires good management information systems; New York officials are collecting an enormous amount of data but not much useful information. Third, effective implementation of Medicaid managed care is slow going; New York's effort to dramatically accelerate the enrollment process did not work.

Board development in two hospitals: lessons from a demonstration.

A recently concluded demonstration project examined efforts to improve the effectiveness of nonprofit boards. This article focuses on the interventions at two participating healthcare organizations and examines the outcomes of these efforts. Changes made at the Alpha Health Care system included: reduction in the number of boards, term limits established for board members, election of new board chairs for two of the fewer boards, reduction in the size of those boards, implementation of a consent agenda, and reorganization of the boards' committee structure. Fewer changes were implemented at the Beta Hospital, where several initiatives were started but only some of which were retained by the projects' conclusion. Key factors limiting the extent of changes there were the modest interest in an active board by a new CEO and the limited investment of trustees in change. The article concludes with a discussion of lessons learned about board assessment, the use of retreats to initiate board development, and the importance of time management and CEO support to strengthen board effectiveness.

Assessing Medicaid managed care in eastern state.

This case examines the expanding role of managed care programs in improving health care for the poor while controlling runaway health care costs. The case asks what the commissioner of health in a large eastern state should do to effectively monitor Medicaid managed care programs in her state. The commissioner faces intense pressures for cost containment and strong, but not universal, support for the managed care solution to health care cost problems. The commissioner is herself concerned that the cost savings attributed to managed care may not be real and that the unintended effects on health care may be adverse. Her immediate challenge is to determine what kinds of data she should require service providers to submit to her agency so that she may effectively monitor managed care programs for health care quality, provide positive feedback to health care providers, and establish politically credible program oversight.

Management development for mid-level managers: results of a demonstration project.

This article examines a demonstration program to develop skills and experience for middle managers at a mid-sized urban hospital. Many of the middle managers selected for the program lacked formal management training or management experience prior to their present position. Elements of the program are summarized and first year accomplishments examined. Issues associated with continuation and replication of the program are discussed so that other hospitals may benefit from the lessons learned during development and implementation.

The hospital community benefit standards program and health reform.

This article suggests that the community hospital can be an important key to health reform at the local level; that community benefit guidelines are acceptable to hospitals and community leaders in a 49-site national demonstration program; and that these guidelines can prove useful for communities in moving toward health reform. Types of community involvement by hospitals are categorized, and examples of each type are developed. Community benefit programs can be a promising approach to effectively respond at the local level to the problems of poor health status, lack of access to care, and increasing health care costs. Addressing financing of care without attention to changes in the delivery system will not lead to effective health reform.

State health policy and rural hospitals.

Many rural hospitals are experiencing difficulties. This article explores the views of various government and hospital officials on state health policy for rural hospitals. The authors discuss how these officials define the rural hospital issues and suggest appropriate state interventions to assure hospital viability and local access to care. The authors recommend that states, hospitals, and communities decide through a formal process what level of health and medical care should be available in rural areas, and states assist in low-cost ways those rural hospitals that are ready to change or that, with help, will be ready to make such operational changes as service reconfiguration, affiliations, and working agreements with other health care organizations to continue and improve local access to health care.

The case of the unhealthy hospital.

On a cold March morning, Bruce Reid, Blake Memorial Hospital's new CEO, visited the Lorris housing project clinic, one of six off-site clinics operated by Blake Memorial. He was not encouraged by what he saw: peeling paint, leaking pipes, and cramped conditions. When he asked Renée Dawson, the clinic's primary care physician, how she endured the conditions, she just stared at him. "What are my options?" she asked. That was a good question. Blake Memorial was in poor financial health, due to rising costs and stagnating revenue. The hospital's quality of care was also a major problem. In addition, the clinics were losing over $250,000 a year. As Reid worked on Blake Memorial's 1992 budget, he saw he would have to cut some services in order to fund others. One of the services he was considering cutting was the clinic program. But there were a number of conflicting forces that Reid had to consider. On the political front, the recently appointed commissioner of health services said she would challenge Blake Memorial's tax-exempt status if Reid dismantled the clinics. Within the hospital were two warring factions. One wanted more high-tech services for the hospital and favored closing the clinics. "Instead of clinics, we should have a shuttle bus from the housing projects to the hospital," one doctor suggested. The other faction wanted to expand the clinics. "Wherever the service is most needed, that is where the hospital should be," argued the clinics' director. Reid must decide what to cut and what to keep. But to do so, he must first settle on Blake Memorial's long-term mission.(ABSTRACT TRUNCATED AT 250 WORDS)

Improving hospital board effectiveness: an update.

This article defines governance as the making or not making of important decisions and the related distribution of legitimate power and authority to make them. A distinction is drawn between what governing boards do that is not restricted to governance, and governance that is not the exclusive function of governing boards. This article focuses on governing boards. Recommendations are made for improving the effectiveness of hospital governing boards. Discussed in detail are integrating clinician and administrative governance; supporting management in managing change; focusing and energizing the board on policymaking; and, specifying and evaluating the hospital's contribution to the health of a defined population at reasonable cost. The author surveys the current hospital environment and reconsiders and updates his 1985 recommendations on improving governance. Board effectiveness is reconceptualized, and those recommendations that have been made to improve board structure and function are reviewed. Governing boards are shown to work differently in multihospital systems, hospital alliances, and under restructuring. A research agenda to improve hospital board effectiveness is proposed.

The hospital-based rural health care program: a consortium approach.

The Hospital-Based Rural Health Care Program is a national initiative of The Robert Wood Johnson Foundation. The goals of the program are to strengthen the ability of rural hospitals to provide a high quality of care and to promote the financial stability of these institutions. The four-year demonstration program began on 1 January 1988 and provides up to $9 million in grants and $7.5 million in loans to 13 consortia of 182 rural hospitals. Evaluation of the program will be made by a team headed by Ira Moscovice of the University of Minnesota. This article discusses the programs being implemented and explains why the demonstration is important for rural hospitals and rural health care. The characteristics of grantee consortia and environments are presented, and examples of programs by one consortia and measurable objectives for a program undertaken by another consortia are described. First-year experience in the demonstration is reviewed briefly, and opportunities and constraints for program implementation are noted.

The work of effective CEOs in four large health organizations.

This paper examines CEO effectiveness in four large health care organizations by asking CEOs for their conceptualizations of CEO effectiveness in their organization; by asking the close associates of CEOs for their perceptions of CEO accomplishments, methods, and agendas; and by observing and speculating on the episodes of work with which CEOs are involved. It is suggested that CEO effectiveness can be associated with the type of episodes that CEOs choose to manage or participate in and the results achieved per episode are relative to costs in CEO time and organizational resources. There is insufficient data in this study to justify these conclusions but enough data to warrant further specification and testing of hypotheses in this area. Differences are observed in the episodes of work that the CEOs do and it is believed that these differences relate to varying sets of organizational circumstances.

Reflections on health management education.

Responses of 29 interviews summarise problems in health management and health management education and point to available options in response to these problems. Views are presented regarding accredited graduate programs and their strengths and weaknesses. Recommendations are made on various issues relating to the education of health services managers and include: revising curricula and exploring new methods of teaching health management; developing closer linkages with clinician educators and health managers; undertaking or expanding related missions of continuing professional education and multidisciplinary research and evaluation. Commentary follows in response to these recommendations from the perspectives of education and practice.

Implementing swing-bed services in small rural hospitals.

Since 1983, twenty-six small rural hospitals in five states have been developing models of the "swing-bed" concept as part of a coordinated national demonstration project. Based on the experiences of these hospitals, swing-bed programs use excess hospital capacity to provide short-term, post-acute care in rural communities where there are nursing home shortages, and, thus, help avoid the need for new nursing home construction. The availability of swing-bed services in rural hospitals has allowed the elderly patient to receive a full-range of long-term care services within the community to avoid transfer to a nursing home outside the community. Introduction of services also has improved patient care for all hospitalized elderly. Finally, the revenue from the swing-bed services has helped to stabilize small, rural hospitals faced with declining utilization. The demonstration has provided evidence that the swing-bed program has the potential to deliver a needed service to the rural elderly while contributing to the preservation of the small, rural hospital as a valuable community resource.