The implications of affiliations between Catholic and non-Catholic health care organizations for availability of reproductive health services.

Four case studies of successfully negotiated affiliations between Catholic and non-Catholic organizations reveal the strategies employed to address a range of reproductive health services.

PIP: This article summarizes multiple case studies on decision-making with regard to reproductive health services in affiliations between Catholic and non-Catholic organizations. A database on the number and types of affiliations was compiled during 1990-1996 to provide a national profile of such organizations. Findings of case studies revealed that affiliations between Catholic and non-Catholic health care organizations are diverse in structure, motivated by market and financial issues, and display diverse strategies with regards to reproductive health services. In addition, strategies for providing more comprehensive women's health care were evident in 3 of the 4 case studies. Availability of contraceptive services, female and male sterilization, and infertility services generally was unchanged as a result of affiliations. This shows that affiliations themselves did not significantly affect policies or practices with regards to their provision. Successful negotiations between Catholic and non-Catholic partners involve explicit strategies concerning reproductive health services, some of which curtail specific services and some of which enhance services. Finally, policy-makers have an important role in ensuring that communities receive full disclosure of the nature of affiliations and their possible impact on availability of services.

Strategic activity and financial performance of U.S. rural hospitals: a national study, 1983 to 1988.

This study examines the effect of 13 strategic management activities on the financial performance of a national sample of 797 U.S. rural hospitals during the period of 1983-1988. Controlled for environment-market, geographic-region, and hospital-related variables, the results show almost no measurable effect of strategic adoption on rural hospital profitability and liquidity. Where statistically significant relationships existed, they were more often negative than positive. These findings were not expected; it was hypothesized that positive effects across a broad range of strategies would emerge, other things being equal. Discussed are possible explanations for these findings as well as their implication for a rural health policy relying on individual rural hospital strategic adaptation to environmental change.

Rural hospital administrators and strategic management activities.

This study examines the association of characteristics of rural hospital administrators and the adoption of seven strategic activities in a national sample of 797 U.S. rural hospitals during the period 1983-1988. Based on the premise that managerial activities can affect organizational change, we test five hypotheses relating head administrator characteristics to strategic adaptation, controlling for environment-market and hospital-related variables. Bivariate analysis of the strategic adoption showed a positive association with administrative turnover and a negative association with head administrator age. Multivariate logistic regression showed that only high levels of turnover were associated with strategic activities, net of control variables. The implications of these findings and the lack of predictive power of other rural hospital administrator characteristics--especially affiliation with the American College of Healthcare Executives--are discussed within the context of a "strategic management policy" for rural hospitals.

Rural hospital-based alcohol and chemical abuse services: availability and adoption, 1983-1988.

Data from a 1983-88 retrospective panel study of 797 rural (non-Metropolitan Statistical Area) U.S. hospitals revealed that less than one in five (18.7%) had any alcohol and chemical abuse (ACA) service. About one-third of both inpatient and outpatient services had been established during the study period, but few hospitals not offering these services planned to offer them in the immediate future. These findings support other studies that the availability of such services may not meet population need or demand, although non-hospital-sponsored services might partially fill the gap. Bivariate analysis showed that hospital locations in counties that were more densely populated, had higher per capita income and had more physicians per 1,000 population were positively associated with ACA services. Hospitals that were in the New England, Mid-Atlantic, East North Central census divisions, and were large according to number of beds, presence of psychiatric services, availability of psychiatrists and other nonphysician personnel, certain organizational arrangements and strategic management activities were positively associated with ACA services. Multivariable logistic regression suggested the presence of psychiatric services as a key correlate of ACA services, and the scarcity of psychiatric personnel in rural areas appears to have been a major reason for the infrequency of rural hospital-sponsored ACA services.

Horizontal and vertical integration-diversification in rural hospitals: a national study of strategic activity, 1983-1988.

This study examines both the magnitude of and factors influencing the adoption of 13 horizontal and vertical integration and diversification strategies in a national sample of 797 U.S. rural hospitals during the period 1983-1988. Using organization theory, hypotheses were posed relating environmental and market factors, geographic location, and hospital characteristics to the adoption of horizontal and vertical integration and diversification. Results indicate that only one of 13 strategies was adopted by more than 50 percent of all rural hospitals during the study period, and that most of the directional hypotheses were not confirmed using Cox's proportional hazards models. In particular, environmental and market factors were unrelated to the strategies studied. Issues of methodology and theory are discussed; however, during an historically turbulent period, both relatively low levels of rural hospital strategic activities and lack of predictive power of the theory suggest caution in relying heavily on a policy for rural hospital survival that is dependent on individual market-oriented strategic behavior.

Medical malpractice claims filed by Medicaid and non-Medicaid recipients in Maryland.

Several databases available in Maryland are used to investigate whether Medicaid recipients are more likely than other persons to engage in medical malpractice litigation. All malpractice claims filed during 1985 and 1986 (N = 1037) were updated for outcomes through 1989 and described with regard to the payer status of claimants. The proportion of claims filed by persons enrolled in Medicaid before and/or during the alleged malpractice incident was lower than the proportion of state residents enrolled in Medicaid. In addition, the proportion of obstetric claims filed by Medicaid recipients was identical to their proportion of hospital discharges for obstetric services during the period in which the incidents occurred.

America's rural hospitals: a selective review of 1980s research.

We review 1980s research on American rural hospitals within the context of a decade of increasing restrictiveness in the reimbursement and operating environments. Areas addressed include rural hospital definitions, organizational and financial performance, and strategic management activities. The latter category consists of hospital closure, diversification and vertical integration, swing-bed conversion, sole community provider designation, horizontal integration and multihospital system affiliation, marketing, and patient retention. The review suggests several research needs, including: developing more meaningful definitions of rural hospitals, engaging in methodologically sound work on the effects of innovative programs and strategic management activities--including conversion of the facility itself--on rural hospital performance, and completing studies of the effects of rural hospital closure or conversion on the health of the communities served.

Practice changes in response to the malpractice litigation climate. Results of a Maryland physician survey.

Data from a 1987 survey of Maryland physicians in three specialties (internal medicine, family or general practice, and obstetrics-gynecology) were used to study the types of changes physicians have made in their practices during the last 2 years as a result of the current malpractice litigation climate. Overall, 51% reported making some type of practice change. The practice changes that physicians reported reflect both risk-reduction (e.g., increased use of tests) and risk-avoidance (e.g., cutting back high-risk patients) strategies, although risk-reduction actions were reported more frequently. Raising patient fees was also reported. Specialty predicts whether or not physicians make each type of change; in particular, obstetrician-gynecologists are more likely to report practice changes of all types. Prior litigation experience does not, in general, predict practice changes. The implications of the types of changes reported for access to care and costs of care were considered.

CEO-board relationships under hospital corporate restructuring.

Corporate restructuring has been increasing among the nation's hospitals, but little research has been devoted to assessing how, if at all, this phenomenon affects hospital management and policymaking. This study examines CEO-board relationships in corporately restructured hospitals in relation to more traditionally structured institutions. Analysis of survey responses from 1,179 restructured and 2,010 nonrestructured hospitals indicates that boards of restructured hospitals provide CEOs with greater operational flexibility and control but, at the same time, hold them more accountable for their performance.

The effects of corporate restructuring on hospital policymaking.

Hospital corporate restructuring is the segmentation of assets or functions of the hospital into separate corporations. While these functions are almost always legally separated from the hospital, their impact on hospital policymaking may be far more direct. This study examines the effects of corporate restructuring by community hospitals on the structure, composition, and activity of hospital governing boards. In general, we expect that the policymaking function of the hospital will change to adapt to the multicorporate structure implemented under corporate restructuring, as well as the overlapping boards and diversified business responsibilities of the new corporate entity. Specifically, we hypothesize that the hospital board under corporate restructuring will conform more to the "corporate" model found in the business/industrial sector and less to the "philanthropic" model common to most community hospitals to date. Analysis of survey data from 1,037 hospitals undergoing corporate restructuring from 1979-1985 and a comparison group of 1,883 noncorporately restructured hospitals suggests general support for this hypothesis. Implications for health care governance and research are discussed.

Malpractice claims experience associated with fertility-control services among young obstetrician-gynecologists.

Threatened and actual medical malpractice claims associated with delivery of fertility-control services are studied in a national sample of 1,420 recently trained obstetrician-gynecologists who had been in practice an average of 3 years at the time of the survey. Nine percent of respondents report having been threatened with a fertility-control-related lawsuit, and 5.5% report being named as a defendant in such a suit. The types of services named most frequently as the basis of threatened lawsuits are sterilizations and abortions. In logistic regression analyses, variables found to significantly increase the risk of both threatened and actual lawsuits are number of years in practice and number of abortions provided during the last year of practice. Treatment of more minority patients significantly reduces the risk of both threatened and actual claims. Type of practice arrangement, physician gender, and attitudes toward physician-patient communication are among the variables found not to affect the risk of litigation. Implications for provision of fertility-control services are discussed.

Diffusion and adoption of CDC guidelines for the prevention and control of nosocomial infections in US hospitals.

Since 1981, the Centers for Disease Control (CDC) has been publishing Guidelines for the Prevention and Control of Nosocomial Infections as a useful reference tool in infection control. The extent to which practices recommended by CDC to reduce hospital-acquired infections have been successfully diffused and adopted were evaluated in a stratified random sample of 445 US hospitals that were sent a questionnaire in 1985. The data suggest that over 84% of infection control practitioner respondents (78% response rate) are aware of each guideline, although small hospitals (less than 50 beds) are least likely to be aware of the guidelines or to have reviewed them thoroughly. Adoption of the recommendations remains far from universal, ranging from 23% to 75% for 16 specific recommendations investigated. Smaller hospitals were significantly less likely than large hospitals to have adopted each suggested policy. Recommendations that carried Category I rankings were more likely to be adopted, as were those procedures that had cost-savings implications.

Models of governance in multihospital systems. Implications for hospital and system-level decision-making.

This study utilizes data from a national survey of 159 multihospital systems in order to describe the types of governance structures currently being utilized, and to compare the policy making process for various types of decisions in systems with different approaches to governance. Survey results indicate that multihospital systems most often use one of three governance models. Forty-one percent of the systems (including 33% of system hospitals) use a parent holding company model in which there is a system-wide corporate governing board and separate governing boards for each member hospital. Twenty-two percent of systems in the sample (but 47% of all system hospitals) utilize what we have termed a modified parent holding company model in which there is one system-wide governing board, but advisory boards are substituted for governing boards at the local hospital level. Twenty-three percent of the sampled systems (including 11% of system hospitals) use a corporate model in which there is one system-wide governing board but no other governing or advisory boards at either the divisional, regional or local hospital levels. A comparison of systems using these three governance approaches found significant variation in terms of system size, ownership and the geographic proximity of member hospitals. In order to examine the relationship between alternative approaches to governance and patterns of decision-making, the three model types were compared with respect to the percentages of systems reporting that local boards, corporate management and/or system-wide corporate boards have responsibility for decision-making in a number of specific issue areas. Study results indicate that, regardless of model type, corporate boards are most likely to have responsibility for decisions regarding the transfer, pledging and sale of assets; the formation of new companies; purchase of assets greater than $100,000; changes in hospital bylaws; and the appointment of local board members. In contrast corporate management is relatively uninvolved in these issues, again regardless of governance model type. There is substantial variation in the locus of decision-making responsibility by governance model type for a variety of other issues, however, including: hospital-level service additions and deletions; operating and capital budgets; medical staff privileges, hospital-level long-range planning; hospital CEO performance evaluation and the appointment of hospital CEOs.(ABSTRACT TRUNCATED AT 400 WORDS)

Formal relationships among governing boards, CEOs, and medical staffs in independent and system hospitals.

This study examines the impact of hospital participation in multi-institutional arrangements on formal relationships between hospital governing boards and chief executive officers (CEOs) and between governing boards and hospital medical staffs. Hypotheses are derived from Mintzberg's general theory of organizational design and are tested using combined data from three American Hospital Association Surveys of nonfederal, short-term hospitals. Analysis results provide considerable support for the study hypotheses. CEOs were found in general to have more formal influence in decisionmaking but also were more likely to be held accountable for performance standards in those hospitals that are part of multi-institutional arrangements. In addition, analyses using both 1976 and 1982 survey data indicate that hospital participation in multi-institutional arrangements is associated with lower levels of formal involvement of the medical staff in institutional decisionmaking. Relationships, for the most part, remain unchanged after the introduction of statistical controls for hospital size. One important issue raised by these findings is the possible impact on hospital performance of less participation by medical staff in the governance of hospitals whose boards are either responsible for multiple hospitals or accountable to higher organizational authority.

Multi-institutional arrangements: relationships between governing boards and hospital chief executive officers.

This investigation focuses on the impact of multi-institutional arrangements on the role of governing boards in limiting or enhancing the managerial autonomy of individual hospitals. Data from a 1979 Special Survey by the American Hospital Association (N = 4213) are used to examine governing board-administrator relationships as a function of the degree of autonomy and scope of responsibility of the hospital governing board. It is hypothesized that governing boards responsible for multiple hospitals or for multiple nonhospital organizations and those boards accountable to a higher organizational authority will exercise more formal control over hospital chief executive officers (CEOs) than will boards of single or autonomous hospitals. The analysis assumes that formal control by the governing board over the management function of the individual hospital is exercised partly through soliciting or limiting participation by hospital administrators in key policy decisions and through the evaluation of administrative performance. Therefore, it is anticipated that hospitals governed by boards with multiple responsibilities as well as hospitals governed by boards accountable to a higher authority will be (1) less likely to have CEOs who are members of the governing board executive committee, (2) more likely to have annual performance reviews of the CEO by the governing board, and (3) more likely to have such reviews conducted according to preestablished criteria. Study results provide general support for the hypotheses with respect to hospital boards with multiple responsibilities: the data suggest that such boards do exercise greater control over hospital administrators and these effects do appear to be stronger for hospitals in the private sector. Hospitals governed by boards accountable to a higher authority, however, are more likely to have CEOs who are members of the governing board executive committee--a pattern in direct opposition to that hypothesized. Furthermore, these boards are no more likely to conduct annual CEO performance reviews than are boards with more autonomy. Boards accountable to higher authorities are more likely, however, to use preestablished criteria when such reviews are conducted. This general pattern is similar whether hospital boards are accountable to religious authorities, to investor-owned corporate boards, or to the boards of not-for-profit multi-institutional systems. A different pattern emerges, however, for boards accountable to a state, county, or local government authority.(ABSTRACT TRUNCATED AT 400 WORDS)

Patient understanding and satisfaction as predictors of compliance.

Patients' satisfaction with the communicative aspects of their medical visits and understanding of their prescription drug regimens were measured for a sample of visits to a prepaid medical plan in a mid-Atlantic metropolitan area. The 1367 patients, who visited either the Department of Adult Medicine or the Urgent Care Center during a 2-week period and their physicians completed questionnaires as part of an ongoing quality assessment study. A 50% random sample of these patients was interviewed by telephone a week after their visits. Compliance was found to be positively correlated with understanding of drug instructions but negatively correlated with satisfaction with communication during the visit. Our findings suggest that satisfying doctor-patient interactions do not necessarily reflect effective communication about drug regimens.

Impact of divergent evaluations by physicians and patients of patients' complaints.

Physicians' estimates of patients' anxiety, discomfort or pain, and activity limitation were compared with reports by their patients on the same dimensions. The data were collected as part of a series of quality assessment studies at a prepaid group practice serving 19,000 people in a Mid-Atlantic metropolitan area. Analysis of the data showed that physicians underestimated the three dimensions 35 percent of the time and that activity limitation was the dimension most often underestimated. Patients whose physicians correctly estimated their discomfort or pain were more likely to receive prescriptions than patients whose physicians underestimated their discomfort or pain. Patients whose physicians underestimated their activity limitation were most likely to report dissatisfaction with the treatment given. The results are consistent with a growing body of evidence suggesting that physicians who show concern about their patients and a desire to understand their problems establish better therapeutic relationships.