Creating the strategic future of long-term-care organizations.

The operating environment in the health care industry is turbulent--organizations are expected to adapt or die. This paper addresses the structure of a strategic planning process for long-term-care organizations. Nursing homes, assisted living (personal care) facilities, continuing care retirement communities, adult day services centers, hospice programs and home- and community-based agencies face both opportunities and threats. The authors recommend an eight-step process for strategy making: plan to plan; external analysis; internal analysis; vision; matching current and future strategies; strategy choice; action and linkage to operations and budget. A case example illustrates the concepts. Long-term-care leaders are encouraged to plan for their future or face a future planned by competitors and regulators.

Commentary: methodological issues for quality management in long-term care.

The interest in quality management in long-term care has been rapidly escalating. This movement to assess and improve quality parallels the effort carried out by hospital management in the past 10 years. The methodological concerns of the 2 areas are similar. This essay identifies 10 issues to which quality management leaders should pay attention as they begin to expand the capability of addressing quality in long-term care: client-centered performance versus whole-organization performance; standardization of methods and instruments; reliability; and validity, multimethod thinking, the meaning of data, comparability of data across organizations, cost barriers, feedback mechanisms, management use of quality data, and public control of data.

Engineering quality through organization change: a study of patient care initiatives by teams.

This report presents a summary and analysis of the continuous quality improvement and organizational change and redesign initiatives undertaken by the unit and service boards organized under the auspices of the HORIZONS Project. Board initiatives were identified and summarized by staff through interviews with the chairpersons and representatives of the boards and review of records. Forty-nine projects from the three pilot units were identified. Each project was classified according to outcome--positive, negative, mixed, and unknown. Sixty percent of initiatives had positive outcomes, and only three initiatives (6%) were negative. Case characteristics were summarized according to board identification, problem, outcome indicators, data baseline, proposed and selected solutions, implementation strategy, monitoring plan, results, change issues, and lessons learned. The study concludes that the board initiatives embody the HORIZONS Projects approach to improving patient care and improving quality of working life for staff and doing so in a budget-neutral manner. The HORIZONS boards process has moved the organization toward more open, collaborative forms of decision making than hitherto practiced.

Improving the quality of health services organization structure by reengineering: circular design and clinical case impact in an academic medical center.

Innovation to improve the quality of structure and process in health care organization is reported in this case example of change in an academic medical center. Interactive planning and the circular organization design concept were the driving principles and methods. This report presents the needs for and initial obstructions to change, planning and project design work, a description of the change process, and illustrative accomplishments to date--two cases, one of conscious sedation policy and one of nuisance pages. Evaluative criteria for judging the progress and lessons of the project regarding key design characteristics also are included.

Medical and health administration education in managed care: needs, content and readings.

With both public and private reform initiatives moving toward managed care, curriculum designs are timely and useful to a diverse audience. This paper discusses the need for and design of education in managed care in medical schools and health services programs. The pressures for offering education regarding managed care are derived from interests of various actors of the health system e.g. regulators, purchasers, providers and consumers. The content of education in managed care is defined in seven areas: (1) managed care and health systems design-history and concepts; (2) environment and governmental policy; (3) models, products, services, outcomes and quality; (4) managed care economics and finance; (5) organization and strategic management; (6) legal issues; and (7) future designs/redesigns. Education in managed care is delivered by universities, professional associations and private training and development corporations. All can benefit from a dialogue on curricular content.

Culture audits: a tool for change.

The culture audit, which has five phases--needs awareness, diagnosis, planning, action, and evaluation--is a critical tool for easing cultural transformation in healthcare organizations. The objective of the audit--usually conducted by outsiders--is to help leaders better understand the current culture and adapt the culture to enhance organizational performance. Most leaders contract with an outsider to facilitate the needs exploration process, often with the guidelines of an advisory team of managers and staff. During the diagnosis phase, the audit team chooses the data-gathering methods, collects and analyzes the data, and develops a model of the culture. The third phase of the culture audit involves planning interventions. Once leaders have a clear picture of their organization's culture, they must ascertain whether the culture will enhance or impede the changes demanded by healthcare reform and an increasingly competitive environment. During the action phase, the culture begins to move toward its desired future. This transition generally requires change in all the organization's systems, including technology, structure, rewards, decision making, budgeting, and managing. Finally, the organization assesses the impact of its culture on its performance. Using the original diagnosis as a baseline and the organization performance goals, the evaluation process maps the changing culture against the benchmark beginning and the goals.

Ombudsmen, patient complaints, and total quality management: an examination of fit.

BACKGROUND: In response to mounting health care costs in the United States and Canada, there is considerable national discussion of health care quality, including the importance of assessing and monitoring patient satisfaction and of responding to complaints. Many physicians and health care administrators cringe at the mention of using patient complaints and satisfaction levels as quality measures; others perceive the need to develop multiple source indicators of patient care. At the same time, leaders are seeking programs and methods that contribute to the continuous improvement of all aspects of health care organizations. DISCUSSION: The use of patient ombudsmen and patient complaints in quality management programs is reviewed and the relation between the two functions--ombudsmen/complaint handling and total quality management--is discussed. Purposes, objectives, problem-solving processes, program operations, data use, and the outcomes of ombudsmen efforts are reviewed. Since ombudsmen programs value patient feedback, empower customers, and help contribute to the diagnosis of organizational areas for improvement, they are consistent with the intent and workings of quality teams. The activities of ombudsmen can contribute to the broader effort to manage the whole organization toward the continuous improvement of quality.

Academic health centers and HMOs: a systems perspective on collaboration in training generalists physicians and advancing mutual interests.

Academic health centers (AHCs) and health maintenance organizations (HMOs) often hold each other at arm's length because of fundamental organizational differences. AHCs view HMOs as too intrusive in the clinical management of patients and too concerned with the financial bottom line. HMOs view AHCs as organizationally fragmented and expensive in providing health care services. AHCs must expand their primary care networks and reassess their mission and public accountability in training a more balanced physician workforce. HMOs are growing rapidly and need well-trained generalist physicians to support that growth. This paper uses an organizational systems model in examining AHCs and HMOs to identify common needs, mutual interests, areas for potential collaboration, and bridging strategies. These include health care systems development, professional education, information management systems, and health services research. As the financing and delivery of health care continue to change and to become more integrated, both organizations have much to gain from collaboration.