The public health implications of world trade negotiations on the general agreement on trade in services and public services

Trade ministries from the World Trade Organization's (WTO's) 144 member states are presently deciding which public services to open to foreign competition under the complex liberalisation rules of the general agreement on trade in services (GATS). A frequent criticism of the WTO system is that it reduces national autonomy over public policy. However, respect for national sovereignty is asserted in the GATS treaty. Here, we examine claims made by the WTO and others that GATS exempts public services and does not require their privatisation. We discuss trade treaty processes that can subject public services to commercial rules, the treaty's flexibility with respect to national autonomy, and the effect of GATS in situations in which national autonomy is not protected. We conclude that national autonomy over health policy is not preserved under GATS, and that accordingly, there is a role for international standards that protect public services from the adverse effect of trade and market forces.

Use of the balanced scorecard in health care

Since Kaplan and Norton published their article proposing a balanced scorecard, the concept has been widely adopted by industry and health care provider organizations. This article reviews the use of the balanced scorecard in health care and concludes that the balanced scorecard: (1) is relevant to health care, but modification to reflect industry and organizational realities is necessary; (2) is used by a wide range of health care organizations; (3) has been extended to applications beyond that of strategic management; (4) has been modified to include perspectives, such as quality of care, outcomes, and access; (5) increases the need for valid, comprehensive, and timely information; and (6) has been used by two large-scale efforts across many health care organizations in a health care sector, which differ, namely in the units of analysis, purposes, audiences, methods, data, and results.

You only get out what you put in. Make a lasting impression

This is the first submission of our new regular feature, the “Members' Speak Out” column. It has been designed to enhance and stimulate dialogue amongst our members and ultimately ignite the fires of debate. We encourage you to respond to these columns and let your voice be heard.

Strategic management and public policy

Making strategic decisions that ensure a productive fit between the internal situation and external environment of a healthcare entity--sometimes, even decisions that ensure its survival--is a great challenge. The author suggests that hospitals must adopt specific strategies to anticipate and respond appropriately to changes in policy.

Adoption of regulatory compliance programmes across United States healthcare organizations: a view of institutional disobedience

The growing acceptance of evidence-based decision-support systems in healthcare organizations has resulted in recognition of information accuracy as a key area of organizational management. In the United States, rigid data mandates related to information management have met with some resistance from healthcare provider groups, who have traditionally found little relevance between personalized healthcare practice and accurate information. Variation in management practice poses quality problems in such an environment, since it precludes comparisons across larger markets or areas, a critical component of evidence-based quality assessments. In this study, a national census of health information managers was employed to provide a benchmark of the degree of such variation, examining how proper billing compliance practices vary across organization types as well as market area indicators. Findings here suggest that managers continue to ignore, to some extent, regulatory compliance standards, despite nationwide laws that mandate adoption of uniform compliance practices and programmes. The level of adoption of compliance management in this study varied significantly across practice characteristics and areas, suggesting the existence of barriers to cross-market comparative performance assessment.

Gaining and maintaining commitment to large-scale change in healthcare organizations

Healthcare administrators have sought to improve the quality of healthcare services by using organizational change as a lever. Unfortunately, evaluations of organizational change efforts in areas such as total quality management (TQM), continuous quality improvement (CQI), and organizational restructuring have indicated that these change programmes have not fulfilled their promise in improving service delivery. Furthermore, there are no easy answers as to why so many large-scale change programmes are unsuccessful. The aim of this analysis is to provide insights into practices that may be utilized to improve the chances of successful change management. It is proposed that in order to effect change, implementers must first gain commitment to the change. This is done by ensuring organizational readiness for change, surfacing dissatisfaction with the present state, communicating a clear vision of the proposed change, promoting participation in the change effort, and developing a clear and consistent communication plan. However gaining commitment is not enough. Many change programmes have been initially perceived as being successful but long-term success has been elusive. Therefore, maintaining commitment during the uncertainty associated with the transition period is imperative. This can be done by successfully managing the transition using action steps such as consolidating change using feedback mechanisms and making the change a permanent part of the organization's culture.

How healthcare wins with consumers who want more

With consumerism on the rise, many hospitals are responding to high patient expectations by embracing a journey that "hard wires" a culture of service and operational excellence into their organizations. The "healthcare flywheel" describes a way to frame the process, by explaining how hospitals can harness employee passion for making a difference in patient lives to create self-sustaining momentum for change. Organizations can be guided in their journey by nine principles that align goals and measure results under five "pillars" to better set and respond to patient expectations, increase organizational focus on service and performance, measure performance against expectations, and create highly effective leaders. A brief case study of Sarasota (Fla.) Memorial Health Care System is included to illustrate how consumer-driven initiatives also increase profitability.

Healthcare Lean

Lean Thinking is an integrated approach to designing, doing and improving the work of people that have come together to produce and deliver goods, services and information. Healthcare Lean is based on the Toyota production system and applies concepts and techniques of Lean Thinking to hospitals and physician practices.

Management mistakes in healthcare: a disturbing silence

The belated but formal acknowledgment of medical errors and their impact has been well documented. Curiously, the topic of management or executive mistakes in healthcare is not raised in professional meetings nor, until recently, addressed by an article in health administration journals.

ROI under scrutiny: the radical redefinition of a core concept

This article offers a three-part analysis for identifying and assessing return on investment in healthcare information technology (IT) projects. Returns to IT can be financial, clinical, or structural. The goal is to identify key areas of measurable returns to both assess the value of a project before it is undertaken and to assess the actual value returned to the organization. Given the choice, many senior executives still prefer to rely on classic financial analyses, but the true value of a project is often found in the clinical and structural returns. Still, project-specific assessments do not answer the core question of whether long-term strategic investment in IT leads to a systemic strategic advantage to healthcare organizations. This article addresses these issues and indicates opportunities for further investigation.

The value of information technology in healthcare

Not only will healthcare investments in information technology (IT) continue, they are sure to increase. Just as other industries learned over time how to extract more value from IT investments, so too will the healthcare industry, and for the same reason: because they must. This article explores the types of business value IT has generated in other industries, what value it can generate in healthcare, and some of the barriers encountered in achieving that value. The article ends with management principles for IT investment.

Competency-based health services management education: contemporary issues and emerging challenges

Health service executives increasingly recognize managerial competencies as an important element of contemporary health services management education and practice. This paper addresses reasons for the growing interestin the topic, provides a brief review of selected literature, and presents findings from two Delphi studies of the identification and use of competencies in health services management. The two studies reveal that there is a high level of agreement among academicians and practitioners concerning which domains of competencies are effectively addressed in health management education, but many still have concerns regarding how the competencies should be applied. The paper concludes with unresolved issues and their implications for future research.

Does organisational culture influence health care performance? A review of the evidence

OBJECTIVE

To review the evidence for a relationship between organisational culture and health care performance.

METHODS

Qualitative comprehensive review: all empirical studies exploring a relationship between organisational culture (broadly defined) and health care performance (broadly defined) were identified by a comprehensive search of the literature. Study methods and results were analysed qualitatively to provide a narrative review with integrative discussion.

RESULTS

Ten studies met the inclusion criteria. There was considerable variation in the design, study setting, quality of reporting and aspects of culture/performance considered. Four of the ten studies reviewed in detail claimed to have uncovered supportive evidence for the hypothesis that culture and performance are linked. All the other studies failed to find a link, though none provided strong evidence against the hypothesis.

CONCLUSIONS

There is some evidence to suggest that organisational culture may be a relevant factor in health care performance, yet articulating the nature of that relationship proves difficult. Simple relationships such as 'strong culture leads to good performance' are not supported by this review. Instead, the evidence suggests a more contingent relationship, in that those aspects of performance valued within different cultures may be enhanced within organisations that exhibit those cultural traits. A striking finding is the difficulty in defining and operationalising both 'culture' and 'performance' as variables that are conceptually and practically distinct. Considerably greater methodological ingenuity will be required to unravel the relationship(s) between organisational culture(s) and performance(s). Current policy prescriptions, which seek service improvements through cultural transformation, are in need of a more secure evidential base.

A theoretical model for the optimal allocation of health resources in Greece

This paper presents a theoretical model that enables us to rate the efficiency of health resources in different regions. The model is based on the theory of production and refers to two specific regions. The hypotheses that determine the relationship between health care resources and their indicators are examined as well as the necessary conditions for the optimal regional allocation of these resources.

Straight talk new approaches in healthcare. Performance management: assuring your financial and performance goals are met

Performance management is a topic thrown around a lot in executive suites, but its key tenets are sometimes misunderstood. To be successful, performance management involves setting strategy at the board and executive levels and making day-to-day decisions at the line-manager level. But the process won't work unless those line managers have clearly defined goals to achieve as well as relevant reliable and timely information to assist them in monitoring their performance and making operational decisions to improve outcomes. Modern Healthcare and Pricewaterhouse Coopers present Straight Talk in the tenth installment of Straight Talk we discuss the steps necessary to build a successful performance-management program. The session was held at Modern Healthcare's Chicago head-quarters on January 7, 2003. Charles S. Lauer, publisher of Modern Healthcare, was the moderator.

Changing the healthcare culture: the consumer as part of the system of care

As more information on the poor quality of healthcare becomes available, consumers, purchasers, and health plans are asking questions that will change healthcare delivery and the practices of purchasers. Past practices that include fragmented approaches; fleeting incentives; short-term, transaction-based payment structures; and failure to engage the customer are coming to an end. They are being replaced by collaborative and systemic views. Consumers, through their purchasers of healthcare, are demanding new methods, new metrics, and a higher standard of accountability for all parties. Purchasers themselves are turning up the heat on providers to act with the consumer perspective in mind and are advocating continuous, consumer-driven healthcare delivery.

The occupation of healthcare management: relating core competencies to growth as a distinct profession

There are many questions regarding the education of the healthcare manager. Some would argue that rather than focus on specific issues of core competencies and licensing, the discussion should be directed toward the successful development of healthcare management as a distinct profession. Two elements in defining a profession, education and legal restraints, are particularly relevant to healthcare management. It would be extremely difficult, if not impossible, for healthcare management to achieve recognition as a distinct profession in the traditional sense. There is no unique body of knowledge on which the profession is based, and no mechanism for credentialing to restrict practice. The organizational framework, however, does exist to better position the MHA-prepared graduate as the preferred candidate to manage healthcare organizations. A professional society needs to be identified as the representative society for the generalist healthcare manager. Core competencies should articulate the integration of academics and practice preparation. To accomplish the latter, academic accreditation requirements relating to faculty credentials should encourage practice-based credentials in addition to the current exclusive focus on academic credentials.

Healthcare in Ontario: what has the system learned?

In many ways SARS unmasked some painful truths about our existing system. Throughout the crisis we had to face head-on the unintended outcomes that flow from a healthcare delivery system designed as a series of unconnected silos.

Building upon our values: health care's promises to its patients and communities

Originally presented as an endowed lecture, this paper outlines the values that have always driven health care management and how those values can be used to confront today's challenges. The challenges are discussed in a way that clearly calls for promises to build upon the values that will improve the health care environment and the obligations that health care managers have to fulfill those promises.

A framework for evaluating and continuously improving the NCHL transformational leadership initiative. National Center for Healthcare Leadership

The National Center for Healthcare Leadership transformational leadership project is a broad and ambitious initiative that seeks to bring to the table top leaders from industry and academe. Their charge is to accomplish nothing short of resetting the course for health management education and practice in the coming decades. Four councils were recruited to launch the four major interventions: (1) recruitment and diversity, (2) core competencies, (3) the advanced learning institute, and (4) accreditation and certification. After describing intervention goals, we provide examples of baseline measures for tracking educational and performance outcomes longitudinally. We believe this transformation is only beginning, and it will take many years or decades. The transformation will be most successful if it is guided by data and systematic evaluation.

Toward an understanding of competency identification and assessment in health care management

Given the revolutionary changes occurring in the health care industry, there is increasing agreement that academicians and practitioners must collaborate to identify and prioritize major educational outcomes for health care management. Several competency initiatives have been undertaken or completed in health care and health care management in the last 5 to 7 years. Health care leaders who have undertaken such endeavors reveal that the task is most formidable. This article provides: (1) a summary of progress in competency identification for health management, (2) an historical overview on competency-based education and assessment, (3) a glossary of terms used in discussions on competency-based education and training, and (4) an outline of the challenges and benefits associated with competency modeling.

Managerial Competencies Necessary in Todayʼs Dynamic Health Care Environment

The traditional functions of management--planning, organizing, leading, and controlling--continue to be the key activities used to enable the organization to accomplish its goals and objectives. Though significant changes have occurred in all organizational structures, processes, and managerial styles, these traditional functions remain a constant. What has undergone significant change, as this article examines, are the skills and competencies within each function, which managers must develop and employ if they are to be successful practitioners in today's dynamic health care organizations.

On the value of architecture and facility management in health administration education

This article discusses the role and function of architecture and facility management in health administration education vis-à-vis an interdisciplinary set of courses taught in a graduate-level health administration program. These courses provide the future health care executive with theory and applied knowledge on a variety of topics. These include the history of health care facilities, issues in facility planning and management, principles of patient and staff-focused design, campus master planning, participatory methods to involve end users in the design of their work, and care settings. Additional skills acquired include an introduction to contract negotiations, the reading of technical documents such as blueprints, the post-occupancy assessment of facilities-in-use, and familiarity with future trends. Students address the topic of managerial ethics in relation to the built environment in some detail as a vehicle to illustrate the nature of key fine-grain issues of importance to the health administration scholar and professional. The discussion concludes with the presentation of a model curriculum in this subject area.

A new approach to assessing skill needs of senior managers

Management of health care organizations must improve to meet the well-documented challenges of quality improvement and cost control. Other industries have developed the tools--entry education, mentoring, planned mid-career formal education and experience, and special programs for senior management. The purpose of this paper is to pilot test an alternative method to identify competencies and performance of health care executives. We propose using formal lists of technical, interpersonal, and strategic competencies and specific real events chosen by the respondent to identify and prioritize competencies. Results of a trial with 30 large health care system CEOs and 15 early careerists demonstrate that the method reveals useful depth and detail about managers' educational needs. The results suggest that current thinking about managerial education and learning patterns may be seriously inadequate in several respects. The continued improvement of U.S. health care is a pressing national concern. Quality of care is highly variable and substantially deficient in many institutions (Chassin and Galvin 1998; Committee on Quality of Health Care in America 2001). "Quality improvement should be the essential business strategy for healthcare in the 21st century (Kizer 2001)." Productivity improvements will be essential to balance cost pressures from an aging population and growing technology (Heffler, et al. 2002). Skillful management is necessary to improve quality and productivity. Teams of dozens of caregivers are often required to improve a patient's health. The organizations that provide care have grown larger in response to the greater cost, complexity of operation and finance, and evidence of the success of scale in other industries. While many small professional practices, hospitals, and nursing homes remain, consolidation has created a few dozen provider and intermediary organizations exceeding a billion dollars a year in expenditures. These large health care organizations are, or should be, modern corporate organizations at least as effective as their counterparts in manufacturing, retailing, or finance. To achieve that goal, they will require managers with comparable ability, motivation, and preparation. The National Summit on The Future Of Health Management and Policy Education emphasized the development of "evidence-based management education" by identifying, prioritizing, and measuring mastery of specific skills, knowledge, and abilities (Griffith 2001). Faculty of Association of University Programs in Health Administration (AUPHA) are working with practitioners to identify and prioritize specific learning competencies at the graduate degree level. Their effort focuses on skills teachable in the classroom, and it is expected to lead to measured performance of graduate school cohorts (Griffith 2001). The purpose of this paper is to pilot test an alternative method to identify competencies and performance of health care executives. Although it deliberately draws competency elements from academic sources, it supplements the teachable skills approach with a questionnaire that asks practitioner respondents to identify the skills and knowledge necessary to manage a specific management event and to evaluate the performance of an anonymous colleague against these skills and knowledge.

The balanced scorecard: an incremental approach model to health care management

The balanced scorecard represents a technique used in strategic management to translate an organization's mission and strategy into a comprehensive set of performance measures that provide the framework for implementation of strategic management. This article develops an incremental approach for decision making by formulating a specific balanced scorecard model with an index of nonfinancial as well as financial measures. The incremental approach to costs, including profit contribution analysis and probabilities, allows decisionmakers to assess, for example, how their desire to meet different health care needs will cause changes in service design. This incremental approach to the balanced scorecard may prove to be useful in evaluating the existence of causality relationships between different objective and subjective measures to be included within the balanced scorecard.

Evaluating stakeholder management performance using a stakeholder report card: the next step in theory and practice

In the highly competitive health care environment, the survival of an organization may depend on how well powerful stakeholders are managed. Yet, the existing strategic stakeholder management process does not include evaluation of stakeholder management performance. To address this critical gap, this paper proposes a systematic method for evaluation using a stakeholder report card. An example of a physician report card based on this methodology is presented.

[Recommendations for making quality improvements in administration within local authorities]

OBJECTIVE

To ascertain the methods and issues of industrial administration, that have been systematically chosen by the health and welfare administration in the Iwate Prefectural Government, in order to increase public customer satisfaction.

METHODS

Combined use of TQM and marketing is thought to be the most effective way to increase public customer satisfaction with limited resources. This method secures a quality administrative service capable of corresponding to public needs, by improvement of processes and resources. Therefore we made use of both TQM and marketing.

RESULTS

According to a customer satisfaction survey conducted by Iwate Prefectural Government in May 2001 (mail survey, sent to 234 people, response rate of 88.9%), public customer satisfaction had increased compared to the previous year in the following areas: provision for the elderly, the declining birthrate, disabled persons and universal design. Also, in a policy evaluation conducted during the same year, 207 services were revised and 30 were temporarily closed, abolished or reduced, 20 were merged, and 23 were expanded.

CONCLUSIONS

We cannot sufficiently evaluate the effectiveness of the methods yet because they were only just introduced. However, development of the plan and policy evaluation appear to have been quite effective. From now on we will continue to improve our methods, especially to increase the quality of our administrative resources.

Applying the balanced scorecard in healthcare provider organizations

Several innovative healthcare executives have recently introduced a new business strategy implementation tool: the Balanced Scorecard. The scorecard's measurement and management system provides the following potential benefits to healthcare organizations: It aligns the organization around a more market-oriented, customer-focused strategy It facilitates, monitors, and assesses the implementation of the strategy It provides a communication and collaboration mechanism It assigns accountability for performance at all levels of the organization It provides continual feedback on the strategy and promotes adjustments to marketplace and regulatory changes. We surveyed executives in nine provider organizations that were implementing the Balanced Scorecard. We asked about the following issues relating to its implementation and effect: 1. The role of the Balanced Scorecard in relation to a well-defined vision, mission, and strategy 2. The motivation for adopting the Balanced Scorecard 3. The difference between the Balanced Scorecard and other measurement systems 4. The process followed to develop and implement the Balanced Scorecard 5. The challenges and barriers during the development and implementation process 6. The benefits gained by the organization from adoption and use. The executives reported that the Balanced Scorecard strategy implementation and performance management tool could be successfully applied in the healthcare sector, enabling organizations to improve their competitive market positioning, financial results, and customer satisfaction. This article concludes with guidelines for other healthcare provider organizations to capture the benefits of the Balanced Scorecard performance management system.