Instilling a soul in your organization without losing yours to it

Health-care professionals are accustomed to struggling with ethical considerations brought about by advances in the medical sciences. How aware are these professionals of the ethical dilemmas created by advances in the management sciences? Deeply embedded in organizational and departmental changes are theories, paradigms, and philosophies that often are understood poorly even by their promoters. Although these system changes can occur at glacial speed, they also can be glacial in their effects on an organization's culture. Are individuals aware that the latest implemented management fad is changing their behaviors? By becoming mindful of the potential ramifications of change, individuals increase their ability to behave in a civil manner--that is, ethically choosing to embrace or resist the change. By acting within their own sphere of influence, civil individuals at all levels of the organization collectively instill a soul in their organization rather than losing their own souls to it. This article is adapted from a commencement speech presented to graduates of an executive health-care administration program. Most of these graduates were a mixture of hospital department heads, middle managers, and a few medical and hospital executives. Each year, I distribute my current version of this teaching note or mini-lecture to students completing my leadership class in hope that it will help them put in perspective the appropriate use of the management sciences they intensely study.

IT, patient safety, and quality care

The growing understanding of medical errors as systemic in nature underscores the importance of analyzing and redesigning systems. Best practices in medication safety that promise rapid payback include computerized physician order entry, ongoing tracking and benchmarking, and the creation by leadership of nonpunitive environments where this new culture of safety can thrive.

Decision support: a paradigm addition for patient safety

The creation of a decision culture that matches the "decision intensity" of the healthcare field is not a paradigm shift but rather a paradigm addition that properly addresses all aspects of information, from how it is delivered to how it is managed. These changes will take healthcare beyond its current emphasis on efficient transaction systems to reach safe and effective clinical decision environments, which cannot be achieved with transaction mentalities and processes.

Managing system errors and failures in health care organizations: suggestions for practice and research

The inherent design of health delivery systems predisposes them to errors and gradual rates of improvement. Health care executives and researchers should understand the importance of system errors and the role of leadership in removing perturbations that adversely affect health care organization performance. This article presents insights on strategies for addressing system errors and for reducing the magnitude of the problem.

The role of performance referents in health services organizations

Health care executives rely on a variety of information sources to evaluate organizational performance. This is because outcomes take on meaning only when compared to referents, or standards of comparison. Although performance referents are widely acknowledged to be important, consideration of their relevance to health services management has been minimal. To address this need, we draw on organizational theories and observations from health services organizations to describe the use of performance referents and to provide insights about the possible effects of performance referent selection on strategic choices and performance.

Program revision: a dynamic outcome of evaluation

This critical review of program revision processes is guided by the program management model and considers issues germane to community-oriented health care programs, illustrated by examples from the literature. Options for program revision lie on a continuum from discontinuing a program, to various degrees of adjustments, to no change. Sustainability is the ultimate issue that must be addressed, and community and staff participation is critical for successful program revision.

Integrating knowledge workers and the organization: the role of IT

Agency theory is primarily concerned with the relationship between the principal (employer/purchaser) and the agent (employee/contractor) in the issue of goal-aligned behavior. Jensen and Meckling and others were not referring to a knowledge worker agent in their conceptualization of the principal/agent relationship. The significance of having a knowledge worker agent is that the decision rights are no longer located with the principal but with the agent. This in turn has a tremendous bearing on goal alignment and agency problems. We propose that information systems/information technology (IS/IT), in particular enterprise wide systems, can alleviate these agency problems. We illustrate this through a case example from health care, an industry with a high proportion of knowledge worker agents.

The relationship between continuous quality improvement and research

The adoption of new care processes can take years despite high-quality research findings that support the change in clinical practice. Healthcare quality professionals, with their leadership and continuous quality improvement (CQI) skills, are critical champions in accelerating and supporting the change toward evidence-based practice. Heightened attention to the relationship between CQI, research, and research utilization is vital. This article addresses CQI strategies and research activities that can help organizations advance quality of care and patient outcomes. By broadening their repertoire of CQI methods, healthcare quality professionals can provide more value to their organizations and expand the complex problems and projects that CQI teams can manage.

Improving competitiveness through performance-measurement systems

Parallels exist between the competitive pressures felt by U.S. manufacturers over the past 30 years and those experienced by healthcare providers today. Increasing market deregulation, changing government policies, and growing consumerism have altered the healthcare arena. Responding to similar pressures, manufacturers adopted a strategic orientation driven by customer needs and expectations that led them to achieve high performance levels and surpass their competition. The adoption of integrated performance-measurement systems was instrumental in these firms' success. An integrated performance-measurement model for healthcare organizations can help to blend the organization's strategy with the demands of the contemporary healthcare environment. Performance-measurement systems encourage healthcare organizations to focus on their mission and vision by aligning their strategic objectives and resource-allocation decisions with customer requirements.

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.

Identifying management competencies for health care executives: review of a series of Delphi studies

This analysis reviews a selected body of research that identifies the essential areas of management expertise required of future health care executives. To ensure consistency, six studies are analyzed, utilizing the Delphi technique, to query a broad spectrum of experts in different fields and sites of health care management. The analysis identifies a number of management competencies, i.e., managerial capabilities, which current and aspiring health care executives, in various settings and with differing educational backgrounds, should possess to enhance the probability of their success in current and future positions of responsibility. In addition, this review identifies the skills (technical expertise), knowledge (facts and principles) and abilities (physical, mental or legal power) required to support achievement of these competencies. Leadership and resource management, including cost and finance dimensions, are the highest-rated requisite management competencies. The dominant skills, knowledge and abilities (SKAs) are related to interpersonal skills. The lowest-rated SKAs are related to job-specific, technical skills. Recommendations include the review of this research by formal and continuing education programs to determine the content of their courses and areas for future research. Similarly, current health care executives should assess this research to assist in identifying competency gaps. Lastly, this analysis recommends that the Delphi technique, as a valid and replicable methodology, be applied toward the study of non-executive health care managers, e.g., students, clinicians, mid-level managers and integrated systems administrators, to determine their requisite management competencies and SKAs.

Environmental and organizational determinants of quality management

The aim of the study was to obtain more insight into the organizational and environmental determinants of the implementation of quality management in health care organizations. Primary survey data were collected in 1995 in a large nationwide study within 15 fields of health care and health care-related social services in The Netherlands. In general, there are more differences between health care organizations than between fields of health care. Environmental influence was found to be less important than was expected. Care-oriented organizations have a greater opportunity to involve their patients. It seems that apart from patients, the perceived pressure from other third parties has little influence on the implementation of quality management in health care organizations.

Applying quality improvement principles to achieve healthy work organizations

BACKGROUND

Health care has used total quality management (TQM)/quality improvement (QI) methods to improve quality of care and patient safety. Research on healthy work organizations (HWOs) shows that some of the same work organization factors that affect employee outcomes such as quality of life and safety can also affect organizational outcomes such as profits and performance. An HWO is an organization that has both financial success and a healthy workforce. For a health care organization to have financial success it must provide high-quality care with efficient use of scarce resources. To have a healthy workforce, the workplace must be safe, provide good ergonomic design, and provide working conditions that help to mitigate the stress of health care work.

INTEGRATING TQM/QI INTO THE HWO PARADIGM

If properly implemented and institutionalized, TQM/QI can serve as the mechanism by which to transform a health care organization into an HWO. To guide future research, a framework is proposed that links research on QI with research on HWOs in the belief that QI methods and interventions might be an effective means by which to create an HWO. Specific areas of research should focus on identifying the work organization, cultural, technological, and environmental factors that affect care processes; affect patient health, safety, and satisfaction; and indirectly affect patient health, safety, and satisfaction through their effects on staff and care process variables.

SUMMARY

Integrating QI techniques within the paradigm of the HWO paradigm will make it possible to achieve greater improvements in the health of health care organizations and the populations they serve.

The forgotten component of the quality triad: can we still learn something from "structure"?

BACKGROUND

Quality assessment was founded on structural measures, such as accreditation status of facilities, credentialing of providers, and type of provider. Recent efforts in measures development have focused on processes and outcomes because research has suggested that structural measures are not strong markers of the quality of care at the health plan or provider levels. Nevertheless, the literature on the quality of health care contains a number of examples illustrating the potential application of structural measures to the assessment of quality. The continued development of measures of structure-which would at least measure aspects of the physical environment, working conditions, organizational culture, and provider satisfaction--may be helpful because generalizing from studies of process and outcome requires specification of the conditions under which these linkages are found.

A ROAD MAP FOR MEASURES DEVELOPMENT

The Leapfrog Group of large purchasers has promoted the application of three patient safety "leaps" that are, in essence, structural measures: the use of computerized physician order entry, the selective referral of patients to high-volume providers for certain procedures, and the availability of board-certified critical care specialists in intensive care units. Structural measures, like process and outcomes measures, face the same challenges of standardization, reliability, validity, and portability. Field testing of potential measures will be required to examine the feasibility and added value of these measures in real-world settings.

CONCLUSION

Research to date suggests that a new cadre of structural measures of health care quality, which have largely been overlooked in the recent measures development boom, have the potential to fill in important gaps in our ability to assess quality.

Does a healthy health care workplace produce higher-quality care?

BACKGROUND

The multiagency Quality Interagency Coordination Task Force (QuIC) coordinates activities and plans for quality measurement and improvement across all the U.S. federal agencies involved in health care. One of its working groups focuses on the health care workforce and ways to improve the quality of care that it provides. In October 1999 four government agencies, under the aegis of the QuIC, convened a conference to examine how health care workplace quality influences the quality of care. A healthy workplace is one in which workers will be able to deliver higher-quality care and in which worker health and patients' high-quality care are mutually supportive. In October 2000 a follow-up conference was held to focus on a specific aspect of health care quality-patient safety.

WHAT WE STILL NEED TO KNOW

Although enough is known to justify some initiatives to improve the quality of the health care workplace, participants in both meetings agreed that the evidence to prove these associations is weak and that there has been too little research to evaluate the impact of interventions intended to improve quality through improvements in the health care workplace. New evidence-based information is needed to test the theory of the nature of the relationship between working conditions and care quality.

CONCLUSION

The tradition of evidence-based decision making needs to be applied to health care management as it has in medicine and nursing, to show how staffing, environment, organization, and culture can each can affect the quality of care.

The impact of staffing and the organization of work on patient outcomes and health care workers in health care organizations

BACKGROUND

Numerous reports in the popular press express concern about the restructuring or lowering of staffing levels in health care organizations and the impact on the quality of patient care. Overtime and other extended shifts also represent work stresses for health care workers. This article reviews the research literature on the relationships among staffing, organization of work, and patient outcomes, and it discusses research findings on the relationship between staffing and the health of health care workers. RESEARCH ON STAFFING, ORGANIZATION, AND PATIENT OUTCOMES/STAFF WELL-BEING: Safe staffing level requirements have been identified for nursing homes, but only in extremely limited cases for hospitals, home care, or other health settings. There is little information about the impact of staffing levels and the organization of work on health personnel or on patient outcomes. There is almost no information about staffing and patient outcomes in home health and ambulatory care. Much of the research on staffing and quality has been discipline specific; future research should reflect the interdisciplinary nature of health care delivery rather than the impact of a particular occupation.

RESEARCH USE

Research is conducted to increase the scientific base per se and to inform decision making. Who should decide staffing levels and the organization of work? Professionals, employers/owners, the government, and consumers all have significant interest in staffing levels and the organization of care. Improving health care quality requires research about the critical staffing and organization of work variables. This requires obtaining appropriate data, conducting the research, and widely disseminating the findings.

If improvement of the quality and value of health and health care is the goal, why focus on health professional development?

Connecting organization and issue-centered strategies for the improvement of health care with health professional development strategies offers an exciting opportunity for the next efforts to improve health care.

Managing strategic outsourcing in the healthcare industry

Hospitals and healthcare systems are facing increased financial difficulties because of the Balanced Budget Act of 1997 and managed care. As a result, healthcare executives face the challenge of reducing costs while maintaining quality patient care. One of the strategic tools healthcare executives use to meet this challenge is outsourcing. Even though outsourcing has many benefits, outsourcing will fail if not managed successfully. Senior executives must choose outsourcing managers who have the necessary leadership capabilities. Managing outsourcing requires an understanding of outsourcing strategy, the benefits and risks of outsourcing, the evaluation process, and the methods to managing strategically. With appropriate management, strategic outsourcing should provide healthcare executives with a viable strategy for controlling costs and maintaining quality patient care.

Restraint, seclusion standards raise questions

Several of the Joint Commission's new restraint and seclusion standards have prompted caregivers to seek additional clarification.

Reducing health care risk. The challenge is to make everyone feel accountable

Are employees punished or praised for acknowledging errors, raising concerns about safety, or identifying recurrent medical mishaps? To reduce risk, managers must promote a safety culture where everyone shares a sense of accountability and takes responsibility for high-quality care.

Ensuring management excellence in the healthcare system

We believe that if we improve healthcare management, we will improve quality, reduce cost, and open opportunities to expand access. The present support for healthcare management, however, needs improvement in every aspect. Beginning with attracting young people, progressing through entry education, continuing education, and the special preparation for senior management, what we need overall is a program of continuous improvement. We need specific goals, measures of how well we achieve those goals, and accountability for that achievement. We need programs that attract and reward excellence and that make mediocrity untenable. The purpose of this article is to identify and expand the elements of such a program.