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

Chain Hospitals in the Health Industry: A Scoping Review of Principles and Definitions

In order to provide quality and cost-effective health care, hospitals have used a variety of organizational models. Chain hospitals are one type of organization and service delivery model. Based on the diversity, multiplicity, and ambiguous nature of concepts related to chain hospitals, this study is an attempt to explain the concepts and components of such hospitals. Five main databases were searched for this purpose. Scopus, PubMed, WOS, ProQuest, and Wiley library databases were accessed from inception to September 2022. English-language studies describing chain hospital models were included. Two independent authors screened full-text papers, and data were extracted using a self-designed form. A thematic analysis was used to identify key components of the chain hospitals. A total of 38 papers from 8472 documents met the inclusion criteria and were included in the study. Among the selected studies, there were 23 quantitative studies, 6 qualitative studies, 5 mixed studies, 3 review studies, and 1 gray report. A review of the results revealed 55 different definitions of chain hospitals, as well as 6 main components and 16 subcomponents. Among the extracted components, 60% were related to the organization dimension, 15% to governance, 9% to decision rights, 8% to policies and procedures, and 4% to service delivery. In order to launch a multihospital system involving chain hospitals in a country, it is necessary first to define the concept of this hospital. The study's findings should be used by policymakers and officials in each country before implementing an inter-hospital cooperation system (MHS, chain hospital, etc.). Future researchers may also find inspiration in the study's findings and focus on these hospitals' establishment, effectiveness, and financial effects.

Defining the functions of public health governance

We conducted a literature review in 2011 to determine if accepted governance functions continue to reflect the role of public health governing entities. Reviewing literature and other source documents, as well as consulting with practitioners, resulted in an iterative process that identified 6 functions of public health governance and established definitions for each of these: policy development; resource stewardship; continuous improvement; partner engagement; legal authority; and oversight of a health department. These functions provided context for the role of governing entities in public health practice and aligned well with existing public health accreditation standards. Public health systems research can build from this work in future explorations of the contributions of governance to health department performance.

Governance forms in health systems and health networks

Debates about the relative advantages of health systems versus more loosely structured health networks have largely ignored issues of how these different organizational forms are governed. Based on comparisons of two large samples of health systems and health networks, our findings indicate that the majority of both types of organized delivery systems have governing bodies separate from those of affiliate organizations, high proportional representation by affiliate organizations, and similar board size.

On a hiding to nothing? Assessing the corporate governance of hospital and health services in New Zealand 1993-1998

In New Zealand the governance of public sector hospital and health services has changed significantly over the past decade. For most of the century hospitals had been funded by central government grants but run by locally elected boards. In 1989 a reforming Labour government restructured health services along managerialist lines, including changing governance structures so that some area health board members were government appointments, with the balance elected by the community. More market oriented reform under a new National government abolished this arrangement and introduced (1993) a corporate approach to the management of hospitals and related services. The hospitals were established as limited liability companies under the Companies Act. This was an explicitly corporate model and, although there was some modification of arrangements following the election of a more politically moderate centre-right coalition government in 1996, the corporate model was largely retained. Although significant changes occurred again after the election of a Labour government in 1999, the corporate governance experience in New Zealand health services is one from which lessons can, nevertheless, be learnt. This paper examines aspects of the performance and process of corporate governance arrangements for public sector health services in New Zealand, 1993-1998.

Community control and pricing patterns of nonprofit hospitals: An antitrust analysis

Traditional control of nonprofit hospitals by the communities they serve has been offered as justification for restraining antitrust enforcement of mergers that involve nonprofit hospitals. The community is arguably a constraint on a nonprofit's inclination to exercise market power in the form of higher prices; however, community control is likely to be attenuated for hospitals that through merger or acquisition become members of hospital systems--particularly those that operate on a regional or multiregional basis. We report findings from a study in which we examined empirically the relationship between market concentration and pricing patterns for three types of nonprofit hospitals that are distinguishable based on degree of community control: an independent hospital, a member of a local hospital system, and a member of a nonlocal hospital system. Study results indicated that when conditions existed to create a more concentrated market, (1) all three types of nonprofit hospitals exercised market power in the form of higher prices, and (2) hospitals that were members of nonlocal systems were more aggressive in exercising market power than were either independent or local system hospitals. The results have important implications for antitrust enforcement policy.

A broader vision for managed care, Part 1: Measuring the benefit to communities

For the past quarter-century managed care plans have been judged almost exclusively in terms of their influence on the health and health care of individual enrollees. However, policymakers are now paying attention to the ways in which health care organizations affect the broader well-being of their communities. These forms of "community benefit" emerged originally from legal criteria for tax exemption but are increasingly applied to all health care organizations, whatever their form of ownership. In this paper we identify different paradigms for defining community benefit and trace the factors that have encouraged or discouraged their application to health care. We suggest several strategies encouraging managed care plans to broaden their goals to include community benefit.

Governing integrated health delivery systems: meeting accountability requirements

Many Canadian provincial governments are exploring methods to increase the integration of health services in an effort to improve the care provided, while maintaining or reducing the costs. Integrated health delivery systems are being implemented in the United States, Britain and other European countries. Such systems aim to provide a full continuum of care to a defined target population under a financing system of capitation. This article explores the issues associated with the governance accountabilities of an IDS. A review of potential governance models is completed, and the factors that influence the choice of a governance model for an integrated delivery system are presented. In 1987. Ewell identified governing boards as the weakest link in the integrated health care systems of the United States. It is suggested that early attention to governance in the development of IDS models in Canada may improve the effectiveness of these systems.

Review of the multi-hospital arrangements literature: benefits, disadvantages and lessons for implementation

The multi-hospital arrangements literature is reviewed for Canada and the United States. There is a notable lack of evaluations on the outcomes of these arrangements, especially in the Canadian context. For evaluations that do make it to the literature, generalizability of conclusions is difficult because most is based on case studies and relates to "for-profit" U.S. hospitals. We are forced to conclude, however, that there is little definitive evidence that quality of care is improved by multi-hospital arrangements or to support or refute the claims of better human resources deployment. The most striking organizational benefit appears to be that institutions considering merger or other arrangements are forced into explicit considerations of their mission and goals. Many of the potential disadvantages of multi-hospital arrangements may be ameliorated with appropriate strategic planning and attention to detail during negotiation of the arrangement. As new multi-institutional arrangements may cause harm as well as reap benefits, careful evaluation is needed.

Governing boards and profound organizational change in hospitals

Over the past decade the importance of governing boards as policy-making setting and oversight units within organizations has increased dramatically. Although this is true for both corporate- and private-sector organizations (Bacon and Brown 1977; Gelman 1988), it is particularly relevant to the health sector. Hospital governing boards, long considered inconsequential in hospital management, have recently become subject to closer scrutiny. The role of governing boards in decisions affecting hospital strategy and hospital performance is once again a topic of some interest in boardrooms and hospital trade journals. Impressive evidence of the renewed interest in governance is provided by the funding of an instructional consortium by the S.K. Kellogg Foundation to help strengthen trusteeship and governing board decision making, and to improve education for health services managers in the area of governance. Members of the consortium include the Hospital Research and Educational Trust, the American Hospital Association, the American College of Healthcare Executives, and the Association for University Programs in Health Administration. Among the activities being undertaken by this consortium is the development of a self-assessment tool/methodology for boards, a bibliography and reference guide on effective governance for practicing trustees, research workshops for faculty in health administration programs, and a teaching guide on governance and trustee leadership. Despite this interest, the question with which we began this article persists. Do governing boards make a difference? In the course of our review of previous work on governance we found that, more often than not, that question has been transformed into: how do boards influence hospital performance? And very often that question has been further narrowed into: which board structure leads to better hospital performance? We have argued for a respecification of the initial question. Rather than pursuing a definition of the maximally performing governing board, we should perhaps shift our focus back to a fuller understanding of board structure and function, and its influence on hospital change. The model developed here combines four essential, and very basic, questions: 1. What are the basic dimensions that underlie structural variation in different types of governing boards? 2. How do these board types influence structural change in hospitals? 3. How is the effect of board influence on change itself likely to change over time as a function of the hospital's general pattern of growth, decline, stability, or instability?(ABSTRACT TRUNCATED AT 400 WORDS)

[Multihospital systems and their reality in Catalonia]

The objective of this article is to compare the development of hospital systems in USA with multi-hospitals or other hospital association formulas that currently exist in Catalonia. Our purpose is to check if the theory, that has influenced the development of these hospital systems in US is consistent with the hospital systems in Catalonia, specifically in the cases of: Consorci Hospitalari de Catalunya, Unió Catalana d'Hospitals, future Consorci d'Hospitals de Barcelona, among others. In addition we analyze the consequences that would appear if the Public Hospital Network of Catalonia (xarxa hospitalaria d'utilització pública: XHUP) (1) is considered as a hospital system; that is, considering this Hospital Network as a hospital system in coexistence with other preexistent hospitals, could take advantage in the financial management as well as in the introduction in the market simulation systems to stimulate the efficiency in the provision of public hospitals.