Strategic groups and performance differences among academic medical centers

Inventory and analysis of literature on the organisation of eight European academic medical centres-A scoping review

Academic Medical Centres (AMCs) are important organisations for shaping healthcare. The purpose of this scoping review is to understand the scope and type of evidence related to the organisation of European AMCs. We selected the study population intending to obtain a demographic cross-section of European countries: Czech Republic, Germany, Latvia, the Netherlands, Poland, Spain, Sweden and the UK. We focused our search strategy on the relationship between medical schools and AMCs, the organisation of governing bodies, and legal ownership. We searched the bibliographic databases of PubMed and Web of Science (most recent search date 17-06-2022). To enrich the search result, we used Google search engines to conduct targeted searches for relevant websites. Our search strategy yielded 4,672 records for consideration. After screening and reviewing full-text papers, 108 sources were included. Our scoping review provided insight into the scope and type of evidence related to the organisation of European AMCs. Limited literature is available on the organisation of these AMCs. Information from national-level websites complemented the literature and provided a more complete picture of the organisation of European AMCs. We found some meta-level similarities regarding the relationship between universities and AMCs, the role of the dean and the public ownership of the medical school and the AMC. In addition, we found several reasons why a particular organisational and ownership structure was chosen. There is no uniform model for AMC organisations (apart from some meta-level similarities). Based on this study, we cannot explain the diversity in these models. Therefore, further research is needed to explain these variations. For example, by generating a set of hypotheses through in-depth case studies that also focus on the context of AMCs. These hypotheses can then be tested in a larger number of countries.

Measuring the academic value of academic medical centers: describing a methodology for developing an evaluation model at one Academic Medical Center

Background

Academic Medical Centers (AMCs) must simultaneously serve different purposes:

Delivery of high quality healthcare services to patients, as the main mission, supported by other core missions such as academic activities, i.e., researching, teaching and tutoring, while maintaining solvency.

This study aims to develop a methodology for constructing models evaluating the academic value provided by AMCs and implementing it at the largest AMC in Israel.

Methods

Thirty five practiced educators and researchers, academic experts, faculty members and executives, all employed by a metropolitan 1500-bed AMC, were involved in developing academic quality indicators. First, an initial list of AMCs’ academic quality indicators was drafted, using a literature review and consulting scholars. Afterwards, additional data and preferences were collected by conducting semi-structured interviews, complemented by a three-round Delphi Panel. Finally, the methodology for constructing a model evaluating the academic value provided by the AMC was developed.

Results

The composite academic quality indicators methodology consists of nine indicators (relative weight in parentheses): ‘Scientific Publications Value’ (18.7%), ‘Completed Studies’ (13.5%), ‘Authors Value’ (13.0%), ‘Residents Quality’ (11.3%), ‘Competitive Grants Budget’ (10.2%), ‘Academic Training’ (8.7%), ‘Academic Positions’ (8.3%), ‘Number of Studies’ (8.3%) and ‘Academic Supervision’ (8.0%).

These indicators were grouped into three core categories: ‘Education’, ‘Research’ and ‘Publications’, having almost the same importance on a scale from zero to one (0–1), i.e., 0.363, 0.320, and 0.317, respectively. The results demonstrated a high level of internal consistency (Cronbach-alpha range: 0.79–0.86).

Conclusions

We have found a gap in the ability to measure academic value provided by AMCs. The main contribution of this research is the development of methodology for constructing evaluation models for AMCs academic performance. Further studies are needed to further test the validity and reliability of the proposed methodology at other sites.

Electronic supplementary material

The online version of this article (10.1186/s13584-019-0334-4) contains supplementary material, which is available to authorized users.

Strategies of High-Performing Teaching Hospitals

Teaching hospitals are large and complex, and under constant financial pressure. In this study, we examine the financial performance of 80 large teaching hospitals in the 20 largest cities in the U.S. over the last five years, to identify which strategic and operational management factors separate high-performing hospitals from lower-performing ones. Results suggest that growth strategies should continue to be sought for improving long-term financial condition. Operational efficiency was less important than market share, economic status of surrounding community, hospital size, and teaching intensity. This study's findings should help guide strategic planning for teaching hospitals.

Organisational benefits of a strong research culture in a health service: a systematic review

Objective The aim of the present study was to determine whether there is an association between having research culture in a health service and better organisational performance. Methods Using systematic review methods, databases were searched, inclusion criteria applied and study quality appraised. Data were extracted from selected studies and the results were synthesised descriptively. Results Eight studies were selected for review. Five studies compared health services with high versus low levels of research activity among the workforce. Three studies evaluated the effect of specific interventions focused on the health workforce. All studies reported a positive association between research activity and organisational performance. Improved organisational performance included lower patient mortality rates (two of two studies), higher levels of patient satisfaction (one of one study), reduced staff turnover (two of two studies), improved staff satisfaction (one of two studies) and improved organisational efficiency (four of five studies). Conclusions A stronger research culture appears to be associated with benefits to patients, staff and the organisation. What is known about this topic? Research investment in the health workforce can increase research productivity of the health workforce. In addition, investment in clinical research can lead to positive health outcomes. However, it is not known whether a positive research culture among the health workforce is associated with improved organisational performance. What does this paper add? The present systematic review of the literature provides evidence that a positive research culture and interventions directed at the health workforce are associated with patient, staff and organisational benefits. What are the implications for practitioners? For health service managers and policy makers, one interpretation of the results could be to provide support for initiatives directed at the health workforce to increase a research culture in health services. However, because association does not imply causation, managers need to interpret the results with caution and evaluate the effect of any initiatives to increase the research culture of the health workforce on the performance of their organisation.

Comparison between a multi-pavilion hospital and a single pavilion hospital

Background and aim

Defining and measuring hospital efficiency is a hard task, in spite of the agreement that hospitals need to be efficient. Thus, while research might focus on the relationship between costs and outcomes, measurements differ significantly across studies.

The aim of the present study is to compare a multi-pavilion hospital with a single hospital from Cluj-Napoca, Romania.

Methods

Statistical and financial (effective expenses, salaries, drugs, materials, reagents, food) indicators were used to compare two hospitals from Cluj-Napoca: the Adults’ Clinical Hospital in Cluj-Napoca, and the Rehabilitation Hospital from Cluj-Napoca respectively. Data related to these indicators were collected at each hospital level, between 2004 and 2010.

Results

When investigating the expenses on medicine, data showed the two hospitals had similar values in 2004, 13.09% and 14.43% for the multi-pavilion hospital and single hospital, respectively. After 2004, the expenses started to drop simultaneously, being around 11% in 2006 and 2007 for both hospitals. The mortality rate was significantly different for the two hospitals. The multi-pavilion had a much higher mortality rate, when compared to the single hospital. From 2004 until 2007 a steady increase was observed for the multi-pavilion hospital, from 1.09 to 2.57 respectively.

Conclusion

The significant differences found between the two hospitals look being unavoidable, as long as they seem to stem from the hospitals’ ownership, their addressability and their targeted diseases and associated procedures.

Engagement in research: an innovative three-stage review of the benefits for health-care performance

Background

There is a widely held assumption that research engagement improves health-care performance at various levels, but little direct empirical evidence.

Objectives

To conduct a theoretically and empirically grounded synthesis to map and explore plausible mechanisms through which research engagement might improve health services performance. A review of the effects on patients of their health-care practitioner's or institution's participation in clinical trials was published after submission of the proposal for this review. It identified only 13 relevant papers and, overall, suggested that the evidence that research engagement improves health-care performance was less strong than some thought. We aimed to meet the need for a wider review.

Methods

An hourglass review was developed, consisting of three stages: (1) a planning and mapping stage; (2) a focused review concentrating on the core question of whether or not research engagement improves health care; and (3) a wider (but less systematic) review of papers identified during the two earlier stages. Studies were included inthe focused review if the concept of ‘engagementinresearch’ was an input and some measure of ‘performance’ an output. The search strategy covered the period 1990 to March 2012. MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science and other relevant databases were searched. A total of 10,239 papers were identified through the database searches, and 159 from other sources. A further relevance and quality check on 473 papers was undertaken, and identified 33 papers for inclusion in the review. A standard meta-analysis was not possible on the heterogeneous mix of papers in the focused review. Therefore an explanatory matrix was developed to help characterise the circumstances in which research engagement might improve health-care performance and the mechanisms that might be at work, identifying two main dimensions along which to categorise the studies:the degree of intentionalityandthe scope of the impact.

Results

Of the 33 papers in the focused review, 28 were positive (of which six were positive/mixed) in relation to the question of whether or not research engagement improves health-care performance. Five papers were negative (of which two were negative/mixed). Seven out of 28 positive papers reported some improvement in health outcomes. For the rest, the improved care took the form of improved processes of care. Nine positive papers were at a clinician level and 19 at an institutional level. The wider review demonstrated, for example, how collaborative and action research can encourage some progress along the pathway from research engagement towards improved health-care performance. There is also evidence that organisations in which the research function is fully integrated into the organisational structure out-perform other organisations that pay less formal heed to research and its outputs. The focused and wider reviews identified the diversity in the mechanisms through which research engagement might improve health care: there are many circumstances and mechanisms at work, more than one mechanism is often operative, and the evidence available for each one is limited.

Limitations

To address the complexities of this evidence synthesis of research we needed to spend significant time mapping the literature, and narrowed the research question to make it feasible. We excluded many potentially relevant papers (though we partially addressed this by conducting a wider additional synthesis). Studies assessing the impact made on clinician behaviour by small, locally conducted pieces of research could be difficult to interpret without full knowledge of the context.

Conclusions

Drawing on the focused and wider reviews, it is suggested that when clinicians and health-care organisations engage in research there is the likelihood of a positive impact on health-care performance. Organisations that have deliberately integrated the research function into organisational structures demonstrate how research engagement can, among other factors, contribute to improved health-care performance. Further explorations are required of research networks and schemes to promote the engagement of clinicians and managers in research. Detailed observational research focusing on research engagement within organisations would build up an understanding of mechanisms.

Study registration

PROSPERO: CRD42012001990.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

The association of strategic group and organizational culture with hospital performance in China

BACKGROUND

The policy environment in China is rapidly changing. Strategic planning may enable hospitals to respond more effectively to changes in their external environment, little evidence exists on the extent to which public hospitals in China adopt different strategies and the relationship between strategic decision-making and hospital performance.

PURPOSES

The purposes of our study were to determine the extent to which different hospitals adopt different strategies, whether strategies are associated with organizational culture and whether hospital strategies are associated with hospital performance.

METHODOLOGY

Presidents (or vice presidents), employees, and patients from 87 public hospitals were surveyed during 2009. Measures of strategic group were developed using cluster analysis based on the three dimensions of product position, competitive posture, and market position. Culture was measured using a tool developed by the investigators. Performance was measured based on profitability, patient satisfaction, and employee satisfaction with overall hospital development in the recent 5 years. The association of strategic group and organizational culture with hospital performance was analyzed using multivariate models.

FINDINGS

Chinese public general hospitals were classified into five strategic groups that had significant differences in product positioning, competitive posture, and market position. Hospitals of similar types based on regulation adopted different strategies. Organizational culture was not strongly associated with hospital strategic group. Although strategic group was associated with hospital profitability and patient satisfaction in the models with or without control for hospital location, these effects did not persist after controlling for organizational culture, hospital level, and hospital location.

PRACTICE IMPLICATIONS

It is important for public hospitals in China to make effective strategic planning and align their organizational culture with the strategies for better execution and therefore better performance. Moreover, the method of hospital strategic grouping in the study provides a new way to analyze management issues within a strategic group and between strategic groups.

Effects of morning report case presentation on length of stay and hospitalisation costs

CONTEXT

The primary goal of discussing patient cases during the morning report is to teach appropriate clinical decision making. In addition, the selection of the best diagnostic strategy and application of evidence-based patient care are important. Reducing hospital costs is fundamental to controlling inflation in health care costs, especially in university hospitals that are subject to budget constraints in developing countries. The goal of this study was to explore the effect of morning report case presentation on length of stay (LoS) and hospitalisation costs in a university teaching hospital.

METHODS

A total of 54 patients whose cases had been presented at morning report sessions in the department of internal medicine during a 3-month period (presented group) were selected and their medical records reviewed for data on final diagnosis, hospital LoS and detailed hospital costs. A control group of 104 patients, whose cases had not been presented, were selected on the basis that their final diagnoses matched with those of the presented group. In addition, the groups were matched for age, sex, occupation, comorbidities and insurance coverage. Final diagnoses were based on International Classification of Disease 10 (ICD-10) diagnostic code criteria.

RESULTS

The mean ± standard deviation (SD) hospital LoS was 8.32 ± 4.11 days in the presented group and 10.46 ± 4.92 days in the control group (p = 0.045). Mean ± SD hospitalisation costs per patient were significantly lower in the presented group (US$553.43 ± 92.16) than the control group (US$1621.93 ± 353.14) (p = 0.004). Although costs for paraclinical services were similar, there were very significant reductions in costs for medications used during hospitalisation and bed-days (p = 0.002).

CONCLUSIONS

Discussing clinical aspects of patient cases in morning report sessions facilitates the management process and has a significant effect on LoS and hospitalisation costs in patients admitted to hospital.

Positioning matrix of economic efficiency and complexity: a case study in a university hospital

At the end of 2010, the Federico II University Hospital in Naples, Italy, initiated a series of discussions aimed at designing and applying a positioning matrix to its departments. This analysis was developed to create a tool able to extract meaningful information both to increase knowledge about individual departments and to inform the choices of general management during strategic planning. The name given to this tool was the positioning matrix of economic efficiency and complexity. In the matrix, the x-axis measures the ratio between revenues and costs, whereas the y-axis measures the index of complexity, thus showing "profitability" while bearing in mind the complexity of activities. By using the positioning matrix, it was possible to conduct a critical analysis of the characteristics of the Federico II University Hospital and to extract useful information for general management to use during strategic planning at the end of 2010 when defining medium-term objectives.

A FUZZY DATA ENVELOPMENT ANALYSIS FOR CLUSTERING OPERATING UNITS WITH IMPRECISE DATA

Data envelopment analysis (DEA) is a non-parametric method for measuring the efficiency of peer operating units that employ multiple inputs to produce multiple outputs. Several DEA methods have been proposed for clustering operating units. However, to the best of our knowledge, the existing methods in the literature do not simultaneously consider the priority between the clusters (classes) and the priority between the operating units in each cluster. Moreover, while crisp input and output data are indispensable in traditional DEA, real-world production processes may involve imprecise or ambiguous input and output data. Fuzzy set theory has been widely used to formalize and represent the impreciseness and ambiguity inherent in human decision-making. In this paper, we propose a new fuzzy DEA method for clustering operating units in a fuzzy environment by considering the priority between the clusters and the priority between the operating units in each cluster simultaneously. A numerical example and a case study for the Jet Ski purchasing decision by the Florida Border Patrol are presented to illustrate the efficacy and the applicability of the proposed method.

Applying the Balanced Scorecard approach in teaching hospitals: a literature review and conceptual framework

Teaching hospitals (THs) simultaneously serve three different roles: offering medical treatment, teaching future doctors and promoting research. The international literature recognises such organisations as 'peaks of excellence' and highlights their economic function in the health system. In addition, the literature describes the urgent need to manage the complex dynamics and inefficiency issues that threaten the survival of teaching hospitals worldwide. In this context, traditional performance measurement systems that focus only on accounting and financial measures appear to be inadequate. Given that THs are highly specific and complex, a multidimensional system of performance measurement, such as the Balanced Scorecard (BSC), may be more appropriate because of the multitude of stakeholders, each of whom seek a specific type of accountability. The aim of the paper was twofold: (i) to review the literature on the BSC and its applications in teaching hospitals and (ii) to propose a scorecard framework that is suitable for assessing the performance of THs and serving as a guide for scholars and practitioners. In addition, this research will contribute to the ongoing debate on performance evaluation systems by suggesting a revised BSC framework and proposing specific performance indicators for THs.

Health Care Delivery Restructuring and Productivity Change: Assessing the Veterans Integrated Service Networks (VISNs) Using the Malmquist Approach

This study evaluates the productivity changes for the Veterans Integrated Service Networks (VISNs) that the Veterans Health Administration (VHA) created, comparing performance in 1994 with that in 2004. This represents periods before and after the VHA in 1995 reconfigured provider units into 21 regionalized delivery systems and engaged in other important system innovations. Productivity is measured using the Malmquist Index approach (a longitudinal version of the data envelopment analysis [DEA]). Results indicate that the VISN restructuring generally produced improvements in overall productivity (Malmquist scores) and in VISN adaptations to structural/technological change. They also show that the VISNs overall did not produce “changes in efficiency,” reflecting challenges they may have faced in making “technical change” through management adaptations. The findings are consistent with what would be expected, given the major changes that did occur within the VHA in recent years as well as the before and after design used in this study.