Consequences of organizational change in U.S. hospitals

Rapid improvement in organ procurement organization performance: Potential for change and impact of new leadership

Recently proposed rulemaking from Centers for Medicare and Medicaid Services would change how organ procurement organizations (OPOs) are evaluated. The proposals include using national inpatient death data to define a standardized denominator to calculate comparable donation rates among OPOs. Based on these objective metrics, OPOs not performing at a prespecified threshold will be required to rapidly improve performance to avoid decertification. We sought to determine whether rapid OPO improvement was possible based on objective donation metrics, and whether leadership change was associated with rapid improvement. We evaluated United Network for Organ Sharing and Centers for Disease Control and Prevention (CDC) data from 2011 to 2018, and measured donation rates using CDC data on inpatient deaths from causes consistent with donation, based on the location of deaths. During the two 4-year cycles, we found that an OPO's ranking relative to other OPOs was fairly static, with more than 90% of the OPOs at risk of flagging at the end of each 4-year cycle (2014, 2018) being in the bottom 75% of OPOs in the preceding 3 years. In multivariable logistic regression models, leadership changes were only statistically significantly associated with an improvement in OPO rankings during the 2011-2014 cycle. These data demonstrate that rapid improvements in OPO performance are uncommon, and while leadership changes increase the odds of rapid improvement, they do not guarantee improvement.

Predictors of nutrition care process and terminology use, applicability and importance within Asia-Pacific dietitians

AIM

Many dietitians are yet to incorporate the Nutrition Care Process and Terminology (NCPT) into practice. The present study investigated factors predicting (i) NCPT use, (ii) perceived importance of NCPT implementation and (iii) perceived NCPT applicability to personal dietetic practice among dietitians in the Asia-Pacific region.

METHODS

Dietetic association members from Australia, New Zealand and Singapore were invited to participate in an online survey assessing NCPT implementation, knowledge, and self-rated familiarity, attitudes, benefits, concerns, barriers, and enablers. Forward stepwise logistic regression used all factors to identify predictive dietetic characteristics for current NCPT use, importance or applicability to practice.

RESULTS

A total of 377 dietitians (5%-55% of national dietetic memberships surveyed) completed at least one survey question. In logistic regression models, independent positive predictors of current NCPT users were knowledge (P = 0.003), confidence to implement (P = 0.036), confidence to write nutrition diagnoses (P = 0.002) and experiencing managerial support (P = 0.004). Not seeing a reason to change was a significant negative predictor of NCPT use (P = 0.003). An independent positive predictor of dietitians viewing NCPT implementation as important was feeling that it will improve patient care (P < 0.001), while negative predictors were seeing minimal benefit in changing (P < 0.001) and a preference to continue with current routine (P = 0.015). Independent positive predictors of dietitians viewing NCPT as applicable to their practice were NCPT knowledge (P = 0.009), seeing the value of NCPT (P < 0.001) and attendance at workshops or conferences (P = 0.014).

CONCLUSIONS

NCPT implementation may be enhanced thorough activities building confidence, gaining managerial corroboration and demonstration of NCPT benefits, including improved patient care.

Smoke without Fire: Nursing Facility Closures in California, 1997–2001

This paper draws from a rich longitudinal California data set to analyze the scope and nature of nursing home closures between 1997 and 2001, and to present a Cox proportionate hazards model of the risks of closure that arise from a range of facility and market characteristics. When compared with the sample total of 1,482 facilities operating in the baseline year of 1997, only 56 facilities closed through 2001, involving the loss of 3.8% of facilities and 2,915 beds (2.3%). The multivariate Cox model of factors associated with closure reports that: 1) hospital-based facilities are 600% more likely to close than are free-standing homes; 2) reducing bed size by one standard deviation (52 beds) increases the risk of closure by 460%; 3) facilities with losses of 5% or worse are more than twice as likely to close; and 4) a one-standard deviation increase in the spare bed capacity measure of county competition raises the risk of facility closure by 140%.

Rhetorics of Efficiency, Fashion and Politics

Drawing on a content analysis of discourse surrounding five sequential hospital merger decisions, this research examines the role of efficiency considerations, fashion and politics in stimulating the adoption of a managerial idea. The article analyses how different arguments come to be intertwined. It illustrates how rational and institutional arguments are used to legitimate political strategies while simultaneously constituting the apparatus of legitimation for others in a reciprocal process that contributes to the persistence of those same strategies. The article thus confirms the key role of politics, interests and agency in the evolution and constitution of institutions, and in the diffusion of managerial ideas.

Two Decades of Organizational Change in Health Care: What Have we Learned?

The 1980s and 1990s witnessed a substantial wave of organizational restructuring among hospitals and physicians, as health providers rethought their organizational roles given perceived market imperatives. Mergers, acquisitions, internal restructuring, and new interorganizational relationships occurred at a record pace. Matching this was a large wave of study and discourse among health services researchers, industry experts, and consultants to understand the causes and consequences of organizational change. In many cases, this literature provides mixed signals about what was accomplished through these organizational efforts. The purpose of this review is to synthesize this diverse literature. This review examines studies of horizontal consolidation and integration of hospitals, horizontal consolidation and integration of physician organizations, and integration and relationship development between physicians and hospitals. In all, around 100 studies were examined to assess what was learned through two decades of research on organizational change in health care.

Innovation in Healthcare: A Systematic Review of Recent Research

Research on innovations in healthcare organizations published between 1994 and 2004 are here reviewed and summarized. The majority of the 31 identified studies dealt with the adoption of innovations and new practices and were cross-sectional designs applying quantitative methods, or multiple case studies applying qualitative methods. Five pathways for future research are recommended: (a) Multilevel approaches studying innovation simultaneously on individual, group, and organizational levels; (b) a combination of quantitative and qualitative data; (c) use of longitudinal designs (innovation both as the dependent and independent variable); (d) application of experimental designs in interventions; and (e) exploration of innovation generation and structural innovations.

The effect of perceived person-job fit on employee attitudes toward change in trauma centers

BACKGROUND

Employee attitudes toward change are critical for health care organizations implementing new procedures and practices. When employees are more positive about the change, they are likely to behave in ways that support the change, whereas when employees are negative about the change, they will resist the changes.

PURPOSE

This study examined how perceived person-job (demands-abilities) fit influences attitudes toward change after an externally mandated change. Specifically, we propose that perceived person-job fit moderates the negative relationship between individual job impact and attitudes toward change.

METHODOLOGY

We examined this issue in a sample of Level 1 trauma centers facing a regulatory mandate to develop an alcohol screening and brief intervention program. A survey of 200 providers within 20 trauma centers assessed perceived person-job fit, individual job impact, and attitudes toward change approximately 1 year after the mandate was enacted.

RESULTS

Providers who perceived a better fit between their abilities and the new job demands were more positive about the change. Further, the impact of the alcohol screening and brief intervention program on attitudes toward change was mitigated by perceived fit, where the relationship between job impact and change attitudes was more negative for providers who perceived a worse fit as compared with those who perceived a better fit.

PRACTICAL IMPLICATIONS

Successful implementation of changes to work processes and procedures requires provider support of the change. Management can enhance this support by improving perceived person-job fit through ongoing training sessions that enhance providers' abilities to implement the new procedures.

Factors associated with hospital closure and merger: A survival analysis of Dutch hospitals from 1978 to 2010

Health policy in most West European countries is directed at transforming the healthcare systems into more self-regulating and competitive systems. After a period of strong regulation, the Dutch government decided to step back and created conditions in which competition could lead to cost management and quality improvement. The question is whether mergers have contributed to the survival chances of hospitals. This paper describes the results of an analysis performed on the survival of all Dutch hospitals in the years 1978 to 2010. The survival of hospitals during this period was determined and their survival rates were calculated statistically. Furthermore, the relation between a hospital’s lifespan and a number of predictive variables was investigated. In this study, more detailed consideration is given to the fact of whether a hospital merged with another hospital. Bivariate analysis shows that smaller hospitals in particular have been driven out of the market. The difference in lifespan between hospitals which had merged and those which had not, appeared to be significant. However, a multivariate analysis, when corrected for size, type, and location, showed that merging had no significant effect on hospital lifespan.

Organizational Transformation

Health care organization leaders and policy makers seeking ways to reform the delivery of health care have become increasingly interested in transformational change. To foster understanding of how organizational transformation occurs and to stimulate further research, we report findings from a systematic review of empirical research on transformational change in the health care and non–health care literature, with a focus on the antecedents, processes (or paths), and outcomes of transformational change. Fifty-six studies, of which 13 were in health care, met our selection criteria. With one exception, all were published since 1990, indicating the recent upsurge of interest in this area. Limited differences were found between health care and non–health care studies. Available research documents the multiplicity of factors affecting change and the complexity of their interactions, but less information is available about the processes of transformational change than about its antecedents and consequences. Research and practice implications are discussed.

The impact of Medicare's Prospective Payment System on staffing of long-term acute care hospitals: the early evidence

BACKGROUND

Long-term acute care hospitals (LTACHs) treat patients with complex medical conditions requiring hospital care for extended periods of time. In the last decade, Medicare saw spiraling costs for post-acute care settings. The Balanced Budget Act mandated the use of Prospective Payment System (PPS) for all post-acute care settings including LTACHs. Medicare shifted to PPS for LTACHs in October 2002.

PURPOSE

This study analyzes the early effect of Medicare's PPS on the staffing intensity of LTACHs.

METHODOLOGY/APPROACH

The study uses panel data of measures of hospital and market characteristics in years 2001 through 2004. The impact of the payment mechanism, market, and organizational variables on the staffing intensity of LTACHs is evaluated using fixed-effects (within-groups) regression analysis.

FINDINGS

The fixed-effects regression models found that Medicare's PPS was associated with higher staffing intensity of the LTACHs in years 2003 and 2004. Market-level per capita income was significantly positively associated with staffing intensity. No secular trend in staffing intensity was found.

PRACTICE IMPLICATIONS

The concern that the cost containment incentives of PPS would result in lowered staffing levels of LTACHs was not borne out by this study. Further follow-up is required to assess in the longer term the effects of PPS on staffing and quality of care in LTACHs.

Does governance matter? Board configuration and performance in not-for-profit hospitals

As performance accountabilities, external oversight, and market competition among not-for-profit (NFP) hospitals have grown, governing boards have been given a more central leadership role. This article examines these boards' effectiveness, particularly how their configuration influenced a range of performance outcomes in NFP community hospitals. Results indicate that hospitals governed by boards using a corporate governance model, versus hospitals governed by philanthropic-style boards, were likely to be more efficient and have more admissions and a larger share of the local market. Occupancy and cash flow were generally unrelated to hospitals' governing board configuration. However, effects of governance configuration were more pronounced in freestanding and public NFP hospitals compared with system-affiliated and private NFP hospitals, respectively.

Chain Reaction

This paper reports on an exploratory study of nursing home bankruptcy. From state and industry data regarding nearly 1,000 California facilities, it was possible to identify 155 homes in five chains (multi-facility organizations) that were operating in bankruptcy in 2000. When compared with facilities in non-bankrupt chains, while the bankrupt chain facilities had significantly worse financial liquidity, higher administrative costs, and higher payables to related parties, they also had more Medicare residents, fewer Medicaid residents, better solvency, and were located in less competitive county markets and in areas with higher Medicaid reimbursement rates. These findings indicate that, rather than facility characteristics and local market factors, strategic decisions taken at the corporate (chain) level are the major determinants of nursing facility bankruptcy status.

Hospital Turnarounds

Hospital turnarounds are an increasing phenomenon in an era of unrelenting financial pressure on the health care delivery system. However, the literature about hospital turnarounds contains more theories and case reports than research studies, and repeat turnarounds suggest that there is inadequate evidence about what really works. The essential role of the turnaround agent in strategy formulation and especially strategy implementation is the subject of this article. It casts a wide net over the literature of strategy, change, leadership, and management. The article traces the nature and evolution of hospital turnarounds plus the agents that effect them; summarizes the turnaround agent's 10 most potent approaches to strategy analysis and synthesis; and outlines 3 research questions about first, the recurring need for hospital turnarounds altogether; second, longitudinal evidence to support different turnaround approaches; and third, the mechanisms by which the turnaround agent both changes and is changed by the distressed hospital.

Nurse Staffing and Hospital Ownership in California

OBJECTIVE

The purpose of this study is to describe the relationship between nurse staffing and owner type or specific corporate owner in California acute care hospitals.

BACKGROUND

Little empirical data exist regarding nurse staffing as it relates to owner type or specific corporate owner. With minimum staffing ratios scheduled to be implemented in January 2004, this study provides baseline data for evaluating the impact of minimum staffing ratios in California.

METHODS

The study design is descriptive and cross-sectional. Data used in this study are for short-term general hospitals that reported to the California Office of Statewide Health Planning and Development database for fiscal years ending in 1997 through 1999. Six regression models were estimated using pooled data from the 3 years of data.

RESULTS

The most consistent significant findings are: increased patient days or patient discharges predict increased registered nurse (RN) hours; lower RN wages predict increased RN hours; higher technology scores predict increased RN hours; and in 1998 there was an across-the-board decrease in RN hours. Other significant findings include that for-profit hospitals and for-profit systems had fewer RN productive hours for medical-surgical nursing, and select corporate owners, unrelated to profit status, had consistently fewer RN productive hours for medical-surgical nursing.

CONCLUSIONS/IMPLICATIONS

For-profit hospitals and systems behaved differently in the healthcare market environment of the late 1990s. Select nonprofit systems were also using significantly less RN staffing. Other findings support the implication that as technology sophistication increases, there will be a need for increased RN hours to manage the advanced technology. This runs counter to the argument that increasing technology will decrease the need for RN hours. Finally, as discharges go up, the need for RN hours increases.

The Effects of Relative Resource Configuration, Organizational Legitimacy, and Integration on Divestiture Decisions among Health Systems

This study examines the determinants of divestiture in health systems. Financial performance is a common indicator of a hospital's value. However, health systems may consider other factors that influence a hospital's value to the system. To enhance our understanding of hospital divestiture, we identify factors that enhance a hospital's value to the system and thus its likelihood of being retained. Our findings support previous studies that financial performance influences divestiture decisions. At the same time, our results identify three other factors influencing divestiture decisions: relative resource configuration, legitimacy, and integration.

An investigation into the level and impact of merger activity amongst hospitals in the UK's National Health Service

Since 1990 the National Health Service (NHS) has undergone a sustained period of change. This change has been necessary to prepare the NHS for the task of meeting a demand for services that continues to rise more rapidly than the availability of resources. Anecdotal evidence suggests that one of the most popular ways for trusts to improve their ability to meet demand is through mergers with other trusts. However, little rigorous research has been conducted to assess the extent or effectiveness of this strategy. A research project was, therefore, initiated to better understand the extent and impact of merger activity within the NHS. A questionnaire was developed and distributed to the chief executive, finance director, medical director and human resources director in all the 460 trusts that are currently members of the NHS confederation. In total the survey generated 459 responses out of a possible total of 1,840; an encouraging response rate of 25 per cent. The results of this research provide significant new evidence that "merger mania" has taken hold within the NHS. While 46 per cent of all responding trusts indicated that they had already merged, are actively involved in a merger, proposing to merge or are talking to prospective partners, a further 18.7 per cent of all trusts are forming strategic alliances rather than opting for a full merger. The dominant justification for merging are the beliefs that it will facilitate the reconfiguration of services and ultimately improve patient care. The paper concludes with a discussion of the significance of these results, before making recommendations with regard to their implications for future merger activity within the NHS.

U.S. hospital industry restructuring and the hospital safety net

The U.S. hospital industry was reshaped during the 1990s, with many hospitals becoming members of health systems and networks. Our research examines whether safety net hospitals (SNHs) were generally included or excluded from these arrangements, and the factors associated with their involvement. Our analysis draws on the earlier work of Alexander and Morrisey (1988), and not only studies factors affecting SNH participation in multihospital arrangements but also updates their earlier study. We constructed measures for hospital market conditions, management, and mission, and examined network and system affiliation patterns between 1994 and 1998. Our findings suggest that larger and more technically advanced hospitals joined systems in the 1990s, which contrasts with 1980s findings that smaller, financially weak institutions joined systems. Further, SNH participation in networks and systems was more common when hospitals faced less market pressure and where only a limited number of unaffiliated hospitals remained. If networks and systems are key parties in negotiating with private payers, SNHs may be going it alone in these negotiations in highly competitive markets.

Caring and competency

The long-term crisis in nursing, particularly in acute care hospitals, is demonstrated in studies on negligence by the Institute of Medicine in To Err is Human: Building a Safer Health System1 and Crossing the Quality Chasm: A New Health System for the 21st Century.2 A review of the nursing literature reflects unclear definitions of competency and its component caring, and no single theory of competency has been adopted from the literature and used in the education of nurses. The American Nurses 2001 Code of Ethics does not resolve this confusion, because it does not correct the individual acts of nursing incompetencies in acute care hospitals. The author defines caring and competency by providing examples of what they are not in examining 200 actual cases of hospital nursing acts of incompetence by nursing discipline. None of these examples of imputed negligence was reported to the National Practitioner Data Bank because the "corporate shield" protected the nurses by not being named in the complaint nor named as part of the settlement against the hospital.A new model of the hospitalist, the nurse hospitalist, is presented to act as a daily teacher and facilitator for hospital nurses based on a curriculum of day-to-day examples of substandard patient care. This nurse specialist is an inpatient generalist advanced practice nurse who is employed by the hospital and reports to the chief nurse executive. The author proposes that this new model of the nurse hospitalist be devoted entirely to collaborating with nurse leaders, educators, charge nurses, and floor nurses throughout disciplines in advancing the competency of nursing. This daily proactive and prospective model of improving nursing performance in a facultative manner offers strategies to mitigate the limitations of the retrospective model of quality control. Total quality improvement practiced retroactively is ineffective. The author recommends no structural change in the institution but an educational agenda by the nurse hospitalist, with hospital administration to assist nurses in a new learning environment.