[Reorganize hospitals to improve efficiency and quality]

The current economic difficulties and the changed epidemiological picture, characterized by an increase in life expectancy, which shows in the elderly, chronically ill and disabled the main, both health and social, care needs,r equires a remark on the hospital network and organization. Today, most of the application assistance is usually at low intensity of care, whereas the acute event is shrinking. The prevalence of hospital admissions concern the elderly, who get into acute events but on a substrate of chronicity and co-morbidity conditions. There must be a new model of hospital network, with the possibility of converting some hospital centres for medium intensity care and selecting few centres for high intensity care, where concentrating the more expensive technology and the skill and expertise of the professional. The -suggestion is a renewed health planning that detects:- hospitals for widespread disease, equipped with emergency war for minor codes-hospital at high intensity of care for emergency-urgency- hospital for particular fields of medical speciality and research.

[From old to new hospital: physical change and development]

This paper examines a case of organizational change: the moving of a hospital to a new location. The change is considered in the light of two dimensions: the physical change from the old to the new structure ("logistic/physical change") and the change in the mode of working ("change in work-life"). The problem is to understand if, and how, these two change dimensions appear in the employees' (nurses and doctors) representation of the event. A theoretical framework was delineated based on three main constructs, i.e. an idea of organization as: a) the declination in time of the coordinated and interdependent employees' actions (course of decisions and actions); b) an ordering function of the course of decisions and actions rooted in the employee's cognitive schema ("context", "structure"); c) a set of meanings, at different levels, that constitute a common background and shared, in part, by the ordering function ("institutional frame"). A qualitative investigation was carried out, based on narrative in-depth interviews addressed to the top management of the different departments (SOC). A total of 34 medical and nurse managers were interviewed. Analysis of the interviews show that the discontinuous approach may be described according to five different "pure" types (as per Weber's theory). The five types are discussed within the above theoretical framework and in relation to their implications for organizational development.

[Development of organizations in Norwegian hospitals]

BACKGROUND

Hospitals in Norway are changing as a result of altered hospital environments and the constraints they are placed under. This article describes the organizational development in Norwegian hospitals from 1999 to 2005 and discusses whether the developments observed can be interpreted as a modernization of the Norwegian hospital system.

MATERIAL AND METHODS

The article is based on a survey sent to all public hospitals in 2001, 2003 and 2005. In 2001 the hospitals were asked retrospectively about 1999. In 2005, 60 of 63 hospitals responded to the survey.

RESULTS

Results indicate a consistent pattern of organizational development from 1999 to 2005. Some areas change to a greater degree than others; the most noticeable is decentralization in terms of financial routines and personnel responsibilities. Other major organizational developments include ring fencing of elective surgery, co-localization of hospital reception rooms and emergency wards, and increased use of computerized routines, both for patient management and treatment.

INTERPRETATION

It has been demonstrated that Norwegian hospitals are able to change and adapt. Several standardized organizational and leadership structures recommended by official reviews are increasingly being adopted into practice. Hospitals are being modernized.

[Is there a relationship between hospital size and patient experience?]

BACKGROUND

Hospitals in Norway are undergoing changes in structure and organisation. Patient experience has been selected as a national indicator of hospital quality. The objective of this study was to investigate the relationship between hospital size and patient experience.

MATERIAL AND METHODS

A patient experience questionnaire was sent to a representative sample of patients after discharge from 46 somatic hospitals, which were classified by function and by annual number of patients admitted.

RESULTS

10,975 patients (50%) responded. Generally, the patients expressed a positive attitude towards their hospitals. The patient experience was significantly more positive among those discharged from small hospitals than among those discharged from medium-sized or large hospitals, especially with regard to organisation.

INTERPRETATION

Our study shows that patient experience was significantly more positive among those discharged from small hospitals than from medium-sized or large hospitals, especially with regard to organisation. However, the score differences between hospitals are small and should be interpreted with caution.

The impact of IMPACT on St. John's Regional Health Center

St. John's Regional Health Center (SJRHC) is participating in the Institute for Healthcare Improvement's (IHI) IMPACT collaborative, a new IMProvement ACTion network of health care organizations that have joined together to improve patient care. By utilizing the network for sharing ideas, continuous quality improvement tools and support staff and physician involvement, we have achieved three important breakthrough improvements in patient flow in the hospital setting. The areas highlighted in this article are Perioperative Services, Emergency Department Admission, and Transfers to Cardiac Intensive Care Units.

Restructuring fosters better communication

Case management, physicians, and nurses define clinical practice guidelines. Staff reconnected to hospital structure as reporting lines shift. Modified gatekeeping system eliminates redundant, rare authorizations.

Hospitals and reengineering

One of the key success factors for reengineering in hospitals will be the ability of health care leaders to redefine their organizations in terms of process. Hospital managers are responding with anything from mergers to minor shifts in strategic thinking. Some hospital leaders answering the call for significant change are faced without dated models that are complex and inflexible.

Mediating the cultural boundaries between medicine, nursing and management--the central challenge in hospital reform

This paper documents the resilience of medical and nursing profession-based subcultures and the extent of the differences between them. Against this background, we assess the capacity and willingness of medical and nursing managers to promote changes that will extend the accountability of clinicians and engender more evidence-based, financially driven and output-oriented approaches to service delivery.

"Happy Meals" in the Starship Enterprise: interpreting a moral geography of health care consumption

This paper extends earlier explorations of the use of metaphor in the marketing of the Starship Children's Hospital in Auckland, New Zealand, by examining controversy surrounding the opening of an in-hospital McDonalds fast-food outlet. The golden arches have become a key element of many children's urban geographies and a potent symbol of the corporate colonisation of the New Zealand landscape. In 1997 a minor moral panic ensued when a proposal was unveiled to open a McDonald's restaurant within the Starship. Data collected from media coverage, advertising and interviews with hospital management are analysed to interpret competing discourses around the issue of fast food within a health care setting. We contend that the introduction of a McDonald's franchise has become the hospital's ultimate placial icon, adding ambivalence to the moral geography of health care consumption. We conclude that arguments concerning the unhealthy nature of McDonald's food obscure deeper discourses surrounding the unpalatable character of the health reforms, and a perceived 'Americanisation' of health care in New Zealand.

Reengineering outcomes management: an integrated approach to managing data, systems, and processes

The integration of outcomes management into organizational reengineering projects is often overlooked or marginalized in proportion to the entire project. Incorporation of an integrated outcomes management program strengthens the overall quality of reengineering projects and enhances their sustainability. This article presents a case study in which data, systems, and processes were reengineered to form an effective Outcomes Management program as a component of the organization's overall project. The authors describe eight steps to develop and monitor an integrated outcomes management program. An example of an integrated report format is included.

Staffing intensity, skill mix and mortality outcomes: the case of chronic obstructive lung disease

The hospital re-engineering movement has resulted in major changes in hospital staffing. These staffing changes have the potential to reduce staffing intensity and skill mix, both generally and within specific caregiver groups. Prior research has shown that both skill mix and staffing intensity are positively associated with outcomes indicative of the quality of hospital care. This study extends beyond prior research by expanding the scope of staffing intensity and skill mix measures beyond that of physicians and nursing personnel and by focusing on a specific diagnostic group, patients with chronic obstructive pulmonary disease (COPD). Multiple regression analysis was performed using the 30-day post-admission observed mortality rate for Medicare patients being treated for COPD relative to the predicted rate as the dependent variable. Analyses were repeated for 1989, 1990 and 1991. Among the explanatory variables were staffing intensity measures for health care workers that were thought to contribute significantly to the care needed by patients with COPD. The results indicate that the only group of health care workers which showed staffing intensities positively associated with better outcomes in this group of patients was respiratory care practitioners, respiratory therapists and respiratory therapy technicians. The results relative to skill mix were inconclusive. It was concluded that during the 1989-1991 period, hospitals with higher staffing intensities for both respiratory therapists and respiratory therapy technicians had better outcomes for their Medicare inpatients being treated for COPD.

Using the business excellence model to effectively manage change within clinical support services

This article describes the journey of managing the change from seven separate health providing units to one overall team providing a range of services. To facilitate the change the Malcolm Baldrige National Quality Award self-assessment model was used. The benefits and limitations of the model are described as are the activities undertaken to achieve a goal of delivering quality care within a customer driven rather than service driven focus. Finally the learning gained from the change is shared in an attempt to help others undertaking a similar journey.

New study highlights ingredients for reengineering success

Data benchmarks: A new study reveals specific elements to include in a reengineering program to boost its chances of success. The authors' review of the health care literature on reengineering reveals some startling discoveries, including the lack of consensus on defining reengineering and the fact that many hospitals are not finding the cost reductions they hoped for in the first years after completing their programs.

Creating organized delivery systems: the barriers and facilitators

An organized delivery system is a network of organizations that provides or arranges to provide a coordinated continuum of services to a defined population and is willing to be held clinically and fiscally accountable for the outcomes and the health status of the population served. As such, organized delivery systems are at the center of efforts to implement health care reform. Based on analysis of 12 such systems, this article identifies key characteristics that influence what organized delivery systems are able to do, outlines the major obstacles or challenges to achieving greater levels of integration, and then discusses a number of approaches for effectively dealing with these obstacles.

The evaluation of hospital restructuring efforts: satisfaction, quality, and costs

This article reports on study evaluating the effects of hospital restructuring on patient satisfaction, nurse satisfaction, cost of care, and clinical quality. The restructuring involved facility redesign, telecommunications enhancement, and implementation of patient care processes incorporating multiskilled personnel and case facilitation systems. The results indicate improved patient and nurse satisfaction, decreased length of stay and variable cost per patient day, and good clinical outcomes.

The tactical made practical

Mergers are great--until they push past someone's safety zone, until they force tough choices about combining services and business lines. Here's a checklist for maneuvering the dangerous postmerger waters.

The impact of mental health service integration on systemic function: a staff perspective

OBJECTIVE

The purpose of this study was to investigate the perceptions of community staff regarding service process and quality, while a public mental health service integrated acute inpatient and continuing care components.

METHODS

The study employed a naturalistic successive measures design in which community mental health staff completed a questionnaire on three occasions during the integration process.

RESULTS

Staff perceived overall service quality to improve during the integration process with continuity of care being the area subject to greatest improvement.

CONCLUSIONS

The integration of acute inpatient and continuing care services resulted in changes to service process and outcome, which were judged by staff to be beneficial, especially with respect to continuity of patient care.

Roads to recovery

Many paths bring a hospital to the crossroads of collapse. But the road to financial recovery has some uniform features: A great leader. A talented staff looking for direction. A focus on mission and customer service. Sure enough, the winners of our eighth annual Great Comebacks contest have these qualities in common.

Alienation and administration. System restructuring often entails four types of canonical acts

When applying canon law to healthcare transactions, difficulties often arise in determining whether the transaction or restructuring in question constitutes a canonical act of alienation or an act of administration. Changes in system governance may leave local property titles untouched, suggesting that no alienation has taken place, but loss of Catholic identity or a reduced ability to carry out the Church's mission may indeed constitute alienation. Often in restructurings, four types of canonical acts are involved: alienation of property (alienation in the strict sense), acts that can jeopardize the stable patrimony (sometimes called alienation in the broad sense), acts of ordinary administration, and acts of extraordinary administration. While alienation concerns the divestiture of ownership, the general purpose of administration is to preserve goods. Acts of extraordinary administration require certain formalities of consent before they can be carried out. However, the intervention of the Holy See is not required, as it is for acts of alienation. The permission may be granted in principle, before a formal offer is received; after an offer is received; or, in some cases, by a "blanket" indult. A restructuring can amount to an alienation unless care is taken to verify to maintain certain reserved powers, thus ensuring that the work is still under the direction or canonical control of the sponsoring religious institute or diocese. Joint ventures, however, seldom involve insoluble canonical problems. Each situation must be evaluated individually and care taken to ensure that the requirements of both eccleslastical and secular law are met.

Measuring and evaluating hospital restructuring efforts. Eighteen-month follow-up and extension to critical care, Part 1

Increasingly, hospital restructuring is viewed with skepticism because of a lack of systematic and rigorous evaluation of its impact on quality of care. This first article in a two-part series describes comprehensive evaluation of the effects of hospital restructuring on patient satisfaction, nurse satisfaction, costs of care, and clinical quality on four medical-surgical units at a large tertiary hospital. In addition, early application of the model to critical care is described. A quasiexperimental pre- and post-design combined with concurrent control units for selected measures was the overall strategy. The authors conclude that comprehensive restructuring of hospital-based care can take place in a manner that preserves multiple dimensions of quality while decreasing costs. This only can be ascertained, however, through rigorous and systematic measurement and evaluation. Part 2 will detail application and evaluation of the restructuring model in the critical care environment.

Reengineering: deja vu all over again

There is growing interest among hospitals in reengineering. It promises dramatic improvements in performance: Costs will be reduced while work processes, productivity, and patient care will all improve. A review of the health care literature on reengineering shows that little evidence exists to support its claims. This article critiques the existing literature on reengineering and addresses the conundrum hospital executives encounter when faced with the decision to adopt a new management technique--such as reengineering--in the absence of proof of its efficacy.

Don't forget to measure the results of your hospital reengineering effort

Making sure re-engineering efforts can be quantified: Reorganizing a hospital into patient-focused care units must be a results-oriented, data-driven process. A New Jersey hospital developed baseline measures for a variety of outcomes for each new care center so improvement could be ensured and proven using hard and fast data.

Ongoing data monitoring, accountability as important as reengineering itself

After your reengineering success: Don't just sit there! What happens after a process redesign program ends can be just as important as the reengineering effort itself. Just ask officials at this New Jersey facility. Despite a whopping $4 million in savings derived from a major redesign of patient care service delivery, administrators and managers are working just as hard at keeping everyone on their toes with an ongoing monitoring and accountability process. Learn how important those efforts can be to ensuring continued success long after the formal reengineering process is completed.

Quality management: the role of hospital boards

The changing social, political and economic environment has, for the first time, forced hospitals to account for their financial performance. Hospitals have responded to this demand by restructuring, downsizing and implementing efficiencies. At the same time, professionals and consumers are becoming increasingly concerned about the impact of rapid change on the quality of hospital care. In this context, the challenge for all stakeholders is to explicitly outline who is responsible and accountable for assuring high quality hospital care. The purpose of this paper is to discuss the role of hospital boards in relation to quality improvement. A framework currently used by a metropolitan Canadian teaching hospital, to assure continuous quality improvement despite significant budget cuts, is outlined.