The Challenges of Leadership.

Perhaps in no other period in recent times have the challenges leaders face been so profound. In these times of uncertainty and turbulence, we look to leaders who create a sense of purpose, who generate feelings of trust and optimism, and who tap the passion, talent, and efforts of those so essential to the success of the organization and of the people it serves. Our research suggests that becoming the leader whom people look to and admire requires an active commitment to responding to 5 essential leadership challenges. These are (1) creating a sense of purpose, (2) devising means for aligning the actions of the followers with that sense of purpose, (3) establishing a context that enables others to behave in a way that is consistent with the vision and values of the organization, (4) ensuring that the work that is done provides meaning to those engaging in the work activities, and (5) adding to the sum of everyone's knowledge through learning through reflective actions. In this article, we describe these challenges and offer suggestions that you can take to become a more effective and respected leader.

Impact of dialysis reimbursement policies on care outcomes in peritoneal dialysis patients in Taiwan.

The number of treated end stage renal disease (ESRD) patients worldwide has rapidly grown. To prolong their lives ESRD patients require transplantation or dialysis treatment. Limited donor availability has caused most of the ESRD patients to rely on either hemodialysis (HD) or peritoneal dialysis (PD). Taiwan had the highest prevalence rate worldwide and sought to increase the PD utilization through a series of reimbursement incentives. This study evaluated the effect of those policy initiatives. A retrospective longitudinal study using a before-and-after analysis was conducted. ESRD patients initiating either PD or HD were identified from the entire population of Taiwan NHI's beneficiaries. PD patients, before and after the PD-encouraging initiatives, were matched through a propensity score technique, and the change in PD technical failure was analyzed. HD patients were also matched as the control group to assess the impact on PD mortality. The competing risk regression approach for survival analysis was adopted. The results indicate the increase in PD utilization during this period was also accompanied by increases in both technique failure and mortality. Since PD shifts more burden of care to patients, efforts to increase its utilization may require an increase in the education of providers and patients to benefit more effectively. It may also require an increase in staff to provide ongoing training and support as the policy unfolds.

Job and career influences on the career commitment of health care executives: the mediating effect of job satisfaction.

PURPOSE: While there is considerable evidence supporting the relationship between job satisfaction and organizational commitment, the relationship between the antecedents of job satisfaction, organizational commitment and career commitment are not clearly understood. This study seeks to clarify whether these antecedents have an effect independent of job satisfaction on career commitment or whether these antecedents are mediated by job satisfaction. DESIGN/METHODOLOGY/APPROACH: In total, 2,799 questionnaires were mailed out to members of the American College of Healthcare Executives (ACHE). The responses received were 643 (22.9 percent) and after eliminating retirees or students, a sample of 456 respondents currently employed in the health care industry was obtained. Path analysis was conducted to test the hypothetical relationships between work situation, career experiences and career commitment. FINDINGS: It was found that job satisfaction mediated the influences of job tenure and career pattern on career commitment. Job satisfaction partially mediated the influences of perceived job security and one's satisfaction with career on career commitment. Both of these measures had a direct influence on career commitment. Career experience such as sector change was also positively associated with career commitment. RESEARCH LIMITATIONS/IMPLICATIONS: While the research offers some insights into the factors affecting the career commitment of health care executives, the sample was limited to respondents who were members of the American College of Healthcare Executives, and thus may not represent the views of all managers in the health care sector. PRACTICAL IMPLICATIONS: To retain high-valued health care workers it is important that an organization has a work environment that enhances their commitment to their occupation as well as their careers. ORIGINALITY/VALUE: This study clarifies the influence of job satisfaction on the career commitment of health care managers during a very dynamic period.

Assessing the performance of surgical teams.

BACKGROUND: High-performing and high-reliability teams are an important component of service delivery. With a focused emphasis on safety in acute care hospitals, understanding the nature of surgical teams and team performance is an essential component to achieving high-quality surgical care. More information is needed about the challenges to effective team functioning in the operating room, the influence of working conditions, and the environmental context on surgical team performance. PURPOSE: The purpose of this study is to describe the nature of surgical teams and how they perform in the operating room to contribute to a broader knowledge about high-performing and high-reliability teams in health care settings. METHODOLOGY/APPROACH: We conducted a qualitative study involving direct observation and semistructured interviews. Field observations of 10 high-complexity surgeries and face-to-face interviews with 26 members of surgical teams were completed at one university medical center. A conceptual framework derived from the literature was developed to guide the selection of surgeries and surgical teams to be observed. Data were transcribed and analyzed to identify the factors and different conditions that influence the performance of these surgical teams. FINDINGS: The type of coordination and the degree of independent and interdependent coordination vary among the seven observed stages of the surgical process. Most of the surgical teams were ad hoc teams and as such, further challenged by consistently frequent "hand-offs" for break relief. Additional role demands influence the situational dynamics which can alter the adaptive capacity of the team. PRACTICE IMPLICATIONS: The surgical event evokes a changing degree of coordination and adaptation to complexity and uncertainty. In such environments, relational coordination through leadership can contribute to a successful surgical result, improvement of the overall process, including error reduction, and enhanced knowledge creation and dissemination, particularly germane in research university teaching hospitals.

Influences on the career commitment of health-care managers.

The health-care field is undergoing rapid and significant transformation. This transformation has led to the breakdown of traditional career paths for managers in the patient care segment of the industry. To our knowledge, there has not been a systematic examination of how these changes have impacted on the career commitment of managers in this segment of the industry. Building on previous research, we examine the effects of employment-related conditions and career experiences on the career commitment of these managers while controlling for the influence of individual characteristics. Specifically we assess the relationship between employment-related conditions, such as job security, position tenure, industry segment, management level and the extent to which their current position meets their career expectations, and their career experiences, including moving from a non-health-care management position, moving from a different health-care sector, their career stage, career patterns and their satisfaction with their career progression. We found that measures associated with the different employment-related experiences had a more significant influence on career commitment than those measures associated with different career experiences.

The effects of case mix on hospital costs and revenues in managed care environments.

Due to competition and managed care, hospitals have argued that the rate of increase in hospital cost is greater than the rate of increase in hospital revenue. It is important to pay hospitals based on the expected resource use of patients that hospitals treat. However, managed care organizations pay hospitals based on negotiated prices that do not consider the expected resource use of patients. The purpose of this paper is to provide a better understanding of those factors affecting hospital cost and revenue in California using the hospital financial and utilization data for selected years from 1986 to 1998. By developing case mix indexes (CMIs) using all hospital discharges in California, this study found that the coefficients for CMIs in total and inpatient hospital revenue models were greater than those in hospital cost models. Over time, however, the differences in coefficients for CMIs in hospital revenue and cost models become smaller and smaller. Thus, this study shows that the difference between hospital revenues and hospital costs, looking at hospital case mix, has decreased, although hospital revenues are still greater than hospital costs.

Assessing the impact of budget controls on the prescribing behaviours of physicians treating dialysis-dependent patients.

OBJECTIVES: This study examined whether outpatient haemodialysis providers changed their treatment practices with the establishment of an outpatient dialysis global budget (ODGB) through analysing the outpatient visits and medication received by those patients. METHODS: A sample of 4668 observations (patient year) of 1350 haemodialysis with hypertension (HH) patients and 4668 observations of 1436 non-HH (NHH) patients were drawn from the National Health Insurance Research Database over the years from 1999 to 2005. The impact of ODGB on hypertension-related outpatient utilization of HH was estimated using the difference in difference (DID) method and examined in three stages: (1) the fee for service stage, the pre-ODGB (2000), (2) the phase-in stage (2001-2002) and (3) the post-ODGB stage (2003-2005). RESULTS: ODGB implementation did not affect the number of dialysis visits for HH patients. However, it did lead to a reduction in fees for antihypertension drugs used by haemodialysis facilities. There was an increase of 4.06 visits per patient per year (P < 0.001) in the number of non-dialysis outpatient with antihypertensive drugs visits for HH patients compared with the control group. The total fees for antihypertensive drugs for HH patients increased by New Taiwan Dollars (NT$)13 008 (P < 0.001) per patient per year relative to the control group after the implementation of ODGB. CONCLUSIONS: As ODGB was implemented, HH patients received fewer antihypertensive drugs during their dialysis visit. In addition, there was an increase in the number of non-dialysis outpatient visits by HH patients as well as increased payment in the drugs associated with their non-dialysis outpatient visits compared with the control group.

The impact of the 1997 Balanced Budget Amendment's prospective payment system on patient case mix and rehabilitation utilization in skilled nursing.

PURPOSE: This study examines the impact of the post-acute prospective payment system (PPS) on Medicare-funded rehabilitation services in skilled nursing facilities (SNFs) and whether such impact varies under different payment mechanisms. DESIGN AND METHODS: We interviewed 214 Medicare beneficiaries admitted to three SNFs in southern California for rehabilitation. We compared patients' admission characteristics and therapy utilization among those receiving post-acute rehabilitation before and after the implementation of PPS. RESULTS: Patients admitted after PPS implementation were more likely to have orthopedic problems or stroke and poorer self-reported physical health. They had significantly shorter lengths of stay in rehabilitation and received significantly less therapy, although those in managed care had less reduction in treatment after SNF-PPS implementation than those in fee-for-service. IMPLICATIONS: After SNF-PPS implementation, rehabilitation treatment levels in the study sites were reduced. Whereas changes in Medicare managed care were comparatively modest, we observed significant changes in intensity and duration of physical and occupational therapies in Medicare fee-for-service.

The networks and resource exchanges in community-based systems of care.

Despite several decades of government efforts, systems of service delivery to populations with multiple problems remain fragmented and poorly organized. Since the delivery of services to persons with multiple problems often requires the coordinated efforts of several providers in different delivery sectors, the authors argue that a network perspective helps policy-makers and public administrators understand the patterning of relationships between and among these providers. Using an analysis of service delivery systems for older persons in a major urban setting, the authors show how policy-makers and public administrators can use network methods to improve their understanding of the complexity of most human service delivery programs, Findings from this study suggest that, through a focus on the exchange patterns that evolve within and between organizations, an improved understanding of the roles that different organizations play in the service delivery effort can be achieved.

Surgical teams: role perspectives and role dynamics in the operating room.

Observations of surgical teams in the operating room (OR) and interviews with surgeons, circulating registered nurses (RNs), anaesthesiologists and surgical technicians reveal the importance of leadership, team member competencies and an enacted environment that encourages feelings of competence and cooperation. Surgical teams are more loosely coupled than intact and bounded. Team members tend to rely on expected role behaviours to bridge lack of familiarity. While members of the surgical team identified technical competence and preparation as critical factors affecting team performance, they had differing views over the role behaviours of other members of the surgical team that lead to surgical team performance. Observations revealed that the work climate in the OR can shape interpersonal relations and begins to be established when the room is being set up for the surgical case, and evolves as the surgical procedure progresses. The leadership and supervisory competencies of the circulating RNs establish the initial work environment. Both influenced the degree of cooperation and support that was observed, which had an effect on the interactions and relationships between other members of the surgical team. As the surgery unfolds, the surgeon's behaviours and interpersonal relations modify this environment and ultimately influence the degree of team work, team satisfaction and team performance.

The effect of outpatient dialysis global budget cap on healthcare utilization by end-stage renal disease patients.

Controlling the cost of chronic diseases remains one of the vexing problems of developed and developing nations alike. Taiwan, faced with rapidly escalating healthcare costs associated with End Stage Renal Disease (ESRD) services utilization, imposed an outpatient dialysis global budget (ODBG) on outpatient dialysis care. This study, using a before and after study design with a comparison group, assessed the impact of this policy innovation on outpatient, inpatient and emergency room utilization. Using a difference in difference (DID) strategy and the generalized estimating equation (GEE) approach, this study found providers responded to these changes through cost reduction and revenue enhancement strategies. This study extends our understanding of provider responses to changes in reimbursement policies that target one segment of the continuum of care required by chronic disease patients.