Provider diversity in the English NHS: a study of recent developments in four local health economies.

OBJECTIVES: To assess the impact of provider diversity on quality and innovation in the English NHS by mapping the extent of diverse provider activity and identifying the differences in performance between Third Sector Organisations (TSOs), for-profit private enterprises, and incumbent organizations within the NHS, and the factors that affect the entry and growth of new providers. METHODS: Case studies of four local health economies. Data included: semi-structured interviews with 48 managerial and clinical staff from NHS organizations and providers from the private and third sector; some documentary evidence; a focus group with service users; and routine data from the Care Quality Commission and Companies House. Data collection was mainly between November 2008 and November 2009. RESULTS: Involvement of diverse providers in the NHS is limited. Commissioners' local strategies influence degrees of diversity. Barriers to entry for TSOs include lack of economies of scale in the bidding process. Private providers have greater concern to improve patient pathways and patient experience, whereas TSOs deliver quality improvements by using a more holistic approach and a greater degree of community involvement. Entry of new providers drives NHS trusts to respond by making improvements. Information sharing diminishes as competition intensifies. CONCLUSIONS: There is scope to increase the participation of diverse providers in the NHS but care must be taken not to damage public accountability, overall productivity, equity and NHS providers (especially acute hospitals, which are likely to remain in the NHS) in the process.

Clinical integration. Fast forward to clinical integration.

Clinical integration has vaulted from idea to imperative, thanks in part to the new health reform law. This first installment of H&HN's series on the implications of the law looks at two health systems at very different points on the path to clinical integration.

Seeking perfection in healthcare. A case study in adopting Toyota Production System methods.

Virginia Mason Health System's vision to be the quality leader in healthcare means continually adopting new ways of thinking. One change has been shifting from believing defects are to be expected to believing zero defects in healthcare is not only possible, but also necessary. Generally, healthcare has advanced in technology and understanding of disease, but its business and management systems have changed little since the 1950s. Virginia Mason realized it needed a management method to help make real and measurable improvements in safety, quality, service and staff satisfaction.

Hospital ownership and performance: evidence from stroke and cardiac treatment in Taiwan.

This paper compares program expenditure and treatment quality of stroke and cardiac patients between 1997 and 2000 across hospitals of various ownership types in Taiwan. Because Taiwan implemented national health insurance in 1995, the analysis is immune from problems arising from the complex setting of the U.S. health care market, such as segmentation of insurance status or multiple payers. Because patients may select admitted hospitals based on their observed and unobserved characteristics, we employ instrument variable (IV) estimation to account for the endogeneity of ownership status. Results of IV estimation find that patients admitted to non-profit hospitals receive better quality care, either measured by 1- or 12-month mortality rates. In terms of treatment expenditure, our results indicate no difference between non-profits and for-profits index admission expenditures, and at most 10% higher long-term expenditure for patients admitted to non-profits than to for-profits.

Behavioral differences between public and private not-for-profit hospitals in the Italian National Health Service.

In this paper we attempt to identify behavioral differences between public and private not-for-profit hospitals, by exploiting the introduction of the DRG-based payment system in the Italian NHS during the second half of the 1990s. We estimate the technical efficiency of a sample of hospitals for the period 1995-2000 considering an output distance function, and adopting both parametric (COLS and SF) and nonparametric (DEA) approaches. Our results show a convergence of mean efficiency scores between not-for-profit and public hospitals, and seem to suggest that differences in economic performances between competing ownership forms are more the result of the institutional settings in which they operate than the effect of the incentive structures embedded in the different proprietary forms. We also observe a decline in technical efficiency, probably due to policies aimed at reducing hospitalization rates.

Improving comfort and communication in the ICU: a practical new tool for palliative care performance measurement and feedback.

OBJECTIVE: To develop a practical set of measures for routine monitoring, performance feedback, and improvement in the quality of palliative care in the intensive care unit (ICU). DESIGN: Use of an interdisciplinary iterative process to create a prototype "bundle" of indicators within previously established domains of ICU palliative care quality; operationalization of indicators as specified measures; and pilot implementation to evaluate feasibility and baseline ICU performance. SETTING: The national Transformation of the Intensive Care Unit program developed in the United States by VHA Inc. PATIENTS: Critically ill patients in ICUs for 1, > 3, and > 5 days. MEASUREMENTS AND MAIN RESULTS: Palliative care processes including identification of patient preferences and decision making surrogates, communication between clinicians and patients/families, social and spiritual support, and pain assessment and management, as documented in medical records. Application is triggered by specified lengths of ICU stay. Pilot testing in 19 ICUs (review of > 100 patients' records) documented feasibility, while revealing opportunities for quality improvement in clinician-patient/family communication and other key components of ICU palliative care. CONCLUSIONS: The new bundle of measures is a prototype for routine measurement of the quality of palliative care in the ICU. Further investigation is needed to confirm associations between measured processes and outcomes of importance to patients and families, as well as other aspects of validity.

Putting on a clinic in Va. Carilion, a not-for-profit hospital system based in Roanoke, is taking a $100 million risk to become a physician-run venture.

Carilion Health System needs to change or die, according to its leaders, so the Roanoke, Va., organization is converting from a typical not-for-profit system into a physician-run clinic. The switch is an extreme version of an industrywide push to employ doctors. James Thweatt Jr., left, of rival Lewis-Gale, says his hospital joined the trend when it hired 80 specialists from a failing local clinic.

High availability web-based image distribution.

When a health system implements a picture archiving and communication system (PACS), film is no longer the preferred medium of image distribution from a radiology department's perspective. The goal is for the department to be 100% filmless sometime after the installation. However, implementing change can be difficult, and getting to that goal of 100% is sometimes never achieved. Sutter Health has come close, with 90% of studies being filmless. A primary reason lies with the distribution method of providing access to images.

Formulary decision-making about cephalosporins with similar therapeutic uses.

The various costs and intangible factors that enter into formulary decisions in an era of increasingly frequent drug product shortages that can adversely affect patient care and increase treatment costs are described. Pharmacy administration at Carolinas HealthCare System analyzed the costs associated with making a formulary switch from the third-generation cephalosporin ceftriaxone to cefotaxime, which recently became available in generic form and has a similar spectrum of antimicrobial activity and therapeutic uses. Hard dollar costs for purchasing drugs and the supplies needed to administer them; soft dollar costs for staff time spent acquiring, preparing, and administering doses; and intangible factors were considered. A reliable supply of drug product from the manufacturer was an important intangible factor because of frequent drug shortages in the past few years and the adverse effect on patient care and the increased soft dollar costs associated with these shortages. Administrators at Carolinas HealthCare System decided not to make the proposed formulary change after weighing the many factors and costs.

Restructuring hospital-physician relationships for future success.

Integrating physicians into the Healthfirst administration through employment sowed seeds of mutual understanding among these two groups that would benefit the system immeasurably over the next several years. The immediate future, however, saw only cultural upheaval between our hospitals and newly employed physicians, hospitals and nonemployed physicians, employed and nonemployed physicians, as well as specialists and primary care providers. Traditional physician-relationship-building efforts became difficult, if not impossible, to maintain. Essentially, administration was forced to scrap ten years of physician-development plans in order to reconfigure a relations effort that would maintain hospital support from all sides while restructuring the employed medical group. This article describes the evolution of Healthfirst's approach to maintaining effective physician relationships within our healthcare system and its affiliated entities over the past decade. Specifically, the article details the manner in which our system has evolved physician-relations activity to maintain an effective strategy during times of significant change in the healthcare industry.

Searching for nursing's future? Here's how to turn your vision into reality.

Nurses from the Inova Health System, an integrated care system in northern Virginia, used the Future Search process to create an action plan for their future practice.

Nature's images introduce "natural" medical campus. Woodwinds Health Campus opens new doors in Minnesota.

Grand opening of Woodwinds Health Campus in Minnesota combines its unique medical approach with well-established traditions. Everything from the design elements and paper to the opening day activities conforms to the interests and concerns of its potential market, as determined by focus groups.

Better information for the board.

Healthcare managers are making quicker, riskier decisions in an increasingly competitive and regulated environment. Questions have been raised regarding the accountability and performance of boards of these organizations, as board members are not always selected based on their competencies to guide such decisions. Adapting mission and strategy and monitoring organizational performance require information that boards get mostly from management. The purpose of this study was to examine the information that boards regularly get to carry out their functions. I obtained board documents from four not-for-profit hospitals and health systems in different boroughs of New York City. At each institution, I conducted one-hour interviews with at least three board members and three top managers. I also attended at least one board or executive committee meeting and one additional meeting, usually of the finance committee. Principal findings were that the boards get too much data, the same data that management gets, and little comparative data on performance of similar benchmarked organizations. Board members and managers are satisfied with the information that board members get and have no plans to improve their system of shaping, or the quality of, information. Key recommendations to boards and managers are: (1) boards must take greater responsibility for identifying the information that they get and how they wish to get it, (2) managers must ensure that measurable objectives are developed, against which organizational performance can be evaluated, (3) boards must get information that is targeted and shaped to better fit board functions, (4) managers must develop information sets for main service lines, (5) boards must get information on the expectations and satisfaction levels of key stakeholders, (6) boards must get better and more focused information on performance of benchmarked institutions, and (7) boards must get less hospital operating data on a monthly basis.

Merging, de-merging, and emerging at Deaconess Billings Clinic.

Complexity theory offers a powerful model for effective mergers of health care organizations that differs substantially from customary approaches. Exploring how Deaconess Billings Clinic in Montana evolved from two separate and very different cultures provides insight into how organizations can apply a complex adaptive system (CAS) model of mergers to create more truly integrated health care systems. DBC's merger illustrates the phenomenon of emergence in complex systems, whereby structures arise that are not a synthesis of the pre-existing cultures or the result of a new culture being imposed. Instead, the merger is understood as an ongoing, self-organizing process appropriately characterized by fits and starts, feelings of uncertainty, and other natural challenges of change and growth. By squarely surfacing the distinct cultures of the organizations through abundant interaction, relationship building, and information flow, differences can be creatively transformed, resulting in deep-seated change and the emergence of a genuine, shared health care system culture.