Development and pilot of a multicriteria decision analysis (MCDA) tool for health services administrators.

INTRODUCTION: Health administration is complex and serves many masters. Value, quality, infrastructure and reimbursement are just a sample of the competing interests influencing executive decision-making. This creates a need for decision processes that are rational and holistic. METHODS: We created a multicriteria decision analysis tool to evaluate six fields of healthcare provision: return on investment, capacity, outcomes, safety, training and risk. The tool was designed for prospective use, at the beginning of each funding round for competing projects. Administrators were asked to rank their criteria in order of preference. Each field was assigned a representative weight determined from the rankings. Project data were then entered into the tool for each of the six fields. The score for each field was scaled as a proportion of the highest scoring project, then weighted by preference. We then plotted findings on a cost-effectiveness plane. The project was piloted and developed over successive uses by the hospital's executive board. RESULTS: Twelve projects competing for funding at the Royal Brisbane and Women's Hospital were scored by the tool. It created a priority ranking for each initiative based on the weights assigned to each field by the executive board. Projects were plotted on a cost-effectiveness plane with score as the x-axis and cost of implementation as the y-axis. Projects to the bottom right were considered dominant over projects above and to the left, indicating that they provided greater benefit at a lower cost. Projects below the x-axis were cost-saving and recommended provided they did not harm patients. All remaining projects above the x-axis were then recommended in order of lowest to highest cost-per-point scored. CONCLUSION: This tool provides a transparent, objective method of decision analysis using accessible software. It would serve health services delivery organisations that seek to achieve value in healthcare.

The effect of integration of hospitals and post-acute care providers on Medicare payment and patient outcomes.

In this paper we examine empirically the effect of integration on Medicare payment and rehospitalization. We use 2005-2013 data on Medicare beneficiaries receiving post-acute care (PAC) in the U.S. to examine integration between hospitals and the two most common post-acute care settings: skilled nursing facilities (SNFs) and home health agencies (HHA), using two measures of integration-formal vertical integration and informal integration representing preferential relationships between providers without formal relationships. Our identification strategy is twofold. First, we use longitudinal models with a fixed effect for each hospital-PAC pair in a market to test how changes in integration impact patient outcomes. Second, we use an instrumental variable approach to account for patient selection into integrated providers. We find that vertical integration between hospitals and SNFs increases Medicare payments and reduces rehospitalization rates. However, vertical integration between hospitals and HHAs has little effect, nor does informal integration between hospitals and either PAC setting.

[Organizational forms of emergency medicine from the viewpoint of hospital management. Discipline-specific or interdisciplinary?]. / Organisationsformen der Notfallmedizin aus Sicht des Krankenhausmanagement. Fachspezifisch oder interdisziplinär?

Almost 16 million Germans are treated annually in an emergency room (ER). Most patients are seen in a specialty ER and only 10-20% of all hospitals have a centralized ER facility. Clinical emergency medicine is currently not adequately reimbursed, but represents a major patient entry point for most hospitals. It remains unclear whether the implementation of specialized ER physicians is more cost-effective than centralized specialization. However, it appears reasonable to centralize all ER resources, to optimize the workflow using electronic patient charts and order entry sets and to incorporate the general practitioner into the treatment of simple medical problems.

Hospitals going green: a holistic view of the issue and the critical role of the nurse leader.

The healthcare industry produces millions of tons of waste each year and is one of the largest consumers of energy in the United States. This article focuses on how nurses can facilitate "green" hospitals and work toward environmental sustainability. The authors critically approach the topic from the perspectives of nursing, environmental health, psychology, politics, international health, economics, and ethics. Specifically, the article addresses the critical role of the professional nurse as a leader in the creation of environmentally friendly and holistic clinical practice.

Service collaboration and hospital cost performance: direct and moderating effects.

BACKGROUND: Growing reliance on service provision through systems and networks creates the need to better understand the nature of the relationship between service collaboration and hospital performance and the conditions that affect this relationship. OBJECTIVE: We examine 1) the effects of service provision through health systems and health networks on hospital cost performance and 2) the moderating effects of market conditions and service differentiation on the collaboration-cost relationship. RESEARCH DESIGN: We used moderated regression analysis to test the direct and moderating effects. Data on 1368 private hospitals came from the 1998 AHA Annual Survey, Medicare Cost Reports, and Solucient. MEASURES: Service collaboration was measured as the proportion of hospital services provided at the system level and at the network level. Market conditions were measured by the levels of managed care penetration and competition in the hospital's market. RESULTS: The proportion of hospital services provided at the system level had a negative relationship with hospital cost. The relationship was curvilinear for network use. Degree of managed care penetration moderated the relationship between network-based collaboration and hospital cost. CONCLUSION: The benefits of service collaboration through systems and networks, as measured by reduced cost, depend on degree of collaboration rather than mere membership. In loosely structured collaborations such as networks, costs reduce initially but increase later as the extent of collaboration increases. The effect of network-based collaboration is also tempered by managed care penetration. These effects are not seen in more tightly integrated forms such as systems.

Using auctions for contracting with hospitals when quality matters.

This paper analyzes the problem of contracting with hospitals with hidden information when the number of patients wanting treatment depends on the quality of health care services offered. The optimal policy is characterized in the case of a single hospital. It is demonstrated that the regulator can reduce the information rent by decreasing the quality. When the regulator is assumed to be able to organize an auction for awarding the right to provide the service, we characterize the optimal auction and the first score tendering procedure implementing it. The regulator can reimburse a unit price per treated patient and let the hospital choose the level of quality. It is proved that the expected quality of health care services is greater and the expected payment is lower than in the monopoly case.

Health care financing reform and the productivity change in Finnish hospitals.

The purpose of this study was to analyze productivity and efficiency changes in the production of hospital care in Finland during the period 1988-1994. A special interest was directed to years 1993-1994 because of health care financing reform that took place in 1993. The analysis is based on the Malmquist index approach using linear programming. Positive productivity changes were found particularly towards the end of the observation period, although a few years did not show significant improvements in productivity and efficiency. There was a significantly higher rate of productivity change in 1992-1993 and 1993-1994, suggesting that the state subsidy reform in 1993 may have strengthened hospitals' efforts to improve performance.

[The ASL and hospitals: a model of emerging management]. / ASL e ospedali: un modello di gestione emergente.

The authors analysed the advantages and drawbacks of the legislative rules in the Italian medical services. They underline the impediments to the improvement in the quality and efficiency of both the organizing models and the control system of administration. The authors consider a new trend in the administration system taking place in the most innovative and dynamic units and they analyze the efficacy and speediness of diffusion of this new system. The new model could be extended to the ASL and Hospital as a possible improvement of the present situation. The article is structured in two main parts; in the first one the legal changing, that took place in the last year, in the organization of the national medical system is critically examined; the second one summarized the most significant innovation brought by the new administrative system of ASL and hospital.

Size does matter.

Hospital mergers, like Godzilla's comeback movie, promise that bulk means marketplace brawn. Yet as the dust settles, the payoff isn't always so clear. Promised efficiencies from merging duplicated programs--even shutting down entire hospitals--often fail to materialize. In fact, cutting the deal may turn out to be the easy part.

The effect of managed care on hospital marketing orientation.

Marketing is a central activity of modern organizations. To survive and succeed, organizations must know their markets, attract sufficient resources, convert these resources into appropriate services, and communicate them to various consuming publics. In the hospital industry, a marketing orientation is currently recognized as a necessary management function in a highly competitive and resource-constrained environment. Further, the literature supports a marketing orientation as superior to other orientation types, namely production, product and sales. In this article, the results of the first national cross-sectional study of the marketing orientation of U.S. hospitals in a managed care environment are reported. Several key lessons for hospital executives have emerged. First, to varying degrees, U.S. hospitals have adopted a marketing orientation. Second, hospitals that are larger, or that have developed strong affiliations with other providers that involve some level of financial interdependence, have the greatest marketing orientation. Third, as managed care organizations have increased their presence in a state, hospitals have become less marketing oriented. Finally, contrary to prior findings, for-profit institutions are not intrinsically more marketing oriented than their not-for-profit counterparts. This finding is surprising because of the traditional role of marketing in non-health for-profit enterprises and management's greater emphasis on profitability. An area of concern for hospital executives arises from the finding that as managed care pressure increases, hospital marketing orientation decreases. Although a marketing orientation is posited to lead to greater customer satisfaction and improved business results, a managed care environment seems to force hospitals to focus more on cost control than on customer satisfaction. Hospital executives are cautioned that cost-cutting, the primary focus in intense managed care environments, may lead to short-term gains by capturing managed care business, but may not be sufficient for long-term success and survival. Understanding consumer needs and perceptions, and using appropriate marketing strategies to ensure greater customer satisfaction and repeat business, will be among the key tasks for hospital executives in the future.