Hub and spoke framework for study of surgical centralization within United States health systems.

BACKGROUND: Hospital consolidation into health systems has mixed effects on surgical quality, potentially related to degree of surgical centralization at high-volume (hub) sites. We developed a novel measure of centralization and evaluated a hub and spoke framework. METHODS: Surgical centralization within health systems was measured using hospital surgical volumes (American Hospital Association) and health system data (Agency for Healthcare Research and Quality). Hub and spoke hospitals were compared using mixed effects logistic regression and system characteristics associated with surgical centralization were identified using a linear model. RESULTS: Within 382 health systems containing 3022 hospitals, system hubs perform 63% of cases (IQR 40-84%). Hubs are larger, in metropolitan and urban areas, and more often academically affiliated. Degree of surgical centralization varies ten-fold. Larger, multistate, and investor-owned systems are less centralized. Adjusting for these factors, there is less centralization among teaching systems (p â€‹< â€‹0.001). CONCLUSIONS: A hub-spoke framework applies to most health systems but centralization varies significantly. Future studies of health system surgical care should assess the contributions of surgical centralization and teaching status on differential quality.

Racial and ethnic differences in parents' assessments of pediatric care in Medicaid managed care.

OBJECTIVE: This study examines whether parents' reports and ratings of pediatric health care vary by race/ethnicity and language in Medicaid managed care. DATA SOURCES: The data analyzed are from the National Consumer Assessment of Health Plans (CAHPS) Benchmarking Database 1.0 and consist of 9,540 children enrolled in Medicaid managed care plans in Arkansas, Kansas, Minnesota, Oklahoma, Vermont, and Washington state from 1997 to 1998. DATA COLLECTION: The data were collected by telephone and mail, and surveys were administered in Spanish and English. The mean response rate for all plans was 42.1 percent. STUDY DESIGN: Data were analyzed using multiple regression models. The dependent variables are CAHPS 1.0 ratings (personal doctor, specialist, health care, health plan) and reports of care (getting needed care, timeliness of care, provider communication, staff helpfulness, plan service). The independent variables are race/ethnicity (white, African American, American Indian, Asian, and Hispanic), Hispanic language (English or Spanish), and Asian language (English or other), controlling for gender, age, education, and health status. PRINCIPAL FINDINGS: Racial/ethnic minorities had worse reports of care than whites. Among Hispanics and Asians language barriers had a larger negative effect on reports of care than race/ethnicity. For example, while Asian non-English-speakers had lower scores than whites for staff helpfulness (beta = -20.10), timeliness of care (beta = -18.65), provider communication (beta = -17.19), plan service (beta = -10.95), and getting needed care (beta = -8.11), Asian English speakers did not differ significantly from whites on any of the reports of care. However, lower reports of care for racial/ethnic groups did not translate necessarily into lower ratings of care. CONCLUSIONS: Health plans need to pay increased attention to racial/ethnic differences in assessments of care. This study's finding that language barriers are largely responsible for racial/ethnic disparities in care suggests that linguistically appropriate health care services are needed to address these gaps.

Differences in CAHPS adult survey reports and ratings by race and ethnicity: an analysis of the National CAHPS benchmarking data 1.0.

OBJECTIVE: To examine racial/ethnic group differences in adults' reports and ratings of care using data from the National Consumer Assessment of Health Plans (CAHPS) survey Benchmarking Database (NCBD) 1.0. DATA SOURCE: Adult data from the NCBD 1.0 is comprised of CAHPS 1.0 survey data from 54 commercial and 31 Medicaid health plans from across the United States. A total of 28,354 adult respondents (age > or = 18 years) were included in this study. Respondents were categorized as belonging to one of the following racial/ethnic groups: Hispanic (n = 1,657), white (n = 20,414), black or African American (n = 2,942), Asian and Pacific Islander (n = 976), and American Indian or Alaskan native (n = 588). STUDY DESIGN: Four single-item global ratings (personal doctor, specialty care, overall rating of health plan, and overall rating of health care) and five multiple-item report composites (access to needed care, provider communication, office staff helpfulness, promptness of care, and health plan customer service) from CAHPS 1.0 were examined. Statistical Analyses. Multiple regression models were estimated to assess differences in global ratings and report composites between whites and members of other racial/ethnic groups, controlling for age, gender, perceived health status, educational attainment, and insurance type. PRINCIPAL FINDINGS: Members of racial/ethnic minority groups, with the exception of Asians/Pacific Islanders, reported experiences with health care similar to those of whites. However, global ratings of care by Asians/Pacific Islanders are similar to those of whites. CONCLUSIONS: Improvements in quality of care for Asians/Pacific Islanders are needed. Comparisons of care in racially and ethnically diverse populations based on global ratings of care should be interpreted cautiously.

Building partnerships with the community: lessons from the Camden Health Improvement Learning Collaborative.

This case study describes the Camden City Health Improvement Learning Collaborative (the Collaborative), a community care network initiative formed in 1993. The organization is composed of representatives from local healthcare providers, public agencies, religious organizations, and neighborhoods. The major goal of this initiative is to improve the health status of the community by involving and empowering residents in the solution of their needs. The Collaborative represents a grassroots strategic model of community inclusion in the formulation of goals and programs to improve community health status. The case study describes the dynamics of the Collaborative by examining the following: historical development; political, institutional, and social context; planning process; organization and structure; and performance evaluation. The article concludes with a discussion of the strategic and operational lessons learned from the Collaborative.

Managerial implications of corporate board involvement and perceived market competition for quality improvement in nursing homes.

This study examines the relationships among corporate board involvement, total quality management (TQM) adoption, perceived market competition, and the perceived effect of quality improvement (QI) activities for a sample of nursing homes in Pennsylvania. The findings of this study have several implications for healthcare managers interested in maximizing the effectiveness of QI efforts. Board involvement in quality improvement was an important predictor of QI outcomes in the areas of finance, resident care, and human resources. However, TQM adoption had a positive effect on human resources outcomes only. These findings suggest that board involvement in any organized form of QI may be more important than the adoption of a formal TQM program in the nursing home industry. TQM's emphasis on employee empowerment may account for its positive influence on human resources. Perceived competition was associated with better financial outcomes. Low-cost leadership can be a key to survival in more competitive markets, requiring a focus on efficiency and productivity issues in QI efforts. By focusing on process improvement, the facilities may achieve cost reductions that can result in an improved financial position. Facilities perceived to be in more competitive environments were also more likely to adopt TQM. This is consistent with the assertion by resource-dependence theorists that organizations facing competition for resources must be responsive to the needs of resource-providing constituencies.

The performance impact of context in TQM implementation: the nursing facility industry.

This study develops a model and empirically assesses how# organizational context mediates the impact of total quality management (TQM) implementation on perceived performance in the nursing facility industry. Outcomes are analysed for financial, human resources and resident-care performance. Contextual factors related to TQM implementation include managerial control, reward systems, organizational structure and the extent of implementation. Duration of TQM implementation is included as a control variable. Benchmarking has a positive impact on financial outcomes, and the extent of TQM implementation and required reporting of quality improvement activity results have a positive impact on both financial and human resources performance. The presence of a Quality Steering Council has a positive impact on financial performance, but only among larger facilities.

The impact of geography on hospital electronic health records implementation in alabama: implications for meaningful use.

BACKGROUND: Given relatively less favorable health outcomes in rural Alabama, electronic health records (EHRs) have an even greater potential to improve quality and alleviate disparities if meaningfully used. OBJECTIVES: We examined rural-urban differences as it pertained to perceived barriers, benefits, and motivating factors of EHR implementation. METHODS: We used multivariate logistic models to analyze data collected from a state-wide, self-completed survey of health information management directors in Alabama hospitals. RESULTS: Findings from our analyses indicate that fewer rural hospitals (8%) have implemented EHRs as compared with urban hospitals (18%). Rural hospitals were 71% less likely to consider reduction in costs as a benefit of EHRs (OR = 0.29), and were 75% less likely to consider lack of structured technology as a challenge factor of EHR implementation (OR = 0.25). CONCLUSION: Promotion of EHRs in rural areas is challenging but necessary. Understanding perceived barriers and motivating factors of EHR implementation among rural hospitals can inform policy decisions, especially in light of recent meaningful use initiatives.