Governing board, C-suite, and clinical management perceptions of quality and safety structures, processes, and priorities in U.S. hospitals.

To achieve quality improvement in hospitals requires greater attention to systems thinking than is typical at this time, including a shared understanding across different levels of the hospital of the current state of quality improvement efforts. A self-administered survey assessed the perceptions of board members, C-suite executives, and clinical managers regarding quality activities and structures. This instrument, the Hospital Leadership and Quality Assessment Tool (HLQAT), includes 13 domains in six conceptual areas that we believe are major organizational drivers of quality and safety: (1) commitment of senior leaders, (2) a vision of exemplary quality, (3) a supportive culture, (4) accountable leadership, (5) appropriate organizational structures, and (6) adaptive capability. HLQAT survey results from a convenience sample of more than 300 hospitals were linked to performance on the Centers for Medicare & Medicaid Services (CMS) Core Measures. The results show significantly different perceptions between the groups. Higher HLQAT scores for each respondent group were associated with better hospital performance on the CMS Core Measures. There is no magic bullet--no one domain dominates. Leaders in higher-performing hospitals appear to be more effective at conveying their vision of quality care and creating a culture that supports an expectation that staff and leadership will work across traditional boundaries to improve quality.

The right stuff.

The interviews with board members at 10 high-performing community health systems revealed many other factors that, in the opinions of some, have contributed to their system's strong operating performance; for example, prudent investments in facilities and services, new technology and strategic mistakes by competitors. On the whole, however, the trustees perceived the six factors outlined above as being most influential in their organizations' successful performance in recent years. The table on Page 21 provides a summary of the trustees' views. Numerous factors contribute in varying degrees to organizational performance. Board leaders and CEOs should assess their organization and, as objectively as possible, identify those which are truly pivotal in determining its operating performance. Allocating proper attention and resources to them and monitoring the results on an on-going basis are among the main responsibilities of governing boards in today's challenging health care environment.

Leadership development in MHA programs: a response and commentary.

The transformation of healthcare from a relatively sheltered sector of the economy into one characterized by market competition and volatility has tested the values, abilities, and leadership strategies of healthcare executives. Changes in the scale and complexity of healthcare organizations and in provider reimbursement impose demands on executives that bear little resemblance to those of the past. In light of these challenges, health management programs are reassessing their responsibilities and capacities in the preparation of MHA graduates. Unfortunately, there is a lack of consensus on how students should be trained, advised, and mentored for leadership responsibilities. In our view, MHA programs can begin to address this problem through support of a balanced normative model for leadership training whereby classroom immersion in academic subjects is complemented by exposure to practice and experience. This model must be value-oriented, balancing business imperatives with traditional service ideals, and reality-oriented, balancing the teaching methods of theory and practice. In our view, MHA programs can begin to adapt to this model though student selection, curriculum reform, and involvement by practitioners and alumni.

Private finance and sustainable growth of national health expenditures.

This analysis explores the role of the private sector relative to all health spending among Organization for Economic Cooperation and Development (OECD) countries. Bi-variate regression was employed for 31 countries using current data. It was found that the share of GDP allocated to health varies among countries, ranging from 5 percent in Turkey to 14 percent in the United States. Variation in per capita income explains much of this difference but other factors are important too. One appears to be the role of the private sector in financing health expenditures. Our analysis concludes that concern about rising health sector costs should be placed in a larger context: rising health care costs may be justified if benefits are large enough and cover the opportunity costs of alternative uses of resources.

The effect of case management in substance abuse on health services use.

This study evaluated the effect of case management, as a supplement to traditional substance abuse treatment, on health services utilization. Data for the study were taken from the Iowa Case Management Project (ICMP). The ICMP evaluated case management using a randomized research design. Residential clients who agreed to participate were randomly assigned to one of four case management conditions. The first three conditions were variations of the Iowa Case Management (ICM) model: (a) Inside Case Management, (b) Outside Case Management, and (c) Telecommunications. Case management clients in these three conditions were eligible for 12 months of case management. The fourth condition, the control condition, received no additional case management through ICMP. The study results show that the use of case management decreased the use of mental health services while increasing clients' use of inpatient care, access to physician, and the emergency room. It was expected that case management would increase, in the short run, the substance abuser's use of health services due to staying longer in treatment and seeking medical care that would be otherwise neglected. However, in the long run such early use of necessary health services might reduce the clients' use of avoidable, more costly care. Case management should be looked at as an investment with long-term payoffs.

Leadership in health care and the leadership literature.

Crossing the Quality Chasm, the Institute of Medicine's recently issued report on the quality of health care in America, is a call to arms for the urgent redesign of the U.S. health care system. The big question confronting health care organizations is how to mount new strategies that will enhance organizational effectiveness and reduce system failures as well as individual errors. Redesign implies organizational restructuring and engineering as well as serious steps in organizational development, with the emphasis on leadership enhancement strategies focused on performance excellence. This article addresses the state of the leadership literature and concludes that massive new investments will have to be made to tackle the issues of leadership training and accountability.

Effectiveness of case management in substance abuse treatment.

Health officials have promoted case management as a promising intervention in substance abuse treatment (Ridgely & Willenbring, 1992). The relationship between organizational mission combined with case management and different types of outcomes has not been explored in studies, but they are worth noting and exploring further. This study, which is part of a larger clinical trial, examined the 3-, 6-, and 12-month effectiveness of case management in a residential setting for individuals treated for substance abuse. Clients who agreed to participate were randomly assigned to one of four study groups. The groups received face-to-face case management and one telecommunication case management, while the fourth was the control group. Results from the analysis revealed only modest support for the effectiveness of case management as a supplement to traditional treatment. The face-to-face case-managed groups achieved improvements on the legal, employment, and psychiatric domains exceeding that achieved by the control group. Because of the short-term follow-up of the study, conclusive evidence of the effects of case management could not be drawn. This study is a valuable stepping stone, however, to further research in the field and as an aid to policymakers who are interested in knowing more about the effects of case management.