Should Hospital Emergency Departments Be Used as Revenue Streams Despite Needs to Curb Overutilization?

This case asks how a hospital should balance patients' health needs with its financial bottom line regarding emergency department utilization. Should hospitals engage in proactive population health initiatives if they result in decreased revenue from their emergency departments? Which values should guide their thinking about this question? Drawing upon emerging legal and moral consensus about hospitals' obligations to their surrounding communities, this commentary argues that treating emergency departments purely as revenue streams violates both legal and moral standards.

Examining 'institutional entrepreneurship' in healthcare redesign and improvement through comparative case study research: a study protocol.

INTRODUCTION: Healthcare service redesign and improvement has become an important activity that health system leaders and clinicians realise must be nurtured and mastered, if the capacity issues that constrain healthcare delivery are to be solved. However, little is known about the critical success factors that are essential for sustaining and scaling up improvement initiatives. This situation limits the impact of these initiatives and undermines the general standing of redesign and improvement activity within healthcare systems. The conduct of the doctoral research detailed in this study protocol will be nested within a broader parent study that seeks to address this problem by drawing on the theory of 'institutional entrepreneurship'. The doctoral research will apply this idea to understanding the capacities and capabilities required at the organisation level to bring about transformational change in healthcare services. METHODS AND ANALYSIS: The parent study is predominantly qualitative, is multilevel in nature and has been codesigned with five partner healthcare organisations. The focus is a sector-wide attempt in an Australian state jurisdiction to transfer new redesign and improvement knowledge into the public healthcare system. The doctoral research will focus on the implementation of the sector-wide approach in one healthcare service in the jurisdiction. This research involves interviews with project team members and stakeholders involved in two improvement initiatives undertaken by the health service. It will involve interviews with redesign and improvement leaders and senior managers responsible for the overall health service improvement approach. The methods will also include immersive fieldwork, interviews and focus groups. Appropriate methods for coding and thematic extraction will be applied to the qualitative data. ETHICS AND DISSEMINATION: Ethical approval has been granted by the health service and Monash University Human Research Ethics Committee. Dissemination will be facilitated via academic publication, industry reports and workshops and dissemination events as part of the broader project.

District decision-making for health in low-income settings: a case study of the potential of public and private sector data in India and Ethiopia.

Many low- and middle-income countries have pluralistic health systems where private for-profit and not-for-profit sectors complement the public sector: data shared across sectors can provide information for local decision-making. The third article in a series of four on district decision-making for health in low-income settings, this study shows the untapped potential of existing data through documenting the nature and type of data collected by the public and private health systems, data flow and sharing, use and inter-sectoral linkages in India and Ethiopia. In two districts in each country, semi-structured interviews were conducted with administrators and data managers to understand the type of data maintained and linkages with other sectors in terms of data sharing, flow and use. We created a database of all data elements maintained at district level, categorized by form and according to the six World Health Organization health system blocks. We used content analysis to capture the type of data available for different health system levels. Data flow in the public health sectors of both counties is sequential, formal and systematic. Although multiple sources of data exist outside the public health system, there is little formal sharing of data between sectors. Though not fully operational, Ethiopia has better developed formal structures for data sharing than India. In the private and public sectors, health data in both countries are collected in all six health system categories, with greatest focus on service delivery data and limited focus on supplies, health workforce, governance and contextual information. In the Indian private sector, there is a better balance than in the public sector of data across the six categories. In both India and Ethiopia the majority of data collected relate to maternal and child health. Both countries have huge potential for increased use of health data to guide district decision-making.

Case studies from three states: breaking down silos between health care and criminal justice.

The jail-involved population-people with a history of arrest in the previous year-has high rates of illness, which leads to high costs for society. A significant percentage of jail-involved people are estimated to become newly eligible for coverage through the Affordable Care Act's expansion of Medicaid, including coverage of substance abuse treatment and mental health care. In this article we explore the need to break down the current policy silos between health care and criminal justice, to benefit both sectors and reduce unnecessary costs resulting from lack of coordination. To draw attention to the hidden costs of the current system, we review three case studies, from Washington State, Los Angeles County in California, and New York City. Each case study addresses different aspects of care needed by or provided to the jail-involved population, including mental health and substance abuse, emergency care, and coordination of care transitions. Ultimately, bending the cost curve for health care and criminal justice will require greater integration of the two systems.

Implementing and sustaining evidence-based practice in juvenile justice: a case study of a rural state.

US juvenile justice is at the forefront of experimentation with the evidence-based paradigm, whereby the best available research is utilized to help inform more rational and effective practice. Increasingly, state governments are playing a major role in this endeavor. Maine is one of these states and is the focus of this article. Using a case-study design, we set out to develop a fuller understanding of the events and processes that have contributed to the development, implementation, and sustainment of evidence-based practice in juvenile justice in the state. Four major themes emerged. First, Maine has benefited from strong and lasting leadership within its corrections department. These leaders paved the way for the implementation and sustainment of programs, including finding innovative ways to use existing resources. Second, the adoption of the Risk-Need-Responsivity model was important in laying the groundwork for the use of evidence-based programming. Third, collaborations within and among state agencies and public and private groups were essential. Finally, buy-in and support from multiple stakeholders was and continues to be essential to Maine's work. Ongoing problems remain with respect to ensuring agencies prioritize fidelity to the model and locating increasingly scarce funding. Implications for other states are discussed.

Organizational injustice: third parties’ reactions to mistreatment of employee / Injusticia organizacional: reacciones de las terceras partes ante el maltrato al empleado

Background: Research on organizational injustice has mainly focused on the victim’s perspective. This study attempts to contribute to our understanding of third parties’ perspective by empirically testing a model that describes third party reactions to mistreatment of employees. Method: Data were obtained from a sample (N = 334) of Spanish employees from various organizations, nested into 66 work-groups, via a survey regarding their perceptions of organizational mistreatment. Structural equation modeling was used to analyze the data. Results: The proposed model had a limited fit to the data and it was re-specified. Organizational mistreatment, employee performance, and employee organizational commitment explained internal attributions blaming the organization. Moreover, coworkers’ organizational identification showed a positive impact on external attributions of responsibility. Lastly, supportive organizational climate and internal attributions accounted for a large percentage of variance in coworkers’ perceptions of organizational unfairness. Conclusions: The final model explains the perceptions of injustice on the basis of internal attributions of responsibility in the face of organizational mistreatment of employees (AU)

Antecedentes: la investigación sobre la justicia organizacional se ha centrado en la perspectiva de la víctima. En este estudio intenta contribuir en la comprensión de la perspectiva de las terceras partes comprobando empíricamente un modelo que describe las reacciones de la tercera parte ante el maltrato de los empleados. Método: los datos fueron obtenidos de una muestra (N= 334) de empleados españoles de diversas organizaciones, incluidos en 66 grupos de trabajo, a través de una encuesta relativa a sus percepciones maltrato organizacional. Se usó el modelado de ecuaciones estructurales para analizar los datos. Resultados: el modelo propuesto tuvo un ajuste limitado a los datos y fue re-especificado. El maltrato organizacional, el rendimiento del empleado y el compromiso organizacional explicaban las atribuciones culpando a la organización. Más aún, la identificación organizacional del observador influía positivamente sobre la atribución de responsabilidad hacia fuera de la organización. Además el clima organizacional de apoyo y las atribuciones internas daban cuenta de un importante porcentaje de la varianza en las percepciones de los compañeros sobre la injusticia organizacional. Conclusiones: el modelo final explica las percepciones de injusticia a través de las atribuciones internas de responsabilidad en relación con el maltrato organizacional a los empleados (AU)

"Casing" the research case study.

The wide variation in definitions of the research case study can make it difficult for health sciences researchers to see all of the possibilities for this form of inquiry. Case studies are defined here as singular combinations of diverse arrays of methodological approaches directed toward maintaining "empirical intimacy" with the one or more temporally and spatially defined objects researchers construct and target for study. The cases selected for study are made as opposed to found through an iterative and theory-laden process called "casing." Case- as opposed to variable-oriented analysis helps researchers maintain "empirical intimacy" with the cases in their case studies. Case studies may be useful in enhancing programs of research in instrument and intervention development.

Caregiving, residence, race, and depressive symptoms.

The objective of this study is to evaluate the psychological responses to caregiving between black and white dementia caregivers measured by self-reports of depressive symptoms evaluating the impact of sub-components of the Center for Epidemiologic Studies Depression Scale (CES-D) and residential arrangements of the caregiving dyad. The method included 87 intergenerational family caregivers enrolled in the Duke Caregiver Study (50 white and 37 black). Total CES-D and the four sub-components were modeled as dependent measures in separate linear regressions. Three models were examined. The first model tested race, living arrangements, and their interaction. The second model adjusted for age, gender, education, income, health status, cultural justification for caregiving, crime concerns, systolic blood pressure, diastolic blood pressure, and glycosylated hemoglobin. A third model added adjustment for caregiver burden. The results showed that there was a significant race by residence interaction for CES-D, somatic symptoms and depressive affect such that when the dyads are living apart-with the care recipient in their own home or in an institutional setting-whites reported more depressive symptoms than blacks. When the dyads lived together, this was reversed, and blacks reported higher depressive symptoms than whites. To conclude, all the parameters such as race, living arrangements, and the components of depression need to be taken into account to understand the impact of caregiving on the emotional health of caregivers.

A multilevel confirmatory factor analysis of the Practice Environment Scale: a case study.

BACKGROUND: Practice Environment Scale (PES) data are collected from RNs in nursing units in hospitals that are members of the National Database of Nursing Quality Indicators (NDNQI). Patient and RN information are collected to aid in quality improvement and research at the nursing unit level. The data were collected from the individual RN, but items are worded so that analyses can be conducted at the individual, unit, or hospital level. There is a need to examine the validity of the PES at both the individual and the unit level. OBJECTIVE: To describe multilevel confirmatory factor analysis via a case study for investigating the validity of the PES, a measure of the nursing practice environment. APPROACH: The PES was administered to 72,889 RNs from 4,783 nursing units (16 unit types; e.g., critical care and obstetric) in 2007. The PES has 31 items in five different domains. A multilevel confirmatory factor analytic model was fit with a structure on the basis of the five domains. From this model, an estimate was sought between unit loadings and within unit loadings to investigate factorial, convergent, and discriminant validity at both the unit and the RN levels. To investigate criterion-related validity, the five PES domains were correlated with the seven job enjoyment items adapted from the National Database of Nursing Quality Indicators at the unit and RN levels (also using a multilevel model). RESULTS: The multilevel factor analysis provides evidence of factorial, convergent, discriminant, and criterion-related validity at both the unit and the RN levels. DISCUSSION: The PES is a valid instrument for use in quality improvement and research both at the unit and individual RN levels.

Innovation for personalization: a healthcare case study.

This paper describes a research and innovation platform for the development of ideas relating to the investigation of blood perfusion in peripheral tissue. The Loughborough Innovation Platform for Health Technologies (LIPHT) can be used to demonstrate the use of the research and innovation pipe-line in more than one dimension. For this paper the first dimension considered is that of 'blue sky' idea through to their exploitation for the benefit of users and at the same time creating a wealth stream; the second dimension is the changing market as the ideas develop--from a hospital-based instrument operated by clinicians through to a point and click device for the use by the knowledgeable layman in the community. The starting point for these developments is a medical device known to many people as the 'finger clip' that measures arterial blood oxygen saturation; the end point is an optical device capable of imaging blood perfusion.

Generation of political priority for global health initiatives: a framework and case study of maternal mortality.

Why do some global health initiatives receive priority from international and national political leaders whereas others receive little attention? To analyse this question we propose a framework consisting of four categories: the strength of the actors involved in the initiative, the power of the ideas they use to portray the issue, the nature of the political contexts in which they operate, and characteristics of the issue itself. We apply this framework to the case of a global initiative to reduce maternal mortality, which was launched in 1987. We undertook archival research and interviewed people connected with the initiative, using a process-tracing method that is commonly employed in qualitative research. We report that despite two decades of effort the initiative remains in an early phase of development, hampered by difficulties in all these categories. However, the initiative's 20th year, 2007, presents opportunities to build political momentum. To generate political priority, advocates will need to address several challenges, including the creation of effective institutions to guide the initiative and the development of a public positioning of the issue to convince political leaders to act. We use the framework and case study to suggest areas for future research on the determinants of political priority for global health initiatives, which is a subject that has attracted much speculation but little scholarship.

Learning by doing: the value of case studies of health impact assessment.

The nine health impact assessment (HIA) case studies in this issue represent a considerable contribution to the HIA literature and provide a number of lessons. These lessons include the value of using evidence in HIA to aid decision-making; the various forms that stakeholder and community involvement in HIA can take; and the fact that HIA can act as a catalyst for intersectoral engagement. They also highlight challenges faced by HIA practitioners, including time, methods of assessment, developing evidence summaries and considering equity.

Two-tier Haddon matrix approach to fault analysis of accidents and cybernetic search for relationship to effect operational control: a case study at a large construction site.

The Haddon matrix is a potential tool for recognizing hazards in any operating engineering system. This paper presents a case study of operational hazards at a large construction site. The fish bone structure helps to visualize and relate the chain of events, which led to the failure of the system. The two-tier Haddon matrix approach helps to analyze the problem and subsequently prescribes preventive steps. The cybernetic approach has been undertaken to establish the relationship among event variables and to identify the ones with most potential. Those event variables in this case study, based on the cybernetic concepts like control responsiveness and controllability salience, are (a) uncontrolled swing of sheet contributing to energy, (b) slippage of sheet from anchor, (c) restricted longitudinal and transverse swing or rotation about the suspension, (d) guilt or uncertainty of the crane driver, (e) safe working practices and environment.

Factors influencing ergonomic intervention in construction: trunkman case study.

This case study examines factors affecting the use of equipment designed to prevent lower back strain in laborers who pour concrete on major highway construction sites. Qualitative methods of organizational analysis were used to characterize factors identified from interviews and participant observation. The major obstacles to the use of the control on site were 1. Managers placing a low priority on ergonomics. 2. Safety officers' limited power in organizational hierarchies. 3. Rationalizing, rather than challenging, resistance to change. 4. Lack of a forum to share knowledge about interventions. Several organizational factors impeded the adoption of a technically effective, low-cost safety control on the site studied. The implementation of the control ultimately resulted from actions taken by the investigators, suggesting that safety programs present at the site are not always adequate to realize feasible interventions.