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PubMedDate not supplied

Tacit collusion among hospitals in price competitive markets.

Horizontal and vertical mergers, and coalition and network building activity have recently escalated in the US hospital industry in response to actual and threatened increases in competition. Parties to this industry's consolidation state that increased efficiency is the primary motive. However, increased consolidation may lead to increased awareness of inter-dependence, and facilitate 'conscious parallelism', or tacit collusion. In conjunction with this, selective contracting practices by payors with hospitals for negotiated prices may have increased the awareness of interdependence among price-competing hospitals. We posit that cost asymmetries arising from first-mover advantages to merged hospitals and multihospital chain members may be used strategically in local markets to facilitate tacit arrival at profit maximizing prices. Thus, hospital mergers and acquisitions which enhance efficiency in the short run may not yield net gains to society in the long run, as they may alter incentives which parameterize the potential for implicit cooperation. This outcome depends upon mitigating local market conditions, such as capacity utilization and market power held by payors. The current view that safeguarding emerging price competition is important necessitates careful analysis of how merger is likely to affect bargaining power between hospitals and purchasers. This complexity precludes the use of simple antitrust rules or guidelines in this industry.

Antitrust Laws↗
PubMedDate not supplied

Public sector hospitals and organizational change: an agenda for policy analysis.

An important feature of health care systems in recent years is the change in the organizational position and relations of public sector hospitals. Health sector reforms have led to increasing heterogeneity in the organizational location and status of public sector hospitals and new organizational forms of public-private relations are being developed by and for hospitals. These changes can have important implications for health and health care. They raise issues around equity, control, accountability and performance of health care. Yet the policy process in practice may be failing to develop and implement appropriate forms of policy formulation on health sector reform. This paper focuses on the organizational position and relations of hospitals within public sector health services. It firstly outlines key elements of health sector reform and relates these to two dimensions of organizational change for hospitals: increasing heterogeneity and forms of public-private relations. The paper provides a descriptive format for classifying forms of hospital organizational change and proposes a framework of six questions for analysing these organizational forms. This may be used to assess the appropriateness of specific policies to particular country situations and to develop more open debate around hospital organizational forms.

Decision Making, Organizational↗
PubMedDate not supplied

Hospital autonomy: the experience of Kenyatta National Hospital.

An increasing number of countries are exploring the introduction or expansion of autonomous hospitals as one of the numerous health reforms they are introducing to their health system. Hospital autonomy is one of the forms of decentralization that is focused on a specific institution rather than on a political unit. It has gained much interest because it is an attempt to amalgamate the best elements of the public and private sectors in how a hospital is governed, managed and financed. This paper reviews the key elements of the concept of hospital autonomy, the reasons for its expanded use in many countries and a specific example of making a major teaching hospital autonomous in Kenya. A review of the successful experience of Kenyatta National Hospital and its process of introducing autonomy, with regard to governance, operations and management, and finances, lead to several conclusions on replicability. The legal framework is a critical element for successfully structuring the autonomous hospital. Additionally, success is highly dependent on the extent to which there is adequate funding during the process of attaining autonomy due to the length of the transition period needed. Autonomy must be granted within the context of the national health system and national health objectives and be consistent with those aims and their underlying societal values. Finally, as with decentralization, success is dependent upon the preparation done with the systems and management necessary for the proper governance and operation of autonomous hospitals.

Decision Making, Organizational↗
PubMedDate not supplied

Managing retrenchment in French public hospitals: philosophical and regulatory constraints.

The French hospital system is experiencing economic stresses similar to those experienced by US hospitals. Pressures for cost containment have occurred due to changes in health care funding. The public hospital system is facing unprecedented severe retrenchment. Innovative strategies for managing retrenchment have been restricted by regulatory and philosophical constraints. What is needed is to provide more autonomy for individual hospital managers together with greater accountability for achievement of results.

Financial Management↗
PubMedDate not supplied

Health care reforms in the French hospital system.

The French health care system, like other health care systems, entered the 1990s in a state of flux. During the 1980s, attempts to curb health care expenditure had a limited impact with the liberal and pluralist values of the health system undermining reform strategies. In 1991 the French government introduced a new hospital reform which had four main strands: rationalizing public and private health care provision; introducing a medical logic into the hospital service; increasing hospital autonomy and strengthening participation and involvement in the hospital system. However, these reforms left untouched the financing of the health service. Consequently there remains a need for a more fundamental reform of the management and financing of the French health care system.

Budgets↗
PubMedDate not supplied

Decentralization of management responsibility: the case of Danish hospitals.

This article examines a specific management reform at three hospitals in a Danish county. Management reform at the hospital level implies a decentralization of responsibility and power to the departmental level. Along with increased responsibility and power, departments get the message: keep your budgets and keep your output level. This preliminary analysis indicates that departmental budgets can be a way of containing costs in clinical departments. Non-staff expenditures especially are subjected to reductions. The system still seems to 'favour' doctors and nurses, but less than in a system with traditional budgetary institutions. The behaviour of the top-management teams shows that the output constraint is not seriously meant. Departments are allowed to reduce capacity, with declining output, with the knowledge of the top-management team. The declining output makes it easier to departments ceteris paribus to keep within their budgets. And that makes it easier for the top-management team to keep the overall hospital budget. The obligation to keep the overall hospital budget is thus an important criterion of success in the eyes of the political masters of hospitals.

Budgets↗
PubMed2002

Linking mental health and addiction services: a continuity-of-care team model.

Reorganization of mental health care delivery services at a Department of Veterans Affairs medical center addressed problems with the coordination of addiction treatment and mental health programming for patients with significant psychiatric and addiction comorbidity. Clinical services were organized into interdisciplinary continuity-of-care teams that follow patients across different levels of care. The teams provide addiction treatment through "universally available" resources such as a partial hospital addiction rehabilitation module. Continuity of care remains within the team structure as clinicians follow patients throughout their rehabilitation course. Patient and staff satisfaction focus on improved accessibility of addiction services and continuity of care providers across time and levels of care. Overall inpatient utilization and recidivism decreased after model implementation.

Continuity of Patient Care↗
PubMedDate not supplied

Does service diversification enhance organizational survival?: Evidence from the private substance abuse treatment system.

The rate of closure among US substance abuse treatment facilities in the private sector is considerable, further reducing access to treatments that are already in short supply in many locales. Using a nationally representative sample of 450 substance abuse treatment centers, this research considers the extent to which specific types of service diversification reduce the likelihood of treatment center closure in the private sector. Over the study period, 26.4% of centers ceased to offer substance abuse treatment services. There was mixed evidence that centers offering a more diversified array of services had a lower likelihood of closure. Specifically, the number of treatment tracks tailored to specific demographic groups was negatively associated with the likelihood of closure. There was a positive association between closure and offering an inpatient psychiatric program. These findings suggest that there may be strategic benefits in expanding services to meet the needs of diverse clientele.

Adult↗
PubMed2002

[Improving productivity by implementing RIS and PACS throughout the clinic: a case study].

PROBLEM: How are improvements in productivity in connection with RIS/PACS to be defined? What do they cost? To limit the problem to the relevant topics, we first describe the objectives of a radiology department and the identified bottlenecks in the workflow. How to define and assess the improvements is discussed. METHODS: The case in question for this study is the RIS/PACS project at the "Klinikum der Universität München, Campus Grosshadern". The goals of the project and its present status are reviewed. The project is not yet completed, so this is a "midterm" report. RESULTS AND DISCUSSION: We describe the status of the achieved and not yet achieved goals and of the eliminated bottlenecks. On the plus side, for example, nearly 100% of all digitally generated images (except mammogramms) are digitally archived. They are accessible to the same percentage in radiology via PACS and in the hospital via the webbased intranet image distribution system when needed. In some radiology areas, such as multislice CT, already the reporting can no longer be performed without softcopy image interpretation. However, the full elimination of hardcopy images is still not reality, since the distribution to DICOM viewers for selected requesters with demands for almost reporting quality, high cost image displays is still in the testphase. To reduce film costs, images are being printed on a high resolution paper printer in addition to the intranet distribution during this transition period. On the negative side, due to a lack of job positions in the transcription rooms, about 40% of the reports are still being handwritten by radiologists. Furthermore, the dictated and transcribed reports are usually still not available early enough in the RIS and thereby in the intranet report distribution of the hospital. Here only a speech recognition system can remedy the situation. As soon as this problem is solved and the image distribution to the DICOM viewers works routinely, the reports and the images will be accessible within minutes to maximally within some hours after the examination. CONCLUSION: The goals reached so far suffered delays due to unforeseen problems and pitfalls. Altogether, a quieter operation and workflow in radiology has already been achieved, due to less inquiries from the requestors for unfinished examinations, images and/or image copies.

Computer Systems↗
PubMed2002

[Quality management in a radiology department].

PURPOSE: To increase the quality of internal and external interactions (patients, clinical colleagues, technicians, radiologists) in a department of radiology. METHOD: Accompanied by a well-experienced adviser workshops have been performed dealing with different topics like "contact to patients," "performance of the radiological report and interaction with the referring colleague" or "research and teaching." A catalogue of different actions was defined to reduce hindrances within the internal and external work-flow. RESULTS: A total number of 53 actions was defined and related to different persons who were responsible for the realisation of the measures within a time interval. Six months after starting the quality management 46 (86%) of the defined actions were realised successfully, and another 4 (8%) measures were still running. There was a moderate increase of satisfaction of the patients and clinical colleagues considering the waiting time. CONCLUSIONS: A quality management in a radiological department allows an optimisation of the internal and external interactions. However, the guidance of a well-experienced adviser is as essential as the continuous control of successful finished measures.

Education↗
PubMed2001

The impact of organisational change on outcome in an intensive care unit in the United Kingdom.

OBJECTIVES: To study the change in outcome for patients admitted to an intensive care unit following the establishment of a team of resident medical staff and a change from an "open" to a "closed" organisational format. DESIGN: Database review of prospectively collected data. SETTING: Intensive care unit of a postgraduate teaching hospital. SUBJECTS: 1134 admissions to the intensive care unit over a 3-year period, of whom 476 (42%) followed elective surgery. MAIN OUTCOME MEASURE: Hospital mortality corrected for illness severity by using the APACHE II scoring system. RESULTS: Crude hospital mortality fell from 28% before the changes to 20% afterwards (P = 0.01). With correction for case-mix factors, the probability of death after the changes was reduced by almost half (OR 0.51; CI 0.32, 0.82, P = 0.005). CONCLUSION: A "closed" format of organisation of the delivery of care may result in improved outcomes for patients admitted to intensive care units.

APACHE↗
PubMed1993

NHS reforms and resource management: whither the hospital?

This paper considers whether resource management (RM) as currently constituted in the National Health Service (NHS) is likely to fulfil its aim of efficiency. For the individual hospital RM has two key features: changes in managerial structure and changes in information systems. The paper assesses the extent to which the hospital behavioural model that implicitly underlies RM can be judged to reflect well the actual behaviour of hospitals. It is noteworthy that in the RM literature there is no explicit statement about the assumed underlying behaviour of the NHS hospital. Here the author selects the Harris model of hospital behaviour as providing the best explanation of internal hospital organisation. Harris represents the two lines of authority, physicians and administrators (managers in the present-day NHS), as two firms within the hospital structure, each with its own managers, objectives and constraints, making this model particularly appealing as a basis for analysing RM. Using this model the paper concludes that RM alone and as currently constituted will not be successful in promoting efficiency, because the structural and cultural mechanisms put in place by RM will not sufficiently affect physician behaviour.

Economic Competition↗
PubMed1996

Public autonomous hospitals in sub-Saharan Africa: trends and issues.

Since the late 1980s, many countries in Africa have been granting increased autonomy to their main teaching hospitals. This policy has significant international support but has been evaluated little from either theoretical or empirical perspectives. This paper attempts to fill this gap by assembling evidence from policy documents, theoretical debates and empirical evidence of related policy changes in other contexts such as the development of trust hospitals in the UK NHS. The paper attempts to locate the policy in the broader context of the package of health sector reform measures proposed at international level, and to identify the role it is intended to play in the achievement of the implicit objectives of that package. The objectives identified are improvements in allocative efficiency and equity, improvements in internal efficiency and improvements in responsiveness, accountability and choice. Each of these objectives presents difficulties which suggest that only modest short-term expectations of the policy can be justified. Given the lack of evidence from existing experience, a research agenda is suggested, which aims to provide information to guide further implementation of the policy.

Africa South of the Sahara↗
PubMed1984

Some limits to the hospital as a negotiated order.

This paper examines issues of freedom and constraint by employing the negotiated order perspective in an analysis of a merger of three health care institutions. The findings give support to the importance of negotiated order considerations in understanding the social organization of health care, for they suggest that there are some limits to negotiations which take place within medically dominated settings.

Attitude of Health Personnel↗
PubMedDate not supplied

The OASIS program: redesigning hospital care for older adults.

A major factor in poor outcomes for hospitalized older adults is the health care delivery system. If acute care is not designed to address their altered response to illness and treatments, functional needs, and psychosocial issues, they are at significant risk for hospital-acquired complications and loss of functionality. Each health system should develop its own acute geriatric care program based on its resources and a plan for geriatric competency for all its health care workers. The OASIS pilot was created by taking elements from programs around the country that have succeeded in reengineering care for older adults. This pilot addressed the acute care of older patients scattered across 2 medical units in a 500+ bed community hospital. Outcomes demonstrated that coordinated, geriatric specific care had a positive, measurable impact on the quality of care, costs, and provided geriatric support to physicians and hospital staff.

Acute Disease↗