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PubMed2000

Employment relationships in Victorian public hospitals: the Kennett years.

From 1992 to 1999, the Kennett government in Victoria moved to competitive market models of service delivery and the measurement of service provision through casemix funding. Public hospital managers were given greater accountability for the costs and provision of service delivery and a new range of service providers, many from the private sector, entered the public health market. The decentralisation of the industrial relations system led to new developments in bargaining that brought both opportunities and problems. In the Victorian public health system there was an increasing emphasis on decentralisation in both service provision and employment relations. In this paper I suggest that there were contradictions in these developments for government, and new challenges and difficulties for employers, employees and trade unions.

Contract Services↗
PubMed1999

Improved trauma care after reorganisation: a retrospective analysis.

OBJECTIVE: To shorten the time to make a diagnosis and to begin definitive treatment of severely injured patients, thereby improving their medical care. DESIGN: Retrospective analysis. SETTING: Teaching hospital, Sweden. SUBJECTS: 61 patients who had sustained high-energy injuries, including head injury which required surgical intervention, and fracture of the femoral shaft before (1987-1988 n = 23) and after (1991-1993 n = 38) the reorganisation. INTERVENTION: Trauma care was reorganised during the year 1989-1990 and the concept of early multidisiplinary treatment with the general surgeon as trauma-leader was adopted. MAIN OUTCOME MEASURES: The time required to make a diagnosis and begin definitive treatment as well as the assessment of medical care taking account of the patient's general condition and other injuries. RESULT: The immediate medical care was classified as delayed or inappropriate in 9 of 23 patients before, and in 2 of 38 patients after, the reorganisation (p = 0.001). The time needed to make a diagnosis was less than 4 hours in all cases. The time needed to start definitive treatment of head injuries was less than four hours in 9 of 12 patients before, and in 18 of 21 patients after the reorganisation. The internal fixation of femoral fractures was started within four hours in 2 of 11 femoral fractures before, compared with 12 of 17, after the reorganisation. CONCLUSION: The time to beginning definitive treatment of severe injuries was shorter after the reorganisation, as a result of early participation of members of the trauma team.

Accidental Falls↗
PubMed1995

Re-engineering the hospital: a house without rooms.

Re-engineering of health care systems is defined, and the experience with re-engineering at a medical center is discussed. Re-engineering is a business concept that involves totally redesigning work processes to achieve much higher efficiencies and quality; it should not be confused with cost cutting, downsizing, and continuous improvement. Re-engineering seeks to combine multiple jobs into one, empower workers and make them more accountable, sequence the elements of work more naturally, create greater flexibility, and blur or remove organizational boundaries. Re-engineering at The Ohio State University Medical Center began with the formation of an operations improvement team consisting of department heads. Work processes were selected for re-engineering and prioritized, and teams were created to identify activities calling for radical change, such as activities that wasted time, could be done on an outpatient basis, or were duplicative. It was concluded that the redesign had to focus on the entire medical center, not the individual departments. A list of the characteristics of a better organization was prepared and distributed to the staff, along with other documents to help them understand the need for change. The operations improvement team specified expected outcomes of the re-engineering, and each re-engineering team developed measures of these outcomes. Many of the recommendations submitted have been implemented. One innovation has been the consolidation of the duties of utilization-review nurses, continuity-of-care nurses, social workers, and patient-education nurses into a single job category. When the medication-use re-engineering team meets, it will not be re-engineering the pharmacy department, it will be addressing the drug-use process. A medical center is re-engineering itself so that it will be able to continue to meet the health care needs of the community it serves.

Efficiency, Organizational↗
PubMed1995

Collaborating with re-engineering consultants: maintaining resources for the future.

The negotiations of a pharmacy department with a consulting firm hired to help cut the institution's staff are described. In July 1994 Duke University Medical Center announced its intention to reduce the number of full-time equivalents (FTEs) from 6500 to 5000 and hired a consulting firm. The pharmacy department was scheduled to be studied for 16 weeks. The entire pharmacy staff was educated about the initiative and about what management expected of the staff during the process. Each assistant director of pharmacy was asked to lead the "operations improvement process," as the re-engineering plan was called, in his or her area of responsibility. The assistant directors were to describe key work activities and their time requirements and develop instruments for measuring work activities. Data were collected on supplemental resource requirements for paid time off and educational and meeting time. Resource requirements for clinical pharmacy specialists and other selected staff members were determined separately. The data were collected for one fiscal month, and the assistant directors then began negotiating human-resource requirements with the consultants. The director finalized the negotiations and presented the results to the hospital's leaders and the consulting firm's executives. It was proposed to reduce total pharmacy FTEs by only 5%, and the department actually gained 1 pharmacist FTE. Far greater reductions were proposed for most other departments (the entire medical center lost more than 800 FTEs). The pharmacy department at Duke dealt successfully with a re-engineering initiative. Strategies that contributed to the success included teamwork, active participation by the entire staff, empowering a core group to help lead in the process, and substantiating the value of the pharmacy's services to the medical center and its patients.

Consultants↗
PubMed1995

Re-engineering for dramatic improvement in the medication-use process.

Planning for re-engineering the medication-use process at a university hospital is described. In summer 1992 the University of Cincinnati Hospital hired a consultant on quality to help with work-process improvement and re-engineering. By early 1993, re-engineering for patient-focused care was under way. Within a year of the implementation of patient-focused care in a pilot unit, it was realized that all departments that provided direct and indirect care would also have to undergo re-engineering. In August 1994 a retreat was held to begin the re-engineering effort in the pharmacy department. The retreat participants set as goals of the re-engineering (1) support of the hospital's strategic initiatives, (2) getting the right drug to the right patient at the right time, (3) improved patient outcomes, and (4) reducing the pharmacy labor and drug budget. Pharmacy activities for re-engineering were identified, and two planning teams were created, a pharmacy production team and a pharmacy knowledge-transfer team. The production team was made responsible for re-engineering dispensing, inspecting, producing, storing, and transporting, and the knowledge-transfer team was assigned teaching, recording, treating, and monitoring. A detailed plan was prepared for each team to follow using a framework provided by the consultant and consisting of strategy, technology, process, and personnel. Careful planning and a consultant helped a university hospital prepare for organizationwide re-engineering.

Focus Groups↗
PubMed2003

Melting public-private boundaries in European health systems.

Renewed debates about the superiority of either predominantly public or predominantly private health services arrangements have tended to be more ideologically charged than conceptually precise. Historically, the public/private split in European systems has often been more sharply defined in principle than in practice. This real-world variation was further complicated during the 1990s by reforms that enabled publicly owned hospitals and health centres to manage their daily operations more independently. Most recently, several new initiatives have established complex cross-boundary arrangements that cannot easily be characterized as either public or private. This article presents a conceptually rigorous four-part classification of past public/private arrangements that can provide a theoretical baseline from which to judge future cross-boundary developments.

Delivery of Health Care↗
PubMed1999

Reengineering the role of a nurse manager in a patient-centered care organization.

The Department of Veterans Affairs Medical Center in New York City expanded the role of a nurse manager to a manager and leader of the interdisciplinary team within a structure reorganized to focus on patients. As the literature noted the critical nature of the role of a middle manager, an interdisciplinary team reached the consensus that a registered nurse with progressive clinical and head nurse experience should be the first-line manager in a patient-centered care organization. The process of reengineering the role of a Patient Care Team Coordinator (PCTC), the support systems designed to develop the new leadership role, and the benefits associated with the changes implemented are discussed. The functional statement for the PCTC's position is included, as well as an organizational structure to show how staff are grouped to promote the continuity and coordination of care provided to patients.

Continuity of Patient Care↗
PubMed2002

Work site change and psychosocial well-being among health care personnel in geriatric wards--effects of an intervention program.

The study evaluated the effect of a change of work site and organization on work environment and psychosocial parameters: the change involved health care personnel at a geriatric hospital. Another aim of this study was to evaluate the effects of a structured psychoeducational intervention program. The study found few changes in the indices of interest on the experimental and control wards. There were, however, significant improvements in social climate, goal quality, and independence of work on the control ward. The investigators postulated that too much external support hampers a group's ability to actively cope with change and might actually lower a group's ability and self-esteem. In order to achieve successful organizational change, psychosocial intervention programs for personnel must be performed by a well-informed, well-chosen, and experienced counsellor who is well tailored to the local organization.

Adaptation, Psychological↗
PubMed1988

Effects of a faculty prepaid group practice in a pediatric primary care clinic.

Medical student and resident education at a hospital-operated pediatric primary care clinic (PPCC) was threatened by chronic financial deficits and by a state mandate that all patients receiving medical care through the state Aid to Families with Dependent Children program be enrolled in a health maintenance organization (HMO). To comply with the mandate, the PPCC was reorganized in 1984 as a faculty-operated prepaid group practice independent of the hospital. The new PPCC contracted with an HMO to provide care, with reimbursement based on capitation. The PPCC continues to serve the same patient population as before the reorganization, continues its teaching activities, and no longer has financial deficits. The experience at this clinic shows that converting to a faculty prepaid group practice can be cost-effective, promote efficiency, and improve faculty-hospital relations. Such a group practice is an appropriate organization for maintaining medical education programs while providing care in a capitation payment system.

Aid to Families with Dependent Children↗
PubMed1996

Evaluation of the VA's Pilot Program in Institutional Reorganization toward Primary and Ambulatory Care: Part I, Changes in process and outcomes of care.

PURPOSE: To evaluate the impact of the reorganization of an academic Veterans Affairs medical center toward primary and ambulatory care--including the implementation of a medical-center-wide interdisciplinary firm system and ambulatory care training program--on the quality of primary ambulatory care. METHOD: Randomly selected male veterans visiting the Veterans Affairs Medical Center in Sepulveda, California, were surveyed in 1992, early in the implementation of the program, and in 1993, after the program had been fully implemented. Two surveys were used: one before the veterans saw their primary care providers (practice-based survey) and the other immediately after patient visits (visit-based survey). Survey-participant data were then linked to computerized utilization and mortality data. Survey topics were mapped to the medical center's strategic plan and goals for ambulatory care, and focused on patients' reports about the care they had received in terms of continuity, access, preventive care, and other aspects of the biopsychosocial model of care. Administrative computer data were then used to evaluate effects on medical center workload. Statistical analyses included analysis of variance, analysis of covariance, chi-square, and logistic regression. RESULTS: For practice-based comparisons, complete data were available for 1,262 veterans in 1992 and 1,373 in 1993. For visit-based comparisons, complete data were available for 1,407 veterans in 1992 and 643 in 1993. Results included statistically significant improvements in continuity of care and detection of depression as well as increased rates of preventive care counseling (smoking and exercise). The proportion of veterans reporting being seen by physicians increased, as did the proportion of patients seen for check-ups rather than for acute problems. Fewer patients were seen in subspecialty clinics than in general medicine clinics. Patient satisfaction increased, hospitalizations decreased, and death rates decreased. Alcohol counseling and access to care for acute symptoms declined. Workload shifted from subspecialists to generalists and from inpatient care to outpatient care. CONCLUSION: The institutional reorganization toward primary and ambulatory care succeeded in substantially improving the quality of ambulatory care, reflecting improvements in the system of care and of health care provider training in ambulatory care.

Ambulatory Care↗
PubMed1996

Evaluation of the VA's Pilot Program in Institutional Reorganization Toward Primary and Ambulatory Care: Part II, A study of organizational stresses and dynamics.

BACKGROUND: Many academically affiliated hospitals are moving from an inpatient, subspecialty orientation in their patient care and educational programs toward a greater emphasis on ambulatory and primary care. Few studies have focused on the organizational, staffing, and management issues involved in implementing these changes. METHOD: The authors carried out a qualitative evaluation of the process of change in an academic Department of Veterans Affairs hospital during implementation of a major ambulatory primary care program. They interviewed four top managers individually and 59 top and middle managers, house officers, and patients in focus groups in the spring of 1992, nine months after implementation of the key components of the program. Four raters independently evaluated written transcripts of focus-group sessions and identified themes. RESULTS: The main problems identified were difficulty with administrative integration between inpatient and outpatient services; need for training, retraining, and orientation; tensions due to changes in roles and organizational culture; and inefficiency due to the need for frequent negotiations in daily work life. These four problems reflected tensions associated with new demands imposed by matrix management, changing job descriptions, policies and procedures, and changing patterns of communication and record keeping. CONCLUSION: During the process of implementation of a primary care focus throughout a medical center, extra demands upon staff are inevitable and should be anticipated and planned for. Twelve key factors for successful organizational change are discussed.

Administrative Personnel↗
PubMed1992

Critical strategies for successful rural hospitals.

Not all rural hospitals are in a depressed financial situation. Many can and have achieved financial performance levels which match their urban counterparts. Cost control is the single most important management strategy which differentiates the successful from the unsuccessful rural hospital. Labor productivity is much higher in the financially successful rural hospital than in the unsuccessful hospitals. Reduced length of stay is also especially critical in the overall cost containment program.

Capital Expenditures↗
PubMed1996

Downsizing and financial performance in rural hospitals.

This article examines the association between downsizing and financial performance in a national sample of 797 U.S. rural hospitals from 1983-1988. The results indicate that downsizing occurred in about 15 percent of all rural hospitals and that a positive association between downsizing and financial performance was unconfirmed.

Efficiency, Organizational↗