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An assessment of the introduction of a multi-skilled worker into an acute care setting.

The first reengineering project undertaken by the Sunnybrook Health Science Centre after adopting a philosophy of patient-focused care was the introduction of a new category of worker: the multi-skilled service assistant. This article describes the experiences of the first two cohorts of service assistants and assesses the changes made to the work itself and the integration of the new workers into the work environment. It concludes by sharing recommendations for introducing a new work role.

Decision Making, Organizational↗

More than "bandaids": emotional support and education during the downsizing process.

This paper illustrates the importance of giving emotional support and education to patients, families, staff and managers at The Queen Elizabeth Hospital, Toronto during the Spring 1992 downsizing effort. The Queen Elizabeth Hospital is a 601-bed, two-site facility which provides complex specialized rehabilitative and supportive care, teaching and research, as well as specialty programs in rehabilitation, geriatric service, geriatric psychiatry and long-term care. Downsizing at The Queen Elizabeth Hospital meant the consolidation and closure of 82 long-term beds, on one nursing unit at each site, to offset a projected budget deficit of $5.4 million. Internal restraint over the past year and during the budget process reduced this deficit to $2.8 million, thus necessitating further downsizing consideration. Background information includes a review of the recent downsizing literature. This paper describes the informal and formalized support activities that took place during the two-month process and the educational sessions that were provided on a regular basis. It gives specific attention to methodology and rationale. The authors also make recommendations for the successful implementation of a downsizing process which can be beneficial to any health care setting involved in bed closure.

Employment↗

Patient-focused care: the systemic implications of change.

Continuous quality improvement and customer identification have become pivotal concerns for modern management. It is evident that much past activity in health care has been narrowly focused, technologically based and of unknown efficiency. Identifying the patient as primary and overarching customer for health service organizations serves to simplify, refocus and redesign institutions so that resources and personnel are organized and allocated based on patient-care needs. Health care facilities can, accordingly, be ranked on the basis of their commitment and achievement with regard to patient-focused care. Quality becomes a matter of providing excellent and efficient medical care and satisfying the demands of the larger patient experience. Redefining the organization in the context of patient need profoundly changes the work place, creating less rigid, flattened organizational structures and emphasizing leadership rather than managerial activities.

Canada↗

Innovations in human service technologies. Strengthening health care delivery systems.

The authors report on innovative approaches to the organization of health services and the delivery of patient care in 19 U.S. hospitals and hospital networks. Strengthening patient care is the focus of this initiative. Hospital-wide interdisciplinary planning and the subsequent trial of new human service technologies are explored.

Delivery of Health Care↗

Leadership crisis in psychiatric services: a change theory perspective.

In 1990, after twenty years of service, the psychiatrist who had been Director of Psychiatric Services at Alpha Hospital decided to take an early retirement. What followed was a dramatic leadership struggle, which peaked with the resignation (in the summer of 1992) of most of the hospital's psychiatrists. In the years since, there has been a great deal of healing. The psychiatrists are all back at work. Joint leadership of the services is established under the direction of a (psychiatrist) Clinical Director and a (non-psychiatrist) Administrative Director. Management of the programs and services has been reorganized to a much more efficient and effective system. And feelings among the key players are more trusting and collaborative. This paper will explore how this crisis may be understood in terms of change theory. It will also outline the process utilized to resolve the crisis, and will draw implications for other mental health administrators who, in these times of rapid and dramatic change, will undoubtedly confront similar challenges.

Forecasting↗

Health service structures, management and professional practice: beyond clinical management.

At the heart of the operation of the health system is the relationship between managers and the various professionals who provide clinical services. While there is an inherent conflict between these two groups, this conflict has been avoided in the past by the managers playing a supporting rather than a controlling role. However, the current demands of cost-control are placing managers and professionals into direct conflict; a situation that many organisations are addressing by putting clinicians into management roles. This measure has had initial success in some situations, but it is argued that this success will be limited because clinical departments are not able to address many of the broader issues that affect the performance of health services. This paper proposes an alternative approach that will enable these broader issues to be effectively addressed, and also reduce the structural conflict.

Australia↗

Maintaining patient satisfaction in a hospital reorganization.

A review of inpatient satisfaction data for MUSC provides both comfort and cause for additional study. Although overall satisfaction rates of 89 and 88 during the period of organizational change indicate stable patient perceptions, one must reflect upon these scores in greater detail. For example, although survey response rates in the 36 percent to 28 percent range appear customary for this type of survey, absolute numbers of discharge responses averaged 496 for the four quarters reported. Some confidence can be taken in the fact that overall survey scores were highly consistent in the 89 to 88 range for the entire reporting period. Moreover, the fact that workforce performance variables such as medication errors and patient occurrence reports did not change indicates that patient care did not deteriorate during this period. Although one could argue that in a time of workforce reduction, employees may work more diligently in order to ensure job security, and that work deterioration may be more apparent over a longer period of observation, this limited view suggests that, at least in the acute phase, work performance was maintained. Future studies should review the relative effectiveness of the specific strategies adopted by MUSC management to ensure high levels of patient care. For example, although MUSC adopted a fairly comprehensive communications effort, it is difficult to discern whether timeliness, variety, or repetition contributed more to the effectiveness of the communications program. Such information could help managers develop focused change implementation strategies. It appears from the inpatient survey data collected by UHC and from the two work performance monitors that MUSC's approach to change management has been able to preserve acceptable levels of patient satisfaction in the face of significant organizational change. Furthermore, these strategies may have been helpful in countering the turbulence caused by large scale change or, at the very least, insulating the care site from potentially negative effects.

Academic Medical Centers↗

The reform of hospital care in the Netherlands.

OBJECTIVES: This article provides a short overview of the structure of hospital care in the Netherlands. It discusses a number of hospital reform programs that have been started since the early 1980s and others more recently proposed. Attention has also been given to the potential impact of hospital reform. METHODS: Descriptions of hospital structure, planning, financing, payment of medical specialists, and hospital workforce and services provide a context for a discussion of current hospital reform programs. Trends in hospital care delivery, strategic management, and internal organization are examined. RESULTS: The relationships between the hospital and other health-care providers, health insurers, employers, and patients are found to have a significant impact on the future of the hospital. The interconnections of these four factors will help form the basis for an understanding of ongoing hospital change. CONCLUSIONS: Hospital care has been subject to rapid change during the last two decades, as hospitals become centers for acute specialized medical care. This development has important consequences for the position of hospitals in the health-care delivery network, as they become one of a number of providers in a more integrated delivery system. It should be noted that the changes in hospital care cannot be understood as the results of a single reform program, but rather as the result of a long series of reform efforts.

Economics, Medical↗

An aging population with chronic disease compels new delivery systems focused on new structures and practices.

Patients now, more than ever, need reassurance that they are indeed the focus of the healthcare team. Patients enter the healthcare system knowing that there are worldwide shortages of key personnel, that physicians can no longer afford malpractice coverage and are many times practicing "defensive medicine," and that there are reported issues in terms of patient safety that may affect their own care within a hospital setting. With inpatient care becoming increasingly focused on "curing" via application of new and advanced technologies, patients are beginning to ask the question "Does anyone care?" To answer that question, Baptist Hospital of Miami, part of Baptist Health South Florida, committed to the hospital-wide implementation of a new model of practice. In this model, a patient care facilitator (PCF) becomes the primary point person for the patient during their stay. Each PCF leads a "Twelve Bed Hospital," a smaller segment of the patient care center where staff work with the PCF to make the whole inpatient experience more personalized. Initial results of the pilot implementation are promising. Research is underway to assess the overall effects of this practice model on continuity of care, patient safety, satisfaction, efficiency, and effectiveness of patient care.

Aged↗

Does hospital rundown affect long-stay clients?

In order to examine what happens to long-stay clients who remain in hospital, a retrospective analysis of annual surveys between 1984 and 1992 was undertaken. Data were derived from the REHAB scale, which provides measures of patient Total General Behaviour (TGB) and Deviant Behaviour (DB), together with data from the Supplementary Information Questionnaire (SIQ). Results indicate that skills and behaviour, as measured by TGB, do not deteriorate as a function of continuous length of stay or increasing age. However, TGB for certain clients is adversely affected by a reduction in the level of structured activity occurring during major episodes of contraction leading up to closure. In contrast, DB, which is relatively high for this group, fluctuates independently of rundown. The implications for hospital services in transition are discussed.

Aged↗

Meeting patient expectations: healthcare professionals and service re-engineering.

A central theme underpinning the reform of healthcare systems in western economies since the 1980s has been the emphasis on reorienting service provision around the patient. Healthcare organizations have been forced to re-appraise the design of the service delivery process, specifically the service encounter, to take account of these changing patient expectations. This reorientation of healthcare services around the patient has fundamental implications for healthcare professionals, specifically challenging the dominance of service professionals in the design and delivery of health services. Utilizing a qualitative methodological framework, this paper explores the responses of healthcare professionals to service redesign initiatives implemented in acute NHS hospitals in Scotland and considers the implications of such professional responses for the development of patient-focused service delivery. Within this, it specifically examines evolving professional perspectives on the place of a service user focus in a publicly funded healthcare system, professional attitudes towards private sector managerial practices, and the dynamics of changing professional behaviour.

Attitude of Health Personnel↗

Specialty-service lines: salvos in the new medical arms race.

Hospitals and physicians are developing and marketing discrete and profitable specialty-service lines. Although closely affiliated specialist physicians are central to hospitals' service-line products, other physicians compete directly with hospitals via physician-owned specialty facilities. Specialty-service lines may be provided in a variety of settings, both inside and outside traditional hospital walls. Thus far, the escalating battle between hospitals and physicians for control over specialty services has not affected hospital profitability. However, as the scope of care that can be safely performed in the outpatient arena expands, physician competition for control over specialty services may threaten hospitals' financial health.

Economic Competition↗

The strategies and autonomy of university hospitals in competitive environments.

University-owned hospitals face increasingly threatening and unstable environments. This article examines the strategies that university-owned hospitals are using, and can use, to respond to their changing environments. Further, it examines factors that can hinder or promote the effective development of university-owned hospital strategies.

Commerce↗

Hospital turnarounds--thinking strategically.

Healthcare executives throughout the country are losing confidence that their organizations can remain viable without significant organizational change. Now is the time to review principal trends in this area--conversions and partnerships--and to assess how well particular arrangements seem to be working.

Hospital Administration↗

The well-structured hospital-physician partnership.

Presbyterian Intercommunity Hospital began its journey along the right path toward successful diversification when it decided to modify, rather than destroy, the legal structure of InterHealth.

California↗