Changes in Hospital Performance after Ownership Conversions

This paper examines the effects of ownership conversions on hospital performance between 1987 and 1998 in areas of financial performance, staffing, capacity, and unprofitable care. Conversions to government and for-profit ownership both increased the profit margin: the former due to rising revenue, and the latter due to reduced operating costs and rising revenue. Hospitals that converted to for-profit ownership had the greatest reduction in staffing relative to other converted hospitals. There was little change in bed capacity after conversion to for-profit status, but some reductions in bed capacity after conversion to government or nonprofit status. No conversion of any kind led to a reduced amount of unprofitable care, but conversion to private ownership (nonprofit and for-profit) increased the probability of trauma center closures.

Planning Staff and Space Capacity Requirements during Wartime

Determining staff and space requirements for military medical centers can be challenging. Changing patient populations change the caseload requirements. Deployment and assignment rotations change the experience and education of clinicians and support staff, thereby changing the caseload capacity of a facility. During wartime, planning becomes increasingly more complex. What will the patient mix and caseload volume be by location? What type of clinicians will be available and when? How many beds are needed at each facility to meet caseload demand and match clinician supply? As soon as these factors are known, operations are likely to change and planning factors quickly become inaccurate. Soon, more beds or staff are needed in certain locations to meet caseload demand while other locations retain underutilized staff, waiting for additional caseload fluctuations. This type of complexity challenges the best commanders. As in so many other industries, supply and demand principles apply to military health, but very little is stable about military health capacity planning. Planning analysts build complex statistical forecasting models to predict caseload based on historical patterns. These capacity planning techniques work best in stable repeatable processes where caseload and staffing resources remain constant over a long period of time. Variability must be simplified to predict complex operations. This is counterintuitive to the majority of capacity planners who believe more data drives better answers. When the best predictor of future needs is not historical patterns, traditional capacity planning does not work. Rather, simplified estimation techniques coupled with frequent calibration adjustments to account for environmental changes will create the most accurate and most useful capacity planning and management system. The method presented in this article outlines the capacity planning approach used to actively manage hospital staff and space during Operations Iraqi Freedom and Enduring Freedom.

How geographical information systems analysis influences the continuum of patient care

As the vast repository of data about millions of patients grows, the analysis of this information is changing the provider-patient relationship and influencing the continuum of care for broad swaths of the population. At the same time, while population health management moves from a volume-based model to a value-based one and additional patients seek care due to healthcare reform, hospitals and healthcare networks are evaluating their business models and searching for new revenue streams. Utilizing geographical information systems to model and analyze large amounts of data is helping organizations better understand the characteristics of their patient population, demographic and socioeconomic trends, and shifts in the utilization of healthcare. In turn, organizations can more effectively conduct service line planning, strategic business plans, market growth strategies, and human resource planning. Healthcare organizations that use GIS modeling can set themselves apart by making more informed and objective business strategy decisions.

Developing a strategic human resources plan for the Urban Angel

In healthcare a significant portion of the budget is related to human resources. However, many healthcare organizations have yet to develop and implement a focused organizational strategy that ensures all human resources are managed in a way that best supports the successful achievement of corporate strategies. St. Michael's Hospital, in Toronto, Ontario, recognized the benefits of a strategic human resources management plan. During an eight-month planning process, St. Michael's Hospital undertook the planning for and development of a strategic human resources management plan. Key learnings are outlined in this paper.

Health facilities planning: determining infrastructure requirements for form and function from clinical and operational capabilities

This article describes the practical application of documenting the operational concept and scope of services for military combat hospitals providing joint health service support during Operation Iraqi Freedom. Due to the rapid changes that take place in healthcare in general, and, in particular, in a large, rapidly maturing military theater of operations, a clear operational concept and accurate scope of services is essential for hospital commanders and medical planners. A highly structured, yet flexible collaborative approach to health facility requirements development begins with a clinical concept of operations (CONOPS). Initial, up-front investment of time in the requirements process, and subsequent reviews and revisions result in a definitive description of the clinical and operational requirements. Those requirements in turn become the authoritative source for space, building systems, equipment, functional arrangements, and financial justification. A recent case study highlights the utility of the CONOPS document in translating the necessary clinical capabilities and capacities into facility space and building systems required to support them in a very tight schedule driven process normally not associated with the military construction program and in particular medical projects.

Decentralising tuberculosis services from county tuberculosis dispensaries to township hospitals in China: an intervention study

SETTING

County tuberculosis (TB) dispensaries are the basic health care unit for the provision of TB services in China. In the rural hills of the western provinces of China, however, county centres are often far from patients' homes.

OBJECTIVE

To evaluate whether decentralisation would result in improvements in patient access to TB services while maintaining the quality of the DOTS strategy.

METHODS

The present study compared TB services that were decentralised to township hospitals with two comparable control groups where township hospitals continued to routinely refer suspects to the county TB dispensaries. Training and supervision of quality control were provided. Routine TB reporting data were reviewed. A questionnaire-based survey was conducted for 171 new TB patients enrolled from 1 April 2005 to 31 July 2006.

RESULTS

Patients in the decentralised group spent less on travel and treatment for TB. The TB case notification rates increased significantly in the decentralised group, but remained unchanged in the control groups. Compared with the control groups, the decentralised group had improved treatment outcomes after 16 months. A higher quality of care was also observed in the decentralised group.

CONCLUSION

The decentralised model showed better patient access and quality of care. The study demonstrated that decentralising TB services to the township level, especially vital in China's poorly accessible areas, was feasible.

Strategy development for anticipating and handling a disruptive technology

The profession of radiology has greatly benefited from the introduction of new imaging technologies throughout its history. Therefore, it would seem reasonable for radiologists to believe that the emergence of a new imaging technology can generally be foreseen with sufficient advance notice to allow the appropriate levels of time, effort, and money to be devoted toward incorporating it into radiology practice. However, in his seminal work, Christiansen characterized a new form of technologic innovation, known as "disruptive technology," whose emergence often heralds the replacement of market leaders in an industry by competitors who are quicker in adopting and deploying the new technology. This article briefly describes the phenomenon of disruptive technology and addresses the challenges that organizations face in dealing with disruptive technology. The article raises 4 questions about the future of radiology: (1) Are health care and radiology vulnerable to disruptive technology? (2) What kinds of change may be in store for the radiology profession? (3) Can the radiology profession prepare itself to recognize and respond to a disruptive innovation among a group of new imaging technologies? and (4) How should a radiology organization decide whether to invest significant resources in a potentially disruptive technology? This article addresses these questions by reviewing key insights from leading "gurus" in the fields of competitive strategy and technology management and applying them to radiology. This illustrates how and why (despite past successes) the radiology profession may still have a blind spot in recognizing and handling disruptive technologies.

Design and Ergonomic Considerations for the Filmless Environment

Planning and executing the redesign of a traditional institutional radiology reading room to conform to the radically different requirements of digital imaging are reviewed, with examples drawn from the authors' experience and from the growing body of literature on this subject. Included are best-practice recommendations and real-life examples on initial design and planning, stakeholder involvement, identifying and hiring consultants, architectural planning, the designation of a radiology point person, rethinking room and workstation design, the selection of ergonomic furniture and fittings, identifying optimal environmental elements, fine tuning and lessons learned, and going digital.

Business Plan to Establish a CT Colonography Service

The authors describe the University of Iowa Department of Radiology's business planning process to initiate a new service in computed tomographic colonography (CTC). Also known as virtual colonoscopy, CTC is a noninvasive technology that offers less risk, and potentially similar sensitivity and specificity, than conventional optical colonoscopy (OC). Although not currently covered by all insurance payers, about a year ago, the Centers for Medicare and Medicaid Services instituted temporary Current Procedural Terminology codes (Category III) for CTC. In locales where the procedure is not covered by insurers, it is likely to be sought by patients willing to pay out of pocket to undergo noninvasive cancer screening as an alternative to OC. Thus, CTC could become the preferred method of colon cancer surveillance by insurance providers in the near future. In developing the business plan, the authors reviewed pertinent scientific and clinical data to evaluate the need for and efficacy of CTC. Local market data were used to estimate patient and procedure volumes and utilization. The authors modeled financial expectations with respect to return on investment on the basis of recently reported models specific to CTC, resource requirements, and the operational impact of the new service on existing hospital and departmental clinical functions. Because there are few local providers of CTC in the authors' region, the business plan also included a publicity campaign and plan to market the new service, stimulate general public interest early, and differentiate the program as a leader in applying this unique new technology to promote cancer screening. Finally, the planning committee acknowledged and accommodated needs specific to the missions of an academic medical center with respect to research and education in designing the new service.

[Analysing strengths and weaknesses: opportunities and threats for service providers in the German health care system]

Hospitals in the German health care system are confronted with increasing economic competition due to paradigm shifts in funding inpatient treatment. Major hospitals, such as university hospitals, will be under significantly greater pressure to keep up the ability to compete by uniform per case payment. The new hospital funding system based on a Diagnosis Related Group (DRG) system and the economic competition involved require analyses of organisational and locational factors. Cooperativeness and efficient utilisation of resources, properties and staff will be determining factors to secure existence. Adequate responses and strategies are essential to cope with the growing operating requirements. Carrying out an analysis identifying one's own strengths and weaknesses, opportunities and threats will help to focus activities and sustainable strategies into areas where the strengths and the greatest opportunities lie. An example of the process of strategic planning and positioning is shown for a university department of dermatology.

Using data to make decisions and drive results: a LEAN implementation strategy

During the process of facility planning, Fairview Laboratory Services utilized LEAN manufacturing to maximize efficiency, simplify processes, and improve laboratory support of patient care services. By incorporating the LEAN program's concepts in our pilot program, we were able to reduce turnaround time by 50%, improve productivity by greater than 40%, reduce costs by 31%, save more than 440 square feet of space, standardize work practices, reduce errors and error potential, continuously measure performance, eliminate excess unused inventory and visual noise, and cross-train 100% of staff in the core laboratory. In addition, we trained a core team of people that is available to coordinate future LEAN projects in the laboratory and other areas of the organization.

Preparedness of households and catering establishments for incidents involving radioactive contamination

This short paper describes a number of investigations carried out to ensure preparedness for crises involving radioactivity to catering operations and private households in Finland. The specific recommendations for catering kitchens during crises were published in 1994. A study to determine the level of adherence to these recommendations is summarised here, together with its findings and subsequent recommendations. Another study on the pre-planning of crisis menus is described. New challenges for the catering kitchens are touched upon. A crisis food preparation booklet for households is described and based on consumers' attitudes suggestions are made for how this can be improved in the future.

Planning and developing a diagnostic imaging center

The convergence of an aging population, new technology, and an increasing number of clinical applications and reimbursements has created a favorable environment for ambulatory imaging centers. From a patient's perspective, features such as easy access, parking, appointment availability, and a setting that caters to outpatients are attractive compared with the hospital environment. Before embarking on a venture, the execution of a careful, thorough planning process, from the inception of the idea to the opening, is vital to success. This article provides guidance on the process by discussing the process of determining whether a project is feasible; developing a business plan that will measure potential success; locating, financing, and planning space; contractor selection and project management; and planning operations.

Establishing and training health care facility decontamination teams

Recent terrorist events, changes in Joint Commission on Accreditation of Healthcare Organizations requirements, and availability of grant funding have focused health care facility attention on emergency preparedness. Health care facilities have historically been underprepared for contaminated patients presenting to their facilities. These incidents must be properly managed to reduce the health risks to the victims, providers, and facility. A properly equipped and well-trained health care facility team is a prerequisite for rapid and effective decontamination response. This article reviews Occupational Safety and Health Administration (OSHA) training requirements for personnel involved with decontamination responses, as well as issues of team selection and training. Sample OSHA operations-level training curricula tailored to the health care environment are outlined. Initial and ongoing didactic and practical training can be implemented by the health care facility to ensure effective response when contaminated patients arrive seeking emergency medical care.

Linkages in the rural continuum: the balanced budget act and beyond

PURPOSE

This study examined how rural hospitals altered their postacute and long-term care strategies after the Balanced Budget Act of 1997 (BBA97).

DESIGN AND METHODS

A nationally representative sample of 540 rural hospital discharge planners were interviewed in 1997. In the year 2000, 513 of 540 discharge planners were reinterviewed. The study is a descriptive analysis of how rural hospitals formed new and altered existing organizational strategies during a time of turbulent changes in federal government reimbursement policy. We classify rural hospital strategic behavior in 1997 according to the Miles and Snow typology of Prospectors, Analyzers, Defenders, and Reactors, and then we examine how the various hospital types altered key strategies following BBA97.

RESULTS

Between 1997 and 2000, more than 26% of sampled rural hospitals that did not participate in the swing-bed program in 1997 (44/167) had chosen to do so in 2000, whereas only 3% of those using swing beds in 1997 had eliminated them (12/346). Other strategies such as divestiture of hospital-based nursing homes were related to concurrent swing-bed adoption. Rural hospitals also increased their reliance on formal linkages with external providers of long-term care.

IMPLICATIONS

After the BBA97 reimbursement changes, rural hospitals increased their reliance on swing beds and formal linkages to external providers. We observed changes in overall strategy types, away from the Defender and toward the Prospector and Analyzer strategy types. Our findings illustrate the importance of swing beds as a critical buffer for rural hospitals challenged by the uncertainty of the post-BBA97 environment.

Concepts and techniques for planning and implementing a program for renovation of an emergency obstetric care facility

As emergency obstetric care (EmOC) services are being upgraded, many health planners are considering structural changes to the health facility. Preparing for a renovation is a long process which involves three phases: assessment, planning and implementation. Input from many sources during the course of this process is important. Some design objectives, simple planning techniques and cost considerations are presented. In this paper we discuss some of the critical aspects (based on published literature) in assessing, planning and implementing renovations at an EmOC facility. The actual in-the-field experience of renovations and repairs will be explored in a second paper in this issue.

Planning and implementing a program of renovations of emergency obstetric care facilities: experiences in Rajasthan, India

Even though many governments and donors are now putting resources into upgrading facilities, the study of the renovation process is one of the most neglected aspects of quality improvement in emergency obstetric care (EmOC). In a previous publication, we discussed basic concepts and simple techniques to assess, plan and implement renovations. Here we focus on actual in-the-field experiences of the renovation process initiated by the health system in Rajasthan, India and the valuable lessons obtained from it. With the advice of the technical members of the Averting Maternal Death and Disability Program (AMDD) and the United Nations Population Fund (UNFPA), the facilities achieved noticeable changes in the physical infrastructure. As a result, the quality of EmOC services improved. We analyze these experiences critically and draw out lessons which may be instructive for future renovation efforts.

The effect of hospital ownership choice on patient outcomes after treatment for acute myocardial infarction

I examine the effect of ownership choice on patient outcomes after the treatment for acute myocardial infarction. I find that for-profit and government hospitals have higher incidence of adverse outcomes than not-for-profit hospitals by 3-4%. In addition, the incidence of adverse outcomes increases by 7-9% after a not-for-profit hospital converts to for-profit ownership, but there is little change in patient outcomes in other forms of ownership conversion. The findings are robust, whether I use the entire sample or subsamples of hospitals that share similar hospital and market characteristics.

Business planning for university health science programs: a case study

Many publicly funded education programs and organizations have developed business plans to enhance accountability. In the case of the Department of Dentistry at the University of Alberta, the main impetus for business planning was a persistent deficit in the annual operating fund since a merger of a stand-alone dental faculty with the Faculty of Medicine. The main challenges were to balance revenues with expenditures, to reduce expenditures without compromising quality of teaching, service delivery and research, to maintain adequate funding to ensure future competitiveness, and to repay the accumulated debt owed to the university. The business plan comprises key strategies in the areas of education, clinical practice and service, and research. One of the strategies for education was to start a BSc program in dental hygiene, which was accomplished in September 2000. In clinical practice, a key strategy was implementation of a clinic operations fee, which also occurred in September 2000. This student fee helps to offset the cost of clinical practice. In research, a key strategy has been to strengthen our emphasis on prevention technologies. In completing the business plan, we learned the importance of identifying clear goals and ensuring that the goals are reasonable and achievable; gaining access to high-quality data to support planning; and nurturing existing positive relationships with external stakeholders such as the provincial government and professional associations.

The value of the facilities management function in the UK NHS community health-care sector

This paper stresses the importance of the strategic integration of the organisational facilities management function as being an essential prerequisite towards facilities and organisational effectiveness. The impact of both the strategic and operational facilities management function on community health-care facility users is also documented. The value of the facilities management function in terms of other health-care related organisational core deliverables is also observed. Mechanisms for general organisational facilities management improvement are identified and a number of facilities management performance measuring tools outlined.

Experiencing change: progress and pitfalls

A small, rural community takes the effort to make the transition from a skilled nursing facility to an assisted living model of care delivery. These changes are needed because of the cost and access of services available in this setting. The system of care delivery being considered is based on the model called Aging in Place (AIP).

Weapons of mass destruction events with contaminated casualties: effective planning for health care facilities

Biological and chemical terrorism is a growing concern for the emergency preparedness community. While health care facilities (HCFs) are an essential component of the emergency response system, at present they are poorly prepared for such incidents. The greatest challenge for HCFs may be the sudden presentation of large numbers of contaminated individuals. Guidelines for managing contaminated patients have been based on traditional hazardous material response or military experience, neither of which is directly applicable to the civilian HCF. We discuss HCF planning for terrorist events that expose large numbers of people to contamination. Key elements of an effective HCF response plan include prompt recognition of the incident, staff and facility protection, patient decontamination and triage, medical therapy, and coordination with external emergency response and public health agencies. Controversial aspects include the optimal choice of personal protective equipment, establishment of patient decontamination procedures, the role of chemical and biological agent detectors, and potential environmental impacts on water treatment systems. These and other areas require further investigation to improve response strategies.

Team-based planning: new tools for new times

The collaborative process of team-based planning draws upon the strengths of a team and develops the skills that healthcare providers need to build consensus during this time of significant change. This article describes three examples of team-based planning and shows how applying an integrated set of tools can help formulate plans and create new options to meet the challenges facing today's healthcare organizations.

Strategic cycling: shaking complacency in healthcare strategic planning

As the conditions affecting business and healthcare organizations in the United States have become more turbulent and uncertain, strategic planning has decreased in popularity. Strategic planning is criticized for stiffling creative responses to the new marketplace and for fostering compartmentalized organizations, adherence to outmoded strategies, tunnel vision in strategy formulation, and overemphasis on planning to the detriment of implementation. However, effective strategic planning can be a force for mobilizing all the constituents of an organization, creating discipline in pursuit of a goal, broadening an organization's perspective, improving communication among disciplines, and motivating the organization's workforce. It is worthwhile for healthcare organizations to preserve these benefits of strategic planning at the same time recognizing the many sources of turbulence and uncertainty in the healthcare environment. A model of "strategic cycling" is presented to address the perceived shortcomings of traditional strategic planning in a dynamic environment. The cycling model facilitates continuous assessment of the organization's mission/values/vision and primary strategies based on feedback from benchmark analysis, shareholder impact, and progress in strategy implementation. Multiple scenarios and contingency plans are developed in recognition of the uncertain future. The model represents a compromise between abandoning strategic planning and the traditional, linear model of planning based on progress through predetermined stages to a masterpiece plan.

Decision making in high-velocity environments: implications for healthcare

Healthcare can be considered a high-velocity environment and, as such, can benefit from research conducted in other industries regarding strategic decision making. Strategic planning is not only relevant to firms in high-velocity environments, but is also important for high performance and survival. Specifically, decision-making speed seems to be instrumental in differentiating between high and low performers; fast decision makers outperform slow decision makers. This article outlines the differences between fast and slow decision makers, identifies five paralyses that can slow decision making in healthcare, and outlines the role of a planning department in circumventing these paralyses. Executives can use the proposed planning structure to improve both the speed and quality of strategic decisions. The structure uses planning facilitators to avoid the following five paralyses: 1. Analysis. Decision makers can no longer afford the luxury of lengthy, detailed analysis but must develop real-time systems that provide appropriate, timely information. 2. Alternatives. Many alternatives (beyond the traditional two or three) need to be considered and the alternatives must be evaluated simultaneously. 3. Group Think. Decision makers must avoid limited mind-sets and autocratic leadership styles by seeking out independent, knowledgeable counselors. 4. Process. Decision makers need to resolve conflicts through "consensus with qualification," as opposed to waiting for everyone to come on board. 5. Separation. Successful implementation requires a structured process that cuts across disciplines and levels.

Strategic planning/management by objectives. A boon for healthcare administrators

The means of delivering effective, efficient healthcare are undergoing rapid change. Hospitals, clinics, and all organizations must react to change to meet the needs of their clientele and to survive. This article demonstrates how strategic planning can contribute to that end.

A comparison of measures of access to child health clinics and the implications for modelling the location of new clinics

OBJECTIVE

To determine whether measurement of access to existing child health clinics, and modelled location of new clinics, was affected by the spatial definitions of the target population.

METHOD

Populations requiring childhood screening services were defined as located at individual households, and at geographic and population-weighted centroids of small and large areas. Straight-line and network distances were measured and compared from these origins to varying numbers of existing clinics. The same origins were used to model sets of locations for new clinics, and access levels were again compared.

RESULTS

Travel distances for 82,499 annual baby-visits to 140 existing clinics were between 136,000 km and 84,000 km, depending on origin definition. An analysis based on small area centroid data was as accurate as one based on household data. Planning solutions for new clinics located on the basis of few large areas, with populations centred at spatially defined centroids, resulted in poorer access for the population (231,000 km of travel) than one based on many small areas with populations centred at population weighted centroids (194,000 km of travel).

IMPLICATIONS

Public access to health facilities will be improved if decisions about their locations are aided by the application of spatial analysis techniques based on small area definitions.

Enhancing the family medicine curriculum in deliveries and emergency medicine as a way of developing a rural teaching site

BACKGROUND

The urban family practice residencies of Memphis were not providing sufficient training or encouragement to young physicians for practice in rural communities.

METHODS

In 1990, the Department of Family Medicine, in partnership with the State of Tennessee Health Access Act and the Baptist Health Care System, developed a teaching practice in a rural county of western Tennessee. The family practice curriculum included special skills in advanced women's health care and emergency medicine so that uniformly trained physicians could provide around-the-clock coverage in the hospital, including the delivery of babies and first-hour emergency care.

RESULTS

After 7 years, the group now includes six full-time board-certified, OB-capable family physicians. In addition, faculty members from the department's urban program in Memphis are required to contribute a "mini locum tenens" of 2-3 days of rural coverage per month. Since 1992, the practice has provided care for more than 54,000 continuity office visits, 81,000 emergency department visits, more than 3,500 hospital admissions, and 621 obstetrical deliveries. Since 1994, residents have been assigned to the site full time, with growth to 12 (4-4-4) residents assigned to this location as of 1997. Several graduates from the initial group of residents have remained in the community after graduation, and three others have established practices in rural areas. Most recently, control of the practice is being transferred from the family medicine department to the university's corporate group practice. This may result in fundamental changes in the practice's operation.

CONCLUSIONS

The approach described in this report may be useful for the expansion of urban departments of family medicine into rural and underserved communities.

Trends in siting strategies

The ethics and efficacy of notifying neighbors in advance of the establishment of group housing for the chronically mentally ill has generated much controversy, and recent federal anti-discrimination legislation has supported its discontinuation. In this study, representatives from 72 Massachusetts mental health agencies were interviewed regarding the siting strategies used in their most recent group housing development, and the community responses to that site. A majority of agencies were found to have used advance notification, and there was a significant association between notifying neighbors and community opposition. Agencies using advance notification were also significantly more likely to initiate post-siting community outreach activities.

Local health services: some lessons from their evolution in Bolivia

For a decade, numerous projects in Bolivia have tried to put in practice the concept of local health systems. But, so far, no significant changes have been made and local health services still are the 'poor relation' of the system. The main components of the projects-expansion of health facilities, training of health personnel and institutional decentralization-were not designed to respond to the complexity of the problems encountered. Decentralization was implemented at the level of health districts but not accompanied by redefinition of functions at the central level, and challenged by civil servants' attempts to save their jobs. While training activities did introduce new methods and subjects, they were too often reduced to short workshops or seminars. Health facilities were built without regard for their significance beyond health care. A strategic approach is needed to adapt the planning process to the degree of liberty allowed by society.