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PubMed2004

Leading change when business is good. Interview by Paul Hemp and Thomas A. Stewart.

Lou Gerstner's was a hard act to follow. As CEO in what were arguably IBM's darkest hours, Gerstner brought the company back from the brink. After nearly ten wrenching years, in which the big-machine manufacturer remade itself into a comprehensive software, hardware, and services provider, business was looking good. So the challenge for Sam Palmisano, when he took over as CEO in 2002, was to come up with a mandate for a second act in the company's transformation. His primary aim was to get different parts of the company working together so IBM could offer customers "integrated solutions"--hardware, software, services, and financing--at a single price. As part of this effort, he asked all of IBM's 320,000 employees, in 170 countries, to weigh in on a new set of shared corporate values. Over a 72-hour period, thousands of IBMers throughout the world gave Palmisano and his executive team an earful in an intranet discussion dubbed "Values-Jam," an often-heated debate about the company's heart and soul. Twenty-four hours into the exercise, at least one senior exec wanted to pull the plug. The jam had clearly struck a chord with employees, but it was a dissonant one, full of rancor and discontent. Palmisano let the discussion continue, and the next day, the mood began to shift. The criticism became more constructive. Out of the million words generated by the jam grew a set of values that, as Palmisano explains in this interview, are meant to guide the operational decisions made by IBM's employees-and, more important, to serve as Palmisano's mandate to continue the reinvention of the company.

Administrative Personnel↗
PubMed1981

Medicaid program; extended phase out provisions of intermediates care facilities for the mentally retarded (ICFs/MR) correction plans: Health Care Financing Administration. Notice of proposed rulemaking.

This regulation would authorize intermediate care facilities for the mentally retarded (ICFs/MR) to negotiate revisions to their 1977 plans of correction for Life Safety Code, living, dining, and therapy area deficiencies under certain circumstances. Under this proposed regulation, the Secretary would be authorized to approve revised plans of correction from facilities which have completed at least 25 percent of their original plans of correction under 42 CFR 442.115 (c) and (d) and which propose to phase out an increased number of previously certified beds not already schedules for phase out under the existing plan of correction. The timetable for the phase out and the actual number of beds to be phased out will be negotiated with target figures established for each six-month period of the plan, with the total time for the plan not to exceed five years from the effective data of the final rule. Facilities would still be required to meet the July 18, 1982 deadline currently established in 42 CFR 442,115(b) for those aspects of existing plans of correction which include construction or renovation of units which will remain in use after planned phase out is completed. The intent of this regulation is to stimulate an overall reduction in the number of certified beds in large residential facilities, while forestalling further expenditures of capital funds for the renovation of existing facilities or the construction of new units where an expanded phase out of units is feasible.

Health Facility Planning↗
PubMed2002

Influence of commercial information on prescription quantity in primary care.

BACKGROUND: In the last few years we have witnessed many publicly-financed health services reaching a crisis point. Thus, drug expenditure is nowadays one of the main concerns of health managers, and its containment one of the first goals of health authorities in western countries. The objective of this study is to identify the effect of the perceived quality stated in commercial information, its uses, and how physicians perceive the influence it has on prescription amounts. METHODS: A cross-sectional study of 405 primary care physicians was conducted in Galicia (north-west Spain). The independent variables physician's education and speciality, physician's perception of the quality of available drug information sources, type of practice, and number of patients were collected, through a postal questionnaire. Environmental characteristics of the practice were obtained from secondary sources. Multiple regression models were constructed using as dependent variables two indicators of prescription volume. RESULTS: The response rate was 75.2%. Prescription amounts was found to be associated with perceived credibility of information provided by medical visitors, regulated physician training, and environmental characteristics of the practice (primary care team practice, urban environment). CONCLUSIONS: The study results suggest that in order to decrease prescription amounts it is necessary to limit the role of pharmaceutical companies in physician training, improve physician education and training, and emphasize more objective sources of information.

Attitude of Health Personnel↗
PubMedDate not supplied

Assessment of quality of life in adolescent patients with orthopaedic problems: are adult measures appropriate?

New pressures of accountability brought on by a rapidly evolving system of health care financing have underscored the need for standardized, valid measures of patient outcome that reflect the effect of clinical intervention on all aspects of quality of life. In response, there has been a burgeoning interest in the area of outcomes assessment and measurement of quality of life after orthopaedic intervention in adults, but less attention has been focused on the assessment of broadly defined outcomes in children. In an effort to borrow from the broader adult experience in this area, the authors sought to examine whether the Medical Outcomes Study Short Form 36 (SF-36) or the EuroQol questionnaire, widely accepted adult health status measures, would be valid in this setting. These two measures were administered to 196 adolescent patients (10-18 years old) seeking orthopaedic evaluation. Tests of scale properties and construct validity show that these properties are maintained in this population, but neither instrument reflected known differences in health status among this cohort. Most importantly, both the SF-36 and the EuroQol exhibited serious ceiling effects (most respondents scored at the top of their scales), despite evidence indicating those patients often had suboptimal health status. Thus, neither the SF-36 nor the EuroQol is valid for use in this population. The assessment of pediatric health status demands outcomes measures specifically designed to reflect the unique needs of this population.

Adolescent↗
PubMed2007

A multilevel analysis on the determinants of regional health care expenditure: a note.

Health care in most countries is a rather "local good" for which the fiscal decentralization theory applies and heterogeneity is the result. In order to address the issue of multijurisdictional health care in estimating income elasticity, we constructed a unique sample using data for 110 regions in eight Organisation for Economic Co-operation and Development (OECD) countries in 1997. We estimated this sample data with a multilevel hierarchical model. In doing this, we tried to identify two sources of random variation: within- and between-country variation. The basic purpose was to find out whether the different relationships between health care spending and the explanatory variables are country specific. We concluded that to take into account the degree of fiscal decentralization within countries in estimating income elasticity of health expenditure proves to be important. Two plausible reasons lie behind this: (a) where there is decentralization to the regions, policies aimed at emulating diversity tend to increase national health care expenditure and (b) without fiscal decentralization, central monitoring of finance tends to reduce regional diversity and therefore decrease national health expenditure. The results of our estimation do seem to validate both these points.

Age Factors↗
PubMed1981

Deinstitutionalization of the retarded: trends in public policy.

Essential public policy features of the national movement to return institutionalized mentally retarded people to community settings include issues related to institutional census trends, class action litigation, cost "savings," and funding. The deinstitutionalization of retarded people is following a different course from that of the mentally ill; it started later and is occurring more gradually. Right-to-habilitation lawsuits in Alabama and Pennsylvania illustrate the class action suit; gains from litigation in the 1970s have been mixed, however. Comprehensive community care is not necessarily any cheaper than comparable institutional care. Trends in state construction expenditures, the Reagan Administration's proposal for block grants, and impending human services budget cuts are current funding issues. So that advocates of the disabled can more closely monitor future developments in state and federal policy, three continuing annual studies are proposed: a comparison of states' funding of programs for retarded people; and evaluation of nationwide data obtained in accreditation surveys; and a historical and contemporary description of the operations of each of the 50 state service systems.

Community Mental Health Services↗
PubMed1975

Current systems of delivery of oral health services.

It is suggested that in implementing, extending and redirecting systems of delivery of oral health services we should be maximizing preventive care, indirect payment and targeting for need, wheras for manpower employment and type the accent should be on selecting the best blend for the specific services to be provided, with a readiness to use constructive initiative in all areas. In associated operations research, the urgent need is for sound data on the effectiveness and efficiency of different payment systems, and on the optimal blend of private and public, professional and auxiliary manpower. What has been achieved in the delivery of oral health services over the past 50 years has been no mean feat, but what lies ahead to be done both in developed and developing countries is a task of herculean proportions.

Delivery of Health Care↗
PubMed2004

A longitudinal study of Medicaid payment, private-pay price and nursing home quality.

Quality of care problems have persisted for decades within U.S. nursing homes. A potential state-level policy towards addressing this concern is the level of Medicaid payment. However, a number of studies have found that an increase in Medicaid payment is associated with lower quality in the presence of certificate-of-need (CON) laws and bed construction moratorium regulations, which serve as barriers to entry within the nursing home industry. Instead of relying on potentially confounded cross-sectional comparisons, this study presents novel, panel-based evidence that incorporates aggregate private-pay price data. These estimates almost uniformly indicate that an increase in the Medicaid payment rate raises nursing home quality. When compared to the earlier literature, these new findings are attributed to changes over time in the market for nursing home care related to the growth in nursing home substitutes.

Financing, Personal↗
PubMedDate not supplied

[Short-term effects of exposure to urban air pollution on human health in Europe. The APHEA Projects (Air Pollution and Health: a European Approach].

During the '80s, evidence was collected that air pollutants concentrations close to, or lower than, air quality standards could negatively influence public health at short term, i.e. within a few days. The European Union financed, between 1993 and 1995, the study "Short term effects of Air Pollution on Health: a European Approach using epidemiological time-series data" (APHEA-1 project), involving more than 25 millions inhabitants in 15 cities, investigated between 1977 and 1991. In this paper, the main results, already published in various scientific journals, are reported. The health effects were studied as mortality for natural causes, cardiovascular and respiratory diseases, and as emergency hospital admissions for all respiratory diseases, bronchial asthma, and chronic obstructive pulmonary disease (COPD). The pollutants whose measures were available for the analysis are sulphur dioxide (SO2), nitrogen dioxide (NO2), particulate matter (PM) measured either as black smoke or total suspended particulate, and ozone (O3). The analysis was carried out by each participating group following a detailed protocol, defined during various workshops, through the construction of Poisson regression models, adjusted for autocorrelation and overdispersion, accounting for variables influencing the daily count of deaths, such as long time trends, season, temperature, day of the week. This paper reports the results of the meta-analysis, performed using the values of each city, as relative risk of dying or being admitted to hospital associated with increases of 50 micrograms/m3 in the 24 hours average concentrations of each pollutant. The daily number of natural deaths was associated with increases in the levels of PM, SO2, O3, and NO2. Cardiovascular and respiratory deaths were associated with increases of the levels of PM, SO2, and O3; cardiovascular deaths were associated also with increases of NO2 concentrations. Emergency hospital admissions for the whole group of respiratory disorders are less consistently associated with PM, SO2, and NO2, whereas there is evidence of association with O3. COPD admissions are related to the air pollutant levels, especially those of O3. Lastly, NO2 levels may play a role in exhacerbating asthma, and SO2 levels can have an effect on asthma in children. A second study is currently going on, involving over 40 millions residents in 34 cities. The aims of this project are: to evaluate the dose-response relationship, to investigate on synergy among pollutants, on the "harvesting" phenomenon, on the geographical differences inside Europe and with the U.S. through the collaboration with a similar American study now in progress. The existence of an association between daily variations in the levels of urban air pollution and adverse health effects was confirmed in Europe. This association is weak, but it involves the whole resident population, so it is a major cause of concern from the public health point of view.

Adolescent↗
PubMed1988

Planning for alternative futures in the NHS.

'The NHS needs the ability to move much more quickly' (The Griffiths Report, 1983, p13) This paper grew out of preliminary research undertaken for the research project on which we both work, entitled the Management of Change in the NHS. The project is based in the Centre for Corporate Strategy and Change at the University of Warwick, and is directed by Professor Andrew Pettigrew, who has previously undertaken a longitudinal study of strategic change in ICI (Pettigrew, 1985), and also a pilot study within the NHS which identified the implementation of strategic intent as the jugular problem confronting NHS managers. But a central research problem is why it is that some Health Districts manage to achieve a faster rate of change than others. Hence there was a need to trace the evolution of local systems through time, with the result that the historical analysis of changing is a key aspect of this research. The project is financed jointly by the NHSTA and a consortium of eight of the English Regions and ten case study districts are included. The research design focusses on strategic service changes in both the acute and priority group sectors and incorporates developments and contractions. The choice of strategic changes was informed by a detailed review of the most recent regional strategic plans and the review itself prompted this paper. It led us to a number of observations about the content of the change agenda. First, there is a high rate of change projected in the current strategic round and earlier studies of incrementalist approaches to change may have to be revised (Hunter, 1980; Ham, 1981). Secondly, these regional change agendas to a great extent reflect national/central policy and the pattern is one of uniformity. These standard agendas include RAWP; the construction of a DGH network; the run-down of long-stay mental illness/handicap hospitals; cost improvements and an increase in health promotion activity. Thirdly, alongside the top-down mechanisms to secure implementation of national objectives, another mode of planning emerges which more closely approaches the concept of 'local learning' (Glennester et al, 1983) where organisations seek to explore possible forces for change and how they might respond. Planning here is seen as a means of 'problem-sensing' and awareness building (Quinn, 1980) and getting new issues onto the agenda (Pettigrew, 1985). The paper will explore the content of the change agenda in detail and the nature of the planning process.(ABSTRACT TRUNCATED AT 400 WORDS)

Forecasting↗
PubMed1990

[Overview of research in Chile by several epistemolometric indicators].

Scientific productivity in Chile was studied examining a data bank constructed with the publications indexed by the Institute for Scientific Information during 1987 and 1988. The bank excludes meeting abstracts and contains the full title of the published paper, the list of authors, addresses, field, and the nature of collaboration between two or more institutions. The articles were classified in different fields and tabulated according to the institution from which they originated. Although biology remains to be the more productive subject (26.5%) followed by medical sciences (23.9%) and chemistry (12.3%), articles in mathematics and physics continued their increase as in previous years. Using the scientometric indicators published by Braun et al., the impact of the research originated in Chile in biology, physics and mathematics was compared to that attained in Argentina, Brazil, Mexico and Venezuela. The role of the chilean National Research Fund and the output of the financed research projects were also analyzed. The successful results obtained during the first years in which the National Research Fund has been involved in the support of the scientific activity in Chile, confirms the need to strengthen its budget, according to the goals stated in the National Plan for Science and Technology for Development.

Chile↗
PubMed2003

Making waves: systems change on behalf of youth with HIV/AIDS.

PURPOSE: To document the effects of five Special Projects of National Significance (SPNS), funded by the Health Resources and Services Administration (HRSA), on HIV care, related service systems, policy, planning, and funding for youth with HIV/AIDS. METHODS: Literature on services and systems integration and technology transfer is used as a conceptual framework for the examination of HIV-informed, youth-specific changes at the local, state, and national levels. The Principal Investigators for each project and/or the Project Evaluators were interviewed several times to capture "snapshots" of evolving results from the Projects' varied activities in New York City; Newark, New Jersey; Chicago; and Miami. Some changes were consciously targeted, and others occurred serendipitously. This work covers the funding period from 1996 through 2000. RESULTS AND CONCLUSIONS: There were many "ripple" effects that emanated from these Projects' presence and activities. Important lessons were learned about why systems change is necessary to effectively serve youth with HIV, how to make constructive changes happen, and how to sustain changes once they are achieved. Successful strategies included, but were not limited to, consensus-building among stakeholders, participatory planning and decision-making, collaborative referral and linkage agreements, staff sharing, co-locating services, providing technical assistance, consultation, cross-training, and engaging consumers as partners in communicating new technologies and in advocating for change.

Adolescent↗
PubMed1975

The anonymous administrator. A five-year experience as a medical administrator in Tasmania.

The task of reorganizing and modernizing Tasmanian hospital and health services during the past five years is described. It is shown that substantial improvements can be achieved, despite a lack of authority to match responsibility. The keys to achieving these improvements were: a logical development of objectives; a careful documentation of facts; a sense of timing for the introduction of new measures; the use of independent management consultants; above all, ample finance. The major problems were the anonymous nature of the work which prevented adequate consultation with those affected by the changes, and the very adverse effect on incentives caused by poorly informed community groups exerting pressure on governments. Further improvements could be achieved by the establishment of a health commission or board consisting of full and part time members responsible through a minister to Parliament.

Australia↗
PubMed2003

Threats to the estimation of benefit: are preference elicitation methods accurate?

Stated preference methods are used to estimate the value that people place on health care. The data that emerges from these studies is used to guide health policy. However, relatively little is known about how individuals make decisions in a preference elicitation task. Two methods (willingness to pay and conjoint analysis) are considered within the context of the literature from psychology (and also environmental economics) regarding how people construct preferences, process information, and make decisions. There is substantial evidence that individuals employ heuristics (cognitive shortcuts) in order to simplify tasks they are presented with. The use of heuristics implies that people ignore much of the information they are presented with and make decisions which would not be considered rational in the economic sense. These stated preference methods assume that individuals trade between the different attributes of a good or service when making decisions - an assumption that other theories predict is wrong. The implications of this are discussed.

Attitude to Health↗
PubMed1981

Role of local health departments in the delivery of ambulatory care.

Many people (40 per cent) receive each year some personal health service provided by local health departments. A substantial number of poor children (50 per cent) look to public agencies including health departments for all or part of their medical care. A number of departments including those represented in this study come close to serving as the guarantor of basic medical care for entire constituent populations, reaching those people who are not reached by other provider systems. Health departments over the past decade have increased their involvement as providers of medical care, in part assisted by such federal initiatives as WIC, and Medicaid. Health departments have institutionalized many of the innovations generated by federal demonstration projects of the 1960s, and continue a tradition as centers of important innovation in styles and continuity of health care. The health departments studied are notable in many respects, not the least of which is their constructive relationship with private providers. Some health departments appear to function at high levels of effectiveness in a dual fashion alongside private provider systems. Other departments interact or accommodate with private providers in ways that appear beneficial to the populations they serve. It would appear that both public and private provider systems are essential, and that they need not compete; they can provide mutual reinforcement for achieving universal and equitable health services in the public interest.

Child↗
PubMed1991

The Medicare assignment controversy: the construction of public-professional conflict.

The conflict between the elderly and organized medicine over "mandatory assignment" and "balance billing" is a significant public policy issue. Considerable ideological importance has been attached to this conflict by both sides, despite the relatively modest proportion of total revenue for physician services received through balance billing in payment for care of Medicare beneficiaries. The positions of these two coalitions are examined as well as the efforts of the Physician Payment Review Commission (PPRC) to craft a public policy response. Three alternative resolutions--those adopted by Congress in 1989 on the recommendation of the PPRC, the Canadian solution, and actions taken on a state level--are then contrasted. The concentrated impact on the elderly of balance billing practices is considered as a problem, especially for elderly of limited income and resources. Justification of the practice is typically provided by the profession on the ideological grounds of preservation of professional autonomy rather than economic gain, which also reflects the current relatively limited use of balance billing; a significant majority of all claims submitted in the United States are now assigned to physicians. A continuation of the gradualist strategy of the PPRC is endorsed as the most appropriate short-range solution to these problems, which diminish in significance with a more comprehensive national health financing scheme.

Aged↗
PubMed1995

Health care reform and medical education: forces toward generalism.

The transformation of U.S. health care is driven by underlying principles. The tensions between what exists now and what will emerge over the next 15 years pervade health care delivery and financing, the doctor-patient relationship, the provider-payer relationship, and the atmosphere within educational institutions for the health professions. The institutions that early on develop the capacity to forge and sustain strategic partnerships will be well positioned to take advantage of the opportunities of a rapidly changing system, but those that do not will risk being isolated without the diversity of resources needed to make meaningful contributions to health care. The tensions also drive major changes in the way health professionals are educated, trained, and deployed. Health care reforms will dramatically change the culture of the medical school in areas of patient care, research, and education programs. These institutions face external pressures to change and internal barriers to change, not the least of which are the lack of sustained leadership and collective vision. Academic medical centers must take active steps now to assess their strengths and weaknesses objectively, look realistically at options, and construct new, mutually beneficial partnerships that will be the keys to success.

Academic Medical Centers↗
PubMed1994

A nationwide survey of day-care for children with mental retardation in Japan.

We conducted the first nationwide survey on day-cares (DCs) for mentally retarded preschoolers in Japan by sending a questionnaire to 686 such facilities, 460 (67.1%) of which responded. There were three types of DCs. Type I was a small facility, financed by a local government but not established by the Child Welfare Act. Type II was a non-residential facility founded by the Act and usually run by a private welfare organization. Type III was a unit in a large rehabilitation center for various handicapped persons established and run by a local government. We proposed a model DC having 9 staff members to be placed nearby consumers to improve the early treatment system for mentally retarded children in Japan.

Child↗