Look out for Stage 3. How hospitals can survive as markets move toward managed-care dominance.
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Capital Financing↗
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ACKNOWLEDGE: a tool to support knowledge capturing.
Knowledge management enhances organizational competitive advantages by supporting the capture, maintenance and communication of the business processes knowledge to organization members. ACKNOWLEDGE is a tool that supports tacit and explicit knowledge capturing. Organization members can use this tool to exteriorize knowledge related to organizational processes activities. The acquired knowledge is filtered, packed and stored into the organizational memory in order to be reused by other members during processes activities execution.
Brazil↗
Those conversion blues.
With the ever-increasing market penetration of capitated payment systems throughout health care markets, average payment rates for health services have dropped correspondingly. At the same time, the added competitive pressures from managed care organizations have served to increase the demand for new capital investment in information systems, lower cost facilities, and innovative modes for delivering all types of health care services. As a result, many nonprofit health care organizations have converted, or have attempted to convert, to for-profit status in an effort to gain access to the public equity capital markets. As hospitals, Blue Cross and Blue Shield organizations, and other nonprofit health care organizations across the U.S. seek to convert to for-profit status, they are finding the path is not easy. Access to capital, operating efficiencies, and the need to accelerate movement into new markets are offset by public benefit obligations, potential private inurement, and significant political cost issues. The bottom line is whether the conversion will be structured to both protect the public interest and allow the health care organization the flexibility and access to capital it needs in order to continue as a viable, competitive organization into the next millennium.
Blue Cross Blue Shield Insurance Plans↗
Pressure ulcers in an age of managed care: a nursing perspective.
Successful competition for acquisition of capitated groups and maintenance of existing managed care contracts require demonstrations of cost controls, positive clinical outcomes, and customer satisfaction. In preparation for, and in response to managed care, healthcare providers must assure equality in their supply and demand equation if they are to survive and prosper. Iatrogenic pressure ulcers represent a major healthcare problem illustrative of this point. Successful pressure ulcer prevention and treatment programs in all practice settings demand: 1) administrative support, 2) access to staffing and supplies, 3) multidisciplinary ownership, 4) integration of science-based knowledge of risk factors, risk assessment tools, pathophysiology, and appropriate management into clinical practice, and 5) dissemination of knowledge.
Algorithms↗
Not your father's Blue Cross/Blue Shield.
The Blues landscape is a swirl of activity as the nation's 62 independent plans struggle to remain competitive in today's managed-care environment. Collectively, Blue Cross and Blue Shield plans serve 66.3 million people in widely differing markets. Although the plans have unique cultures, they're merging, affiliating in consortia, creating for-profit subsidiaries and converting to for-profit status. And to borrow from the Oldsmobile slogan, these are definitely not your father's Blues plans.
Blue Cross Blue Shield Insurance Plans↗
Same-day surgery: management issues and future growth.
Policy makers in all countries are searching for cost-effective, quality health care. In the realm of surgical care, one response to modern cost and quality pressures is same-day surgery. This article discusses three aspects of same-day surgery programs: key management issues; analysis of competitiveness; and, the growth potential of same-day surgery. Today's managers of same-day surgery programs are most concerned with issues related to their customers, be they physicians, insurers, or patients. Indeed, program managers identify market research, program development, and patient, physician, and facility management as areas critical to success. An exploratory survey carried out of ten same-day centers indicates that programs must excel in two areas to succeed. First, they must develop efficient and appropriate operations. Second, they must communicate aspects of these operations to different customers, realizing that each customer type is interested in different aspects of the program. This article provides a framework for the analysis of customer interests. It also suggests that surgery centers satisfy customer preferences rather better than do hospital outpatient programs. Same-day surgery will increase. Uncertainty lies in how quickly and in what form such activities in hospitals and centers will develop. Countries will likely experience different growth patterns, according to the relative power of factors affecting both the supply and demand of same-day surgery.
Ambulatory Surgical Procedures↗
Plant responses to atmospheric CO2 enrichment with emphasis on roots and the rhizosphere.
Empirical records provide incontestable evidence of global changes: foremost among these changes is the rising concentration of CO(2) in the earth's atmosphere. Plant growth is nearly always stimulated by elevation of CO(2). Photosynthesis increases, more plant biomass accumulates per unit of water consumed, and economic yield is enhanced. The profitable use of supplemental CO(2) over years of greenhouse practice points to the value of CO(2) for plant production. Plant responses to CO(2) are known to interact with other environmental factors, e.g. light, temperature, soil water, and humidity. Important stresses including drought, temperature, salinity, and air pollution have been shown to be ameliorated when CO(2) levels are elevated. In the agricultural context, the growing season has been shortened for some crops with the application of more CO(2); less water use has generally, but not always, been observed and is under further study; experimental studies have shown that economic yield for most crops increases by about 33% for a doubling of ambient CO(2) concentration. However, there are some reports of negligible or negative effects. Plant species respond differently to CO(2) enrichment, therefore, clearly competitive shifts within natural communities could occur. Though of less importance in managed agro-ecosystems, competition between crops and weeds could also be altered. Tissue composition can vary as CO(2) increases (e.g. higher C: N ratios) leading to changes in herbivory, but tests of crop products (consumed by man) from elevated CO(2) experiments have generally not revealed significant differences in their quality. However, any CO(2)-induced change in plant chemical or structural make-up could lead to alterations in the plant's interaction with any number of environmental factors-physicochemical or biological. Host-pathogen relationships, defense against physical stressors, and the capacity to overcome resource shortages could be impacted by rises in CO(2). Root biomass is known to increase but, with few exceptions, detailed studies of root growth and function are lacking. Potential enhancement of root growth could translate into greater rhizodeposition, which, in turn, could lead to shifts in the rhizosphere itself. Some of the direct effects of CO(2) on vegetation have been reasonably well-studied, but for others work has been inadequate. Among these neglected areas are plant roots and the rhizosphere. Therefore, experiments on root and rhizosphere response in plants grown in CO(2)-enriched atmospheres will be reviewed and, where possible, collectively integrated. To this will be added data which have recently been collected by us. Having looked at the available data base, we will offer a series of hypotheses which we consider as priority targets for future research.
Journal Article↗
Transport, space, entropy, diffusion and flow. Elements underlying separation by electrophoresis, chromatography, field-flow fractionation and related methods.
We describe here some elements common among separation methods, including the requirement for separative transport, the sensitive utilization of space, and the dissipative (band broadening) roles of entropy, diffusion, and flow. We focus on the need to carefully manage the unceasing competition between separative and dissipative transport in all high resolution methods. We then examine the more specific roles these elements play in influencing separation in several important analytical separation techniques. We begin with electrophoresis and sedimentation, which are conceptually among the simplest of systems because they require no flow and only a single dimension of space. The conflict between separative and dissipative transport is examined closely for these systems and it is shown that the outcome is a theoretical plate number which can be expressed as a ratio of two energies: a structuring energy--delta mu ext, which organizes the separation, and thermal energy RT, which is responsible for its dissipation. It is explained why optimal separation is most often achieved in thin layers or in capillary tubes. Chromatography and field-flow fractionation are then described as two closely related methods in which flow is powerfully coupled with a simple enrichment process occurring at right angles to flow. Unlike electrophoresis, these systems are intrinsically two-dimensional. It is shown how flow and diffusion processes both assume two diametrically opposite roles: those of aiding separation and simultaneously causing its dissipation. With a few equations it is demonstrated that the dissipative role is best contained by reducing the thickness (diameter) of the system or of certain elements within the system.
Chemical Fractionation↗
Evidence-based medicine. Interpreting studies and setting policy.
The ascendancy of EBM has been accompanied by a greater awareness of its shortcomings. It is increasingly evident from the cost, length, and difficulty of performing RCTs that studies cannot be launched to address every question in medicine. Good evidence is often lacking in medicine. Epistomologists question the very notions of evidence and the suitability of current study designs and measurement tools to research the salient issues of concern to patients and others concerned with quality. Lack of evidence of effectiveness does not prove ineffectiveness, yet, in reaction to EBM, insurance companies and government often make this inference to justify decisions to withhold coverage or research support. The unbridled enthusiasm for the evidence-based practice guideline of the early 1990s has been tempered by a more mature understanding of its limitations. Not many practice guidelines are developed well, and the implementation of flawed guidelines can cause harm. The seven-step process outlined earlier is slow, laborious, and expensive (sometimes costing hundreds of thousands of dollars). Moreover, there is little evidence that either the rigor of the methods or the guidelines themselves have a meaningful effect on practice behavior or patient outcomes. To the most cynical observers, the only consistent beneficiaries of guidelines are payers, who use guidelines with considerable success in reducing costs, lengths of stay, and utilization rates. Even ardent advocates of guidelines acknowledge the evidence that disseminating reviews and recommendations, by itself, fails to motivate clinicians to increase delivery of effective interventions and to abandon ineffective ones. This absence of response has stimulated a closer look at the barriers to behavior change and the design of thoughtful implementation strategies that begin with, but reach beyond, simple guidelines. Tools such as reminder systems, standing orders, academic detailing, peer review and audit, feedback, and health system changes recognize that knowing what to do is only one piece of an increasingly complex puzzle. The competitive marketplace of managed health care has added new economic influences on clinician behavior but is also fueling private-sector interest in good research. Patients, clinicians, and policy makers will continue to seek better data concerning what works in medicine and what does not.
Cohort Studies↗
Report of the NASPE policy conference on arrhythmias and the athlete.
INTRODUCTION: This consensus statement summarizes the proceedings of The Expert Consensus Conference on Arrhythmias in the Athlete of the North American Society of Pacing and Electrophysiology (NASPE) on detecting, evaluating, and treating athletes with cardiovascular disorders that predispose to cardiac arrhythmias. METHODS AND RESULTS: The participants in the open policy conference were selected by the codirectors (Drs. Estes and Olshansky) based on expertise and contributions to the literature. All participants provided a referenced summary of their presentation. The writing group used the information from all published scientific studies, clinical trials, registries, clinical experience, and expert opinion to make recommendations regarding screening, evaluation, management, eligibility for competition, and a range of other medical, social, and legal issues regarding the recreational and competitive athlete. The codirectors of the symposium synthesized the participants' reports for this and made revisions according to suggestions of all members of the writing committee. The manuscript was reviewed by four independent reviewers assigned by the NASPE Committee for the Development of Position Statements and NASPE Board of Trustees. CONCLUSION: Despite considerable advances in knowledge regarding the diagnosis, therapy, and mechanisms of arrhythmias in the athlete, much remains unknown. Continued basic, clinical, and epidemiologic research is needed. Current screening techniques to detect athletes lack sensitivity and specificity. Evaluation of standardized screening programs with tracking of long-term outcomes is needed. Officials from athletic, academic, medical, and legal institutions need to form strategic partnerships to develop policy related to assessment of risk and assumption of responsibility for athletic activities.
Arrhythmias, Cardiac↗
Critical pathway experience at Cedar-Sinai Medical Center.
Critical pathways provide an excellent tool for promoting multidisciplinary efforts to develop optimal, cost-competitive plans for managing patient care. The pharmacy department can play a variety of roles in developing and implementing critical pathways. In advocating optimal drug selection and monitoring, pharmacists can help their institutions reduce costs while maintaining or improving quality of care.
California↗
Views of doctors in the United Kingdom about their own professional position and the National Health Service reforms.
BACKGROUND: In the course of national studies of doctors' career choices and progression, we received spontaneous comments from respondents about job satisfaction and the National Health Service reforms. To assess whether such comments were representative, or whether they reflected minority views, we added questions to subsequent questionnaires to gauge systematically how doctors view their own professional position and the wider NHS. METHOD: Self-administered questionnaire were sent to all 10,504 qualifiers of 1977, 1988 and 1993 from UK medical schools. RESULTS: A total of 7391 responded (70 per cent). Most doctors in UK medicine were positive about the career opportunities they have had (66 per cent of relevant respondents), their future prospects (68 per cent) and their present position (80 per cent). Few were positive about the NHS reforms (9 per cent) and the effects of the reforms on their own professional work (9 per cent). Only 0.2 per cent of the 1993 qualifiers scored their impression of the internal market as 'strongly favourable'. CONCLUSIONS: In recent years the NHS shifted from a collaborative to a competitive model of management of health care with the establishment of an internal market. The great majority of respondents viewed recent changes and the internal market unfavourably. This is not, however, a reflection of more widespread discontent with their work. The majority viewed their own professional opportunities and present position favourably.
Attitude of Health Personnel↗
The role of U.S. public hospitals in urban health.
Public hospitals in the United States play a key role in urban health. In many metropolitan communities, public hospitals maintain the health care safety net. Most urban public hospitals have evolved to not only provide care for the indigent but also to serve their communities in other ways, including serving as major providers for tertiary services such as trauma and those that support homeland security; serving as the foundation for primary care services; continuing to train a significant number of physician, nurses, and other medical personnel; and providing laboratories for clinical medical research. Federal budget cuts such as those in the Balanced Budget Act of 1997, recent state budget deficits, competition for Medicaid Managed Care, and the growth in the number of uninsured have led to a decline in revenues among urban public hospitals. To be better stewards of scarce resources, public hospitals have moved to reduce inpatient demand by adopting prevention strategies that are aimed at addressing the determinants of health, the complex interactions among social and economic factors, the physical environment, and individual behavior. These factors contribute to health status and offer opportunities to intervene and improve community health. Urban public hospitals, to be successful in the next stage of their evolution, need to learn to manage the "in-betweens"--partnering with governmental and nongovernmental entities to identify and work together on common health and safety issues. If public hospitals engage the community successfully, building trust and establishing new capability and capacity, urban public hospitals will survive, evolve, and continue their tradition of service.
Cities↗
Ten-year experience in managing a capitated ophthalmology carve-out by an academic eye center.
A 10-year experience of managing a capitated opthalmology carve-out by an academic health unit is presented. Lessons learned regarding pricing, utilization, and managing this contract are discussed. Handling the cost of education and remaining competitive is presented as a not-insurmountable hurdle. Academic health units can compete in today's environment; however, the learning curve is steep and the problems many.
Academic Medical Centers↗
The conflict management style of staff nurses and nurse managers.
Conflict is recognized as being a common occurrence in both everyday personal and professional nursing life, and it is now generally agreed that conflict can be both problematic and potentially beneficial to both individuals and organizations. There is a large amount of anecdotal and narrative literature about the nature and sources of conflict which fails to reflect upon the complexities and theoretical perspectives that exist. There are also few research studies which examine the nature of nursing conflict and how conflict is managed by nurses in the workplace. This study presents a review of some aspects of conflict and its management and specifically investigates the conflict management style of staff nurses and nurse managers in the hospital setting. The results suggest that avoidance is the most commonly used conflict management strategy, with competition being the least favoured.
Adaptation, Psychological↗
How endangered is dynamic psychiatry in residency training?
The future of psychodynamic psychotherapy in residency training is in jeopardy. New priorities and forces currently aligned in academic psychiatry challenge the importance of psychodynamic psychotherapy and, by extension, its core concepts of the unconscious, defense and resistance, transference and countertransference, and the past repeating itself in the present. The exit of psychoanalysts from academic centers in the last quarter of the past century was propelled by forces including biological psychiatry, managed care, and competition from other mental health disciplines. ACGME psychotherapy competencies introduced in 2001 renewed the focus on psychotherapy training in residency and set a residency training standard for psychotherapy competency. A recent shift in academia prioritizing evidence-based medicine and a shortage of psychiatrist researchers may threaten those gains.
Biological Psychiatry↗
Health services management manpower and education: outlook for the future.
There is much concern about administrative costs in health care. But little has been written on the market for health managers. This article discusses Bureau of Labor Statistics data estimating a total of 362,500 health managers in the United States in 1990 and projections showing an increase to 517,800 in 2005. The article further discusses the composition of health care employment in terms of settings and functions, and evaluates the implications of a rapidly changing market for health administrators. The authors conclude that sufficient demand exists for AUPHA programs to produce more graduates, but that curriculum should be revised and should place greater emphasis on efficient production of health services. This will provide qualitative differentiation and give health management training a competitive advantage over business and other educational backgrounds.
Career Choice↗
Swedes test capitalist waters in new health system reforms.
While most Swedes say they're satisfied with their socialized health care system, problems ranging from long waits for surgery to a growing federal deficit have prompted health officials to inject some elements of American-style managed care and competition. Reforms include abandoning central primary care clinics in favor of allowing patients to choose a family physician; privatizing some hospitals; and separating health financing from delivery.
Data Collection↗