Health Care Policy, Performance and Finance Strategic Issues in Health Care Management
Scharer, Linda K., Care Management Journals
HEALTH CARE POLICY, PERFORMANCE AND FINANCE STRATEGIC ISSUES IN HEALTH CARE MANAGEMENT Huw T. O. Davies and Manouche Tavakoli (Eds.) Burlington, VT: Ashgate, 2004, 291 pp., $39.00 (hardcover).
What are the current trends and ideas in the organization and delivery of health care that stimulate technological advances, leading to a more effective use of resources? This area of inquiry attracts many participants, and there is merit in providing a forum to share information and ideas.
This book is a product of The Fifth International Conference of Strategic Issues in Health Care Management (2002, University of St. Andrews). Twenty countries were represented at the conference and the 18 articles selected for inclusion were chosen from more than 100 presentations. The participants were economists and individuals interested in research and structure in organization management. The text, annotated with graphs and charts, is organized into four sections: Health Care Policy and Technology Assessment; Policy and Performance; International Policy Innovation; and Organizing Innovation. The editors, members of the faculty at the sponsoring University of Aberdeen, have written a preface that places the articles in a framework citing the contributions of individual chapter authors.
An indication of the relative importance of each section may be discerned from the number of pages per section as well as the number of articles included. section I (Healthcare Policy and Technology Assessment) is 43 pages and has 3 articles (chapters). Section II (Policy and Performance) is 95 pages and has 5 articles. section III (International Policy Innovation) is 87 pages and has 6 articles. section IV (Organizing Innovation) is 143 pages and has 3 articles. In length, Organizing Innovation is first, but in number of articles, International Policy Innovation is superior.
Section I (Healthcare Policy and Technology Assessment) is really the conceptual basis for the sections that follow, yet it is the briefest in ratio of articles to pages. In "Health Technology Assessment: More Questions Than Answers?" the authors undertake a thorough analysis of 64 health technology assessments (HTAs). The study focuses specifically on those HTAs developed by the British National Health Service Program in relation to clinical practice. The authors believe that the designs are often flawed, and there is a lack of emphasis on cost and clinical effectiveness. The article concludes with a recommendation for "more effective alignment of resources and incentives to those who innovate and evaluate in health care, rather than depend on the systematic review of weak primary evidence." In other words, this approach has not proved useful for the purpose intended, namely, providing guidance to policy makers and clinicians about cost-effective choices or better clinical outcomes.
The second chapter presents a case of local implementation of a health care intervention. "NICE Works: A case Study of the Local Implementation of NICE Guidelines." NICE is the acronym for National Institute of Clinical Excellence. The authors conclude that there is a lack of information on how local authorities should implement these strategies. Managers rather than clinicians generally take the lead in implementation. Costs also vary from the national estimate. It appears that more work and understanding are required for practical application.
The final chapter in this section is titled "The Effect of United Kingdom Neonatal Staffing Study Results on the Prior Views of Neonatal Doctors: A Bayesian Analysis." The study focuses on how an individual's quantified belief is modified with the introduction of new data. The more strongly a belief is previously held, the more convincing is the need to change to an opposite position. The issue at hand was the "optimal configuration of service for providing neonatal intensive care services." In other words, the consideration is smaller units versus larger facilities. Previously held beliefs are therefore an indication to predict resistance to change. It should be noted that the hypothesis depends on the clarity of questions used in the survey and may not take into account practices already in place for care of more complex cases at larger units.
Section II, Policy and Performance, begins with a chapter that perhaps has most applicability and relevance to administrators and clinicians concerned with patient care, albeit not long-term care. The title of the first chapter in this section is "Hospital-Physician Relationships: Comparing Administrators' and Physicians' Perceptions." The author, Thomas Rundall, is a professor of organized health systems at the University of California. The article considers the relationship between hospitals and physicians in a sample of West Coast hospitals with the purpose of improving relationships and identifying barriers and key facilitators. The article contains survey questions and identification of the inherent problems in changing to a managed care environment, including the loss of autonomy and a reduction in revenue.
The fifth chapter is called "The Invisible Cost of Repeated Cycles of Organizational Restructuring," by Jason Nickels. The author postulates that repeated restructuring has a negative effect on morale and performance. The study was conducted in Wales where the document Improving Health in Wales: A Plan for NHS and Its Partners resulted in the ending of five Welsh Health Authorities. Furthermore, this was the seventh restructuring in the last 10 years. The author offers suggestions on how to manage change by letting employee concerns be heard, providing explicit job expectations, using a facilitator in the early stages of change, and recognizing the anxiety concerned with change. The author supports his conclusions through interviews and observations made by searching the literature. This subject has relevance for the current continuous restructuring of U.S. health organizations. Although the author's observations may appear self-evident, the difficulty probably comes from the translation of guidance into implementation as well as a lack of awareness or caring for the unintended side effects on individual employees.
The sixth chapter discusses themes for a "System of Medical Error Disclosure: Promoting Patient Safety Using a Partnership of Patient and Provider." The author, Bryan Liang, is a professor at the University of Houston Law Center, Health and Policy Institute. He advocates the approach of system analysis, rather than the current climate of individual shame and blame, to promote quality of care. He discusses his approach through five principles (themes). These are
1. mutual respect, trust, responsibility, and partnership;
2. system education for providers and patients;
3. clear standard operating procedure;
4. objectivity of disclosure; and
5. communication through mediation.
The author believes that this method will result in fewer malpractice cases because many patients appear to sue because the provider fails to achieve a working relationship with the patient. The article also contains an extensive reference section.
Chapter 7, "Accountability in the Canadian Health Care Systems: Fitting the Pieces of the Puzzle Together," by Carl-ArIy Dubois and Jean-Louis Denis, explores four models of competing accountability. These models are characterized as political, professional, bureaucratic, and managerial. The study, undertaken in three Canadian provinces, shows that multiple forms of accountability are desirable. Each model has strengths and weaknesses, but the professional and bureaucratic models do not always recognize the requirements or needs of society.
The final chapter in section II is titled "Building an Organisational Framework for Effective Clinical Governance," by Elaine Moss and Peter Totterdill. In this article, the setting is the British National Health Service. The authors advocate a more team-oriented approach characterized by employee participation. A focus on meeting short-term targets fails to take into account the values of long-term learning and adaptation. The authors conclude: "... distortions in the implementation of clinical governance result in quality assurance without quality improvement."
In section III (International Policy Innovation), Daniilidou, Souliotis, and Kyriopoulos consider "Roemer's Law: Does it Apply in Greece?" (Milton I. Roemer, die reader will recall, has stated: "The optimal supply of hospital beds needed by each country, for planning purposes, has been a subject of study and debate everywhere. If there is an assured payment system, it seems that almost any additional hospital beds provided will tend to be used, up to a ceiling not yet determined.") The article focuses on examples of change and confirms through statistical analysis that the supply of hospital beds correlates with increased admissions. The Roemer finding is significant, because reduction of hospital beds is one way to control costs. One interesting observation for readers of a long-term care journal is that the elderly are not using facilities at the same rate as their growth in the population. One explanation according to the authors is the Greek tradition of caring for the elderly at home, as well as the growing provision of home health services.
"Reflections of Globalization on Public Health," by Cilingiroglu and Ozcebe, lists six effects of globalization on health. They are speed and spread of disease, standardization of medical education, availability of dangerous products, changes in health systems, new rules for cross-border flow, and increased inequalities within and among countries that increase health risks. The authors use health information in Turkey to support their thesis.
Chapter 11, "Opportunity Knocks: Ten Years of Health Care Reform Strategic Policy Implementation and Maori Health Development in New Zealand," by Stewart, Kuraia, and Everitt, focuses on the ascendancy of Maori power and the development of Maori co-purchasing organizations (MAPO). The lead author of this chapter is the chief executive officer of the Te Tai Tokerau MAPO Trust. The plan as of 2001 is to establish Primary Health Organizations (PHOs) to reach local health goals. The PHOs will involve the community in the governance and decision-making. The authors are proud of the reforms initiated by the Maori.
Chapter 12, "Reorganizing Health Care Delivery in Hospitals: Structure and Processes to Serve Quality," by Federico Lega, traces the journey from functional design to a managed care, cost-conscious environment. There is a discussion of both vertical and horizontal integration. Resource pooling receives strong support, as do multidisciplinary work groups. Lega discusses the design of the hospital of the future, which may consist of an emergency room, intensive care unit, and diagnostic services, with more care brought to the home. The author believes that the immediate trend will be to specialized hospitals within a network.
Chapter 13, "Access to Pharmaceuticals in Transition Countries" by Hofmarcher and lietz of Institute of Advanced Studies in Vienna, whose research was funded by the World Bank, has as its purpose, examining "access, purchasing and market control mechanisms in Slovakia, Georgia and the Ukraine." The authors note that the high price of drugs, along with co-pay requirements, has an adverse effect. Furthermore, application of quality standards is uneven. This lack of availability certainly would affect the care of the elderly.
Chapter 14, "Health Insurance in Iran: Opportunities and Complexities," by Mehdi Russel, explores the development of health insurance in Iran as a way to reform the health systems. In these systems, spending constitutes 5.7% of the gross national product. The current system is characterized by 40 regional health authorities. The emphasis has been on disease prevention and health promotion measures. National health insurance (NHI) in Iran is not new, beginning with railway workers 100 years ago. The author believes that NHI was not implemented at the best time from a socioeconomic standpoint. He concludes with recommendations to improve the system, including development of private services, decentralization, adopting cost control policies, and promoting information and research studies.
In section IV (Organizing Innovation), Chapter 15, "Improving the Operation of Operating Theatres: Data Triangulation, Change Management and Action Research in Operating Theatres," was written by Boaden, a lecturer in operations management, and Bamford, a process improvement officer at Manchester Royal Infirmary. It is therefore appropriate that they wish to identify and verify causes of delays in schedules.
The study collected both anecdotal and qualitative data. Anecdotal data were gathered through interviews and focus groups. The comments were then mapped with the frequency of responses added. The problems listed were "theatre porters unavailable, lists arriving late in theatres, inexperienced staff communication between ward and theatre, equipment problems, surgeon unavailable, anesthetist unavailable, inaccurate assessment of operating time, lack of beds, order of lists changed." These anecdotal observations were then compared to the log maintained on procedures. Although the qualitative and quantitative data results differed from each other, the information identified the perceptions of those involved as well as inhibitions in blaming a senior individual. In response to the observations, the following programs were initiated: tracking the activity of theater porters, holding weekly utilization meetings, enhancing management information systems to give information to the managers and staff members. The concluding section offers a valuable road map for investigating issues in general: evaluate comments in the context in which they are made; use more than one source of data/information; value communication for its power to increase awareness; recognize that some factors may be outside the scope of the investigation; concentrate on what can easily be changed.
Chapter 16, "Job Satisfaction and the Modernization Project: A Longitudinal Study of Two NHS Acute Trusts," by Fisher, Harris, Kirk, Leopold and Leverment, members of the Department of Resource Management at the Nottingham Business School of Nottingham Trent University, concerns itself with the "best fit" approach of the modernization project proposed for the National Health Service (NHS) and the contrary findings of the Chartered Institute of Personnel and Development (CIPD). The premise of the government is that job satisfaction will improve performance. The survey reveals that there is very little job satisfaction in terms of pay, recognition, flexibility in hours, and access to training and development to have effective managers available to cope with poor performance and in representation by trade unions. The above-mentioned items are part of an official document that was intended to lead to better job satisfaction and therefore work performance. The authors advocate a more decentralized targeted approach with an emphasis on human resources.
Chapter 17, "The Relation Between Patient Volume, Staffing, Workload and Adherence to Selected National Standards and Risk-Adjusted Outcomes in UK Neonatal Intensive Care Units: A Prospective Study," by Tucker, Parry, McCabe, Nicolson, and Tarnow-Mordi, investigates outcome measures in neonatal units. The authors conclude that there is no difference in outcome between low, medium, and high volume neonatal intensive care units, once adjustments are made for clinical risk and illness seventy. This finding contrasts with conventional wisdom and illustrates the value of research in innovating change. This article does have a link to physician beliefs as discussed by Tucker and Parry in Chapter 3.
In conclusion, what is the relevance to the reader of the Journal of Long Term Home Health Care of a review of conference proceedings focusing on organization? In general, some articles are more relevant to the reader than others. The articles chosen are quite technical in nature and do not address issues of longterm health care except perhaps Chapter 9 and its examination of an unanticipated finding of the application of Roemer's Law. The international imperative to reduce health cost discussed throughout the conference is appropriate to remember. Methods of research presented are also useful.
Reviewer: Linda K. Scharer, MUP
New York, NY…
Questia, a part of Gale, Cengage Learning. www.questia.com
Publication information: Article title: Health Care Policy, Performance and Finance Strategic Issues in Health Care Management. Contributors: Scharer, Linda K. - Author. Journal title: Care Management Journals. Volume: 6. Issue: 1 Publication date: Spring 2005. Page number: 39+. © Springer Publishing Company 2008. Provided by ProQuest LLC. All Rights Reserved.