Advances in Health Care Management: Volume 3

This paper presents the results of an extensive literature review of quantitative and qualitative studies that relate the internal work environment to nurse withdrawal behavior and nurse performance. A model depicting the interrelationships and descriptive tables are developed on the basis of this review. Studies indicate a “vicious spiral to the bottom” whereby cuts in nurse staffing result in a negative work environment characterized by work overload, poor nurse physical and mental health, and low job satisfaction. This environment, in turn, increases nurse withdrawal behavior and adversely affects nurse performance. Implications for public policy, management and future research are discussed.

With health care costs rising, increased attention has been paid to the human resource practices of hospitals. This chapter examines the effects that staffing levels and wages of registered nurses have on hospitals' average lengths of stay. Based on data from 352 California hospitals, we show that both increased staffing levels and wage rates relate to decreased average lengths of stay. Furthermore, based on our most complete and accurate models, it appears that wage may be more effective for improving the average lengths of stay than would increasing the quantity of RNs. The results of this chapter have a number of implications for human resource practices of RNs and for future research on health care management practices.

A predictive, nonexperimental design was used to test Kanter's work empowerment theory in a random sample of 412 Canadian staff nurses. Empowered individuals reported higher affective commitment and work satisfaction. Moreover, empowered employees experienced greater organizational trust, which in turn influenced these job attitudes. Since research has shown that affective commitment is related to productivity, our results suggest that fostering environments that enhance perceptions of empowerment will have positive effects on employees and ultimately, enhance organizational effectiveness.

This paper investigates how hospital work environments and manager behavior influence nurses' responses when faced with unexpected problems, or exceptions. Data from a qualitative study involving 239 hours of observation of 26 hospital nurses at nine hospitals suggest that exceptions occur frequently and that the work design of hospital nurses leads them to respond to exceptions through first-order problem solving, addressing only immediate symptoms without attempting to alter underlying causes. This pattern of behavior contrasts with recommended approaches found in the quality improvement literature (Ackoff, 1978; Deming, 1986; Juran, Godfrey, Hoogstoel & Schilling, 1999; Kepner & Tregoe, 1976). An implication of our findings is that health care managers may need to tailor front line quality improvement processes to meet the demands of the health care delivery environment — in which exceptions are so frequent as to be considered virtually routine — rather than expecting health care workers to engage in quality improvement practices developed for work environments with different characteristics. Building on empirical observations from our study, we draw from two literatures — healthcare management and organizational behavior — to develop a model of problem solving behavior by hospital nurses. The model proposes that nurse manager coaching, support, and proficiency, together with features of the organizational context — training, self management, work design, group norms, and reward interdependence — influence nurses' problem solving behavior through the mediating variable of nurse cognition (psychological safety and motivation). The use of a problem solving coordinator moderates the problem-solving behavior's impact on performance outcomes.

The concepts of population health management in both theory and practice have significant implications for improving health care quality and lowering costs. I discuss the importance of defining the perspective and populations for population health management. Lifestyle management strategies emphasize health risk reduction and prevention techniques as they target a relatively healthy population. Demand management approaches extend lifestyle management strategies by concentrating on consumer demand for medical care services. Disease management techniques typically focus on individuals with chronic conditions such as diabetes, congestive heart failure, or asthma. These programs offer targeted health and care management services to help coordinate the needs and care of individuals with those specific diseases. Catastrophic care management services extend the disease management approach to provide health management services for individuals with catastrophic illnesses or injuries. Disability management approaches are designed from an employer's perspective to improve worker productivity by focusing on strategies to reduce injuries, avoid illness, and better manage employee disability. Information technologies especially are important in developing and implementing each of the above population health management strategies. A conceptual model of population health management integrates the theory and the practice of population health management on both individual and organizational levels. Lastly, I discuss practical and research issues around developing and applying a population health management model in the U.S.

The thesis of this paper is that patient emotions have not been sufficiently integrated into patient-centeredness, a well-established organizing principle of health care management. We first review the scientific knowledge on emotions that is of relevance to support their being a core component of patient-centeredness. We then report a field study designed to investigate the mechanisms by which emotions influence care outcomes (specifically, patient satisfaction). Structural analyses performed on self-reports by 283 minor care patients in an Emergency Department revealed that both positive and negative emotions influence satisfaction indirectly by biasing patient perceptions of quality of care in a valence-congruent direction.Negative emotions have an additional direct effect on satisfaction. Patients who were made to wait longer to see the physician not only manifested a progressive deterioration of their emotional states (i.e. decrease in positive affects and increase in negative affects) but their satisfaction judgments became more importantly formed on the basis of emotions. Implications of the research for healthcare management are discussed.

A key issue in innovation research is to understand the effects of changes in regulatory practices and incentive systems on how much innovation takes place and where those inventive activities will occur. There is anecdotal evidence, and some empirical evidence, that changes in medical device regulation in Europe may be shifting new product development research, clinical trials and experimentation from North America to Europe. Results from this study indicate that in the field of medical equipment, patents granted to European inventors have increased at a faster rate from 1996 through 2000 than for North American inventors. This reverses the trend found from 1991 through 1995. Organizational learning theory implies that if this trend in growth continues there may be serious consequences in North America for the future of medical device innovation, healthcare implications for patients in need of access to clinical trials of new technology and the loss of the potential benefits for the training of future researchers and physicians in the U.S.

The management literature has explored and recognized that managers' perceptions of their hospitals' external conditions or environment are important antecedents to effective strategic choices and, therefore, superior performance. We have less understanding, however, of the relationship between managers' perceptions of their hospitals' internal conditions called capabilities and performance. This study draws from organizational theories to suggest that, due to the unique nature of capabilities, assessment of managers' perceptions of capabilities is also important to shaping strategy. An extensive field study identifies capabilities and explores relationships between managers' perceptions of capabilities and an objective measure of hospital success.

There are approximately 120 academic health centers (AHC) in the U.S. today whose mission is to deliver critical, tertiary care while also providing graduate medical education and conducting cutting-edge medical research. This traditional mission is overlaid by the social mission or the provision of highly specialized, complex or innovative care not readily available from other community providers to those who need it, including the poor. These missions make AHCs unique; however, they also are the focus of much controversy surrounding the management of AHCs. On one hand, there are those who advocate that AHCs operate similar to business organizations, thereby adapting strategies accordingly and revising their missions as necessary. On the other hand, there are those who believe in the uniqueness of AHCs and the necessity of upholding their traditional missions. Following from this, this paper presents a review of the literature that focuses on the changing environment facing AHCs and their strategic responses. In doing this, we argue that many are “copy cat” strategies that may have been successful for community hospitals and general business organizations but may not necessarily be appropriate for AHCs. At the end, this paper provides a debate on the mission and strategic direction of AHCs, particularly in light of the business or enterprise model and raises questions about the future management of these institutions.

This paper develops a theory regarding the determinants of post-bankruptcy performance of healthcare firms. Specifically examined are the potential effects of strategic change (i.e. refocusing), organizational size, slack and munificence on post-bankruptcy performance. It is theorized that bankrupt healthcare firms that refocus have greater post-bankruptcy performance than all other firms. It is also theorized that greater organizational size, slack, and munificence enhance post-bankruptcy performance. The theory developed in this paper highlights the benefits of refocusing the diversified healthcare firm, the liabilities associated with diversification in the healthcare industry, and organizational ecology theories and perspectives regarding organizational size, slack, and munificence. In addition, this paper aims to provide richer insight into our understanding of the post-bankruptcy performance of healthcare firms.

How health care managers make sense of stakeholders and act strategically within these inter-organizational relationships has significant impact on organizational survival and performance. Existing research on stakeholder management has focused on managing dyadic relationships with individual stakeholders. We propose, based on serendipitous findings from a prior research study, that organizations exhibit distinct configurations — stakeholder management styles — in the ways in which they manage their kwy stakeholders. To explicate this notion, we review potential theoretical configurations of stakeholder management styles, including a well-known stakeholder typology, which focuses on the concepts of threat and cooperation. Based on this review, we develop a typology that shifts the focus from individual stakeholders to a focus on the organizations and their orientation toward managing a portfolio of stakeholders. We use secondary data analyses of a national sample of 686 medical group executives to conduct an exploratory study of how and whether stakeholder management styles are likely to impact multiple indicators of organizational performance. We conclude with propositions for future research, as well as implications for managerial practice.