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Volume 47, Number 3
May/June 2002

  1. INTERVIEW
    Interview with Rupert Evans, FACHE, president, Institute for Diversity in Health Management, Kyle Grazier
  2. QUALITY AND SAFETY
    Case Management: A Serious Solution for Serious Issues, Alan E. Cudney
  3. STAFFING
    The Nursing Shortage: Why Is It Happening?, Steven M. Barney
  4. PERSPECTIVE
    Eliminating the Disparities in Treatment: The Link to Healing a Nation, David Barton Smith
  5. ARTICLES
    • Managing the Workforce Reduction: Hospital CEO Perceptions of Organizational Dysfunction, Kent A. Rondeau and Terry H. Wagar
    • Applying the Balanced Scorecard in Healthcare Provider Organizations, Noorein Inamdar and Robert S. Kaplan
    • Comparison of Specialty Referral Patterns of Primary Care Providers, Maj Linda W. Fisher

Executive Summary
Kent V. Rondeau, Ph.D., assistant professor, health policy and management,
Department of Public Health Sciences, University of Alberta, Edmonton, Canada, and Terry H. Wagar, Ph.D., LLB, professor, Department of Management, Saint Mary's University, Halifax, Nova Scotia, Canada

Over the past few years many nations have undertaken activities aimed at restructuring and reengineering their health system as a means of achieving greater cost effectiveness and consumer responsiveness. Most efforts at reforming healthcare delivery have been accompanied by the downsizing of healthcare organizations. Organizations that are undergoing decline or significant workforce contractions are widely believed to experience a number of negative or dysfunctional attributes as a consequence of reductions in, or redeployments of, their labor force. For organizations undergoing planned workforce reductions, much speculation has been made in an attempt to identify a set of "best practices" that have the potential to mitigate the dysfunctional consequences associated with large permanent reductions in the workforce.

This article explores the relationships among workforce-reduction practices and perceptions of organizational dysfunction in a large sample of Canadian hospitals. Results of the analysis suggest that the application of certain "progressive" workforce-reduction practices preceding, during, and subsequent to the downsizing process may play an important role in mitigating some of these dysfunctional organizational consequences. This research provides some evidence to suggest that how a workforce reduction is carried out may have a greater effect on organizational effectiveness than either the magnitude or severity of the overall workforce reduction.


Executive Summary
Noorein Inamdar, doctoral candidate in health policy and management, Harvard Business School, Boston, Massachusetts, and Robert S. Kaplan, Marvin Bower Professor of Leadership Development, Harvard Business School, Boston, Massachusetts

Several innovative healthcare executives have recently introduced a new business strategy implementation tool: the Balanced Scorecard. The scorecard's measurement and management system provides the following potential benefits to healthcare organizations:

  • It aligns the organization around a more market-oriented, customer-focused strategy
  • It facilitates, monitors, and assesses the implementation of the strategy
  • It provides a communication and collaboration mechanism
  • It assigns accountability for performance at all levels of the organization
  • It provides continual feedback on the strategy and promotes adjustments to marketplace and regulatory changes

We surveyed executives in nine provider organizations that were implementing the Balanced Scorecard. We asked about the following issues relating to its implementation and effect:

  1. The role of the Balanced Scorecard in a well-defined vision, mission, and strategy
  2. The motivation for adopting the Balanced Scorecard
  3. The difference between the Balanced Scorecard and other measurement systems
  4. The process followed to develop and implement the Balanced Scorecard
  5. The challenges and barriers during the development and implementation process
  6. The benefits gained by the organization from adoption and use

The executives reported that the Balanced Scorecard strategy implementation and performance management tool could be successfully applied in the healthcare sector, enabling organizations to improve their competitive market positioning, financial results, and customer satisfaction. This article concludes with guidelines for other healthcare provider organizations to capture the benefits of the Balanced Scorecard performance management system.


Executive Summary
MAJ Linda W. Fisher, R.N., M.H.A., CHE, nurse methods analyst, Dwight David Eisenhower Army Medical Center, Fort Gordon, Georgia

Difficulty, perceived by 17 treatment facilities, of obtaining specialty referral appointments to Dwight David Eisenhower Army Medical Center (DDEAMC), a major referral center, prompted this study that utilizes provider profiling as a tool to answer three questions that examine the problem: (1) Is the difficulty in obtaining referral appointments real or perceived? (2) Are the referral patterns of the providers contributing factors in the perceived inability to meet the demand for specialty appointments? (3) If the providers' referral patterns are a contributing factor, which provider behaviors need to be modified? Major findings of the study included:

  1. the referral rate of the primary care providers was 8 percent, compared to the national average of 7.5 percent;
  2. interns and residents were provider outliers with referral rates of 11.7 percent and 13.5 percent, respectively; and
  3. of the 32,182 referral appointments requested during Fiscal Year 1999, slightly less than 2.4 percent were disengaged.

Data analysis indicates opportunities for improvement of referral rates in DDEAMC's department of primary care by addressing the referral practices of residents and interns, which will therefore decrease the number of disengaged patients. By decreasing the number of referrals, the organization will more effectively control internal costs in an era of shrinking budgets.