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Volume 48, Number 1
January/February 2003

Volume 48, Number 1
January/February 2003

I. INTERVIEW
Interview with Philip A. Newbold, FACHE president and CEO, Memorial Hospital and Health System, South Bend, Indiana, Kyle Grazier

II. CAREERS
New Ways of Thinking About Career Success, Mike Broscio and Jay Scherer

III. STRATEGIC MARKETING
Strategic Positioning: Where Does your Organization Stand?, Howard J. Gershon

IV. ARTICLES

  • The Roles of Senior Management in Quality Improvement Efforts: What Are the Key Components? Elizabeth H. Bradley, Eric S. Holmboe, Jennifer A. Mattera, Sarah A. Roumanis, Martha J. Radford, and Harlan M. Krumholz
  • THE LONG-TERM COSTS OF CAREER INTERRUPTIONS, Patricia G. Ketsche and Lisette Branscomb
  • UNDERSTANDING ORGANIZATIONAL DESIGNS OF PRIMARY CARE PRACTICES, Alfred F. Tallia, Kurt C. Stange, Reuben R. McDaniel, Jr., Virginia A. Aita, William L. Miller, and Benjamin F. Crabtree

V. Fellow Project
The Development of a Customer Excellence Master Plan, William J. Lafferty

Executive Summary
The Roles of Senior Management in Quality Improvement Efforts: What Are the Key Components?
Elizabeth H. Bradley, Ph.D., associate professor, Department of Epidemiology and Public Health, Yale School of Medicine, New Haven, Connecticut; Eric S. Holmboe, M.D., associate professor, Department of Medicine, Yale University School of Medicine; Jennifer A. Mattera, assistant director, Yale-New Haven Hospital Center for Outcomes Research and Evaluation, New Haven, Connecticut; Sarah A. Roumanis, R.N., project coordinator, Yale-New Haven Hospital; Martha J. Radford, M.D., system director, Clinical Quality, Yale-New Haven Health System, and associate professor of medicine, Section of Cardiovascular Medicine, Yale University School of Medicine; and Harlan M. Krumholz, M.D., professor of medicine and epidemiology and public health, Department of Medicine and Epidemiology and Public Health, Yale University School of Medicine

With increasing attention directed at quality problems and medical errors in healthcare organizations, the ability of senior management to promote and sustain effective quality improvement efforts is paramount to their organizational success. We sought to define the key roles and activities that comprise senior managers' involvement in improvement efforts directed at physicians' prescription of beta-blockers after acute myocardial infarction (AMI). We also developed a taxonomy to organize the diverse roles and activities of managers in quality improvement efforts and proposed key elements that might be most central to successful improvement efforts.
Results are based on a qualitative study of 8 hospitals across the country and included in-depth interviews with 45 clinical and administrative staff from these hospitals. The findings help identify a checklist that senior managers may use to assess their own and others' participation in quality improvement efforts in their institutions. By reinforcing their current involvement or by identifying potential gaps in their involvement in quality improvement efforts, practitioners may enhance their effectiveness in promoting and sustaining quality in clinical care.

Executive Summary
THE LONG-TERM COSTS OF CAREER INTERRUPTIONS
Patricia G. Ketsche, M.B.A., Ph.D., assistant professor, Institute of Health Administration, JMR College of Business, Georgia State University, Atlanta, Georgia, and Lisette Branscomb, M.B.A., senior research associate, Institute of Health Administration, JMR College of Business, Georgia State University

This article is based on a study that analyzed the long-term salary implications of career choices made by healthcare administrators. The study used a cohort of graduates from a single health administration program; these individuals had comparable levels of human capital at the outset of their careers. We estimated the effect of periods of part-time employment and job interruptions-voluntary and involuntary-on long-term salary progression. We also estimated the impact of other career choices, such as membership in a professional organization or the decision to relocate. After controlling for these choices, we estimated the residual effect of gender on salary. We found that voluntary interruptions had a greater effect on long-term salary growth than did involuntary interruptions of the same length or periods of part-time employment.
Individuals evaluating options for balancing career and family constraints should understand the long-term cost of choosing a career interruption rather than part-time employment during periods of heightened responsibilities outside the workplace. Healthcare administrators should also be educated about the positive association between professional memberships and career advancement to make informed decisions about participation in such organizations.
Surprisingly, after controlling for all choice variables, gender had no measurable effect on long-term salary growth. Half of those who indicated a voluntary interruption for dependent care reasons preferred part-time or flexible-hour work if it had been available. These results suggest a pool of healthcare administrators who might compete for positions if more part-time opportunities were available.

Executive Summary
UNDERSTANDING ORGANIZATIONAL DESIGNS OF PRIMARY CARE PRACTICES
Alfred F. Tallia, M.D., associate professor and vice chair, Department of Family Medicine, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, New Brunswick, New Jersey; Kurt C. Stange, M.D., Ph.D., professor, Departments of Family Medicine, Epidemiology and Biostatistics, and Sociology, Case Western Reserve University, Cleveland, Ohio; Reuben R. McDaniel, Jr., Ed.D., Charles and Elizabeth Prothro Regents Chair in Health Care Management and professor, Department of Management Sciences and Information Systems, The University of Texas at Austin; Virginia A. Aita, Ph.D., assistant professor, Department of Preventive and Societal Medicine, University of Nebraska Medical Center, Omaha; William L. Miller, M.D., chair, Department of Family Practice, Lehigh Valley Hospital and Health Network, Allentown, Pennsylvania; and Benjamin F. Crabtree, Ph.D., professor and research director, Department of Family Medicine, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School

During the past decade, many hospitals experienced difficulty integrating primary care practices into their health systems. We hypothesized that this difficulty may be, in part, a result of limited understanding of practice organizational designs. The structure and function of practices have not been well studied. In this article, we answer the following questions: Are practices all the same, or do variations in their organizational design exist? Do hospital designs predict the designs of affiliated practices? If variation exists, what are the management implications?
Eighteen family practices, including nine affiliated with five separate hospital systems, were studied using an in-depth comparative case study design. A content analysis of the rich descriptive data from these cases indicates that a great variety exists in the organizational design of primary care practices, and this variety appears to be influenced by the initial conditions under which the practice was organized. Hospital system design in and of itself did not predict the design of affiliated practices. In fact, both affiliated and independent practices exhibited a range of design characteristics, some of which did not fit traditional models. Hospital systems that allowed greater flexibility of practice organizational designs were more effective at integrating and managing practices. Practice response to environmental change was greater when practice autonomy was highest.
These findings suggest that a science of practice organizational design separate from that of hospitals is needed to help explain the success and failure of practices within health systems and to provide information for planning practice change.