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Volume 49, Number 1
January/February 2004

I. INTERVIEW
Kathryn McDonagh, FACHE, president and CEO, CHRISTUS SPOHN Health System, Kyle Grazier

II. STRATEGIC MARKETING
Creating Market Opportunities: Innovation Is the Key, Howard J. Gershon and
Alex Pattakos


III. PHYSICIAN-EXECUTIVE RELATIONS
Physicians and Nurses: Friends or Foes? Barbara LeTourneau

IV. ARTICLES

  • Whose Side Are You On? Interdependence and its Consequences in Management of Healthcare Delivery, Kent D. Fairfield
  • A Strategic Response to the Challenges Presented by Older Patients with Alzheimer's Disease and Other Types of Dementia, Brian Kaskie and Sarah Coddington
  • The Role of Leadership in Instilling a Culture of Safety: Lessons from the Literature, Hirsch S. Ruchlin, Nicole L. Dubbs, and Mark A. Callahan

V. FELLOW PROJECT
Critical Nature of the J-1 Visa Waiver Program for Foreign Medical
Graduates, Mark G. Tozzio

Executive Summary
Whose Side Are You On? Interdependence and its Consequences in Management of Healthcare Delivery, Kent D. Fairfield

Healthcare employees who are committed to the organization and go the extra mile are especially needed today. An empirical study of visiting nurse agency employees showed that a sense of being "in the same boat" with management, or perceiving outcome interdependence, contributed to positive behaviors. Supervisors were generally more inclined than were their subordinates to perceive this interdependence, to be committed, and to exhibit good citizenship behavior. Unexpectedly, physical therapists who worked as hourly part-time contractors reported even stronger feelings of being in the same boat with management and being more committed than the supervisors. Such a sense of partnership could have been a result of the therapists' long-term relationship with the agency over an indefinite time. They might have also felt that they worked voluntarily and autonomously, rather than under close supervision.

These findings point to various management actions that can engender a feeling of interdependence, pride in the organization, and fairness of treatment. One step is to involve employees in joint goal-setting, organized around "our problems" not just the person's own concerns. Authentic downward communication and the sharing of operating results can convey to employees the major issues that challenge the organization. Such information makes it possible for employees to provide vital input, if not actually take on more decisions themselves. Executives can expect less commitment and less inclination from employees to go above and beyond what is expected if they fail to acknowledge good performance and if they accentuate differences between the most-senior leaders and lower-level employees.


Executive Summary
A Strategic Response to the Challenges Presented by Older Patients with Alzheimer's Disease and Other Types of Dementia, Brian Kaskie and Sarah Coddington

Clinical dementia has become one of the most serious and persistent health problems affecting persons over the age of 65. Efforts to find a cure for Alzheimer's disease and other causes of dementia are ongoing, while healthcare executives continue to face a number of challenges. Access to targeted programs and services for persons with dementia is lacking. The costs of program development and service delivery are substantial. Persons with dementia who do use services often do not receive the most effective and efficient care, and their providers often do not receive sufficient payment. Because few examples exist of how healthcare executives can appropriately respond to these challenges, we created an operational planning strategy. This strategy defines the challenges presented by persons with dementia, identifies four viable responses, and describes two factors that will contribute to successful implementation of these responses. If healthcare executives begin planning now, then the challenges presented by one of the more serious health problems of the next 20 years can be mitigated.


Executive Summary
The Role of Leadership in Instilling a Culture of Safety: Lessons from the Literature, Hirsch S. Ruchlin, Nicole L. Dubbs, and Mark A. Callahan

The publication of To Err Is Human has highlighted concern for patient safety. Attention to date has focused primarily on micro issues such as minimizing medication errors and adverse drug reactions, improving select aspects of care, and reducing diagnostic and treatment errors. However, attention is also required to a macro issue-an organization's culture and the level of leadership required to create a culture.

This article discusses the concepts of culture and leadership and summarizes two paradigms that are useful in understanding the precursors of medical errors and developing interventions to prevent them: normal accident theory and high-reliability organization theory. It also delineates approaches to instilling a safety culture. Normal accident theory asserts that errors result from system failures. An important element of this perspective is the need for a system that collects, analyzes, and disseminates information from incidents and near misses as well as regular proactive checks on the system's vital signs. Four subcultures are necessary to support such an environment: a reporting culture, a just culture, a flexible culture, and a learning culture.

High-reliability organization theory posits that accidents occur because individuals who operate and manage complex systems are themselves not sufficiently complex to sense and anticipate the problems generated by the system. Lessons learned from high-reliability organizations indicate that a safety culture is supported by migrated distributed decision making, management by exception or negotiation, and fostering a sense of the "big picture." Lessons from other industries are also shared.