Arnold D. Kaluzny

Total quality management in health: making it work.

Many health organizations are trying total quality management (TQM). This approach represents a total paradigm shift in health care management and presents a series of potential conflict areas in the way health organizations are managed. These areas include TQMs participatory approach versus professional and managerial authority, collective versus individual responsibility, quality assurance and standards versus continuous improvement, and flexible versus rigid objectives and plans. This article reviews the areas of conflict and suggests a number of action guidelines for the successful implementation of TQM.

Alliances in health care: What we know, what we think we know, and what we should know

Alliances are the organizations of the future. This article builds on the lessons from industry identifying important areas requiring definition and basic understanding of alliance structure, process, and outcome in health care services.

Innovation of health services: a comparative study of hospitals and health departments.

al variables affecting the innovation of high-risk versus low-risk health service programs in two types of health care organizations: hospitals and health departments. It was found that variables are differentially related to both the type of program and the type of organization. Organizational size was a critical factor in program innovation as it relates to high-risk services in hospitals and low-risk services in health departments. Excluding size, characteristics of the staff, such as cosmopolitan orientation and training, were prime predictors for both high- and low-risk programs in health departments and low-risk programs in hospitals. The degree of formalization was the primary predictor of innovation of high-risk programs in hospitals. Cosmpolitan orientation of the administrator was a critical factor in the innovation of high-risk programs in both hospitals and health departments. The assessment of change in health care organizations, and particularly program innovation, has received increasing attention by social scientists. Using a wide range of explanatory variables, research, with few exceptions, has tended to concentrate on explaining variation in the innovation of a single program or that of aggregate change. For a review of these studies see Kaluzny (1972). While this represents progress, it is important to consider two underlying problem areas. First, it is necessary to inquire into the general area of programmatic change and whether factors associated with program innovation differ by type of program innovated. Essentially, this exploration involves assessment of a set of services and activities that have common characteristics, making possible generalization from known determinants of innovation of one program to other programs with similar characteristics. Secondly, explanation of differences by type of organization is necessary to provide insight into the specific organizational setting under which

Not-so-strange bedfellows : Models of interaction between managed care plans and public health agencies

Alliances between managed care plans and public health agencies are a growing phenomenon in local health care markets, with profound implications for health care quality, cost, and accessibility. A typology of interorganizational relations between managed care plans and local public health agencies is drawn from observations of over 60 public health jurisdictions. Relations are described along three dimensions corresponding to the strategic intent, functional operation, and structural design of each alliance type. The identified models of interaction reveal the motivations for forming alliances, the mechanics of their operation, and the possible outcomes. These alliances suggest that a wide range of interorganizational strategies is possible in order to pursue the shared interests of local public health agencies and managed care plans. Nonetheless, public health agencies may face challenges in forging managed care alliances that benefit community-wide populations and that are open to participation by the full spectrum of health care providers in the community.

Translating research into evidence-based practice: the National Cancer Institute Community Clinical Oncology Program.

The recent rapid acceleration of basic science is reshaping both our clinical research system and our healthcare delivery system. The pace and growing volume of medical discoveries are yielding exciting new opportunities, yet we continue to face old challenges to maintain research progress and effectively translate research into practice. The National Institutes of Health and individual government programs increasingly are emphasizing research agendas that involve evidence development, comparative‐effectiveness research among heterogeneous populations, translational research, and accelerating the translation of research into evidence‐based practice as well as building successful research networks to support these efforts. For more than 25 years, the National Cancer Institute Community Clinical Oncology Program has successfully extended research into the community and facilitated the translation of research into evidence‐based practice. By describing its keys to success, this article provides practical guidance to cancer‐focused, provider‐based research networks as well as those in other disciplines. Cancer 2010.

Using an Office System Intervention to Increase Breast Cancer Screening

AbstractOBJECTIVE: To evaluate an innovative approach to continuing medical education, an outreach intervention designed to improve performance rates of breast cancer screening through implementation of office systems in community primary care practices. DESIGN: Randomized, controlled trial with primary care practices assigned to either the intervention group or control group, with the practice as the unit of analysis. SETTING: Twenty mostly rural counties in North Carolina. PARTICIPANTS: Physicians and staff of 62 randomly selected family medicine and general internal medicine practices, primarily fee-for-service, half group practices and half solo practitioners. INTERVENTION: Physician investigators and facilitators met with practice physicians and staff over a period of 12 to 18 months to provide feedback on breast cancer screening performance, and to assist these primary care practices in developing office systems tailored to increase breast cancer screening. MEASUREMENTS AND MAIN RESULTS: Physician questionnaires were obtained at baseline and follow-up to assess the presence of five indicators of an office system. Three of the five indicators of office systems increased significantly more in intervention practices than in control practices, but the mean number of indicators in intervention practices at follow-up was only 2.8 out of 5. Cross-sectional reviews of randomly chosen medical records of eligible women patients aged 50 years and over were done at baseline (n=2,887) and follow-up (n=2,874) to determine whether clinical breast examinations and mammography, were performed. Results for mammography were recorded in two ways, mention of the test in the visit note and actual report of the test in the medical record. These reviews showed an increase from 39% to 51% in mention of mammography in intervention practices, compared with an increase from 41% to 44% in control practices (p=.01). There was no significant difference, however, between the two groups in change in mammograms reported (intervention group increased from 28% to 32.7%; control group increased from 30.6% to 34.0%, p=.56). There was a nonsignificant trend (p=.06) toward a greater increase in performance of clinical breast examination in intervention versus control practices. CONCLUSIONS: A moderately intensive outreach intervention to increase rates of breast cancer screening through the development of office systems was modestly successful in increasing indicators of office systems and in documenting mention of mammography, but had little impact on actual performance of breast cancer screening. At follow-up, few practices had a complete office system for breast cancer screening. Outreach approaches to assist primary care practices implement office systems are promising but need further development.

Collaboration to Improve Community Health: Trends and Alternative Models

BACKGROUND Many health care organizations have begun to pursue collaborative approaches for addressing community-level health issues. To understand how these community health alliances develop and operate, a descriptive study was conducted within a nationally selected group of 60 local communities and supplemented by detailed case studies in 8 communities. ALLIANCE MODELS A broad array of organizations were found to participate in community health alliances. Moreover, alliances were found to vary considerably. Strategically, alliances focused on one of three primary objectives: acquiring needed organizational knowledge and skills; addressing common resource needs; and pursuing a shared organizational mission. Functionally, alliances were observed in the areas of service delivery, planning and policy development, surveillance and assessment, and education and outreach. Structurally, alliances were found to operate through one of four interorganizational arrangements; informal collaboration, contractual agreements, shared governance, and shared ownership. ALLIANCE DEVELOPMENT Organizational characteristics such as ownership type, organizational proximity, and market share appear to be important in the development of community health alliances. Community and market characteristics--including health resource availability, HMO penetration, and market consolidation--also appear to be influential in alliance development. Longitudinal observations suggest that alliances evolve over time in response to changing community health needs and organizational objectives. ALLIANCE MANAGEMENT Several managerial tasks appear to be important to successful alliance operations, including developing a shared vision of collaboration; devising explicit strategies for addressing participation constraints; ensuring the compatibility of organizational incentives; managing communication and information flows across organizations; and developing appropriate processes for performance monitoring. CONCLUSIONS The observed variation in alliance structures and functions appears healthy rather than problematic, as organizations develop arrangements to fit community needs, organizational capacities, and market conditions.

Building Client Centered Systems of Care: Choosing a Process Direction for the Next Century

Forecasting the future of health care is difficult. However, we argue that this future will include the movement of health care through process improvement (enhancement) toward the objective of mass customization. This article discusses how mass customization might apply to specific portions of client-centered health care.

A life cycle model of continuous clinical process innovation.

EXECUTIVE SUMMARY The changing healthcare environment has created a sense of urgency for continuous innovation in clinical care processes. Managers and clinicians are investing unprecedented funds and energy in the development of various clinical process innovations (CPI) such as clinical pathways, electronic workstations, and various forms of information technology. While increasing attention has been paid to the development of such initiatives, our understanding of how best to disseminate and ensure their use is limited. In this first of two articles dealing with the dissemination and use of CPI in integrated delivery systems, we present a “life cycle” model of the dissemination process and suggest opportunities for managing CPI. The management of CPI requires more than just an understanding of the factors that may facilitate or impede its implementation and use. Managers require an understanding of the actual process so that they can assess the specific implementation stage at which the organization is presently operating, and design appropriate interventions that can affect the process. A furture article will identify the factors that facilitate and inhibit the process and suggest some intervention strategies.

Managed care and public health

Current themes in public health public health and managed care - an introduction managed health care and its relationship to public health applications of managed care and privatization in the public sector case studies in public health and managed care.