Megan McHugh

Institutional and Economic Determinants of Public Health System Performance

OBJECTIVES Although a growing body of evidence demonstrates that availability and quality of essential public health services vary widely across communities, relatively little is known about the factors that give rise to these variations. We examined the association of institutional, financial, and community characteristics of local public health delivery systems and the performance of essential services. METHODS Performance measures were collected from local public health systems in 7 states and combined with secondary data sources. Multivariate, linear, and nonlinear regression models were used to estimate associations between system characteristics and the performance of essential services. RESULTS Performance varied significantly with the size, financial resources, and organizational structure of local public health systems, with some public health services appearing more sensitive to these characteristics than others. Staffing levels and community characteristics also appeared to be related to the performance of selected services. CONCLUSIONS Reconfiguring the organization and financing of public health systems in some communities-such as through consolidation and enhanced intergovernmental coordination-may hold promise for improving the performance of essential services.

Identifying dimensions of performance in local public health systems: results from the National Public Health Performance Standards Program.

This article uses data from the National Public Health Performance Standards Program to explore how the performance of essential public health services varies across communities and to identify underlying domains of activity that appear to drive variation in performance. Cross-sectional data were used from 315 local public health jurisdictions located within seven states that participated in the Performance Standards Program pilot tests between 1999 and 2001. Results demonstrate that local public health systems vary considerably in the extent to which they perform essential services and meet established performance standards. Factor analysis results indicate that four underlying domains of activity explain much of the variation observed in the individual performance measures, and that achieving performance standards for a single essential public health service often involves more than one underlying domain of activity. The findings suggest that composite measures constructed from the Performance Standards Program can assist public health decision makers in monitoring the performance of public health systems and identifying promising pathways for improving performance.

High-performance work systems in health care management, Part 1: Development of an evidence-informed model

Background: Although management practices are recognized as important factors in improving health care quality and efficiency, most research thus far has focused on individual practices, ignoring or underspecifying the contexts within which these practices are operating. Research from other industries, which has increasingly focused on systems rather than individual practices, has yielded results that may benefit health services management. Purpose: Our goal was to develop a conceptual model on the basis of prior research from health care as well as other industries that could be used to inform important contextual considerations within health care. Methodology/Approach: Using theoretical frameworks from A. Donabedian (1966), P. M. Wright, T. M. Gardner, and L. M. Moynihan (2003), and B. Schneider, D. B. Smith, and H. W. Goldstein (2000) and review methods adapted from R. Pawson (2006b), we reviewed relevant research from peer-reviewed and other industry-relevant sources to inform our model. The model we developed was then reviewed with a panel of practitioners, including experts in quality and human resource management, to assess the applicability of the model to health care settings. Findings: The resulting conceptual model identified four practice bundles, comprising 14 management practices as well as nine factors influencing adoption and perceived sustainability of these practices. The mechanisms by which these practices influence care outcomes are illustrated using the example of hospital-acquired infections. In addition, limitations of the current evidence base are discussed, and an agenda for future research in health care settings is outlined. Practice Implications: Results may help practitioners better conceptualize management practices as part of a broader system of work practices. This may, in turn, help practitioners to prioritize management improvement efforts more systematically.BACKGROUND : A capable workforce is central to the delivery of high-quality care. Research from other industries suggests that the methodical use of evidence-based management practices (also known as high-performance work practices [HPWPs]), such as systematic personnel selection and incentive compensation, serves to attract and retain well-qualified health care staff and that HPWPs may represent an important and underutilized strategy for improving quality of care and patient safety. PURPOSE : The aims of this study were to improve our understanding about the use of HPWPs in health care organizations and to learn about their contribution to quality of care and patient safety improvements. METHODOLOGY/APPROACH : Guided by a model of HPWPs developed through an extensive literature review and synthesis, we conducted a series of interviews with key informants from five U.S. health care organizations that had been identified based on their exemplary use of HPWPs. We sought to explore the applicability of our model and learn whether and how HPWPs were related to quality and safety. All interviews were recorded, transcribed, and subjected to qualitative analysis. FINDINGS : In each of the five organizations, we found emphasis on all four HPWP subsystems in our conceptual model-engagement, staff acquisition/development, frontline empowerment, and leadership alignment/development. Although some HPWPs were common, there were also practices that were distinctive to a single organization. Our informants reported links between HPWPs and employee outcomes (e.g., turnover and higher satisfaction/engagement) and indicated that HPWPs made important contributions to system- and organization-level outcomes (e.g., improved recruitment, improved ability to address safety concerns, and lower turnover). PRACTICE IMPLICATIONS : These case studies suggest that the systematic use of HPWPs may improve performance in health care organizations and provide examples of how HPWPs can impact quality and safety in health care. Further research is needed to specify which HPWPs and systems are of greatest potential for health care management.

Understanding the Safety Net: Inpatient Quality of Care Varies Based on How One Defines Safety-Net Hospitals

A challenge to investigating quality of care at safety-net hospitals is the absence of a standard method for identifying these hospitals. The authors identified three different, commonly used approaches for classifying hospitals as safety-net providers. Analyzing national data on hospital demographics and quality of care, they found little overlap among these three sets of hospitals. Under two definitions, safety-net providers clearly underperformed on quality compared with non-safety-net providers; under a third definition, results were mixed. How one defines safety-net providers can affect health services research outcomes and policy recommendations.

Health Benefits In 2010: Premiums Rise Modestly, Workers Pay More Toward Coverage

Our annual analysis of health benefits contains findings from interviews of 2,046 public and private employers surveyed during January-May 2010. Average annual premiums in 2010 were

High-performance work systems in health care management, part 2: qualitative evidence from five case studies.

5,049 for single coverage and

Job-Based Health Insurance: Costs Climb At A Moderate Pace

13,770 for family coverage--up 5 percent and 3 percent from 2009, respectively. Workers paid more toward premiums in 2010, and more workers are in consumer-directed plans and plans with high deductibles than in 2009. Thirty percent of firms reported that they reduced the scope of benefits or increased cost sharing because of the recession. Surprisingly, the percentage of firms offering health benefits in 2010 increased to 69 percent, up from 60 percent in 2009. The change was largely driven by a thirteen-percentage-point increase in the number of firms with three to nine workers that offered benefits (up from 46 percent in 2009 to 59 percent in 2010). The reason for this increase is unclear.

Medicare's Policy to Limit Payment for Hospital-Acquired Conditions: The Impact on Safety Net Providers

Background: A capable workforce is central to the delivery of high-quality care. Research from other industries suggests that the methodical use of evidence-based management practices (also known as high-performance work practices [HPWPs]), such as systematic personnel selection and incentive compensation, serves to attract and retain well-qualified health care staff and that HPWPs may represent an important and underutilized strategy for improving quality of care and patient safety. Purpose: The aims of this study were to improve our understanding about the use of HPWPs in health care organizations and to learn about their contribution to quality of care and patient safety improvements. Methodology/Approach: Guided by a model of HPWPs developed through an extensive literature review and synthesis, we conducted a series of interviews with key informants from five U.S. health care organizations that had been identified based on their exemplary use of HPWPs. We sought to explore the applicability of our model and learn whether and how HPWPs were related to quality and safety. All interviews were recorded, transcribed, and subjected to qualitative analysis. Findings: In each of the five organizations, we found emphasis on all four HPWP subsystems in our conceptual model-engagement, staff acquisition/development, frontline empowerment, and leadership alignment/development. Although some HPWPs were common, there were also practices that were distinctive to a single organization. Our informants reported links between HPWPs and employee outcomes (e.g., turnover and higher satisfaction/engagement) and indicated that HPWPs made important contributions to system- and organization-level outcomes (e.g., improved recruitment, improved ability to address safety concerns, and lower turnover). Practice Implications: These case studies suggest that the systematic use of HPWPs may improve performance in health care organizations and provide examples of how HPWPs can impact quality and safety in health care. Further research is needed to specify which HPWPs and systems are of greatest potential for health care management.

Medicare’s Payment Policy for Hospital-Acquired Conditions: Perspectives of Administrators From Safety Net Hospitals

Each year the Kaiser/HRET Survey of Employer Health Benefits takes a snapshot of the state of employee benefits in the United States, based on interviews with public and private employers. Our findings for 2009 show that families continue to face higher premiums, up about 5 percent from last year, and that cost sharing in the form of deductibles and copayments for office visits is greater as well. Average annual premiums in 2009 were

Adoption of CT Colonography by US Hospitals

4,824 for single coverage and