Shortell and Kaluzny’s Healthcare Management, Coursework Example

The text notes that, “Traditionally, physicians have held great authority over patients. The main reason for this has been the significant asymmetries in knowledge, information, and access. For instance, physicians posses the clinical knowledge and skill patients seek when accessing care” (Burns, Bradley, Weiner, 2011). The authors do further point out that one significant aspect of power that has been traditionally granted to physicians is there ability to prescribe medication. This gives them substantial influence over the medical decisions made, as different medications can have alternating side effects and set patients on a specific course of recovery that once entered  could potentially lead to more problems if modified or changed altogether. This however does not mean positions of power are stagnant within the medical industry. I do believe this position of power is changing due to the enormous amount of information available online and regulations passed recently through the Affordable Care Act. The relationship between the physician and patient has expanded dramatically with the implementation of the Affordable Care Act as it has given patients more options and thus more control over their healthcare decisions. For example, in the past, patients were required to stick strictly to a select few healthcare providers but with ACA, they can now receive care from a wider range of healthcare service providers within their state or even outside of their state. In addition, patients have more affordable options enabling them to shop around across different caregivers.

The way ACA impacts caregivers, physicians and administration is that it forces them to be more transparent in regards to the services they provide and the cost of such services. There are more regulations protecting patients who have single payer plans as well as large companies with more than 99 employees. There are also tighter regulations for companies with 50 to 99 employees that, while less strict than those applicable to larger corporations, are much stricter than healthcare regulations prior to the passing of ACA. For example, prior to the passing of ACA, employers could only offer healthcare to employees that worked 35 to 40 hours per week claiming them as full-time workers. Now, the entire staff hours are averaged to account for 30 work hours per employee to be considered full-time. The impact this has on caregivers, administrators and physicians is that it introduces a large number of new, in some cases first time patients, who have a wide range of medical conditions that must be treated. Many of these patients have conditions that might otherwise gone untreated or that might have called for different forms of care prior to ACA. For the most part, while the relationship between administrators, patients, physicians and nurses still has many of its traditional power hierarchies in place, there are major changes influencing healthcare as a whole and these changes are putting power in the hands of individuals who were once virtually powerless. The shift is making quality healthcare a priority over the secondary interests of administrators or physicians.

Power, politics and conflict management are the three main focuses mentioned by the authors in regards to negotiation. The preferred strategy seems to be power as it is the one true form form of authority put into action. The authors define power as the ability of one stakeholders ability to exert influence over others. Politics is largely the semantic or policy based letter of the law. The rules upon which one must comply, but these can be influenced by power. Conflict management entails the process through which power plays are mediated and controlled. The authors specifically point out that in the relationship that exists within HCOs there are hierarchies of power between administrators, physicians, patients and nurses. They say these power shifts can be seen occurring within the healthcare system itself when accreditations are up for grabs. This can specifically be seen occurring between physicians and administrators.

The main tactic that should be used to reach satisfactory conclusion in negotiation is to acquire power power but to remain consciously aware of political interests, and desired outcomes of all parties involved. A side note of the section point out how patients have become empowered by the Internet and information technology which seeks to challenge the patriarchal-like relationship between doctor and patient. The ability for a patient to gather information online puts them in a powerful position in regards to negotiating some of the terms and treatments related to their diagnosis; likewise, ACA is an example of politics working in their favor. On the same note, satisfactory conclusions are based in compromise and it is most probable that if physicians and administrators find ACA regulations or the power provided to patients by the Internet to be too imposing on their interests, they will leverage the power they have to produce a result that more adequately meets their needs as well. The most telling example of this can be seen in regards to conflicts in tort law, such as healthcare related lawsuits. Tort legislation is a critical issue because it is the political meeting point between patient protection and hospital and physician protection. On one end healthcare quality is a major priority and patients need to be protected from medical malpractice, but on the other end the law shouldn’t be abuse. Hospitals tend to have the upper hand in respect to medical malpractice as they have more lawyers and funding to assist them at their goals.

The Henrietta Johnson Medical Center provides a wide range of family health services, such as generic medicine, prenatal and adolescent care to adult and geriatric medicine.

Structure

The center is structured through the inter working of different departments, specifically, the Family Medicine, Dental, Podiatry, Women’s Health, On-site laboratory testing, Financial counseling, Referrals to specialists, Medicaid Enrollment help department, the language interpretation department and Physicians on call 24 hours a day. The structure of the hospital is setup in such a way that administrators, physicians and nurses are all aware of what one another is doing through a cloud computing system that enables them to keep track of patient data such as diagnosis, medical prescriptions, patient symptom reports, and clinician activity. The structure is also responsible for putting in place safety guidelines and protocols which ensure all hospital staff maintain a hygienic and secure environment for patients. The core aspect of the hospital structure is a tier system that accounts for priority care conditions.

Process

Medication errors are largely reduced through the processing of electronic medication data tracking systems; likewise most medical practitioners have become accustom to the improved quality structure of the hospital which requires special training workshops for all employees two times per month. The staff also implore evidence based practices to ensure quality is provided to all patients through the use of past results combined with study. Examples of this process can be seen in how departments interact where the financial department corresponds with the lab, or the 24 hour physician hotline forwards documentation of calls to the primary physician, or another example can be seen in how nurses communicate across all departments to ensure quality of care is uniform.

Outcomes

The outcomes of the medical facility are largely reliant on the the relationships between all of the respective departments. For example, the language interpretation department plays a substantial role in ensuring patient needs are met in regards to patient physician interaction. The hospital also has a clinical ladder system set in place for higher quality performance from users and higher quality outcomes. Clinical ladders are interdisciplinary systems setup to provided nurses with stepping stones to higher tier positions and enable them to establish expertise. Pierson, Liggett and Moore (2010), chronicle a study of a clinical ladder program that was incorporates protocols of a 257-bed medical facility. The program, created by the nurses for nurses, developed into a core aspect of their evidence-based practices, for hiring and setting milestones. It better enables nurses to develop skills over time. The study notes that, “this clinical ladder program has been used to encourage staff nurses to reach outside of their comfort zone to develop new skills. In this way, it has served as a means to identify leadership potential as a tool toward succession planning” (Pierson, Liggett, & Moore, 2010). This is the same type of clinical ladder program implemented by Henrietta Johnson Medical Center to instill confidence in nurses and to expand their skills. It’s also used as a viable tool for succession management (Pierson, Liggett, & Moore, 2010). Examples of outcomes produced through clinical ladder systems are improved medication tracking, improved sanitation regimen, and improved performance management and succession management through a documented track record.

Despite the fact Hospital A had more funding than hospital B, it is more likely the second hospital will be more successful because by pulling ideas for quality improvement from the current staff, hospital B is better able to benefit from the experience of healthcare practitioners who develop ideas in a clinical setting. The Hospital B method does not just benefit from experienced staff, but from staff that identify the exact needs relevant to the exact location where the improvements will be applied. Hospital A, by utilizing a special team for quality improvements is at a disadvantage. Even if the team members have experience in a clinical setting, it cannot be assumed that these proposed changes can be universally applied across all situations and that they will work under all conditions. Areas that might be most vulnerable to quality improvement methods are aspects of hospital operations related to communication protocols that secure the efficiency of shared information between hospital staff, as well as performance management methods. For example, many organizations fail to utilize effective performance management routines, like employee assessments, because they don’t issue assessments frequently enough or do not protect the privacy of caregivers or other practitioners involved. In this respect, hospital has an advantage over hospital B, because people who work in close correspondence. When someone personally knows the ins and outs of an HCOs operations they are more likely to be able to identify the areas where quality can be improved, but also they are less likely to report on the failures and inefficiencies of their co-workers in fear that it might politically jeopardize their own career. This is where Hospital A’s method might have an advantage as an outside team brought in to make quality improvements is less likely to harbor the same bias. They will critically assess all performance history and place no favor on any one particular members of the HCO’s staff.

Specifically in respect to the billing department and operations in the emergency room, bias can play a significant role when human factors are taken into account. For example, it is common in many hospitals for doctors getting their residency and nurses in study to attend near the location where they earned their degree. Often these individuals establish themselves within the community where the HCO is housed, making it even more likely they feel a special connection with their coworkers and patients that extends outside of the hospital. This can create a conflict of interest in regards to quality improvement. In the billing department, when patients are unable to acquire the necessary financing for medical procedures, direct human interaction between billing department representatives and the patients could possibly result in cut corners or misguided acts of favoritism that aren’t fiscally efficient, but that don’t always benefit patients the way they may initially be intended. Likewise, hospital staff working side by side in an emergency room under stressful conditions may opt to disregard inefficiencies in their co-workers out of a sense of loyalty. While they may be trying to protect their fellow staff, in reality they are doing both their coworker and the hospital an disservice as the cause of such inefficiencies might be due to structural issues in hospital operations that can’t identified without an accurate performance audit. In this way, Hospital A has the advantage over Hospital B’s method because it’s less likely to harbor bias.

In sum, overall however, Hospital B’s method is still the best option as it takes into account experience in the exact clinical setting being assessed for QI implementation. The experience in the field, and the benefits that come from it, far outweigh the favoritism and bias commonly developed within set corporate cultures.

I personally believe that Continuous Quality Improvement (CQI) is most applicable to the healthcare setting because as Revere, Black, and Huq (2004), find, Six Sigma is more effective in business settings that focus primarily in the business world. It fails to account for medical conditions. The authors note that, “Examines Six Sigma as a strategy for improving service which tries to reduce defects and therefore improve a firm’s marketing position. Looks at how this as been applied in business and then examines its place in healthcare. Concludes that the few healthcare institutions that have implemented Six Sigma have done so in the interest of business and not so much in the area of patient care, where it is proposed that it will improve things dramatically” (Revere, L., Black,  & Huq, 2004). Continuous Quality Improvement is a method that accounts for specific aspects of the hospital setting that might no be recognized through a strategic management standpoint. There are aspects of hospital or healthcare organization operations that are not compatible with the traditional business sector, such as healthcare options, administrators, and the relationship between patients, physicians and nurses. These aspects of the health care industry make CQI a vital necessity for the real improvement of the system. The most important aspect of continuous quality improvement is that is that it’s a bottom up strategy that incorporates all members of HCO staff, whereas Six Sigma focuses primarily on the management techniques used to direct staff in a desired direction. CQI more internal and attempts to integrate itself within the specific corporate culture of the organization it seeks to improve. Six Sigma is an external factor focusing more on leadership and it’s much more objective than subjective in its application. It could be argued that Six Sigma provides a better focus on financial concerns, but in respect to healthcare, I feel quality should take priority of factors like billing and economic policy or efficiency.

Information technology has evolved in such a way that a large majority of medical conditions can be researched on the Internet through the help of qualified physicians. While it is always recommended that patients seek the assistance of a physician, they can now inform themselves prior to arrival make decisions based on what they feel best suits their individual needs combined with an array of experienced support backing them. Patients no longer enter HCO’s on their own. This can specifically be seen with facilities like Dental Care Centers, as a wide range of potential patients seek guidance on homeopathic medicine and natural ways to cure dental infections or cavities without going through the drastic measure of having teeth pulled or removed. The dental profession comes under heavy fire as many clinicians take different approaches to treating teeth. This is especially true across international borders. Information technology has equipped both patients and physicians with the ability to communicate with one another to enhance quality performance in regards to diagnosis, prescriptions, and treatment. The most important way information technology has influenced HCO’s is through the ability of patients to write reviews of certain HCO’s and physicians. This puts practices in jeopardy but also enables the cream to rise to the top and equips patients with an invaluable tool to find ideal care.

As the case notes the cost of hardware and software play a significant role in the development of a sound tracking system. The case states that the software licensing is estimated to be 1 million to 1.5 million. The capital budgeting problem this creates calls for the use of financial planners and managers. There is also the challenge of introducing the. Staff to time consuming training programs that can help them overcome the learning curve associated with learning a new system. In addition to a team of financial planners, there would need to be a team that can assess the adaption period, specifically how long it will take for new staff to become accustomed to the system verses current staff. There will also need to be a solid process put in place for transitioning from the old tracking method to the new medical record tracking tool. As this technology is largely about communication as well it is essential that possible medication errors are averted and that all treatment and diagnosis are still issued professionally without problems. In order to ensure this is the case, it may be necessary for the blood center to shut down it’s operations and provide staff with a boot camp like training period once the system has been thoroughly put in place. This is especially important considering that the vendor chosen is responsible for providing and efficient effective service but also instructing staff on how to use it through a training process, who in turn must train new staff for years to come. it might be necessary to put in place a periodic tutorial period or training period for this purpose.

I personally do not think I should lead the effort, but employ a project manager specifically put in place to handle the job of forming a team to complete the project of new implementation. This entails all aspects of integrating new technological tools and setting up network system infrastructure. As CEO, I will monitor progress and make sure the project stays within budget and is completed by the set time frame. I will also mediate the interest of internal and external stakeholders. The reason I think it’s best that I do not personally lead the effort is because by giving the job to a project manager, I can take an objective view of its progress, and reduce my emotional involvement. I also think that a project manager professionally trained in project management would have a higher probability of meeting budgetary and deadline requirements.

The best way to assure that all staff have completed the mandatory education necessary to adapt to the new system is to require them to be certified in compliance with the National Council of State Boards of Nursing as well as the skill sets required for the technical application of system provided by the new vendor. This should be integrated as a standard aspect of their employment. To ensure the implementation process is adequate, they may need to qualify for scheduled test-off evaluations on how the new technology should be implemented within the field, where they will be walked through specific protocols. The greatest challenge will be the initial learning curve for all staff as a whole to overcome. Past studies demonstrate that the urgency of hospital care, specifically that posed by the demands of critical care units. Nursing Informatics need to work closely with nursing managers and staff nurses during the planning and implementation process. While it is always expected that, there will be some resistance to new systems, patients encounter potentially life-threatening errors during their stay in hospitals due to complications with medication errors and faulty prescription tracking. Adapting to an eMAR based system can substantially reduce the chances for this to occur, but in the precess of adaption significant attention needs to be placed on routine and training elements related to medication tracking. Efforts must also be made to integrate training for this system in local nursing schools for admitting new nurses into the facility. A preference can then be placed on admitting those nurses who have already been trained in using the system.

References

Burns, L., Bradley, E., & Weiner, B. (2011). Shortell and Kaluzny’s Healthcare Management: Organization Design and Behavior. Cengage Learning.

Pierson, M. A., Liggett, C., & Moore, K. S. (2010). Twenty years of experience with a clinical ladder: a tool for professional growth, evidence-based practice, recruitment, and retention. Journal of continuing education in nursing, 41(1), 33.

Revere, L., Black, K., & Huq, A. (2004). Integrating Six Sigma and CQI for improving patient care. The TQM Magazine, 16(2), 105-113.