a. Profit requirement, benchmarks, forecasts

b. Competition, forecasts, PDCA cycles

c. Benchmarks, negotiated agreements, lean processes

d. Negotiated agreements, historic constraints, urgent patient needs

Correct answer: (a) Profit requirement, benchmarks, forecasts (Page 309 Griffith and White Text) - Text also adds competition, forecasts, historic constraints and negotiated agreements to the list of constraints.

In the book Understanding the U. S. Healthcare Services System by Barton, there are a number of forces influencing changes in the U. S. health services delivery system.  The forces include:

• The raised level of consciousness that employers and payers are experiencing about the costs of providing employee health insurance
• The perverse incentives that fee-for-service care establishes
• The effects on utilization of self-referral, doctor-shopping, and open access to specialists
• The need for both private and public payers to better predict total health expenditures
• The need for accountability of health expenditures within a society
• The belief that optimal rather than maximal use of limited resources is more appropriate
• The need to increase efficiency in the system, including the appropriate use of inpatient and outpatient services and the reduction of overcapacity. 

 I am sure there are several more forces that are just as important that have developed over the past few years.  How do you think the impact on the current Administration will change these forces overall. 

In the book Understanding the U. S. Healthcare Services System by Barton, there are three dimensions of hospital organization that are important to gain an understanding of the health services system.  Which of the following is not a dimension mentioned in the literature?

1. How an individual hospital is organized to perform its functions
2. How hospitals may be linked into systems
3. How the hospital gains community involvement and positive interaction through the governing board.
4. The hospital’s relationship to other health services functions and facilities in its community

Answer:  c.  How the hospital gains community involvement and positive interaction through the governing board.

A Clinical Support System (CSS) such as a Health Promotion Center focuses efforts on preventive care. Education of the public is necessary about poor life style behaviors. Educating young people about the dangers of poor dietary habits, smoking, sexual behaviors, alcohol abuse, drug abuse, and violent acts continues to be an important area to focus. Those that need to provide education at the local level include hospitals, physicians, nurses, other healthcare providers, schools, and law officials.

Reducing healthcare consumption, by people taking responsibility for their own life style behaviors, will decease overall healthcare spending. Preventive care is the best solution in reducing healthcare spending, because decreasing the potential of developing chronic illness and lessening the amount of violent behavior will result in less demand for healthcare.

Costs of Chronic Disease

The United States cannot effectively address escalating health care costs without addressing the problem of chronic diseases: 

• More than 90 million Americans live with chronic illnesses. 
• Chronic diseases account for 70% of all deaths in the United States. 
• The medical care costs of people with chronic diseases account for more than 75% of the nation’s $1.4 trillion medical care costs. 
• Chronic diseases account for one-third of the years of potential life lost before age 65. 
• Hospitalizations for pregnancy-related complications occurring before delivery account for more than $1 billion annually.
• The direct and indirect costs of diabetes are nearly $132 billion a year. 
• Each year, arthritis results in estimated medical care costs of more than $22 billion, and estimated total costs (medical care and lost productivity) of almost $82 billion. 
• The estimated direct and indirect costs associated with smoking exceed $75 billion annually. 
• In 2001, approximately $300 billion was spent on all cardiovascular diseases. Over $129 in lost productivity was due to cardiovascular disease. 
• The direct medical costs associated with physical inactivity was nearly $76.6 billion in 2000. 
• Nearly $68 billion is spent on dental services each year. (CDC, 2005)

Cost-Effectiveness of Prevention: Benefits Associated with Healthy Behaviors.

• For every $1 spent on water fluoridation, $38 is saved in dental restorative treatment costs. 
• For a cost ranging from $1,108 to $4,542 for smoking cessation programs, one quality-adjusted year of life is saved. Smoking cessation interventions have been called the gold standard of cost-effective interventions. 
• The direct medical costs associated with physical inactivity were $29 billion in 1987 and nearly $76.6 billion in 2000. Engaging in regular physical activity is associated with taking less medication and having fewer hospitalizations and physician visits. 
• For each $1 spent on the Safer Choice Program (a school-based HIV, other STD, and pregnancy prevention program), about $2.65 is saved on medical and social costs. 
• For every $1 spent on preconception care programs for women with diabetes, $1.86 can be saved by preventing birth defects among their offspring. 
• According to one Northern California study, for every $1 spent on the Arthritis Self-Help Program, $3.42 was saved in physician visits and hospital costs. 
• A mammogram every 2 years for women aged 50–69 costs only about $9,000 per year of life saved. This cost compares favorably with other widely used clinical preventive services. 
• For the cost of 100 Papanicolaou tests for low-income elderly women, about $5,907 and 3.7 years of life are saved. 
• After controlling for physical limitation and major socioeconomic factors, more than 12% of annual medical costs of the inactive persons with arthritis is associated with physical inactivity. Physical activity interventions may be a cost-effective strategy for reducing the burden of arthritis. (CDC, 2005)

The broad consider of health concept is increasing being used by employers and managed care organizations who face financial pressures to reduce their medical costs. Employers’ use of health risk appraisal questionnaires is a recognition that their employee’ health can be improved, less expensively, by changes in their lifestyle behavior. Incentives given to their employees to stop smoking, reduce their weight, and exercise enable employers to retain a skilled workforce, while reducing medical expenditures. The emphasis by managed care organizations on reducing per capita medical costs is leading several of them to identify high-risk groups who can benefit form early preventive measures to reduce costly medical treatments. (Heshmat, 2001, p. 93)

The incentives to adhere to healthy lifestyle behaviors is better and improved health and less cost to the consumers, healthcare providers, and third-party payers,

Barriers to clinical support services include all  the following areas except:

A.    High cost

B.   Low technical quality

C.  High customer satisfaction

D.  Doctor ignorance that leads to inapropriate use

Answer:  C (page 299)

If you are familiar with a healthcare system outside of the US, please consider sharing your thoughts and insights about reforms and/or programs that have helped improve access and quality, reduce health disparities, and/or make the system less costly.  If this posting is of interest, Sean Hardiman added a post on 10/15, that you would enjoy reading.

 1)  What do you think the objective of health care reform should be?  What do you think the objective is, given everything you've seen and read?

2)  Do you think that public health will improve as a result of the health care reform legislation, as currently proposed?  Who is the legislation good for, who is it not good for, and what do you think the net result will be for improving health outcomes for patients?

3)  Why do you think there is an unwillingess among some quarters to view health care services as a public good, like the military, utilities, fire services and police departments, that should be available to everyone, regardless of income or ability to pay?

So my intention with these questions is not to create a political firestorm on the boards, but rather to try to better understand what people in the industry actually think about what is happening and what seems to be coming down the line.  Very interested in your responses!

One of the "Questions to Debate" at the end of chapter eight asks the best way for a small hospital in a well managed healthcare system to obtain service. There are three options listed; Stand Alone, Outsource; or Affiliate.

There is not a simple answer to this question, as each alternative would have merit in certain circumstances and depend on  the service being provided. Considering the hospital  is part of a"Well-managed" system, the probability of providing the service itself and being successful may be higher than if the hospital was independent. Of course, if there is another provider in the area that provided the service and the volumes would not support an additional provider, then outsourcing with the existing provider may make the most sense. However, should volumes support adding the service, which would put the facility in direct competition with the other provider, affiliation may be a good alternative.

The CEO of our health system explainedtome his view on this type of situation saying, "collaboration is a better alternative than competition"

Obviously, this decision would require thorough analysis to determine the cost/benefit of the various methods to provide this service. I am interested to hear your feedback on the thought of collaboration vs. competition.

The toxic nursing workplace environment created by dysfunctional aspects of internal and external influences creates a culture as a liability. Cultural liability is amplified when nurses experience burnout because of heavy workloads and lack of recognition. The most pressing trends that contribute to destructive workplace behaviors and foster toxic healthcare work environments include an increasing nurse workload because of an aging and growing population, increasing age of the registered nurse workforce and nurse faculty, increasing turnover of nurses, decreasing enrollment in nursing schools, and cost-cutting pressures of managed care (Jorgensen-Huston, 2003). The increased job stress associated with heavy workloads is amplified and turnover is increased when nurse managers, physicians, patient family members, patients, or coworkers fail to recognize nurses for good performance and impose abusive interactions.

The lack of recognition coupled with decreased job satisfaction intensifies destructive workplace behaviors, increases turnover, affects patient outcomes, and amplifies costs to the organization.

The cost to replace a staff nurse was 1.2 to 1.3 times that of a nurse's average annual salary. High vacancy and turnover rates can adversely affect patient outcomes due to the loss of experienced staff and increased stress on the remaining nurses whose already heavy workload increases to overcome the effect of vacancies. (Texas Center for Nurse Workforce Studies, 2006, p.2)

Therefore, the goal for healthcare leaders is to mitigate the effects of destructive workplace behaviors causing the toxic work environment by creating a healthy work environment that supports the nurse.

Culture as an Asset

In a healthy workplace environment, nurses thrive because of increased morale, increased job satisfaction, and decreased turnover. “The environment in which RNs work is an essential issue in their job satisfaction and turnover…. and a healthy work environment is the base for recruiting and retaining nurses and ultimately for providing optimal care for patients…” (Ulrich, Lavandero, Hart, Woods, Leggett, & Taylor, 2006, p. 46). Hospitals that have achieved Magnet Status – best practices in nursing - have high satisfaction, low turnover, and optimized nurse-to-patient ratios.

Factors that contribute to Magnet Status include nurse autonomy and control over his or her working environment and effective/respectful communication among nurses, physicians, team members, and management.

The American College of Critical Care Nurses (AACN) recognized the issue of hostile or destructive workplace behaviors, mandated a zero tolerance for abuse policy, and identified some components in a healthy workplace environment to include collaborative communication; mutual respect; competent nursing leadership; protection from physical, verbal, and emotional abuse; influence and control over practice; professional development; and recognition.

Despite the AACN policy for zero tolerance for abuse, an open – online survey reported over “9000 instances” (Ulrich et al, 2006, p.54) of verbal, emotional, and physical abuse.  Nurse leaders must strive to create healthy work environments; however, as evidence from the survey results more research is needed to address destructive workplace behaviors of nurses, groups of nurses, coworkers, leadership or physicians, and clients.

References

Jorgensen Huston, C. (2003). Quality health care in an era of limited resources: Challenges and opportunities. Journal of Nursing Care Quality, 18(4), 1-12.

Texas Center for Nursing Workforce Studies. (2006, September). The economic impact of the nursing shortage. E-Publication # 25-12515.

Ulrich, B., Lavandero, R., Hart, K., Woods, D., Leggett, J. & Taylor, D. (2006). Critical care nurses’ work environments: A baseline status report. Critical Care Nurse, 26(5), 46-56.