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Outsourcing in health care has become increasingly common as health system administrators seek to enhance profitability and efficiency while maintaining clinical excellence. When clinical services are outsourced, however, the outsourcing organization relinquishes control over its most important service value: high-quality patient care. Farming out work to an external service provider can have many unintended results, including inconsistencies in standards of care; harmful medical errors; declines in patient and employee satisfaction; and damage to clinicians' morale and income, and to the health organization's culture, reputation, and long-term financial performance. Research on outsourcing in the areas of emergency medicine, radiology, laboratory services, and environmental services provides concerning evidence of potentially large downsides when outsourcing is driven by short-term cost concerns or is planned without diligently considering all of the ramifications of not keeping key clinical and nonclinical services in-house. To better equip health system leaders for decision-making about outsourcing, we examine this body of literature, identify common pitfalls of outsourcing in specific clinical and nonclinical health services and scenarios, explore alternatives to outsourcing, and consider how outsourcing (when necessary) can be done in a strategic manner that does not compromise the values of the organization and its commitment to patients.

When people think about trust in the context of health care, they typically focus on whether patients trust the competence of doctors and other health professionals. But for health care to reach its full potential as a service, trust must also include the notion of partnership, whereby patients see their clinicians as reliable, caring, shared decision-makers who provide ongoing "healing" in its broadest sense. Four interrelated service-quality concepts are central to fostering trust-based partnerships in health care: empathetic creativity, discretionary effort, seamless service, and fear mitigation. Health systems and institutions that prioritize trust-based partnerships with patients have put these concepts into practice using several concrete approaches: investing in organizational culture; hiring health professionals for their values, not just their skills; promoting continuous learning; attending to the power of language in all care interactions; offering patients "go-to" sources for timely assistance; and creating systems and structures that have trust built into their very design. It is in the real-world implementation of trust-based partnership that health care can reclaim its core mission.

The service sector has been rocked by the COVID-19 pandemic. This stems in large part from the inseparable, high-contact nature of many services. During a pandemic, multiple forms of contact – customer-to-customer, customer-to-employee, employee-to-employee, and customer/employee-to-air/surfaces – can lead to serious illness or death. The urgent need for increased separability and decreased contact have led to a wave of service adaptations (firms’ efforts to improve safety) and service transformations (innovations that bolster safety while offering additional benefits that are superior to what existed previously). COVID-19 has made service safety paramount, with most attention being paid to minimizing disease transmission. However, safety needs in a pandemic extend beyond physical to include interrelated domains of emotional, financial, and information safety. Physical safety is the absence of harm or injury. Emotional safety is relief from mental distress arising from pandemic-related personal traumas. Financial safety concerns minimizing economic insecurity related to the pandemic. Information safety refers to people’s sense of confidence that they have the information they need to make good decisions, information that is trustworthy. We describe the unique service transformations addressing these safety concerns of Hong Kong International Airport, Henry Ford Health System (Detroit), Innocent Bystander (Australia), and Service Now that are likely to continue after the pandemic has passed. Important questions for service researchers to guide managers in reinventing how they create, deliver, and market services are highlighted.

Shared decision making (SDM) is on the international healthcare agenda among patient advocacy groups and decision makers in healthcare worldwide [1–5]. In Denmark, implementation of SDM with all ca...

Traditional medical training focused on curing disease may not prepare clinicians to provide comfort and solace to their patients facing life-limiting illness. But dying patients and their families still need healing, and clinicians can actively facilitate it. We explore the clinician's role in the healing journey through the lens of pediatric brain cancer. Specifically, we examine how clinicians can help affected families find their way from "focused hope" (which centers on cure) to "intrinsic hope," which offers a more realistic and resilient emotional foundation as the child's death approaches and letting go becomes essential. Drawing on their clinical experience and medical knowledge, clinicians can help families comprehend the lessons that their seriously ill child's body has to teach, highlighting the importance of cherishing the present and creating new memories that outlast the disease. Clinicians can avoid the mindset of "nothing more can be done," emphasizing that there is plenty to do in providing physical, emotional, and spiritual comfort. Clinicians can learn how to be "unconditionally present" for patients and families without immersing themselves in anguish and, eventually, how to help the family find freedom from despair and a full life that still honors the child's memory.

The benefits of shared decision-making (SDM) in health care delivery are well documented, but implementing SDM at the institutional level is challenging, particularly when patients have complex illnesses and care needs, as in cancer. Denmark’s Lillebaelt Hospital, in creating The Patient’s Cancer Hospital in Vejle, has learned key lessons in implementing SDM so that the organization’s culture is actually being transformed. In short, SDM is becoming part of the fabric of care, not a mere add-on to it. Specifically, the hospital chose and structured its leadership to ensure that SDM is constantly championed. It organized multiple demonstration projects focused on use of decision aids, patient-reported outcome measures, and better communication tools and practices. It designed programs to train clinicians in the art of doctor-patient communication. It used research evidence to inform development of the decision aids that its clinicians use with their patients. And it rigorously measured SDM performance in an ongoing fashion so that progress could be tracked and refined to ensure continuous improvement. Initial data on the institution’s SDM initiatives from the Danish national annual survey of patients’ experiences show substantial progress, thereby motivating Lillebaelt to reassert its commitment to the effort, to share what it has learned, and to invite dialogue among all cancer care organizations as they seek to fully integrate SDM in daily clinical practice.

Providing excellent medical care, especially during the current pandemic, demands the generosity of health care workers—requiring them to make sacrifices while exhibiting emotional strength, resilience, and compassion. This article describes how institutional generosity is critical in supporting health care workers and in enabling health care organizations to succeed and thrive.

The wonders of high-tech cancer care are best complemented by the humanity of high-touch care. Simple kindnesses can help to diffuse negative emotions that are associated with cancer diagnosis and treatment—and may even help to improve patients’ outcomes. On the basis of our experience in cancer care and research, we propose six types of kindness in cancer care: deep listening , whereby clinicians take the time to truly understand the needs and concerns of patients and their families; empathy for the patient with cancer, expressed by both individual clinicians and the care culture, that seeks to prevent avoidable suffering; generous acts of discretionary effort that go beyond what patients and families expect from a care team; timely care that is delivered by using a variety of tools and systems that reduce stress and anxiety; gentle honesty, whereby the truth is conveyed directly in well-chosen, guiding words; and support for family caregivers, whose physical and mental well-being are vital components of the care their loved ones receive. These mutually reinforcing manifestations of kindness—exhibited by self-aware clinicians who understand that how care is delivered matters—constitute a powerful and practical way to temper the emotional turmoil of cancer for patients, their families, and clinicians themselves.

Patients are often reluctant to assert their interests in the presence of clinicians, whom they see as experts. The higher the stakes of a health decision, the more entrenched the socially sanctioned roles of patient and clinician can become. As a result, many patients are susceptible to "hostage bargaining syndrome" (HBS), whereby they behave as if negotiating for their health from a position of fear and confusion. It may manifest as understating a concern, asking for less than what is desired or needed, or even remaining silent against one's better judgment. When HBS persists and escalates, a patient may succumb to learned helplessness, making his or her authentic involvement in shared decision making almost impossible. To subvert HBS and prevent learned helplessness, clinicians must aim to be sensitive to the power imbalance inherent in the clinician-patient relationship. They should then actively and mindfully pursue shared decision making by helping patients trust that it is safe to communicate their concerns and priorities, ask questions about the available clinical options, and contribute knowledge of self to clinical decisions about their care. Hostage bargaining syndrome is an insidious psychosocial dynamic that can compromise quality of care, but clinicians often have the power to arrest it and reverse it by appreciating, paradoxically, how patients' perceptions of their power as experts play a central role in the care they provide.

Many companies are increasingly selling hybrid bundles, which comprise one or more goods and one or more services. Hybrid bundle pricing depends on understanding consumer willingness to pay (WTP) for the bundle, which rests on trade-offs among the benefits from four key drivers: service autonomy, complementarity, service quality variability, and overall bundle quality (basic vs. premium). The effects of these drivers and their interactions on the WTP of hybrid bundles are unknown. The authors develop hypotheses and test them rigorously using incentive-aligned choice-based conjoint and hierarchical Bayesian analysis. The results offer important guidelines for developing appropriate hybrid bundles. If a typical firm under budget constraint has to offer either of two hybrid bundles, one with high complementarity or one with service autonomy, the results suggest that it should offer the bundle with high complementarity. Furthermore, contrary to the conventional wisdom of minimizing service quality variability for premium quality bundles relative to basic quality bundles, the results recommend lowering service quality variability for basic quality bundles but maintaining it for premium bundles.

COVID-19 is a worldwide crisis—cruelly infectious, fast-moving, and lethal It has stressed or overwhelmed health care infrastructures on a global scale In the United States, hospitals have been ravaged Workers who provide for basic needs on which everyone’s health depends have put their own health at greater risk It is the very threat to these workers—and, by extension, to all of us—that offers an opportunity to reimagine the concept of “essential services” during a crisis and, thereby, better control our destiny (Berry 1999) In the initial months of the COVID-19 pandemic, the United States was woefully unprepared to fully support and protect the health care, farm, grocery, pharmacy, sanitation, utilities, transportation, delivery, police, fire, and other workers who help keep the entire population safe and well The lack of personal protective equipment for clinical health care staff rightly received the greatest public attention Largely unrecognized, however, were other essential health care staff who also were at risk: respiratory therapists who assist in intubations and other procedures, custodians who clean patients’ rooms, physical therapists who help intensive care unit patients recover strength and mobility, paramedics, drivers and cleaners of ambulances, and others These equally essential health care workers have lower pay and status but need support and protection just the same

Nonclinical and clinical-support personnel serve patients on the front lines of care. Their service interactions have a powerful influence on how patients perceive their entire care experience, including the all-important interactions with clinical staff. Ignoring this reality means squandering opportunities to start patients out on the right foot at each care visit. Medical practices can improve the overall care they provide by focusing on nonclinical and clinical-support services in 5 crucial ways: (1) creating strong first impressions at every care visit by prioritizing superb front-desk service; (2) thoroughly vetting prospective hires to ensure that their values and demeanor align with the organization's; (3) preparing hired staff to deliver excellent service with a commitment to ongoing training and education at all staff levels; (4) minimizing needless delays in service delivery that can overburden patients and their families in profound ways; and (5) prioritizing the services that patients consider to be most important. We show how cancer care illustrates these principles, which are relevant across medical contexts. Without nonclinical and clinical-support staff who set the right tone for care at every service touchpoint, even the best clinical services cannot be truly optimal.

Patient-centered access (PCA) to primary care services is rapidly becoming an imperative for efficiently delivering high-quality health care to patients. To enhance their PCA-related efforts, some medical practices and health systems have begun to use various tactics, including team-based care, satellite clinics, same-day and group appointments, greater use of physician assistants and nurse practitioners, and remote access to health services. However, few organizations are addressing the PCA imperative comprehensively by integrating these various tactics to develop an overall PCA management strategy. Successful integration means taking into account the changing competitive and reimbursement landscape in primary care, conducting an evidence-based assessment of the barriers and benefits of PCA implementation, and attending to the particular needs of the institution engaged in this important effort. This article provides a blueprint for creating a multifaceted but coordinated PCA strategydone aimed squarely at making patient access a centerpiece of how health care is delivered. The case of a Wisconsin-based health system is used as an illustrative example of how other institutions might begin to conceive their fledgling PCA strategies without proposing it as a one-size-fits-all model. a 2014 Mayo Foundation for Medical Education and Research n Mayo Clin Proc. 2014;89(10):1406-1415

Preference for Mayo Clinic as the source of care for serious illness was nearly 3 times greater than the second-leading academic medical center in an internally commissioned 2012 national survey of US households conducted by an external, independent research firm. With more than 4100 physicians and scientists on staff, more than 61,000 employees overall, medical practices in 77 communities, 23 hospitals, $8.8 billion in gross revenue, 1 and the highest brand preference among academic medical centers, Mayo Clinic has come a long way since its beginning. In 1863, Dr William Worrall Mayo came to Rochester, Minnesota, as a medical examiner for Civil War draftees. Following the war, he established a privatepracticeinRochester.Histwosons,William J. and Charles H., went to medical school in the 1880s and then joined the family medical practice. The brothers were skilled, active surgeons who performed a wide range of procedures. Early adopters of antiseptic and aseptic surgical techniques that kept infection rates low, the brothers also benefited from the development of reliable and safe anesthesia that extended the operating time for complex procedures. 2 Word of the brothers’ surgical success spread, and growing numbers of patients from other states and eventually other countries came to the “Mayos’ clinic” for surgery. The

Patients with the most complex health profiles consume a disproportionate percentage of health care expenditures, yet often receive fragmented, suboptimal care. Since 2003, Wisconsin-based Gundersen Health has improved the quality of life and reduced the cost burden of patients with complex health profiles with an integrated care coordination program. Those results are consistent with data from the most successful care coordination demonstration projects funded by the Centers for Medicare and Medicaid Services. Specifically, Gundersen's program has been associated with reduced hospital stays, lower costs for inpatients, less use of inpatient services, and increased patient satisfaction. Gundersen's success is rooted in its team-based approach to coordinated care. Teams, led by a subspecialty-trained nurse, have regular, face-to-face contact with patients and their physicians in both inpatient and outpatient settings; involve patients deeply in care-related decisions; access a system-wide electronic medical record database that tracks patients' care; and take a macrolevel view of care-related factors and costs. Gundersen's model offers specific take-home lessons for institutions interested in coordinated care as they design programs aimed at improving quality and lowering costs. This institutional case study provides a window into well-executed care coordination at a large health care system in an era when major changes in health care provision and reimbursement mechanisms are on the horizon.

An urgent need in American health care is improving quality and efficiency while controlling costs. One promising management approach implemented by some leading health care institutions is Lean, a quality improvement philosophy and set of principles originated by the Toyota Motor Company. Health care cases reveal that Lean is as applicable in complex knowledge work as it is in assembly-line manufacturing. When well executed, Lean transforms how an organization works and creates an insatiable quest for improvement. In this article, we define Lean and present 6 principles that constitute the essential dynamic of Lean management: attitude of continuous improvement, value creation, unity of purpose, respect for front-line workers, visual tracking, and flexible regimentation. Health care case studies illustrate each principle. The goal of this article is to provide a template for health care leaders to use in considering the implementation of the Lean management system or in assessing the current state of implementation in their organizations.

Focus on Families, Not Just Patients No one doubts the importance of patientcentered care, but pediatric cancer centers know that true patient centerednessmeans having clinicians work in dynamic partnership with sick children’s families. As a child’s primary source of strength and support, the family is a vital part of the health care team. When the family is fully integrated into the care process, the child is more likely to thrive. Indeed, more than a decade ago, pediatric hospitals started using familycentered rounds toactively involvepatients and their families in decision making. By helping the family understand both the inpatient care plan and the discharge plan, family-centered rounds improve efficiency and staff satisfaction. Overall, families are more likely to be considered members of the care team in pediatric than in adult cancer care—a missed opportunity in the adult setting. Pediatric cancer teams recognize that thechild’swell-being and the family’swellbeing aremutually reinforcing. Indeed, the “Standards for the Psychosocial Care of Children With Cancer and Their Families” call for routine assessment of the psychosocial needs of pediatric oncology patients, parents and caregivers, and siblings. Evidence also shows that cognitive behavioral interventions reduce distress in parents and other family members. It is critical to identify which members of the adult patient’s personal network can best inform care planning and provide support during the diagnosis, treatment, and follow-up phases of care. In pediatric and adult cancers alike, support must extend beyond the walls of the medical facility. This support often includes nursing-like duties, such as ongoing medication management, injections, and wound care. An important early service is to train key members of the patient’s support system in how to provide safe, effective in-home care. Pediatric cancer centers are more likely than adult centers to prepare a patient’s family and friends for these roles. One adult care organization that actively pursues family centeredness is Maggie’s, a 17-center network in the United Kingdom that offers adults with cancer and their families a range of free financial, informational, emotional, and social support services. For example, Maggie’s organizes so-called kitchen table venues where patients and families meet and talk with one another and with other families, as well as stress-management sessions for the entire family. At Maggie’s Kids’ Days and Teen Days events, children whose parents have cancer participate in support, informational, and play activities.

After building a strong relationship with her medical oncologist and giving informed consent for intensive chemotherapy, a middle-aged woman with newly diagnosed large cell lymphoma was ushered through an unmarked door into a large, poorly lighted, windowless room. She saw12 closely spaced infusion chairs, separated only by thin, dingy curtains. Nurses with their backs to the patients sat in front of computer monitors scattered throughout the room. She found little room to navigate through patients, family members, and staff on her way to the only available chair. Although she hadmanaged her fears with poise during the preceding weeks, she now experienced severe anxiety and a sudden loss of confidence in her oncologist. Cancer care is a high-emotion service. The need for the service alone elicits intense emotions. Patients’ experiences, good and bad, accumulate as a result of clues embedded in these experiences. Clues are the signals patients perceive in using a service. When interacting with a system of care, patients filter clues, organizing them into a set of impressions. Patients may perceive clues rationally or emotionally, and clues may be defined by their presence or absence. Optimizing cancer patients’ service experiences requires sensitive management of the clues that comprise the overall service. Well-managed clues can evoke positive feelings, such as trust and hope. Poorly managed clues can exacerbate negative emotions, such as anxiety, stress, helplessness, anger, and fear. Themore important, variable, complex, and personal the service, the more cluesensitive customers are likely to be. Few services are more important, variable, complex, and personal than cancer care. Cancer patients are likely to be acutely aware of experiential clues during health care. What may seem to clinicians and staff to be a minor detail can constitute a powerful stimulus to patients. As one cancer patient said in an interview: “Patients are ultra-sensitive to the doctor’s words as clues to whether they will live or die.”

Critics of the American healthcare system recite a long list of problems, including rising out-of-pocket costs, inconvenient access, overuse of emergency departments, uncoordinated medical records, and declining numbers of primary care doctors. To address these issues, some new venues have evolved, such as retail and urgent care clinics; however, the emergency department has become the only service provider available to all patients on a 24/7 basis. It is time to reinvent the system. The concept of patient-centered medical homes offers a structure for integrating innovations that can transform the delivery of healthcare. In this model, each patient develops an ongoing relationship with a primary care physician supported by a team of caregivers. An integral feature is the electronic medical record, which facilitates coordinated communication and decisions. Access expands beyond the traditional physician office visit to satellite services tailored to individual needs. Services center on whole-person care, including wellness and preventive counseling, as well as acute and chronic care. Adoption of the patient-centered medical home transforms healthcare delivery into a system that benefits everyone.

The economic storm experienced globally is the perfect time for companies to recommit to improving service quality. Quality service creates value for customers, and superior value – the best way to compete at any time – is the only way to compete during a recession. This article discusses and dissects the pillars of competing with service excellence: great employees, reliable service, respect and pleasant surprises, and convenience.

Companies commonly adopt “the customer is always right” maxim as a basic premise for delivering quality service. A close examination of customer behavior, however, reveals that customers can be not only wrong but also blatantly unjust. Unfair customers take advantage of being “always right” by demanding unwarranted privileges and compensation, adversely affecting companies and, in some cases, employees and other customers. Companies can actually strengthen their ability to deliver quality service by dealing effectively with unfair customers.

Corporate generosity is a critical input to business success. Effective generosity is a strategic business decision: it is purposeful, channeled, integrated, and results-oriented. In effectively generous firms, the relationship between social and financial performance is mutually reinforcing, creating a “virtuous circle” that benefits not only the firm but also employees, customers, and the community. Five guidelines will help managers establish and execute effective corporate generosity.

A strong services brand is built and sustained primarily by customers’ interactions with the provider. A services branding model depicts the dynamics of brand creation. From the interrelationships among the presented brand, external communications, and customers’ experiences emerge brand awareness, meaning, and, ultimately, equity. The Mayo Clinic case study illustrates the services branding model by showing how one organization has created, extended, and protected a powerful brand through an unwavering commitment to the well-being of its customers. Managers outside of healthcare can benefit from three branding lessons embedded in the Mayo Clinic story: (1) attend to organizational values; (2) play defense, not just offense; and (3) turn customers into marketers.

Executive Overview Because customers' assessment of services is based on performances rather than objects, they rely on the numerous clues that are embedded in performance when choosing services and evaluating service experiences. Indeed, it is often small clues that influence a customer's overall perception of an experience. Customers form perceptions based on the technical performance of the service (functional clues), the tangibles associated with the service (mechanic clues), and the behavior and appearance of service providers (humanic clues). Functional, mechanic, and humanic clues play specific roles in creating the customer's service experience, influencing both rational and emotional perceptions of service quality. Clearly and consistently designing and orchestrating clues is a critical management responsibility; businesses need to be “clue conscious” and add “clue management” to their job descriptions.

The subject of service convenience is important in service economies, yet little is known about this topic. The consumer convenience literature—strong in certain respects, underdeveloped in other respects—gives insufficient attention to service convenience. The prevailing pattern is either to treat service convenience generally or to lump services and goods together into an overall convenience construct. The authors seek to stimulate a higher level of research activity and dialogue by proposing a more comprehensive and multidimensional conceptualization of service convenience and a model delineating its antecedents and consequences. The authors build their case by systematically examining the convenience literature, explicating the dimensions and types of service convenience, developing the overall model and related research propositions, and presenting directions for further research.

Executive Overview As consumer skepticism grows, companies are forced to compete for credibility in the marketplace. The customer confidence needed for long-term loyalty can be earned only by firms that establish an image of fairness. Fairness is especially important for service firms, whose product is intangible and difficult to evaluate, forcing consumers to rely on trust. When consumers are vulnerable or disadvantaged, violation of justice principles can trigger perceptions of unfairness. Such perceptions produce intense reactions from customers, who are often driven to get even with the firm.

Understanding why customers are receptive to relationships with service providers is a key issue in relationship marketing. This paper suggests that four broad drivers—environmental variables, partner variables, customer variables and interaction variables—affect customers' receptivity to relationship maintenance. Customers may maintain relationships either because of constraints (they “ have to” stay in the relationship) or because of dedication (they “want to” stay in the relationship). The potentially differential effects of these dual motivations on customers' subsequent relationship attitudes and behaviors are examined. A model of relationship maintenance is developed and propositions are presented regarding the antecedents and consequences of customers' relationship maintenance. Theoretical and practical implications of the paper are discussed.

If service quality relates to retention of customers at the aggregate level, as other research has indicated, then evidence of its impact on customers’ behavioral responses should be detectable. The authors offer a conceptual model of the impact of service quality on particular behaviors that signal whether customers remain with or defect from a company. Results from a multicompany empirical study examining relationships from the model concerning customers’ behavioral intentions show strong evidence of their being influenced by service quality. The findings also reveal differences in the nature of the quality-intentions link across different dimensions of behavioral intentions. The authors’ discussion centers on ways the results and research approach of their study can be helpful to researchers and managers.

Relationship marketing is an old idea but a new focus now at the forefront of services marketing practice and academic research. The impetus for its development has come from the maturing of services marketing with the emphasis on quality, increased recognition of potential benefits for the firm and the customer, and technological advances. Accelerating interest and active research are extending the concept to incorporate newer, more sophisticated viewpoints. Emerging perspectives explored here include targeting profitable customers, using the strongest possible strategies for customer bonding, marketing to employees and other stakeholders, and building trust as a marketing tool. Although relationship marketing is developing, more research is needed before it reaches maturity. A baker’s dozen of researchable questions suggests some future directions.

Executive Overview Delivering excellent service is a winning strategy. Quality service sustains customers' confidence and is essential for a competitive advantage. Yet many companies are struggling to improve service, wasting money on ill-conceived service programs and undermining credibility with management rhetoric not backed up with action. Are there guidelines to help managers chart a service-improvement strategy for their organizations? We think so. In this article ten lessons from an extensive ten-year study of service quality in America are presented—lessons that we believe apply across industries and are essential to the service-improvement journey.

The authors respond to concerns raised by Cronin and Taylor (1992) and Teas (1993) about the SERVQUAL instrument and the perceptions-minus-expectations specification invoked by it to operationalize service quality. After demonstrating that the validity and alleged severity of many of those concerns are questionable, they offer a set of research directions for addressing unresolved issues and adding to the understanding of service quality assessment.

Employee wellness programs have often been viewed as a nice extra, not a strategic imperative. But the data demonstrate otherwise, according to Berry, of Texas AM University; Mirabito, of Baylor University; and Baun, of the University of Texas MD Anderson Cancer Center. Their research shows that the ROI on comprehensive, well-run employee wellness programs is impressive, sometimes as high as six to one. To achieve those kinds of results, employers cannot merely offer workers afew passes to a fitness center and nutrition information in the cafeteria. The most successful wellness programs are supported by six essential pillars: engaged leadership at multiple levels; strategic alignment with the company's identity and aspirations; a design that is broad in scope and high in relevance and quality; broad accessibility; internal and external partnerships; and effective communications. Companies in a variety of industries--including JohnsonJohnson, Lowe's, H-E-B, and Healthwise--have built their employee wellness programs on all six pillars and have reaped big rewards in the form of lower costs, greater productivity, and higher morale. Those benefits are not easy to achieve, and verifiable paybacks are never a certainty. But the track record inspires emulation, especially when you see the numbers.

etween 1995 and 2010, the percentage of Johnson & Johnson employees who smoke declined by more than two-thirds, and the number with high blood pressure or who are physically inactive declined by more than half. In the late 1970s, Johnson & Johnson chairman James Burke established 2 health-related goals: encourage employees to become the healthiest in the world and reduce the cost of health care for the firm. The company's wide-ranging employee health promotion program includes nutrition education, weight management, tobacco cessation, stress management, onsite fitness, and other services. Johnson & Johnson's commitment to being a "healthy company" is paying off. The company estimates that its health promo- tion program has saved $250 million on health care costs during the past decade. 1 We have conducted primary field research to study workplace health promotion (WHP) programs, often called wellness programs, at Johnson & Johnson and 9 other em- ployers. The organizations vary in size and in industry, but all have integrated, successful WHP programs that empha- size whole-person wellness. In these organizations, well- ness extends beyond physical health to include emotional and spiritual health. Stress management and disease pre- vention are priorities. Our research and related literature suggest a link between strategic WHP and lower health risks, lower health care use, and improved productivity for employees. 1-7 A 2008 survey of large manufacturing firms indicates that 77% have a WHP program, although substantially fewer offer comprehensive programs encom- passing whole-person wellness. 2 Small employers are less likely to offer WHP programs. 8

Despite deep and vocal disagreements over health care reform, virtually everyone believes that the current system is not economically sustainable. We are spending too much and getting too little in return. This recognition has spurred health care leaders to examine every aspect of hospital operations. But what about the health care building itself, the physical environment within which patient care occurs? Too often, cost-cutting discussions have overlooked the hospital structure. Changes in the physical facility provide real opportunities for improving patient and worker safety and quality while reducing operating costs. The "Fable hospital," an imaginary amalgam of the best design innovations that had been implemented and measured by leading organizations, was an early attempt to analyze the economic impact of designing and building an optimal hospital facility. (1) The Fable analysis, published in 2004, showed that carefully selected design innovations, though they may cost more initially, could return the incremental investment in one year by reducing operating costs and increasing revenues. Reactions to the Fable paper varied. Many felt it presented a compelling case and stimulated health care leaders and architects to think differently about balancing onetime building costs with ongoing operating costs. Others voiced skepticism about whether the benefits were as great as described and asked for more evidence. Today, the Fable hospital is no longer imaginary. During the past six years, numerous hospitals have implemented many of its attributes and have evaluated their impact on patients, families, and staff. (2) Several are members of the Center for Health Design's Pebble Project, a group of organizations that apply evidence-based designs to improve quality and financial performance. Two Pebble hospitals are featured in essays accompanying this article. These and other pioneering organizations and their architecture/design teams are introducing such interventions as larger single-patient rooms, which reduce the incidence of health care-associated infections; wider bathroom doors, which reduce patient falls; HEPA filtration and other indoor air quality improvements, which reduce health care-associated infections; appropriate task lighting in medication dispensing areas, which reduces medication-related errors; hydraulic ceiling lifts in patient rooms and bathrooms, which reduce patient and staff lift injuries; and art and music, which reduce anxiety and depression and speed recovery. Since 2004, much has changed that affects decision-making about health care construction and design. It is time for a fresh look at the Fable hospital. Drawing on the latest design and health care knowledge, research, the 2010 health reform law's emphasis on value and quality improvement, and our collective experience, we present Fable hospital 2.0. The Changing Health Care Landscape Five major health care trends are relevant to our analysis: the growth of evidence-based design, the safety/ quality revolution, pay for performance and increasing consumer transparency, sustainability and green design, and access to capital. The growth of evidence-based design. The Center for Health Design's definition of evidence-based design is "the process of basing decisions about the built environment on credible research to achieve the best possible outcomes." That evidence is much more abundant. In 1998, a review found fewer than one hundred solid studies. (3) A 2004 analysis found more than six hundred worthy studies. (4) In 2008, a team found twelve hundred methodologically sound studies. (5) Facility design guided by credible research has become the standard for architects and designers, as witnessed by conferences focused on evidence-based design and the appearance of new publications. (6) More than five hundred health care and design professionals have been accredited by the Center's Evidence-Based Design Accreditation and Certification program, which was launched in 2009. …

In this note we respond to Brown, Churchill, and Peter's (1993) critique of SERVQUAL's difference-score conceptualization. We demonstrate that the claimed psychometric superiority of the alternative non-difference score conceptualization is debatable. We also argue that the SERVQUAL conceptualization offers richer diagnostics.

The growth of services marketing as an academic field offers insight into how a new field of study develops. This article examines specific forces that contributed to and accelerated or inhibited knowledge creation, dissemination, and utilization in services marketing. Multiple methods were used to explore this question. The analysis reveals that services marketing developed academically because it filled a need in marketing practice. Industry assumed an influential role in the development of the academic field of services marketing.