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Reports of medical mistakes have splashed across newspapers and magazines in the United States. At the same time, instances of overuse, underuse, and misuse of management tactics and strategies receive far less attention. The sense of urgency associated with improving the quality of medical care does not exist with respect to improving the quality of management decision making. A more evidence-based approach would improve the competence of the decision-makers and their motivation to use more scientific methods when making a decision. The authors of this article consider a study of 68 U.S. health services managers that found a low level of evidence-based management behaviors. From the findings, four strategies are suggested to increase health systems managers' use of research evidence to improve decision making: focusing evidence-based decision making on strategically important issues, developing committees and other structures to diffuse management research throughout the organization, building a management culture that values research, and training managers in the competencies required to apply research evidence to health services management decisions. To aid the manager in understanding and applying an evidenced-based approach to decision making, the article provides practical tools, techniques, and resources for immediate use.

We wish to thank the three commentators for enriching our discussion of evidence-based health services management (EBHSM). Each piece extends our discussion of EBHSM in important ways. We agree with nearly all of the commentators' substantive comments and offer the following reactions as a way of pushing the discussion forward. Damore asks why EBHSM has not been used more extensively in healthcare organizations. While agreeing with the barriers to EBHSM we identified, Damore gives greater emphasis to barriers that largely lie outside an individual organization's immediate sphere of influence: (i) the lack of standardized definitions and measures of management success, (2) the paucity of accurate and valid data on the effects of management decisions adjusted for local differences in culture, values, and managers' interpersonal and leadership skills, and (3) the challenge of providing evidence-based management information to practitioners in a convenient, efficient, and accessible manner. Damore calls for renewed and improved organizational benchmarking efforts, both for the immediate value such efforts will generate for healthcare managers and for the stimulus benchmarking will provide for the field to address the three barriers he identifies. We certainly agree with Damore's comments, but we hope that healthcare managers will not wait until these difficult external challenges are overcome before undertaking internal efforts to increase the use of evidence in decision making. Even with the limited structures and resources currently available, healthcare managers could use appropriate research evidence in making decisions to a much greater extent, and organizations could begin to reward managers who do so. Our interviews revealed that managers are not rewarded nor are they punished in any significant ways for their obtaining, or failing to obtain, the most relevant data for strategic decision making that are available at reasonable cost. In fact, some improvement in this situation is already under way. We found in our interviews that managerial incentives are being realigned modestly in the right direction as a result of the influence of evidence-based medicine and nursing and the rapid deployment of pay-for-performance initiatives by external payers. However, much more could be done about external barriers, and we appreciate Damore's comment, which broadens the discussion and rightly emphasizes much-needed publicly accepted standards of organizational performance and the availability of regional and national resources to measure and usefully report performance across multiple organizations. We appreciate the connection Fine makes between EBHSM and the related field of managerial epidemiology. His suggested questions, in the ten examples, extend our discussion to health policy and public health decision making. He (in agreement with Damore) suggests that greater emphasis on organizational benchmarking will be a stimulus to EBHSM, and (in agreement with Shortell) he argues that consultants, especially those with expertise in industrial engineering and related fields, can be excellent knowledge brokers for health services managers. We appreciate the current and future potential roles consultants may play, but we also agree with Fine's warning that "the opportunity to transform the enterprise into one whose central culture is eager for data-driven managerial decision making is compromised by the Outside expert syndrome.'" Extensive use of consultants should occur in the context of an overall organizational strategy for EBHSM, not as a replacement for it. Finally, we note that Fine suggests that one of the reasons EBHSM is so little used is that many students in healthcare management training programs have significant deficiencies in quantitative analysis and related competencies. Ironically, we have little evidence to help us with this question. We suspect that the training problem lies mainly with the faculties and not the students. …

Article-at-a-Glance Background Use of electronic medical records (EMRs) in health care organizations can reduce medical errors and improve quality of care through physicians' increased use of evidence-based patient care processes. However, only 20%–25% of physician organizations have adopted EMRs. A study was undertaken to determine the characteristics of primary care medical groups that distinguish EMR adopter from nonadopter organizations. Methods A quantitative nationwide survey was undertaken of all primary care medical groups in the United States with 20 or more physicians; data were collected on 738 medical groups (70% response rate). Results Fewer than one-third of the medical groups reported having either patients' medical records or progress notes in an EMR. Large organizations with relatively fewer practice locations were more likely to adopt an EMR. Discussion Large medical groups are more likely to have the financial and human resources necessary to overcome barriers to the adoption of an EMR. Knowing the influence of the other organizational characteristics on EMR adoption will help prepare organizational leaders for the complicated process of achieving consensus among physicians and others in medical groups on the expenditure of funds and other resources to acquire an EMR. Financial incentives for all medical groups will help drive EMR adoption, but financial and technical assistance aimed specifically at smaller groups is particularly warranted. Widespread adoption of EMR among medical groups will take time.

Purpose. To document use of health risk appraisals (HRAs) by U.S. physician organizations as part of their overall approach to health promotion and to identify associated organizational characteristics. Methods. Telephone survey of 1590 physician organizations in the United States; surveys were conducted in organizations comprising 20 or more physicians and were conducted between September 2000 and September 2001 (70% response rate). Chi-square tests and logistic regression analysis were used to examine the association between organizational characteristics and routine administration of HRAs. Results. Only 22.5% of physician organizations in the United States routinely administer HRAs. External quality incentives, information technology capabilities, and status as a medical group vs. an independent practice association are associated with greater odds of the routine use of HRA. Discussion. Increased use of external quality incentives and information technology in physician organizations may be important in supporting the use of HRAs.

The performance of medical groups is receiving increased attention. Relatively little conceptual or empirical work exists that examines the various dimensions of medical group performance. Using a national database of 693 medical groups, this article develops a scorecard approach to assessing group performance and presents a theory-driven framework for differentiating between high-performing versus low-performingmedical groups. The clinical quality of care, financial performance, and organizational learning capability of medical groups are assessed in relation to environmental forces, resource acquisition and resource deployment factors, and a quality-centered culture. Findings support the utility of the performance scorecard approach and identification of a number of key factors differentiating high-performing from low-performing groups including, in particular, the importance of a quality-centered culture and the requirement of outside reporting from third party organizations. The findings hold a number of important implications for policy and practice, and the framework presented provides a foundation for future research.

In many developed countries, including the United States and the United Kingdom, the relationships between doctors and hospital managers are strained. The purposes of this article are to examine survey data from the United States and the United Kingdom on doctor-manager relationships and to identify the sources of strain common to both countries as well as those particular to each country's health system. The two countries exhibited many similarities. A very high proportion of respondents from both countries identified external factors-such as governmental budget cuts, pressure from third parties to increase physicians' workload, and the turbulence of the policy environment-as important barriers to improving doctor-manager relationships. Other common sources of strain were concerns over resource availability and the relative power of doctors and managers. Sources of relationship tension particular to each country were also found. Substantial divergence of opinion was expressed with respect to internal factors that affect doctor-manager relationships. Respondents from the United States were more negative than those from the United Kingdom in their ratings of teamwork and communication between doctors and managers, and they were also less likely to have confidence in the medical staff. Respondents from the United Kingdom were more likely to believe that hospital management is driven more by financial than clinical priorities. Managers can implement several strategies to improve doctor-manager relationships, including greater organizational transparency in decision making; more frequent communication between managers and doctors; and more physician involvement in decision making, especially with regard to important resource-related decisions, and in organizational governance.

Background Health promotion programs can be effective in improving the delivery of clinical preventive services and in improving population health; however, the availability of health promotion programs offered through physician organizations, such as medical groups and independent practice associations, are largely unknown. Methods This research uses data from the National Study of Physician Organizations and the Management of Chronic Illness, conducted by the University of California, Berkeley, to document the extent to which physician organizations offer health promotion programs. Of 1587 physician organizations nationally with 20 or more physicians, 1104 participated, for a response rate of 70%. Results Overall, 60% of physician organizations offer at least one health promotion program targeting one or more of eight areas: prenatal education (42%), smoking cessation (39%), nutrition (39%), weight loss (34%), health risk assessments (25%), stress management (25%), substance abuse (20%), and sexually transmitted disease prevention (16%). Factors positively associated with offering health promotion programs include the following: outside reporting of quality measures, public recognition for quality measures, clinical information technology systems, being a medical group, and ownership by a hospital or health plan. Conclusions Physician organizations in the United States have a long way to go in offering these important programs to their patients. However, our findings also suggest that health plans, purchasers, and policymakers can play a positive role in increasing the use of these programs. By offering recognition and incentives for quality improvement, and by funding the expansion of information technology, the healthcare community can encourage and enable physician organizations to increase the availability of health promotion programs nationally.

The relationship between clinicians and managers is central to the success of health care reform and improvement. This paper assesses how they see each other. This paper expands and elaborates on survey data originally published as a ‘short report’ in the BMJ (BMJ 2003;326:626-8). Data reproduced with permission.

Data from a national study of medical groups and independent practice associations are used to examine the extent to which California physician organizations are different from physician ...

American hospitals have undergone three waves of organizational restructuring in the past two decades. These changes have had direct effects on a key set of employees--nurses. A review of the relevant literature to identify the ways in which hospital restructuring affects the work of registered nurses focuses on three important structural characteristics of nursing work: nurses' work roles, workload, and control of work. The review concludes that the impact of restructuring on each of the characteristics affects nurses' satisfaction with their work and may also affect the quality of patient care. While much of the policy debate around restructuring focuses on the extent to which reductions in nurse staffing levels affects quality of care, it is important to examine not only changes in nurse staffing levels, but changes in the work performed by registered nurses, as well.

Patient trust has been identified as an important element in the patient-physician relationship. However, common features of managed care, such as risk-sharing, utilization review, and limitations on benefits, may erode the traditionally high trust that patients have in their physicians. High trust is not always justified; rather, an optimal level of trust arises from the level of interdependence between patients and physicians. This analysis of the interrelationship between patient-physician trust and some of the key facets of managed care has important implications for managed care. A return to high levels of trust may be impracticable, and new strategies for balancing trust-building efforts by caregivers with checking mechanisms accessible to patients are recommended.

This article assesses the extent to which the availability of HIV/AIDS services in the Baltimore and Oakland eligible metropolitan areas (EMAs) increased after receipt of funding under Title I of the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act. Survey data on the availability of HIV/AIDS services in each EMA were collected from samples of organizations at two points in time: 1 year before (1991) and 1 year after (1993) the Oakland and Baltimore EMAs received their first installments of CARE Act Title I funds. Cross-sectional and longitudinal analyses of the data were performed to assess changes in the availability of HIV/AIDS services. The results showed that after CARE Act Title I funding became available, the availability of ambulatory medical and social support services in the Baltimore and Oakland EMAs increased. However, the way service availability increased varied significantly, reflecting differing opportunities and constraints present in each community. In Baltimore, the increase in the availability of HIV/AIDS services was due largely to the creation of new organizations that used Title I funds to provide services (system expansion). In Oakland, relatively few new organizations were created, but existing organizations added new HIV/AIDS services (service line expansion). Our data also indicated that in both EMAs the majority of HIV/AIDS organizations receiving Title I funds expanded the capacity of their existing services to meet growing demand.

This article proposes a framework for the study of the effects of market forces on health promotion and disease prevention (HP/DP) in integrated delivery systems (IDSs). We describe the evolution of IDSs in the United States and review the limited research on the extent to which IDSs have integrated HP/DP. We propose a typology of HP/DP activities that provides a comprehensive model of the types of HP/DP services and functions that an IDSs may incorporate. Finally, we identify and discuss the major market stages through which IDSs are transitioning, and within each market stage we identify the major forces that may influence IDS decisions to incorporate HP/DP services.

An observational study of the Oakland Eligible Metropolitan Area and its Ryan White CARE Act Title I HIV health services planning council, officially known as the Alameda/Contra Costa HIV Planning Council, has been in progress since October 1992. Until June 1994, the Oakland planning council had a bifurcated organizational structure, with a component council for Alameda County and a component council for Contra Costa County. This case study focuses primary on the Alameda Component Planning Council (ACPC) and reveals that since its inception, the ACPC has struggled with numerous difficult issues, including volunteer membership, part-time staff support, membership selection and composition, conflict of interest, tensions among competing interest groups, conflicting demands from patientsJconsumers, and tensions among competing service delivery organizations. In spite of the substantial effort required to address these issues, the ACPC managed to fulfill its basic responsibilities of prioritizing the service ...

Background: Primary care providers (PCPs) in safety net settings face barriers to optimizing care for patients with diabetes. We conducted this study to assess PCPs' perspectives on the effectiveness of two language-concordant diabetes self-management support programs. Methods: One year postintervention, we surveyed PCPs whose patients with diabetes participated in a three-arm multiclinic randomized controlled trial comparing usual care (UC), weekly automated telephone self-management (ATSM) support with nurse care management, and monthly group medical visits (GMVs). We compared PCP perspectives on patient activation to create and achieve goals, quality of care, and barriers to care using regression models accounting for within-PCP clustering. Results: Of 113 eligible PCPs caring for 330 enrolled patients, 87 PCPs (77%) responded to surveys about 245 (74%) enrolled patients. Intervention patients were more likely to be perceived by PCPs as activated to create and achieve goals for chronic care when compared with UC patients (standardized effect size, ATSM vs UC, +0.41, p = 0.01; GMV vs UC, +0.31, p = 0.05). Primary care providers rated quality of care as higher for patients exposed to ATSM compared to UC (odds ratio 3.6, p < 0.01). Compared with GMV patients, ATSM patients were more likely to be perceived by PCPs as overcoming barriers related to limited English proficiency (82% ATSM vs 44% GMV, p = 0.01) and managing medications (80% ATSM vs 53% GMV, p = 0.01). Conclusions: Primary care providers perceived that patients receiving ATSM support had overcome barriers, participated more actively, and received higher quality diabetes care. These views of clinician stakeholders lend additional evidence for the potential to upscale ATSM more broadly to support PCPs in their care of diverse, multi-linguistic populations.

President Clinton's American Health Security Act proposes to reform and integrate the medical care and public health service delivery systems. Historically, there have been examples of efforts to integrate public health and medical activities. Yet, while many have acknowledged the inherent value of such an integrated approach to improving health, the fact is that these efforts have had only limited success. The "new deal" President Clinton has proposed for these health institutions is examined in this context. If the notion of integration is taken seriously--that is to mean the extent to which each system's diverse activities complement each other, fitting together to form an integrated whole--then it will not be easy to achieve. Review of the "visions" of public health and medicine and of examples of efforts to integrate public health and medicine in this country suggest five conditions that must be met if successful integration is to be achieved. While the resources necessary to integrate public health and medicine are great, of equal importance is the acceptance of a shared vision of an integrated health care system, and of the respective roles and responsibilities of public health and medical care in that system. The benefits to our nation's health of proceeding in this way, however, are enormous. As we move into the twenty-first century, an integrated system of public health and medical care services is our nation's best hope for not only improving the health of all our citizens, but for closing the "health gap" between socioeconomically disadvantaged groups and the rest of the population.

Background Integration of medical care across clinicians and settings could enhance the quality of care for patients. To date, there is limited data on the levels of integration in practice. Our objective was to compare primary care clinicians' perceptions of clinical integration and three sub-aspects in two healthcare systems: Kaiser Permanente, Northern California (KPNC) and the Danish healthcare system (DHS). Further, we examined the associations between specific organizational factors and clinical integration within each system. Methods Comparable questionnaires were sent to a random sample of primary care clinicians in KPNC (n = 1103) and general practitioners in DHS (n = 700). Data were analysed using multiple logistic regression models. Results More clinicians in KPNC perceived to be part of a clinical integrated environment than did general practitioners in the DHS (OR = 3.06, 95% CI: 2.28, 4.12). Further, more KPNC clinicians reported timeliness of information transfer (OR = 2.25, 95% CI: 1.62, 3.13), agreement on roles and responsibilities (OR = 1.79, 95% CI: 1.30, 2.47) and established coordination mechanisms in place to ensure effective handoffs (OR = 6.80, 95% CI: 4.60, 10.06). None of the considered organizational factors in the sub-country analysis explained a substantial proportion of the variation in clinical integration. Conclusions More primary care clinicians in KPNC reported clinical integration than did general practitioners in the DHS. Focused measures of clinical integration are needed to develop the field of clinical integration and to create the scientific foundation to guide managers searching for evidence based approaches.

Our study assesses how work-related monetary and nonmonetary factors affect physicians' job satisfaction at three academic medical centers in Germany and the United States, two countries whose differing health care systems experience similar problems in maintaining their physician workforce. We used descriptive statistics and factor and correlation analyses to evaluate physicians' responses to a self-administered questionnaire. Our study revealed that German physician respondents were less satisfied overall than their U.S. counterparts. In both countries, participation in decision making that may affect physicians' work was an important correlate of satisfaction. In Germany other important factors were opportunities for continuing education, job security, extent of administrative work, collegial relationships, and access to specialized technology. In the U.S. sample, job security, financial incentives, interaction with colleagues, and cooperative working relationships with colleagues and management were important predictors of overall job satisfaction. The implications of these findings for the development of policies and management tactics to increase physician job satisfaction in German and U.S. academic medical centers are discussed.

The purpose of this paper is to discover the extent to which evidence-based practices and computer systems for managing chronic illness are used within Swedish primary health care.The methodology was a replication of a similar national USA survey study and an interview study.The findings show large variations and an under-use of a number of evidence-based care management practices and of IT for managing depression, heart disease, asthma, and diabetes in Sweden. Follow-up interview studies with heads of primary care centres gathered their views about the factors which helped and hindered improving care and prevention for these patient groups.The study data identify actions which would significantly improve the quality of care for people suffering from chronic illnesses. Effective prevention and management of chronic illness in primary care can reduce unnecessary patient suffering and lower costs of care.Evidence of effective methods for managing these illnesses has been reported, but it is not known how widely these methods or information technology are used in primary care outside the USA. The paper gives the first comprehensive nation-wide data on the use of evidence-based practices and computer systems for managing chronic illness in primary care in a European public health care system. It provides information allowing targeted actions which would improve quality of care which are low cost and high cost saving in the long term.

Berichte uber medizinische Behandlungsfehler sind in vielen Zeitungen und Zeitschriften verteilt uber die ganzen Vereinigten Staaten aufgetaucht. Zur gleichen Zeit erhalten Beispiele eines ubermaβigen, verminderten oder falschen Einsatzes taktischer Managementstrategien weitaus weniger Beachtung. Die drangende Notwendigkeit, die man in Zusammenhang mit der Qualitatssteigerung der medizinischen Versorgung sieht, scheint im Zusammenhang mit der Qualitatssteigerung der Entscheidungsprozesse des Managements nicht zu existieren. Ein eher evidenzbasierter Ansatz wurde die Kompetenzen der Entscheidungstrager und ihre Motivation, innerhalb des Entscheidungsprozesses wissenschaftlich geprufte Methoden einzusetzen, verbessern. Diesem Artikel liegt eine Untersuchung mit 68 Managern des Gesundheitswesens zugrunde, bei denen nur ein geringes Maβ an evidenzbasiertem Managementverhalten beobachtet wurde. Auf Grundlage der Untersuchungsergebnisse werden vier Strategien vorgeschlagen, um Manager im Gesundheitswesen dazu zu bewegen, Entscheidungen auf Basis wissenschaftlicher Nachweise zu treffen: ▪ Konzentration auf evidenzbasierte Entscheidungsprozesse bei strategisch wichtigen Themen, ▪ Entwicklung von Komitees und anderen Strukturen, um Managementforschung innerhalb der Organisation zu verbreiten, ▪ Aufbau einer Managementkultur, die Forschung wertschatzt, ▪ Kompetenzschulungen von Managern, um wissenschaftliche Nachweise auf Entscheidungen im Gesundheitswesen anwenden zu konnen.

In recent years, spurred by developments in evidence-informed medicine, a movement to strengthen evidence-informed managerial decision making in healthcare organizations has emerged in the United States and in other countries. The drivers of this movement include demands by payers and consumer groups for improved quality of care, increased operational efficiency, and greater accountability from healthcare organizations. But numerous barriers to managers' use of evidence in decision making exist, including time pressures, perceived threats to autonomy, preference for colloquial knowledge based on individual experiences, difficulty accessing the relevant evidence base, reliance on external consultants (and others) to determine the quality of the information, and lack of resources. To help managers overcome these barriers, we developed the Informed Decisions Toolbox. It provides tools to help managers efficiently perform the six key steps in the evidence-informed approach to decision making: (1) framing the management question, (2) finding sources of information, (3) assessing the accuracy of the information, (4) assessing the applicability of the information, (5) assessing the actionability of the evidence, and (6) determining if the information is adequate. To build an organizational environment conducive to evidence-informed decision making, we suggest four leadership-driven strategies: (1) recognize and respond to the growing demand for accountability as a strategic issue, (2) establish organizational structures and processes for knowledge transfer, (3) build a questioning organizational culture, and (4) build organizational research capabilities. With organizational support, managers who use the tools presented in the Informed Decisions Toolbox will be able to take control of the decision-making process, will be less reliant on colloquial evidence and consultants, and will be better able to improve the performance of their organizations.

To determine the extent to which Medicaid managed care (MMC) organizations are engaged in chronic disease care management (CDCM), tailor CDCM for diverse populations, or plan to expand CDCM.Web-based survey of 23 eligible California MMC health plan executives in fall 2005.Frequency distributions of survey responses.Nineteen (83%) of 23 executives responded, representing 2.5 million beneficiaries. Eighteen (95%) MMC plans reported implementing 1 or more elements of CDCM. Although plans used a wide range of CDCM strategies to reach performance goals, most implemented provider awareness activities such as offering guidelines or disease-specific feedback to physician groups. More than half of the plans reported interest in expanding CDCM to include more active interventions such as disease registries, pay for performance, telephone counseling to patients, and other self-management support programs. Few plans reported tailoring their CDCM to vulnerable member populations such as those with limited literacy or limited English proficiency. Executives reported that insufficient financial resources at the plan level, lack of organizational leadership and commitment in physician organizations, and limited information technology in physician offices were barriers to CDCM expansion.California MMC health plans reported substantial interest in CDCM and a desire to increase CDCM. Representatives reported intentions to expand to strategies that more directly engage providers and patients. To ensure that the growing number of vulnerable enrollees with chronic disease receive high-quality care, policy efforts should focus on enabling MMC health plans to more consistently implement and target population-based strategies such as CDCM.

Objective This study sought to explore physician organizations’ adoption of chronic care guidelines in order entry systems and to investigate the organizational and market-related factors associated with this adoption. Design A quantitative nationwide survey of all primary care medical groups in the United States with 20 or more physicians; data were collected on 1,104 physician organizations, representing a 70% response rate. Measurements Measurements were the presence of an asthma, diabetes, or congestive heart failure guideline in a physician organization’s order entry system; size; age of the organization; number of clinic locations; type of ownership; health maintenance organization market penetration; urban/rural location; and presence of external incentives to improve quality of care. Results Only 27% of organizations reported access to order entry with decision support for chronic disease care. External incentives for quality is the only factor significantly associated with adoption of these tools. Organizations experiencing greater external incentives for quality are more likely to adopt order entry with decision support. Conclusion Because external incentives are strong drivers of adoption, policies requiring reporting of chronic care measurements and rewarding improvement as well as financial incentives for use of specific information technology tools are likely to accelerate adoption of order entry with decision support.

Background: Efforts to redesign primary care practices are beginning to address how decisions are made in the practice setting. This study contributes to these efforts by examining associations between staff participation in decision-making, productivity, and turnover in primary care practices. The study is informed by organizational theories of participation that emphasize cognitive and affective influences on employee output and behavior. Methods: This research used data collected from primary care practices involved in a national initiative sponsored by the Robert Wood Johnson Foundation. Cross-sectional survey data on organizational structures and attributes among 49 practices were analyzed. Regression analysis was used to examine associations among practice productivity, staff participation in decision-making, and formal structures such as staff meetings. Associations between staff turnover and participative decision-making were also examined. Results: Staff participation in decisions regarding quality improvement, practice change, and clinical operations was positively associated with practice productivity, whereas formal structures such as staff meetings were not. In addition, higher levels of participation in decision-making were associated with reduced turnover among nonclinicians and administrative staff. Conclusion: Examination of organizational features is increasingly recognized as a key to improving primary care performance. Study findings suggest that one important strategy may be implementation of a participative model emphasizing greater staff involvement in practice decisions. This may enhance information-sharing, work satisfaction, and commitment to organizational decisions, all of which can lead to beneficial outcomes such as increased productivity and stability in primary care practices.

Reports of medical mistakes have splashed across newspapers and magazines in the United States. At the same time, instances of overuse, underuse, and misuse of management tactics and strategies receive far less attention. The sense of urgency associated with improving the quality of medical care does not exist with respect to improving the quality of management decision making. A more evidence-based approach would improve the competence of the decision-makers and their motivation to use more scientific methods when making a decision. The authors of this article consider a study of 68 U.S. health services managers that found a low level of evidence-based management behaviors. From the findings, four strategies are suggested to increase health systems managers' use of research evidence to improve decision making: focusing evidence-based decision making on strategically important issues, developing committees and other structures to diffuse management research throughout the organization, building a management culture that values research, and training managers in the competencies required to apply research evidence to health services management decisions. To aid the manager in understanding and applying an evidenced-based approach to decision making, the article provides practical tools, techniques, and resources for immediate use.

There is substantial disagreement regarding the impact of hospitalists on costs, quality, and satisfaction with inpatient care. The authors reviewed 21 evaluations of the use of hospitalists in U.S. hospitals. Most evaluations found that patients managed by hospitalists had lower total costs or charges than patients in comparison groups and that these savings were achieved primarily by reducing length of stay. Most evaluations found no statistically significant differences in quality of care or satisfaction. However, lack of random assignment limits the ability to draw causal inferences from many of the evaluations. All randomized studies were conducted in teaching hospitals, raising questions as to the generalizability of findings to nonteaching hospitals. Further research is needed to better identify the mechanisms by which hospitalists reduce length of stay and to ascertain which types of hospitalist programs are most effective and which patients are most likely to benefit.

Background While visits to the doctor’s office are appropriate times to advise patients on health behaviors, these opportunities are often missed. Lapses in care quality are no longer attributed solely to individuals, but are also increasingly understood to be the result of organizational factors. This research examines the influence that both practice and provider attributes have on the delivery of preventive services for health behaviors. Methods This study used data collected from the Prescription for Health initiative sponsored by the Robert Wood Johnson Foundation. Quantitative data on 52 primary care practices and 318 healthcare providers were gathered from September 2003 to September 2004, and were analyzed upon completion of data collection. Hierarchical linear modeling was used to examine associations between both practice and provider attributes and preventive service delivery. Results Practice staff participation in decisions regarding quality improvement, practice change, and clinical operations positively influenced the effect of work relationships and negatively influenced the effect of practice size on service delivery. Nurse practitioners and allied health professionals reported more frequent delivery of services compared to physicians. Last, use of reminder systems and patient registries were positively associated with preventive service delivery. Conclusions This study offers preliminary support for staff participation in practice decisions as a positive aspect of teamwork and collaboration. Findings also suggest leveraging nonphysician clinical staff and organized clinical systems to improve the delivery of preventive services for health behaviors.

This article proposes a theory of physician-hospital integration. The theory is developed by building on three streams of scholarship: "new" institutionalism, "old" institutionalism, and the theory of economic markets. The theory uses several key concepts from these theoretical frameworks, including the notions of environmental demands for legitimacy, market demands for efficiency, and agency. To enhance the predictive power of the theory, two new concepts are introduced: directionality of influence between institutional and market forces at the macro-societal level, and degree of separation of institutional and market domains at the local level--which add important predictive power to the theory. Using these concepts, a number of hypotheses are proposed regarding the ideal types of physician-hospital arrangements that are likely to emerge under different combinations of directionality of influence and institutional and market domain separation. Moreover, the theory generates hypotheses regarding organizational dynamics associated with physician-hospital integration, including the conditions associated with high and low prevalence of physician-hospital integration, the extent to which the integrated organization is physician-centric or hospital-centric, and whether physician-hospital integration is likely to be based on loose contractual arrangements or tight, ownership-based arrangements.

Data from a national study of medical groups and independent practice associations are used to examine the extent to which California physician organizations are different from physician organizations in the rest of the United States. California physician organizations are different in many ways: most notably, they are more likely to have external incentives to improve quality and more likely to use recommended care management processes for treating patients with chronic illnesses. The implications of these differences for policy and practice are discussed.

Background. Clinical preventive services improve patient health, and reminder systems can increase the use of such services. However, physician organizations often underutilize clinical preventive service reminders. Little is known about the incentives, capabilities, and organizational characteristics associated with the use of reminders by physician organizations. Methods. The predictors of patient and physician reminder system use were examined in a sample of 1,104 US physician organizations. The cross-sectional sample was obtained through a telephone survey with a 70% response rate. Results. Fifty-one percent of physician organizations used mammogram reminders, 41% used influenza immunization reminders, and 26% used eye exam reminders for patients. Eighteen percent of physician organizations used computer-generated reminders to physicians. Required reporting of data (P = 0.0006), public recognition for quality (P = 0.0002), and IT capabilities (P < 0.0001) were strongly associated with patient reminder use. Medical groups were more likely to use patient-level reminders than independent practice associations (IPAs) (P < 0.0001). Physician reminder use was related to required reporting of data (P < 0.0001) and IT capabilities (P < 0.0001). Conclusions. Physician organizations have relatively low use of preventive service reminders to patients and physicians. Offering quality incentives to physician organizations and improving their IT capabilities may increase the use of preventive service reminders and improve the delivery of preventive care.

Article-at-a-Glance Background Care management processes (CMPs) such as disease registries, reminder systems, performance feedback, case management, and self-management education can improve chronic illness care, yet 50% of physician organizations have instituted few if any CMPs. Methods Site-visit interviews were conducted with 158 leaders at 15 physician organizations, with 3 organizations (1 large medical group, 1 small medical group, and 1 independent practice association [IPA]) chosen randomly in most cases in each of five communities. Results Seven of the 15 organizations had implemented CMPs minimally or not at all. CMPs were most common for diabetes and least common for depression; no IPAs had achieved significant CMP implementation for any of the conditions. The two most commonly mentioned facilitators were strong leadership and organizational culture valuing quality. The top five barriers were poor financial situation, reimbursement that does not reward high quality, inadequate information technology, physician resistance, and physicians being too busy. Discussion Strong leadership and a quality-valuing culture are important facilitators of improved chronic care, but if insurers do not reward chronic care improvement, it is unlikely that CMPs will become permanently institutionalized in physician organizations.

Physician organizations such as medical groups and independent practice associations (IPAs) function as financial intermediaries between the insurer and the individual physician (Robinson 1999b; Penner 1997; Gold et al. 2002). In “three-tier” organizational settings, the insurance firm pays the physician organization on a prospective, retrospective, or blended basis and then the physician organization pays the individual physician, sometimes on a different basis (Conrad et al. 1998; 2002; Kralewski et al. 2000). Prior to the advent of managed care, insurers paid medical groups mostly on the same fee-for-service basis with which they paid physicians working in solo practice, and the medical groups paid their individual physicians on a compatible productivity-based salary schedule (i.e., fee-for-service). This compensation mechanism aligned the incentives of the individual physician with that of the physician organization, both of which profited by increasing the number and complexity of services performed. With the advent of managed care, many health maintenance organizations (HMOs) began to reimburse medical groups on a prospective, capitated basis. Continued payment of individual physicians on a fee-for-service basis created incentive misalignment between the individual physician and the physician organization. This article analyzes the association between market penetration by managed care and the methods developed by physician organizations to pay their individual physician members. In the increasingly cost-conscious health care environment, medical groups are forced to balance the need to maintain individual physician productivity, for which fee-for-service is an effective incentive, with the need to limit the cost of the clinical services provided, for which capitation is an effective incentive. We hypothesize that physician organizations respond to these conflicting imperatives by developing payment methods that blend elements of fee-for-service with elements of capitation, with the relative weights assigned to each depending on the extent of cost-control pressure they face in their local market environment. This focus on blended payment methods for physicians extends the empirical literature on blended payments for hospitals (where Medicare's diagnosis related group [DRG] system includes both prospective and retrospective elements) and the theoretical literature on optimal payments in multi-task principal-agent relationships. We use 2001 data collected as part of the National Study of Physician Organizations, which surveyed medical groups and IPAs with 20 or more physician members. The article presents the distribution of pure prospective, pure retrospective, and blended payment methods for both primary care and specialist physicians, for integrated medical groups and IPAs separately. Variation in payment methods among physician organizations is analyzed in terms of the penetration of the local market by HMOs and in terms of organizational factors such as scale, scope of services, and ownership of the physician entities. The article concludes with a brief discussion of the implications of the analysis for contemporary policy initiatives to improve the quality of care by changing methods of payment for physician organizations and individual physicians.

A well functioning relationship between doctors and managers is crucial if government plans for “modernising” the NHS are to deliver real service improvements. 1 2 We aimed to shed some light on current perceptions of the doctor-manager relationship by examining areas of convergence or divergence of views among a large sample of doctors and managers in the NHS. We conducted a postal questionnaire survey in NHS acute trusts across Great Britain during the summer of 2002. The survey included a census of chief executives and medical directors (from 197 trusts), together with a stratified cluster sample of both medical and non-medical managers at directorate level (clinical directors or their equivalent and non-medical directorate managers or their equivalent) randomly selected from 75 trusts. Comparisons between these different role groups form the central part of the analysis; we assessed variations across all four groups …

ContextOrganized care management processes (CMPs) can improve health care quality for patients with chronic diseases. The Institute of Medicine of the National Academy of Sciences has called for public and private purchasers of health care to create incentives for physician organizations (POs) to use CMPs and for the government to assist POs in implementing information technology (IT) to facilitate CMP use. Research is lacking about the extent to which POs use CMPs or about the degree to which incentives, IT, or other factors are associated with their use.ObjectivesTo determine the extent to which POs with 20 or more physicians use CMPs and to identify key factors associated with CMP use for 4 chronic diseases (asthma, congestive heart failure, depression, and diabetes).Design, Setting, and ParticipantsOne thousand five hundred eighty-seven US POs (medical groups and independent practice associations) with 20 or more physicians were identified using 5 large databases. One thousand one hundred four of these POs (70%) agreed to participate in a telephone survey conducted between September 2000 and September 2001. Sixty-four responding POs were excluded because they did not treat any of the 4 diseases, leaving 1040 POs.Main Outcome MeasuresExtent of use of CMPs as calculated on the basis of a summary measure, a PO care management index (POCMI; range, 0-6) and factors associated with CMP use.ResultsPhysician organizations' mean use of CMPs was 5.1 of a possible 16; 50% used 4 or fewer. External incentives and clinical IT were most strongly associated with CMP use. Controlling for other factors, use of the 2 most strongly associated incentives—public recognition and better contracts for health care quality—was associated with use of 1.3 and 0.7 additional CMPs, respectively (P

Innovations in care management processes have improved the care of patients with chronic illnesses, but many patients still do not receive these benefits. The authors have studied the barriers and facilitators to implementing these improvements in leading US physician practices About 125 million of the 276 million people living in the United States have some type of chronic illness (table 1).1 Four chronic conditions affect nearly half of Americans with a chronic disease: asthma, depression, and diabetes each affect about 15 million,2–4 while five million have congestive heart failure.5 In 1999 these four chronic diseases were directly responsible for 140 000 deaths in the United States6 and generated at least $173bn (£108bn, €170bn) in medical and other costs. 5 7–9 Over the past decade the effectiveness of care for patients with these and other major chronic illnesses has been improved by innovations in care management processes such as the use of guidelines, disease management techniques, case management, and patient education to improve self management of chronic disease.10 However, many patients are not benefiting from these advances. Recent studies indicate that fewer than half of US patients with asthma, depression, and diabetes receive appropriate treatment.11–13 Organisational characteristics of physician practices associated with effective chronic disease care include the use of patient care teams, supportive information systems, and a high volume of patients.14 Hence, we expect that in the United States moderate and large sized, well organised, multispecialty practices are likely to offer chronic disease care that is as good as it gets and provide other physician organisations with benchmarks against which performance can be measured. #### Summary points

The rise of evidence-based clinical practice in health care has caused some people to start questioning how health care managers and policymakers make decisions, and what role evidence plays in the process. Though managers and policymakers have been quick to encourage clinicians to adopt an evidence-based approach, they have been slower to apply the same ideas to their own practice. Yet, there is evidence that the same problems (of the underuse of effective interventions and the overuse of ineffective ones) are as widespread in health care management as they are in clinical practice. Because there are important differences between the culture, research base, and decision-making processes of clinicians and managers, the ideas of evidence-based practice, while relevant, need to be translated for management rather than simply transferred. The experience of the Center for Health Management Research (CHMR) is used to explore how to bring managers and researchers together and promote the use of evidence in managerial decision-making. However, health care funders, health care organizations, research funders, and academic centers need wider and more concerted action to promote the development of evidence-based managerial practice.

Public health interventions have been developed to increase influenza immunization rates among the high-risk elders and patients suffering from cardiopulmonary, metabolic, and other chronic conditions. The relative effectiveness of alternative intervention strategies is not yet well understood. Determination of the most effective strategy should consider characteristics of the target population and the health care delivery system. This meta-analysis of intervention evaluation studies highlights the importance of considering the baseline immunization rate of the target population in selecting the most effective strategy. While the analysis confirms the feasibility of achieving the 60 percent target coverage established in Healthy People 2000, the results also suggest that as coverage levels increase, single-faceted patient-focused interventions may need to be strengthened by the addition of complementary changes in provider behaviors and/or the delivery system. Further research is needed to identify the most cost-effective combination of intervention strategies, particularly in populations with higher immunization coverage.

Objectives. This study explored whether type of outpatient health coverage affected the likelihood of men and women aged 20 to 64 years receiving recommended cancer screening procedures. Methods. Data from the 1989 and 1990 California Behavioral Risk Factor Surveillance Surveys were used to compare Pap smear, mammogram, fecal occult blood test, and proctoscopic examination rates for adults with three different types of private health care coverage (Group/staff model health maintenance organization, Independent Practice Association Model health maintenance organization, indemnity plan) and no outpatient health insurance. Logistic regression models were used to control for sociodemographic and health characteristics and whether individuals had a usual health care provider. Results. Individuals with Group Model health maintenance organization coverage were significantly more likely than those with indemnity plans to have had recent cervical, breast, and colorectal cancer screening, whereas screening likelihood for those with Independent Practice Association model health maintenance organization coverage did not differ substantially from those with indemnity plans. Individuals with no outpatient coverage were less likely to be screened than those with outpatient coverage. The most consistently significant predictor across cancer screening procedures for both men and women was having a usual doctor who knew their medical history. Conclusions. Adults who had private outpatient insurance were more likely to undergo recommended cancer detection procedures than those who did not. Adults who belonged to a health maintenance organization, which emphasizes and pays for a broader spectrum preventive care, were more likely to receive Pap smears, mammograms, and fecal occult blood tests than those covered by indemnity plans. Receiving care primarily from one doctor significantly increased the likelihood of having screening procedures, irrespective of type of health plan.

This study reports the findings of a case study of the health services planning council established in the Oakland, California, eligible metropolitan area (the Oakland EMA) under Title I of the Ryan White Comprehensive AIDS Resources Emergency Act of 1990 (the CARE Act). We gathered primary data through observation of planning council meetings, examination of documentary evidence, and in-depth interviews with key participants. An important finding of this study was the inconsistency observed between the rational, linear planning model embedded in the CARE Act legislation and the politicized, emergent, and, at times, chaotic planning process actually observed in the Oakland EMA. The primary reasons for this inconsistency included confusion among council members about the planning council's responsibilities and authority, as well as its relationship with the local health department; limitations on administrative support at the local level; reluctance of program administrators at the federal level to provide advice concerning development of the council; allegations of conflict of interest among members of the council; pre-existing societal tensions and divisions; concerns about the representativeness of the council's membership; competition among providers of services for funding; conflicting demands for services by persons affected by HIV disease; disagreements between the council and providers of services over policies and procedures for administering the services contracts; and concerns about the council's involvement in the selection of specific agencies for funding, its lapses in compliance with rules of order, and its failure to accurately record minutes of all of its meetings. Despite the challenges faced by the Oakland planning council, it was able to meet its Title I obligations, which resulted in significant increases in the availability of medical and social services for persons affected by HIV disease. However, dealing with the confusion and conflicts described above consumed a considerable amount of the planning council's time and energy and eventually required a complete reorganization of the council to assure its stability and the legitimacy of the Title I program at the local level. Medical Subject Headings (MeSH): health planning councils; health planning organizations; health care coalitions; organization and administration; organizational innovation; models, organizational.