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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.

In health care, a high-emotion service, unintended consequences can be especially problematic. People’s physical, psychological, and financial well-being—even their lives—are at stake. As scientific, technological, and demographic changes make health care a much more complex service to deliver, efforts to anticipate, avoid, and correct unintended consequences become more crucial. Using narrative examples and an extensive review of the data and the literature, we explore these efforts in four domains of U.S. health care: (1) the increasingly widespread, often challenging use of electronic health records; (2) the threat to the patient-clinician relationship from a greater, sometimes narrow emphasis on productivity metrics; (3) the culture of medicine’s frequently misguided prioritizing of treatment over true healing; and (4) the overreliance on family caregivers who are often poorly prepared to care for the seriously ill. We then apply lessons from health care’s unintended consequences to non-health-care services and suggest opportunities for service researchers to contribute to improving health care delivery, a service that all of us need.

PurposeThe purpose of this article is to highlight the importance of the foundational construct of “connection” in linking design and service in performing vital functions in the healthcare sector. “Connection” facilitates patients receiving life-saving and life-improving care at the right time, in the right place, in the right way.Design/methodology/approachThis article discusses various design-improvement initiatives making clear that healthcare, like any labor-intensive service delivered to people, is a human endeavor whose systems and features can be materially and cleverly enhanced once their intricacies are analyzed, understood and then redesigned to move closer to excellence.FindingsBy designing connection into healthcare and thinking holistically about the needs and preferences of users (patients), the functionality and the appeal of healthcare services can be enhanced.Originality/valueThe gap between the service that healthcare aims to deliver – and what it actually delivers – is unacceptably large. This article calls for incorporating connection through design into healthcare as a way to bridge this gap.

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...

Healthcare is a service setting where meeting the needs of customers (patients and their families) is uniquely challenging. But the necessity, complexity, cost, and high-emotion nature of the service, as well as technological advances and competitive dynamics in the industry, make the imperative for service innovation in healthcare especially urgent. Forward-thinking healthcare institutions around the United States are succeeding in establishing a value-creating innovation culture and in implementing operational and strategic service innovations that benefit them and their stakeholders. They view continuous innovation as a non-negotiable goal, prize institutional self-confidence, and include patients and families on the innovation team. Cancer care, in particular, faces a pressing need for service innovation, and some progressive oncology centers are demonstrating what is possible to improve the patient and family service experience. The imperatives, now, are for service innovation to become part of the fabric of how all healthcare institutions, not just the groundbreakers discussed in this article, operate—and for academics in the field of marketing to play a crucial role in that effort.

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 nuts and bolts of planning and designing cancer care facilities—the physical space, the social systems, the clinical and nonclinical workflows, and all of the patient-facing services—directly influence the quality of clinical care and the overall patient experience. Cancer facilities should be conceived and constructed on the basis of evidence-based design thinking and implementation, complemented by input from key stakeholders such as patients, families, and clinicians. Specifically, facilities should be designed to improve the patient experience, offer options for urgent care, maximize infection control, support and streamline the work of multidisciplinary teams, integrate research and teaching, incorporate palliative care, and look beyond mere diagnosis and treatment to patient wellness—all tailored to each cancer center’s patient population and logistical and financial constraints. From conception to completion to iterative reevaluation, motivated institutions can learn to make their own facilities reflect the excellence in cancer care that they aim to deliver to patients.

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.

Patients with cancer who live at home often require help with activities of daily living, basic medical care (eg, injections), social needs, and patient advocacy. Most of that support comes from intimate caregivers, typically members of the patient’s family. These family caregivers themselves require support so that they can be effective and maintain their own well-being while caring for the patient with cancer. Research shows that support for caregivers contributes to achieving these goals. We propose a four-part framework for supporting family caregivers: (1) assess caregivers’ needs using formal measures, just as the cancer patient’s own needs are assessed, (2) educate caregivers for their caregiving roles, most notably, with training in the low-level medical support that cancer patients require at home, (3) empower caregivers to become full-fledged members of the patient’s cancer team, all working toward common goals, and (4) assist caregivers proactively in their duties, so that they retain a sense of control and self-efficacy rather than having to react to imminent medical crises without sufficient resources at their disposal. Funding support for family caregivers requires refocusing on the overall well-being of the patient-caregiver dyad rather than just on the patient. It will necessitate a paradigm shift in reimbursement that recognizes the need for holistic cancer care.

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

To improve understanding of how people diagnosed with cancer perceive the term "cancer survivor" and what influences those perceptions.Patients' reactions to the term were surveyed quantitatively and qualitatively.Women who have primarily experienced breast cancer belonging to The Dr. Susan Love Research Foundation's Army of Women.An online survey including fixed-alternative and open-ended questions.Using the blanket term "survivor" to label a diverse group is problematic; although the term offers a positive identity for some, others reject it or find it offensive, at least for patients like those represented in this study. If cancer patients are going to be labeled, they should choose the one that is most empowering and reflective of their experience. Implications for Psychosocial Providers: Language used in providing care or describing patients is controllable. If evidence exists that a particular term has the potential to inflict psychological harm, why use the term?

The author of this commentary discusses service guarantees and how they could be used in the field of health care to strengthen an organization's culture of service excellence and elevate individua...

Purpose “Big Ideas in Services Marketing”, published in 1987, identified seven precepts fundamental to the just emerging field; this paper aims to explore the relevance of these ideas three decades later and discuss what should be changed and what should be added. Design/methodology/approach Deep reflection on the central ideas proposed in a paper written 30 years ago through the lens of the author’s personal research and learning journey was the basis for preparing this retrospective essay. Findings The seven ideas presented in the original paper have stood the test of time although one of the seven “services branding” was incompletely developed. After 30 years, four more ideas need to be added, i.e. competing on value, meeting and exceeding customers’ expectations, saving customers’ time and effort, and generosity. Originality/value The proposals in the 1987 paper offered an early framework for consideration by scholars who have produced a worthy body of work and brought services marketing into its own as a legitimate discipline.

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.

Personal well-being of service employees and others is declining, yet well-being is likely to influence on-the-job productivity. Workplace wellness programming (WWP) is prevalent among service organizations, but is controversial with critics questioning the appropriateness and efficacy of employer involvement in personal health. To understand how employers engage employees in personal wellness, we conducted a qualitative field study of WWP in 10 diverse organizations. We found lower employee engagement and higher resentment in firms that relied primarily on wellness training, incentives, and impersonal communications. Employee engagement was higher in firms that collaborated with wellness-minded employees to (1) tap into long-standing, deeply held belief systems to forge an inspirational wellness ideology, (2) leverage social capital to recruit participants and resources, and (3) modify the physical environment to signal the importance of healthful behaviors and to reduce obstacles to healthful choices. The three strategies are pillars of social movement (SM) organization. Drawing on the rich SM literature and our fieldwork, we developed and tested an SM-inspired model for cultural and behavioral change. The findings have implications for internal marketing and social marketing theory and for managers seeking to create a culture of health and improve employee productivity and effectiveness in serving customers.

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

This study focuses on the mechanisms by which professional service providers effectively influence customers to adhere to their expert guidance and advice. Eliciting customer adherence is a critical concern for professional service firms since customers of these need-based (rather than want-based) services are often reluctant to adhere, and nonadherence can result in serious negative consequences to customer well-being and firm resource utilization. The study examines this scenario by developing a conceptual framework that integrates the following three theoretical areas: professional services theory, advice utilization theory, and social cognitive theory. The framework proposes associations between professional service provider actions and customer reactions, including adherence to expert advice, adherence intentions, and organizational resources needed to serve the customer (time cost and monetary cost). The study empirically tests the hypothesized relationships based on professional service provider-customer (physician-patient) interactions in a large health care organization setting using both primary survey data and objective, longitudinal customer data encompassing a 48-month period. Results indicate that advice giving frequency and focus on negative consequences impact customer outcomes and the effects are moderated by perceived customer efficacy and service provider efficacy. The findings shed light on the underlying dynamics of customer adherence to advice in professional service settings and provide guidance as to how that adherence can be effectively elicited.

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

A framework for improving health care service quality was implemented at a 12-provider family medicine practice in 2010. A national patient satisfaction research vendor conducted weekly telephone surveys of 840 patients served by that practice: 280 patients served in 2009, and 560 served during 2010 and 2011. After the framework was implemented, the proportion of "excellent" ratings of provider service (the highest rating on a 5-point scale) increased by 5% to 9%, most notably thoroughness (P = .04), listening (P = .04), and explaining (P = .04). Other improvements included prompt test result notification and telephone staff courtesy (each by 10%, P = .02), as well as teamwork (by 8%, P = .04). Overall quality increased by 10% (P = .01), moving the practice from the 68th to the 91st percentile of medical practices in the research vendor's database. Improvements in patient satisfaction suggest that this framework may be useful in value-based payment models.

In 2005, a patient we'll call Don was diagnosed with an advanced oral cancer. He received a grim prognosis citing "immediate surgery" as the best option, even though it would have rendered Don unable to speak. Don sought a second opinion at Mayo Clinic, where a team of three cancer specialists met with him. They recommended radiation and chemotherapy but not surgery. Don and his wife temporarily moved 1,000 miles to Rochester, Minnesota, where he endured three tough months of treatment at Mayo. Today, Don is cancer free; he returns to his original Mayo team for annual checkups.Don had access to high-quality, efficient care, the main goal envisioned for accountable care organizations (ACOs). Often lost in discussions of healthcare reform and the ACO concept is the most serious disease afflicting American healthcare; fragmentation. Many intractable problems related to quality, access, and cost result from the walls-physical and otherwise-separating medical organizations, specialties, departments, buildings, and payment systems. The antidote to fragmentation is integration-not the kind bom of mergers and acquisitions but the type that results from teamwork that leverages experience, information, and technology to provide value for the patient.MAYO'S TEAM-BASED MODELMayo Clinic is a nonprofit, integrated, multispecialty medical practice with more than 60,000 employees. It operates three main campuses in Minnesota, Arizona, and Florida and a community network of clinics and hospitals called the Mayo Clinic Health System.Mayo performs well on quality measures such as readmissions, complications, infections, resource use, and survival rates (Consumer Reports, 2013; Leapfrog Group, 2012) as well as on affordability. According to the Dartmouth Atlas of Healthcare 2008, the cost for the last two years of a patient's life at one leading academic medical center was $93,000; at Mayo it was $53,000 (Wennberg, Fisher, Goodman, & Skinner, 2008). Patients appreciate their overall experience at Mayo, and more than 90% of them voluntarily share favorable word-of-mouth feedback with others (Berry & Seltman, 2008).Mayo Clinic's success derives largely from its commitment to two core values; "The needs of the patient come first" (an aspirational value) and "team-based medicine" (an implementational value) (Berry & Seltman, 2008). An organization's core values are the ideals and principles that shape the behavior of people in the institution, and Mayo's values lie at the heart of its ability to demonstrate positive results.More than 100 years ago, the Mayo brothers imagined a healthcare environment that was much different from the provision of care in their day. Rather than individual doctors proudly entrenched in their own practices and beholden to no one, the Mayos envisioned physicians of many specialties working together with only their patients' well-being to consider. Teamwork was demanded, not simply encouraged. Sharing knowledge was a requirement, not a hope. Integration around the patient's best interest was uncompromising. The Mayos insisted on a fixed salary for physicians so they would have no incentive to provide any more or any less care than the patient required (Clapesattle, 1941).Patients who come to Mayo Clinic with complex medical conditions benefit from the pooling of knowledge within the organization that is relevant to their care-they get the benefit of an integrated team. Despite its many strengths, Mayo isn't perfect. However, a medical organization that has thrived for 150 years and earned worldwide recognition offers valuable lessons-especially on teamwork.CAN ACOs FOSTER GENUINE TEAMWORK?Many health policy analysts and the Centers for Medicare & Medicaid Services view ACOs as keystones to delivering U.S. healthcare effectively and efficiently by promoting collaborative, coordinated care across multiple providers and organizations (Berwick, 2011). …

Service innovativeness, or the propensity to introduce service innovations to satisfy customers and improve firm value at acceptable risk, has become a critical organizational capability. Service innovations are enabled primarily by the Internet or people, corresponding to two types of innovativeness: e- and p-innovativeness. The authors examine the determinants of service innovativeness and its interrelationships with firm-level customer satisfaction, firm value, and firm risk and investigate the differences between e- and p-innovativeness in these relationships. They develop a conceptual model and estimate a system of equations on a unique panel data set of 1049 innovations over five years, using zero-inflated negative binomial regression and seemingly unrelated regression approaches. The results reveal important asymmetries between e- and p-innovativeness. Whereas e-innovativeness has a positive and significant direct effect on firm value, p-innovativeness has an overall significantly positive effect on firm value through its positive effect on customer satisfaction but only in human-dominated industries. Both e- and p-innovativeness are positively associated with idiosyncratic risk, but customer satisfaction partially mediates this relationship for p-innovativeness to lower this risk in human-dominated industries. The findings suggest that firms should nurture e-innovativeness in most industries and p-innovativeness in human-dominated industries.

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.”

A data-driven, comprehensive model for improving service and creating long-term value was developed and implemented at Mayo Clinic Arizona (MCA). Healthcare organizations can use this model to prepare for value-based purchasing, a payment system in which quality and patient experience measures will influence reimbursement. Surviving and thriving in such a system will require a comprehensive approach to sustaining excellent service performance from physicians and allied health staff (e.g., nurses, technicians, nonclinical staff). The seven prongs in MCA's service quality improvement model are (1) multiple data sources to drive improvement, (2) accountability for service quality, (3) service consultation and improvement tools, (4) service values and behaviors, (5) education and training, (6) ongoing monitoring and control, and (7) recognition and reward. The model was fully implemented and tested in five departments in which patient perception of provider-specific service attributes and/or overall quality of care were below the 90th percentile for patient satisfaction in the vendor's database. Extent of the implementation was at the discretion of department leadership. Perception data rating various service attributes were collected from randomly selected patients and monitored over a 24-month period. The largest increases in patient perception of excellence over the pilot period were realized when all seven prongs of the model were implemented as a comprehensive improvement approach. The results of this pilot may help other healthcare organizations prepare for value-based purchasing.