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Home health care has undergone startling changes in the past decade and, in the process, become a strategically important ingredient of health care delivery. However, the question remains whether home health care organizations can deliver the benefits anticipated for integrated care delivery systems. The answer to this question depends to a great extent on whether home health care organizations build vibrant, visionary leadership capable of transforming organizations and motivating staff to deliver high quality and low cost services. This paper examines a case study of transformational leadership as it relates to the quality of working life for nurses, homemakers, and staff. The findings indicate that leader behavior is strongly associated with homemakers', and to a lesser extent staff members', job satisfaction, job involvement, and propensity to remain with the organization. These job attitudes have been shown to be related to higher job performance. The implications for leadership in home health agencies are discussed. [ABSTRACT FROM AUTHOR]

Research on the effectiveness of clinical mock boards for future oral health professionals is conflicting and limited. Despite this, U.S. dental hygiene programs rely on clinical mock board experiences as essential components for preparing students for their clinical board examinations. Differences in programs' mock board characteristics may relate to board exam outcomes. The validity and reliability of mock boards can be questioned when deviations from exam criteria and procedures are made and grading mechanisms are not consistent. The aim of this study was to determine which mock board characteristics were critical in preparing students by exploring the relationships between programs' dental hygiene, local anesthesia, and restorative mock boards and their 2013-14 candidates' performance on the corresponding three Western Regional Examining Board (WREB) licensure exams. Of the 23 U.S. dental hygiene education programs in four states invited to participate, 15 agreed to do so, and 13 consented to have WREB provide their programs' test result data. The mock board coordinators provided data on characteristics of their programs' mock boards with an online questionnaire distributed in 2014. Scores calculated from the responses were compared to performance of the programs' candidates on the corresponding WREB exam. Of the 45 questionnaires (on three exams each x 15 programs), 33 were completed (73.3%). Significant relationships were found between candidates' WREB exam results and the mock boards' intensity scores, remediation, multiple experiences, and examiner calibration scores. The results of this study provide fundamental information about mock board characteristics that may assist educators in facilitating experiences to more effectively prepare students for these high-stakes exams.

Aim: This was a retrospective cohort study that evaluated the differences in glycated haemoglobin (HbA1c) and body mass index (BMI) in veterans with type 2 diabetes mellitus (T2DM), prescribed exenatide twice daily (BID) versus long-acting insulin analog (LAIA) two years after initiation in the United States (US) veteran population., Materials and Methods: Patients were included if they were ≥ 18 years old with T2DM, and initiated exenatide BID or LAIA at the Veterans Health Administration between January 1, 2006 and December 31, 2010. Multivariate models were used to evaluate the changes in HbA1c and BMI between groups, controlling for potential confounders. Logistic regression was used to evaluate the odds of achieving ≥ 0.5% HbA1c reduction based on baseline HbA1c stratifications: low,<7%; moderate, 7% to<9%; and high,≥ 9%., Results: A total of 446 exenatide BID and 51,531 LAIA patients met inclusion/exclusion criteria. On average, exenatide BID patients were significantly older (64 versus 60 years) with a higher BMI (37.8 versus 32.9 kg/m(2)). Baseline HbA1c was 8.2% and 8.8% for exenatide BID and LAIA patients, respectively (P<0.001); otherwise, patients were similar for all other characteristics. Exenatide BID treatment was significantly associated with a 0.32% (95%CI: 0.18-0.47%) greater reduction in HbA1c at two years compared with LAIA. Similar findings were observed for BMI reduction (0.68 kg/m(2); 95%CI: 0.42-0.95 kg/m(2)). Exenatide BID patients with moderate baseline HbA1c had significantly higher odds of achieving ≥ 0.5% HbA1c reduction compared with LAIA patients (OR=1.5; 95%CI: 1.2-2.0)., Conclusions: Veterans treated with exenatide BID had significantly greater reduction in HbA1c and BMI compared with patients treated with LAIA patients two years after initiation., (Published by Elsevier Masson SAS.)

An exploratory epidemiological study was conducted for 319 deceased nuclear workers who had intakes of transuranic radionuclides and histories of employment during the time period from 1943 to 1995. The workers were employed at various facilities throughout the United States, including the Department of Energy defense facilities and uranium mining and milling sites. The majority of individuals were involved in documented radiological incidents during their careers. All had voluntarily agreed to donate their organs or whole body to the United States Transuranium and Uranium Registries. External and internal dose assessments were performed using occupational exposure histories and postmortem concentrations of transuranic radionuclides in critical organs. Statistical data analyses were performed to investigate the potential relationship between radiation exposure and causes of death within this population due to cancers of the lungs, liver, and all sites combined while controlling for the effects of other confounders. No association was found between radiation exposure and death due to cancer (α = 0.05). However, statistically significant associations were found between death due to any type of cancer and smoking (yes or no) (odds ratio = 5.41; 95% CI: 1.42 to 20.67) and rate of cigarette smoking (packs per day) (odds ratio = 2.70; 95% CI: 1.37 to 5.30).

While safety risks are widespread in ambulatory settings, there has been insufficient attention directed at developing the evidence base that is needed to improve ambulatory safety. In this article, the current state of knowledge about ambulatory safety is reviewed. A research agenda in ambulatory safety is proposed, as well as a series of potential interventions that could be used to improve safety in the ambulatory setting.

The previous three articles in this series discussed relative value unit (RVU) basics and touched on some of the more practical applications of RVUs for managing a medical practice. 1-3 This fourth and final article illustrates the what, why, when, where and how of benchmarking RVUs. Benchmarking is often defined as a standard of measurement or evaluation, but in its truest sense, it is the ongoing process of establishing a standard of excellence and comparing activities to that standard. Health care has yet to establish true benchmarks, but it does have performance indicators for better-performing practices based on several criteria.

Ambulatory care providers are being challenged to deliver high-quality care at low cost with easy access. Patient satisfaction with services hinges on the ability of providers to meet these often elusive benchmarks. This article focuses on the barriers to benchmarking patient relations in ambulatory care organizations and strategies for improving patient relations through internal benchmarking that encourages service innovation and performance emphasis. A case study of programmatic benchmarking in the Lovelace Health System is used to illustrate how patient relations can benefit from establishing internal performance thresholds that guide service delivery. Examples from Lovelace's High Risk Pregnancy Program demonstrate the value of benchmarking efforts. The implications for patient relations benchmarking in other ambulatory care settings are discussed.

Medical groups are vitally interested in achieving better operating margins in view of diminishing revenues and cost increases. The answer to this dilemma is heightened productivity. However, raising the productivity of medical care providers does not just automatically happen. It requires innovative thinking and the courage to instill change in the face of resistance. This article examines several medical manufacturing strategies that might be used by medical groups to improve productivity. These strategies are based on proven approaches in business that have been translated for the health care context.

Managed care plans and other health care providers face a difficult task in predicting outpatient mental health services use. Existing research offers some guidance, but our knowledge of which factors influence use is confounded by methodological problems and sampling constraints. Consequently, available findings are insufficient for developing accurate predictions, which managed care plans need in order to formulate fiscally responsible service delivery contracts. This article reviews the primary data sources and research on ambulatory mental health services. On the basis of this review, the probability and intensity of outpatient visits are estimated. The primary predictors of use are also examined because they may help managed care plans forecast use by a given population or group of enrollees. Gender, age, race, education, health status, and insurance coverage are several variables surfacing as statistically significant predictors of use. The implications for planning capitated mental health services are discussed.

Numerous ideas are constantly surfacing on how to manage organizations better. As health care supervisors familiarize themselves with these concepts and consider implementing new strategies, it is important not to forget the basics. This is especially true when considering staff motivation. The value of demonstrating personal concern, or consideration, for staff is examined from the perspective of transformational leadership. It has been suggested that transformational leaders are visionary and demonstrate concern for individual staff members. The association of leader support for personal concern with enhanced job attitudes is analyzed and then illustrated in several health care supervisor situations. A case study of these relationships is presented for a home health agency. The results point to the value of supervisors actively demonstrating concern for staff.

Total quality management (TQM) has become an integral process in service delivery for many health care organizations. This article reviews the fundamental concepts underlying TQM and how TQM is relevant to health care supervisors. In many respects TQM represents a contemporary approach to supervising innovation and change, to analytically solving customer problems, and to implementing continuous quality improvement. Several strategies are examined that health care supervisors can adopt for improving service quality, including cultivating a climate for innovation, motivating by example, leading staff to do what is right and to tolerate no service delivery errors, retraining staff, developing control systems, and creating barrier-free organizations. These strategies are examined from the perspective of achieving continuous improvement in health care settings.

Few studies have assessed the relationship between hospital administrators' efforts at planning and subsequent performance of health care organizations. Nonetheless, planning is viewed as an important mechanism for aligning health services delivery efforts with community needs and operating constraints. When prospective payment (PPS) was first introduced, hospital administrators had little choice other than to plan how they would respond to the new reimbursement policies. However, it is unclear whether they actively undertook planning in an effort to address prospective payment and related pressures. This article presents a case study of rural New Mexico hospital administrators' efforts to respond to prospective payment. Two dimensions of planning effort by administrators--intensity and formality--are analyzed within rural hospitals during the PPS transition (i.e., 1983 to 1987) and after its full implementation (i.e., since 1988). The findings suggest that planning intensity during the PPS transition is associated with higher performance; notably, higher net patient care revenues, lower costs per patient day, higher operating margins, higher net income, and higher planning effectiveness. However, the strength of these associations weakened as PPS was fully implemented. Given the exploratory nature of this evaluative case study, the results should be viewed as preliminary until confirmed by larger studies. The implications for research that evaluates planning-performance relationships in the health care field are discussed.

Rural hospitals confront an inauspicious environment due to changes in patient reimbursement and medical practice. Facing a situation of declining revenues, marketing presents an option for rural hospitals to adapt to the growing constraints. This paper analyzes the determinants of marketing strategy emphasis in rural hospitals. The conceptual model adopted in this study predicts that prior performance and contextual variables explain marketing strategy emphasis. The relationships are examined in a case study of rural New Mexico hospitals. Results suggest that prior performance and several contextual variables explain variations in marketing strategy emphasis. In particular, higher gross patient revenues are associated with more emphasis on television and radio advertising. Furthermore, rural New Mexico hospitals with high numbers of licensed beds and medical staff members, or that are affiliated with a chain organization, place greater emphasis on market research and market planning. The implications for marketing practice in rural hospitals are discussed.

Despite efforts to deinstitutionalize long-term care, it is estimated that 43 percent of the elderly will use a nursing facility at some point. Whether sufficient nursing facility services will be available to rural elderly is debatable due to cutbacks in governmental expenditures and recent financial losses among nursing facilities. This paper explores the challenges confronting rural nursing facilities in maintaining their viability and strategies that might be considered to improve their longevity. A comparative analysis of 18 urban and 34 rural nursing facilities in New Mexico is used in identifying promising strategic adaptations available to rural facilities. Among other considerations, rural facilities should strive to enhance revenue streams, implement strict cost control measures, emphasize broader promotional tactics, and diversify services commensurate with the constraints of the communities and populations served.

Is strategic planning associated with higher levels of performance in health care organizations? Is strategic planning effective? This article examines strategic planning's impact on rural hospital and rural nursing facility performance, organizational characteristics, and strategy. The findings suggest that strategic planning in rural hospitals is strongly associated with higher profits, operating margins and planning effectiveness, and associated to a lesser extent with lower costs and higher revenues per patient day. However, strategic planning does not appear to be associated with higher performance in nursing facilities. The implications for strategic planning in rural health care organizations are discussed.

A cross-sectional study is used to determine how rural New Mexico hospitals altered service diversification, inpatient service emphasis, and service promotion during Medicare's prospective payment system (PPS) transition and posttransition phases. Results suggest that the hospitals implemented distinct strategies in response to PPS. The posttransition strategies were examined for their association with improved revenue and utilization indicators. Few of the service diversification and promotional strategies were consistent predictors of performance. Emphasis on fine-tuning inpatient services was the most promising predictor of higher utilization and revenue measures. The implications for other rural hospitals are discussed.

Rural hospitals are searching for new strategies to enhance utilization in view of constraints introduced by prospective payment and other environmental pressures. Developing physician relations is an approach that is reportedly leading to better hospital-physician collaboration and subsequently to improved utilization. This paper examines rural hospital-physician relations and the association with utilization. The findings suggest that rural hospitals emphasize quality care as well as diagnostic and treatment equipment procurement as methods for building relationships with physicians. These strategies are correlated with efforts to build a larger medical staff. Higher rural hospital utilization, in terms of occupancy, discharges and patient days provided, is associated with a larger medical staff. The results suggest that rural hospitals' attempts to cultivate physician relations have the potential for making significant differences in utilization outcomes. However, the linkages between utilization and physician relations are complex and require further research.

Movers and shakers often demonstrate capabilities that health care managers should recognize before attempting to build productive relationships with them. First, the charisma associated with outstanding leaders is reflected in superior communication skills and presence. Next, a broad experiential base coupled with penetrating analytical skills allows movers and shakers to earn exceptional authority and power. Third, movers and shakers are able to focus on strategic visions. Movers and shakers work through other team members to select and implement solutions that are consistent with organizational mission statements. Fourth, their entrepreneurial mindset enables them to take calculated risks and design creative solutions in response to formidable challenges. Finally, movers and shakers are not reticent to face facts and make tough decisions. Not all movers and shakers possess all of these characteristics equally. Nor are they all concerned about the same issues. As individuals, they bring differing interests and capabilities to health care organizations. Health care managers may strive to cultivate one or more of these characteristics themselves. Self-improvement begins with identifying personal deficiencies and systematically planning to overcome them. Until health care managers mature into movers and shakers, they can coopt the influence and power associated with movers and shakers. By establishing a trusting relationship and using borrowed power constructively, they can earn the respect and confidence of movers and shakers. A third approach promotes power transfer through a continuing viable relationship. Health care managers may need to use some combination of these methods. Additionally, they can consider tailoring various methods into a coordinated strategy. Health care managers have a variety of promising strategies available for building productive relationships with movers and shakers. Pursuit of these strategies may improve personal prospects and promote the achievement of organizational missions and objectives.

Since the initiation of prospective payment, hospitals have been struggling to develop strategies that improve their prospects for long-run viability. Foremost among these strategy formulations have been efforts to build hospital-physician relations. This article reviews several popular strategies designed to achieve mutually satisfying hospital-physician relations.

Medicare's Prospective Payment System (PPS) has introduced a new environment in which hospitals must either alter their strategies for delivering services or face closure. This is a challenge for rural hospitals that often lack the resources and supportive economic climate of their urban counterparts. Few guidelines are available to assist rural hospitals in responding organizationally to PPS-induced constraints. This article examines the plight of rural hospitals from the perspective of strategic adaptation. A conceptual framework is proposed for studying strategic adaptations to PPS by rural hospitals. The implications for developing a sound research methodology are also discussed. On the basis of this research agenda, it may be possible to clarify how rural hospitals should adapt to PPS (and similar) constraints now, and in the future.

The Veterans Administration and the United States Air Force hospitals in Albuquerque recently established a service- and facility-sharing arrangement. In this article, the authors share lessons learned from planning and executing the arrangement-lessons that any organization considering a large-scale joint venture will want to keep in mind.

Many hospitals and health care organizations are contending with fierce financial and competitive pressures. Consequently, programs that do not make an immediate contribution to master strategy are often overlooked in the strategic management process. Research programs are a case in point. Basic science, clinical, and health services research programs may help to create a comprehensive and fundamentally sound master strategy. This article discusses the evolving role of health care organizations in research relative to strategy formulation. The primary costs and benefits from participating in research programs are examined. An agenda of questions is presented to help health care organizations determine whether they should incorporate health-related research as a key element in their strategy.

Organized in 1922, the Lovelace Clinic successfully provided health care services throughout the Southwest utilizing a group practice format under the aegis of a nonprofit foundation. In 1984, the Foundation contracted with Hospital Corporation of America to form a for-profit health care organization which allows the provision of high quality health care through a group practice professional corporation, a 238-bed inpatient facility, a 70,000-member health maintenance organization, and an independent research and education foundation.

There is growing public and corporate interest in health promotion programs. Available literature suggests that health promotion may contribute to greater longevity and life satisfaction while resulting in lower health care costs. Allied health professionals are perfectly positioned to make the difference between a successful or unsuccessful health promotion effort, whether in their own lives or in the lives of patients. However, allied health professionals need to commit themselves to making behavior changes to improve their own health so that they can effectively assist patients in making similar changes. These ideas are demonstrated through a study of an employee health promotion program for allied health professionals in a health maintenance organization.

This article examines whether merger with an investor-owned chain is beneficial to nonprofit hospitals. Drawing on the experience of Lovelace Medical Foundation, a hospital-based group practice in Albuquerque, New Mexico, in its merger with the Hospital Corporation of America, this article describes the uncertainty that accompanies a merger, elucidates specific concerns of nonprofit hospitals about loss of autonomy to a large corporation, and sets guidelines for making sure most anticipated fears fail to materialize as a result of premerger planning.

In brief, Obstetrics, like many other medical specialties, is experiencing the convergence of a number of diverse medical, social and economic trends. As a result there is increasingly intense turmoil in how these services are clinically delivered and in how they are managed--with a profound shift from basically inpatient, institutional care to outpatient care. Hospital executives must be alert to these changes if they expect their clinics and inpatient facilities to remain competitive and to deliver the best possible care under a rapidly changing set of expectations. If executives fail to recognize these pressures and thereby fail to create timely strategic reactions, their organizations may subsequently experience poor long run performance. The issue in obstetrics is not merely one of determining how best to manage obstetrics-related clinics, programs or departments; although this is a significant hospital management problem, it is important to recognize the changes and prevalent patterns, and to begin devising responsive management strategies. See strategies below.

Within medicine there is growing uneasiness and debate about changes in medical care delivery. Much of this concern centers on the evolution of organizations and the role of physicians. The emergence of multi-institutional organizations, the rise of investor-owned health care corporations, and the expansion of group medical practice illustrate the increasing organizational influence in medicine. Added to these trends are new financial incentives confronting both physicians and organizations so that the environment increasingly favors conflict. This article reviews the primary strategies for resolving physician-organization conflicts, including cooperation between physicians and organizations, having physician representatives in governance and management, restructuring incentives, and restructuring organizations. Although these strategies have various merits, we suggest that every physician has a personal responsibility to become more involved in organization and management issues. Physicians can play an important role in guiding the evolution of medicine.