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This study examined whether outpatient haemodialysis providers changed their treatment practices with the establishment of an outpatient dialysis global budget (ODGB) through analysing the outpatient visits and medication received by those patients. A sample of 4668 observations (patient year) of 1350 haemodialysis with hypertension (HH) patients and 4668 observations of 1436 non-HH (NHH) patients were drawn from the National Health Insurance Research Database over the years from 1999 to 2005. The impact of ODGB on hypertension-related outpatient utilization of HH was estimated using the difference in difference (DID) method and examined in three stages: (1) the fee for service stage, the pre-ODGB (2000), (2) the phase-in stage (2001-2002) and (3) the post-ODGB stage (2003-2005). ODGB implementation did not affect the number of dialysis visits for HH patients. However, it did lead to a reduction in fees for antihypertension drugs used by haemodialysis facilities. There was an increase of 4.06 visits per patient per year (P < 0.001) in the number of non-dialysis outpatient with antihypertensive drugs visits for HH patients compared with the control group. The total fees for antihypertensive drugs for HH patients increased by New Taiwan Dollars (NT$)13 008 (P < 0.001) per patient per year relative to the control group after the implementation of ODGB. As ODGB was implemented, HH patients received fewer antihypertensive drugs during their dialysis visit. In addition, there was an increase in the number of non-dialysis outpatient visits by HH patients as well as increased payment in the drugs associated with their non-dialysis outpatient visits compared with the control group.

Background: High-performing and high-reliability teams are an important component of service delivery. With a focused emphasis on safety in acute care hospitals, understanding the nature of surgical teams and team performance is an essential component to achieving high-quality surgical care. More information is needed about the challenges to effective team functioning in the operating room, the influence of working conditions, and the environmental context on surgical team performance. Purpose: The purpose of this study is to describe the nature of surgical teams and how they perform in the operating room to contribute to a broader knowledge about high-performing and high-reliability teams in health care settings. Methodology/Approach: We conducted a qualitative study involving direct observation and semistructured interviews. Field observations of 10 high-complexity surgeries and face-to-face interviews with 26 members of surgical teams were completed at one university medical center. A conceptual framework derived from the literature was developed to guide the selection of surgeries and surgical teams to be observed. Data were transcribed and analyzed to identify the factors and different conditions that influence the performance of these surgical teams. Findings: The type of coordination and the degree of independent and interdependent coordination vary among the seven observed stages of the surgical process. Most of the surgical teams were ad hoc teams and as such, further challenged by consistently frequent \"hand-offs\" for break relief. Additional role demands influence the situational dynamics which can alter the adaptive capacity of the team. Practice Implications: The surgical event evokes a changing degree of coordination and adaptation to complexity and uncertainty. In such environments, relational coordination through leadership can contribute to a successful surgical result, improvement of the overall process, including error reduction, and enhanced knowledge creation and dissemination, particularly germane in research university teaching hospitals.

When a natural disaster occurs, the media directs the public’s attention to the key elements of disaster management and provides accounts of how effective the government is in responding to it. This study analyzed 80 reports contained in 21 stories published in three international newspapers and 35 editorial statements from 21 editorials obtained from two national papers regarding the Japanese government’s responses to the great Hanshin-Awaji earthquake. Issue clusters for different levels of government responding to the crisis were identified. The lack of systematic reactions to the crisis provoked the most media scrutiny. The legitimacy of the government’s behaviors in this area were perceived more negatively by the media than were the inappropriate behavior of elected officials or the lack of care expressed towards the victims by local officials.

Due to competition and managed care, hospitals have argued that the rate of increase in hospital cost is greater than the rate of increase in hospital revenue. It is important to pay hospitals based on the expected resource use of patients that hospitals treat. However, managed care organizations pay hospitals based on negotiated prices that do not consider the expected resource use of patients. The purpose of this paper is to provide a better understanding of those factors affecting hospital cost and revenue in California using the hospital financial and utilization data for selected years from 1986 to 1998. By developing case mix indexes (CMIs) using all hospital discharges in California, this study found that the coefficients for CMIs in total and inpatient hospital revenue models were greater than those in hospital cost models. Over time, however, the differences in coefficients for CMIs in hospital revenue and cost models become smaller and smaller. Thus, this study shows that the difference between hospital revenues and hospital costs, looking at hospital case mix, has decreased, although hospital revenues are still greater than hospital costs.

Despite several decades of government efforts, systems of service delivery to populations with multiple problems remain fragmented and poorly organized. Since the delivery of services to persons with multiple problems often requires the coordinated efforts of several providers in different delivery sectors, the authors argue that a network perspective helps policy-makers and public administrators understand the patterning of relationships between and among these providers. Using an analysis of service delivery systems for older persons in a major urban setting, the authors show how policy-makers and public administrators can use network methods to improve their understanding of the complexity of most human service delivery programs, Findings from this study suggest that, through a focus on the exchange patterns that evolve within and between organizations, an improved understanding of the roles that different organizations play in the service delivery effort can be achieved.

While there is considerable evidence supporting the relationship between job satisfaction and organizational commitment, the relationship between the antecedents of job satisfaction, organizational commitment and career commitment are not clearly understood. This study seeks to clarify whether these antecedents have an effect independent of job satisfaction on career commitment or whether these antecedents are mediated by job satisfaction. In total, 2,799 questionnaires were mailed out to members of the American College of Healthcare Executives (ACHE). The responses received were 643 (22.9 percent) and after eliminating retirees or students, a sample of 456 respondents currently employed in the health care industry was obtained. Path analysis was conducted to test the hypothetical relationships between work situation, career experiences and career commitment. It was found that job satisfaction mediated the influences of job tenure and career pattern on career commitment. Job satisfaction partially mediated the influences of perceived job security and one's satisfaction with career on career commitment. Both of these measures had a direct influence on career commitment. Career experience such as sector change was also positively associated with career commitment. While the research offers some insights into the factors affecting the career commitment of health care executives, the sample was limited to respondents who were members of the American College of Healthcare Executives, and thus may not represent the views of all managers in the health care sector. To retain high-valued health care workers it is important that an organization has a work environment that enhances their commitment to their occupation as well as their careers. This study clarifies the influence of job satisfaction on the career commitment of health care managers during a very dynamic period.

Monkey wrench or helping hand? Are the efforts of interest groups and policy advocates constraining health and social service organizations from responding to changing client needs and expectations? Robert C. Myrtle and Kathleen H. Wilber claim that they do. Furthermore, they claim that these constraints have created a dynamic where \"trying harder to make the delivery system work\" has become a driving force in efforts to improve service delivery. Yet, despite continued efforts, improved functioning of delivery systems remains an illusive ideal. Using the example of the delivery of services to the elderly, they argue that unless policy makers and advocates begin to focus on the dynamic relationships among organizations, inter-organizational fields, and service delivery networks, systems development will continue to be an unobtainable and perhaps even a dysfunctional goal. Without a better understanding of transactional relationships between service delivery components, the authors argue, health and social service organizations will continue \"to try harder to do better\" rather than inventing innovative ways to meet the needs of multiproblem persons.

The use of rehabilitative care has increased greatly. This study evaluates whether managed care affects health outcomes among Medicare orthopedic patients receiving rehabilitative treatments. Managed care versus fee-for-service patients had better outcomes at four months following discharge from skilled nursing facilities. It is important to address predictive factors, such as age, length of hospital stay, debilitation and social living arrangements, which can also influence health outcomes when planning rehabilitative treatment for older patients.