The New Health Care for Profit Doctors and Hospitals in a Competitive Environment (1983) / Chapter Skim
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Physician Involvement in Hospital Decision Making
Physician Involvement in Hospital Decision Making
Pages 73-102
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From page 73... ...
In brief, "micro" decisions involving individual clinical judgment and "macro" decisions involving larger organization-wide resource allocation and policy issues are highly interrelated. The nature of physician involvement in hospital decision making must be understood within this context.
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From page 74... ...
For example, a hospital that becomes part of an investor-owned chain may find its physicians more actively involved in hospital governing board activities than previously. The fourth theme is that decision making may be moving away from the "dual authority" model of split administrative and clinical decisions to a more "shared authority" model based on increasing collaboration between administrators and physicians.
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From page 75... ...
Fourth, evidence bearing on the relationship between physician/hospital decision making and the cost and quality of care is summarized. Finally, a number of future issues influencing physician/hospital decision making are discussed.
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From page 76... ...
These are situations where the efficacies of decisions are known but where there are insufficient funds to implement all of them. Compromise decisions are a major area of physician involvement in hospital decision making, as each specialty group strives to maintain or expand its scope of responsibility.
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From page 77... ...
Physician Involvement in Hospital Decision Making 77
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From page 78... ...
Although it provides some insight, the typology described above is oversimplified. At least two other sources of complexity appear to be important in understanding the nature of the hospital decision-makTABLE 2 Examples of Physician/Hospital Decisions 1.
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From page 79... ...
Physician Involvement in Hospital Decision Making 79
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From page 80... ...
As such, in voluntary hospitals the decision-making process may be somewhat more complex and indeterminate than in investor-owned hospitals. In general, hospitals belonging to a multi-unit system seem likely to be more involved in computational and judgmental decisions than are freestanding individual hospitals.
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From page 81... ...
Thus, as previously noted, hospitals' efforts to expand their ambulatory care activities may meet medical staff opposition because of fear of direct competition for patients and hospital beds.2 Opposition may also be based on philosophical objections to the "corporate practice of medicine." Regulations or changes in payment also can create conflict rather than representing the "common enemy" against which hospitals and physicians can unite. For example, limiting hospital revenues by reimbursing on a case-mix basis may create conflict between a hospital's economic interests and the physicians' economic and professional interests.
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From page 82... ...
Nurses are striving to become more involved in all of these areas. From this general description, it is possible to highlight two general "models" of decision making in hospitals: the dual authority mode} and the shared authority model.
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From page 83... ...
Third-party payers recognize this separation in the form of separate payment policies for ambulatory care versus inpatient care. In brief, although hospitals and physicians are in fact involved in a joint production process, they are largely organized as separate entities; therein lies much of the difficulty in hospital decision making as it pertains to the allocation of scarce resources.
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From page 84... ...
This responsibility can be delegated to the medical staff, but the final accountability resides with the hospital and its governing board. Although subsequent cases have modified and refined this landmark ruling, it has resulted in a fundamental change in the behavior of hospital administrators and trustees toward physicians in regard to establishing institutional accountability for physician behavior.
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From page 86... ...
M "Theory Z.: Implications and Relevance for Health Care Management." Health Care Management Review 7 (Fall 1982)
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From page 87... ...
Types of Physician Decision-Making Involvement Decision-making involvement takes two primary forms: formal and informal. The principal modes of formal physician involvement in hospital decision making are participation in meetings of the board of trustees and in the committee structure of the board, the administration, and the medical stab itself and in hospital/physician compensation arrangements whereby the physician is economically tied to the hospital's welfare.
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From page 89... ...
Arrangements whereby physicians are compensated by hospitals are more often found in teaching hospitals than in nonteaching hospitals.20 They also are more common in for-profit hospitals than in voluntary hospitals.2i Systematic longitudinal data are not available, but a general reading of the literature and conversations with hospital administrators and medical staffs suggest that physician involvement in governing board activities, participation in committees, and hospital-based compensation arrangements is growing. For example, over the past five
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From page 90... ...
This is another area for future research. Evidence Regarding Costs A number of studies have examined the relationship between various aspects of physician involvement in hospital decision making and cost of care.22 These studies generally indicate that the more aware physicians are of the organization's performance and the greater the number of scheduled meetings between such key clinical and patient care departments as radiology, laboratory, and nursing service, the lower the costs will be in specific medical support departments.
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From page 91... ...
The percentage of hospital-based physicians on contract also has been found to be positively associated with lower costs per admission, and physician presence on the executive committee of the governing board also is associated with lower costs per admission.24 91 Evidence Regarding Quality A number of investigators have examined how the relationship between physicians and hospitals may affect the quality of patient care.25 In general, these studies suggest that greater physician participation in hospital decision making is positively associated with higher quality of care, as measured by such indicators as severity-adjusted death rates and postsurgical complication rates. There is also evidence that the greater the hospital administrators' ability to influence decisions within their domain, the higher the quality of care.26 Others have found positive relationships between quality of care and more highly structured medical staffs, as measured by appointment procedures, number of control committees, and percentage of physicians on contract.27 Morlock et al.
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From page 92... ...
The possible demise of the traditional voluntary medical staff organization can be foreseen. It then becomes possible to consider the factors that either promote or constrain the movement toward more shared, collaborative decision-making models.
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From page 93... ...
Continued advances in technology require continual rethinking of diagnostic and treatment protocols and clinical decision-making rules. This increases the rate of change and uncertainty, which in turn leads to greater specialization of function and greater competition among specialties.
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From page 94... ...
The Changing Context of Institutional Decision Making Not only are hospitals under increased public scrutiny because of the continuing rise in costs, but it also seems likely that hospitals will remain under such scrutiny permanently. This is not only because of the continued concern regarding the cost-effectiveness of patient care but also because hospitals, individually and collectively, have taken on more characteristics of industrial enterprises central to the American economy.
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From page 95... ...
The Demise of the Voluntary Medical Staff Fundamental changes in the structure of medical staff organization may be taking place already. A growing number of physicians are affiliating with hospitals as a cost-effective way of starting practices, a growing number of speciality-trained physicians are contracting with one or more hospitals to deliver secondary and tertiary care services, and a growing number of hospital medical staffs are entering into HMO arrangements of various forms.35 As the predicted physician
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From page 96... ...
Hospital reimbursement based on case mix also may require more collaborative decision making as such reimbursement requires administrative and cost data to be integrated with clinical data. Third, as physicians become more closely aligned to hospitals, they may demand greater participation in hospital-wide decision making than they currently have through traditional medical staff organization channels.
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From page 97... ...
Joint decision-making involving medical staffs will need to be developed to gain their participation in an acceptance of change in institutional procedures.36 On the other hand, several factors could impede the development of shared decision-making models. First, increased physician competition, resulting from the developing surplus of physicians, could result in more physicians offering services in direct competition with hospitals.
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From page 98... ...
Evidence regarding the association of more shared decision-making models and the cost and quality of care was summarized. A number of issues pertaining to the changing context of clinical and institutional decision making were presented, suggesting that some fundamental changes may take place in the structure of hospital medical staffs.
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From page 99... ...
Although both types of hospitals may be shifting toward a more shared authority model, investor-owned hospitals may be able to make the adjustment more quickly and easily because of the greater degree of agreement on overall goals and the history of physician involvement in decision making at the governance level of the organization. But it is also important to note that the above differences and their implications may be attenuated by some growing similarities between for-profit and voluntary hospitals in their economic orientations.
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From page 100... ...
"Measuring Hospital Medical Staff Organization and Structures." Health Services Research 14 (Summer 1979)
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From page 101... ...
Horn. "Decision-Making Patterns and Hospital Performance: Relationships Between Case Mix Adjusted Mortality Rates and the Influence of Trustee, Administrators, and Medical Staff in Seventeen Acute Care General Hospitals." Medical Care, in press; Holland, P
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