Health Services Management: A Case Study Approach, Eleventh Edition

by Ann Scheck McAlearney

Overview

Instructor Resources: Instructor’s Manual
 Today’s healthcare managers face increasingly complex challenges and often must make decisions quickly. When a difficult situation arises, managers can no longer simply “look it up” online or in the management literature. Properly “looking it up” involves knowing where and how to look, appropriately framing a research question, weighing valid evidence, and understanding what is required to make proposed solutions work.

Health Services Management: A Case Study Approach offers a diverse collection of case studies to help readers learn and apply key concepts of management, with an emphasis on the use of evidence in management practice. The case study authors, many of whom are practitioners or academics who work closely with practitioners, present realistic management challenges across a variety of settings. They examine potential responses to those challenges by health services managers and other stakeholders, and they provide a platform for meaningful discussion of opportunities and constraints for management decision makers attempting to implement change.

This edition includes 60 case studies—32 of which are brand new—arranged thematically into six sections: The Role of the Manager, Control, Organizational Design, Professional Integration, Adaptation, and Accountability. The new cases include the following:

• Better Metrics for Financial Management
• What Makes a Patient-Centered Medical Home?
• Doing the Right Thing When the Financials Do Not Support Palliative Care
• Hearing the Patient Voice: Working with Patient and Family Advisers to Improve the Patient Experience
• Managed Care Cautionary Tale: A Case Study in Risk Adjustment and Patient Dumping

Learning by example is one of the oldest forms of learning, and the case study approach offers a time-tested way for students and healthcare professionals to develop practical skills that are not easily acquired through lectures. Health Services Management has been used in classrooms since 1978, and this eleventh edition offers a fresh take on a classic text.

Product Details

ISBN-13:	9781567939095
Publisher:	Health Administration Press
Publication date:	09/01/2017
Series:	AUPHA/HAP Book
Edition description:	None
Pages:	460
Product dimensions:	7.20(w) x 10.30(h) x 1.10(d)

About the Author

Ann Scheck McAlearney, ScD, MS, is professor of family medicine and vice chair for research in the Department of Family Medicine at the Ohio State University (OSU) College of Medicine. She also holds courtesy appointments at OSU as professor in the Division of Health Services Management and Policy in the College of Public Health and as professor of pediatrics. In 19 years at OSU, Dr. McAlearney has taught a variety of courses in organizational management, leadership, and strategic management for master’s and doctoral-level students, as well as a course on healthcare organization and financing for medical students. She has over 25 years of health services research experience and has authored more than 200 peer-reviewed publications, 10 books (many coedited), and 80 book chapters. Dr. McAlearney received her bachelor of arts and sciences degree in English and biological sciences from Stanford University, her master of science degree in biological sciences also from Stanford, and her doctor of science degree in health policy and management from Harvard University’s School of Public Health.

Read an Excerpt

CHAPTER 1

PART I

THE ROLE OF THE MANAGER

A leader is best When people barely know that he exists Not so good when people obey And acclaim him, Worst when they despise him. Fail to honor people, They fail to honor you; But of a good leader, who talks little, When his work is done, his aim fulfilled, They will say, "we did this ourselves."

— Lao Tzu

COMMENTARY

Managers work with others to achieve organizational goals. The aspect of this work that they have the greatest control over is their own behavior in relation to their work with others. The cases presented in part I of this book all deal with aspects of the manager's role. This role is determined by what the organization expects the manager to do. Managers do what they are supposed to do, what they want to do, and what they can do.

These cases deal with the following topics: hiring a new manager, firing an existing manager, making decisions as a management team, developing the manager's own career, scoping out a managerial job after the manager has already accepted it, setting priorities for starting out on a management job, recognizing the manager's influence on employee morale, handling conflict among those reporting to the manager, and evaluating performance before promoting a worker to manager.

What Do Healthcare Managers Do?

Managers of healthcare organizations (HCOs) confront reality, develop agendas and networks, and strategize. They work with and react to other managers. Because they generally lack ownership of the firm, healthcare managers are often risk averse. They worry about their own survival as well as goal attainment. They negotiate trade-offs between improving patient care or keeping it from deteriorating, breaking even financially or operating at a profit, and controlling clinician dissatisfaction or engaging clinicians in the organization's mission.

Healthcare managers address a variety of challenges. Purchasers demand low prices, documented quality, and responsive services, and competition — whether from existing or new organizations — may be increasing. HCOs primarily provide medical care, yet a growing emphasis has been placed on efforts to improve population health — whether or not such efforts contribute to the bottom line or have been scientifically validated.

Clinicians may regard managers primarily as "support staff," and they may consider working with managers or meeting at a manager's direction a waste of time relative to the important work of providing patient care. They may view the manager's important work as "relating the organization to its environment" or "coordinating processes of care to achieve measurable objectives." Reasonable people may differ — and they often do — over the extent to which medical care and population health are measurable.

The work of healthcare managers varies by type of organization, as well as by level within the organization. HCO types include academic medical centers, neighborhood health centers, small community hospitals, large public hospitals, visiting nurse services, accountable care organizations serving Medicaid recipients, Veterans Health Administration hospital networks, and health departments, among others. These organizations can be for-profit, not-for-profit, or governmental; large or small; rural, suburban, or urban; financially strong or struggling. The managers of these organizations face different challenges and have different capabilities in responding to these challenges or to market opportunities.

Expectations for Managerial Performance

The healthcare manager's work is being transformed by evolutions in information availability and performance expectations. Managers are expected to lead or colead quality improvement efforts while also implementing initiatives to generate increased revenue. They are expected to maintain costs and increase value relative to costs while also managing relationships with important stakeholder groups. Many managers must strive to meet these expectations while lacking resources that are central to providing high-quality care. Greater performance expectations are being placed on managers in the face of limitations on what HCOs can charge for their services, even though costs often increase at a faster rate.

Managers should ask themselves: Who are the key stakeholders affecting goal achievement? What do these stakeholders expect? How satisfied are they with current performance? Managerial interventions should always be financially and politically feasible. Managers should know where the money is going to come from before they suggest an initiative, and they should know where the buy-in must come from to achieve a successful implementation.

Managers should reflect on what they plan to accomplish over the next 12 months, and they should determine whose support they need to achieve these goals. Every manager should consider her resume as her lifeline and keep it current. She should ask herself: What results did I achieve last year? What results will I achieve this year that show a convincing track record of accomplishment?

Managers, on average, spend six years in their positions. They should consider themselves independent contractors in charge of their own careers, and they should not accept a position without an exit strategy. They should determine in advance the conditions under which they would no longer be willing to work in the position, and they should know what steps to take once that decision has been made.

Thinking Strategically About the Job

Managers should understand the flexibility of their position. Each managerial job has three characteristics: (1) the demands that the manager must actively carry out; (2) the constraints on the position, or those activities that the manager is not allowed to carry out; and (3) the available options or choices about how the manager is going to spend his time and attention (Stewart and Fondas 1992). Managers should reflect on how they can strengthen relationships with the people on whom they depend for goal achievement; managing oneself is essential for this purpose.

Goleman (1998) stresses the importance of emotional intelligence (EI) for management success. He suggests that EI can be learned and that it is more important than IQ and advanced technical skills. The five components of EI are as follows:

• Self-awareness (how managers see themselves being seen by others)

• Self-regulation (thinking before speaking)

• Motivation (the drive to achieve results)

• Empathy (seeing others as they see themselves)

• Social skills (listening and responding)

Another way to think about EI centers on the skills of interaction that enable the manager to hear what people are saying, understand what they are not saying, and adjust what she is saying based on how she sees her message being received by the people she is talking to.

Barends, Rousseau, and Briner (2014) have written extensively on managerial decision making, emphasizing the need for managers to make decisions based on the best evidence available from multiple sources. This process includes the following steps:

• Translating a practical issue or problem into an answerable question

• Systematically searching for and retrieving the evidence

• Critically judging the trustworthiness and relevance of the evidence

• Weighing and pulling together the evidence

• Incorporating the evidence into the decision-making process

• Evaluating the outcome of the decision made

Self-evaluation — reflection on one's skills and experience in terms of the job — is key. McCall, Lombardo, and Morrison (1988) have suggested the following framework for management development:

• Find out about shortcomings.

• Accept responsibility for shortcomings, which may result from a lack of knowledge, skills, or experience, or from personality, limited ability, or being a situational misfit.

• Decide what to do about the shortcomings accordingly. Either build new strengths, anticipate situations, compensate, or change yourself.

Obviously, the manager should also do an assessment of strengths and consider how to take advantage of and build upon strengths. Such an assessment can help ensure a good fit between the job the manager has or seeks and the manager's own skills and experience.

Conclusion

The work of HCOs continues to be standardized, even in the face of new technology, as organizations become larger and work is increasingly contracted out. The world of large and complex HCOs has led to the specialization of managers in areas such as operations, marketing, strategy, knowledge management, internal auditing, compliance, and human resources, among others. Many of these functional specialists and managers have not been trained in healthcare prior to being employed in HCOs. Meanwhile, physicians are increasingly becoming organizational employees, either in their own organizations or as part of large hospitals and health systems. The challenge of interdisciplinary teams largely remains to be solved, as healthcare professionals are trained and organized separately but then expected to work seamlessly together in the delivery of care at the unit or organizational level. Increasingly, metrics and accountability are the order of the day. Each manager must manage his own narrative about whether he is doing well in his job and how he can improve his and his organization's performance.

Discussion Questions

1. How can managers assess the metrics and accountability for effective performance?

2. How is healthcare management similar or dissimilar to management in general?

3. What can a manager do to successfully move from one managerial position to another?

4. What are the obstacles to managerial self-improvement, and how can these best be overcome?

References

Barends, E., D. M. Rousseau, and R. B. Briner. 2014. Evidence-Based Management: The Basic Principles. Center for Evidence-Based Management. Accessed January 24, 2017. www.cebma.org/wp-content/uploads/Evidence-Based-Practice-The -BasicPrinciples.pdf.

Goleman, D. 1998. "What Makes a Leader?" Harvard Business Review 76 (6): 93–102.

McCall, M. W., M. M. Lombardo, and A. M. Morrison. 1988. The Lessons of Experience: How Successful Executives Develop on the Job. Lexington, MA: Lexington Books.

Stewart, R., and N. Fondas. 1992. "How Managers Can Think Strategically About Their Jobs." Journal of Management Development 11 (7): 10–17.

Recommended Readings

Arndt, M., and B. Bigelow. 2007. "Hospital Administration in the Early 1900s: Visions for the Future and the Reality of Daily Practice." Journal of Healthcare Management 52 (1): 34–48.

Barends, E., B. Janssen, and W. Ten Have. 2014. "Effect of Change Intervention: What Kind of Science Do We Really Have?" Journal of Applied Behavioral Science 50 (1): 5–27.

Berry, L. L., and K. D. Seltman. 2008. Management Lessons from Mayo Clinic. New York: McGraw-Hill.

Bock, L. 2015. "Why Everyone Hates Performance Management, and What We Decided to Do About It." In Work Rules! Insights from Inside Google That Will Transform How You Live and Lead, 150–77. New York: Hachette Book Group.

Christensen, C. M. 2010. "How Will You Measure Your Life?" Harvard Business Review 88 (7–8): 46–51.

Gabarro, J. J., and J. R. Kotter. 2005. "Managing Your Boss." Harvard Business Review 83 (1): 5–12.

Gilmartin, M. J., and T. A. D'Aunno. 2007. "Leadership Research in Healthcare: A Review and a Roadmap." Academy of Management Annals 1: 387–438.

Griffith, J. R. 1993. The Moral Challenges of Healthcare Management. Chicago: Health Administration Press.

Griffith, J. R., and K. R. White. 2005. "The Revolution in Hospital Management." Journal of Healthcare Management 50 (3): 170–90.

Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press.

Kovner, A. R. 2000. Healthcare Management in Mind: Eight Careers. New York: Springer.

—. 1987. "The Work of Effective CEOs in Four Large Health Organizations." Hospital & Health Services Administration 32 (3): 285–305.

Lee, T. H., and J. J. Mongan. 2009. Chaos and Organization in Health Care. Cambridge, MA: MIT Press.

McAlearney, A. S. 2008. "Using Leadership Development Programs to Improve Quality and Efficiency in Healthcare." Journal of Healthcare Management 53 (5): 319–31.

—. 2006. "Leadership Development in Healthcare Organizations: A Qualitative Study." Journal of Organizational Behavior 27 (7): 967–82.

Pfeffer, J. 2015. "Take Care of Yourself." In Leadership BS, 171–92. New York: Harper.

Studer, Q. 2004. Hardwiring Excellence. Gulf Breeze, FL: Fire Starter Publishing.

White, K. R., and J. R. Griffith. 2016. "Cultural Leadership." In The Well-Managed Healthcare Organization, 8th ed., 45–73. Chicago: Health Administration Press.

THE CASES

Managers often have a great deal of difficulty making decisions. Hiring decisions are a key challenge, but even more important are the continuous evaluation and motivation of subordinates and colleagues, many of whom may have been hired by a manager's predecessors. If associates do not perform at an expected level of competence, what are the supervisor's options? What are the manager's options if she disagrees with her own boss's expectations or evaluation? If the boss does not fire or transfer an ineffective manager being evaluated, the boss's own effectiveness may suffer because he might not be supported in his efforts to implement strategy or negotiate organizational politics. Removing an ineffective manager may be difficult because the ineffective manager might be loyal, because searching for and training a new manager costs time and money, and because the boss knows that a new hire's performance may not be as anticipated.

The manager's job is often a lonely one, and important decisions often involve personal as well as organizational risks and benefits. In Case 1, titled "The Search Begins for the Next Faculty Practice Administrator for the Department of Surgery," the weighing of risks and benefits is different for Dr. Eric Francis, the chair of surgery, than it is for Bonnie Goldsmith, the faculty practice administrator, or for Goldsmith's eventual successor. Similarly, in Case 2, "The Associate Director and the Controllers," the stakes of the game are higher for Jim Joel, the ambulatory care manager, and Percy Oram, the controller, than for Milton Schlitz, the medical center director of finance, and Dr. Miller Harrang, the chief executive officer of the ambulatory care program.

Why must Joel decide to do anything at all? In Case 1, Dr. Francis must choose a new faculty practice administrator. But in Case 2, Joel can choose to not get involved and allow Harrang and Schlitz to deal with the consequences of Oram's ineffectiveness. How much should it matter to Joel whether Oram remains on the job, so long as Joel can protect his own job? On the other hand, Joel is paid to manage, not to observe or protect himself.

Managers often search for evidence to validate their intuition, and their intuition is often limited by systematic bias, such as confirmation bias, which involves settling on an opinion and arranging evidence to support that opinion. Politics intrudes, further complicating matters, in Case 3, Part 1, titled "What More Evidence Do You Need?" The question remains, "How does one make decisions based on the best available evidence?" Is Sally's approach to evidence-based decision making the right one, or necessary? What are the stakes for Sally, the medical director, and Mark, the CEO? How should one confront the point of view of "if the wagon isn't broken, don't fix it"?

Good management generally makes a difference to the patient, as well as to the organization's ruling coalition. How much of a difference is open to question. But who will look after the manager's interest if she doesn't look after it herself? This is the first rule of managerial survival. Looking after one's own interest does not mean that the manager should close her office door, read reports, and tell subordinates what to do. Instead, there are opportunities to strategically plan one's professional development, as considered in Case 4 and Case 5, titled "Now What?" and "What Then?"

Healthcare managers often face tremendous pressures from government to move in certain directions, as well as resistance from physicians who do not wish to move one step farther than what is required by law. How much value do managers add to performance? Not much, according to Pfeffer and Salancik (1978), who argue that the contribution of managers accounts for only about 10 percent of the variance in organizational performance, and who agree with the sportscaster cliché that "managers are hired to be fired." An increasing amount of evidence, however, indicates that managers do make a difference in organizational performance, if only because they play a key role in obtaining the resources necessary for organizational survival and growth.

(Continues…)

---

Excerpted from "Health Services Management"
by .
Copyright © 2018 Foundation of the American College of Healthcare Executives.
Excerpted by permission of Health Administration Press.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

---

Table of Contents

Preface to the Eleventh Edition,
Reflections on the Eleventh Edition Anthony R. Kovner,
Introduction to the Case Study Approach,
Part I: The Role of the Manager,
Part II: Control,
Part III: Organizational Design,
Part IV: Professional Integration,
Part V: Adaptation,
Part VI: Accountability,
Index,
About the Editors,
About the Contributors,