Appunti Health Care Management

Collaboration Models in Healthcare

PLANNED

Mandated participation: cooperation is mandated by an external group with legal or legitimate authority (e.g. hub-spoke models)

EMERGENT

There are many forms of collaboration that are not the results of spontaneous initiatives taken by single professionals working within or outside hospitals

Regionalization:

Assigning roles to hospitals in a health care system Network structure and Performance

Modello Hub e Spoke

The use of the Hub & Spoke model in medicine starts from the basic assumption that for certain pathologies and/or very complex situations, it is necessary to have rare specialist skills and/or very expensive equipment, which cannot be insured in a widespread way throughout the territory. The model therefore foresees that assistance for such situations is provided by regional or macro-area centres of excellence, called "hubs", to which the patients for whom the level of complexity of the expected interventions exceeds that which can be provided by the peripheral centres.

Called "spoke". Ministerial Decree no. 70 of 2 April 2015, which defines qualitative, structural, technological and quantitative standards for hospital care, provides for a model for emergency medicine based on 4 levels:

• Emergency room hospital;
• Hospital for D.E.A. Level I (spoke);
• D.E.A. Level II Hospital (hub);
• Hospital in a particularly disadvantaged area.

Emergent models of coordination:

• Inter-hospital patient transfers
• Patient sharing
• Specialist sharing

Management Model:

• Planning Selection of objectives
• Decision making (strategic, tactical, operational)
• Organizing
• Division of labor and distribution of responsibilities for selected parts of the main goal of the organization
• Staffing
• Directing/Leading/Actuating
• Provide a leadership in order that the work performed can guarantee the accomplishment of objectives
• Teaching, motivating and coaching people
• Controlling
• Determination of what is accomplished, assessment of performance.

Ensure feedback Organization Design The organizational structure is "the sum total of the ways in which an organization (e.g. a hospital) divides its labor into distinct tasks and then achieves coordination among them" (Mintzberg, 1981). Organizational Design is important because it is related to Quality of care and Patient outcomes Levels of organization design • Several aspects of an organization can be redesigned or changed: Macro Structure 1. Designing a network (strategic alliances, integrated health system, hub & spoke models, etc.) 2. Designing and redesigning a total organization (hospitals, public health units, long-term care facilities, etc.) Micro Structure 3. Designing a work group (task forces and committees, teams, units and divisions) 4. Designing a position: managers, staff positions, health professionals (e.g. disease manager) • Designing Networks and Systems – Centralization vs. decentralization – Coordination of services and patient flow – Analyze

interorganizational relationships

Decide which organizations should have most power

Identify resource transactions

Diffusing innovations

Organization Chart: a graphic representation of formal authority and division of labor relationships

Knowledge Based Organizations

Tacit Knowledge vs Explicit/Modified Knowledge

Social Knowledge

Healthcare facilities are Knowledge Based Organization

Most of the Knowledge is Tacit How do we transfer this knowledge to other Hospitals? The problem, especially with new diseases and activities, is that knowledge is based on experience we have to organize the hospital to managed this tacit, experience-based knowledge

Professional-based nature

Why are physicians so autonomous? Because they have the specific knowledge about how to treat the patient

Levels of Organization Design

Designing a Work Group/Unit

• Clarify
• Specific purpose of group/unit
• Boundaries of group's authority
• Knowledge and skill
• Time frame

per completare la risoluzione del problema, è necessario: - nominare un leader/manager - progettare una posizione - identificare: - mix di competenze e formazione necessaria - principali responsabilità e ruoli - relazione con altre posizioni paritarie - macro-struttura - specializzazione: 1. identificare il raggruppamento di individui e dipartimenti all'interno dell'organizzazione (divisione del lavoro) 2. la specializzazione non è decisa dai manager, ma dai professionisti stessi 3. un livello crescente di specializzazione può creare una eccessiva frammentazione che i manager devono coordinare 4. è necessario trovare il miglior modello organizzativo per coordinare la specializzazione - coordinazione: - include la progettazione di sistemi (collegamenti) per garantire una comunicazione, coordinazione e integrazione efficaci degli sforzi tra unità o dipartimenti - meccanismi di coordinamento: - standardizzazione - collegamenti verticali - collegamenti orizzontali - per coordinare la specializzazione, è necessariocanuse:StandardizationVertical Mechanisms ofCoordinationVertical linkages are used to co-ordinate activities between the top and bottom of an organisation and are designed primarily for control of the organisation. Organisations may use any of a variety of structural devices to achieve vertical linkage, including: 1. Vertical Information Systems (which includes periodic reports, written information and computer-based communications distributed to managers) 2. Hierarchical referral (Hierarchy brings to Professional bureaucracies) Horizontal Mechanisms of Coordination Horizontal (or lateral) linkage refers to the amount of communication and co-ordination horizontally across organizational units. Horizontal linkage mechanisms often are not drawn on the organization chart, but nevertheless are part of organization structure. Some of these include: 1. Information Systems 2. Direct contact (a person in a liaison role between departments) 3. Tasks force 4. Full-time integrator 5. Teams Integrators, Task

Forces & Teams

Full-time integrators: this is not a vertical role, it does not imply hierarchy

• nurse coordinator
• case manager
• disease managers

Task forces and Teams

• Temporary (e.g. tumor boards)
• Permanent (e.g. infection control teams)

Interdisciplinarity

Relational Coordination

Relational coordination refers to «frequent, timely, problem-solving communication carried out through relationships of shared goals, shared knowledge, and mutual respect» (e.g. direct contacts, phone calls, e-mails, intranet, …)

Employees coordinate and collaborate directly with each other across units

Coordination is carried out through a web of ongoing positive relationships rather than because of formal coordination roles and mechanisms

Ladder of Mechanisms for Horizontal Linkage and Coordination

Designs for a variety of health services organizations

From the functional design we move to the more horizontal one of Service Practice Units which is based on patients’ requirements.

rather than focus on skills and the service, we focus on the patient's demand There are some other design in the middle. Functional Design: mainly based on professional clinical specialties most traditional way to organize hospitals Strengths Allows economies of scale within functional departments Enables in-depth knowledge and skill development Enables organization to accomplish functional goals Is best with only one or a few products Weaknesses Slow response time to environmental changes May cause decisions to pile on top, hierarchy overload Results in less innovation, because there is not enough integration Involves restricted view of organizational goals It is the best model to achieve efficiency The main control mechanism is vertical The different company segments are separated low information flow and innovation grade Divisional Grouping: The Clinical Directorate Instead of having emphasis on the functions, we have it on the products. ClinicalDirectorates (or "departments") represent semiautonomous organizational divisional units in which several clinical wards are integrated or merged to integrate healthcare practices and to pursue common care goals. Objectives: Integration (organizational) - Quality (clinical) - Economies of scale (financial) - Skills/Competences (strategic) - Divisional Design: Italian Hospitals The Direttore Sanitario is responsible for the whole hospital while the Clinical Director (es. Dipartimento Chirurgia Generale) is responsible only for his department. Strengths: - Suited to fast change in unstable environment - Leads to customer satisfaction because product responsibility and contact points are clear - Allows units to adapt to differences in products, regions, customers - Decentralizes decision making Weaknesses: - Eliminates economies of scale in functional departments - Leads to poor coordination across product line - Eliminates in-depth competence and technical specialization - Makesintegration and standardization across product lines difficult Pipelines: patient flow logistics Progessive Care modified divisional model Pipelines have different flows of activities that involve different Directorates Example: Pipelines in Emilia Romagna Product-Line or Program Design This is a functional model adjusted to activities that focus on patients Power Balance Transversal units are responsible for "following" patients along the pathway but depend on institutes for budgets and resources. The Head of Unit (Owner) is in charge of coordinating patient flows by reviewing guidelines, analyzing processes, identifying improvements, etc. Efficient coordination flows have been designed both among different hospitals and among the hospital and primary care settings (e.g. chronic diseases and palliative care). Strengths: - Directs the attention of everyone toward the production and delivery of value to the customer/patient - Promotes flexibility and rapid response to changes in customere• Requires a high level of trust and communication among employees• Can lead to conflicts and disagreements if not managed properly• May result in slower decision-making process due to the need for consensus• Not suitable for all types of organizations or industries• Requires ongoing training and development to ensure employees have the necessary skills and knowledge to effectively participate in self-management.