The Well-Managed Healthcare Organization 7th Edition PDF

Seventh Edition The Well-Managed Healthcare Organization continues its position as the most The Well-Managed Healthcare Organization comprehensive resource on healthcare management....

Seventh Edition The Well-Managed Healthcare Organization continues its position as the most The Well-Managed Healthcare Organization comprehensive resource on healthcare management. The This edition draws on the experiences of high-performing and Malcolm Baldrige Award-winning organizations. It describes the key drivers of success: A culture of empowerment and responsive leadership that promotes teamwork among Well-Managed physicians, nurses, and other staff A system for continuous improvement that emphasizes process analysis, negotiated goal setting, measurement, benchmarking, and rewards Kenneth R. White This edition also includes: A new chapter on building a culture of shared values, empowerment, Healthcare communication, and service excellence A new chapter on the organizational infrastructure that sustains continuous improvement Strategies for building clinical processes that delight not only physicians and nurses with effective protocols but also patients with responsive, individualized care Organization Best practices for various operational functions, including comprehensive performance measures and organizational models Strategies for retaining and increasing the contribution of clinical and administrative staff Reader-friendly aids, such as on-the-page definitions of terminology, synopses of chapter contents, and questions for reflection or discussion John R. Griffith About the Authors Kenneth R. White, PhD, FACHE, is a professor in Virginia Commonwealth University’s Department of Health Administration in Richmond, Virginia. He has more than 35 years of experience in healthcare organizations in clinical, administrative, governance, and consulting capacities, as well as academic experience in program development Kenneth R. White and leadership. John R. Griffith, MBA, FACHE, is the Andrew Pattullo Collegiate Professor in the Department of Health Management and Policy at the School of Public Health at The University of Michigan, Ann Arbor. He has received the Gold Medal Award and won multiple publication awards from the American College of Healthcare Executives. John R. Griffith The first edition of The Well-Managed Healthcare Organization won the American College of Healthcare Executive’s James A. Hamilton Book of the Year Award. One North Franklin Street, Suite 1700 Chicago, Illinois 60606-3529 Phone: (301) 362-6905, Fax: (301) 206-9789 ache.org/hap ISBN: 978-1-56793-357-4 Order no.: 2156 The Well-Managed healThcare OrganizaTiOn AUPHA Editorial Board for Graduate Studies HAP Christy H. Lemak, PhD, Chairman University of Michigan Mark Allan Boston University John Baker, PhD University of Arkansas For Medical Sciences M. Nicholas Coppola, PhD, FACHE Texas Tech University Connie J. Evashwick, ScD, FACHE St. Louis University Diane M. Howard, PhD, FACHE Rush University Ana Maria T. Lomperis, PhD St. Louis University John M. Lowe III, PhD Simmons College Michael R. Meacham The Pennsylvania State University Lydia Middleton AUPHA Mark Pauly, PhD University of Pennsylvania Bernardo Ramirez, MD University of Central Florida Andrew T. Sumner, ScD, FACHE Georgia State University Andrea W. White, PhD Medical University of South Carolina Lesly Wilson, PhD University of South Carolina LT Suzanne J. Wood, PhD, FACHE Army-Baylor University The Well-Managed healThcare OrganizaTiOn S e Sv ee vn et hn t Eh d Ei td ii ot ni o n KEnnEth KEnnEth R. WhitE R. WhitE John R. GRiffith John R. GRiffith Chicago, Illinois Your board, staff, or clients may also benefit from this book’s insight. For more information on quantity dis- counts, contact the Health Administration Press Marketing Manager at (312) 424-9470. This publication is intended to provide accurate and authoritative information in regard to the subject matter covered. It is sold, or otherwise provided, with the understanding that the publisher is not engaged in render- ing professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. The statements and opinions contained in this book are strictly those of the authors and do not represent the official positions of the American College of Healthcare Executives, of the Foundation of the American College of Healthcare Executives, or of the Association of University Programs in Health Administration. Copyright © 2010 by the Foundation of the American College of Healthcare Executives. Printed in the United States of America. All rights reserved. This book or parts thereof may not be reproduced in any form without written permission of the publisher. 14 13 12 11 10 5 4 3 2 1 Library of Congress Cataloging-in-Publication Data White, Kenneth R. (Kenneth Ray), 1956- €The well-managed healthcare organization / Kenneth R. White, John R. Griffith. -- 7th ed. € € € p. ; cm. €Griffith’s name appears first on the earlier ed. €Includes bibliographical references and index. €ISBN 978-1-56793-357-4 (alk. paper) €1. €Health services administration. €I. Griffith, John R. II. Title. €[DNLM: 1. €Health Services Administration--United States. €W 84 AA1 W585w 2010] €RA971.G77 2010 €362.1068--dc22 € € € € € € € € € € € € € € € € € €尓 € € € € € € € € € € € €2010014186 The paper used in this publication meets the minimum requirements of American National Standard for Infor- mation Sciences—Permanence of Paper for Printed Library Materials, ANSI Z39.48-1984.∞ ™ Project manager and editor: Jane Calayag; Acquisitions editor: Janet Davis; Book design: Scott Miller; Cover design: Gloria Chantell; Layout: BookComp, Inc. Health Administration Press Association of University Programs A division of the Foundation in Health Administration of the American College of 2000 14th Street North Healthcare Executives Suite 780 One North Franklin Street Arlington, VA 22201 Suite 1700 (703) 894-0940 Chicago, IL 60606 (312) 424-2800 CONTENTS List of Exhibits.........................................................................................xvii Preface..........................................................................................xxiii Chapter 1 Foundations of High-Performing Healthcare Organizations......................................................................1 Chapter 2 Cultural Leadership..............................................................39 Chapter 3 Operational Leadership.........................................................69 Chapter 4 Strategic Leadership: Governance.......................................103 Chapter 5 Foundations of Clinical Performance..................................141 Chapter 6 The Physician Organization................................................182 Chapter 7 Nursing..............................................................................219 Chapter 8 Clinical Support Services.....................................................250 Chapter 9 Beyond Acute Care to Community Health..........................281 Chapter 10 Knowledge Management....................................................317 Chapter 11 Human Resources Management.........................................346 Chapter 12 Environment-of-Care Management.....................................383 Chapter 13 Financial Management........................................................417 Chapter 14 Internal Consulting............................................................459 Chapter 15 Marketing and Strategy.......................................................491 Glossary..........................................................................................527 Index..........................................................................................537 About the Authors...................................................................................553 v DETAILED CONTENTS List of Exhibits.........................................................................................xvii Preface...................................................................................................xxiii Chapter 1 Foundations of High-Performing Healthcare Organizations 1 In a Few Words......................................................................1 Critical Issues.........................................................................1 Questions for Discussion.........................................................2 Activities.................................................................................3 Contribution..........................................................................4 Stakeholders...........................................................................5 Customer Partners.............................................................6 Provider Partners...............................................................9 Sources of Stakeholder Influence......................................11 Ownership............................................................................13 Not-for-Profit, For-Profit, and Government Owners........13 Healthcare Systems..........................................................13 Designing Excellence in an HCO..........................................14 Cultural Foundation of Excellence: Transformational. Management...............................................................16 Operational Foundation of Excellence: Evidence-Based. Management...............................................................23 Strategic Foundation of Excellence: Positioning and. Protection....................................................................30 Suggested Readings..............................................................36 Chapter 2 Cultural Leadership 39 In a Few Words....................................................................39 Critical Issues.......................................................................39 Questions for Discussion.......................................................40 Purpose................................................................................41 Functions.............................................................................41 Promoting Shared Values.................................................43 Empowering Associates....................................................44 Communicating with Associates.......................................45 vii viii The Well-Managed Healthcare Organization Supporting Service Excellence.........................................47 Encouraging, Rewarding, and Celebrating Success...........51 Improving the Transformational Culture.........................52 People..................................................................................52 Sources of Leaders...........................................................52 Qualifications for Leaders................................................53 Leadership Development Programs..................................55 Paths for Beginners..........................................................56 Measures..............................................................................57 The Culture and Leadership Functions............................57 Assessing Leaders as Individuals.......................................60 Ensuring Leadership Continuity.......................................61 Managerial Issues..................................................................62 Starting the Path to Transformational Culture.................63 Maintaining the Ethical Foundation.................................64 Resolving Fundamental Disagreements............................66 Protecting Against Destructive Behavior..........................67 Suggested Readings..............................................................67 Chapter 3 Operational Leadership 69 In a Few Words....................................................................69 Critical Issues.......................................................................69 Questions for Discussion.......................................................70 Purpose................................................................................71 Functions.............................................................................72 Boundary Spanning.........................................................72 Knowledge Management.................................................79 Accountability and Corporate Design...............................82 Continuous Improvement................................................88 Sustaining and Improving the Operational Structure........90 People..................................................................................93 Measures..............................................................................93 Managerial Issues..................................................................94 Starting the Path to Evidence-Based Management...........94 Understanding the Risk Factors of the Model..................97 Suggested Readings............................................................100 Chapter 4 Strategic Leadership: Governance 103 In a Few Words..................................................................103 Critical Issues.....................................................................103 Questions for Discussion.....................................................104 Purpose..............................................................................105 Functions...........................................................................106  Detailed Contents ix Maintaining Management Capability..............................108 Establishing the Mission, Vision, and Values..................110 Approving the Corporate Strategy and Annual Implementation........................................................110 Ensuring Quality of Clinical Care...................................115 Monitoring Performance Against Plans and Budgets......116 Improving Board Performance.......................................119 People................................................................................122 Board Membership........................................................122 Membership Qualifications...........................................122 Board Selection.............................................................124 Board Organization......................................................127 Education and Information Support for Board Members....131 Measures............................................................................132 Managerial Issues................................................................133 Operating Discipline......................................................133 Legal and Ethical Issues of Board Membership...............135 Suggested Readings............................................................137 Chapter 5 Foundations of Clinical Performance 141 In a Few Words..................................................................141 Critical Issues.....................................................................141 Questions for Discussion.....................................................142 Purpose..............................................................................143 Functions...........................................................................144 Ensuring Accurate Diagnosis..........................................144 Ensuring Excellent Care................................................146 Implementing Protocols................................................148 Individualizing Patient Care Planning and Treatment.....162 Improving Community Health......................................163 Improving Clinical Performance....................................165 People................................................................................167 Organization.................................................................167 Measures............................................................................168 Demand and Output.....................................................169 Quality Assessment........................................................169 Patient and Associate Satisfaction...................................172 Managerial Issues................................................................175 Sustaining a Culture of Teamwork and Respect..............175 Credentialing and Ensuring Continued Competence......175 Minimizing and Responding to Unexpected Clinical Events.......................................................................176 Resolving Interprofessional Rivalries..............................176 Suggested Readings............................................................177 x The Well-Managed Healthcare Organization Chapter 6 The Physician Organization 182 In a Few Words..................................................................182 Critical Issues.....................................................................182 Questions for Discussion.....................................................183 Purpose..............................................................................184 Functions...........................................................................184 Achieving Excellent Care...............................................185 Credentialing and Delineating Privileges........................187 Planning and Implementing Physician Recruitment........194 Providing Clinical Education.........................................200 Communicating and Resolving Unmet Needs................203 Negotiating and Maintaining Compensation Arrangements................................................................206 People................................................................................210 Physician Leadership......................................................210 Organization of Physicians.............................................211 Measures............................................................................211 Managerial Issues................................................................211 Managing Conflicting Values.........................................212 Maintaining Adequate Physician Supply.........................214 Negotiating Compensation Arrangements......................214 Suggested Readings............................................................215 Chapter 7 Nursing 219 In a Few Words..................................................................219 Critical Issues.....................................................................219 Questions for Discussion.....................................................220 Purpose..............................................................................221 Functions...........................................................................222 Delivering Excellent Care..............................................222 Coordinating and Monitoring Interdisciplinary Care......228 Educating Patients, Families, and Communities.............230 Maintaining the Nursing Organization...........................231 Improving Nursing Performance....................................234 People................................................................................236 Team Members..............................................................236 Organization.................................................................241 Measures............................................................................241 Managerial Issues................................................................242 Recruitment and Retention............................................244 Improve Nursing’s Effectiveness....................................244 Suggested Readings............................................................246  Detailed Contents xi Chapter 8 Clinical Support Services 250 In a Few Words..................................................................250 Critical Issues.....................................................................250 Questions for Discussion.....................................................251 Purpose..............................................................................252 Functions...........................................................................253 Providing Excellent Care...............................................254 Maintaining Patient Relationships..................................255 Maintaining Consultative Relationships..........................257 Planning and Managing Operations..............................259 Promoting Continuous Improvement............................262 People................................................................................269 Team Members..............................................................269 CSS Management..........................................................270 The HCO Manager.......................................................270 Organization.................................................................271 HCO–CSS Relationships...............................................271 Measures............................................................................272 Managerial Issues................................................................274 Should the HCO Offer the Service?...............................275 How Big Should the CSS Be?........................................275 What Are the Standards of Performance?.......................276 What Form of Affiliation Best Meets the HCO’s Needs?.......................................................................276 Does the CSS Have the Coordination It Needs?............277 Are CSS Activities Correctly Assigned to Professional and Nonprofessional Associates?.......................................277 What Are the Continuous Improvement Goals?.............278 What Are the Long-Term Trends?.................................278 Suggested Readings............................................................279 Chapter 9 Beyond Acute Care to Community Health 281 In a Few Words..................................................................281 Critical Issues.....................................................................281 Questions for Discussion.....................................................282 Purpose..............................................................................286 Functions...........................................................................286 Understanding and Promoting Community Health........286 Establishing a Community Health Strategy....................294 Operationalizing a Community Health Strategy.............302 Improving Performance.................................................304 People................................................................................304 Measures............................................................................305 xii The Well-Managed Healthcare Organization Operational..................................................................305 Strategic........................................................................307 Managerial Issues................................................................307 Promoting and Teaching Community Health.................309 Extending Management Concepts to Community Healthcare Teams......................................................310 Expanding and Integrating Primary Care.......................310 Maintaining the Infrastructure for Community Health...311 Suggested Readings............................................................312 Chapter 10 Knowledge Management 317 In a Few Words..................................................................317 Critical Issues.....................................................................317 Questions for Discussion.....................................................318 Purpose..............................................................................319 Functions...........................................................................320 Ensuring the Reliability and Validity of Data..................320 Maintaining Communications for Daily Operations......327 Supporting Information Retrieval for Continuous Improvement.............................................................329 Ensuring the Appropriate Use and Security of Data........332 Improving Knowledge Management Services Continuously.............................................................333 People................................................................................336 Chief Information Officer..............................................336 KM Planning Committee...............................................336 Organization.................................................................337 Measures............................................................................337 Managerial Issues................................................................339 Exploiting the KM Planning Committee........................339 Promoting the Use of Knowledge................................340 Using Outside Contractors and Vendors........................341 Suggested Readings............................................................343 Chapter 11 Human Resources Management.........................................346 In a Few Words..................................................................346 Critical Issues.....................................................................346 Questions for Discussion.....................................................347 Purpose..............................................................................349 Functions...........................................................................349 Workforce Planning.......................................................349 Workforce Development................................................353 Workforce Maintenance.................................................356  Detailed Contents xiii Empowerment, Transformation, and Service Excellence.363 Compensation and Benefits Management.......................365 Collective Bargaining.....................................................371 Continuous Improvement..............................................372 People................................................................................372 Human Resources Professionals.....................................372 Organization of the Human Resources Department.......372 Measures............................................................................374 Managerial Issues................................................................375 Adequate Funding.........................................................375 Consistent Senior Leadership.........................................377 Perceived Fairness..........................................................377 Strategic Achievement....................................................378 Suggested Readings............................................................378 Chapter 12 Environment-of-Care Management 383 In a Few Words..................................................................383 Critical Issues.....................................................................383 Questions for Discussion.....................................................384 Purpose..............................................................................385 Functions...........................................................................385 Facilities Design, Planning, and Space Allocation...........386 Facilities Maintenance....................................................393 Guest Services...............................................................396 Materials Management Services......................................399 Enhanced Environmental Management..........................400 Performance Improvement and Budgeting.....................405 People................................................................................406 Managers and Professional Personnel............................406 Outside Contractors......................................................407 Training Needs..............................................................407 Incentives and Rewards..................................................408 Organization.................................................................408 Measures............................................................................408 Output and Demand.....................................................409 Resource Consumption and Effectiveness......................410 Quality..........................................................................411 Managerial Issues................................................................412 Facilities Planning and Space Allocation.........................413 Selection and Management of Outsourcing Contracts....413 Integration of Facilities Operations with Other Activities..................................................................414 Suggested Readings............................................................414 xiv The Well-Managed Healthcare Organization Chapter 13 Financial Management........................................................417 In a Few Words..................................................................417 Critical Issues.....................................................................417 Questions for Discussion.....................................................418 Purpose..............................................................................419 Controllership Functions....................................................419 Transaction Accounting.................................................419 Financial Accounting.....................................................422 Managerial Accounting..................................................425 Goal Setting and Budgeting.........................................427 Financial Management Functions......................................434 Financial Planning.........................................................434 Pricing Clinical Services.................................................437 Securing and Managing Liquid Assets............................440 Managing Multicorporate Accounting...........................444 Auditing Functions.............................................................445 Internal Audits..............................................................445 External Audits..............................................................448 Continuous Improvement of the Accounting and Finance Functions..................................................................449 People................................................................................449 Chief Financial Officer...................................................449 Other Professional Personnel.........................................450 Organization of the Finance System...............................450 Measures............................................................................452 Quantitative Performance Measures...............................452 Subjective Quality Assessment........................................452 Managerial Issues................................................................454 Supporting Integrity in All Financial Areas.....................454 Maintaining a Collegial, Blame-Free Culture..................454 Managing Areas at Risk for Conflict...............................454 Suggested Readings............................................................457 Chapter 14 Internal Consulting 459 In a Few Words..................................................................459 Critical Issues.....................................................................459 Questions for Discussion.....................................................460 Purpose..............................................................................461 Functions...........................................................................461 Supporting the Organization as a Whole........................464 Supporting Improvement Projects.................................472 Supporting the Capital Investment Review.....................475 Implementing and Integrating......................................481 Responding to Any Other Factual Concern....................481  Detailed Contents xv Improving Internal Consulting......................................482 People................................................................................482 Team Members..............................................................482 Organization.................................................................482 Measures............................................................................484 Managerial Issues................................................................484 Ensuring Quality of Work..............................................486 Sizing Internal Consulting............................................486 Protecting Associates’ Empowerment............................487 Suggested Readings............................................................488 Chapter 15 Marketing and Strategy 491 In a Few Words..................................................................491 Critical Issues.....................................................................491 Questions for Discussion.....................................................492 Purpose..............................................................................493 Marketing Functions...........................................................494 Identifying and Segmenting Markets..............................496 Listening to Stakeholder Needs......................................497 Developing Brand and Media Relations.........................501 Convincing Potential Customers....................................502 Attracting and Motivating Associates.............................505 Managing Other Stakeholder Relationships....................505 Improving the Marketing Activity..................................508 Strategic Functions.............................................................509 Maintaining the Mission, Vision, and Values..................509 Defining the Strategic Position.......................................509 Implementing the Strategic Position..............................515 People................................................................................515 Associates......................................................................515 Organization.................................................................516 Measures............................................................................516 Strategic Activity............................................................517 Operational Measures....................................................518 Managerial Issues................................................................519 Skills for Successful Strategy...........................................520 Strategic Leadership Requirements...............................520 Multihospital System Contribution...............................521 Suggested Readings...........................................................522 Glossary.................................................................................................527 Index......................................................................................................537 About the Authors...................................................................................553 EXHIBITS Chapter 1 1.1 Components of Healthcare Organizations...............................4 1.2 General Model of Stakeholder–Organization Interaction.........5 1.3 Model of Stakeholder–HCO Interaction.................................7 1.4 Ownership and Size of U.S. Community and Federal Hospitals...........................................................................14 1.5 System Affiliations of U.S. Hospitals.....................................15 1.6 Foundations of Excellence in Healthcare Organizations........16 1.7 Mission, Vision, and Values Baldrige Award Recipients, 2002–2009........................................................................19 1.8 Bronson Methodist Hospital: Mechanisms for Communication, Skill Sharing, and Knowledge Transfer....21 1.9 Mercy Health System Award/Incentive Programs and Objectives.............................................................................24 1.10 Template of Operational Performance Measures for Individual. Teams and Activities..........................................................27 1.11 Template of Strategic Measures of HCO Performance...........28 1.12 Process Analysis: Translating OFIs to Improved Performance......................................................................31 1.13 Competitive Tests for Investment Opportunities...................32 1.14 Strategic Positioning and Monitoring Processes....................33 1.15 Foundations Reinforcing the Agency/Accountability Relationships.....................................................................35 Chapter 2 2.1 Functions of Cultural Leadership..........................................42 2.2 The Service Excellence Chain in Healthcare..........................48 xvii xviii The Well-Managed Healthcare Organization 2.3 Frequently Negotiated Issues and Solution Paths for Excellent HCOs................................................................50 2.4 Measures of Leadership Functions.........................................59 2.5 Relating Leadership and Culture to Mission Achievement.....60 2.6 A Comprehensive Leadership Management Program.............62 Chapter 3 3.1 Functions That Sustain Operational Infrastructure................73 3.2 Boundary Spanning Activities of HCOs................................75 3.3 Elements of the Epidemiologic Planning Model....................76 3.4 Leadership Structure, Communications, and Accountability...................................................................83 3.5 Tests of Successful Leadership Accountability........................85 3.6 Traditional Types of HCOs.................................................86 3.7 Mercy Health System’s Annual Planning Calendar................89 3.8 Qualitative Indicators of OFIs for Maintaining the Cultural and Operational Infrastructure.............................91 3.9 Performance Measures for Infrastructure Functions..............92 Chapter 4 4.1 Functions of the Governing Board.....................................107 4.2 Strategic Scenario Questions for Healthcare Organizations..................................................................112 4.3 Saint Luke’s Hospital Strategic Scorecard............................114 4.4 Ten Measures of Board Effectiveness...................................120 4.5 Typical Standing Committees of the Governing Board........128 4.6 Henry Ford Health System Governance Structure...............131 4.7 Board Member Orientation Subjects...................................133 Chapter 5 5.1 Functions of the Clinical Organization................................145 5.2 Simplified Diagnostic Process..............................................147 5.3 Average Cost for Alternative Prostate Cancer Treatments....148 5.4 HCO Contribution to Excellent Care.................................149 5.5 Example of a Functional Protocol for Medication Order and Fulfillment................................................................151 5.6 Example of a Patient Management Protocol for Acute Chest Pain.................................................................................155 5.7 Core Values of High-Performing HCOs............................166 5.8 Organization of Clinical Services.........................................169 5.9 Profile of Service Line Operational Scorecard......................170 5.10 HCAHPS® Hospital Patient Survey Questions....................173  Exhibits xix Chapter 6 6.1 Functions of the Physician Organization.............................185 6.2 Flowchart of Physician Credentialing..................................189 6.3 Critical Volumes for Specialty Services.................................198 6.4 Cardiac Surgery as an Example of Combined Strategic, Service, and Physician Planning...........................................199 6.5 Advantages of Physician Supply Planning............................200 6.6 Physician Representation on Decision Processes..................204 6.7 Compensation Relationships Between HCOs and Individual Physicians.......................................................................208 6.8 Types of Physician Compensation for Patient Care..............209 6.9 Institutional Clinical Organization Structure.......................212 6.10 Operational Measures of Physician Organization Performance....................................................................213 Chapter 7 7.1 Nursing Functions..............................................................223 7.2 Nursing and the Goals of Excellent Care.............................224 7.3 Nursing Process Example for Airway Management............225 7.4 Example of a Nurse Staffing Model for an Inpatient Unit....233 7.5 Assistance Available to Nursing Teams................................235 7.6 Educational Levels of Nursing Associates............................237 7.7 Nursing Practice Specialties in HCOs..................................240 7.8 Nursing Team Support Structure........................................242 7.9 Nursing Performance Measures...........................................243 Chapter 8 8.1 Clinical Support Services in a Large HCO...........................253 8.2 Functions of the CSS, Showing Service and HCO Contributions..................................................................254 8.3 Conceptual Model of a Sophisticated Scheduling Process............................................................................257 8.4 Improvement Initiatives in Two CSSs.................................265 8.5 Core Organization of the CSS............................................272 8.6 Performance Measures for the CSS.....................................273 Chapter 9 9.1 Conceptual Model of Personal Services for Community Health.............................................................................284 9.2 Functions That Implement a Community Health Mission............................................................................287 9.3 Grouping of Disease and Prevention Forecasts, by Prevention xx The Well-Managed Healthcare Organization Level, Population at Risk, and Service Program................289 9.4 Goals of a Comprehensive Community Health Program.....296 9.5 Examples of Operational Measures for Community Health Programs.........................................................................300 9.6 Community Health Scorecard.............................................308 Chapter 10 10.1 Functions of Knowledge Management Services...................321 10.2 Common Patient Specification Taxonomies.........................324 10.3 Age-Specific, Crude, and Adjusted Rates: Utah Versus Florida.............................................................................325 10.4 Examples of Internal Data Feeding the Data Warehouse....330 10.5 Common Uses of Information in High-Performing HCOs.............................................................................331 10.6 Knowledge Management Planning Process.........................335 10.7 Accountability Structure for the Communications Function..........................................................................337 10.8 Measures of Knowledge Management Performance.............338 Chapter 11 11.1 Functions of Human Resources Management.....................350 11.2 Illustration of Workforce Plan Content...............................352 11.3 Core Files of HRM Knowledge Management......................362 11.4 Typical Improvements for Human Resources Management...................................................................373 11.5 Organization of a Large Human Resources Department.....................................................................374 11.6 Measures of the Human Resource.......................................375 11.7 Measures of Human Resources Management......................376 11.8 Human Resources and the Service Excellence Dynamic.......377 Chapter 12 12.1 Environment-of-Care-Management Requirements..............386 12.2 Functions of Environment-of-Care Services........................387 12.3 Facilities Planning Process...................................................389 12.4 Facilities Maintenance Services............................................394 12.5 Guest Services: Workforce, Patient, and Visitor Support.....397 12.6 Functions of Materials Management...................................400 12.7 Enhanced Environmental Management Requirements.........401 12.8 Environment-of-Care Organization for Large HCOs..........409 12.9 Examples of Demand Measures for Environment-of-Care Functions........................................................................410 12.10 Implications of Cost Accounting on Environmental  Exhibits xxi Services...........................................................................411 12.11 Measures of Quality for Environment-of-Care Services........412 Chapter 13 13.1 Functions of the Finance System.........................................420 13.2 Availability of External Price Information, by Type of Transaction and Level of Aggregate.................................423 13.3 Integrating Strategic and Operational Goal Setting.............428 13.4 Major Budgets and Their Relation to Strategic Goals..........429 13.5 Annual Goal-Setting Cycle..................................................430 13.6 Major Steps in Developing Operations Budgets...................431 13.7 Tests and Adjustments in Financial Planning.......................437 13.8 Pricing Structures for Healthcare Contracts........................439 13.9 Implications of Alternative Funding Sources for an Ambulatory Care Project.................................................441 13.10 Organization of the Finance System....................................451 13.11 Operational Measures of Finance and Accounting...............453 Chapter 14 14.1 Functions of Internal Consulting.......................................462 14.2 Internal Consulting as a Clearinghouse...............................464 14.3 Patient-Oriented Specification Taxonomies.........................468 14.4 Insurance Intermediary and Employer Specification Taxonomies.....................................................................468 14.5 Healthcare Provider Specification Taxonomies....................469 14.6 Run Charts and Control Charts..........................................471 14.7 Checklist for Evaluating Improvement Proposals.................477 14.8 Examples of Programmatic Proposals..................................478 14.9 Programmatic Capital Review Process.................................479 14.10 Operational Performance Measures for Internal Consulting.......................................................................485 Chapter 15 15.1 Functions of Marketing and Strategy...................................495 15.2 Illustration of Marketing Functions.....................................497 15.3 Major Listening Activities..................................................499 15.4 Examples of Alternative Collaborative Structures for HCO Services...........................................................................507 15.5 Spectrum of Potential Relationships with Organizations......508 15.6 Matrix of Market Attractiveness and Advantage...................512 15.7 Miles and Snow Typology of Strategic Types.......................513 15.8 Formal Hierarchy for a Large Marketing Operation............517 15.9 Measures for Specific Campaigns.........................................519 PREFACE The Well-Managed Healthcare Organization, now in its 7th edition, is a text for students pursuing professional careers in managing healthcare organiza- tions (HCOs). It describes actual practices that lead to high performance, based on our careful analysis of a small but reasonably representative set of HCOs that have been studied by competent peers and have produced audit- able evidence of excellence. We believe the evidence of the superiority of these practices passes both academic and professional challenge. The footnotes in each chapter support our belief. There may be other ways to achieve excel- lence, but they have not been documented and quite possibly have not been discovered. Healthcare organizations that follow the methods we describe are well-prepared for health reform. We expect them to continue to thrive. Indirectly, health reform initiatives reinforce our message and are consistent with managing and leading excellent HCOs on the basis of evidence, best practices, benchmarks, and a culture of continuous improvement. The common theme in these organizations is that a specific culture (transformational and evidence-based management) and certain manage- ment activities (listening, measurement, benchmarking, negotiated goal setting, and continuous improvement) are essential to high performance. Specialized teams must complete specified tasks correctly to measured standards. These teams include not only those involved in patient care but also clinical support (e.g., laboratory, pharmacy, imaging), logistics (e.g., information, personnel, training, supplies), or strategic (e.g., finance, in- ternal consulting, enterprise level goals). Each chapter, after Chapter 1, has the following structure: Purpose, Functions, People, Measures, and Managerial Issues. The Functions section describes the unit’s essential contribution to the whole, and the Measures section identifies opportuni- ties to improve that contribution. The challenge in managing HCOs is to sustain excellence over all the teams, and the solution to this challenge lies in two core thrusts: 1. Maintaining a culture that empowers each associate (transformational management) 2. Supporting continuous improvement with measurement, process analysis, negoti- ated goals, and rewards (evidence-based management) xxiii xxiv The Well-Managed Healthcare Organization In excellent HCOs, measurement is central, improvement is constant, leaders respond to associates and patients, professionals communicate as equals, everyone is treated with respect, and authority is derived from knowl- edge rather than rank. These are the foundations of high performance. The record of excellent HCOs shows quite clearly that the new management ap- proach produces excellence in all the sites that now constitute the health- care industry. High-performing HCOs successfully operate the full gamut of healthcare, including doctors’ offices, general and special hospitals, continu- ing care, home care, and hospices. Using The Well-Managed Healthcare Organization Any organization is a collaboration to do what an individual alone cannot do. This collaboration succeeds by division of labor—assigning tasks for individu- als and small teams to complete to achieve the goals of collaboration. The text begins (chapters 1 and 2) with a description of the collaborators, called stakeholders. Performance excellence is built on a comprehensive and well-sup- ported theory of management (Chapter 2). The elements of that theory are as follows: 1. An HCO is supported by many stakeholders who, in turn, benefit from its suc- cess. In general, stakeholders are either “customers” or “providers,” and a key organizational issue is balancing and optimizing the rewards to each group. 2. The goals of the HCO are stated in its mission. Missions of HCOs are similar because all stakeholders share a common purpose of extending the length and quality of life and providing safe, effective, patient-centered, timely, efficient, and equitable care. 3. Goal achievement is evidence-based, using objective measures of performance, comparison to competitors and best practices, goal setting, and continuous improvement. 4. The rewards of improvement are shared among the stakeholders so that both customer and provider stakeholders view the organization as their preferred affiliation. These elements constitute cross-cutting themes that recur throughout the text. From chapter 3 to 15, the text describes the activities of an HCO in three divisions—corporate, clinical, and technical/logistic. Each chapter identifies an activity and the functions it must perform for the whole to suc- ceed, its organization structures and personnel, its measures of performance, and some of the critical areas in which it needs managerial support. Each chapter addresses (1) “what this activity must do well for the whole to suc- ceed” and (2) “how this activity measures and improves its performance.”  Preface xxv Each chapter begins with In a Few Words, a précis of the activity addressed in the chapter; Critical Issues, an outline that emphasizes the distinctions associ- ated with excellence; and Questions for Discussion, five important and easily misunderstood application topics. Chapter 2 describes leadership and the activities required of senior man- agement to build and sustain the HCO’s cultural foundations. Chapter 3 ex- pands the discussion on the operational foundation, exploring the activities that identify opportunities for improvement (OFIs) and lead to improved work processes. Chapter 4 addresses governance, the strategic decision mak- ing that provides effective long-term response to stakeholder needs. Chap- ters 5 through 9 describe the operation of the various clinical and clinical support teams. Chapters 10 through 15 discuss the logistic and strategic support activities. Each chapter addresses purpose, functions, people, measures, and mana- gerial issues associated with the activity. The content of these chapters gives the student the ability to engage in meaningful dialogue with members of any activ- ity or team, to understand how well a team or activity is currently performing and what its current OFIs are, and to assist in translating those OFIs to actual improvement. That pattern of listening, learning, and supporting improvement is what twenty-first century healthcare managers do for a living. HCO managers build excellent organizations by ensuring that the functions are carried out as a whole. The theory demands comprehensive- ness, as failure in one activity contributes to failure in another. The three divisions must all perform; an HCO cannot have clinical excellence without corporate excellence and logistic excellence. The learning manager, therefore, must grasp the totality and interdependence of the HCO as well as the con- tributions expected of each activity. He or she must also understand the ap- plication of the cross-cutting themes—the role of the mission, evidence-based decisions, measured performance, continuous improvement, and reward. The test of learning is the ability to explain these issues to others, such as customer stakeholders, beginning supervisors, and new employees. We believe one effective path to mastery is to use the book partly as a text and partly as a reference. Some of the detail should be memorized, for immediate recall in conversations with others. The functions of the governing board (Chap- ter 4), the way budgets are developed (primarily chapters 3, 4, 7, and 12), and the use of the epidemiologic planning model (every chapter from 4 to 15) are prime examples. Other matters are not unimportant, but when they arise, they can be reviewed through the index and the table of contents. A beginning student might best master the text, not by reading from page 1 to page 600 but rather by interacting with each chapter: 1. Read In a Few Words to focus on the contribution of the activity. 2. Study the Critical Issues, making an effort to relate them to her prior experience. xxvi The Well-Managed Healthcare Organization 3. Review the details of the functions to under- Online Learning System stand how each element contributes to the whole and how each is best implemented. The text offers a two-part online learning system 4. Study the exhibit that shows the performance designed to help students and instructors. measures, and review the Measures section to understand how the measures are defined and The Companion Website is designed for students used. and is available at ache.org/books/Well-Managed7. 5. Check the Managerial Issues section for It contains the following: important elements that relate the activity to management in the organization as a whole An overview of how to use the text to become an and to sustaining high performance. effective healthcare organization manager 6. Review the Questions for Discussion in rela- tion to her or his prior experience, striving A glossary of all the technical terms identified in to understand both the importance of the the text question and the best way it can be answered A folder for each chapter that contains (1) a one- in real HCOs. 7. Consider how the material in the chapter can page guide to mastering the chapter; (2) “Chap- be effectively conveyed to the right people in ter Learning Goals and Milestones,” a list of an HCO—that is, how can it be best sum- the questions a professional should be able to marized in formal policies and procedures, answer and guides to where in the chapter the in training programs, and in day-to-day answers can be found; and (3) “Additional Ques- interactions. tions for Discussion” to supplement the ques- tions in the text. The questions are in addition The text can certainly be mastered in to the five given in each chapter. They illustrate self-study. We believe a class or discussion the issues managers must think about as they re- group and a mentor or teacher can help sub- spond to associates’ questions and opportunities stantially, particularly in the latter steps. for improvement. Instructor Resources are available only to quali- Acknowledgments fied instructors. They contain all the Companion As the editions of The Well-Managed Health- Website elements plus chapter-by-chapter teaching care Organization mount, keeping track of tips, guides for leading the Questions for Discus- all who have contributed to this text by their sion, slides for classroom presentations, and grad- examples becomes difficult. The applications able questions with answer rubrics. (For access, of the HCO recipients of the Malcolm Bal- please apply at [email protected] and include your drige National Quality Award are the most course, university, and department names.) comprehensive documentation of the trans- formational and evidence-based approach. Our visits to Catholic Health Initiatives, Henry Ford Health System, Intermountain Healthcare, Legacy Health Sys- tem, Medicorp Health System, MedStar Health, Moses Cone Health System, and Sentara Healthcare have helped us understand how leading practices are designed and implemented.  Preface xxvii Over a period of time, both of us have worked with specific organiza- tions, including Summa Health System in Akron, Ohio; Allegiance Corpo- ration (a physician hospital organization) in Ann Arbor, Michigan; Mercy Health Center in Oklahoma City, Oklahoma; Mercy International Health Services in Farmington Hills, Michigan; and Bon Secours Health System in Marriottsville, Maryland. We are grateful to these HCOs. We are also grateful for the assistance of our colleagues at the University of Michigan and Virginia Commonwealth University. Kenneth R. White, PhD, FACHE Virginia Commonwealth University Richmond, Virginia John R. Griffith, MBA, FACHE The University of Michigan Ann Arbor, Michigan  1 CHAPTER 1 FOUNDATIONS OF HIGH-PERFORMING HEALTHCARE ORGANIZATIONS In a Few Words Healthcare organizations (HCOs) include all organizations that provide healthcare. The Well-Managed Healthcare Organization focuses on excellent HCOs—those that delight their patients, families, caregivers, and other associates and that provide care that is safe, effective, patient-centered, timely, efficient, and equitable. To achieve excellence, HCOs build a culture around their mission, vision, and values. They empower their associates, encourage them to meet patient and customer needs, measure their performance, and reward them for improvement. They use evidence-based medicine and systematic analysis of work processes. Extensive boundary-spanning and strong internal relationships allow them to meet strategic challenges. They carefully protect their organizational resources from any kind of loss or diversion. Critical Issues in Excellence 1. Emphasizing mission, vision, and values. Make the contribution and importance of care itself a shared value. 2. Building a culture that listens, empowers, trains, and rewards. Begin a program that identi- fies what people see as barriers to their work and remove them. 3. Measuring performance, seeking benchmarks, and negotiating realistic goals. Add quality, customer satisfaction, and associated satisfaction measures for every work unit. 4. Maintaining close relations with all stakeholders. Extend the listening activities so that every major affiliate has a point of contact and is assured of fairness and responsiveness. 1  QUESTIONS FOR DISCUSSION Consider these questions as you read the chapter. 1. This chapter outlines a transformational style of management, emphasizing val- ues, empowerment, communication, trust/accountability, and rewards. Why do high-performing HCOs strive for transformational styles? Some people say that transformational is completely unrealistic; you must enforce order, they say, to have accountability. How is accountability achieved in high-performing, transformational HCOs? How comfortable would you be working in a high-performing, transformational organization? 2. The history and current activities of HCOs are strongly oriented to healing the sick. The first word of this chapter—“patients”—is consistent with that tradition. Some say that the real role of HCOs is community health, including but going well beyond healing the sick. (Contrast the missions of SSM, Bronson, and Saint Luke’s with those of Baptist, Robert Wood Johnson, and North Mississippi in Exhibit 1.7.) Should the text have started with, “Building healthy communities is the focus of HCOs, including patient care but going well beyond”? 3. Systematic change (page 29) is a four-step process: identify, analyze, test, evaluate. What is new about that? Could you achieve systematic change without measurement and benchmarking? Think of your last encounter with a service organization (e.g., HCO, university, restaurant). What would be different if the organization practiced continuous improvement and systematic change? 4. What happens to an organization that fails in its strategic positioning (see Exhibit 1.14)? Can you name an example or two, and then identify with hindsight where they failed? 5. Ben Franklin founded The Pennsylvania Hospital in 1760, before the American Revolu- tion. His fund-raising arguments were as follows:49 We need a refuge for the unfortunate, and Christianity will reward you for your generosity to this cause. (Although Franklin did not say so, Islam, Buddhism, and Judaism also praise charitable behavior.) You might need it yourself this very night. Among other things, we can keep contagious people off the streets. We can certainly handle this better as a community than as individuals. Grants from the Crown and the Commonwealth will lower the out-of-pocket costs. (He might have added that the grants were “new money” that would eventually end up in Philadelphians’ purses.) 2  Chapter 1: Foundations of High-Performing Healthcare Organizations 3 P atients are the focus of healthcare, and in the twenty-first century pa- tients are commonly treated by teams. A single caregiver working alone soon must seek support for clinical needs like laboratory, imaging, and pharmacy, or for logistic ones, like information, facilities, and supplies. For a serious problem, such as heart surgery or recovery from stroke, several differ- ent caregiving teams will be required. Cure will result from the coordinated efforts of close to 100 people bringing highly specialized skills and using an array of diverse equipment and an extensive set of drugs and supplies. Con- tinuing management of the underlying cardiovascular disease will require a different team that will support the patient for months or years. The health- care organization (HCO) creates, supports, and co- ordinates those teams. It is a formal legal entity that Healthcare organization (HCO) reaches across the panorama of medicine, other clini- A formal legal entity that reaches across the pan- orama of medicine, other clinical disciplines, and cal disciplines, and business to identify and deliver business to identify and deliver care to its community care to its community. Activities An HCO supports individualized patient care with an array of teams, as shown in Exhibit 1.1. The caregiving teams differ according to patients’ needs. They are backed by three levels of support—clinical, logistic, and strategic—that are themselves composed of specialized teams. Each patient care team per- forms an activity that is essential to a specific group of patients, and each support team performs an activity that is essential to the work of some or all patient care teams. A small HCO has few patient care activities and contracts with other organizations for support; a large one has a broad array of patient care and support. A healthcare system has many patient care activities in sev- eral geographic locations. Teams are usually housed in purpose-built spaces (e.g., clinics, op- erating rooms, business offices) so that HCO facilities reflect the activities depicted in Exhibit 1.1. With the growth of electronic communication, how- ever, many teams can be geographically remote. A primary care team needs a process that yields timely laboratory results, but that might be a centralized laboratory. All care teams require strategic capability, but it might be provided from the system headquarters in another state. Exhibit 1.1 is static. Any real HCO is highly dynamic in three senses: 1. The HCO constantly responds to the changing array of patients and their changing needs. This makes most HCOs a 24/7/365 operation. 2. The HCO evolves as medicine and management change, reflecting both the latest scientifically proven treatments and new developments in management practices and information technology. 3. The HCO adjusts to the changes in its community’s needs.  4 The Well-Managed Healthcare Organization As the population grows, shrinks, and changes in age and ethnic diver- sity, the epidemiology of disease changes and the HCO must respond. One function of the strategic activities is to manage these changes. While the focus of the clinical and support activities is “this patient, now,” the strategic focus is “all patients, into the future.” Contribution The mission HCOs fulfill is one of humanity’s highest callings: to assist others in the “beginning of life, the end of life, and the shadows of life.”1 HCOs are essential treatment resources for heart disease, cancer, stroke, obstetrics, major trauma, and several hundred other conditions, providing preventive and episodic care, emergency care, surgery, intensive care, rehabilitation, chronic disease main- tenance, and end-of-life care. At least one large HCO exists in virtually every county in the United States and is usually surrounded by several smaller ones such as doctors’ offices. About 60 percent of Americans use HCOs in a given year. Although most contacts are relatively simple office visits, one in ten Ameri- cans is hospitalized and about three in ten require major outpatient care.2 It is a rare family who has not had recent contact with an HCO. That contact is often lifesaving, but it is also often intimate, expensive, life threatening, and frightening. EXHIBIT 1.1 Components of Healthcare Organizations Caregiving Teams* provide care Clinical Support Teams* provide to patients with similar needs. specific clinical services to Major caregiving groups are Caregiving Teams. Important Primary care (family examples are medicine, general internal Clinical laboratory medicine, pediatrics, Caregiving obstetrics, psychiatry, Pharmacy Teams advanced care practitioners) Imaging Acute care (by specialty) Cardiopulmonary Rehabilitation laboratory Home care Clinical Support Teams Surgery/anesthesia/recovery Hospice intensive care Continuing care Physical therapy Logistic Support Teams Social service Strategic Support Teams Strategic Support Teams* provide Logistic Support Teams* provide marketing, governance, internal trained personnel, information, consulting, finance, stakeholder relations facilities, accounting, cash management, and strategic positioning. management, and supplies. They protect the HCO’s culture and tangible resources. *HCOs have varying sets of clinical or clinical support activities. The logistic support and many strategic support activities are required for any clinical activities.  Chapter 1: Foundations of High-Performing Healthcare Organizations 5 The nation’s HCOs are the point of implementation for a healthcare system that has grown from its commitment to “promote the general welfare” (as stated in the Preamble to the Constitution) to be one of America’s largest collective endeavors. The U.S. per capita cost of healthcare is the highest in the world, consuming about one-fifth of the gross domestic product. HCOs and their physician affiliates consume about half of the cost. They justify their cost by meeting powerful individual drives for health and longevity, by mak- ing a substantial direct contribution to their local economies, and by imple- menting a widespread commitment to Samaritanism and social justice. The American healthcare system can be viewed as an investment, contributing to national productivity by adding years of healthy life. Despite its cost, the in- vestment is highly profitable.3 Much of the cost is returned to the community through employment,4 as an HCO is often the community’s largest employer. Stakeholders Formal organizations exist because they fulfill a need Stakeholders that individuals working alone cannot meet,5 and they Individuals or groups (buyers, workers, suppliers, thrive because they fulfill that need better than compet- regulators, and owners) who have a direct interest in ing alternatives.6 By definition, any organization serves an organization’s success many masters or stakeholders—individuals or groups who have a direct interest in its success. Organizations are economic entities shaped by stakeholder needs. Stakeholders are buyers, workers, suppliers, regulators, and owners who cooperate through economic exchanges as shown in Exhibit 1.2. In a free society, stakeholders can choose to participate in the organization or not, and a shortage caused by some stakeholders EXHIBIT 1.2 General Model of Stakeholder–Organization Interaction Owners Individuals or groups who have contributed capital to the organization Capital Returns Customers/Buyers Services Services Suppliers/Workers Individuals or groups Individuals or groups who have needs that Organization who have resources that they want to fulfill they want to contribute Compensation Compensation Laws, regulations, and societal constraints  6 The Well-Managed Healthcare Organization selecting alternative sources is disabling for the organization. Organizational ex- cellence begins with and is measured by stakeholder satisfaction. Exhibit 1.2 reflects most of the world’s economic activity, but reality is not a simple as it suggests. Stakeholders’ desires are inherently conflicting. The buyer wants to buy inexpensively; the supplier to Customers sell dear. Each of us is a stakeholder in many organi- Patients and others who use the services of the organi- zations. Most of us are alternately buyer (i.e., cus- zation and generally compensate the organization for tomer) stakeholders and seller (i.e., provider) those services; also, by extension, other units within stakeholders, and we and our organizations exist in the HCO that rely on a particular unit for service networks of negotiated solutions to those conflicting Providers desires. The most fundamental element is neither our Institutional and personal caregivers such as physi- organization nor our stakeholder desires; it is our cians, hospitals, and nurses ability to negotiate. An important way to understand organizations is as devices to negotiate solutions. Because of the cost, financing structure, im- portance, and the intimate and life-changing nature of healthcare services, American HCOs represent one of the most complex applications of Exhibit 1.2. Several levels of complexity are added. The stakeholder environment for HCOs is shown in Exhibit 1.3; the complexity of HCOs arises from the mul- tiplicity of HCO stakeholders and from the nature of healthcare services. Customer Partners Patients and Patients are the most important stakeholders. They expect, and deserve, care Families that meets the goals summarized in the Institute of Medicine’s report Cross- ing the Quality Chasm: safe, effective, patient-centered, timely, efficient, and equitable.7 They also expect reasonably comfortable amenities and confiden- tiality. Friends and family accompany most patients, and many family mem- bers serve as informal caregivers, so HCOs must establish close and direct relations with them. Patients’ expectations include a major element of trust. Information asymmetry—the organization and its caregivers possess substantially more knowledge about the patient’s needs than the patient does—makes it impos- sible for many patients and families to articulate their needs. Instead, they ex- pect the HCO to do that for them, thoroughly and fairly. Much of the failure in patient relations comes from difficulties with managing that trust. Health Patients rely on a variety of mechanisms to pay for care, which can easily Insurers and cost a large fraction of a family’s annual income. Health insurers and fiscal Payment intermediaries provide most of the revenue to HCOs, making them essential Agencies exchange partners. Private health insurers are agents for buyers, which in- clude governments, employers, and citizens at large. Two large governmental insurance programs—Medicare and Medicaid—are exchange partners with  Chapter 1: Foundations of High-Performing Healthcare Organizations 7 most HCOs. The federal Medicare program deals Intermediary with HCOs through its intermediaries.8 Medicaid, A payment or management agent for healthcare a combination state and federal program that fi- insurance (e.g., Medicare intermediaries that pay nances care for the poor, is run by the state Medicaid providers as agents for CMS) agency or an intermediary. Representing the buyers, payment organizations use contractual requirements, Medicaid agency regulatory support, and incentive payments to im- The state agency handling claims and payments for Medicaid prove the quality, safety, and cost of care. Much health insurance is provided through employment, making employers Buyers important exchange partners. Historically, unions played a major role in estab- lishing health insurance as an employee benefit. Federal, state, and local gov- ernments purchase care for special groups of citizens and also buy insurance as employers do. Buyers, who must meet the demands of their own exchange networks, have taken action to restrict the growth of costs, acting principally through payment organizations. Their pressure is likely to continue. EXHIBIT 1.3 Model of Stakeholder–HCO Interaction Owners Not-for-profit corporations, for -profit corporations, and government entities Patients and families Caregivers differentiated by age, differentiated by gender, and clinical need professional credentials Suppliers/Workers Customers/Buyers Other employees HCO Health insurers and differentiated by job payment agencies description differentiated by carrier Contract providers and kind of coverage differentiated by purpose of contract Buyers Local, state, and federal licenses, permits, and differentiated by Suppliers certifications individual, employer, Private certifications and accreditations Volunteers and government Healthcare-specific laws and regulations General corporate l