This issue offers articles that address the wide interests of our readers. Topics range from operational to strategic issues and from patient care to organizational structure. The articles feature case studies, conceptual work, and empirical studies, and the organizations that are represented include community-based health and human services as well as hospitals. Thus this issue should be of interest to practicing managers as well as researchers.

Despite this variety, there are also links between the articles. In several instances changes in provider reimbursement systems are identified as the impetus for the events that are studied. This is the case, for example, with the Sinay and Campbell paper, the Bazzoli et al. study, as well as the work by Provan et al. The first two focus on hospital mergers. The Sinay and Campbell study compared hospitals that had merged with hospitals that had remained independent on several measures of performance. The research showed that merged hospitals were able to lower their premerger costs within a few years and bring them in line with the costs of hospitals that had not merged. They did so by reducing the number of beds, replacing full-time with part-time employees, and cutting services, while increasing outpatient care. The findings of this article represent a realized strategy; we do not know what the intended strategy was.

Intended strategy is identified in the article by Bazzoli et al., who also studied hospital mergers. These researchers compared hospital mergers in the 1980s with hospital mergers in the 1990s and found that hospitals in both periods identified similar primary reasons for the event, e.g., stronger financial position, operating efficiencies, and service consolidation. Both the earlier and later merger partners undertook reductions in services, nursing staff, and administrative personnel, as part of the merger, but the relative emphasis on these steps differed between the earlier and later mergers. The authors point out that future research is needed to determine whether cost reductions actually occurred as a result of the mergers.

For our part, we were also interested in the consistency of the claims hospitals made in support of the merger in both time periods. We have found hospitals to be quite adept in presenting a variety of strategic moves in ways that are socially acceptable to their stakeholders. Regardless of the time period, it would be hard to imagine stakeholders who would not support their hospital in its desire to strengthen its financial position, become more efficient, or engage in reengineering. These steps all represent laudable conduct during times of tight resources and when hospitals are labeled as inefficient and wasteful. As usual, though, the devil is in the details. Both of the merger studies showed that the event was associated with elimination of services and reductions in patient care staff. It would be interesting to know what effect such consequences had on employment in the community and on access to services. Bazzoli et al. hint at these questions themselves in their discussion when they point out that implementation of mergers must take into account the local market conditions.

While many hospital mergers were encouraged by the changes in the Medicare reimbursement system, managed care and its associated risk taking by providers is another important impetus for structural change in the health care system, as shown in the article by Provan, Milward, and Isett. This research studied the provision of mental health services in an urban area. Under the aegis of a regional authority, three capitated subsystems were created that were responsible for services to the clients. This study, too, reveals that a change in reimbursement (from fee-for-service to capitation) led to changes in services, in this case less hospital care and less case management in favor of more outpatient care and increased use of medication. The findings with respect to services echo the ones in the two hospital merger studies and would be consistent with how we have come to expect providers to behave under tighter resource constraints. What did come as a surprise is that rather than competing, as had been expected, the three subsystems increased coordination and collaboration and in the process made the overall systems more integrated, an outcome the researchers identify as beneficial for the clients.

Unanticipated consequences are common in a system as complex as health care, and an important job for managers is to design systems that minimize or cope with unanticipated events. Many authors who have written about quality improvement in health care have pointed out that such events are rarely the fault of an individual but more likely originate in the context and from the work systems in which the individual functions. This theme is taken up by Yourstone and Smith when they argue that the overall complexity of the system should be the focus in managing systems errors and failures. They make the case that hierarchical authority structures are not well designed for coping with demands in a complex system and that authority structures based on people's skills are superior because they help create connections and integrate input from more individuals. This article contains much food for thought at a time when medication errors have been discussed so extensively in the health care literature as well as the public press.

Quality improvement is also the topic in the article by Meyer and Schweikhart. They study the relationship between dimensions of the Baldrige Award Health Care Criteria (which look at what the organization does with respect to its focus on patients, planning, process management, etc.) and several measures of organizational performance. The researchers found particularly strong associations between the award criteria and patient satisfaction and staff satisfaction. The results were less compelling for other performance measures, such as clinical outcomes and financial performance. These authors allude to the complexity in health care as well when they point out that clinical outcomes are influenced by many factors that are not under management's control. This study points to fruitful areas for future research. Continuous quality improvement is firmly established in health care organizations and information that sheds light on its strengths as well as its limitations can only be helpful to managers.

Another form of outcome-the health status of entire populations-is the topic in the article by Studnicki et al. The article outlines the plans of one integrated delivery system to fashion its services in such a way that they will fit the specific needs of the populations it serves. The article provides a detailed description of a most ambitious data collection effort toward a comprehensive assessment of community needs, which were incorporated in the system's service priorities with the overall goal of improving population health status. It will be interesting to observe whether the system is able to sustain its focus and what the longer-term outcomes will be. The system's goals are certainly laudable and one can only hope for full success.

It gives us pleasure to present these articles to you in the hope that they contain useful information for managers and stimulate future research.

Margarete Arndt, D.B.A.

Barbara Bigelow, Ph.D.