One of the challenges we set for ourselves each issue is identifying unifying themes among the articles. As usual, the articles in this issue represent the wide range of theories and contexts that mark health management research, and also as usual, the richness of the themes that did emerge presents many opportunities for discussion and future research.

We begin the issue with a discussion that uses the article by Koichiro Otani and colleagues on patient satisfaction. The findings of the article and the comments highlight the importance of methodological rigor in patient satisfaction research. Decision making in the health care setting is extremely complex and involves much more than client preference. It also involves knowledge drawn from disparate sources and professional prerogatives.

We wonder what role media play in shaping expectations about the care that one receives as a patient. For years the public has been told that short hospital stays and outpatient care are better, to the point of warnings of hospital-acquired infections as an incentive for fast discharge. In contrast there are many fictionalized television shows that depict physicians working in heroic circumstances, extending themselves not only professionally but personally to respond to patient needs. Too often we look within the health care system to understand what affects patient expectations when perhaps broader social forces also have a significant impact.

The transfer of knowledge between health care organizations on the one hand and health care research, theories developed in other contexts, and non-health care organizations on the other have had considerable interest for us over the years. Looking at the other articles in this issue within that broad context is intriguing. First, Maxwell and Temin examine how Fortune 500 employers integrate quality into their purchasing and contracting decisions. Their finding that employers emphasize different dimensions than their counterparts in the health care sector (they place greater emphasis on customer service and access than clinical quality) has important implications for health care organizations. First, this knowledge enriches our understanding of this important stakeholder. Second, one of the reasons for the difference is that these companies (and the consultants upon whom they rely) lack clinical training. As the authors point out, the provider community has to play a leadership role on this issue. This represents an opportunity for health care organizations to become visible as an important source of information for the business sector. Referring back to our question about the impact of larger social forces, this article also suggests the need to take into account other frames of reference when trying to determine stakeholder expectations or priorities.

The next two articles, in very different ways, consider well-established approaches that have great potential in health care-learning curves and marriage. Waldman, Yourstone, and Smith provide a model of how to begin the process of importing models developed in other sectors (in this case manufacturing) to health care. They cite evidence that a strong positive volume-outcome relationship has been demonstrated for different medical procedures, and they develop a conceptual argument of why the principles of learning curve theory can be transferred to health care.

Often the theories and practices that are applied to health care organizations derive from business. Dooley and Zimmerman's article suggests that we cast our nets further. Using the metaphor of marriage as a lens for assessing mergers, they bring us back to the most important element of mergers-they do not occur between things but rather between people. This need to focus on the person within the numerous interactions echoes concerns expressed by Otani and colleagues.

The final two articles provide an opportunity, as did the article by Maxwell and Temin, to consider what knowledge health care organizations have that can be shared with organizations in other industries. Robinson, Savage, and Campbell argue that telemedicine can be an important method of international collaboration. Cultural differences have a profound impact on the delivery of health care, as is tragically demonstrated in the book by Anne Fadiman, The Spirit Catches You and You Fall Down. Issues of cultural differences impact any industry, but in health care they can have life and death consequences. The study of telemedicine collaboration can offer insights to industries well beyond health care. As is so often the case, management innovations that occur in health care are occurring in the most challenging conditions. Surely if they are successful in health care organizations they have potential for industries that are not so unpredictable and turbulent.

Page explicitly begins his article on the challenges of improving health care quality continuously within and across "virtual" provider organizations in the context of the pressures that physicians and other providers face. While the article draws on experiences in the auto industry, what struck us in reading the article is once again the immense complexity and number of constraints that health care organizations face relative to other organizations. This recommends health care organizations not just as recipients of knowledge developed in other industries, but as critical dispensers of knowledge.

-Barbara Bigelow, Ph.D.

Coeditor

-Margarete Arndt, D.B.A.

Coeditor