At the invitation of Guest Editor Duncan Neuhauser, Professor of Health Management in the Department of Epidemiology and Biostatistics of Case Western Reserve University's School of Medicine, and an Associate Editor of Quality Management in Health Care, a group of outstanding contributors have come together to present their thinking on issues of health care quality management. These authors are all participants in the Medical Management Research Center programs of the Karolinska Institute of Stockholm, Sweden. In carrying out the studies reported here, they had the benefit of access to the extraordinary health care databases maintained in Sweden. As Karin Pukk and her co-authors comment, "[horizontal ellipsis] there are few countries that can match Swedish data collection and the open availability of the data."
To analyze the ways in which Swedish health care provider organizations are dealing with the pressures for systemic improvement, Olsson, Kammerlind, Thor, and Elg surveyed the managers of all primary health care centers and clinical hospital departments in Sweden, achieving a 46% response rate. They found that the principal driver of improvement efforts was an institutionalized process of internal coordination, rather than external influences such as accreditation, customer focus, or benchmarking. They named this process the Internal Collaborative Strategy (ICS), and have provided an analysi and evaluation of its components.
Book, Hellstrom, and Olsson studied managers' perceptions of the value of improvement efforts in Swedish health care organizations. It is important to note that their research focused on those managers who did regard their improvement work as bringing about benefits. The responses even from this generally "favorable" group of managers indicated that more than 50% of them felt that the practices and techniques of quality improvement were complex and associated with difficulties in application. In addition, approximately 50% of these managers perceived a conflict between improvement work and the demands of the ongoing daily work of the organization's members. The authors suggest that this finding indicates a need for accommodative measures to permit the two systems to function in tandem. They state that this adaptation is a primary concern in the health care delivery system. The authors analyze these findings in detail, discussing the implications for the health care delivery system.
Exploring and analyzing national patient injury claims data, Karin Pukk and her co-authors found gender and age differences that strongly suggest not only that women receive care of poorer quality than that accorded to men, but also that these differences exist in the filing and adjudication of malpractice claims.
In another article, Pukk and her co-authors point to the essential role of management in bringing about organizational improvement by providing goals, structures, and incentives. It follows that, to perform effectively in this role, the manager must be aware of the problems. The authors explore the level of awareness of managers concerning an issue-patient safety-that is a vital element in health care quality. They found a low level of awareness of this issue among managers, leading them toconclude that efforts to improve safety will not be high on the management agenda. They recommend that actions be taken to raise managers' awareness of safety problems and issues.
Olsson, Ovretveit, and Kammerlind address the task of developing effective research models in the field of organizational research and of evaluating and applying them in real-world situations. They conclude that the predictive Swedish Organizational Change Model (OCM) could be useful to health care management staff in the effort to bring about effective quality improvement projects.
Striem, Ovretveit, and Brommels examine the impact of organizationwide quality improvement programs and the application of TQM and CQI principles to health care organizations. To do this, they present a case study based on the experience of the 500-bed Danderyd Hospital, one of the four acute care hospitals in the Stockholm region. In addition to a detailed history and evaluation of the multifaceted quality improvement program, they offer their insights concerning the respective roles of managers or administrators and the clinical professional staff in the development and implementation of an organizationwide improvement program.
In discussing the issues in transnational transferability of mechanisms for change, Olsson and Elg compare two models, reflecting, respectively, the Swedish and United States approaches. Although their original objective was to merge the two approaches into one single model, they concluded that this was impossible because of differences between the two models. They recommend additional research on the issues that were explored.
In a wide-ranging interview, William H. Roach, Jr, JD, provides his insights into the implications of the United States Health Insurance Portability and Accountability Act (HIPAA) and on corporate relationships, including transactions between hospitals and physicians.