Do mergers enhance the performance of hospital efficiency?

Due to the wave of mergers that have taken place in the USA, the early 1990s could be labelled as a restructuring era for health care systems. The question of whether mergers have an impact on organizational performance is still an area of interest for health services researchers. In this study, we examined the impacts of horizontal mergers of US hospital's technical efficiency before and after merger using longitudinal Data Envelopment Analysis (DEA). The findings of our study illustrate that mergers do increase a hospital's level of efficiency. Constant returns-to-scale model indicated an overall reduction in input utilisation after merger, compared to variable returns-to-scale model. This indicates the role of scale efficiency as a dominant source of improvement in inefficiency of hospitals involved in horizontal mergers, but not for technical efficiency. Suggestions for future study are provided.     

Performance Monitoring and Competence Assessment in Health Services

Health and health service monitoring is among the most promising research area today and the world work towards efficient and cost effective health care. This paper deals with monitoring health service performance using more than one performance outcome variable (multi-attribute processes), which is common in most health services. Although monitoring whether a health service changes or improves over time is important this is well covered in the current literature. Therefore this paper focuses on comparing similar health services in terms of their performance. The proposed procedure is based on an appropriate control chart. The paper deals with firstly the case when no risk adjustment is required because the health services being compared treat the same patient case-mix which does not vary over time. Secondly it deals with comparing health services where risk adjustment is required because the patient case-mix they service do differ because they service either very different geographical locations or service very different demographics of the same population. The technology developed in this paper could be used for example to assess and compare health practitioners’ competence over time, i.e. to decide if two doctors are equivalent in terms of their outcome performances. The waiting time random variable associated with the run length distribution of the control charts (as well as to competence testing) is studied using a Markov Chain embedding technique. Numerical results are provided that exhibit the value of the proposed procedures.     

Administrative days in acute care facilities: a queueing-analytic approach.

After acute care services are no longer required, a patient in an acute care hospital often must remain there while he or she awaits the provision of extended care services by a nursing home, through social support services, or by a home health care service. This waiting period is often referred to as "administrative days" because the time is spent in the acute facility not for medical reasons, but rather for administrative reasons. In this paper we use a queueing-analytic approach to describe the process by which patients await placement. We model the situation using a state-dependent placement rate for patients backed up in the acute care facility. We compare our model results with data collected from a convenience sample of 7 hospitals in New York State. We conclude with a discussion of the policy implications of our models.     

Representing Medical Protocols for Organizational Simulation: An Information-Processing Approach

Organizational simulations have been used in business, manufacturing, and engineering design tasks to gain insight into organizational process bottlenecks, and to improve the quality and efficiency of processes within these industries. As market pressures demand increased efficiencies within the health care industry, organizational simulation techniques could provide similar insight into the design of better medical care processes, or protocols, in medical organizations. To simulate the process of medical care within a specific organization however, requires models that can represent (1) unpredictable patient responses to care, (2) the flexibility needed to adapt to different patients, and (3) different preferences of health care professionals and the implicit preferences contained within the protocol. Using previous work on simulation in the Virtual Design Team (VDT), and an example protocol drawn from an existing protocol in bone marrow transplantation, we describe extensions to the VDT information-processing representation that will allow us to simulate the performance characteristics of a medical protocol used within a medical organization. Our representational extensions capture the uncertainty of medical care for patients, the activity flexibility within the organization, and the preferences of health care professionals that will make information-processing organizational simulations in the medical domain possible. We believe our representation will provide a robust simulation tool box that can be used to investigate the performance of specific medical protocols within different hospital settings, and explore organizational theory within the health care industry.     

Planning midwifery services to deliver continuity of care

This paper describes a simulation model of maternity services which was developed to support the planning of midwifery services to meet demands for continuity of care. A Government report of maternity services in 1992 emphasised the need to replace the fragmented care offered to pregnant women by a more personalised type of approach. One way of doing this is by the implementation of team midwifery in which care is provided, antenatally, during labour, and then postnatally by either the same midwife or, more usually a small team of midwives.The model described in this paper attempts to assess the effects of team size upon the continuity of care provided to pregnant women under different implementations. Continuity is measured in terms of the percentage of occasions a team midwife will be available to meet the health care demands of pregnant women. The model may be used not only for the evaluation of services already in use, but also for the planning of alternative and better services.     

Insights and decision support for home health care services in times of disasters

Central European Journal of Operations Research - Home health care (HHC) services are of vital importance for the health care system of many countries. Further increases in their demand must be...     

Truck routing and scheduling

The problem is part of a complex software solution for truck itinerary construction for one of the largest public road transportation companies in the EU. In practice a minor improvement on the operational cost per tour can decide whether a freight services company is profitable or not. Thus the optimization of routes has key importance in the operation of such companies. Given an initial location and an asset state one must be able to calculate a cost optimal itinerary containing all Point of Interests. Such an itinerary is an executable plan which exactly specifies the location and activity of an asset during the whole timespan of the itinerary. If parking places and gas stations are included in the planning then it is NP hard to find an optimal solution. This means that for long range tours an approximately optimal solution for refueling has to be given within an acceptable running time. Also the corridoring of the trucks is an important problem so that we try to optimize the performance, hence tours cannot be recalculated at each data arrival. The vehicle assignment part of this work is already finished and applied with very good results. The remaining part is subject of an ongoing research which started at January 2014. The company started to apply and test our product in the beginning of 2015 under increased human supervision. As a consequence of the project a large cost saving is anticipated by the company.     

Supporting decision making to improve the performance of an Italian Emergency Medical Service

An Emergency Medical Service (EMS) plays a fundamental role in providing good quality health care services to citizens, as it provides the first answer in distressing situations. Early response, one of the key factors in a successful treatment of an injury, is strongly influenced by the performance of ambulances, which are sent to rescue the patient. Here we report the research carried on by the authors on the ambulance location and management in the Milano area (Italy), as a part of a wider research project in collaboration with the EMS of Milano and funded by Regione Lombardia. The question posed by the EMS managers was clear and, at the same time, tricky: could decision making tools be applied, based on the currently available data, to provide suggestions for decision makers? To answer such a question, three different studies have been carried on: first the evaluation of the current EMS system performance through statistical analysis; then the study of operational policies which can improve the system performance through a simulation model; and finally the definition of an alternative set of posts through an optimization model. This paper describes the methodologies underlying such studies and reports on how their main findings were crucial to help the EMS in changing its organization model.     

Economic evaluation of chronic conditions: framework for a quasi-Markov process

This paper presents a general model for economic evaluation of treatments of chronic conditions. The model is applicable in the situation where multiple possible treatments are available none of which is completely satisfactory by virtue of either lack of effect of adverse effects occurring for some patients. Treatments may include any process designed to enable patients to manage their condition. Since none are completely satisfactory, the model cannot determine the ‘best’ treatment, merely help identify an order in which treatments should be tried. This economic model must be used in conjunction with clinical or other relevant information. The model should be used to make comparisons between treatment options within one discrete category. The information provided can thus assist allocative microeconomic decisions, where funds must be allocated between specific competing alternatives. These decisions may apply to either purchasers or providers of health care services.     

On comparing the performance of primary care providers

In the past few years primary health care has been characterised as central to the development of the National Health Service in the United Kingdom. Furthermore, performance assessment is seen as a way of achieving care of high standards. Performance indicators and targets are being developed to assess primary care providers, and to develop financial incentives. However, the number of studies that have compared the performance of primary care providers is limited and the existing approaches to evaluation are open to improvement.     

Location of Preventive Health Care Facilities

This paper is focused on the problem of locating preventive health care facilities. The aim is to maximize participation to prevention programs. We assume that distance is a major determinant of participation and people would go to the closest facility for preventive health care. Each facility is required to have more than a predetermined number of clients because of the direct relationship between volume and quality of preventive services. We provide a mathematical formulation and present alternative solution approaches for this new location problem. We report on computational performance of the proposed methods in locating public health centers in Fulton County, Georgia and mammography screening centers in Montreal, Quebec.     

Risk-adjusted control charts for health care assessment

The recent Joint Commission on Accreditation of Healthcare Organization (JCAHO) requirement that hospital accreditation be based upon a Total Quality Management (TQM) approach has focused the attention of health care administrations on the use of techniques such as control charts. However, control charts are not typically adjusted for severity of illness. This adjustment is needed because, unlike industrial organizations, hospitals are not able to control all of their inputs and must accept variances in their patients. In this paper, we present a methodology for adjusting a health care organization's control charts to reflect their patient population's severity of illness during different time intervals. We then demonstrate that risk-adjusting expected patient outcomes can change our assessments of the relative quality of care offered by a health care organization in different time periods.     

The Use of Soft Systems Methodology in the Development of a Simulation of Out-patient Services at Watford General Hospital

The effective and efficient provision of out-patient services may be assisted by the appropriate use of discrete event simulation. Resource use must be carefully monitored and suitable control actions must be taken, if service level and quality are to be maintained, whilst keeping cost increases to a minimum. In itself, simulation provides no means by which system activities may be identified. The use of soft systems methodology as a tool to aid in activity identification for simulation modelling is being explored. The investigation focuses on the effects the participative nature of soft systems methodology has on the acceptability of a simulation model. This case study forms part of a research objective of developing a generic approach to link soft systems methodology and simulation. Its aim is to provide analysts and managers with a process which may assist in planning strategies for health care.     

Integrating restoration and scheduling decisions for disrupted interdependent infrastructure systems

We consider the problem faced by managers of critical civil interdependent infrastructure systems of restoring essential public services after a non-routine event causes disruptions to these services. In order to restore the services, we must determine the set of components (or tasks) that will be temporarily installed or repaired, assign these tasks to work groups, and then determine the schedule of each work group to complete the tasks assigned to it. These restoration planning and scheduling decisions are often undertaken in an independent, sequential manner. We provide mathematical models and optimization algorithms that integrate the restoration and planning decisions and specifically account for the interdependencies between the infrastructure systems. The objective function of this problem provides a measure of how well the services are being restored over the horizon of the restoration plan, rather than just focusing on the performance of the systems after all restoration efforts are complete. We test our methods on realistic data representing infrastructure systems in New York City. Our computational results demonstrate that we can provide integrated restoration and scheduling plans of high quality with limited computational resources. We also discuss the benefits of integrating the restoration and scheduling decisions.     

Optimal location of public health centres which provide free and paid services

A model and a heuristic are presented for finding the most effective location of public health centres providing non-vital services in competition with existing private health centres. While private centres provide only services to customers who can pay for them, public centres provide both paid services to affluent customers, and subsidised services to customers belonging to low-income groups (a hierarchical structure). While low-income customers are assigned to fixed public centres, high-income customers can choose which centre to patronise. To find the solution of this problem, the equilibrium between maximum coverage of low-income population (within a pre-specified distance), and an adequate capture of high-income population must be found. Thus, in the public service, the revenues obtained from paid services are used to partly cover the costs of the subsidised services, and the number of centres that can be located depends on how many high-income clients can be captured. Capture of a high-income client happens when a public centre is located closer to the client than any of the existing private centres. Computational experience with optimal, as well as special heuristic, methods for solving this problem is described.     

Robustness in Practice—The Regional Planning of Health Services

Earlier work has criticized the dominant tendencies in operational research contributions to health services planning as characterized by optimization, implausible demands for data, depoliticization, hierarchy and inflexibility. This paper describes an effort which avoids at least some of these pitfalls. The project was to construct a planning system for a regional health council in Ontario, Canada, which would take account of the possible alternative future states of the health-care system's environment and would aim to keep options for future development open. The planning system devised is described in the paper. It is based on robustness analysis, which evaluates alternative initial action sets in terms of the useful flexibility they preserve. Other features include the explicit incorporation of pressures for change generated outside the health-care system, and a satisficing approach to the identification of both initial action sets and alternative future configurations of the health-care system. It was found possible to borrow and radically 're-use' techniques or formulations from the mainstream of O.R. contributions. Thus the 'reference projection' method was used to identify inadequacies in performance which future health-care system configurations must repair. And Delphi analysis, normally a method for generating consensus, was used in conjunction with cluster analysis of responses to generate meaningfully different alternative futures.     

Developing collective capacity to improve mathematics instruction: Coaching as a lever for school-wide improvement

Mathematics coaching, as typically practiced in US schools tends to be responsive and individually focused work in which coaches respond to invitations from individual teachers to help them improve their teaching. But what does the work of coaching look like if it is organized instead to engage teachers collectively in service of school-wide improvement? This is the question we take up in this paper through examining the case of one school-based elementary mathematics coach whose work more closely aligned with emerging findings in the field of instructional improvement about the power of coaching for school-wide reform. The coach helped to dramatically transform a recent history of poor performance and deficit-oriented narratives pertaining to the school and its children. Through a fine-grain analysis, we illustrate the coach’s work implicated in supporting groups of teachers to come to mutual understanding around and further development of shared high-quality instructional practices. The components of coaching that help support collective capacity are discussed.     

The utility of returns to scale in DEA programming: An analysis of Michigan rural hospitals

In 1984, Banker, Charnes, and Cooper introduced the capability of using data envelopment analysis to assess increasing, decreasing, or constant returns to scale. This analysis would appear to make an important contribution to the health care field because of the regulatory environment within which the industry exists and the competition among hospitals for additional services and capacity. In many states, hospitals must submit a “certificate of need” to prove eligibility to add capacity or services. Agency administrators at the state level should analyze each hospital's production performance to determine the effectiveness of resource utilization. Residents of a state where hospitals are regulated need to know the effectiveness of agencies in allowing resources to be properly allocated to hospitals. Returns to scale analysis can help provide answers to these concerns. We examine Michigan rural hospitals and propose a simple, yet logical procedure for evaluating returns to scale for technically inefficient hospitals.     

基于中医健康云的健康养老服务平台设计与应用

中医健康云能将中医的特色化、标准化与大数据、人工智能应用完美融合。本文基于中医健康云技术和老龄群体对养老服务的迫切需求,对中医健康云服务平台和架构设计进行建设性研究,同时分析中医健康云平台的关键技术所在,进而提出中医健康云在健康养老服务中的应用设计。以期利用互联网与大数据,融合传统中医智慧,对老龄群体的健康进行动态跟踪与实时咨询,为老年群体提供及时、有效和针对性的健康养老服务。     

Every Proposition is a Counterfactual

I present and discuss two logical results. The first shows that a non-trivial counterfactual analysis exists for any contingent proposition that is false in at least two possible worlds. The second result identifies a set of conditions that are individually necessary and jointly sufficient for the success of a counterfactual analysis. I use these results to shed light on the question whether disposition ascribing propositions can be analyzed as Stalnaker-Lewis conditional propositions. The answer is that they can, but, in order for a counterfactual analysis to work, the antecedent and consequent must be related in a particular way, and David Lewis’s Time’s Arrow constraints on comparative world similarity must be relaxed. The upshot is that counterfactual analyses are easy to come by, in principle, even if not in practice. In that sense, it’s easy to be iffy.