This paper reports findings from a study that combined two theoretical perspectives—top manager and network/institutional—to examine the factors influencing organizations to adopt innovative management practices. The study setting was a system of public hospitals and the innovation was Total Quality Management (TQM). Study results indicate that both top manager and network/institutional factors are important determinants of whether and when organizations adopt innovations. However, as predicted, the relative importance of these two sets of factors appears to change as an innovation becomes more widely diffused. Copyright © 2001 John Wiley & Sons, Ltd.

Study results suggest that hospitals and possibly other healthcare organizations should strive to develop a culture emphasizing teamwork and deemphasizing those aspects of bureaucracy that are not essential to assuring efficiency and quality care.

In 2009, tax-exempt hospitals varied markedly in the level of community benefits provided, with most of their benefit-related expenditures allocated to patient care services. Little was spent on community health improvement.

Objective. To examine quality improvement (QI) implementation in nursing homes, its association with organizational culture, and its effects on pressure ulcer care. Data Sources/Study Settings. Primary data were collected from staff at 35 nursing homes maintained by the Department of Veterans Affairs (VA) on measures related to QI implementation and organizational culture. These data were combined with information obtained from abstractions of medical records and analyses of an existing database. Study Design. A cross-sectional analysis of the association among the different measures was performed. Data Collection/Extraction Methods. Completed surveys containing information on QI implementation, organizational culture, employee satisfaction, and perceived adoption of guidelines were obtained from 1,065 nursing home staff. Adherence to best practices related to pressure ulcer prevention was abstracted from medical records. Risk-adjusted rates of pressure ulcer development were calculated from an administrative database. Principal Findings. Nursing homes differed significantly ( po.001) in their extent of QI implementation with scores on this 1 to 5 scale ranging from 2.98 to 4.08. Quality improvement implementation was greater in those nursing homes with an organizational culture that emphasizes innovation and teamwork. Employees of nursing homes with a greater degree of QI implementation were more satisfied with their jobs (a 1-point increase in QI score was associated with a 0.83 increase on the 5-point satisfaction scale, po.001) and were more likely to report adoption of pressure ulcer clinical guidelines (a 1-point increase in QI score was associated with a 28 percent increase in number of staff reporting adoption, po.001). No significant association was found, though, between QI implementation and either adherence to guideline recommendations as abstracted from records or the rate of pressure ulcer development. Conclusions. Quality improvement implementation is most likely to be successful in those VA nursing homes with an underlying culture that promotes innovation. While QI implementation may result in staff who are more satisfied with their jobs and who believe they are providing better care, associations with improved care are uncertain.

Study results can be interpreted as justifying the need to adjust patient satisfaction scores for differences in patient population among health care organizations. However, from a policy perspective, such adjustments may ultimately create a disincentive for health care organizations to customize their care.

Provisions of the Affordable Care Act (ACA) encouraged tax-exempt hospitals to invest broadly in community health benefits. Four years after the ACA's enactment, hospitals had increased their average spending for all community benefits by 0.5 percentage point, from 7.6 percent of their operating expenses in 2010 to 8.1 percent in 2014.

This study demonstrates a modest effect in improving provider adherence to quality standards for a single measure of diabetes care during the early phase of a pay-for-performance program that placed physicians under limited financial risk. Further research is needed to determine the most effective incentive structures for achieving substantial gains in quality of care.

Objective. To compare the costs of physician-owned cardiac, orthopedic, and surgical single specialty hospitals with those of full-service hospital competitors. Data Sources. The primary data sources are the Medicare Cost Reports for 1998-2004 and hospital inpatient discharge data for three of the states where single specialty hospitals are most prevalent, Texas, California, and Arizona. The latter were obtained from the Texas Department of State Health Services, the California Office of Statewide Health Planning and Development, and the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project. Additional data comes from the American Hospital Association Annual Survey Database. Study Design. We identified all physician-owned cardiac, orthopedic, and surgical specialty hospitals in these three states as well as all full-service acute care hospitals serving the same market areas, defined using Dartmouth Hospital Referral Regions. We estimated a hospital cost function using stochastic frontier regression analysis, and generated hospital specific inefficiency measures. Application of t-tests of significance compared the inefficiency measures of specialty hospitals with those of full-service hospitals to make general comparisons between these classes of hospitals. Principal Findings. Results do not provide evidence that specialty hospitals are more efficient than the full-service hospitals with whom they compete. In particular, orthopedic and surgical specialty hospitals appear to have significantly higher levels of cost inefficiency. Cardiac hospitals, however, do not appear to be different from competitors in this respect. Conclusions. Policymakers should not embrace the assumption that physician-owned specialty hospitals produce patient care more efficiently than their full-service hospital competitors.Key Words. Hospitals, specialty, cost , inefficiency, competition During the last 25 years, the U.S. hospital industry has undergone dramatic changes in its competitive landscape. Such changes include the consolidation of independent hospitals into systems, the rise of a proprietary sector, a marked shift from inpatient care to ambulatory services, and formation of hospital-physician joint ventures (Federal Trade Commission and Depart- As their number has increased, SSHs have become the center of an intense debate about their value to the U.S. health care industry. Proponents of SSHs argue that these organizations can set a new competitive benchmark for hospital services by promoting cost efficiency, augmenting patient choices, and providing quality health care at competitive prices. In this vein, a number of business strategists have argued that hospitals can create value in health care by increased focus and specialization of services (Herzlinger 1997(Herzlinger , 2004Porter and Teisberg 2004). Opponents of SSHs claim that these organizations engender unfair competition by targeting patient referrals, offering services that encourage overutilization, focusing on the most profitable patien...