Downsizing and Organizational Restructuring: What Is the Impact on Hospital Performance?

Abstract

In recent years, hospitals have radically restructured their operations while significantly downsizing their workforces. To date, little is known about the combined effect of these change processes on organizational functioning. There have been few large‐scale studies investigating how hospitals have performed when both organizational restructuring and downsizing are used concurrently. The research reported here sets out to separate and isolate the independent and combined effect of organizational restructuring and downsizing on hospital performance. In particular, it aims to address the following question: Do hospitals which undergo significant organizational restructuring while maintaining their workforce complement perform any better than hospitals that institute significant restructuring while heavily downsizing, and any better than hospitals which heavily downsize but undertake little or no organizational restructuring? Categorical regression analysis results from a sample of 285 Canadian acute care hospitals suggest that organizational restructuring and downsizing have differential impacts on organizational performance. Hospitals which undertook significant organizational restructuring while heavily downsizing were perceived to perform better than hospitals that heavily downsized but conducted little or no organizational restructuring, but performed worse than hospitals that undertook significant restructuring while maintaining their workforce complement. However, when the method of conducting the change management process was controlled for, these performance differences were reduced or eliminated.     

The attractiveness of local and national list labels: the role of socio-economic inequalities on the success of electoral lists

ABSTRACT

According to the nationalisation hypothesis, it is sometimes argued that electoral lists competing at local elections under a national party label are more likely to win. Yet, in many countries, local lists are still much present. This article seeks to assess the attractiveness of local and national list labels at local elections. Following Rokkan’s hypothesis of the nationalisation of local politics, we test the role of socio-economic inequality on the success of electoral lists across local polities. Based on an original dataset distinguishing the labels of 1.012 electoral lists – be they local, mixed or national – in the 262 Walloon municipalities in Belgium, the multilevel regression demonstrates that local and mixed labels present a significant electoral advantage vis-à-vis national party labels. However, the article shows that this electoral gain decreases as economic inequalities increase: national labels, especially left-wing parties, attract more voters as inequalities rise.     

Declining partisan representation at the sub-national level: assessing and explaining the strengthening of local lists in Italian municipalities (1995–2014)

In Western democracies political representation at the national level is still dominated by (old and new) political parties. This article shows that, instead, the representative role of parties may have declined at the local level. In Italy, for instance, the average share of municipal seats held by non-partisan councillors has almost tripled in the last 20 years. By using an original data set, this article classifies different types of Italian local lists, assesses their relationship with traditional parties and explains territorial variation in their success. The results suggest that local lists have become substantially stronger in small municipalities, in regions characterised by weak or declining political subcultures and where regionalist parties are absent or irrelevant. Finally, contrary to the expectation that declining partisanship is linked to modernisation processes and direct civic engagement, local lists have achieved their best results in the less developed areas of the country.     

Independent Mayors and Local Lists in Large Polish Cities: Towards a Non-partisan Model of Local Government?

The enormous success of local independent lists and independent mayors in Poland suggests it is important to examine their distinctive features, analyse the place they occupy in local politics, and explore the model of local government they encourage. This paper deals with these topics by investigating some extreme cases of non-partisanship at the local level. Research was conducted in three arbitrarily chosen Polish cities governed by independent mayors and dominated by independent lists in the local legislatures. Mixed quantitative and qualitative methods were used: a survey among city councillors; and individual key-informant interviews (IDI). Non-partisans appear to be a separate category of local politicians, different in terms of their views on politics. They explain their non-partisanship using anti-partisan, historical or tactical justifications. It seems that non-partisanship can be a means of institutionalising a particular manner of understanding and engaging in politics. Local lists organised by independent mayors are informal, concentrating on the leader and performing only some of the traditional functions of parties. This paper demonstrates that, due to the vague nature of the links between local politicians and their administration, independent councillors may serve only as a ‘democratic addition’ to a local administration headed by a skilful manager.     

Levels of Centralisation and Autonomy in Russia’s ‘Party of Power’: Cross-Regional Variations

The institutionalisation and nationalisation of Russia’s party system, which is dominated by United Russia (Edinaya Rossiya—UR), has played a major role in the building of Putin’s ‘power vertical’. Nevertheless, despite the fact that formal relations within UR are highly centralised, informal practices allow for far greater degrees of regional autonomy. Focusing on UR’s candidate selection for the 2011 Duma election this article provides an examination of cross-regional variations in the relations between UR’s Party Centre and its regional branches. As electoral legislation requires the segmentation of party lists into ‘regional groups’, the composition of the regional lists, specifically the share of ‘native candidates’, is considered as an indicator of the level of autonomy of regional branches. Ordinal regression analysis confirms our main theoretical hypotheses. In the more financially autonomous regions, UR’s regional branches will have more leverage and bargaining power in their relations with the Party Centre. A second important factor is heterogeneity: the more a region’s socio-economic indices deviate from the national average (either up or down), the less its UR branch is subordinate to the Party Centre.     

The boundaries of generosity: Can administrators in charity hospitals provide “free care?”

The medical marketplace changes of the 1980's and 1990's have helped to redefine the charity care role which charity hospitals have played. How might charity hospital administrators succeed in fulfilling this responsibility, while simultaneously protecting the financial well-being of their institutions? This paper discusses how increases in charity care volume may relate to declining opportunities for cost-shifting, increased pressures for revenue-raising utilization policies, and limited support from government to subsidize uncompensated care. “Charity” and “free care” concepts are discussed, and economic and historical perspectives are introduced to provide the context for studying this issue.

The 1980's experience of charity hospitals in Massachusetts provides examples of specific policies within a state in which uncompensated care played a pivotal role in the debate over universal coverage. But there has been a quite recent refocussing upon the nonprofit hospitals' tax exemption. If such political pressures in the 1990's require a review of community benefits standards at charity hospitals, then perhaps the resolution of access questions for the poor and uninsured within forthcoming national health care reforms properly will take into account considerations of quality of care.     

Medicare reimbursement,debt financing,and measures of service efforts and accomplishments in the healthcare industry

This paper investigates the relationships among selected SEA measures and Medicare reimbursement. The findings generally indicate that those hospitals most heavily reliant on Medicare reimbursement are characterized by different levels of service efforts and accomplishments than other hospitals. The empirical analysis also provides evidence of a linkage between SEA measures and market measures of the risk associated with bonds issued by the sample hospitals.     

Supervisor Relationships,Teamwork, Role Ambiguity and Discretionary Power: Nurses in Australia and the United Kingdom

This paper reports comparative research comparing the relationship between supervisor-subordinate relationships, teamwork, role ambiguity and discretionary power for nurses working in public and private sector hospitals in Australia and the UK. The findings indicate that the four factors accounted for approximately a quarter of the variance for nurses in the UK and almost a fifth of the variance for nurses working in public sector hospitals. Moreover, the findings identify a significant difference across all variables for nurses working in public sector hospitals compared with private sector with nurses in the private sector having higher satisfaction levels and perceiving lower levels of role ambiguity. There were fewer differences for nurses working in Australian hospitals compared with UK hospitals with nurses in Australia perceiving a better supervisor-subordinate relationship and nurses in the UK perceiving greater satisfaction with teamwork.     

Public hospitals as competitors for medicaid revenue: the case study of St. Louis regional medical center

Medicaid revenues may determine whether public hospitals will survive. Public hospitals participate aggressively in the public market competition for their states’ Medicaid dollars. States must decide whether the survival of public hospitals, as providers of last resort to both Medicaid and uninsured patients, is of continuing importance to their Medicaid programs. Cities, if the states were willing, alternatively could voucher uninsured patients and direct Medicaid patients to the private hospitals that would outlive closed public hospitals. In fact, Medicaid's managed care programs already have heightened this competition, by organizing sufficiently large populations of prepaid Medicaid patients to attract networks of private providers to offer discounted prices, in competition with public hospitals for this market.

Although Medicaid has been a comparatively poor payer, nationally, almost half of public hospitals⁷ funding comes from this source of revenue. Urban public hospitals can barely live with Medicaid revenues, but the extent to which they can live without Medicaid revenues is being determined by surprising new turns in market competition for the revenue. A period of expansive and expensive new congressional mandates for the joint federal-state program was followed in the early 1990s by the introduction by the states of Medicaid revenue maximization strategies. The states’ funding levels, the bases for matching federal contributions, were artificially elevated by provider taxes, provider donations, and intergovernmental transfers. The revenue from all these sources was returned to these providers through the Disproportionate Share Hospital subsidy program for Medicaid-dependent hospitals, as soon as the federal revenue match was calculated, based upon the inflated figures. These practices currently are being stymied, and states simultaneously have escalated competitive bidding by private market managed care providers for Medicaid patients. Missouri has been in the forefront of states moving to maximize the federal Medicaid revenue match and to return Disproportionate Share Hospital funds to providers. St. Louis's public hospital, Regional Medical Center, has been weaned off its local government subsidies, as the intergovernmental transfer and DSH enticements compromised the stability of that hospital's revenue picture. Now, unprotected by an integrated healthcare system or other major role in a regional hospital network, this urban public hospital must struggle to survive within its Medicaid managed care competitive market. The question for the state of Missouri is whether perpetuating a future for Regional will ensure its Medicaid patients a traditional caring public medicine alternative as a fallback position, if Medicaid's present foray into the private market goes awry. For Regional and the city of St. Louis, the question is whether they can any longer count upon traditional state Medicaid revenue and financial support.     

Quasi-market Transformation: An Institutionalist Approach to Change in UK Hospitals

Quasi-market transformation (QMT) refers to the process by which the dominant organizational form in a field is replaced, following the introduction of a quasi-market. In this article, analysis of comparative case-study data reveals that, until the early 1990s, a common interpretive scheme, or set of values and norms, underpinned a set of structures and systems in many UK hospitals. These similarities of form are represented as the directly managed (DM) hospital archetype. When change initiatives challenged this archetype, the outcomes were negotiated and the interpretive scheme remained largely unscathed. Following the introduction of a quasi-market in 1991, a new trust hospital interpretive scheme has emerged. For the first time, UK hospitals have experienced transformation and now display an alternative set of structures and systems. This article explains how the trust hospital archetype has become legitimized through different tracks of change within individual hospitals.     

Organizational Citizenship Levels of Physicians in Public Hospitals

The aim of this study is to define organizational citizenship levels of physicians working in public hospitals. The population of the study consists of the physicians employed in the hospitals run by the Ministry of Health in Istanbul. The Organizational Citizenship Level Scale was used for the collection of data. It was found that the participants’ organizational citizenship levels were the highest in the “conscience” subsection and the lowest in the “praising the organization” subsection. Findings of this study provide clear information for the decision-makers and hospital managers in developing working conditions of physicians in public hospitals.     

Placement activities of MPA programs and their parent institutions (#)

Results from a survey of NASPAA member programs indicate that NASPAA programs and their parent institutions provide a wide range of placement services. Less than 60 percent of the 68 respondents had a formal placement program at the department level. One fifth of these programs do not provide training in job search techniques, a quarter do not subscribe to placement newsletters, a third do not provide assistance in resume preparation, a third do not assist their students in preparing for interviews, and two- thirds do not provide mock interviews. More than three-quarters do not publish lists of their new graduates and four-fifths do not send these lists to prospective employers. Fortunately, institutional and departmental programs supplement one another in many universities. Nevertheless, central placement agencies do not offer all of these services. Five institutions did not have a formal central placement agency. Public administration programs will improve their placement services for a variety of pragmatic reasons.     

Industrial rationalization of a cottage industry: multi-institutional hospital systems

The environment facing hospitals, generally supportive until the 1970s, may now be characterized as complex, turbulent, and constrained. In response to such environmental conditions, hospitals have adopted new strategies and structures. The strategies, described as corporate rationalization, have led away from the traditional structure of freestanding, autonomous hospitals and toward the formation of multi-institutional systems. These systems are designed to provide sufficient strength to cope with the environment, to acquire scarce and valued resources, to allow organizational stability, to achieve organizational purpose, to enable growth and/or survival, and to enhance market position. The impact of multi-hospital systems is viewed in two major areas: acquisition, retention, and utilization of economic and human resources, and organizational, political, and social factors.     

Terrorism Watch Lists,Suspect Ranking and Decision-Making Biases

The large number of names on terrorism watch lists raises the problem of monitoring. Given the existing resource constraints and other logistical considerations, efficient and accurate ranking of individuals in terms of threat posed is of paramount importance. This process, however, may be impacted by reference points, diminishing sensitivity, loss aversion, and other aspects of the human decision-making process that introduce biases. This article explores the relevance of decision-making processes and biases to the specific task of ranking and monitoring individuals whose names have been placed on a terrorism watch list.     

Public accountability in higher education and health: an international perspective

Hospitals and universities in British Columbia (BC), and indeed in Canada generally, face a serious loss of faith in the self-regulatory model of funding and external governance whereby, essentially, they are given resources and the autonomy to use them as they see fit. Generally, the last two decades in Canada have been a period of scarce resources, loss of external confidence, general funding limitations, some additional pressures in the form of increased controls and accountability requirements, but little evidence that hospitals and universities are willing to respond positively to these new pressures. The argument of the paper is that responding to pressures for improved accountability reporting may be the price of preserving autonomy and relative funding levels. An active, cooperative response to external concerns about information will enable hospitals and universities to shape the information agenda to their advantage--at the very least, having it reflect reasonably accurately their circumstances and performance. The paper argues further that hospitals should begin by addressing patient care measures and universities should begin by dealing with measures of teaching performance.     

Plus ça change: Electoral law reform and the 2008 Romanian parliamentary elections

Romania reformed the law governing its parliamentary elections between 2004 and 2008, shifting from a complex proportional representation system based on county-level party lists to a complex uninominal system in which each district for the Chamber of Deputies and the Senate elects one representative. The change in law emerged after more than a year of heated political controversies, including partisan and personal animosity between President Basescu and Prime Minister Tariceanu, a failed attempt at impeachment, a deadlocked special electoral commission, a failed popular referendum, an unfavorable constitutional court ruling, and a confusing final accord brokered under deadline. Qualitative comparison of the 2004 and 2008 laws reveals that the heralded reform merely added an additional layer of calculation to the previous electoral system. Quantitative analysis using counterfactual estimation reveals that the new law had absolutely zero effect on the partisan outcome. In the conclusion, we explore the implications of these findings for Romanian politics and the politics of electoral reform more generally.     

Measuring state fragility: a review of the theoretical groundings of existing approaches

State fragility has become a resonant term in the development discourse over the past decade. In its early days it served as a catch-all phrase used by donor organisations to draw attention to the need to assist ‘fragile states’. In response to the call for a better understanding of how to deal with these countries, there was a surge in measures of fragility. However, it was not long before academics pointed to the murkiness and fuzziness of the term, and identified several caveats to most of the proposals for quantification. This paper reviews existing approaches to operationalise this concept, distinguishing between those that offer no ranking or only partial rankings of fragile states, and those providing ordinal lists of countries. The examination of their theoretical underpinnings lends support to the critical view that most existing approaches are undermined by a lack of solid theoretical foundations, which leads to confusion between causes, symptoms and outcomes of state fragility.     

A Two-Pronged Approach? Combined Leadership Styles and Innovative Behavior

This article examines the relationship between transformational, transactional, and empowering leadership and the innovative behavior of public sector employees. Instead of investigating their association individually, this article focuses on the interaction between different types of leadership. The analysis is based on a survey from one of Denmark’s largest hospitals (n = 1,647). The main result is that empowering leadership, which focuses on employee capacity, moderates the association between transformational leadership, which is directed at motivation, and innovative behavior. The findings emphasize the importance of not only focusing on a single leadership style but also understanding how they work in combination.     

Nurses' Job Satisfaction and Turnover Intentions over a Six‐Year Period of Hospital Downsizing and Amalgamation

This longitudinal panel study examined the job satisfaction and turnover intention of 111 nurses employed in four community hospitals in Canada. Data were collected in 1991, again in 1992 following hospital restructuring and downsizing associated with budget cutbacks, in 1995 at the beginning of an amalgamation initiative, and in 1997 during the amalgamation which also involved restructuring and downsizing. In 1992, following the first hospital restructuring and downsizing, nurses reported a significant decrease in satisfaction with their career future and with their hospital but a significant decrease in turnover. A different picture emerged in 1997. Nurses reported a significant decrease in overall job satisfaction, satisfaction with the kind of work they were performing, the amount of work, their physical working conditions, their career future and their hospital. They also reported a significant increase in turnover intention. As Canada is currently entering a period of nurse shortage, the restructuring and downsizing these hospitals engaged in between 1992 and 1997 are likely to have serious consequences for the recruitment and retention of nurses in the future.