De ziekenhuisfinanciering: uitdagingen, sterktes en kansen tot verbetering

Hospital care is an important link of our healthcare system. The development of an appropriate organization and financing design that stimulates effective, fair and qualitative care is therefore a crucial challenge. In today’s context, Belgian hospital care is being financed in a complex and fragmented way. There are different financial flows that are being designed in close collaboration with the sector. This leads to a rather opaque system, sometimes with very little coordination between the different financial flows. The way physicians and hospitals are being paid needs to be reconsidered and will need to reward quality one way or the other. The patients themselves will also need to take up new roles, and sick funds will need to be involved in improving the current hospital financing system

Physician-hospital alignment : economic, administrative and professional aspects

Hospitals face challenging times. Currently many Western countries are seeking ways to increase the efficiency of care delivery and improve the quality care. Physicians have a major impact on hospital performance. This doctoral dissertation focuses on alignment of self-employed physicians. Economic, administrative and professional aspects are considered. The first chapter discusses the context and main characteristics of hospital-physician relationships in Belgium. The following chapters present five academic studies. We conclude with the general discussion of our findings. In a first study we developed an integrative conceptual framework of physician-hospital alignment including economic and noneconomic exchange. Building on the available literature and the theoretical insights of agency theory and social exchange theory, risk and trust were identified as two key antecedents. Since the payment framework cannot be neglected when studying physician-hospital alignment we continued with a second study focusing on the relationship between provider financial risk bearing and physician-hospital integration. These first two studies were followed by three empirical studies. In the third study two comparative case-studies were performed to investigate the contractual mechanisms in physician-hospital exchanges. Besides the contract, the relationship established on the basis of the transactions taking place was studied. The fourth study comprises a qualitative study of administrative and professional aspects of the noneconomic relationship between physician and hospital. Drawing on the concepts of the psychological contract we developed a rich understanding how mutual obligations and areas of ambiguity are perceived. In the fifth study we quantitatively investigated the impact of noneconomic exchange (administrative and professional psychological contract breach) and economic exchange (distributive and procedural organizational justice) on physicians’ organizational attitudes and organizational citizenship behaviours. In addition we focus on the moderating role of the Chief Medical Officer and organizational trust in these relationships. The final chapter summarises the theoretical, methodological and practical implications of this dissertation

Lean Six Sigma in de zorgsector: droom of nachtmerrie?

De gezondheidszorg wordt geconfronteerd met belangrijke uitdagingen. Deze uitdagingen vragen antwoorden op macroniveau (bv. Het maken van fundamentele beleidskeuzen), maar evenzeer concrete oplossingen op mesoniveau en microniveau (Hoe gaan we als organisatie om met deze uitdagingen?). Lean Six Sigma kan hierbij helpen

In the eye of the beholder: mutual obligations and areas of ambiguity in the hospital-physician relationship

Internationally, many countries are increasing provider accountability for cost and quality of the delivered care. In this challenging environment hospital executives struggle to build effective hospital-physician relations. However, despite the importance of the hospital-physician relationship there has been little research which has examined how physicians and hospital executives describe the terms of their working relationship. This paper seeks to fill this gap by reporting findings of a qualitative study in which we explored the psychological contract between physicians and the hospital they practice at. In-depth interviews with physicians and executives (n=30) of three Belgian hospitals were performed. Our analysis of the transcribed interviews yielded a rich understanding of how physicians and hospital executives interpret and experience mutual obligations and areas of ambiguity within their psychological contract. We found that a distinction should be made between on the one hand administrative obligations (adequate operational support, responsive decision making processes and attractive facilities) and on the other hand professional obligations (clinical excellence and physician autonomous medical decision making). In addition, two areas of ambiguity could be identified reflecting both dimensions of the psychological contract. Firstly, physicians act as independent caregivers generating professional fees. A trade-off exists in their day-to-day interaction with the hospital. Therefore the interpretation about the way the care should be organized differs between executives and physicians. Secondly, hospital prospective financing systems lay the accent on cost-effective care from a societal perspective. In contrast, physicians are remunerated mainly by fee-for-service. The extent to which physicians should take into account the impact that their medical decisions have on the hospital bottom line varies. Our aspiration is that the findings of this study will assist in supporting hospital executives and physicians to build cooperative relationships needed to improve the quality and cost-effectiveness of current health care delivery

An integrative model of the management of hospital physician relationships

Hospital Physician Relationships (HPRs) are of major importance to the health care sector. Drawing on agency theory and social exchange theory, we argue that both economic and noneconomic integration strategies are important to effective management of HPRs. We developed a model of related antecedents and outcomes and conducted a systematic review to assess the evidence base of both integration strategies and their interplay. We found that more emphasis should be placed on financial risk sharing, trust and physician organizational commitment

Measuring performance in healthcare

Hospitals invest in process management and process optimization from an organizational and patient perspective to increase efficiency and simultaneously the quality of their operations. Consequently, the use of process-oriented performance measurement systems gains importance. This study contributes to the development of a dashboard for the process of hip surgery using a case study design. We integrate strategic goals of hospital management and different stakeholders with the analysis of Business Process Management and Hospital Information Systems’ data. Process-oriented KPIs were integrated into the dashboard using a three-step approach. Dashboards enable healthcare organizations to put process-oriented performance measurement into practice

Fulfilment of administrative and professional organisational obligations and nurses' customer-oriented behaviours

Aim: The aim of the study was to examine the relationship between the perceived quality of organisational exchange and nurses' customer-oriented behaviours. Background: Hospitals face increasing competitive market conditions. Registered nurses interact closely with patients and therefore play an important front-office role towards patients. Methods: A cross-sectional study was conducted. Registered nurses (n = 151) of a Belgian hospital received a questionnaire to assess the fulfilment of administrative and professional organisational obligations and their customer-oriented behaviours. Results: We found a positive relationship between psychological contract fulfilment and nurses' customer-oriented behaviours. More precisely administrative and professional psychological contract fulfilment relates significantly to nurses' service delivery and external representation. In case of internal influence only administrative psychological contract fulfilment was significantly related. Conclusions: Nurses' perceptions of the fulfilment of administrative and professional obligations are important to their customer-oriented behaviours. Implications for nursing management Nurse managers must be aware of the impact of fulfilling both administrative and professional obligations of registered nurses in order to optimise their customer-oriented behaviours

Fulfillment of administrative and professional obligations of hospitals and mission motivation of physicians

Background: To be successful, hospitals must increasingly collaborate with their medical staff. One strategic tool that plays an important role is the mission statement of hospitals. The goal of this research was to study the relationship between the fulfillment of administrative and professional obligations of hospitals on physicians' motivation to contribute to the mission of the hospital. Furthermore the mediating role of the physicians' emotional attachment to the hospital and moderation effect of the exchange with the head physicians were considered. Methods: Self-employed physicians of six hospitals participated in a survey. Descriptive analyses and linear regression were used to analyse the data. Results: The results indicate that affective commitment mediated the relationship between psychological contract fulfillment and mission statement motivation. In addition, the quality of exchange with the Chief Medical Officer moderated the relationship between the fulfillment of administrative obligations and affective commitment positively. Conclusion: This study extends our understanding of social exchange processes and mission statement motivation of physicians. We showed that when physicians perceive a high level of fulfillment of their psychological contract they are more committed and more motivated to contribute to the mission statement. A high quality relationship between physician and Chief Medical Officer can enhance this reciprocity dynamic