hospital performance and managerial education

Managerial Education and Management in Healthcare (2017). In this article Nicholas Bloom et al investigate the link between hospital performance and managerial education by collecting a large database of management practices and skills in 2000 hospitals across nine countries.

They document:

• A large variation of management practices within each country
• The index “better management” is positively associated with improved clinical outcomes such as survival rates from AMI.
• There's evidence that a hospital’s proximity to a university which supplies joint business and clinical education is associated with a higher management practice score (and better clinical outcomes).
• The bundle of managerial and clinical skills has an impact on hospital management quality.
• Management matters for hospital performance and that the supply of managerial human capital may be a way of improving hospital productivity.
• Given the enormous pressure health systems are under, this may be a complementary way of dealing with health demands in addition to the usual recipe of greater medical inputs.

The correlations they describe are only suggestive as they do not have panel data or experimental evidence to track out causal impacts. Such evidence from either randomized control trials or natural experiments is an obvious next step in their agenda.

painting: Blue star (2016)

________________________________________________________

Ideas are becoming more expensive to find.

In Are Ideas Getting Harder to Find? (NBER Working Paper No. 23782), Nicholas Bloom, Charles I. Jones, John Van Reenen, and Michael Webb argue that, to maintain a given rate of economic growth, resources devoted to research must increase over time.

In many growth models, economic growth arises from people creating ideas, and the long-run growth rate is the product of two terms: the effective number of researchers and their research productivity.

The authors present a wide range of evidence from various industries, products, and firms showing that research effort is rising substantially while research productivity is declining sharply. They cite both aggregate evidence and measures of R&D productivity in specific industries, in particular computers, agriculture, and medicine.

A good example is Moore’s Law. The number of researchers required today to achieve the famous doubling every two years of the density of computer chips is more than 18 times larger than the number required in the early 1970s. Across a broad range of case studies at various levels of (dis)aggregation, they find that ideas — and in particular the exponential growth they imply — are getting harder and harder to find. Exponential growth results from the large increases in research effort that offset its declining productivity.

They argue that a single-minded focus on the quantity of undiscovered ideas is unhelpful. It is not just how many ideas for productivity growth are left, but what it would cost to get them out of the ground – and, crucially, how much we’re prepared to spend to do it. For a long time, geologists have been forecasting ‘peak oil’, only to be surprised by new deep-sea discoveries and shale oil. We, likewise, see a continuing stream of innovations. But, just as newer oil sources are increasingly costly to extract, coming up with new ideas is getting more expensive. There have been technological improvements, but these require the devotion of ever-growing amounts of resources to the research process to maintain steady rates of improvement

These days, pushing the frontier of knowledge out requires mastering an ever-larger body of knowledge, meaning that students have to stay longer in university, and researchers increasingly work in larger teams whose members are more specialised. This all pushes up costs. Returning to the oil metaphor, we are digging deeper into a trickier part of the rock.

Access to the article (pdf): Are Ideas Getting Harder to Find?
Commentary from the authors: Ideas aren’t running out, but they are getting more expensive to find


photo: Until our two activists and our members of the Catalonia Cabinet could come back to Catalonia and will be released from jail I'll publish a dark photo.
 _________________________________________________________________

Community resilience

Resilience is defined as the capacity of any dynamic system to anticipate and adapt
successfully to difficulties.

• Individual resilience is the process of, capacity for, or outcome of adapting well in the face of adversity, trauma, tragedy, threats, or significant sources of stress.
• Community resilience is the ability of communities to withstand and recover from community stressors as well as to learn from past stressors to strengthen future response and recovery efforts.

What is a community stressor? A community stressor is an event that negatively impacts a community physically, emotionally, or economically. Stressors differ by communities, but examples include:

• Weather-related disasters (e.g., hurricanes or severe snowstorms)
• Economic downturns or high poverty rates
• Gun violence or drug-related crimes
• Environmental issues (e.g., climate change or global warming)

Two interesting articles
1. A toolkit to teach people about community resilience so that they can then educate others about resilience and resilience building. RAND TOOLKIT COMMUNITY RESILIENCE

2. Spanish paper from Juan de Dios Uriarte Arciniega (Universidad Pais Vasco and Ex-director Academia de la Ertzaintza). LA PERSPECTIVA COMUNITARIA DE LA RESILIENCIA

I think Catalan and Spanish people are not prepared to the adverse effects that they will occur soon and they have not been doing anything to build a community resilience.
Me as an individual also I'm not prepared. I'm afraid.

(*) Photosolde: Les parque __________________________________________________________________

Back to basics: how to manage conflict: shark, owl, fox, turtle or teddy bear?

In any Conflict Situations you may respond in one of these five ways defined by Kenneth W. Thomas and Ralph Kilmann: competitive, collaborative, compromising, avoiding, accommodating.

In such situation, we can describe a person’s behaviour along two basic dimensions: (1) assertiveness, the extent to which the individual attempts to satisfy his own concerns, and (2) cooperativeness, the extent to which the individual attempts to satisfy the other person’s concerns.

These five Conflict Styles are:

• COMPETITIVE: The shark (Might makes right). Competing is assertiveness and uncooperative- -an individual pursues his own concerns at the other person’s expense. This is power-oriented mode, in which ones uses whatever power seems appropriate to win one’s own position- -“standing up for your rights, defending a position when you believe is correct, or simply trying to win.

disadvantage: relationships damage

• ACCOMMODATING: The Teddy bear (kill your enemies with kindness). Accommodating is a unassertive and cooperative—the opposite of competing. When accommodating, an individual neglects his own concerns to satisfy the concerns of the other person, there is an element of self-sacrifice in this obeying another person’s order when one would prefer not to, or yielding to another’s point of view.

disadvantage: long term resentments

• AVOIDING. The Turtle (Leave well enough alone). Avoiding is unassertive and uncooperative—the individual does not immediately pursue his own concerns or those of the other person. He does not address the conflict. Avoiding might take the form of diplomatically sidestepping an issue, postponing an issue until a better time or simply withdrawing from a threatening situation.

disadvantage: long term resentments

• COLLABORATIVE. The owl (Two heads are better than one). Collaborating is both assertive and cooperative—the opposite of avoiding. Collaborating involves an attempt to work with the other person to find so me solution which fully satisfies the concerns of both persons. It means digging into an issue to identify the underlying concerns of the two individuals and to find an alternative which meets both sets of concerns. Collaborating between two persons might take the form of exploring a disagreement to learn from each other’s insights, concluding to resolve some condition which would otherwise have them competing for resources, or confronting and trying to find a creative solution to an interpersonal problem.

disadvantage: time and difficulty. Possible need an outside facilitator.

• COMPROMISING. The fox (Split the difference). Compromising is intermediate in both assertiveness and cooperativeness. The objective is to find some expedient, mutually acceptable solution which partially satisfies both parties. It falls on a middle ground between competing and accommodating. Compromising gives up more than competing but less than accommodating. Likewise, it addresses an issue more directly than avoiding, but doesn’t explore it in as much depth as collaborating. Compromising might mean splitting the difference, exchanging concessions or seeking a quick middle-ground position.

disadvantage: optimal solution missed

photo: (*) Photosolde
__________________________________________________________________

Tips for charity leaders

 

The king's fund in their work with charities wants to highlight some of the most common challenges they face in leadership: They share a short report with 10 tips for charity leaders

1. Take time to reflect and learn: a necessity not a luxury
TIP: Leaders need time to reflect on the organisation’s work, to examine their leadership styles, to learn new ways of working, and to receive support. In such a challenging environment for charities, it’s more important than ever to not see this as a luxury.

2. Build strong relationships with your board
TIP: Analyse the relationships between you and your board; make sure your organisation examines board skills and leadership and has a critical eye on trustee roles. Surfacing these issues are the first steps towards making positive change.

3.Your trustees' report should offer a full picture
TIP: The trustees’ report should not just be left to the finance manager and treasurer; it is worth investing time and effort in producing a full and accurate reflection of your organisation.

4. Present and analyse your data carefully
TIP: Invest time in pulling your data together, being clear on the difference between your activities and your impact and in articulating your value. Provide a good narrative, including how you are responding to the findings, that will make sense to those outside your organisation.

5. Weigh up the opportunities and risks of partnerships
TIP: Carefully weigh up the opportunities and risks of partnership work – both of taking part and of not taking part, there are pros and cons for each. Small organisations can easily be sidelined in partnership working, so be assertive when negotiating terms and articulating the distinctive value you bring, and make sure you are clear on areas such as budgets, quality, responsibility and risk.

6. Manage capacity and demand to ensure sustainability
TIP: Give yourself time to ‘think outside the box’ and be entrepreneurial; face up to tough decisions and change and make sure you keep abreast of new opportunities. Look after yourself and your staff to minimise stress, and don’t be afraid of saying no to new services, particularly if you can’t afford to run them.

7. Don't ignore succession planning and empowering teams
TIP: A more distributed approach to leadership across an organisation, where different staff can represent and carry out key tasks for the charity, receiving training and development to do so, will make organisations more resilient.

8. Ask if you don't know the answer
TIP: Don’t be afraid to get help if you need it – it will reduce the pressures of leadership but could also be an organisational risk if you don’t.

9. Produce engaging funding applications
TIP: If you can, try to get someone who is not as close to the work to read and sense-check funding applications before they are submitted. If you can’t do that, consider honestly whether your application would stand out if it was the 30th or even 100th one you had read.

10. Don't bury your head in the sand if the money is running out
TIP: You will have a better chance of solving any funding problems if you predict them well in advance and explore your options carefully. Keep trying to diversify income – difficult but important, and tell your funders as early as possible if you think you will have a problem; they may be able to renegotiate with you or reschedule payments to help see you through.

photo: (*) Photosolde
Petita ofrena floral als refugiats
__________________________________________________________________

Boards: when a nonprofit needs to make tough decisions, do you have the right brains in the room?

The 'Nine steps' publication and supporting material is the third edition published to help sport and not-for-profit organisations from New Zealand to improve governance structures and processes. Its supported by Sport New Zealand

Web access with support material to download: Nine steps to effective governance - building high-performing organisations

Here I would like to focus on Board Needs. My experience reveals the importance of having a knowledgeable and engaged board, a board that understands its fiduciary role, its managerial role and depending on the type of institution its fundraising role. Boards members should have:

EXPERTISE: knowledge, skills, and experience
The initial challenge is to determine what relevant knowledge, skills and experience the board needs. The degree to which particular sets of knowledge, skills and experience might be required will depend on the business of the organisation, the challenges facing it and its specific current and prospective circumstances.

• It is preferable that all candidates will have some degree of governance experience and a basic understanding of board work.
• It is important for a board to include people who can understand: 1) an organisation's culture and what motivates the behaviour of those within it; 2) the economic drivers of its performance; 3) where its best growth opportunities lie; and the risks that it faces.
• Focus on what people will DO rather than what people ARE
• Emphasize diversity and demographic characteristics like gender, sexual identity, disability, age and geographical variables like nationality or location of residence..

INDIVIDUAL ATTRIBUTES
A second important selection factor is the set of attributes that relates to a person's ability to contribute and collaborate in a group decision-making context. Without personal attributes that assist an individual's knowledge, skills and experience to be taken up by the board, he or she is unlikely to add value as a member of the board.

• Independence - free to think for themselves
• Intelligence - ability to understand and be critically analytical
• Moral compass and integrity
• Good judgement and personal confidence -ability and courage to raise difficult issues
• Emotional intelligence - manage their egos, respect and be able to understand the needs and feelings of others
• Open mindedness and ability to challenge their decisions
• Outcome-oriented - more interested in impact than in process
• Motivation - they want to join the board for the right reasons 

photo: (*) Photosolde
_____________________________________________________________________

gender gap grows with age

 

"Gender gap in the Spanish labour market and its evolution through the life cycle". In this article Sara de la Rica analyses the gender gap.

The data (the sample are highly educated workers and full-time equivalents) explains:

• The gender gap increases with age specially until 30-34 years. From 15% in the hourly wages in 20-24 years old to 20% in 30-34 years old. After that, the gender gap is mainly constant.
• There is a lack of promotion in women at the age 30-34. The type of data can't explain if this is voluntary or a firm-decision.
• Women receive less in one of the two components of the salary: the variable part like bonus.

Access Journal (Spanish pdf): Revista de Ciencias y Humanidades (diciembre 2016)
Short video resume (Spanish 5minutes): gender gap

photo: (*) Photosolde 

_____________________________________________________________________

Policies tend to emphasize education and formal training. Most firms don't have strategies to optimize the gains from informal learning at work.

Andries de Grip professor of Economics and director of the Research Centre for Education and the Labour Market (ROA), School of Business and Economics in Maastricht University has written an article in the IZA World of labor, the independent economic research institute that conducts research in labor economics and offers evidence-based policy advice on labor market issues.

Some interesting points:

• In dynamic jobs, workers continuously face skills obsolescence. Workers who are employed in industries with high rates of technological change are better able to retain their productivity at an older age than workers in sectors that are less dynamic. Workers who experience skill obsolescence appear to learn more on the job and participate more often in training, which lowers the risk of employment loss. 

• The OECD’s Program for the International Assessment of Adult Competencies (PIAAC) measures the relevance of informal learning at the workplace in its member countries. Many workers report that informal learning at work—learning by doing or learning from supervisors or co-workers—is relevant for them on a daily basis, although there are large differences across countries.  The percentage of workers who are involved in learning by doing every day ranges from 12% in Korea to 53% in Spain, while the percentage of workers who learn new things from supervisors or co-workers ranges from 10% in Korea to 36% in Spain.  

• Recent studies find that much of the performance of newly hired workers is driven by learning by doing or learning from peers or supervisors in the workplace. Descriptive data show that workers learn a lot from the various tasks they perform on the job. Informal learning is far more important for workers’ human capital development than formal training courses. Most firms do not have adequate human resource management strategies to optimize informal learning in the workplace.

Access to the article (full article): Informal learning at work (2017)

photo: Chinese-American children in San Francisco, 1936. Alfred Eisenstaedt—The LIFE Picture Collection/Getty Images
_____________________________________________________________________

from "third sector" to "plural sector"

Henry Mintzberg born in Canadà in 1939 is an internationally renowned academic, author and researcher and professor of Management Studies at the Desautels Faculty of Management of McGill University in Montreal, Quebec, Canada.

He published an article in 2015 where he explained that a "A healthy society requires a respected public sector, a responsible private sector, and a robust plural sector".

He defended the name of "plural sector" instead labels like "nonprofit sector" or "third sector". In his opinion the name "plural" will help this sector take its rightful place alongside the other two (public vs private) and also help us to appreciate the unique role it has to play in restoring that balance.

Main ideas:

• Why "plural": The plurality of the sector: we can find cooperatives, foundations, clubs, religious orders, think tanks, activist NGO's, services NGO's, voluntary, social economy. He divides in four groups: mutual associations, benefit associations, protection associations and activists associations. There is a variety of this sector's associations and a wide range forms of ownership.
• Radical renewal: The plural sector has to lead the radical renewal "in communities on the ground, with groups of people who exhibit the inclination, independence and resourcefulness to tackle difficult problems head on".
• The plural sector has to leave form its obscurity. They have to have their own acts together, collectively, enabling pluralism but not dispersion of their efforts. It has to focus on its distinctiveness and partnership with each other.
• It's time to rebalance the power: Each sector needs to maintain sufficient influence in a society to be able to check the excesses of the other two.

Access full article (pdf): Time for the plural sector (2015)

photo: (*) Photosolde "The world begins with every kiss. photo-mosaic designed by Joan Fontcuberta"

_____________________________________________________________________

the effect of competition on the quality of health care

In 2016 Martin Gaynor with Rodrigo Moreno-Serra and Carol Propper were awarded the American Economic Association Prize for the best paper published in the American Economic Journal: Economic Policy in 2012-15.

In their article they examined the impact of the introduction of a pro-competition policy, in 2006, on hospital outcomes in England. They found strong evidence that under the regulated price regime hospitals within the NHS engaged in activities that increased quality of patient care.

The NHS reforms resulted in significant improvements in mortality and reductions in length of stay without changes in total expenditure or increases in expenditure per patient. .

In 2006 the NHS mandated that all patients requiring treatment be given the choice of five different hospitals (Choose and Book) and adopted a payment system in which hospitals were paid fixed, regulated prices for treating patients (payment by results based, PbR on DGR's). The reform gave patients more choice (via the mandated five alternatives and the end of selective contracting), increased the incentive for hospitals to win business and moved hospitals from a market determined price environment to a regulated price environment.

The introduction of competition can be an important mechanism for enhancing the quality of care patients receive even in a set up where hospitals are not profit maximizers. Attracting patients becomes very important. Given that price is fixed, the only way managers can do this is by undertaking effort to increase quality. The reforms made attracting patients tougher in less concentrated markets and so managers had greater incentives to improve quality in these markets. This increases managerial incentives to improve quality effort as competition grows stronger.

This is one empirical study on "yardstick competition (competence by comparison)" among health care organizations.

Access full article and data sets: Death by Market Power: Reform, Competition, and Patient Outcomes in the National Health Service (2013)

Related post:  some controversies about competition in health care

photo: (*) Photosolde
_____________________________________________________________________

health technology/expenditure relationship

The effect of insurance expansion on the diffusion of new technologies is not a well-understood phenomenon.

Burton A. Weisbrod published in 1991 in the Journal of Economic Literature: The Health Care Quadrilemma: An Essay on Technological Change, Insurance, Quality of Care, and Cost Containment. The Weisbrod proposition in his article is that the expansion in health care insurance produces a cost increasing in new technologies and how new technologies induces demand for insurance. There is an inexorable link between the broadening and deepening of health insurance coverage and the development of new health-care technologies.

Joan Costa-Font and Alistair McGuire  and Victoria Serra-Sastre published in 2012 The “Weisbrod Quadrilemma” Revisited: Insurance Incentives on New Health Technologies

In their study, they attempted to produce empirical tests of Weisbrod thesis and find supportive evidence. The paper presents evidence of a link between insurance and technology diffusion using OECD panel data and taking advantage of a dynamic specification structure. The empirical estimates indicate that higher degrees of private expenditure on health care correlate with higher levels of R&D in health care, consistent with the hypothesis forwarded by Weisbrod that increasing insurance coverage boosts technology adoption. However, their findings also suggest that increasing public funding of health care appears to lower technological adoption, which is consistent with the exercising of monopsony power and an objective of cost containment.

photo: (*) Photosolde
_____________________________________________________________________

Women 20 (W20): Gender disparities

Gender equality contributes to strong, sustainable and balanced economic growth.

At their summit in Brisbane in 2014, G20 leaders agreed to focus on gender equality challenges at the strategic level. They committed to ‘women’s full economic and social participation' to reducing the gender gap in participation by 25 per cent by 2025; and to bringing more than 100 million women into the labour force.

To make the world’s premier economic forum accountable for progress on this crucial front, the engagement group known as the ‘Women 20’ (W20) was created in early 2015.

Progress towards gender equality at work has been slow. Contrary to conventional wisdom, global rates of female labour force participation have stagnated, or even fallen, in recent decades.

This paper-brief seeks to inform the work of the W20 in expanding women’s economic opportunities. It begins by outlining the origins and objectives of the W20, then highlights the key gaps in economic opportunities for women and girls in G20 countries, identifying common challenges as well as distinguishing features and constraint

Main conclusions:

1. To close labour force participation gaps is to change legal rules and institutions that restrict women’s opportunities, and to review the scope for specific measures and investments to support the expansion of opportunities.
2. Governments should eliminate all legal discrimination against women and review policies to support their participation in the labour market, including investment in social infrastructure for the care of children and the elderly.
3. Governments can also lead by example, including by undertaking gender audits of their own workforces, and increasing the share of public procurement sourced to companies that meet specified gender criteria.
4. Private-sector leadership and innovation on gender equality are also needed to promote and support progress.

Research paper (2015) (pdf.) A Profile of Gender Disparities in the G20: What is Needed to Close Gaps in the Labour Market

photo: (*) Photosolde
_____________________________________________________________________

Kenneth J. Arrow the "Albert Einstein of economics"

In October 29th of 1990, Kenneth J. Arrow was invited to give the opening lecture ("Exellence and Equality in Education") in the Economics Faculty at the Pompeu Fabra University founded the same year by the Government of Catalonia. He came to Barcelona with with wife Selma Schweitzer. 

A group of Ph.D students organized a route in Barcelona with them. First we went to visit La Pedrera and then we went to have lunch in Els 4 Gats.

For us, a group of 23 years old, recently graduated economists were a great pleasure and an honour to stay with them.

Kenneth J. Arrow is considered one of the most important economists in economic theory .

Ramon Marimon first dean of the Economics Faculty in 1990 has said about him: "Ken Arrow also pioneered endogenous growth theory by showing how far countries can go by the simple process of ‘learning by doing,’ but now I realize he was referring to his own life…he really did an incredible lot!

As Andreu Mas-Colell said "The surprising thing about him is that he only got one Nobel Prize".

Related post about Kenneth J. Arrow: If you'd like to understand what health economics is, don't miss Ken Arrow __________________________________________________________________________

clinical trails, conflicts of interest

"if professional societies and medical institutions do not demonstrate vigorous self- regulation and a commitment to keeping patients interests paramount, public trust may diminish, and more external regulation may be imposed" (Bernard Lo)

"Particularly attention must be paid when researchers offer some medical benefit that can be integrated easily into a course of treatment. Although subjects in these trials are offered a treatment of unproven efficacy, many mistakenly believe that they are receiving cutting-edge treatment guaranteed to improve their condition. This therapeutic misconception may be reinforced when subjects receive the experimental treatment from the same physician who has administered all of their care in the past, in contrast to being referred to a clinical investigator located in an academic setting with a reputation for conducting research" (Karine Morine, et al)

• Article (*.pdf): Managing conflicts of interest in the conduct of clinical trials (2002)
• Article (*.pdf): The future of conflicts of interest: A call for professional standards (2012)

photo: (*) Photosolde
_____________________________________________________________________

winter is coming and there's no bed in hospital that can resist it

The Nuffield Trust is looking closely at some of the big issues behind pressure on the NHS in winter months. Prof John Appleby Director of Research and Chief Economist presents some solutions:

• For some hospitals, the answer is simple: providing more beds and more staff will help them weather the storm through winter.
• For most others, recording bed occupancy in real time rather than taking a snapshot each day will help them to better coordinate the flow of patients.
• And for virtually all, reducing delays once patients are medically fit to leave hospital is essential.

Recent articles to look forward by Nuffield Trust and The Health Foundation in relation to winter pressures:

1) Winter bed pressures (2016)
2) How to help health care flow to winter pressures (different materials) 

and the Report of the Health Committee appointed by the House of Commons to examine the policy, administration and expenditure of the Department of Health and its associated bodies

3) 3rd Report - Winter pressure in accident and emergency department (2016)

Photo: Aaron Harris / Reuters (2014)
_____________________________________________________________________