Healthcare Leadership/ MHA6999 Week 1 Project

CASE 6

From Nothing to Something: Defining Governance and Infrastructure in a Small Medical Practice

Dea Robinson

Midtown Neurology was started by a single physician who had been practicing in the community for nearly 20 years. As the practice grew, it evolved from a “mom-n-pop” operation to a more complex model. The founding physician recruited four new neurologists to join and continue to help build the practice. Subsequently, however, the new doctors took over and forced him out of the practice.

The large urban hospital with which Midtown was affiliated achieved Level 1 trauma status, providing additional new opportunities for the practice. The neurologists took on the many responsibilities, including one of stroke team for the hospital. Contractual rural outreach was practiced utilizing telemedicine throughout the state and provided a robust revenue stream.

While still a small physician group, it required a difficult call schedule. Tracking call and distributing it equitably became a challenge. The main reason for this was the founding physician had written a proprietary program exclusively for this purpose. Now the practice was beholden to the very person they had forced out of the practice for a vital part of communication with the other practices regarding the call schedule. This was very unusual, as physicians don’t typically write proprietary software for a practice. In addition, the entire platform including the billing program, which he also developed, used MS-DOS.

The practice employed a practice manager who had started with the founding physician. As the practice grew, the manager did not keep up with the basics of managing a practice. Her information relating to billing, reimbursement, and changes to current CPT and ICD-9 issues was out of date. She was also ignorant of the contracts the practice had, but more importantly the impact of those contracts on the practice and how to carry them out appropriately.

While the physicians were very productive, several significant management problems became apparent as the practice grew. In particular, the infrastructure suffered and there was no governance. Infrastructure for a private practice is different from that of a corporate model. For example, in a corporate model individual departments exist with defined responsibilities to support the needs of the corporation and other areas of the entity, such as an IT department. Conversely, in a private practice when IT systems need repair, the responsibility falls to the administrator or manager, and this individual must know how to address and fix the problem. In this instance, the IT department and the owner of the practice were one and the same. Because of the proprietary nature of the software, outsourcing was not an option. The practice essentially was backed into a corner because of the lack of necessary infrastructure upgrades, such as in the case of IT. This dynamic created tension and frustration for the manager of the practice and the employees. The situation did not allow management to function normally in some instances.

The governance structure of the group required change after the solo physician hired the new neurologists. The new physicians had a more contemporary view of what a practice should look like and how it should function. This concern was the basis of many governance and trust problems. The IT and billing systems were grossly outdated, but the founding physician had taken great pride in his proprietary abilities and had not allowed changes. This attitude was prevalent in nearly every decision made, from what referring physicians the group would associate with to choices of staff. When decisions needed to be made, there was not a single voice for the practice, and this created confusion for the hospital and other referring colleagues. The group was resistant to appointing anyone as president and this habit had continued after the founding physician was forced out.

The physicians did not particularly like or trust each other. No one wanted anyone to become the practice leader or be the voice of the practice when building relationships with referring physicians. Each physician wanted to have his or her own individual PC and to run different revenue streams through the practice. All were secretive about their side deals. Employment contracts were never created and thus potential partner arrangements or what constituted partnership did not exist. Policies, procedures, and basic business documents, such as an employment manual for the staff, were never written or implemented.

Having access to neurological consultations on a 24/7 basis is a huge benefit for a Level 1 trauma hospital. The group was able to fulfill the need for the hospital; however, the outpatient piece of the practice suffered. Therefore, the hospital recruited three other physicians for the group to take over the out-patient portion of the practice. Due to the unstable relationship of the current physicians in the group, all three of these physicians subsequently left the practice, leaving the responsibility of finding replacements with the remaining physicians.

A requirement for smooth governance is the ability of the physicians, staff, and managers to trust each other. As the relatively new administrator of the practice you have come to realize that one of your first challenges is to bring the importance of governance to the attention of these physicians. You will also need to educate the physicians on the consequences of “going off on their own” and making arrangements on the side.

Discussion Questions

1.    What are three organizational issues going on in this case? Which organizational theories do you think apply best to this situation?

2.    Make a list of things you need to do as the new administrator and prioritize them. Provide a rationale for your list and priorities.

3.    How would you gain the trust of the individual physicians in light of the fact they do not trust anyone on the staff?

4.    What specific management strategies would you work to put in place?

5.    How would you engage the staff to help the infrastructure gain strength?

6.    What processes and dynamics need to be in place before starting the process of recruiting new physicians to work in the practice?

7.    What objectives for success could you use in determining if governance was going in a better direction?

8.    Can you see consequences to patient care with a fractured group? Explain why.

ADDITIONAL RESOURCES

Borkowski, N. (2011). Organizational behavior in health care (2nd ed.). Sudbury, MA: Jones and Bartlett.

Buchbinder, S. B., & Shanks, N. H. (2012). Introduction to health care management (2nd ed.). Burlington, MA: Jones & Bartlett.

Hayes, D. F. (2008). Starting a medical practice 101: Governance. Orchard Park, NY: Byzan Med, LLC. Retrieved from http://www.businessandmedicine.com/essays/governance.pdf

Healthcare Strategy Group. (2009). Governance models that work. Physician Strategy News. Louisville, KY: Healthcare Strategy Group. Retrieved from http://www.healthcarestrategygroup.com/newsletters/article.php?show=governance_models_that_work

Stearns, T. H. (1999). How physician/administrator teams work in small groups: Six steps to make it happen. Medical Group Management Journal, 46(3): 44–48, 50.

Zinober, J. W. (1991). A physician’s guide to practice governance. Medical Group Management Journal, 38(2): 54–56, 59–60.

CASE 8

Governing Board vs. Management

Louis Rubino

Lakeview Hospital Medical Center is a for-profit 250-bed hospital in a small but growing community that is rich with large internet businesses. The governing Board has recently been overhauled with about half being returning members and the other half being newly appointed. In an effort to have more “outsiders” on the Board of Directors (those who have no financial ties to the hospital), the longtime Chairman of the Board, Rick Brennan, and hospital CEO Marsha Choy scoured the surrounding area for experts in certain competencies who could enrich the Board deliberations. They found and recommended an attorney familiar with health care insurance laws, a professor from the state university who used to be a hospital system corporate executive, a local politician who is pushing for implementing policy in the community to improve individual health behaviors, and a former patient who is quite vocal about improving the health services at the hospital.

During the orientation for the new Board members, Rick and Marsha were very careful to address the fiduciary responsibility placed on the Board of Directors. They emphasized how the Board is to set the mission and vision of the hospital and develop matching strategies to propel the organization into the future. The new Board members are very enthusiastic and show great interest in advancing the hospital especially as health care reform takes hold. During the orientation, though, Marsha made a presentation that showed the various performance measures for the hospital, many of which are readily available to the public on the internet. The Board members are very dismayed to see how Lakeview falls below the other competing hospitals in their community, even the public safety-net facility. The new Board members pledge that this will not continue under their “watch.” Rick and Marsha start to get nervous about how much involvement the new Board members will have in the operations of the hospital.

During the Board meetings, it is clear that there is a big difference between the new and old Board members. The more senior Board members are reading their reports and making comments but then defer to management on handling the implementation and monitoring of the issues being addressed. The newer Board members feel that they need to get more actively involved to assure change is occurring. The Board members read from one of their ongoing educational pieces on health care trends about executive rounding. They decided that each Board member should visit a particular area of the hospital every month and report back at the Board meetings on the staff and patient responses to their inquiries.

The staff is enjoying meeting the new Board members as they make rounds and are not shy about telling them all the things they think are wrong with the management of the hospital. The newer Board members are concerned over the remarks and urge Rick and Marsha to address these issues at the Board meetings. They try to accommodate the request but now the Board meetings are running over four hours long and becoming more focused on daily management than on strategy formulation.

Communication is being altered on many levels. The communication between the Board of Directors and management of the hospital has changed from emphasizing being equal partners in the improvement of the hospital to being more hierarchical with management having to provide explanations on the issues raised due to the Board rounds. The more senior Board members are frustrated with the shift in their meetings and are starting to be silent during the discussion on these issues and are developing a pattern of leaving the meetings early. The administrative team is telling the employees not to engage the Board members in any discussion that could get them in trouble. And worst of all, improvements have not been demonstrated in the latest public reports.

Discussion Questions

1.    Do you feel it is appropriate for Board members to be making executive rounds in the hospital? If so, should they alter how they are responding to the issues they are hearing about?

2.    What role should Rick take on as he tries to address this transformation of the Board’s involvement into operations. What about Marsha’s role?

3.    How should the agenda of the Board meeting be changed to perhaps review the issues being raised yet not prolong the length of the meeting?

4.    Are there other ways the new Board members can be engaged in the improvement process that might not be viewed as taking over management of the hospital?

ADDITIONAL RESOURCES

Belmont, E., Haltom, C. C., Hastings, D. A., Homchick, R. G., Morris, L., Taitsman, J., Peisert, K. C. (2011). A new quality compass: Hospital boards’ increased role under the Affordable Care Act. Health Affairs, 30(7), 1282–1289.

Buchbinder, S. B., & Shanks, N. H. (Eds). (2012). Introduction to health care management (2nd ed.). Burlington, MA: Jones & Bartlett.

Studer, Q. (2008). Results that last. Hoboken, NJ: John Wiley & Sons.

White, K. R., & Griffith, J. R. (2010). The well-managed healthcare organization (7th ed.). Chicago, IL: Health Administration Press.

CASE 9

Transitioning to a New Leader

Louis Rubino

The Surgery Department at St. Gerard, a major academic medical center, is in the midst of change. New leadership has been appointed, which is rapidly changing the culture of the clinical area. The past Director was Dr. Marshall, who was a laid-back administrator/manager. He had been the Director for over 10 years and had become very comfortable in his position. Times were such that the academic medical center did very well. It could rely on not only strong revenue from good paying patients, but a steady stream of investment income, based on a successful fundraising campaign from a few years back. Dr. Marshall had a strong relationship-oriented leadership style and got along well with all his direct reports. He empowered the physicians, residents, nurses, and other operating room staff to manage their areas without much of his involvement. He was well-liked and oftentimes socialized with the Department personnel outside of work.

The downward trend with the economy has taken its toll on St. Gerard. The insurance mix has changed from a private base with partial government program support to one highly dependent on government payers. The community demographics have changed to being older and, therefore, more Medicare patients have entered the facility. The unemployment rate surrounding St. Gerard has increased and many people who once had private insurance through their employers are now on state aid (Medicaid). The net revenue of all departments has decreased, especially in the Surgery Department, not only from the change in payer mix, but also because elective surgeries are being postponed.

Dr. Marshall received a lot of pressure from the Vice President of Medical Affairs to decrease costs in the operating room. He did not feel up to the challenge at this point in his career and decided to retire earlier than he once expected. A new physician has been appointed as the Interim Director. Dr. Silver is a much younger surgeon who has impressed the VP with her efficient surgeries. She has the best on-time operations and all her peer scores are in the 90th percentile. She has been very effective working with the nurses on improving their Surgical Care Infection Prevention Scores (SCIP) and is active in the Surgery Department meetings, often volunteering to be on special subcommittees.

Dr. Silver is anxious to turn things around. Even though she is only appointed as Interim Director, she wants to prove her abilities as an administrator and make some immediate changes in the Department. She has weekly meetings with her medical directors and managers. She is enforcing hospital rules that have been ignored for many years, like the dress code and appropriate professional behavior. She makes rounds daily and even scrubs up to observe what is happening during procedures. Dr. Silver believes in accountability and is holding her staff responsible for good performance and for reducing costs. A few employees have already been written up for not following through on policy changes. She tries to stay current by reading journals in the field and has read an article about the value of transparency in work units. Impressed with this best practice, she immediately begins posting productivity results, which embarrasses the poorer performing doctors and clinical staff.

The Surgery Department faculty and staff are grumbling about all the changes taking place. Even though they seem to understand the necessity for all the changes and more active leadership, they feel Dr. Silver is micromanaging and does not trust them. They also believe that the changes are just happening too fast. The faculty and staff are concerned about their job security. The more senior associates want to approach Dr. Silver and let her know of their concerns. The more junior associates are afraid to be included in this meeting and would rather just stay silent and see how things progress. Now these two groups of workers are beginning to form a division due to how they want to address these issues.

Discussion Questions

1.    What should the faculty and staff do to address their concerns over Dr. Silver’s leadership?

2.    Do you think Dr. Silver’s being an “Interim” Director affects the way the associates are reacting?

3.    What do you think Dr. Silver should have done to make an easier transition for the employees after Dr. Marshall’s departure?

4.    Should the Vice President of Medical Affairs get involved if the physicians come to him and say that the morale is down in the Surgery Department due to the new Director’s style?

5.    Would you rather work under a Director with Dr. Marshall’s leadership style or Dr. Silver’s and why?

ADDITIONAL RESOURCES

Buchbinder, S. B., & Shanks, N. H. (Eds.). (2012). Introduction to health care management (2nd ed.). Burlington, MA: Jones & Bartlett.

Manion, J. (2011). From management to leadership: Strategies for transforming health care (3rd ed.). San Francisco, CA: Jossey-Bass.

Northouse, P. G. (2012). Introduction to leadership: Concepts and practice (2nd ed.). Thousand Oaks, CA: Sage.

Studer, Q. (2009). Straight A leadership: Alignment, action, accountability. Gulf Breeze, FL: Fire Starter.

Totten, M. K., & Paloski, D. (2011). Transparency: Considerations for CEOs and boards. Healthcare Executive, 26(5), 76–78.

CASE 10

The Toxic Leader

Marie-Elena Barry

Kyle was a BSN-prepared psychiatric nurse with two years of nursing experience under his belt, and was viewed by his peers as being a senior nurse. Currently, he attends a graduate program part-time to earn his MSN, with hopes to be a manager of an inpatient psychiatric unit. Whenever Kyle was on duty he was always in charge of the 12-bed inner city psychiatric unit. He worked on 3 West caring for young adult patients who suffered from developmental disabilities with a codiagnosis of psychiatric conditions such as schizophrenia, autism, or bipolar disease.

Every Tuesday and Thursday afternoon, the unit participates in patient care conferences. The purpose of the conference is to discuss patients who represent a challenge for staff or someone who has behaviors that require interdisciplinary collaboration in order to provide a safe and therapeutic milieu. In order to maintain compliance with The Joint Commission, the psychiatrist, nurse manager, pharmacist, psychologist, and representatives of nursing, social work, and recreational therapy are expected to attend. Jackie, the unit manager, is the Chair of the patient care conferences.

The psychiatric unit follows a primary care nursing model, and Kyle was the primary nurse for K.C. Kyle reflected that just two days prior to the scheduled care conference, K.C. was verbally threatening to staff and patients. Additionally, he stopped eating and was banging his head on the wall. On the day of the patient care conference, K.C. had physically assaulted another patient. Kyle, having just two years of nursing experience, was having difficulty in managing K.C.’s disturbing behavior. Kyle acknowledged that K.C. was a danger to himself and others, and Kyle was looking for guidance and support from the health care team.

Thursday at 2 pm, Kyle entered the conference room, as expected, only to find that he and the recreational therapist were the only staff present. This wasn’t unusual since when Jackie, the unit manager, sporadically attended rounds, she was often late. Ten minutes after the meeting was supposed to start, Jackie passed by the conference room while talking on the phone, and asked the person she was speaking with to hold on for a minute. As she hurriedly walked away, Jackie told Kyle and the recreational therapist the meeting was cancelled and, “Oh, by the way, didn’t you get my e-mail?” Kyle was speechless. He had never received an e-mail from Jackie, and was disappointed as yet another patient care conference went unattended by the management team.

In the meantime, Kyle was at a loss on how to positively manage the care for K.C. The unit was getting out of control as K.C. was becoming more aggressive with other patients. On the afternoon of the cancelled meeting, Kyle saw Jackie and asked her for a moment of her time. Jackie stated that she was late for an appointment as she briskly walked towards the door. She asked Kyle to e-mail her so they could set up an appointment for a more convenient time. Immediately, Kyle sent an e-mail to Jackie stating that he was accessible anytime, even on his days off. Days went by and Kyle never received a reply.

On Kyle’s next shift, he patiently waited for his unit manager to arrive. He needed to discuss the care of K.C. with her. When Jackie finally arrived at work, she was wearing a too-short sequined dress, large gold hoop earrings, and three-inch heels. As she had barely entered the psychiatric unit, Kyle noticed that she was hanging on Martin’s arm and giggling flirtatiously. Kyle remembered that Martin was complaining earlier that morning that he had scheduled a meeting with Jackie to discuss a staff squabble. To make matters worse, Martin, who was a younger and less senior nurse followed Jackie into her office and slouched comfortably into the leather chair across from her desk. Jackie hurriedly ran into her office and closed the door.

Discussion Questions

1.    What is going on in the case?

2.    What is the nature of this organizational problem?

3.    Which theory or theories best describe the behavior of the nurse manager?

4.    How does Jackie’s behavior affect workplace morale?

5.    What kind of clinical and financial impacts do you think Jackie’s behaviors might have on the hospital?

6.    What further actions do you recommend for Kyle to manage the safety of his patient and the unit? What kind of data will Kyle need to collect?

7.    How would you handle this scenario if you were Kyle?

8.    Provide your reflections and personal opinions as well as your recommendations for addressing this problem.

Role Play

Kyle: One student is Kyle. It is that student’s job to confront Jackie. Keeping in mind the Discussion Questions and Additional Resources for this case, how can Kyle ensure safe, effective patient care and protect himself in this situation?

Jackie: One student is Jackie, the unit manager. It is that student’s job to convince Kyle that his fears are unfounded. She is his boss and Chairperson of the patient care conferences. Keeping in mind the Discussion Questions and Additional Resources for this case, how can she defend her behaviors?

ADDITIONAL RESOURCES

Borkowski, N. (2011). Organizational behavior in health care (2nd ed.). Sudbury, MA: Jones and Bartlett.

Buchbinder, S. B., & Shanks, N. H. (Eds.). (2012). Introduction to health care management (2nd ed.). Burlington, MA: Jones & Bartlett.

Dupree, E., Anderson, R., McEnvoy, M., & Brodman, M. (2011). Professionalism: A necessary ingredient in a culture of safety. The Joint Commission Journal on Quality and Patient Safety, 37(10), 447–455.

Fallon, L. F., & McConnell, C. R. (2007). Human resource management in healthcare: Principles and practices. Sudbury, MA: Jones and Bartlett.

Kusy, M., & Holloway, E. (2009). Toxic workplace! Managing toxic personalities and their systems of power. San Francisco, CA: Jossey-Bass.

Malloy, T., & Penprase, B. (2010). Nursing leadership style and psychosocial work environment. Journal of Nursing Management, 18, 715–725.

Morrison, E. E. (2011). Ethics in health administration: A practical approach for decision makers (2nd ed.). Sudbury, MA: Jones and Bartlett.

Patterson, K., Grenny, J., McMillan, R., & Switzler, A. (2004). Crucial confrontations. New York, NY: McGraw-Hill.

Patterson, K., Grenny, J., McMillan, R., & Switzler, A. (2011). Crucial conversations: Tools for talking when stakes are high (2nd ed.). New York, NY: McGraw-Hill.

Perez, B., & Liberman, A. (2010). Sexuality in the workplace: Where do we stand? The Health Care Manager, 29(2), 98–116.

CASE 11

Inappropriate Client Behavior

Joshua H. Buchbinder

The management of Peak Performance Health and Wellness Club has received several emails and verbal complaints about an unidentified male club member allegedly masturbating while using the equipment in the club. The only description they have of the accused is that he is an older, white male with glasses.

Jim Roberts is a personal trainer and is just about to start a morning session with a client. A young woman he knows and trusts comes up to Jim with a frantic expression. “Come quickly.” She can barely get the words out. “There’s a man on the stationary bike who is staring at a woman’s chest and masturbating.”

Jim excuses himself from his session and goes to see for himself. The member points out the accused male, and Jim immediately contacts his department head and another male trainer, just in case there’s an incident.

Jim taps the accused member on the shoulder. “Can I have a word with you?”

The older man agrees, and they step over to the side. Jim knows this man and has had conversations with him in the past regarding his joint surgery and his postoperative rehabilitation. Jim believes he should be able to get to the bottom of this matter quickly.

“A member reported to us that you were touching yourself inappropriately.”

“What’s inappropriate? Your definition of inappropriate and mine might be completely different!”

“Were you fondling yourself?”

“What’s fondling? I don’t know what that means.”

“You had your hands in your pants.”

He shrugs. “So, we have to adjust ourselves. I can have my hand in my pants.”

At this point Jim becomes frustrated and just comes out and asks, “Were you masturbating?”

The member becomes very defensive and says, “I never do that, I can’t believe you accused me of that, I’m offended !”

Jim asks the man to stay where he is. He knocks on the general manager’s (GM) door and quickly fills him in on the situation. Jim and his team escort the accused member to the GM’s office.

The GM repeats the same line of questioning, and the man gives verbatim answers to the ones he gave Jim. Eventually, the GM gets as frustrated as Jim was and asks, “Were you masturbating?”

The man puts his hand on his chest and an indignant expression on his face. He shouts, “I NEVER DO THAT! I demand to face my accuser; I have the right to face my accuser. I’ve been a member since this club opened! I can’t believe that you would suggest this.”

At this point the GM is not amused or buying his story. He simply tells the man his membership will be on suspension pending an investigation.

The member continues to argue but eventually calms down. He then asks, “How will you let me know your decision?”

The GM tells him that the club will call him. “Can you e-mail me instead? Let me give you my personal e-mail.”

The GM agrees and tells him that he’ll have to leave. After the member leaves, the GM tells Jim to close the door.

He looks at Jim with a wry smile and says, “That guy is so guilty. He wants me to e-mail him privately so his wife won’t find out.”

Jim goes upstairs with his boss to speak with the female member who reported the incident. When he finds her, she is with another female member. The second female member tells Jim that he was the same man that she saw masturbating on a treadmill and wrote an email about. Jim’s boss takes statements from the two female members so Jim can return to his now shortened session with his client.

Discussion Questions

1.    What are the facts in this situation?

2.    Should anyone who observed the behavior feel obligated to report it? Why do you think only female members reported the behavior?

3.    Is this a criminal activity and should it be reported to police?

4.    Should the club install video surveillance equipment to deter this and other inappropriate member behaviors? Provide a rationale for your response.

5.    Do you think this situation was handled properly? If yes, what were three things that were done right? If no, what do you think should have been done differently? Provide a rationale for your response.

6.    How could these types of behaviors be prevented in the future? Provide your reflections and personal opinions as well as your recommendations and rationale for what, if anything, might have been done differently in this case.

ADDITIONAL RESOURCES

Applebaum, V. (2009, July). 12 rules of gym etiquette. IDEA Fit Tips, 7(7). Retrieved from http://www.ideafit.com/fitness-library/12-rules-of-gym-etiquette

Bates, M. (2007). Health fitness management: A comprehensive resource for managing and operating programs and facilities (2nd ed.). Champaign, IL: Human Kinetics.

Borkowski, N. (2011). Organizational behavior in health care (2nd ed.). Sudbury, MA: Jones and Bartlett.

Buchbinder, S. B., & Shanks, N. H. (Eds.). (2012). Introduction to health care management (2nd ed.). Burlington, MA: Jones & Bartlett.

Fallon, L. F., & McConnell, C. R. (2007). Human resource management in healthcare: Principles and practices. Sudbury, MA: Jones and Bartlett.

Morrison, E. E. (2011). Ethics in health administration: A practical approach for decision makers (2nd ed.). Sudbury, MA: Jones and Bartlett.

Patterson, K., Grenny, J., McMillan, R., & Switzler, A. (2004). Crucial confrontations. New York, NY: McGraw-Hill.

Patterson, K., Grenny, J., McMillan, R., & Switzler, A. (2011). Crucial conversations: Tools for talking when stakes are high (2nd ed.). New York, NY: McGraw-Hill.

CASE 12

A Lottery for Employee Attendance

Sharon B. Buchbinder

Delmarva Nursing Home (DNH) is faced with a pressing absenteeism problem among its predominantly African American CNAs. On weekends and the days before and after holidays, about one-third (33%) of the Certified Nursing Assistants (CNAs) call out sick. You are the Nursing Home Administrator (NHA) and you have estimated the cost of absenteeism is over $6,000 per month. In addition, those employees working the now nearly empty shifts are becoming increasingly dissatisfied and looking for work elsewhere. Losing CNAs is expensive too, as replacing the lost staff will cost even more money than the absenteeism.

The Administrator in Training (AIT) is taking a course on organizational behavior and discussed the problem with her professor. The instructor suggested that she look at the literature on employee bonuses for attendance. After reading a few articles, the AIT suggested a new program. Give the employees who show up to work scheduled bonuses. To be fair to all, she recommended that a lottery should be held each week. The names of all the CNAs who had worked every scheduled shift that week would be given numbers, then a random number generator (RNG) would pick the number of the winning CNA for a prize of $500. At the end of the month, all CNAs who had come to work every day, as scheduled, would have their numbers run through the same RNG for double the money. At the end of six months, the prize would be for quadruple the cash. One year of perfect attendance and employees would be eligible for cash, large household appliances, or a paid vacation.

The AIT’s plan has now been in effect for three months and absenteeism at DNH has dropped from 33% to 6%. This lower absenteeism rate has brought a new problem with it: presenteeism. Regardless of how ill they are, CNAs are arriving at work and demanding their name be put down for the lottery. What should you do?

Discussion Questions

1.    What is going on in this case?

2.    What is the nature of the organizational behavior problem?

3.    What are three factors contributing to this problem?

4.    Why do you think the employees are coming in sick?

5.    What type of data would you need to gather to address this problem?

6.    Which theory or theories do you believe best explain the behaviors of the employees?

7.    Provide three possible solutions to the new problem of people coming in sick.

8.    Should this lottery have been implemented? What are the underlying issues the AIT and NHA might have missed?

9.    Provide your reflections and personal opinions as well as your recommendations for addressing these problems.

ADDITIONAL RESOURCES

Borkowski, N. (2011). Organizational behavior in health care (2nd ed.). Sudbury, MA: Jones and Bartlett.

Buchbinder, S. B., & Shanks, N. H. (Eds.). (2012). Introduction to health care management (2nd ed.). Burlington, MA: Jones & Bartlett.

Hassink, W. H., & Koning, P. (2009). Do financial bonuses reduce employee absenteeism? Evidence from a lottery. Industrial & Labor Relations Review, 62(3), 327–342.

Johns, G. (2011, October). Attendance dynamics at work: The antecedents and correlates of presenteeism, absenteeism, and productivity loss. Journal of Occupational Health Psychology, 16(4), 483–500.

Morrison, E. E. (2011). Ethics in health administration: A practical approach for decision makers (2nd ed.). Sudbury, MA: Jones and Bartlett.

Office of Minority Health. (2001). National standards for culturally and linguistically appropriate services in health care: Final report. Washington, DC: U.S. Department of Health and Human Services.

CASE 13

Disorder in the House

Sharon B. Buchbinder

You are the new administrator of a primary care clinic in an academic medical center in a mid-Atlantic state. The clinic serves a large Medicaid and SCHIP population, as well as underinsured self-pay clients. The physicians, who are all employees, have come to you with a list of their top 10 complaints. Led by Dr. Kidd, a smart, vocal pediatrician, all the physicians employed at the clinic are threatening to go elsewhere unless something can be done about their concerns, which are as follows:

1.    The clinic is in a high-crime area and several employees have been mugged on their way to and from work.

2.    Theft inside the clinic is rampant. Despite locks and keys, purses, medications, and supplies keep disappearing.

3.    Patients come with problems ranging from preventative care to emergency conditions—yet they are all treated the same. Last year, a patient nearly died in the waiting room because she had to wait so long to be seen.

4.    Patient information is in paper files, which are not always where they belong. Losing files is not uncommon, which leads to lost time in diagnosing and treating patients due to retesting.

5.    The woman at the registration desk takes unscheduled breaks and two-hour lunches, which slows up everything.

6.    We understand the building is old, but it doesn’t have to be dirty. The janitor is absent most days and when he is here, he won’t clean. He sits in the parking lot and smokes.

7.    We never know who to go to for assistance with clerical work. The nurses say it’s not their job and the registration clerk laughs if we ask for assistance. We can’t take care of ordering supplies and scheduling vacations and take care of patients!

8.    Our patient records are so disordered that, if we need to find someone in a hurry with an abnormal test result, we can’t find their chart to find the patient. This is dangerous!

9.    The exam rooms must be cleaned between patients. Doctors shouldn’t do this, nurses won’t do this. The janitor is out back smoking. Whose job is it?

10.    Parking costs employees $15 per day—and that’s at a cheap lot. You have to do something about the cost of parking!

Discussion Questions

1.    What are the facts of this case?

2.    What is the nature of the organizational behavior problem(s)?

3.    What are three factors contributing to this dilemma?

4.    Who should be responsible for addressing these organizational issues?

5.    Make a list of problems at this clinic to be addressed in order of priority. Provide a rationale for each item and the order of each item on your list.

6.    What are the organizational strengths the administrator needs to rely on in this clinic? What are the weaknesses the administrator needs to address?

7.    The new administrator is making a list of short- and long-term goals for this clinic. What should they be and what resources will the new administrator need?

8.    Have you ever worked in an environment that had similar problems? Knowing what you now know, what do you think were the major contributors to that situation? Provide your reflections and personal opinions as well as your recommendations for addressing these problems.

ADDITIONAL RESOURCES

Borkowski, N. (2011). Organizational behavior in health care (2nd ed.). Sudbury, MA: Jones and Bartlett.

Buchbinder, S. B. & Shanks, N. H. (Eds.). (2012). Introduction to health care management (2nd ed.). Burlington, MA: Jones & Bartlett.

Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health (NIOSH). (2002). Violence: Occupational hazards in hospitals. Retrieved from http://www.cdc.gov/niosh/docs/2002-101/pdfs/2002-101.pdf

Gacki-Smith, J., Juarez, A. M., Boyett, L., Homeyer, C., Robinson, L., & MacLean, S. L. (2009). Violence against nurses working in US emergency departments. JONA: Journal of Nursing Administration, 39(7/8), 340–349.

Morrison, E. E. (2011). Ethics in health administration: A practical approach for decision makers (2nd ed.). Sudbury, MA: Jones and Bartlett.

Office of Minority Health. (2001). National standards for culturally and linguistically appropriate services in health care: Final report. Washington, DC: U.S. Department of Health and Human Services.

Spector, P. E., Coulter, M. L., Stockwell, H. G., & Matz, M. W. (2007, April–June). Perceived violence climate: A new construct and its relationship to workplace physical violence and verbal aggression, and their potential consequences. Work & Stress, 21(2), 117–130.

Zevon, W. (2004). Disorder in the house [Song]. Retrieved from http://www.youtube.com/watch?v=siqJq-8Sr6U

CASE 14

Managing Health Care Professionals: Five Mini-Case Studies with Role Play

Sharon B. Buchbinder

1. SEXUAL HARASSMENT ALLEGATION

A male nurse complains to his unit manager that he is being sexually harassed by a coworker, a female nurse. The female denies the charge. The female employee has received consistently excellent annual performance appraisals and has never been a “problem employee.” The male employee has received a poor annual review and has been disciplined for chronic tardiness. He is on the verge of being terminated.

Role Play

Male Nurse: One student is the male nurse who is making the complaint. It is that student’s job to convince his unit manager that he has been sexually harassed by his coworker. Keeping in mind the Discussion Questions and Additional Resources for this case, how can the male nurse convince his manager that this complaint has nothing to do with his poor annual review and recent discipline?

Unit Manager: One student is the unit manager. It is that student’s job to sort through the allegations and decide what to do next. The male nurse has a bad track record. The unit manager knows that if an allegation of sexual harassment is in play, an employee cannot be terminated or it will appear to be a vindictive termination. Keeping in mind the Discussion Questions and Additional Resources for this case, how can the unit manager deal with this appropriately and effectively?

2. YOU DON’T LOVE ME ENOUGH

Allison arrived at work early and stopped by the cafeteria for a quick cup of coffee before she headed up to the floor. She was looking forward to her shift and mentoring Lynne, a novice nurse. While paying the cashier, Allison felt a tap on her shoulder.

“Hi, Lynne! How are you?” Allison said and smiled.

“Didn’t you hear me calling to you in the parking lot?” Lynne asked.

“No, I was listening to my tunes,” Allison said and tapped her shirt pocket.

“I guess your music is more important than I am!”

“Lynne, I didn’t hear you. What’s wrong?”

“I give and give,” the novice’s voice ratcheted up the octaves, growing louder with each word. “I help, all the time, without being asked. What do I get? You treat me like dirt!” Lynne grabbed napkins from the dispenser, held them over her face, and wailed. “I’m going to the nurse manager to see about getting a new mentor. You really don’t care about me. I can’t be ignored like this!”

Role Play

Lynne, the Novice: One student is the novice nurse. It is that student’s job to explain (between hysterical sobs) why she wants a new mentor. Keeping in mind the Discussion Questions and Additional Resources for this case, how can the novice convince Allison that she needs (and deserves) more attention than she’s receiving from Allison.

Allison, the Mentor: One student is Allison, the mentor nurse. It is that student’s job to talk Lynne off the ledge and get her grounded. Allison has mentored a lot of new nurses. She understands this is a tough time for newbies. Keeping in mind the Discussion Questions and Additional Resources for this case, how can Allison deal with this appropriately and effectively?

3. SWITCH WITH ME—OR ELSE!

Beverly reviewed the new schedule, happy that she’d put in her request for the weekend six months in advance. She and her husband were going to New York, and she couldn’t wait. When she came out of the locker room, she almost bumped into her coworker, Carl.

“Yikes! They’ve got me down to work on my son’s birthday,” he said. “I need you to switch with me.”

“I wish I could help you out, but it’s my anniversary.”

“You and your husband can celebrate anytime. My kid’s only going to turn two years old once.” Carl towered over her and glared. “You have to switch with me. Or else.”

Role Play

Carl: One student is Carl, the bully. It is that student’s job to convince Beverly to switch days off with him. Keeping in mind the Discussion Questions and Additional Resources for this case, how can Carl convince Beverly she really wants to switch with him, for her own good?

Beverly: One student is Beverly. It is that student’s job to stand her ground and set boundaries. She has seen Carl bully other nurses into switching schedules with him, and she’s not about to let him do it to her. Keeping in mind the Discussion Questions and Additional Resources for this case, how can Beverly deal with Carl appropriately and effectively?

4. PASSED OVER

Angie Lopez has been working in the Billing Department at Great West Medical Center (GWMC) as a Customer Service Representative for five years. She is an excellent worker, with a great track record of soothing upset patients and families who have problems with payments. When a position opens up for a Customer Service Supervisor, her supervisor, who is getting promoted to another department, tells Angie she should apply. She thinks she is a shoo-in. Excited to be identified for this new role, Angie pursues the opportunity and interviews well. She thinks she has the job. Then she finds out a 62-year-old white man from a totally different area, with no experience in GWMC, was selected for the position. She goes to Elly in HR and asks why she didn’t get the job.

Role Play

Angie Lopez: One student is Angie. It is that student’s job to meet with the HR Representative and express her concerns about being passed over for the job. Keeping in mind the Discussion Questions and Additional Resources for this case, how can Angie communicate her concerns in a professional, appropriate, and effective manner?

HR Representative: One student is Elly, the HR Representative. It is that student’s job to share with Angie what she is legally allowed to share regarding the hiring process, including the educational preferences for the position. Among other things, the man who won the job has a BS in Business and 10 years of customer service experience with a competitor hospital. Angie has an AAS in Business. Keeping in mind the Discussion Questions and Additional Resources for this case, how can the HR Representative let Angie know that she is a valued member of the GWMC team? What kind of suggestions can HR provide Angie to improve her opportunities for advancement?

5. THE WHITE RABBIT

Dr. Lapin, a psychiatrist at Best Hospital, was quite a character. For five years in a row, he dressed up for Halloween as the White Rabbit. He’d hop around the hospital and look at his giant pocket watch and repeat, “I’m late, I’m late, for a very important date!” This year, Dr. Lapin dressed as the White Rabbit for Halloween, which fell on a Monday, and for every day of the week thereafter. On Friday, Nurse Bettie, a staff nurse who has known Dr. Lapin for over 10 years, stopped him in the hallway and said, “Dr. Lapin, it’s a cute costume, but don’t you think you’re overdoing it this year?” The doctor cocked his bunny ears, looked at the RN and said, “Who’s Dr. Lapin? I’m the White Rabbit and I have to find the Red Queen.” Nurse Bettie thought he was kidding until she saw him raise his hands into paws and bound down the hall. She watched in horror as Dr. Lapin hopped into the crowded Best Hospital lobby, jumped up and down on a sofa, and shouted, “I’m late, I’m late! I can’t find the Red Queen!”

Role Play

Dr. Lapin: One student is Dr. Lapin. He has a date. He’s late for it. He can’t find the Red Queen. Dr. Lapin is evidencing a serious mental health problem. He is unable to express himself except to hop and repeat, “I’m late, I’m late! I can’t find the Red Queen!”

Nurse Bettie: One student is Nurse Bettie. She is very concerned about her friend and coworker’s mental health as well as the safety of the visitors in the Best Hospital lobby. It is this student’s job to decide the best strategy for dealing with this crisis.

Keeping in mind the Discussion Questions and Additional Resources for this case, how can Nurse Bettie deal with Dr. Lapin in a professional, appropriate, and effective manner?

Discussion Questions

1.    What are the known facts in each of these scenarios?

2.    What organizational behavior problems do these cases illustrate?

3.    Are there cultural differences that might explain the behaviors in these cases?

4.    What role does Emotional Intelligence play in these scenarios?

5.    What legal and ethical dilemmas do these cases demonstrate?

6.    What principles of power and influence are at play in each of these scenarios?

7.    Have any of these situations ever happened to you at work? What did you do? Provide your reflections and personal opinions as well as your recommendations for what you would do differently now. Provide a rationale for your response.

ADDITIONAL RESOURCES

Borkowski, N. (2011). Organizational behavior in health care (2nd ed.). Sudbury, MA: Jones and Bartlett.

Buchbinder, S. B. (2009, July 29). Emotional intelligence and leadership. Retrieved from http://blogs.jblearning.com/health/2009/07/29/emotional-intelligence-and-leadership/

Buchbinder, S. B., & Shanks, N. H. (Eds.). (2012). Introduction to health care management (2nd ed.). Burlington, MA: Jones & Bartlett.

The Consortium on Research for Emotional Intelligence in Organizations. (2009). The emotional competence framework. Retrieved from http://www.eiconsortium.org/reports/emotional_competence_framework.html

DelPo, A., & Guerin, L. (2002). Dealing with problem employees: A legal guide. Berkeley, CA: Nolo.

Dewa, C. S. (2007). Mental illness and the workplace: A national concern. The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie, 52(6), 337–338.

Dingfelder, S. F. (2006, April). Whispers as weapons. Monitor on Psychology, 36(4), 62–64.

Fallon, L. F., & McConnell, C. R. (2007). Human resource management in healthcare: Principles and practices. Sudbury, MA: Jones and Bartlett.

Heathfield, S. (2006). Rise above the fray: Options for dealing with difficult people at work. Retrieved from http://humanresources.about.com/od/workrelationships/a/difficultpeople.htm

Kelly, L. (2011). “I know it shouldn’t but it still hurts” Bullying and adults: Implications and interventions for practice. Nursing.theclinics.com. doi:10.1016/j/cnur.2011.08.003

McLeod, J. (2007). Cruel intentions? Nursing Management, 14(4), 16–18.

Morrison, E. E. (2011). Ethics in health administration: A practical approach for decision makers (2nd ed.). Sudbury, MA: Jones and Bartlett.

Negri, L. (2009). Why has a woman with mental illness been fired? Discourses on fairness and diversity management. Work: Journal of Prevention, Assessment & Rehabilitation, 33(1), 35–42.

Office of Minority Health. (2001). National standards for culturally and linguistically appropriate services in health care: Final report. Washington, DC: U.S. Department of Health and Human Services.

Patterson, K., Grenny, J., McMillan, R., & Switzler, A. (2004). Crucial confrontations. New York, NY: McGraw-Hill.

Patterson, K., Grenny, J., McMillan, R., & Switzler, A. (2011). Crucial conversations: Tools for talking when stakes are high (2nd ed.). New York, NY: McGraw-Hill.

Roberts, S., Demarco, R., & Griffin, M. (2009). The effect of oppressed group behaviours on the culture of the nursing workplace: A review of the evidence and interventions for change. Journal of Nursing Management, 17, 288–293.

CASE 15

Take a Number

Sharon B. Buchbinder

Dr. Guiles, a 63-year-old male with prostatic cancer, is in his car, on his way to be admitted to The Best Medical Center, a 1,000-bed teaching hospital. He has the following classic symptoms:

•    “Weak flow of urine.

•    Frequent urination (especially at night).

•    Trouble urinating.

•    Pain and burning during urination.

•    Blood in his urine or semen.

•    Back pain that doesn’t go away.” (National Cancer Institute, n.d.)

His enlarged prostate is the size of a lemon and his symptoms are unbearable. A modest man, he is embarrassed by this condition, which is one of the reasons that it took him so long to get it treated. His urologist is the best physician in the world. Dr. Guiles knows his medical treatment will be superb. Having mustered up his courage to have the surgery, he finally goes to the hospital early in the morning to be admitted.

When he enters patient registration, he’s ordered to “take a number and sit down.” Although there are only two patients in the waiting area at 7:00 in the morning, he has to wait an hour to be admitted. Miss Peach, the admitting clerk, is surly throughout the admission process, barking at him and snatching papers out of his hand. At last, she puts his wrist band on, hands him the stack of admitting documents, and points him in the general direction of the floor. It takes him over 20 minutes to find the floor and the nursing station, due to difficulty walking and the need to urinate frequently.

Dr. Guiles stands in front of the nursing station and tries to figure out who should receive the papers, when the charge nurse exclaims, “You should have been here an hour ago!” The nurse’s aide escorts him to his door and leaves Dr. Guiles there. The professor discovers his room is full of people, family members of his roommate. Several of the family members are sitting on his bed. He tells the family members that they are in his bed and he is having surgery in the morning. He really needs to get some rest. And he needs to use the bathroom, but someone is in there. The roommate’s family ignores him and continues to chat among themselves. When he limps back out to the nursing station to explain the situation, the charge nurse harrumphs and says, “You won’t get any special treatment here just because you’re some hot-shot professor.” Using his cell phone, the patient calls his doctor and tells him he’s leaving.

Discussion Questions

1.    What are the facts of this case?

2.    What is the nature of the organizational behavior problem?

3.    What are three factors contributing to this problem?

4.    Which theory or theories do you believe best explain the behaviors of the employees?

5.    What are the top three management issues in this case?

6.    What should the physician do? What should the patient do?

7.    Who should be responsible for addressing these organizational issues?

8.    Provide your reflections and personal opinions as well as your recommendations for addressing these problems.

ADDITIONAL RESOURCES

Borkowski, N. (2011). Organizational behavior in health care (2nd ed.). Sudbury, MA: Jones and Bartlett.

Buchbinder, S. B., & Shanks, N. H. (Eds.). (2012). Introduction to health care management (2nd ed.). Burlington, MA: Jones & Bartlett.

Morrison, E. E. (2011). Ethics in health administration: A practical approach for decision makers (2nd ed.). Sudbury, MA: Jones and Bartlett.

National Cancer Institute. (n.d.). General information about prostate cancer. Retrieved from http://www.cancer.gov/cancertopics/pdq/treatment/prostate/Patient/page1

Office of Minority Health. (2001). National standards for culturally and linguistically appropriate services in health care: Final report. Washington, DC: U.S. Department of Health and Human Services.

Sanford, K. (2011). A new customer service partnership for hospitals and physicians. Healthcare Financial Management, 65(12), 48–52.

CASE 16

The Write Candidate

Sharon B. Buchbinder

Nancy Nottingham is a finalist for a Women’s Services Nurse Manager position at Ipecac County Teaching Hospital (ICTH). In addition to having an MSN and an MBA, she has over a decade of progressively responsible experiences working with diverse populations in county teaching hospitals. After a series of telephone interviews with the recruiter and human resources, Nancy has been invited to fly to New York from Baltimore for an all day series of face-to-face interviews. After a marathon six-hour day meeting with potential team members, Nancy is feeling good. She is in the zone and feels as if she has known everyone all her life. The staff nurses are warm and friendly and tell her they can’t wait to start working with her.

Her final interview is with the Chief Nursing Officer (CNO) of ICTH, Dr. Mary Marvelous. A plump, middle-aged woman with an MSN and a PhD in Clinical Psychology, Mary has just been promoted to the CNO role the week before. On the way to the final interview, Nancy shares with the recruiter that she is very excited and honored to be meeting Dr. Marvelous. Nancy says, “She must be awesome!”

Nancy expects Dr. Marvelous to be like the other people she met that day. Instead, the CNO is hostile and condescending from the moment she lays eyes on Nancy. The woman refuses to shake Nancy’s hand at first, and only does it because the recruiter waits for the CNO to extend her hand. Dr. Marvelous frowns when she invites Nancy to have a seat and dismisses the recruiter with a wave of her hand. The CNO sits behind her desk, folds her arms over her chest, crosses her legs and glares at Nancy over her glasses.

“Well,” Dr. Marvelous barks, “Tell me about yourself.”

After a brief synopsis of her life, Nancy tells her that her latest accomplishment is that she has written a chapter in a health care management textbook. In fact, she brought a reprint for Dr. Marvelous. The CNO flips through the pages and tosses it across her desk. “You can take it back. It will only gather dust and clutter up my shelves. What else?”

Nancy shares that she also writes fiction.

Dr. Marvelous actually smiles. “What kind?”

Encouraged by the CNO’s friendly expression, Nancy smiles back and says, “Romance.”

Dr. Marvelous’ smile turns back into a frown. “Is it porn?”

Bewildered, Nancy asks, “What do you mean?”

The CNO says, “Do you write anything describing sex between a man and a woman?”

Nancy responds that some of her fiction does have sex scenes, but that the majority of literature in the world has some depiction of sex.

Dr. Marvelous stands. “There is absolutely no way I would ever hire a nurse manager who writes porn. It would damage the reputation of this hospital.”

Nancy can’t believe that in this day and age someone this educated—with a degree in clinical psychology, no less—could behave this way. ICTH is a county teaching hospital with a sex change clinic and sex therapists on staff, who have dealt with a lot racier material than Nancy wrote about in her spare time. The CNO’s remarks make no sense in light of the mission, vision, and value statements posted all over their website, print materials, and walls of their building.

Nancy thanks Dr. Marvelous for her time and leaves, shell-shocked. She goes home and writes a polite thank you e-mail to the recruiter and formally withdraws her application for the position. She receives an astonished e-mail back from the recruiter who asks, “I’m at a loss. What happened?”

Discussion Questions

1.    What is going on in this case?

2.    What is the nature of the organizational behavior problem?

3.    Why do you think Dr. Marvelous responded this way?

4.    Do you think Nancy Nottingham should have told the CNO that she wrote fiction?

5.    Are there first amendment rights that Dr. Marvelous is violating? Is it any of her business if Nancy writes romance novels?

6.    ICTH is a county hospital funded by taxpayers. Does the CNO have the right to hire who she wants?

7.    Which theory or theories do you believe best explain the behaviors of the CNO?

8.    Should Nancy have withdrawn her application? What should Nancy Nottingham do on her next job interview? Should she be forthright? Or should she keep mum about her budding romance writer career?

9.    Provide your reflections and personal opinions as well as your recommendations for addressing this problem.

ADDITIONAL RESOURCES

Borkowski, N. (2011). Organizational behavior in health care (2nd ed.). Sudbury, MA: Jones and Bartlett.

Buchbinder, S. B., & Shanks, N. H. (Eds.). (2012). Introduction to health care management (2nd ed.). Burlington, MA: Jones & Bartlett.

Kusy, M., & Holloway, E. (2009). Toxic workplace! Managing toxic personalities and their systems of power. San Franciso, CA: Jossey-Bass.

Morrison, E. E. (2011). Ethics in health administration: A practical approach for decision makers (2nd ed.). Sudbury, MA: Jones and Bartlett.

Office of Minority Health. (2001). National standards for culturally and linguistically appropriate services in health care: Final report. Washington, DC: U.S. Department of Health and Human Services.

CASE 17

The Price of Hubris

Susan Judd Casciani

Edgar Roman was a physician with a private practice in Brightville, West Virginia, a small rural community about an hour’s drive from Eden, the nearest metropolitan area. There were no other physicians in the area, but as a family medicine practitioner, Dr. Roman was able to provide care for everyone. He had been operating his practice for over 20 years and had come to know all of the local residents. He enjoyed the relationships he had built with them over time. The local mining company was the only major employer in the area; almost everyone in Brightville worked at or had retired from the mine.

Many of Dr. Roman’s patients had the need for chronic and specialized care. There were three hospitals located in close proximity to each other in Eden; however, Dr. Roman always referred his patients to one specific hospital, Cardinal Health. Dr. Roman was held in high regard by Cardinal Health due to his high volume of patient referrals, and he very much enjoyed the prestige this provided him. The two other hospitals, Aspirant Hospital and Hope Healthcare, had regularly tried to “court” Dr. Roman to send his referrals to them, but Dr. Roman believed that if he split his referrals between hospitals, he would not be viewed with the same high esteem that he enjoyed with Cardinal Health.

Shortly after Independence Day this past summer, Dr. Roman began to notice a decline in his monthly visit volumes. It was slight at first, but now after four months it was obvious to Dr. Roman that he was not experiencing an anomaly. Plus, with flu season now getting into full swing he should be seeing an increase in monthly visits, not a decrease. Dr. Roman also noticed that the patients he was seeing tended to be the younger, healthier ones—families with young children for example. No longer did he have a high volume of patients with chronic conditions or those needing specialized care referrals. Dr. Roman knew something was up, but he had no idea what.

One Saturday Dr. Roman decided to visit his old fishing spot on the far side of town. He hoped that a few hours alone on the lake would give him time to try to make some sense of what was going on with his practice, and to see if he could figure out a way to stop his visit volumes from declining. Just as he reached the far side of town he noticed the storefront that had always been a hair salon now had a new name—Aspirant Hospital Physicians! He slammed on his brakes in disbelief, causing the driver behind him to honk in disgust. Dr. Roman pulled into the parking lot and tried to comprehend what he was seeing. A sign on the storefront indicated that the clinic was staffed by a nurse practitioner, and that patients were provided with access to specialty physicians at Aspirant Hospital via synchronous telehealth offered onsite! Dr. Roman was incredulous. He now understood all too late what was going on with his visit volumes.

Discussion Questions

1.    From a strategic planning perspective, what is really going on in this case?

2.    Identify three factors that Dr. Roman ignored with respect to his practice’s continued success.

3.    Identify two realistic and feasible solutions that Dr. Roman could implement to attempt to recover his visit volumes.

4.    What strategies could Dr. Roman use to approach any/each of the three hospitals in his quest to recover his medical practice revenue base?

5.    In retrospect, what should Dr. Roman have done differently with respect to strategic planning to prevent this situation from occurring?

ADDITIONAL RESOURCES

Buchbinder, S. B., & Shanks, N. H. (Eds.). (2012). Introduction to health care management (2nd ed.). Burlington, MA: Jones & Bartlett.

Porter, M. E. (2008). The five competitive forces that shape strategy. Harvard Business Review, 86(1), 78–93.

CASE 18

Isn’t It Great? My Boss Got Promoted and I Got His Job!

Nancy H. Shanks

My boss, Mick, had always wanted to be in senior management. He finally got the opportunity when he was recruited to become the Chief Operating Officer (COO) of our company Health Informatics Associates (HIA). He was very excited to have been tapped for this position and everybody, including me, thought he was a perfect fit for the job.

The company did a national search to fill his position as Director of Accounting and Finance. After a lot of soul-searching and encouragement from others, I applied for the position. There were many very well-qualified applicants from outside the organization, but in accord with HIA’s policy to promote from within, I was offered the position. I had known Mick for several years and reported to him in the Department. I felt confident that, since he had supported me to take over the Department, I could continue to work well with him as one of his direct reports and that he would continue to be an excellent mentor for me. This seemed like the ideal situation, perhaps too good to be true.

The first couple of months in my honeymoon as the Director went pretty smoothly. I worked hard to get up-to-speed on all of the subunits in the Department. I met regularly with the unit managers to assure that I learned the issues of concern and to get to know them better and on a more personal base. I thought that the Department was doing well, that my managers were supportive, and that everyone was working together as a team. I had, however, been these managers’ peer for several years, but now was their boss.

One day my administrative assistant said in passing that she’d seen Sally, the Accounting Manager, coming out of a meeting with Mick and wondered what that was about. Then, I got wind that Jane, the Chief Reimbursement Analyst, who had worked closely with Mick had several lunch meetings with him in order to discuss some issues. Next there was Steve, the Payroll and Compensation Manager, who had been hired by Mick many years ago and was a good friend; he seemed to be putting bugs in Mick’s ear about some things not going so well in the Department. None of these concerns had been raised with me.

In my biweekly meeting with Mick he had mentioned a couple of things that had happened that he could only have known about if he were there when they happened or someone had told him directly. We discussed how to address the problems, but I left the meeting with some concerns. I got the feeling that these managers were bypassing me and going to discuss issues directly with Mick. Initially, I thought this was just them having difficulty getting used to me being the boss, but as time passed the situation continued and I started to get a little paranoid. I decided to try to nip this in the bud and suggested that people not bother Mick with minor problems, as he had bigger fish to fry now. The situation didn’t change; Sally, Jane, and Steve kept it up.

Discussion Questions

1.    What is going on in this situation? What are the facts?

2.    What is the nature of this organizational problem?

3.    Do you think the new supervisor is part of the problem? Does she need a mentor/coach?

4.    Should she approach Mick to talk about and get his advice on how to address her concerns? How should she go about this, without coming off as being too paranoid?

5.    Would a good strategy be to enlist Mick’s help with this, suggesting that he send folks back to the Department to address their concerns?

6.    What advice do you think Mick will give? What will he do to help her?

7.    Should she meet with Sally, Jane, and Steve individually to discuss their behavior? How should she approach this with them?

8.    Have you ever worked with someone who kept bypassing you as their supervisor? What kind of strategies did you use to solve this problem? Provide your reflections and personal opinions as well as your recommendations for addressing this problem along with a rationale for your suggestions.

Role Play

The New Supervisor: One student is the new supervisor. It is that student’s job to come up with a strategy to approach and speak with her COO, Mick, about how he keeps taking meetings with her direct reports and how she needs his support to create an effective work relationship with her employees. Keeping in mind the Discussion Questions and Additional Resources for this case, how can the new supervisor remain calm, put herself in Mick’s shoes, and walk out with a solution that puts her back in the driver’s seat for the department? (Hint: Take a look at the case on Emotional Intelligence, “The New Manager Needs a Coach.”)

Mick: One student is Mick, the new COO. It is that student’s job to convince the new supervisor that he really isn’t trying to undermine her. He just happens to know all the answers and people keep coming to him. He likes having an open door policy. He thinks it’s healthy. Keeping in mind the Discussion Questions and Additional Resources for this case, how can Mick defend his behaviors and support the new supervisor? Is it possible to do both? Or is this an either/or situation?

ADDITIONAL RESOURCES

Buchbinder, S. B., & Shanks, N.H. (Eds.). (2012). Introduction to health care management (2nd ed.). Burlington, MA: Jones & Bartlett.

Cloke, K., & Goldsmith, J. (2000). Resolving conflicts at work. San Francisco, CA: Jossey-Bass.

The Consortium on Research for Emotional Intelligence in Organizations. (2009). The emotional competence framework. Retrieved from http://www.eiconsortium.org/reports/emotional_competence_framework.html

Dana, D. (2001). Conflict resolution. New York, NY: McGraw-Hill.

Goleman, D. (1998, December). What makes a leader? Harvard Business Review 82(1), 82–91.

Goleman, D. (2006). Social intelligence. New York, NY: Bantam Books.

Patterson, K., Grenny, J., McMillan, R., & Switzler, A. (2000). Better than duct tape: Dialogue tools for getting results and getting along. Plano, TX: Pritchett Rummler-Brache.

Patterson, K., Grenny, J., McMillan, R., & Switzler, A. (2004). Crucial confrontations. New York, NY: McGraw-Hill.

Patterson, K., Grenny, J., McMillan, R., & Switzler, A. (2011). Crucial conversations: Tools for talking when stakes are high (2nd ed.). New York, NY: McGraw-Hill.

Wood, J. T. (2007). Interpersonal communication: Everyday encounters (6th ed.). Boston, MA: Wadsworth.

ASE 19

Strategies for Dealing with Health Care Reform

Nancy H. Shanks

The CEO of North Eastern Hospital (NEH), Jim James, had been playing the waiting game, assuming that he had plenty of time to prepare for how his institution would be impacted by the Affordable Care Act (ACA). When the Supreme Court upheld the constitutionality of President Obama’s signature legislation in June 2012, Jim realized he and his staff needed to quickly rethink the hospital’s position and shift strategies. While they had initially seen the health care reform provisions of the ACA as burdensome, now he wanted the staff to think about the opportunities that it offered and how it could enhance NEH and help it to fulfill its mission in serving the community.

The more Jim read and thought about the provisions of the new law, the more convinced he became of the benefits. Since a primary goal of the ACA was to bring the uninsured into coverage, large number of uninsured in the community would soon have access to care. And, with insurance companies being required to provide coverage for those with preexisting conditions, these folks would also have access.

There were many negative stereotypes associated with both groups. While some of these people were indeed very ill, it was also clear that the fact that people didn’t have insurance did not necessarily mean they were sick. In reality, many were healthy individuals who, for whatever reason, were uninsured. Some were seasonal workers in organizations that didn’t provide coverage to their employees, others opted not to buy coverage, and there were those who just could not afford it and would now be subsidized. Additionally, some with preexisting conditions had in the past been denied insurance coverage on the basis of relatively minor problems, such as sinusitis, a prior knee injury, removal of a small benign tumor, and so on.

This looked to Jim like a bonanza. Jim wanted to find ways to connect these groups to his hospital, as well as its associated outpatient clinics and excellent pool of physicians and other health care professionals. This led him to thinking about new programs, modifying existing programs, developing marketing strategies, finding ways to capitalize on the pent-up demand for services in the short run, and becoming the provider of choice in the long run.

Discussion Questions

1.    What should NEH do? Would you recommend developing new programs? Or, should existing programs be expanded to meet the increased demand? Provide the rationale for what you propose.

2.    Are there areas of the hospital where demand might be reduced? For example, many of the uninsured may have used the ER as their point of access to care in the past. What would you propose to change this behavior and to address issues relating to the ER?

3.    What marketing strategies might be developed to attract this new clientele?

4.    Have there been more recent changes to the ACA on which you would recommend the hospital focus? Be specific.

5.    Have other changes taken place in your state with regard to other groups of patients, such as those enrolled in Medicaid and the Children’s Health Insurance Program (CHIP)? How can NEH respond to meet the needs of these groups?

ADDITIONAL RESOURCES

Abelson, R. (2012, June 21). Billions of dollars are in play over health care law. New York Times. Retrieved from http://www.nytimes.com/2012/06/22/health/billions-of-dollars-in-play-over-health-care-law.html?ref=reedabelson

Affordable Care Act. See http://www.healthcare.gov/index.html

Buchbinder, S. B., & Shanks, N. H. (Eds.). (2012). Introduction to health care management (2nd ed.). Burlington, MA: Jones & Bartlett.

Clemans-Cope, L., Kenney, G. M., Buettgens, M., Carroll, C., & Blavin, F. (2012). The Affordable Care Act’s coverage expansions will reduce differences in uninsurance rates by race and ethnicity. Health Affairs, 31(5), 920–930.

Kaiser Family Foundation. (2010). Mapping the effects of the ACA’s health insurance coverage expansions. Retrieved from http://healthreform.kff.org/en/coverage-expansion-map.aspx

Liptak, A. (2012, June 28). Supreme Court upholds health care law, 5-4, in victory for Obama. New York Times. Retrieved from http://www.nytimes.com/2012/06/29/us/supreme-court-lets-health-law-largely-stand.html?ref=health&pagewanted=print

Tavernise, S. (2012, June 21). Those already ill have high stake in health ruling. New York Times. Retrieved from http://query.nytimes.com/gst/fullpage.html?res=9C07E0DD163BF930A15755C0A9649D8B63&ref=sabrinatavernise

Vega, T. (2012, June 21). Insurers seek to soften their image, no matter how court rules on health act. New York Times. Retrieved from http://www.nytimes.com/2012/06/22/us/politics/insurance-companies-are-trying-to-soften-their-image.html?ref=tanzinavega

Weaver, C. (2012, July 5). Ruling underscores hospitals’ strategy. Wall Street Journal. Retrieved from http://professional.wsj.com/article/SB10001424052702304441404577481060091946508.html

White House. (2012). The Affordable Care Act is helping millions of Americans like you. Retrieved from http://www.whitehouse.gov/the-press-office/2012/06/28/fact-sheet-affordable-care-act-secure-health-coverage-middle-class

CASE 20

What Can I Do? I Think My Boss Is a Bully!

Nancy H. Shanks

Our department has been in turmoil for a couple of years. Our previous department director was great, did an excellent job, and was a good leader. He got along with almost everyone and had worked at the medical center for many years. Things went south as a result of a disagreement with an employee in our department. Our boss gave this employee a bad evaluation after documenting poor performance, lack of productivity, and lack of competence. The staff member retaliated claiming discrimination. Our director’s boss (a VP), the HR Director, and the corporate attorney all sided with the staff member. The politics of the situation got pretty ugly and our director decided it was time to retire.

Soon after, a search was undertaken to recruit his replacement. The VP and hiring authority had always made new hires that were good fits for the departments and their cultures, as well as someone recommended by the search committee. This time the VP hired the person who she wanted, going against others’ recommendations. No one in the department thought this person was a good fit when she interviewed, but were overruled.

Afterward, everyone agreed that the decision had been made and we would welcome this new director to the department. She came on board like gang-busters and immediately started changing things. While some of her ideas were good, most were a reflection that she didn’t make any effort to understand our department or the medical center. She was pushy in meetings, was very demanding of everybody in the department, set deadlines that were unrealistic, demeaned the support staff in front of others, and was aggressive with others in the medical center. She even was telling us inside the department and in other departments how to do our jobs. A major concern has been her lack of professionalism, particularly when she proceeded to “bad mouth” our old boss, telling everyone what a poor job he had done and what a mess he had left for her.

Two other things have occurred that are worrisome. Our new boss and the VP have become fast friends. Our boss doesn’t act the same way when she’s in meetings with the VP. And, she has also befriended the problem employee, the one who got cross-wise with our old boss. Despite this person’s documented poor performance, our boss cuts her a lot of slack and does not hold her to the same standard as the rest of us.

When the new boss first arrived, I really tried to give her the benefit of the doubt. I know how difficult change can be and I worked hard to try to accept and support her. I have always been a really good employee. I have gotten excellent evaluations and have always done a terrific job. I’m a good team player, volunteering to assist when the department needs someone to step up and help out on a special project and go the extra mile. I’ve also always been respectful of and worked well with others. Now, however, the new boss has become very critical of my work and keeps telling me I’m doing things wrong that I know are being done correctly. I’ve talked to several colleagues who feel the same way. A couple of folks already have found other positions and left. Our department is getting a reputation as a bad place to work, the morale of those still here has plummeted, and people seem to be taking a lot of sick leave. Everybody feels like they are being bullied by the new boss. I used to love my job and coming to work, but now I dread it and am not sure how to handle this.

Discussion Questions

1.    Is it me? Am I just having trouble dealing with the changes in the department?

2.    Given what has transpired so far, what do you think I should do?

3.    Do you think I should approach my new boss to discuss my concerns?

4.    Should I talk to someone else at the medical center about this? With whom? Should I do this alone or with others?

5.    How has the new boss handled this change and her transition into the department and the medical center? What things do you think my new boss is doing right and what is she perhaps not handling so well?

6.    Do you think that the new boss is a bully?

7.    What do you think should be done about the situation? Do you think this is a likely outcome in the short term? What will likely happen long term?

ADDITIONAL RESOURCES

Bridges, W. (2009). Managing transitions: Making the most of change. Philadelphia, PA: Da Capo Press.

Buchbinder, S. B., & Shanks, N. H. (Eds.). (2012). Introduction to health care management (2nd ed.). Burlington, MA: Jones & Bartlett.

Cloke, K., & Goldsmith, J. (2000). Resolving conflicts at work. San Francisco, CA: Jossey-Bass.

Meece, M. (2009, May 10). Backlash: Women bullying women at work. New York Times. Retrieved from http://www.nytimes.com/2009/05/10/business/10women.html?pagewanted=all

Namie, G., & Namie, R. (2009). The bully at work: What you can do to stop the hurt and reclaim your dignity on the job. Naperville, IL: Sourcebooks.

Namie, G., & Namie, R. (2011). The bully-free workplace: Stop jerks, weasels and snakes from killing your organization. Hoboken, NJ: John Wiley & Sons.

Patterson, K., Grenny, J., McMillan, R., & Switzler, A. (2000). Better than duct tape: Dialogue tools for getting results and getting along. Planos, TX: Pritchett Rummler-Brache.

Van Dusen, A. (2008). Ten signs you’re being bullied at work. Forbes. Retrieved from http://www.forbes.com/2008/03/22/health-bullying-office-forbeslife-cx_avd_0324health.html

Washington State Department of Labor & Industries. (2011). Workplace bullying and disruptive behavior: What everyone needs to know. Olympia, WA: Washington State Department of Labor & Industries. Retrieved from http://www.lni.wa.gov/Safety/Research/Files/Bullying.pdf

CASE 21

Whose Decision Is It About Which Positions Are Filled?

Nancy H. Shanks

During a recent economic turndown that impacted the entire country, University Medical Center was forced into cut-back management mode. With less funding coming from state government to support the institution, every department was required to tighten its budget, new hires were deferred, and everyone was expected to pitch in to keep the institution afloat. It had been a rough couple of years and one that was very stressful for the entire staff.

As the economy began to recover and the Medical Center’s fiscal situation began to ease, a few new positions were made available. Each of the four major divisions (Patient Care, Finance, Support Services, and Human Resources) was allocated a single position to fill, with the decision about allocation needing approval of all of the division VPs. Each VP was asked to provide justification for their particular area.

Linda, the VP of Patient Care, reviewed her numbers and decided that the position in her division was most needed in the Imaging Department. While the Lab, Diagnostic Services, Rehab, Nursing, and Quality departments were also shorthanded, Imaging had experienced the highest volume increases and was generating the most revenue with the fewest number of employees, as it had experienced the most attrition during the hiring freeze and was in her opinion most in need. The other VPs concurred with and approved Linda’s recommendation.

The next day Linda arrived at work bright and early, with the goal of preparing for the regular biweekly department directors’ meeting scheduled for later that day. She had sent out the meeting agenda, which noted that Patient Care had received one new position and that it had been allocated to Imaging. She had just gotten her coffee, when there was a knock at her door. Cheryl, the Nursing Director, came in and barely sat down before she burst out, “How could you give the one position in Patient Care to Imaging? And, how is it possible that the only revenue-generating division in the hospital got only one new position? All the positions should have been allocated to us.”

Taken somewhat aback and being unprepared for the conversation, Linda explained the rationale for the decision; that the process had been shared, discussed among and approved by all of the VPs; that morale was low across the Medical Center; and that the idea was to share the positions, thereby beginning to meet the needs of all divisions. She also stated, “I understand that every one of the Patient Care departments is hard pressed at this point and needs more staff. I also empathize with all the divisions who have had to struggle to do more with less. Please understand that the decision was made in the best interest of the hospital as a whole.”

Cheryl was clearly very upset and would have none of it. She shouted at Linda, “You don’t do enough to support and go to bat for Patient Care and Nursing.”

Linda resented that and quickly replied, “I spend the majority of my time supporting our needs. I always go to bat for all departments. I can’t believe you are accusing me this way.”

Cheryl kept up her attack, saying, “You should have consulted with me before you made this decision. I should have had the opportunity to justify why Nursing had a greater need than Imaging.”

At this point Linda had had enough. She realized that nothing she was going to say or do was going to assuage Cheryl’s anger. She also recognized that this was typical of Cheryl’s behavior, having seen such outbursts many times before. She calmly asked Cheryl to settle down, to leave her office, and to rethink her position before the directors’ meeting. She closed with, “Let’s discuss this further when all of the department directors are together.”

Discussion Questions

1.    Why do you think this confrontation happened?

2.    What factors influenced the positions taken by the various parties?

3.    How could Linda have managed her decision to propose the hire differently?

4.    How could Cheryl have handled the situation and her behavior differently?

5.    What type of management style did Linda exhibit?

6.    What type of management style was Cheryl expecting?

7.    How would you go about resolving this conflict? What should Linda do to prepare for and present this issue at the directors’ meeting?

8.    What can be done to prevent these types of conflicts from happening in the future?

ADDITIONAL RESOURCES

Buchbinder, S. B., & Shanks, N. H. (Eds.). (2012). Introduction to health care management (2nd ed.). Burlington, MA: Jones & Bartlett.

Cloke, K., & Goldsmith, J. (2000). Resolving conflicts at work. San Francisco, CA: Jossey-Bass.

Dana, D. (2001). Conflict resolution. New York, NY: McGraw-Hill.

Ibarra, H., & Hansen, M. T. (2011). Are you a collaborative leader? Havard Business Review, 89(7/8), 68–74.

Saj-nicole, A. J., & Beyer, D. (2009). How to pick a good fight. Havard Business Review, 87(12), 48–57.

Sutton, R. I. (2009). How to be a good boss in a bad economy. Havard Business Review, 87(6), 42–50.

CASE 22

Changing Patient Behavior: When Obesity Is a Death Sentence

Nancy H. Shanks and Sharon B. Buchbinder

The special meeting of the staff of the Adelphia Neighborhood Health Center was scheduled by Mary, the Executive Director. She and the Board of Directors had just completed the Center’s strategic plan, for which one of the most important strategic goals was to develop a variety of efforts to try to address the problems of obesity in the community.

Like so many communities across the country, Adelphia’s population was becoming increasingly overweight and obese. In fact, its statistics in this regard mirrored those for the United States as a whole. Approximately 35% of the U.S. population was obese in 2009–2010 (Ogden, Carroll, Kit, & Flegal, 2012). Another 33% of the population was deemed to be overweight. The impacts of obesity are very real, both for individuals and society. According to Ogden et al. (2012, p. 1), obese individuals are at “very high risk of developing other diseases, such as type 2 diabetes, heart disease, and hypertension,” to name a few. Overweight individuals are also at risk for becoming obese. This has many consequences, including lost productivity, reduced quality of life, and increased utilization of the health care system.

The economic costs of obesity have also been well documented. Cawley and Meyerhoefer (2012) “estimate that total medical costs for the full non-institutionalized population of adults aged 18 and older was $190.2 billion in 2005…. [Those] estimates imply that 20.6% of U.S. national health expenditures is spent treating obesity-related illness.” Recent data suggest that the numbers have plateaued in the last 10 years. However, given the escalations in health care spending and the prevalence of obesity, the estimated expenditures on treatments have continued to increase in recent years.

Obesity is a function of multiple factors. While it is probably influenced by genetics, it is clearly directly related to eating and nutritional factors, as well as exercise. Addressing these issues requires behavior change, which is clearly very difficult. Mary, the Board of Directors, and the staff were all concerned that the prevalence of obesity in all population groups had become a huge public health problem both at the national and local level. If the clinic did not make significant efforts, the obesity trend would continue with deadly consequences. In addition to concerns about the health effects of obesity on the population they served, Mary worried Adelphia Neighborhood Health Center was running on a razor-thin margin. If they didn’t get a handle on this epidemic soon, and all the services needed to treat the impact of obesity, they wouldn’t be able to continue to provide basic care, like immunizations in the well-baby clinic.

To begin working on the Health Center’s strategic goal, Mary sent the following e-mail:

The Board and I are concerned about the issue of obesity on several different fronts.

•    First, we, as health care providers and managers need to practice what we preach. It seems important for us to begin to work on our own health, to focus internally and come up with strategies for the Health Center to assist the staff with obesity issues, to encourage staff members to address their own issues relating to weight management, and to promote our own wellness. We have a great opportunity to become role models in this regard.

•    Second, as you all know, we serve an ethnically diverse group of patients from Adelphia’s inner city. Many are obese and in population groups at a very high risk of developing other diseases. We need to develop strategies to try to help our patients address these issues.

•    Third, our mission as a neighborhood health center is to serve the broader community. There are many opportunities for the Health Center to reach out to subgroups of the Adelphia community. For example, we already operate several school-based clinics and participate in health fairs at several community centers. We could develop some additional programming for these sites that focuses on physical activity, nutrition, and obesity issues.

•    Finally, federal, state, and local governments, as well as national and local foundations, are all very concerned about the problem of obesity in this country (Let’s move, n.d.) There seems to be funding available that could be sought to assist us in our efforts.

In preparation for our meeting, put on your thinking caps and come up with a couple of strategies and ideas for programs that address these issues. Let’s have a great brain-storming session.

Discussion Questions

1.    How can we go about motivating ourselves, the rest of the staff, our patients, and the community to change their behaviors? What’s required to effect behavior change? What works? What doesn’t?

2.    What activities or programs might we create for the staff? Should they be informal or formal? If formal, should they become part of our benefit package? How can we encourage staff to participate?

3.    Should we challenge the Board to a competition?

4.    What types of programs could we develop for our patients and their families? How should we go about this? What role should different staff members play in this? How can we encourage patients and their families to participate?

5.    What should we do in the community at large? Should we mainly focus on educational or other types of programs? Should we plan to do these on a pilot basis and focus on specific target population groups? Where might we get our best bang for our buck?

6.    Is there funding available to assist us with some of these endeavors?

7.    How will we monitor our outcomes? Do we need to develop a way to evaluate how we are doing in each of these areas?

8.    Is this a short-term proposition? Or, should we be planning to continue with all of these efforts on an on-going basis?

ADDITIONAL RESOURCES

Begley, S. (2012). As America’s waistline expands, costs soar. Reuters. Retrieved from http://www.reuters.com/article/2012/04/30/us-obesity-idUSBRE83T0C820120430

Belluck, P. (2010, January 14). Obesity rates hit plateau in U.S., data suggest. New York Times. Retrieved from http://www.nytimes.com/2010/01/14/health/14obese.html?pagewanted=print

Cawley, J., & Meyerhoefer, C. (2012). The medical care costs of obesity: An instrumental variables approach. Journal of Health Economics, 31(1), 219–230.

Domaszewicz, S., Havlin, L., & Connolly, S. (2010). Health care consumerism: Incentives, behavior change and uncertainties. Benefits Quarterly, 26(1), 29–35.

Dunbar-Jacob, J. (2007). Models of changing patient behavior. American Journal of Nursing, 107(6), 20–25.

Finkelstein, E. A., Fiebelkorn, I. C., & Wang, G. (2003). National medical spending attributable to overweight and obesity: How much, and who’s paying? Health Affairs—Web Exclusive. doi: 10.1377/hlthaff.w3.219.

Finkelstein, E. A., Trogdon, J. G., Cohen, J. W., & Dietz, W. (2009). Annual medical spending attributable to obesity: Payer and service-specific estimates. Health Affairs—Web Exclusive. doi: 10.1377/hlthaff.28.5.w822-w831

Flegal, K. M., Carroll, M. D., Kit, B. K., & Ogden, C. L. (2012). Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999–2010. JAMA, 307(5), 491–497.

Let’s Move. (n.d.). Retrieved from http://www.letsmove.gov/

O’Day, R. F. (2012). Effective incentive design. Benefits Magazine, 49(2), 36–40.

Ogden, C. L., Carroll, M. D., Kit, B. K., & Flegal, K. M. (2012). Prevalence of obesity in the United States, 2009–2010. NCHS data brief, no 82. Hyattsville, MD: National Center for Health Statistics. Retrieved from http://www.cdc.gov/nchs/data/databriefs/db82.pdf

Why is the 21st century being referred to as “the age of behavior change?” [Video]. Retrieved from http://www.youtube.com/watch?v=yHQ4Kn-2-zU&feature=related