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Aging is a growing concern in American society, whether one examines the issue in terms of growth of the elderly population, growth in expenses related to this population segment, or a concern about quality of life for people as they grow older. The population of the U.S. has aged throughout the twentieth century. While in 1900, only 4.1% of all Americans were over 65, the figure increased to 12.8% by 2000. The oldest old in the population, those 85 and over, increased even more, from only 590,000 people in 1900 to 3.7 million people in 2000. It is estimated that by 2030, when the baby boomers have become old, more than 20% of the U.S. population will be over 65. Some estimates are that those 85 and over will quadruple in size by 2030. Even given the reality that people are remaining physically healthy and may work longer than in the last generation, it is overwhelmingly clear that one of the major overall policy issues of the next several decades will be how to fund both the social and health services needs of the ever increasing elderly portions of the U.S. population. Nor is this issue of an aging population only a U.S. problem. Most developed countries are already experiencing this issue, and there are some European countries, such as Italy, that are already experiencing a declining population due to birth rates below replacement. When this happens in a country, then the elderly as a proportion of the population increase, and the issues of rising health care costs linked to changing population demographics become important policy issues in that country (Quadagno, 2005).

Hospitals within the United States consistently have injury rates that are over twice the national employee injury rate. Hospital safety studies typically investigate care providers rather than support service employees. Compounding the lack of evidence for this understudied population is the scant evidence that is available to examine the relationship of support service employees’ perceptions of safety and work-related injuries. To examine this phenomenon, the purpose of this study was to investigate support service employees’ perceptions of safety leadership and social support as well as the relationship of safety perception to levels of reported injuries.

A nonexperimental survey was conducted with the data collected from hospital support service employees (n=1,272) and examined: (1) relationships between safety leadership (supervisor and organization) and individual and unit safety perceptions; (2) the moderating effect of social support (supervisor and coworker) on individual and unit safety perceptions; and (3) the relationship of safety perception to reported injury rates. The survey items in this study were based on the items from the AHRQ Patient Safety Culture Survey and the U.S. National Health Care Surveys.

Safety leadership (supervisor and organization) was found to be positively related to individual safety perceptions and unit safety grade as was supervisor and coworker support. Coworker support was found to positively moderate the following relationships: supervisor safety leadership and safety perceptions, supervisor safety leadership and unit safety grade, and senior management safety leadership and safety perceptions. Positive employee safety perceptions were found to have a significant relationship with lower reported injury rates.

These findings suggest that safety leadership from supervisors and senior management as well as coworker support has positive implications for support service employees’ perceptions of safety, which, in turn, are negatively related to lower odds of reporting injuries.

The rising of chronic illness and the continuous aging of the global population requires a re-organization of health care systems based on relations and exchange of information to address patient needs in the community. The re-organization of health care systems involves interconnected changes and the development of integrated health care information systems and novel eHealth services. In Crete, the Foundation for Research and Technology-Hellas has developed HYGEIAnet, a Regional Health Information Network (RHIN) to contribute to the re-organization of health care systems and information sharing. We present HYGEIAnet, some of the most critical and novel eHealth services developed and deployed, discuss the impact of an RHIN on health care processes, and explore innovative models and services for health delivery and the coordination of care. We then critically discuss lessons learned regarding the effective management of change to overcome organizational and cultural issues in such large-scale initiatives. The paper concludes with policy and practice recommendations for managing change processes in health care organizations.

Occupational injury in the health care sector in the United States rates among the highest of all industries. Specific to hospital support service workers (e.g., Food & Nutrition, Environmental Services), studies have shown that injury rates for support service workers tend to be among the highest of hospital personnel, and yet there is a shortage of research investigating the safety climate of these workers. Therefore, the purpose of this study is to examine safety perceptions of support service workers. Surveys were used to measure safety climate leadership factors (per the AHRQ's Survey of Patient Safety Culture) to determine if they are related to individual safety perceptions, as well as ratings of work unit safety. Following established safety climate research, we examined the role of the work environment (e.g., supervisor support and work unit culture) on safety perceptions. We found that both supervisor and organizational safety leadership are positively related to individual safety perceptions and supervisor support. Organizational safety leadership and work unit culture were positively related to work unit safety rating. Our findings demonstrate that the antecedent factors and pathways that promote a positive safety climate among health care providers functions in a similar manner for support service workers. These findings contribute to a better understanding of occupational safety of this understudied work group and provide evidence to hospital administration that developing a strong safety climate among support service workers is not entirely different from what is required to promote a robust safety climate across an organization.

Purpose – This chapter frames the topic of organizing for sustainable health care in terms of the environmental trends that have rendered current health care approaches unsustainable, the embeddedness of health care in society's triple bottom line, and the need to build adaptive capability within the complex health care ecosystem.

Design/methodology/approach – We synthesize documented trends and empirical findings regarding the viability of current approaches to health care, and provide a theoretically framed treatment of the adaptation process in the complex health care system that can lead to the emergence of sustainable approaches.

Findings – There is a misfit between current approaches to delivering health care and the requirements and trends in contemporary society. Fundamental transformation is required that entails a broadening of purpose, a future orientation, and a rethinking of how health care adds value and how it is embedded in society.

Originality/value – By reconceptualizing health care reform as intricately related to societal sustainability and the triple bottom line, we open the possibility of transcending a narrow focus on reengineering to create more efficient organizations and work processes that consume fewer resources and deliver greater value. We invite health care practitioners and scholars to rethink all the connections in the health care ecosystem, and the need to build in self-organizing capabilities and adaptive capacity. The cases in this book provide knowledge from systems engaged in fundamental transformation, analyzed through the lenses of theoretical frameworks that help us better understand essential dynamics involved in creating sustainable health care systems.

Purpose – This chapter argues that the concept of agility is an effective robust framework for designing sustainable health care systems.

Design/methodology/approach – This case study of Alegent Health was based on 7 years of data collection. It includes observations of meetings, large-group interventions, and other activities; site visits to different hospitals in the system to observe changes in practice; interviews with Alegent Health executives, primary care physicians, hospital presidents, specialist physicians and physician groups, and health systems staff and nurses; and a variety of archival data including meeting minutes, video tapes, conference proceedings, and web site material.

Findings – The Alegent Health system has evolved over time according to the principles of agility. It built a series of new capabilities that contribute to improved clinical outcomes, sustained financial results, and more socially and ecologically responsible results. Designing health care systems based on agility is a more effective and sustainable approach than relying on legislative or other criteria.

Originality/value – The discussion of sustainability in health care has focused primarily on specific projects or how to respond to specific technological, regulatory, or clinical changes. Alegent Health's experience provides important lessons, opportunities, and challenges that can help advance our understanding of effective health care and use organizational agility to create more sustainable health care systems. This chapter provides health care system administrators an alternative design option.

A common observation is that both single- and multi-payer health care systems will achieve lower overall costs if they use primary care gatekeeping. Questioning this common wisdom, we focus on the health care access system, that is, the way in which patients gain access to health care. Gatekeeping, the use of primary care providers to control access to more specialized physician and hospital services, has come under intense scrutiny in the United States and in Europe. The few international comparative studies that have focused on the issues of quality of care, cost containment, and patient satisfaction find weak or no support for common assumptions about gatekeeping. Hence, we examine the institutional environments in seven countries in order to: (a) define and categorize health care access systems; (b) identify the components of a health care access system; (c) explore the notion of a strategic fit between health care financing systems and access system configurations; and (d) propose that the health care access system is a key determinant of process-level cost efficiency. Drawing upon institutional and governance theories, we posit that the structure and organization of an access system is determined by how it addresses six essential questions: Who is covered? Which services are included? What are the points of access? How much time elapses before access? What are the ways of selecting among points of access? and Are services and their quality the same for everyone? This analytical framework reveals that national health care access systems vary the most in their points of access, access times, and selection mechanisms. These findings and our explanations imply that access systems are one of the only tools for demand management, that any lasting change to an access system typically is implemented over an extended time period, and that managers of health care organizations often have limited freedom to define governance structures and shape health care service production systems.

The incipient HIV/AIDS epidemic in Chile poses challenges for responsiveness of the Chilean national health care system, Fondo Nacional de Salud (FONASA) (National Health Funds), especially given the sociocultural forces for inertia in FONASA. Thus, the issue is what is the nature of the forces for change. A grounded theory approach was applied to interview data from two qualitative studies, one with HIV/AIDS advocates and activists as interviewees and the other with Chilean low-income women. The stories of their experiences with and perceptions of FONASA revealed major issues facing FONASA, including quality of care and ethics. Ways in which these issues are being addressed by the activists result in constructed environmental dynamism. A conceptual model of the forces for change was developed including actors, strategies, and targets of change that constitutes organizational environmental dynamism. The construct of environmental dynamism has international applicability, particularly to governmental health systems, which are influenced by strong sociocultural forces.

In this chapter, I develop an analysis of the institutional logics which have shaped the organizational field of public sector mental health and which provide a framework for understanding the complexities facing policy makers, providers, researchers, and community mental health advocates.

I first assess the current state of public sector mental health care. I then describe institutional theory, which focuses our attention on the wider social values and priorities (i.e., institutional logics) which shape mental health care. In the current post-deinstitutionalization era, there are three competing institutional logics: recovery and community integration, cost containment and commodification, and increased social control over those with severe mental disorders. Each of these logics, and the conflict between them, is explicated and analyzed. I then develop a theoretical framework for understanding how conflicting institutional logics are resolved. In the concluding section of this chapter, I offer some guidance to both researchers and advocates seeking meaningful system level reform.

Researchers studying mental health policy need to understand how competing institutional logics work to shape the political climate, economic priorities, and types of services available.

Advocacy is critical for meaningful reform, and a fourth institutional logic – that of social justice – needs to be developed by which to evaluate policy reforms and service offerings.

Recently, the institutional performance model has been used to explain the increased distrust of health care system by arguing that distrust is a function of individuals’ perceptions on the quality of life in neighborhood and social institutions. We examined (1) whether individuals assess two dimensions of distrust consistently, (2) if the multilevel institutional performance model explains the variation of distrust across neighborhoods, and (3) how distrust patterns affect preventive health care behaviors.

Using data from 9,497 respondents in 914 census tracts (neighborhoods) in Philadelphia, we examined the patterns of how individuals evaluate the competence and values distrust using the Multilevel Latent Class Analysis (MLCA), and then investigated how neighborhood environment factors are associated with distrust patterns. Finally, we used regression to examine the relationships between distrust patterns and preventive health care.

The MLCA identified four distrust patterns: Believers, Doubters, Competence Skeptics, and Values Skeptics. We found that 55 percent of the individuals evaluated competence and values distrust coherently, with Believers reporting low levels and Doubters having high levels of distrust. Competence and Values Skeptics assessed distrust inconsistently. Believers were the least likely to reside in socioeconomically disadvantaged and racially segregated neighborhoods among these patterns. In contrast to Doubters, Believers were more likely to use preventive health care, even after controlling for other socioeconomic factors including insurance coverage.

Our findings suggest that distrust patterns are a function of neighborhood conditions and distrust patterns are associated with preventive health care. This study provides important policy implications for health care and future interventions.