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Quality management is high on the reform agenda of both universities and hospitals. This paper studies how quality management is implemented: who is responsible for QM and which instruments are used? The guiding research question is whether these two very distinct professional organizations respond in similar or different ways to a common reform trend. To analyze the extent of isomorphic tendencies a cross-sectoral, descriptive data analysis with data from 135 hospitals and 83 universities in Germany has been conducted. The results show that QM in hospitals is more elaborated in terms of quality instruments and at the same time more standardized. Universities, in contrast, follow quite individualistic ways to organize quality management.

Researchers recommend a reorganization of the medical profession into larger groups with a multispecialty mix. We analyze whether there is evidence for the superiority of these models and if this organizational transformation is underway.

We summarize the evidence on scale and scope economies in physician group practice, and then review the trends in physician group size and specialty mix to conduct survivorship tests of the most efficient models.

The distribution of physician groups exhibits two interesting tails. In the lower tail, a large percentage of physicians continue to practice in small, physician-owned practices. In the upper tail, there is a small but rapidly growing percentage of large groups that have been organized primarily by non-physician owners.

While our analysis includes no original data, it does collate all known surveys of physician practice characteristics and group practice formation to provide a consistent picture of physician organization.

Our review suggests that scale and scope economies in physician practice are limited. This may explain why most physicians have retained their small practices.

Larger, multispecialty groups have been primarily organized by non-physician owners in vertically integrated arrangements. There is little evidence supporting the efficiencies of such models and some concern they may pose anticompetitive threats.

This is the first comprehensive review of the scale and scope economies of physician practice in nearly two decades. The research results do not appear to have changed much; nor has much changed in physician practice organization.

The research analyzes good practices in health care “management experimentation models,” which fall within the broader range of the integrative public–private partnerships (PPPs). Introduced by the Italian National Healthcare System in 1991, the “management experimentation models” are based on a public governance system mixed with a private management approach, a patient-centric orientation, a shared financial risk, and payment mechanisms correlated with clinical outcomes, quality, and cost-savings. This model makes public hospitals more competitive and efficient without affecting the principles of universal coverage, solidarity, and equity of access, but requires higher financial responsibility for managers and more flexibility in operations.

In Italy the experience of such experimental models is limited but successful. The study adopts the case study methodology and refers to the international collaboration started in 1997 between two Italian hospitals and the University of Pittsburgh Medical Center (UPMC – Pennsylvania, USA) in the field of organ transplants and biomedical advanced therapies.

The research allows identifying what constitutes good management practices and factors associated with higher clinical performance. Thus, it allows to understand whether and how the management experimentation model can be implemented on a broader basis, both nationwide and internationally. However, the implementation of integrative PPPs requires strategic, cultural, and managerial changes in the way in which a hospital operates; these transformations are not always sustainable.

The recognition of ISMETT’s good management practices is useful for competitive benchmarking among hospitals specialized in organ transplants and for its insights on the strategies concerning the governance reorganization in the hospital setting. Findings can be used in the future for analyzing the cross-country differences in productivity among well-managed public hospitals.

We present a description and analysis of the current reforms in the French system of “assurance maladie”, or its health insurance system, particularly as they bear on quality at the hospital level. The measurement and management of quality play a significant role in the reform, thus providing a particularly timely example for health care policy makers, researchers, and managers. We discovered several lessons from the French experience. First, the issue of workload influenced thinking about how best to build a given indicator, and led to careful evaluation of the added value of additional data collection. In some cases the indicators are actually more of a screen or filter than an actual assessment of quality, with particularly high or low values signaling the need for further investigation rather than serving as assessments per se. Second, the development and implementation of quality indicators (QIs) demand the involvement of professionals in the process. Third, process indicators seemed to be more useful than outcome indicators. Fourth, expectations for quality management should be aligned with feasibility and with the reality of measurement system. For example, the workload is closely tied to the state of the hospital data collection systems (indicators selection). Lastly, the twin objectives of quality improvement and accountability do not necessarily mesh easily or well.

Performance management (PM) has been developed to a central part of health care reforms. However, ideas of performance are traditionally contested in the health care sector and split up between a professional and a bureaucratic understanding of effective service delivery. With the rise of New Public Management, an additional layer of PM instruments has been put on the already existing structures. As a result, different PM regimes can be distinguished, which vary in the way they define performance, blame underperformance and design accountability instruments to ensure appropriate behaviour. The paper investigates the institutional design of PM schemes of three different cases – Denmark, Germany and England – which are representative for different PM regimes.

This chapter draws on a study conducted in the mid 1990s to compare management differences between three different groups of South African hospitals, in order to understand how these differences might have affected hospital functioning. The groups were public hospitals; contractor hospitals publicly funded but privately managed; and private hospitals owned and run by private companies. Public sector structures made effective management difficult and were highly centralized, with hospital managers enjoying little autonomy. In contrast, contractor and private groups emphasised efficient management and cost containment. These differences appeared to be reflected in cost and quality differences between the groups. The findings suggest that in the context of a country such as South Africa, with a relatively well-developed private sector, there is potential for the government to profit from the management expertise in the private sector by identifying lessons for its own management structures, and by contracting-out service management.

This study sets out to shed light on those infrastructures underlying the ubiquitous, yet contested nature of governing by numbers. Investigating the 30-year long emergence of Germany’s “external quality assurance system” for hospitals, the authors show how methods for quantifying quality align with broader institutional and ideational shifts to form a calculative infrastructure for governance. Our study focuses on three phases of infrastructural development wherein methods for calculating quality, institutions for coordinating data and reform ideals converge with one another. The authors argue that the succession of these phases represents a gradual layering process, whereby old ways of enacting quality governance are not replaced, but augmented by new sets of calculative practices, institutions and ideas. Thinking about infrastructures as multi-layered complexes allows us to explore how they construct possibilities for control, remain stable over time and transform the fields in which they are embedded. Rather than governance being enacted according to a singular goal or value, we see an infrastructure that is flexible enough to support multiple modalities of control, including selective intervention, quality-based competition and automatized budgeting. Infrastructural change, instead of revolving around crises in measurement, is shaped by incubation periods – times of relative calm when political actors, medical practitioners, mathematicians, and many others explore and reflect past experiences, rather than follow erratic reforms fads. Finally, analysing infrastructures as multi-layered constructs underlines how they produce multiple images of care quality, which not only shift existing power relations, but also change the ways we understand and make sense of public services.

The long-term financial stability of hospital systems represents a “grand challenge” in health care. New ownership forms, such as private equity (PE), promise to achieve better financial performance than nonprofit or for-profit systems. In this study, we compare two systems with many similarities, but radically different ownership structures, missions, governance, and merger and acquisition (M&A) strategies. Both were nonprofit, religious systems serving low-income communities – Montefiore Health System and Caritas Christi Health Care.

Montefiore's M&A strategy was to invest in local hospitals and create an integrated regional system, increasing revenues by adding primary doctors and community hospitals as feeders into the system and achieving efficiencies through effective resource allocation across specialized units. Slow and steady timing of acquisitions allowed for organizational learning and balancing of debt and equity. By 2019, it owned 11 hospitals with 40,000 employees and had strong positive financials and low reliance on debt.

By contrast, in 2010, PE firm Cerberus Capital bought out Caritas (renamed Steward Health Care System) and took control of the Board of Directors, who set the system's strategic direction. Cerberus used Steward as a platform for a massive debt-driven acquisition strategy. In 2016, it sold off most of its hospitals’ property for $1.25 billion, leaving hospitals saddled with long-term inflated leases; paid itself almost $500 million in dividends; and used the rest for leveraged buyouts of 27 hospitals in 9 states in 3 years. The rapid, scattershot M&A strategy was designed to create a large corporation that could be sold off in five years for financial gain – not for health care integration. Its debt load exploded, and by 2019, its financials were deeply in the red. Its Massachusetts hospitals were the worst financial performers of any system in the state. Cerberus exited Steward in 2020 in a deal that left its physicians, the new owners, holding the debt.

Although it is widely acknowledged that health care delivery systems are complex adaptive systems, there are gaps in understanding the application of systems engineering approaches to systems analysis and redesign in the health care domain. Commonly employed methods, such as statistical analysis of risk factors and outcomes, are simply not adequate to robustly characterize all system requirements and facilitate reliable design of complex care delivery systems. This is especially apparent in institutional-level systems, such as patient safety programs that must mitigate the risk of infections and other complications that can occur in virtually any setting providing direct and indirect patient care. The case example presented here illustrates the application of various system engineering methods to identify requirements and intervention candidates for a critical patient safety problem known as failure to rescue. Detailed descriptions of the analysis methods and their application are presented along with specific analysis artifacts related to the failure to rescue case study. Given the prevalence of complex systems in health care, this practical and effective approach provides an important example of how systems engineering methods can effectively address the shortcomings in current health care analysis and design, where complex systems are increasingly prevalent.