Tension in New Zealand's Public Hospitals: Performance Effects of Sharpening Incentives

<p>New Zealand's health sector reforms in the mid-1990s introduced corporate institutions and market disciplines to public hospitals. Yet the reorganisation of New Zealand's public hospitals into Crown Health Enterprises (CHEs) led to severe criticisms. Ultimately the CHEs were replaced with non-profit Hospital and Health Services. This thesis focuses on three major criticisms of the CHEs. We use game theory to provide a formal and novel analysis of interactions that could cause an organisation's performance to differ markedly from the reformers' expectations. The analysis explains how a stylised set of reforms could fail to achieve their objectives. Chapter 2 analyses public hospital throughput data over the reform period. We find that the CHE reforms were independently associated with an increase in hospitals' treatment costs. This chapter motivates the theoretical analyses of the three criticisms of the CHEs. We structure the theoretic analysis using an organisational hierarchy with four actors: a funder, an (hospital) administrator, a (medical) specialist and a (health) consumer. The first criticism was that CHE Boards paid bonuses despite managers failing to achieve performance targets. Chapter 3 examines when a funder may want to revise the budget of an organisation and to pay the administrator a bonus despite failing to meet a target. We introduce three features of the CHE reforms that conventional soft budget constraint models partly or entirely neglect: funder bargaining power, revisable targets and performance bonuses. A flexible budget constraint paired with bonuses can be efficient in the light of uncertainty. The second criticism was that costs escalated despite strong managerial incentives for cost control. Chapter 4 argues that such incentives could disrupt trust in an organisation. We show that sharpening the administrator's incentives for cost control can create a misalignment between the administrator and the specialist and cause costs to escalate. Our result, that incentivising a measurable dimension of performance can worsen performance of that same task, contrasts with the conventional game-theoretic literature. The third criticism was that the reforms let doctors manipulate managers, resulting in inefficiency. The first model of Chapter 5 shows that an administrator might want to encourage a specialist to influence public opinion. We modify the first model to reflect a feature of the reforms: managerial efforts aimed at improving the organisation's operation. The administrator can damage a whistle-blower's credibility, to the detriment of specialists and patients. Both models give original insights into how the reforms could let an administrator take advantage of his role. In this multi-layered model, the administrator may intentionally reduce communication. The CHE reformers expected performance incentives to flow through a corporate structure to improve efficiency. Rather than a cascade of beneficial incentives, incomplete contracts could cause unintentional negative interactions. Tension and perverse incentives could have caused costs to rise, necessitating budget revisions and additional bonus payments, while permitting administrators to silence whistle-blowers. This research shows how complex organisations that rely on soft information can benefit from systems that enhance trust and collaboration, and may be harmed by unhealthy tension.</p>

Tension in New Zealand's Public Hospitals: Performance Effects of Sharpening Incentives

<p>New Zealand's health sector reforms in the mid-1990s introduced corporate institutions and market disciplines to public hospitals. Yet the reorganisation of New Zealand's public hospitals into Crown Health Enterprises (CHEs) led to severe criticisms. Ultimately the CHEs were replaced with non-profit Hospital and Health Services. This thesis focuses on three major criticisms of the CHEs. We use game theory to provide a formal and novel analysis of interactions that could cause an organisation's performance to differ markedly from the reformers' expectations. The analysis explains how a stylised set of reforms could fail to achieve their objectives. Chapter 2 analyses public hospital throughput data over the reform period. We find that the CHE reforms were independently associated with an increase in hospitals' treatment costs. This chapter motivates the theoretical analyses of the three criticisms of the CHEs. We structure the theoretic analysis using an organisational hierarchy with four actors: a funder, an (hospital) administrator, a (medical) specialist and a (health) consumer. The first criticism was that CHE Boards paid bonuses despite managers failing to achieve performance targets. Chapter 3 examines when a funder may want to revise the budget of an organisation and to pay the administrator a bonus despite failing to meet a target. We introduce three features of the CHE reforms that conventional soft budget constraint models partly or entirely neglect: funder bargaining power, revisable targets and performance bonuses. A flexible budget constraint paired with bonuses can be efficient in the light of uncertainty. The second criticism was that costs escalated despite strong managerial incentives for cost control. Chapter 4 argues that such incentives could disrupt trust in an organisation. We show that sharpening the administrator's incentives for cost control can create a misalignment between the administrator and the specialist and cause costs to escalate. Our result, that incentivising a measurable dimension of performance can worsen performance of that same task, contrasts with the conventional game-theoretic literature. The third criticism was that the reforms let doctors manipulate managers, resulting in inefficiency. The first model of Chapter 5 shows that an administrator might want to encourage a specialist to influence public opinion. We modify the first model to reflect a feature of the reforms: managerial efforts aimed at improving the organisation's operation. The administrator can damage a whistle-blower's credibility, to the detriment of specialists and patients. Both models give original insights into how the reforms could let an administrator take advantage of his role. In this multi-layered model, the administrator may intentionally reduce communication. The CHE reformers expected performance incentives to flow through a corporate structure to improve efficiency. Rather than a cascade of beneficial incentives, incomplete contracts could cause unintentional negative interactions. Tension and perverse incentives could have caused costs to rise, necessitating budget revisions and additional bonus payments, while permitting administrators to silence whistle-blowers. This research shows how complex organisations that rely on soft information can benefit from systems that enhance trust and collaboration, and may be harmed by unhealthy tension.</p>

A Comparison of Medical Ethics and Managerial Ethics in the Health Sector

<p>This multidisciplinary doctorate research draws on the disciplines of psychology and philosophy in its consideration and comparison of medical ethics and managerial ethics in the health sector. There is very little research which has compared the ethics of doctors and managers even though they work alongside each other in health organisations. Hence this thesis not only adds to the body of knowledge but also contributes a new perspective to applied ethics via the multidisciplinary approach. The empirical research was conducted in three phases. First, a pilot study which interviewed via the repertory grid method six doctors and managers from a Crown Health Enterprise (i.e. a public sector health provider organisation which manages a number of hospitals). Second, a series of repertory grid interviews conducted with nineteen doctors and managers from seven Crown Health Enterprises throughout New Zealand. In the third phase, the ethical constructs and role perceptions identified in the first and second phases were incorporated into a questionnaire which was distributed to 799 doctors and managers in three Crown Health Enterprises. The questionnaire posed a range of questions on role perceptions, ethical dilemmas faced, influences on ethically challenging decisions, ethical issues, and required respondents to rate an ethical manager, ethical doctor, unethical manager and unethical doctor on a range of constructs and rate which construct contributed the most to being an ethical manager and to being an ethical doctor. The main aim was to identify similarities and differences between doctors and managers. The questionnaire analysis revealed a complex three way interaction between doctor/manager raters and the ethical/unethical doctor/manager being rated. This interaction was best represented by seven of the bipolar constructs. Additionally it was found that a highly ethical doctor was seen as honest, focused on patients' best interests, and principled - has standards which are lived up to privately and publicly. The highly ethical manager was seen as honest, flexible and open to others' ideas, recognises and uses the skills of others for their good and the good of the health service, committed to and works hard for the public health service, and takes a long term/strategic view of issues and the wider implications of decisions. Overall it was concluded that the results showed that medical ethics and managerial ethics can be discussed within a general moral framework which allows for different priorities in each role. And that the fundamental difference in priorities between doctors and managers, lay in their basic role orientation - doctors focused on the patient, and managers focused on the organisation.</p>

A Comparison of Medical Ethics and Managerial Ethics in the Health Sector

<p>This multidisciplinary doctorate research draws on the disciplines of psychology and philosophy in its consideration and comparison of medical ethics and managerial ethics in the health sector. There is very little research which has compared the ethics of doctors and managers even though they work alongside each other in health organisations. Hence this thesis not only adds to the body of knowledge but also contributes a new perspective to applied ethics via the multidisciplinary approach. The empirical research was conducted in three phases. First, a pilot study which interviewed via the repertory grid method six doctors and managers from a Crown Health Enterprise (i.e. a public sector health provider organisation which manages a number of hospitals). Second, a series of repertory grid interviews conducted with nineteen doctors and managers from seven Crown Health Enterprises throughout New Zealand. In the third phase, the ethical constructs and role perceptions identified in the first and second phases were incorporated into a questionnaire which was distributed to 799 doctors and managers in three Crown Health Enterprises. The questionnaire posed a range of questions on role perceptions, ethical dilemmas faced, influences on ethically challenging decisions, ethical issues, and required respondents to rate an ethical manager, ethical doctor, unethical manager and unethical doctor on a range of constructs and rate which construct contributed the most to being an ethical manager and to being an ethical doctor. The main aim was to identify similarities and differences between doctors and managers. The questionnaire analysis revealed a complex three way interaction between doctor/manager raters and the ethical/unethical doctor/manager being rated. This interaction was best represented by seven of the bipolar constructs. Additionally it was found that a highly ethical doctor was seen as honest, focused on patients' best interests, and principled - has standards which are lived up to privately and publicly. The highly ethical manager was seen as honest, flexible and open to others' ideas, recognises and uses the skills of others for their good and the good of the health service, committed to and works hard for the public health service, and takes a long term/strategic view of issues and the wider implications of decisions. Overall it was concluded that the results showed that medical ethics and managerial ethics can be discussed within a general moral framework which allows for different priorities in each role. And that the fundamental difference in priorities between doctors and managers, lay in their basic role orientation - doctors focused on the patient, and managers focused on the organisation.</p>

Growth and wood anatomical adjustments of Fraxinus excelsior to the infestation of the invasive fungus Hymenoscyphus fraxineus

&lt;p&gt;Since the 1990s the invasive fungus Hymenoscyphus fraxineus has led to severe crown dieback and high mortality rates in Fraxinus excelsior in Europe. In addition to a strong genetic control of tolerance to the fungus, previous studies have found high landscape variability in the severity of dieback symptoms. However, apart from heat and humidity-related climate conditions favoring fungal development the mechanistic understanding of why smaller or slower growing trees are more susceptible to dieback remains less well understood.&lt;/p&gt;&lt;p&gt;Here, we analyzed three stands in Switzerland with a unique setting of eight years of intra-annual diameter growth and annual crown health assessments, together with ring-width and quantitative wood anatomical measurements preceding the monitoring, to investigate if wood anatomical adjustments can help better explaining the size-related dieback phenomenon.&lt;/p&gt;&lt;p&gt;We found that slower growing trees or trees with smaller crowns already before the arrival of the fungus were more susceptible to dieback and mortality. We show that defoliation directly reduces growth as well as maximum earlywood vessel size, and that the positive relationship between vessel size and growth rate causes a positive feedback amplifying crown dieback. Because leaf necrosis happens during late summer when ring formation has already finished, photosynthesis is heavily reduced during a time when non-structural carbohydrates (NSCs, sugars and starch) are stored. Thus, we hypothesize that a lack of NSCs (mainly sugars) leads to lower turgor pressure and smaller earlywood vessels in the next year impeding efficient water transport and photosynthesis, and is responsible why smaller and slower growing trees show stronger symptoms of dieback and higher mortality rates.&lt;/p&gt;

Ectomycorrhizal Colonisation in Declining Oak Stands on the Krotoszyn Plateau, Poland

We describe the ectomycorrhizal (ECM) root tips and the diversity of mycorrhizal fungal species at three English oak (Quercus robur) sites (two 120 year old sites and one 60 year old site). The three oak stands in decline, located in western Poland, were characterized by a low degree of vital ECM colonization: 30.2%, 29.1% and 25.6% at Krotoszyn (K), Piaski (P) and Karczma Borowa (KB), respectively. DNA (ITS) barcoding revealed a total of 18 ECM fungal species. Based on exploration types, ectomycorrhizae were classified with respect to ecologically relevant features. The contact type was significantly correlated with C:N and Corg, while the short distance type was correlated with Ca, phosphorus (P2O5) and pH. The medium distance exploration type was significantly correlated with fine-grained soil particle size fractions: coarse silt (0.05–0.02 mm) and fine silt (0.02–0.002 mm), and clay (<0.002 mm). The long distance type showed a similar pattern to the medium distance smooth type, but was also correlated with nitrate (N). The values of biometric root parameters of oak trees at the analysed forest sites were arranged as follows: K > P > KB, and were opposite to the condition of the tree crowns. A negative correlation of vital ECM root tip abundance with the crown health status of oaks was observed, whereas higher ECM diversity reflected better crown health in the oak stands studied.

Studies of defoliation on ICP sample plots level I in Republic of Serbia

Project of forests condition monitoring (ICP Forests) operates as an international European project in which, on grid of ICP sample plots (bioindication points) condition of forests has been monitored annually in continuity, including recording data on defoliation with evidencing any damage to the trees. The main goal of the program is monitoring of condition of forests on a permanent, representative surfaces, arranged in a systematic grid distributed on the territory of of Europe. This paper analyzes the data on defoliation as part of the results of the forest conditions monitoring on ICP sample plots on the territory of the Republic of Serbia, in the period 2012-2016. The assessment of defoliation is performed on the experimental fields regardless of the cause of loss of leaves, because the results are not aimed to determinate the cause-and-effect relationships, but only to represent the state of defoliation on this study sample plots in the researched period. Assessment and analysis of the degree of crown defoliation has been presented for most common tree species as the most noticeable crown health indicators. Linking these results with other indicators of environmental conditions will provide more concrete informations, and draw conclusions about the vitality of the plants depending on ambient conditions.