By Layman, Elizabeth J; Bamberg, Richard
Health care employers of allied health personnel and the academic programs producing these professionals have had to cope with an environment of major changes and ongoing turbulence. To better understand the descriptions of and research on the health care environment in relation to strategic typologies, an integrative literature review was conducted. Drawing from multiple disciplines, the information presented offers potential models and approaches to assess and respond to a turbulent health care environment for both schools of allied health and allied health practice sites. The integrative literature review revealed that innovation can enhance profitability if not pursued with fragmentation of an organization’s core identity. Prospector and analyzer approaches appear to offer greater viability in a turbulent health care environment than reactor or defender types. Differentiation of services can be pursued to produce a unique reputation for a health care organization. J Allied Health 2006; 35:50-60.
STRATEGIC PLANNING is a key responsibility of leadership. Survival in a turbulent health care environment depends on skills in strategic management.’ Reflecting this view, more than 90% of leaders of schools of allied health rated strategic planning as an important or very important skill for deans.2 This skill becomes more important as business and corporate models are adopted and used in higher education.
The disciplines of allied health are positioned at the intersection of two industries with turbulent environments: health care and higher education. The health care environment has been described as turbulent.1,3 Other similar terms include uncertain, hyperturbulent, and unstable.4-6 These descriptions of the environment are derived from and build on the classic research of the 1950s through the 1970s.7-14 As a whole, higher education has faced boom and bust financing in past decades.15,16 In particular, allied health education has faced waxing and waning workforce needs, unevenly distributed across its academic programs.17 Selecting the appropriate strategy to cope with these turbulent environments is the responsibility of leadership in practice and in the academy.
Allied health practitioners across allied health practice sites in the continuum of care and academic leaders in schools of allied health can benefit from an understanding of the concept of environment. First, consultants and executives justify various goals and strategies in terms of environmental factors or changes in the environment. Grasping the underlying body of knowledge will help allied health practitioners and academic leaders to either successfully refute the consultants’ recommendations or to implement the executives’ strategic directives. second, applying the concept of environment will benefit practitioners and academic leaders in their managerial roles as they develop goals and strategies for their own departments or units. Third, because the supply and demand for allied health professionals varies over time and across health care sites, allied health professionals must be particularly savvy and alert as they manage their careers and position themselves for long-term staying power. Finally, as a prcis on the environment and its effect on health care organizations, this report serves as a means to individual leadership development.
Through an integrative review of the literature, this article provides ( 1 ) an overview of the health care environment over the past 20 years and a synopsis of the current environment for allied health education, (2) a summary of strategic typologies, including those used in health care, and (3) an outline of the outcomes of strategic choices with an emphasis on the turbulent environment of health care. The report closes with recommendations distilled from the literature.
Health Care Environment
Industrial and historical context are important to understand the health care environment. As Starbuck and Mezias note, “Someone from an industry that has been growing 3% per year might classify 10% as dynamic, while someone from an industry that has been growing 30% per year might regard 10% as static.”18 Therefore, explicitly anchoring this report within the industry and history of health care is meaningful.
TABLE 1. Theories of the Organizational Environment: Contributions of the Classicists
“Turbulence exists when changes faced by an organization are nontrivial, rapid, and discontinuous.”19 According to Achrol, short cycles of technological innovation and obsolescence and the explosion of knowledge drive turbulence.20 Based on these factors, most theorists characterize the world’s environment as turbulent and predict increasing turbulence.20,21 With 1981 as the demarcation line, Beekun and Ginn, using Emery and Trist’s typology, categorize the health care environment of the 1970s as “placid-clustered” and the 1980s as turbulent.10,22 Other researchers and theorists agree that the 1980s began the period of turbulence.23-25
Four macrodynamic trends in health care were the basis for this turbulence.22’26 The trends are (1) sociocultural (wellness, self- care, and consumerism), (2) technological (shorter life cycles, higher costs, and rapid obsolescence), (3) economic (the diagnosis- related group [DRG] payment system, cost cutting, and managed care), and (4) competitive (women’s clinics, urgent care centers, and competition).26 Turbulence is not uniformly experienced across the continuum of care. For example, turbulence began in the hospital industry with the implementation of the DRG payment system; a more recent implementation of a prospective payment system in the home health industry may similarly change its environment.27
Continued changes in health care financing, organization, and delivery increased the level of turbulence and uncertainty in the 1990s1,28,29 and 2000s.30-32 Friedman and Goes describe this turbulence for health care organizations as “unremitting.”31 As early as 2000, Rotarius and Liberman characterized the environment of health care as hyperturbulent.5 Scientific process, however, requires a systematic assessment against criteria derived from environmental typologies.
Allied Health Academic Environment
Schools of allied health face the additional challenges of the environment of higher education. Recent years have seen calls for accountability, as well as the ongoing cycles of public financing based on recession and prosperity.15,16 Edgerton, former deputy director of the Fund for Improvement of Postsecondary Education and past president of the American Association of Higher Education, emphasizes the transitory nature of leadership in higher education and the ongoing difficulties that problem presents.33 Another challenge is the shifting mix of allied health professionals in health care.34 Workforce needs are not uniform across allied health professions, sectors of the continuum of care, and geographic areas.17 Workforce needs affect numbers of students in academic programs and their subsequent job placement rates after graduation. Finally, it is perceived that the factors in the environment of health care have restricted the ability of academic programs to place students in sites for clinical education.35 The complexity of these situations increases the environmental turbulence for schools of allied health.
Major Environmental Typologies
The environment is the “totality of physical and social factors that are taken directly into consideration in the decision-making behavior of individuals in the organization.”8 Jurkovich elaborates that external environment is the “total set of sectors outside the organization which, in turn, is a role cluster bound together by a set of rules that prescribes behavior and establishes sanctions when rules are violated.”36 The external environment has been further delineated into the source of impact and the nature of impact.37 The contributions of the early researchers in the 1950s through the 1970s are listed in Table 1.7-14 These researchers hypothesized that a fit should occur between an organization and its environment.
Subsequent theorists and researchers expanded the work of the early environmental researchers. These expansions may prove fruitful for researchers in the allied health sectors of health care and the academy. For the hyperturbulent environment, in 1984, McCann and Selsky extended Emery and Trist’s typology from four environments to five.21 The fifth type is the “partitioned environment” in which “complexity and change exceed the collective adaptive capacity” of organizational members.21 Partitioning is the segmenting of the environment to better secure scarce resources and skills. Partitions can be based on geography, community, or human competencies. Most recently, in 2000, Zajac et al. proposed a model of dynamic strategic fit based on data from a turbulent period in the financial industry.38 Four quadrants of strategic change are derived: (1) beneficial strategic change, (2) insufficient strategic change, (3) excessive change, and (4) beneficial inertia. The first and fourth quadrants produce dynamic fit, while the second and third produce dynamic misfit. Of the “fit” quadrants, beneficial change was better in terms of performance than inertia. Of the “misfit” quadrants, excessive change was better in t\erms of performance than insufficient change.
It is incumbent on the researcher to specify the typology because, while the concept of environment is “easy enough to grasp intuitively, it has been given numerous definitions.”19 Moreover, researchers need to identify the typology because the meanings associated with terms vary by typology. For example, Burns and Stalker provide no definition of “stable,” apparently defaulting to the dictionary’s meaning.9 On the other hand, Jurkovich uses the language of “stable,””unstable,” and “instability” to refer to the predictability of variables: “both the value of important variables- independent and intervening-and the kinds of relevant variables in the set are changing unpredictably.”36 Clarity demands specification and definition.
Major Strategic Typologies
Typologies of organizational strategies have been developed through work with specific industries40,41 or environments42-44 or from consideration of generic activities.45,46 Some typologies were developed particularly in the health care industry.1,47,48 Table 2 summarizes the strategic typologies. Strategic typology aligns technology, structure, and process to the organization’s market.49
Research on Outcomes of Strategic Choices in Health Care
The research using strategic typologies identifies strategic responses that allow health care organizations to adapt to the turbulent environment (Table 3). The research also identifies problematic responses that diminish organizational performance and jeopardize survival. Miles and Snow’s typology is the most commonly used.
Miles and Snow describe 3 viable strategic approaches. (1) Prospectors are innovative and flexible, researching and exploiting new products and market opportunities. (2) The main trait of defenders is stability by offering only a limited range of products aimed at a narrow segment of the market. (3) Analyzers, who are a hybrid of types 1 and 2, use a stable core of services for profit and sustenance and monitor trends for selective entrance into new services where the institution may have a competitive advantage.40 The fourth approach, reactors, is a failure for long’term, strategic success due to inconsistencies in strategy, technology, structure, and process.
Using Miles and Snow’s typology, Beekun and Ginn studied hospitals’ shifts in strategies over time as the environment became turbulent.22 Chief executive officers (CEOs) of 76 acute care hospitals in the Northeast self-assessed their strategic types. The researchers found that “defenders decreased from 17 hospitals to 7, and reactors dropped from 13 to 6; prospectors increased from 22 to 30, and analyzers increased from 24 to 33.”22 Furthermore, the researchers concluded that the choice of strategy affected the closeness of the linkage between both internal functional areas and between the organization and external elements.22
Ginn also used Miles and Snow’s typology to examine the strategic choices of acute care hospitals in Texas during a turbulent period.23 Classifying 77 hospitals into strategic types, the researcher used both external assessment and self-typing. “Defenders were the most prevalent type in the period from 1976 through 1980. . . . Analyzers were the most prevalent type in the period from 1980 through 1985. … This shift was accomplished primarily by the movement of defenders to analyzer and prospector strategies, and not by some random shifting of all strategy types.”23 Moreover, in this study, prior strategy was the only predictor of strategy change; type of ownership, system membership, and size were not predictors.
Forte and Hoffman also used Miles and Snow’s typology in a single state, Florida, to assess the strategic actions of acute care hospitals.50 The researchers analyzed archival data (1981-1990) from the American Hospital Association and the Florida Hospital Cost Containment Board. The performance measure comprised several financial indicators (total margin, operating margin, total revenue relative to adjusted patient days, ratio of net operating revenue to the total number of beds, and percent occupancy). Both before and after the environmental shift, prospectors and analyzers had higher performance scores than reactors and defenders. Moreover, reactors who changed to prospectors performed better than reactors who did not change.
In 2003, Castle reported on his investigation of the strategic choices of nursing home facilities in five states.51 Data collection occurred in a changing environment after federal regulatory reforms to the nursing home industry were made. Using a questionnaire, 416 nursing facility administrators self-typed their organizations by the Miles and Snow strategic types. Of these facilities, 17% were prospectors, 25% defenders, 31% analyzers, and 27% reactors. The prospector orientation was generally associated with the highest quality outcomes in terms of low rates of physical restraint, urethral catheterization, and pressure ulcers. Based on results from a similar study of proprietary nursing homes in the early 1970s,52 Castle theorized that the “poor performance of nursing facilities in the past” was attributable to their orientations as analyzers or reactors.51
TABLE 2. Strategic Typologies
In 1994, Dansky and Brannon surveyed a sample of executives of home health agencies in 11 states.53 They used a researcher- designed variation of Miles and Snow’s framework. With a usable response rate of 34%, the researchers concluded that the analyzer orientation significantly predicted commitment to quality improvement, after controlling for degree of bureaucracy, ownership, size, and affiliation.
Shortell et al. examined strategic adaptation processes in turbulence.54,55 They compiled data from eight leading hospital systems composed of 366 hospitals in 45 states. Findings showed that hospitals changed their strategies from 1985 to 1987 in response to changes in the environment in nonrandom ways, most often influenced by their prior strategy.55 At both time points, analyzers and prospectors were the most common strategic types. In terms of numbers, the prospectors showed the greatest gain and the analyzers the greatest loss between the time points. Prospector hospitals operated in communities with the highest number of physicians per capita and the greatest population growth. This munificent environment attracted competitors; thus, prospectors faced the greatest degree of competition in their local markets. Defender hospitals were found in the least munificent environments with a higher percentage of their population below poverty level and fewer physicians per capita. Defenders faced the most regulated environment, while the environment of analyzer hospitals was not particularly competitive. The researchers theorized that this relatively noncompetitive environment allowed analyzers time to monitor trends and selectively develop new services. Reactor hospitals faced both stringent regulation and stiff competition, which may have prevented consistent formulation and implementation of strategy. All four strategic types had similar volumes of charity care, although consistent with their location, defenders provided the most charity and uncompensated care. In terms of financial indicators, prospectors were significantly more profitable and had a greater share of the market.54 Finally, for the future, the researchers “found a continuing shift toward analyzer and prospector orientations and away from the defender.”54
TABLE 3. Summary of Health Care Outcomes of Strategic Typology
Green et al. focused on 135 small to medium U.S. hospitals in a turbulent environment.56 These researchers modified Dess and Davis’ refinement of Porter’s typology, resulting in 28 competitive methods more aligned to the language of health care.56,57 Four strategic action orientations based on the 28 competitive methods were identified.
1. Strategic analyzers are externally focused. The unifying concept under this orientation is their “emphasis on strategic awareness” through offensive, proactive competition.56
2. Quality providers are internally focused. This orientation is characterized by the phrase “quality through highly skilled employees” and total quality assessment.56
3. Price negotiators are externally focused. These hospitals emphasize innovative pay practices, such as incentive-based programs, to lower labor costs and have “little regard for overall efficiency.”56
4. Cost-efficiency providers are internally focused. These hospitals focus on operational efficiencies but do not develop services or forecast future needs and, consequently, may lose sight of changing consumer needs.56
Lament et al. used Porter’s typology in the discontinuous environment (i.e., major upheavals) of acute care hospitals.45,58 The sample was 172 general, acute care hospitals in one state. The researchers examined objective data from the American Hospital Association and a state cost-containment publication. The researchers concluded that aligning strategy to the environment results in higher performance.58 Specifically, in discontinuous environments, Porter’s differentiation strategy will be associated with higher performance than will other strategy types.58
Kumar et al. conducted a large study on management practices in hospitals from which they were able to report on several phases.48,59,62 They used Porter’s typology,60 their own typology with two strategic approaches derived from Porter’s typology,48 and another Porter-derived typology derived by another group of researchers.61,62 Kumar et al. used Miles and Snow’s measure of external environment, modified for the hospital environment.60’62 The researchers surveyed hospital CEOs using random samples generated from the American Hospital Association’s list of hospitals. Findings from this research group’s various studies are described below.
Hospitals’ activities in environmental scanning vary across fou\r taxonomic groups: neophytes, inadequates, incompletes, and sophisticates.59 The groups are based on the presence of a comprehensive information system for scanning data and the hospitals’ abilities to collect and store scanning data, obtain market data, evaluate efficacy of new services, monitor customer satisfaction, and use scanning data in strategic planning. Environmental scanning of sophisticates is associated with significantly higher performance in terms of occupancy, expenditures, and payroll than environmental scanning of neophytes, inadequates, and incompletes.59
Hospital administrators adopting the cost leadership strategy perceive greater uncertainty related to the environmental sectors of suppliers and government/regulatory bodies.60 Those adopting the differentiation strategy perceive greater uncertainty in the sectors of customers and competitors.60
In an environment of high uncertainty in the sectors of competitors, customers, and finances, the differentiation strategy is associated with perceived superior performance in terms of return on capital, retaining customers, and controlling expenses.61 In an environment of low uncertainty, the cost leadership strategy leads to superior performance.61 Uncertainty in the sectors of suppliers and government/regulatory bodies is particularly associated with loss of viability of the cost leadership strategy.61
Hospitals with a market orientation demonstrate superior performance in terms of return on capital, success of new services, and success in controlling operating expenses.62 This outcome is strengthened in environments with high market turbulence and competitive hostility.62
Hospital administrators who perceived a stable and predictable environment were more likely to pursue an efficiency-oriented strategy, while administrators who perceived a dynamic and unpredictable environment were more likely to pursue a market- focused strategy.48 Hospitals pursuing a market-focused strategy performed better on three performance indicators: return on new services/facilities, growth in revenue, and market share. Efficiency- oriented hospitals performed better on the indicator of cost containment, while no difference was seen in the indicator of profit margin.48
Using the typology that they formulated, Topping et al. and Malvey et al. found that academic health centers usually utilized combinations of strategies from expansion and stabilization/ contraction.47,63 The researchers noted that the strategies of academic health centers were similar to the strategies of community hospitals and regional systems. The researchers doubted the viability of cost leadership, creation of managed care organizations and research operations, and focus/cost. For a turbulent environment, the researchers recommended innovative strategies based on distinctive competencies. For academic health centers, their competencies are rooted in their unique missions in high-tech and specialized care and research.63
Langabeer also investigated the strategies of 100 U.S. academic health centers in a turbulent environment.1 The researcher found that the strategies of product market and pricing had “substantial influence” on financial performance.1 For hospitals, the researcher defines “product market” as choosing the “optimal patient mix.”1 From this choice, the hospital derives its emphases on various services, such as primary care or surgical specialties. In this study, pricing was the most significant strategy for improving financial performance. The teaching hospitals were able to charge higher prices (premium pricing) corresponding to their perceived higher quality or reputations.
Ten sets of researchers did not use a typology.64-73 The_ findings of their studies, however, do relate to performance of health care organizations in turbulent environments. Leaders in health care may appreciate the relevant information these associated studies provide.
Drain et al. investigated the utility of a model for the prediction of closure of rural hospitals.64 The researchers used a random sample of 40 rural, nonfederal, acute care community hospitals from the American Hospital Association for 1985-1990. From cost report data, the researchers found that the model predicted the closure of hospitals with very low return on assets, very high uncompensated care burden, average to low financial support considerations, and average to high expenditures per adjusted discharge. The investigators concluded that the model provided information so that rural hospital leaders could evaluate and develop strategic initiatives.
Mick et al. also investigated the strategic management of rural hospitals in a national sample of 787 U.S. rural hospitals from 1983 to 1988.61 The researchers found the hospitals that adopted strategic initiatives had more frequent administrator turnover (i.e., instability in leadership). Some, although not all, of the administrator turnover could be explained by the rotation of administrators through multihospital chains.
Stephan et al. also examined the influence of the CEO and the curvilinear relationship between an organization’s multimarket contacts and the likelihood of entry into rivals’ markets.66 In this study, the sample was 395 acute care hospitals in California in 1980- 1986. Longer-term CEOs were more likely to act in ways consistent with the multimarket environment. However, newer CEOs did not act in ways consistent with mutual forbearance in the multimarket environment and thus exceeded acceptable levels of rivalry and competition. The researchers conjecture that this lack of astuteness or this sheer hubris could be detrimental to their hospitals.66
Thomas et al. also focused on the hospital CEOs, investigating the direct and indirect effects among their sensemaking processes and performance.6′ In 1987, questionnaires comprising two scenarios, each with 16 information cues, were sent to 545 public access hospitals in Texas. The usable response rate was 29%. The researchers found that when CEOs interpreted issues as controllable, they were more likely to effect changes in hospital services. Most importantly, hospitals that implemented more changes in services had higher performance in terms of occupancy, profitability, and admissions than those that did not.
Using a longitudinal design, Lee and Alexander followed changes in all U.S. community hospitals from 1981 to 1994.68 The researchers characterized the period as turbulent. Hospital closure was the dependent variable. Independent variables were the hospitals’ core structures, peripheral structures, organizational characteristics, and environmental characteristics. The researchers found that change in hospital specialty, a core change, reduced the risk of closure. Contrary to the researchers’ expectations, the two most frequent peripheral changes, downsizing and leadership change, resulted in more closures.”68 Moreover, “multiple core changes reduced closure risk, while multiple peripheral changes increased the risk.”68
Meyer et al. focused on industry-level analysis during discontinuous change.69 They studied medical-surgical hospitals in four counties contiguous to San Francisco Bay. The researchers collected data over 16 years, with the number of hospitals ranging between 45 and 57. Data collection methods included “structured interviews with industry experts and hospital CEOs, naturalistic observations, responses to mailed surveys, inspection of organizational documents, and analysis of secondary data.”69 From 1987 to 1989, the researchers found a rapid and “pronounced shift away from competition among free-standing hospitals toward affiliation into overlapping provider networks.”69 The researchers assert that these networks were an entrepreneurial response to discontinuous change in the health care industry.69 Finally, the researchers propose that discontinuous change within an industry “stimulates the formation of interorganizational relationships, . . . promotes experimentation with new organizational forms, . . . and precipitates affiliations spanning industry boundaries.”69
Ruef examined archival data from 617 hospitals in California for 1980-1990.70 The researcher found that generalist hospitals were more able to change their services or structures to fit changes in their environments than were specialty hospitals, possibly because generalist hospitals have less entrenched core technologies than do most specialty hospitals.
Irwin et al. investigated the effect of adoption of technology on hospitals.71 The sample was 169 general, shortterm, acute care hospitals in Florida. The researchers analyzed 1990 archival data from the American Hospital Association and the Florida Hospital Cost Containment Board. The researchers found that adoption of technological innovation by large hospitals in munificent environments did not result in a competitive advantage. Competitors in the market also adopted the technology, and overall there was underutilization resulting in insufficient revenues to offset the initial investment costs. On the other hand, smaller hospitals in poorer environments did show improved performance. The investigators theorized that technological innovation allowed these hospitals to differentiate themselves or to stanch the flow of patients to larger hospitals or they were simply more judicious in their acquisition of technology.
Walston and Kimberly studied reengineering as a strategy in a rapidly changing health care environment in 1996.72 They investigated the adoption of reengineering in general, medical- surgical hospitals with more than 100 beds in metropolitan statistical areas. The findings suggested that both economic and institutional factors influenced the adoption and extensiveness of reengineering, with institutional factors playing the greater role. Hospitals with the greater uncertainty in patient volumes engaged in fewer reengineering activities. Finally, the m\ost important factor in the adoption of reengineering was its adoption by competitors in the market area.
Using archival data and a 1989 listing of hospitals from the American Hospital Association, Zinn et al. also investigated interorganizational relationships.73 These researchers focused on interorganizational relationships relative to autonomy, contracts, and alliances. Autonomy was defined as the freedom to make decisions about use and allocation of internal resources independent of the demands and expectations of partners. Based on the data of 1,661 hospitals, the researchers concluded that hospitals with greater resources, contracts with preferred provider organizations, and a more favorable payer mix were more likely to join alliances. Conversely, hospitals in more competitive and less munificent environments, such as those with high penetration of health maintenance organizations and those in rural settings, were more likely to be contract managed.
Figure 1 summarizes the outcome results of the reviewed studies. The best predictor of future strategy is current strategy. Organizational stability with a core of services, along with flexibility for adoption of innovation, allows health care organizations to enter new service markets where they may have competitive edges. The best survival profile integrates these aspects.
Based on the review and summary figure, innovation can enhance profitability if not pursued with fragmentation of an institution’s core identity. Prospector and analyzer approaches appear to offer greater viability in a turbulent health care environment than reactor or defender types. Differentiation of services can be pursued to produce a unique reputation for a health care facility, such as regional Mayo Clinics derived from the original facility in Rochester, Minnesota. All in all, environmental assessment and awareness along with familiarity with strategic approaches are necessary to survive in a turbulent health care environment.
Recommendations
Based on the authors’ integrative review of this research literature, it appears that some strategic models are more useful in health care environments and possibly specifically in allied health practice settings. Several propositions that can be tested by future empirical research on the health care environment that will emerge over the next two decades can be derived. These propositions are displayed in Table 4 with suggestions for some specific measures of success. These propositions could be researched relative to the larger health care environment or at specific practice sites or departments of allied health professions.
Additionally, recommendations specifically pertaining to allied health academic faculty/researchers and to allied health practitioners are also made based on the reviewed literature. Because almost all of the research to date on the turbulent health care environment and the response of institutions and professionals has been outside the specific practice settings, departments, and institutions of allied health professionals, much can be done simply in the way of replicating past studies but using allied health practitioners and managers. More specific recommendations are below.
FIGURE 1. Research summary: outcomes of strategic choices in health care.
RECOMMENDATIONS FOR ALLIED HEALTH ACADEMIC FACULTY/RESEARCHERS
1. Use both objective and perceptual measures because both are relevant in complex, dynamic models of organizational adaptation.74,75
2. Specify the theoretical framework or typology and define terms operationally. Use inductive methods because these approaches more consistently identified types and performance over time than deductive approaches.76 Conduct longitudinal studies because cross- sectional approaches can sometimes be misleading.76
3. Consider investigating the practice environments of allied health professionals and the allied health academic environment in terms of Jurkovich’s 64 types36 or McCann and Selsky’s partitioned environment model.21
4. Conduct studies relative to today’s environment. Most typologies and models were investigated during the years bracketing the implementation of the Medicare inpatient prospective payment system. As one set of researchers noted, this implementation represented “a naturally occurring experiment where the entire competitive landscape shifted abruptly.”50 While this event proved fruitful at the time, more than 20 years have passed. Do the typologies and models show rigor over time? Are findings similar after implementation of the physician payment system of resource- based relative value scales or Medicare’s outpatient prospective payment system? Do findings from single-site studies (i.e., hospitals or nursing homes) generalize to organized delivery systems and alliances?
5. Assess allied health academic units relative to changes in the disciplines and degree levels of programs offered over the past 20 years, including perceptions of how the practice environment for the represented allied health professionals influenced decisions as to program closures and new program developments. Some schools or units of allied health have closed associate degree programs and now offer only baccalaureate and graduate programs to not spread available resources too thin in light of dwindling state and federal funding.77 Some allied health schools have chosen to offer only graduate-level programs,78 possibly in part due to the increasing entrylevel requirements of some allied health accrediting bodies and in part to concentrate resources on research intensification, while other schools have added associate degree programs,78 possibly to expand enrollment and increase the unit’s formula funding.
TABLE 4. Propositions for Future Research
6. Conduct studies using the Miles and Snow strategic types40 for various allied health practice sites and professions in relation to financial and organizational indicators of success as health care entities. Conduct the same studies but use Porter’s strategic types.45 Such research will determine whether certain strategic approaches are more successful overall in allied health or whether different approaches may be successful in different allied health professions or in different practice settings.
RECOMMENDATIONS FOR ALLIED HEALTH PRACTITIONERS
1. Consider pursuing professional development in environmental scanning and strategic planning and management to assume expanded roles in flatter, team-based health care organizations. Bezzina et al. from Canada applied the model of the professional practice leaders.79 In this study, the professional practice leaders developed shared clinical decision-making structures, assisted in the application of professional standards, and allocated budgets. Disciplines represented were clinical nutrition, diagnostic imaging, laboratory services, nursing, occupational therapy, pastoral care, pharmacy, physiotherapy, respiratory therapy, social work, and speech-language pathology.
2. Develop information systems to collect information in the environmental sectors with the greatest impact on the organization’s strategic initiatives, and collect these data specifically for allied health professionals in their practice sites, departments, or institutions.
Conclusions
Similar to health care institutions, schools of allied health have faced a turbulent environment in responding to the changing allied health personnel needs of the health care facilities served. Changes in numbers, levels, types, and skill mixes of allied health professionals have been necessitated in part by the changes that health care employers have made in response to a changing and turbulent health care environment. We have seen dramatic changes (i.e., a discontinuous environment) among health care employers relative to their need for certain health professionals. Cycles of shortage crises and oversupply within a decade are not uncommon in the allied health professions, leading to expansion of some schools of allied health and abrupt closures of others. Accrediting bodies for allied health academic programs in conjunction with various allied health professional organizations have added to the turbulence with requirements for an increased degree level to the master’s degree for some allied health programs. Such mandates have caused rifts in some schools of allied health among lead administrators, program directors or department chairs, and program faculty. Schools of allied health have struggled and continue to do so to find their particular niche in preparing allied health professionals for a viable, lifelong career. While some schools of allied health have narrowed their focus of academic offerings, others have broadened their offerings and/or implemented service- based units or practice plans to establish their niche.77,78
As educational institutions have become more accountable to consumers and have begun to operate more and more under a business model, the need for academic programs and schools of allied health to conduct environmental scanning and strategic planning has become more critical for survival. Lack of attention to gathering environmental data from the consumers (i.e., employers) of a school’s graduates and translating the outcomes of this environmental scanning to selection of viable strategic approaches can cause an allied health academic unit to fall victim to program or school closure. An infusion of administrative staff from the business world who have strong backgrounds in environmental assessment and organizational strategic planning may increase the chances for survival of allied health education programs or schools serving employers in a regional, hyperturbulent health care environment.
This integrative literature review provides the distinctions among key concepts and models for understanding the health care environment and strategic approaches. An understanding of these distinctions shouldallow allied health leaders to precisely assess their turbulent environments. By understanding these concepts as they apply to health care and other industries, allied health leaders can gain a broader view and situate the allied health professions in the current society. The major strategic typologies provided may serve as models of understanding and application for schools of allied health and allied health practice sites to survive their cyclic, turbulent environments relative to their unique but interconnected service markets. The application of the reviewed research offers an arena of research for allied health academic faculty by direct application to the specific practice sites, departments, and institutions of the individual allied health professions.
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Elizabeth J. Layman, PhD, RHIA, CCS, FAHIMA
Richard Bamberg, PhD, MT(ASCP)SH, CLDir(NCA), CHES
Dr. Layman is Professor and Chair, Department of Health Services and Information Management, and Dr. Bamberg is Professor and Chair, Department of Clinical Laboratory Science, School of Allied Health Sciences, East Carolina University, Greenville, North Carolina.
Received July 28, 2004; revision accepted March 23, 2005.
Address correspondence and reprint requests to: Elizabeth J. Layman, PhD, RHIA, CCS, FAHlMA, Department of Health Services and Information Management, School of Allied Health Sciences, East Carolina University, Greenville, NC 27858-4353. Tel 252-328-2202; fax 252-328-4470; e-mail [email protected].
Copyright Association of Schools of Allied Health Professions Spring 2006
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