Pediatric Healthcare Survey by H D R

2014 â&#x20AC;&#x153;What keeps you up at night?â&#x20AC;? Healthcare industry leaders reveal insights into current challenges and opportunities in pediatric healthcare.

TOP 3 RESPONSES TO KEY QUESTION

“WHAT KEEPS YOU UP AT NIGHT?”

17%

12%

HEALTHCARE REFORM

COMMUNICATION/ INTERNAL POLITICS

19% FUNDING/ COST OF CARE

102

# OF TOTAL RESPONSES TO ONLINE SURVEY

# OF RESPONDENTS TO KEY QUESTION

Pediatric Survey | What keeps you up at night?

What keeps you up at night? By better understanding challenges, we can start the conversation regarding solutions.

Background The healthcare industry is currently in the midst of a dramatic transformation. While the coming year will be strongly shaped by the implementation of the Affordable Care Act, the industry will also see a continuation of trends that precede that new law. Providers will continue to confront cost and funding issues, new information technology challenges, operational changes and the need to improve quality of care. (Meyer, 2014) Children’s hospitals are facing their own unique set of challenges during this transformative time. According to the National Association of Children’s Hospitals and Related Institutions, there are approximately 200 children’s hospitals in the United States. These free-standing children’s hospitals serve about 12% of all hospitalized children, are responsible for 20% of the cost of treating children, and train about 25% of all pediatricians in the United States. More than 8.3 million outpatient visits are provided by children’s hospitals. (National Associaton of Children’s Hospitals and Related Institutions, 2013) Recently, HDR set out to gain insight into what specific challenges the leaders of these children’s hospitals are experiencing and to answer the question “What keeps pediatric healthcare leaders up at night?”. As a leader in healthcare design and research, HDR developed an online survey to pinpoint specific challenges that pediatric healthcare leaders are facing within their organizations. A team of experts within HDR developed the survey questions, relying on both industry experience and current research to inform the categories. The survey was made available to attendees at the NACHRI conference in May 2013 and the CHA conference in October 2013 to better understand these challenges and to start the conversation surrounding potential solutions. We asked hospital administrators, senior managers, nurses, physicians, and other leaders in the industry: “What keeps you up at night?” and “What are the top challenges facing your hospital/ industry?” 102 healthcare industry leaders from across the United States shared their insights and concerns.

1 4

2 1

1 1 44

*2 Anchorage, Alaska

Demographics A total of 102 participants including nurses, physicians, administrators, etc. working directly in the healthcare industry completed the online survey.

•• •• •• ••

Akron, OH (1) Anchorage, AK (2) Aurora, CO (2) Arkansas (1)

•• •• •• •• •• •• •• •• •• •• •• ••

Austin, TX (3) Baltimore, MD (1) Baton Rouge, LA (2) Birmingham, AL (3) Boise, ID (1) Boston, MA (1) Charleston, SC (1) Chicago, IL (4) Cincinnati, OH (2) Dallas, TX (1) Dayton, OH (1) Denver, CO (2)

*respondent did not write city

•• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• ••

Fort Worth, TX (1) Grand Rapids, MI (2) Greenville, SC (2) Hackensack, NJ (1) Hartford, CT (2) Hershey, PA (2) Houston, TX (2) Indianapolis, IN (1) Iowa City, IA (1) Jackson, MS (1) Kansas City, MO (2) Lebanon, NH (1) Lexington, KY (1) Long Beach, CA (2) Los Angeles, CA (2) Madison, WI (4) Memphis, TN (2)

•• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• ••

Milford, CT (1) Mobile, AL (1) Morristown, NJ (1) Minneapolis, MN (1) New Haven, CT (1) New York, NY (4) Oklahoma City, OK (1) Omaha, NE (1) Orange, CA (4) Orlando, FL (1) Pasadena, CA (1) Pensacola, FL (1) Philadelphia, PA (2) Portland, OR (1) Providence, RI (4) Richmond, VA (1) Roanoke, VA (1)

•• •• •• •• •• •• •• •• •• •• •• •• •• ••

Sacramento, TX (1) San Antonio, TX (1) San Francisco, CA (1) South Bend, IN (2) Springfield, MO (1) St. Louis, MO (1) St. Paul, MN (1) St. Petersburg, FL (1) Tacoma, WA (1) Tampa, FL (1) Temple, TX (1) Tulsa, OK (1) Washington, D.C. (4) Winston-Salem, NC (1)

Pediatric Survey | What keeps you up at night?

Overall responses by industry Respondents were asked to identify the role that most closely represented their job title. The roles included: Senior manager, Hospital administrator, physician, nurse executive, nurse, public relations and marketing professional, information technology professional, and fundraiser. Twelve participants selected “other” and identified themselves as working in the following roles: •• •• •• •• •• •• •• •• •• •• •• ••

Certified Child Life Specialist Child Advocacy Child Life Specialist Clinical Quality Project Coordinator Educator Government Relations Internal Consultant LPC Specialist Photographer Research Coordinator Research Coordinator Social Worker

16%

14%

SENIOR MANAGERS

HOSPITAL ADMINISTRATORS

14%

PHYSICIANS

NURSE EXECUTIVES

14%

12%

OTHER

PR/MARKETING

11%

NURSES

FUNDRAISING

1% IT PROFESSIONALS

HEALTHCARE INDUSTRY RESPONDENTS

Top Challenges In order to identify the key issues pediatric leaders are currently faced with, respondents were first asked to rank, in order of importance the top three challenges facing their organizations. 97 participants provided rankings. Categories available to rank included: •• •• •• •• •• •• ••

Quality of Care (operational efficiencies) Quality of Care (physical environment) Cost of Care Delivery of Care (improving patient outcomes) Delivery of Care (developing new strategies) Staff satisfaction, retention and recruitment Technology and IT Integration

After selecting the top challenges facing their hospital, respondents were then asked to expand on specific variables contributing to those challenges. Cost of Care was the most frequent variable ranked as a number one challenge, followed closely by Quality of Care (operational efficiencies). According to its website, Data Advantage defines a hospital’s quality by

#1 Challenge

#2 Challenge

#3 Challenge

19 16

9 Quality of Care = 57 total (Operational Efficiencies)

Cost of Care = 46 total

Staff Satisfaction = 34 total

each hospital’s success in several areas, including both quality of care and affordability. (Data Advantage—Hospital Value Index, 2010) The fact that these measures are being evaluated by outside organizations may contribute to the findings that they are perceived as top challenges within children’s hospitals themselves.

Technology = 33 total

18 6

Delivery of Care = 41 total (Developing New Strategies)

Quality of Care = 29 total (Physical Environment)

Delivery of Care = 40 total (Improving Patient Outcomes)

Pediatric Survey | What keeps you up at night?

Breakdown of Top Challenges After ranking their top 3 challenges, respondents were asked to select variables from a predefined list which they believe contribute to each challenge. Participants could select any number of contributing variables, or write in their own. Because of this format, responses in this section do not add up to 100%. The seven challenges are listed below along with the frequently selected contributing variables.

Variables 01 Quality of Care (Operational Efficiencies) Of respondents who ranked quality of care (operational efficiencies) in their top 3 challenges: •• 43% selected Patient’s average length of stay •• 43% selected patient safety and security •• 43% selected Lean strategies •• Other variables mentioned included “developing meaningful metrics” and “clinic flow” 02 Cost of Care Of respondents who ranked cost of care in their top three challenges: •• 70% selected Medicaid reimbursement •• 57% selected Standardization of Healthcare Protocol/ Processes and Healthcare Reform •• 39% selected Lean strategies (waste stream management) 03 Delivery of Care—Developing New Strategies Of respondents who ranked delivery of care—developing new strategies in their top three challenges: •• 70% selected new patient care delivery models •• 40% selected healthcare consolidation and adaptive reuse of existing facilities 04 Delivery of Care—Improving Patient Outcomes Of respondents who ranked delivery of care—improving patient outcomes in their top three challenges: •• 80% selected leveraging multidisciplinary expertise •• 47% selected efficient patient care staff procedures •• 40% selected leveraging research to improve outcomes

05 Staff Satisfaction Of respondents who ranked staff satisfaction in their top three challenges: •• 100% selected staff shortages •• 67% selected recruitment and retention concepts •• 33% selected aging staff and staff stress reduction strategies 06 Technology Of respondents who ranked technology in their top three challenges: •• 56% selected health information systems •• 56% selected workflow management systems •• 56% selected communication systems 07 Quality of Care (Physical Environment) Of respondents who ranked quality of care (physical environment) in their top three challenges: •• 67% selected integration of evidence-based design concepts •• 56% selected general appearance •• 44% selected access to rehabilitation areas •• 44% selected creating a healing environment •• 44% selected physical standardization of rooms. One respondent commented that a major obstacle was “inadequate physical space.”

Investment Intentions When asked how inclined respondents were to invest in new facilities or renovations to their existing facility, 45% indicated that they were “more inclined, 38% “didn’t know” and 17% were “less inclined.” According to the 2013 HFM/ASHE Construction Survey, cancer treatment (27 percent) and children’s hospitals (20 percent) were the top two specialty hospitals either being built or planned within three years, though both figures were down from a year earlier. (Carpenter & Hoppszallern, 2013) When planning and designing these new children’s hospitals, it is important to proactively address the challenges listed above in terms of both the physical environment and the strategic planning aspects of these new facilities.

38%

45%

More inclined

Don’t know

17%

Less inclined

Pediatric Survey | What keeps you up at night?

What keeps you up at night? Following the top challenge rankings, survey participants were asked the closing question of “What keeps you up at night? In your opinion, is there one disruptive issue that the industry or your hospital needs to address that is currently not being talked about?” 69 participants answered this open-ended question and categories were derived based on a coding process of participant’s verbatim responses. A majority of respondents cited issues falling under funding/cost of care (19%) and healthcare reform (17%). Communication and internal politics also received high responses with 12% of respondents indicating that this is a major issue facing their organization. Bita Arbob Kash, assistant professor at Texas A&M University, recently conducted a study which identified emerging themes for success factors related to change initiatives across U.S. Hospitals. Similar to the issues identified in our survey, communication, financial resources/accountability, and market forces/external demands were all identified as top success factors in the study. (Kash, Spaulding, Johnson, & Gamm, 2014) If these variables can be harnessed in a way that inspires new solutions and organizational change in response to current challenges, children’s’ hospitals may be even more successful in responding to changing market demands.

19%

17%

FUNDING/COST OF CARE

HEALTHCARE REFORM

12%

10%

COMMUNICATION/ INTERNATIONAL POLITICS

PROCESS/OPERATIONS

10%

SAFETY/ERRORS

PHYSICAL ENVIRONMENT

STAFFING CONCERNS/ RETENTION

ACCESS TO CARE

OUTCOMES

IMAGE/PUBLIC RELATIONS

3% INFORMATION TECHNOLOGY

Funding/Cost of Care 19% of overall respondents listed issues pertaining to funding or cost of care as their number one concern. Responses related to funding/cost of care included (among others): •• •• •• •• ••

Cost of medical care in the U.S. Funding Funding for programs Grant funding is very crucial for all my programs Lack of adequate funding for healthcare, low reimbursement for Medicaid, APR-DRG’s, while medical complexity of care increasing •• Management of costs

15% 31%

Senior Manager

Other

Hospital Administrator

15%

Physician

15%

Nurse Executive

Fundraising

PR/Marketing

Breakdown of participants who listed issues under Funding/Cost of Care in response to the question “What keeps you up at night?”

Financial challenges are not new to children’s hospital leaders but have been confounded by new regulation and market demands. According to Boston Children’s Hospital (2014), children are nearly three times less likely to require healthcare services than adults. However, when they do become ill, they require more— and more costly—support. Treating children requires more staff and resources per patient for a number of reasons: •• Many children are unable to fully communicate or explain their needs. •• Pediatric patients require closer monitoring. •• Sick children need help with daily activities that ill adults can manage on their own. •• Caregivers need to support parents and well siblings, as well as sick children. (Boston’s Childrens Hospital, 2014) Both inpatient care and rehabilitation services for pediatric patients also tend to require more clinical support and technology. Additionally, tracking and benchmarking quality in the delivery of pediatric care is challenging because there is not a centralized large payer (such as Medicare) that provides the benchmarking. The Children’s Hospital Association identifies several key issues related to funding/cost of care in children’s health and children’s hospitals, including Medicaid reimbursement, which pays for the healthcare of one-fifth of all children and more than 40 percent of patient care in children’s hospitals. Federal funding for biomedical and health services research and funding for graduate medical student training in pediatrics are also key issues identified. (Children’s Hospital Association, 2010) According to Sherman and Mankovetskiy (2008), hospital management and senior management need to be proactive in making changes to secure the financial health of their hospital. This could mean eliminating services that are losing money, negotiating cost-cuts for rapidly increasing expenses such as insurance or conducting internal audits as needed and acting on the results should be considered in cost behavior analyses.

Pediatric Survey | What keeps you up at night?

Case study New Hanover Regional Medical Center, Betty H. Cameron Women’s and Children’s Hospital Wilmington, North Carolina Caregivers at children’s hospitals face unique challenges in communication. Effective communication is more crucial, and often more complicated, than with adult patient populations due to the sensitive nature of pediatric care. Our survey revealed specific issues regarding internal communication which healthcare providers are currently facing. The areas mentioned include communication among care team members; communication between the care team and the patient; communication between healthcare providers; and communication among staff providing different services. HDR created a master plan for the Betty H. Cameron Women’s & Children’s Hospital that included key considerations related to communication. In addition to the adoption of an electronic medical record system—promoting electronic communication of patient information throughout the hospital—these considerations included design of the NICU design, recommendations for technological systems and strategies for signage and wayfinding. Originally envisioned to be an open ward, the NICU was redesigned using a private room model to better serve patients and families. This private room NICU design ensures privacy for family conversations as well as conversations between family members and caregivers. The NICU also includes decentralized nurse charting stations and nurse teaming areas. The charting stations were strategically placed between each pair of rooms to provide visibility into patient rooms, and line up across the corridor with one another in order to foster nurse communication. These stations are supplemented by the shared teaming area, an enclosed room secluded from the patient rooms that nurses can utilize for more sensitive peer conversations.

12 BED POD Family Zone

Staff Zone

Above: Floor plan showing family and staff zones in the NICU

HDR also provided recommendations to ensure that technological communication systems are effective, up-todate, efficient, and easy to use, now and in the future. Among the recommendations was the installation of a Nurse Call Responder system to serve as a communication portal for staff. This system can effectively issue Code & Critical Alerts, support nurse call functions using wireless telephone, enable both person-to-person and mass communications, locate staff within the building, and support paging considerations. Design of the signage and wayfinding system ensures that visitors and patients can intuitively navigate the facility. Separate entrances for caregivers and visitors separate traffic and are clearly labeled to minimize confusion. First-time visitors are guided to a communication desk where staff can help them navigate the facility and answer questions about their loved ones. These strategies were tactically implemented to improve communication among care team members as well as patients and families, creating an environment most suitable to provide excellent patient care.

Healthcare Reform

16%

Senior Manager

17% of respondents listed issues related to healthcare reform in response to “What keeps you up at night?” Responses related to healthcare reform included: •• •• •• •• ••

Accountable care Government regulation and cost cutting How will healthcare be paid for? Healthcare reform Medicaid cuts

Healthcare reform is tied closely to the issues related to funding and cost of care. The Government Performance and Results Act of 1993 signaled the government’s focus to include quality of care measures in addition to cost control. The evaluation of quality of care and cost cutting measures continues in the recent healthcare reform acts. As a result, hospitals must manage based on both criteria. Provisions for expanding quality measures, especially measures focused on outcomes and efficiency are included in the Affordable Care Act. (N.A.C.H. Health Reform Summary 2010) Hospitals must now track and report quality of care measures and many of these measures are made available to the public with monitoring organizations and patients using them to evaluate hospital care. Further, Medicare and Medicaid reimbursements are affected by quality of care measures. Controlling costs and, at the same time, maintaining or improving quality of care seems to be exactly what is driving concern in healthcare industry leaders. Medicaid and the Children’s Health Insurance Program (CHIP) are major payers for many children’s hospitals. Their contribution to the bottom line may continue to grow as healthcare reform initiatives are implemented. Because Medicaid covers more than a third of all children, Medicaid reimburses a large percentage of discharges from children’s hospitals. As a result, children’s hospitals are disproportionately affected by changes to Medicaid. (Kellis & Rumberger, 2010)

17% Other

17%

25%

PR/Marketing

Hospital Administrator

17%

Physician

Nurse Executive Breakdown of participants who listed issues under Healthcare Reform in response to the question “What keeps you up at night?”

Pediatric Survey | What keeps you up at night?

Case study Banner Health’s Cardon Children’s Medical Center Mesa, Arizona Healthcare reform has created concern for leaders in the healthcare industry because reimbursements are tied to quality and cost of care measures. Hospitals must respond by finding ways to improve outcomes while becoming more efficient. At Cardon Children’s Medical Center in Mesa, Arizona, the design team held focus groups with children, families, Banner healthcare professionals, and Banner Health executives to gain inspiration for the hospital’s design. A reoccurring idea in discussions was designing an experience where children felt at home and at ease. To keep the design team focused on a child’s perspective, “Through the Eyes of a Child” was used as a guiding principle for the project. With this in mind, the design engages children with different themed “neighborhoods,” using environmental themes such as the beach or the American Southwest to create a playful yet calming environment for patients, caregivers and their families. Water, trees and natural light welcome visitors at the lobby entrance and reinforce the serene atmosphere. Family lounges, interactive play areas, kitchens, and laundry rooms help create a home away from home. To improve the patient experience, children’s patient rooms have been designated as “safety zones.” These private rooms feature ample family space, ensuring all parents and family can be close by. Separate areas for performing potentially frightening or painful procedures are located away from these safety zones. Making the patient room relatively “pain-free” encourages children to associate the patient room with comfort and safety. Patient experience surveys, conducted by NRC Picker, showed an 31% increase in the overall rating of hospital units four months after the new Cardon facility opened, compared to six months before the opening. HDR implemented various elements of positive distraction at Cardon Children’s Medical to help alleviate a child’s fears and improve the quality of their experience.

•• Neighborhood Design: Patients don’t have rooms, but rather ‘homes’ with doorways that look like those of homes. Paint and a little imagination have turned doorways into the entrance to a log cabin, a beach house, or an adobe dwelling. The interiors of the rooms are brightly colored and feature panoramic views of the surrounding communities and distant mountains. •• Family-centered care: To provide for the emotional needs of patients and families, all rooms include a built-in L-shaped sleeper sofa, which folds out to accommodate two adults. Dietary stations and laundry facilities are found on each patient floor for family use, ensuring parents can use time waiting for a loved one practically. Decentralized nurse stations are positioned directly outside each room, close enough to keep an eye on patients but distant enough to allow privacy. Each patient floor also features a separate room for parents, where they can talk and share their experiences with other parents our simply take a break and decompress away from the action. •• Forever Young Zone: A multipurpose auditorium, the Forever Young Zone, is a “medical-free” area of the hospital. Located just outside the PICU for easy access for high-acuity patients, the space can be reconfigured to host various activities including plays, runway shows and movies. •• Play rooms: Every floor has its own age-appropriate play room, where patients can interact with each other or spend time with Child Life specialists. Playrooms on each floor include flat screen TV’s, computers and toys to engage children of all ages. •• Banner Children’s Hospital School: Classrooms on each floor staffed by full-time teachers provides space where children can keep up with their studies while in the hospital. All of these strategies resulted in a state-of-the-art space where children feel welcomed and at ease. Everything in the hospital was created for a purpose: to aid in the healing process.

Communication/ Internal Politics 12% of respondents identified Communication/Internal Politics as a concern that keeps them up at night. Verbatim responses related to communication included: •• Communication among services •• Inadequate communication between healthcare team members, and between the team and the patient, is the biggest disconnect in healthcare that I see that is not being adequately addressed •• Lack of communication between healthcare providers •• Openness. Ability to talk to staff regarding issues and errors without feeling of blame •• Physician engagement in operations and patient engagement activities

Below are examples of internal communication strategies hospitals around the country are currently exploring:

13% 13%

Nurse

37%

Nurse Executive

Senior Manager

25%

Physician

12%

Hospital Administrator Breakdown of participants who listed issues under Communication/Internal Politics in response to the question “What keeps you up at night?”

Children’s hospitals face unique challenges when they try to make practical improvements in their communication with children and family members. Effective communication is more crucial, and often more complicated, than it is with adult patients. Additionally, hospitals face challenges with internal communication among employees and managers alike. A study published in the Journal of Communication in Healthcare identified common characteristics of verbal communication in multi-professional teams at four acute care hospitals and the factors influencing them. The most challenging communicative situations described by the participants were waiting for and combining information from different chart systems, handing over information to other practitioners, and communicating responsibility between units and shifts as well as getting sufficient information through when calling someone (Rabol, McPhail, Ostergaard, Anderson, & Mogensen, 2012). Mello (2014) suggests that strong support from top leadership at the hospital insurer levels, and adequate staff resources, are critical for the implementation and success of communication and resolution programs.

•• Emergency Medical Associates, Parsippany, N.J.—Utilizes a communication portal site to allow employees to make suggestions, provide anonymous recommendations and identify compliance issues. •• Bon Secours Virginia, Richmond—The CEO holds bimonthly luncheon with employees off campus, fielding questions and asking for input. •• West Valley Medical Center, Nashville—”Ask an O,” direct e-mail links to CEO, CNO, CFO and COO are on the hospital intranet’s front page. (Modern Healthcare, 2013)

Pediatric Survey | What keeps you up at night?

Case study UCSF Benioff Children’s Hospital Oakland, Walnut Creek Clinic, Walnut Creek, California New regulations and market demands are increasing pressure for U.S. children’s hospital leaders to address already formidable financial challenges. In our survey, 19% of respondents listed financial issues as their No. 1 concern; These responses included “funding for programs”, “management of costs”, and “cost of medical care.” Among facilities faced with financial challenges was Children’s Hospital & Research Center Oakland (CHRCO), an HDR client since 2006. Significant upgrades to the facility’s infrastructure were required in order for CHRCO to continue its mission of providing care for the children of Oakland and the East Bay while maintaining profitability. Originally envisioned as a replacement facility, economic considerations scaled back the project to an addition and retrofit of their existing facility. To deliver solutions that incorporated economic considerations, HDR used an integrated approach to master planning, combining financial and strategic planning with clinical and operational considerations. Planning studies and seismic evaluations guided decisions on which areas of the facility should be saved, upgraded, or replaced. Developing a phasing plan created an orderly timeline for these moves and helped the client estimate project costs.

HDR also developed a high-level implementation plan showing steps required for completion. The plan was phased to minimize implementation risks. Refined project cost estimates were provided, reflecting “typical” engineering and construction costs, as well as fees and any cost penalties or “special” costs which might affect the project budget. The total estimated cost of the mandated seismic upgrade was $400 million. This planning effort, along with other pressures, led hospital leadership to consider a partner to ensure long-term sustainability. A new affiliation was formed in 2014 with the University of California San Francisco (UCSF) Benioff Children’s Hospital and CHRCO, and as a result, Oakland was renamed UCSF Benioff Children’s Hospital Oakland. The resulting financial stability will help the Children’s Oakland foundation raise money for the $175 million first phase of its seismic upgrade and expansion

Conclusion Pediatric hospitals face a unique set of challenges during this time of rapid healthcare transformation. Our survey revealed the top challenges hospitals are facing (cost of care and quality of care) as well as key issues keeping pediatric healthcare leaders up at night (cost of care, healthcare reform, and communication). By identifying these common challenges and sharing them with the industry as whole, conversations can be initiated to develop solutions and craft strategic interventions.

Works Cited Innovative Internal Communications Tools and Practices some Best Places are Using. (2013). Modern Healthcare, 43(43), S27. Boston’s Childrens Hospital. (2014). Quality and Costs. Retrieved April 15, 2014, from Boston’s Childrens Hospital : http://www.childrenshospital.org/about-us/not-for-profit-status/ quality-and-costs

Mello, M. (2014). Implementing Hospital-Based Communication and Resolution Programs: Lessons Learned in New York City. Health Affairs, 33(1), 30-38.

Carpenter, D., & Hoppszallern, S. (2013, February 1). Market Reset. Retrieved April 25, 2014, from Health Facilities Management: http://www.hfmmagazine.com/display/HFM-newsarticle.dhtml?dcrPath=/templatedata/HF_Common/NewsArticle/ data/HFM/Magazine/2013/Feb/0213HFM_FEA_CoverStory

Meyer, H. (2014). 2014 Promises Challenges, Changes, Growth. Modern Healthcare, 44(1), 15.

Children’s Hospital Association. (2010). Public Policy: Healthcare Reform. Retrieved April 11, 2014, from Children’s Hospital Association: http://www.childrenshospitals.net/AM/ Template.cfm?Section=Health_Care_Reform2

National Associaton of Children’s Hosptials and Related Institutions. (2013, November). Children’s Hospital Association. Retrieved April 2014, from Children’s Hospital Association: http://www.childrenshospitals.net/AM/ Template.cfm?Section=Publications2&Template=/TaggedPage/ TaggedPageDisplay.cfm&TPLID=204&ContentID=45300

Kash, B. A., Spaulding, A., Johnson, C. E., & Gamm, L. (2014). Success Factors for Strategic Change Initiatives: A Qualitative Study of Healthcare Administrators’ Perspectives. Journal of Healthcare Management, 59(1), 66-81. Kellis, D. S., & Rumberger, J. S. (2010). Healthcare Reform and the Hospital Industry: What Can We Expect? Journal of Healthcare Management, 283-297.

Lang, T., & Jones, R. (2012). Cost Behavior as a Significant Factor in Predicting the Quality and Success of Hospitals: A Literature Review. Academy of Health Care Management Journal, 8(1), 3-7.

National Association of Children’s Hospitals. (2010). N.A.C.H. Health Reform Summary.

Rabol, L. I., McPhail, M., Ostergaard, D., Anderson, H., & Mogensen, T. (2012). Promoters and barriers in Hospital Communication: A Focus Group Study. Journal of Communication in Healthcare, 129-139. Sherman, A. H., & Mankovetskiy, B. (2008). Prognosis negative. Medical-related financial distress. New Jersey Law Journal.