Strategic Leadership and Future Delivery Healthcare

Strategic Leadership and Future Delivery Models The issue of life expectancy at birth is a relatively novel one. Before the 19th century for instance, the United Kingdom -- the country with the longest time-series of measured life expectancy -- had not measured this variable at all. It is nevertheless estimated that the life expectancy at birth was between 30 and 40 years -- today, it is around 80 (Roser, 2016).

Within the United States, it is of 79 years; in Japan it is of 84 and Monaco (the highest expectation in the world) is of 89 years (Central Intelligence Agency, 2016). There are still countries with lower life expectancies, but the people in all countries across the globe are expected to life at least 49 years, with Chad having this lowest expectancy of life at the time of birth, followed by Guinea-Bissau and Afghanistan with 50 and Namibia and Somalia with 51 (Central Intelligence Agency, 2016).

In all aspects nevertheless, the life expectancy has increased significantly over the past two centuries, and this trend is observed in both developed as well as under-developed regions of the globe and it is a result of a multitude of forces, such as increased living standards, increased access to health care, improved population education, better technologies and so on. And in this new global setting, the patients become more and more demanding and expect higher quality medical services.

In response to this growing demand of today's society, the HCAHPS has been created as a standardized method of collecting and measuring information regarding the patient experience in hospitals (Centers for Medicare and Medicaid Services, 2016). Based on the findings, the patients can analyze hospitals, compare them and choose to seek medical attention at the facility they find most suitable for their needs.

In terms of the medical care providers, these can use the HCAHPS surveys to analyze the means in which their patients view them, to compare themselves with other hospitals and sector averages and, based on their findings, to develop new methods by which to improve their services of medical care. This is therefore the scope of this project, to assess the current state of the Los Angeles Community Hospital and to propose methods of improvement within the facility. A.

Los Angeles Community Hospital HCAHPS scores The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a national standardized set of assessments collected from recent patients and targeting eleven specific quality issues. The current project assesses the HCAHPS data for the Los Angeles Community Hospital in an effort to improve the quality of the medical act as this is provided to those patients with fewer resources available. The institution's most recent HCAHPS data (as of May 2016) is presented below: Quality issue Always Usually Sometimes / Never 1.

Patients who reported that their nurses communicated well 57% 22% 21% 2. Patients who reported that their doctors communicated well 62% 17% 21% 3. Patients who reported that they received helps as soon as they wanted 44% 28% 28% 4. Patients who reported that their pain was well controlled 52% 27% 21% 5. Patients who reported that staff explained about medicines before giving it to them 44% 20% 36% 6. Patients who reported that their room and bathroom were clean 48% 24% 28% 7. Patients who reported that the area around their room was quiet at night 28% 29% 43% 8.

Patients who reported that they were given information about what to do during their recovery at home Yes 73% No 27% 9. Patients who understood their care when they left the hospital Strongly agree 32% Agree 50% Disagree/strongly disagree 18% 10. Patients who gave their hospital a rating on a scale from 0 (lowest) to 10 (highest) 9 or 10 42% 7 or 8 27% 6 or lower 31% 11.

Patients who reported they would recommend the hospital Yes, definitely 38% Probably 30% Probably/definitely not 32 At an overall look, the Los Angeles Community Hospital reveals a series of patient dissatisfactions, such a high percentage of its patients (32 per cent) stating that they would not recommend this hospital or nearly a third of its patients having rated it 6 or lower.

A better view of the HCAHPS scores for the LA Community Hospital will be created throughout the following section, as the survey results are compared with those in the state, the country and two other hospitals in the region. B. Analysis of the HCAHPS scores 1. Comparison with the state and national averages Always Usually Sometimes / Never 1. Patients who reported that their nurses communicated well Los Angeles Community Hospital 57% 22% 21% California average 75% 19% 6% National average 80% 16% 4% 2. Patients who reported that their doctors communicated well Los Angeles Community Hospital 62% 17% 21% California average 78% 16% 6% National average 82% 14% 4% 3.

Patients who reported that they received helps as soon as they wanted Los Angeles Community Hospital 44% 28% 28% California average 62% 26% 12% National average 68% 23% 9% 4. Patients who reported that their pain was well controlled Los Angeles Community Hospital 52% 27% 21% California average 69% 23% 8% National average 71% 22% 7% 5. Patients who reported that staff explained about medicines before giving it to them Los Angeles Community Hospital 44% 20% 36% California average 61% 19% 20% National average 65% 17% 18% 6. Patients who reported that their room and bathroom were clean Los Angeles Community Hospital 48% 24% 28% California average 70% 20% 10% National average 74% 18% 8% 7.

Patients who reported that the area around their room was quiet at night Los Angeles Community Hospital 28% 29% 43% California average 51% 33% 16% National average 62% 29% 9% 8. Patients who reported that they were given information about what to do during their recovery at home Yes No Los Angeles Community Hospital 73% 27% California average 85% 15% National average 86% 14% 9. Patients who understood their care when they left the hospital Strongly agree Agree Disagree/strongly disagree Los Angeles Community Hospital 32% 50% 18% California average 49% 44% 7% National average 52% 43% 5% 10.

Patients who gave their hospital a rating on a scale from 0 (lowest) to 10 (highest) 9 or 10 7 or 8 6 or lower Los Angeles Community Hospital 42% 27% 31% California average 68% 22% 10% National average 71% 21% 8% 11.

Patients who reported they would recommend the hospital Yes, definitely Probably Probably/definitely not Los Angeles Community Hospital 38% 30% 32% California average 69% 24% 7% National average 71% 24% 5% In short, the comparison of the Los Angeles Community Hospital with the averages in the country and the state reveal the following: LA Community Hospital has weaker nurse communication skills, well below the state and national averages Doctor communication at the LA Community Hospital is also weaker than the doctor-patient communications at other hospitals in the state and the country The response time when patients need help is significantly lower at LA Community Hospital Pain management was also decreased at the LA Community Hospital Patient information regarding the administered medicine is also lower at the LACH (Los Angeles Community Hospital) Room and bathroom cleanliness were significantly lower at the LACH than the national and state averages Patients at LACH reported higher levels of noise than other patients; for instance, while 43 per cent of LACH patients stated that their rooms were quiet only sometimes or even never, at the national level, only 9 per cent of the patients had this problem Fewer LACH patients stated that they were given information upon their leaving the hospital and fewer of them actually understood what they had to do when they left the hospital Lower hospital rating by the patients; while at the national level, only 8 per cent of the patients rate their hospitals 6 or lower, the LACH was rated 6 or lower by 31 per cent of its patients.

Also, while at the national level, only 5 per cent of the patients stated they would not return to the same hospital, the patients at LACH who stated they would not return accounted for 32 per cent of the responses. 2. Score comparison with Cedar's Sinai Medical Center and the Good Samaritan Hospital Always Usually Sometimes / Never 1. Patients who reported that their nurses communicated well Los Angeles Community Hospital 57% 22% 21% Cedars-Sinai 75% 20% 5% Good Samaritan 73% 21% 6% 2. Patients who reported that their doctors communicated well Los Angeles Community Hospital 62% 17% 21% Cedars-Sinai 78% 16% 6% Good Samaritan 80% 16% 14% 3.

Patients who reported that they received helps as soon as they wanted Los Angeles Community Hospital 44% 28% 28% Cedars-Sinai 62% 29% 9% Good Samaritan 60% 27% 13% 4. Patients who reported that their pain was well controlled Los Angeles Community Hospital 52% 27% 21% Cedars-Sinai 70% 23% 7% Good Samaritan 69% 24% 7% 5. Patients who reported that staff explained about medicines before giving it to them Los Angeles Community Hospital 44% 20% 36% Cedars-Sinai 61% 18% 21% Good Samaritan 60% 20% 20% 6. Patients who reported that their room and bathroom were clean Los Angeles Community Hospital 48% 24% 28% Cedars-Sinai 71% 22% 7% Good Samaritan 65% 24% 11% 7.

Patients who reported that the area around their room was quiet at night Los Angeles Community Hospital 28% 29% 43% Cedars-Sinai 52% 33% 15% Good Samaritan 52% 32% 16% 8. Patients who reported that they were given information about what to do during their recovery at home Yes No Los Angeles Community Hospital 73% 27% Cedars-Sinai 86% 14% Good Samaritan 85% 15% 9. Patients who understood their care when they left the hospital Strongly agree Agree Disagree/strongly disagree Los Angeles Community Hospital 32% 50% 18% Cedars-Sinai 49% 45% 6% Good Samaritan 41% 52% 7% 10.

Patients who gave their hospital a rating on a scale from 0 (lowest) to 10 (highest) 9 or 10 7 or 8 6 or lower Los Angeles Community Hospital 42% 27% 31% Cedars-Sinai 77% 17% 6% Good Samaritan 71% 22% 7% 11.

Patients who reported they would recommend the hospital Yes, definitely Probably Probably/definitely not Los Angeles Community Hospital 38% 30% 32% Cedars-Sinai 81% 16% 3% Good Samaritan 73% 22% 5% In comparison to the Good Samaritan and Cedars-Sinai Medical Center: Nurse communications are significantly poorer at the LACH The same is true for doctor communications; for instance, while at the LACH, only 62 per cent of the respondents stated they doctors always communicated well with them, the numbers for Cedar-Sinai and the Good Samaritan were 78% and 80% respectively.

While at these two later institutions only 6 and 4 per cent of the respondents stated poor communications with the doctors, at the LACH, 21 per cent of the patients stated that their doctors communicated well only sometimes or never.

Responsiveness to patients' needs is also lower at the Los Angeles Community Hospital (44 per cent comparative to 60 and 62%) Pain management is also lower -- 52 per cent as opposed to 69 and 70 per cent; patient information in terms of medication used was also significantly lower at the LACH (44 per cent in comparison to 60 and 61 per cent) Quiet and room cleanliness were also significantly lower at the Los Angeles Community Hospital, as was the level of information patients received upon leaving the hospital The patients leaving the LACH were less likely to understand the treatment they still needed upon release and they were also less likely to recommend the hospital to their friends and families; with Cedar-Sinai for instance, 81 per cent of the interviewed patients stated they would recommend the hospital, while with the Los Angeles Community Hospital, only 38 per cent of the patients stated they would recommend the hospital.

With Cedar-Sinai, 3 per cent of the patients stated they would not recommend the institution, while with the LACH, it was 32 per cent of the patients who stated they would not recommend the institution. The differences are impressive and in all eleven quality aspects, the Los Angeles Community Hospital shows significant shortages in comparison to both national and state averages, as well as the two selected hospitals.

Ultimately, based on the HCAHPS scores, the Los Angeles Community Hospital is rated as a one star medical facility, and the Good Samaritan Hospital and Cedars-Sinai Medical Center are both rated as three star medical facilities in Los Angeles; the maximum possible on the HCAHPS scale is of five stars. 3. Survey response rates In the computation of the HCAHPS data for the Los Angeles Community Hospital, a total of 602 surveys were completed, at a survey response rate of 17 per cent.

The Medicare website nevertheless mentions that the 17 per cent figure is an educated estimation and that there were registered some discrepancies in the process of data collection (Medicare.gov, 2016). In the computation of the HCAHPS data for the Good Samaritan Hospital, a total of 527 surveys were completed, a response rate of 22 per cent. Numerically speaking then, fewer surveys were completed by the patients at Good Samaritan, but the patients at this institution were more inclined to provide their feedback.

Last, in the case of the Cedars-Sinai Medical Center, a total of 618 surveys were completed by the patients, totaling a response rate of 23 per cent. Both numerically as well as in terms of response rate, the data collected from this third institution is greater than the data collected from the Los Angeles Community Hospital. 4.

Hospital demographic patient population and services provided The Los Angeles Community Hospital is one of the five medical institutions operated by the Alta Hospitals Systems LLC, all located in the Los Angeles County and all totaling up to 590 licensed beds and 721 physicians. All five hospitals are accredited by Det Norske Veritas Healthcare Inc.

(DNV) and they set out to operate within the communities in a means in which they create a reputation of "delivering high quality care to the communities that we serve while providing easy access to our services" (Alta Hospitals Systems LLC, 2016). The hospitals' administration also points out that they continually follow local physicians in order to ensure that they are able to provide the best care to their patients.

As part of the Alta Hospitals System, the Los Angeles Community Hospital at Los Angeles operates a total of 130 beds and it is integrated in the general acute care hospitals category (the dominant category of hospitals in the United States, providing the widest and largest array of medical services).

The LACH strives to provide quality and comprehensive care in the following service sectors: Heart attack care Heart failure care Pneumonia care Surgical care Emergency care Preventive care Children's asthma care Stroke care Blood clot prevention and treatment Pregnancy and delivery care (Medicare.gov, 2016). The Los Angeles Community Hospital is able to electronically receive results from the laboratory, which increases the efficiency and quality of the medical act. The hospital is also able to track the lab results and to make electronic referrals between visits.

They use an inpatient safe surgery checklist, but they do not use an outpatient safe surgery checklist (Good Samaritan and Cedars-Sinai both employ also the outpatient safe surgery checklist). In terms of medical imaging, the quality of the services seems to be decreased, yet Medicare has been unable to collect sufficient data in order to create solid findings. In other words, too few patients were subjected to imaginary investigations at the LACH for them to be reported and constitute reliable findings (Medicare.gov, 2016).

The hospital does not set out to educate young doctors and students and it is not a teaching hospital, nor does it operate its own trauma section. Even the emergency section is often on stand-by, patients being sometimes redirected towards other medical institutions (Healthcare Atlas, 2010).

The Los Angeles Community Hospital is controlled by investors and it registers a 37.3 per cent reimbursement rate on the dollar paid by the patients, meaning that it also receives funds from the government through the Medicaid program, by serving people eligible for the Medicaid; through its collaboration with the state and the necessary reporting and standards, the LACH is classified as a disproportionate share hospital and it aims to make medical care services more accessible and affordable to the larger population, especially those least afford it.

The LACH as such serves the people in the Los Angeles County and it has not extended its services to other counties. It seeks to provide medical care to the low-income category of people, who are often unable to pay for these services elsewhere.

The core market addressed by the Los Angeles Community Hospital is as such characterized by the following demographics: An estimated 2.8 million of people addressed, in a total area of 240 square miles, revealing a population density of 11,734 people per square mile -- this is slightly higher that the 10,800 population density in the community, but significantly higher than the 226 people per square mile density at the state level.

In terms of race, the patients served in the core market of LACH are: 68 per cent Hispanics, 13 per cent black, 8 per cent white and 7 per cent Asian. At a state level, only 8 per cent of the population are Hispanics and 0.5 per cent are blacks. These categories are significantly under-served in other medical institutions and they represent the main patient groups at the LACH.

Age-wise, the majority of the patients served are between the ages of 18 and 64 (62 per cent), followed by the age group below 18 years old (29 per cent) and only 8 per cent for the population below 65 years -- this reveals a lower life expectancy for the patients seeking medical attention at the Los Angeles Community Hospital In terms of poverty levels, more than half of the LACH's patients live in poverty -- 22 per cent of them at 100% poverty rate and 44 per cent of them at a 200% poverty rate; at the state level, 45 per cent of the people live in poverty (Healthcare Atlas, 2010).

Ultimately then, the Los Angeles Community Hospital provides medical care -- to the best of its limited abilities -- to the people who most need it, but who least afford it. 5. Potential impact of the environmental and community factors on the HCAHPS scores The HCAHPS scores for the Los Angeles Community Hospital are low, the lowest in all comparisons completed and at the level of all eleven quality aspects.

At this stage then, a question is being posed relative to whether or not there are any external factors that could have negatively affected the scores of the assessed hospital. a. Cultural dynamics The Los Angeles Community Hospital addresses mainly the people in the community, most of whom are living below the poverty line (over 60 per cent of the patients live in poverty). The scope of the hospital is to address these people who cannot afford high-end medical care and provide them with the health care they need.

The very fact that this is the unchallenged status quo at the hospital means that the patients are unable to pay for the medical treatments, which in turn translates into decreased financial resources for the hospital. Probably overworked and understaffed personnel, who is unable to provide high quality bed side care, resulting therefore in low scores for nurse and doctor communication. b.

Educational dynamics As it has already been mentioned, the patients treated at the Los Angeles Community Hospital are living in poverty -- some in extreme poverty even -- and they have reduced economic means. Data on the educational levels of the LACH patients are not available -- such a study has not yet been conducted -- but.

Based on the generally accepted link between high education and high income, it is assumed that the patients served by the LACH have low levels of education -- exceptions are nevertheless likely to be incurred, but the assumption is that the wider part of the patients possess low levels of education.

Therefore, it is considered possible for some of the patients to be unable to read and write well enough in order to complete the surveys, resulting therefore in low numbers of surveys completed and even errors registered in the data collection process -- which have been reported by Medicare.gov. c. Socio-economic dynamics Given the marketplace in which the LACH operates, it is widely accepted that its patients have a lower socio-economic status and lower possibilities to pay for the medical services, resulting then in low hospital resources.

The socio-economic dynamic in the community then contributes to the hospital's HCAHPS scores. 6. Potential financial impact on the organization The scope of the Los Angeles Community Hospital -- as its very name states -- is to provide medical care for the community, rather than to generate high profits or become a teaching or innovative hospital. But the problem it encounters is linked to its long and short-term sustainability.

In other words, it is likely for the hospital to still be able to provide its medical services within the short-term and to barely operate. Within the long-term nevertheless, it is possible for the patients assessing hospitals to review the HCAHPS scores and decide to look for medical care in different hospitals, rather than at LACH.

And this issue is even more so important at this hospital since patients with emergency issues will normally seek the closest hospital -- LACH's emergency services are currently uncertain, meaning that patients will likely avoid it. And the second category of patients, who seek medical care on non-emergent basis, will conduct their thorough research in order to identify the hospital which best serves their needs, which has the most experience with their condition, the best reviewed doctors, the most innovative technologies.

Within the long-term then, it is highly likely for the exact patients who could afford to pay for the medical services to avoid LACH altogether and seek treatment elsewhere. a.

Potential impact on quality outcomes The HCAHPS review the experience of patients in terms of the eleven quality issues mentioned previously (communication with the nurses, communications with the doctors, delivery of help when needed, pain management, room and bathroom cleanliness, medication information, quiet at night, information of further home recovery, understanding what to do upon leaving the hospital, hospital rating and recommendation of the hospital to other people).

The low scores of the latest HCAHPS is likely to act as a trigger, pulling the hospital in a vicious circle in which low quality assessments lead to fewer and fewer patients, and also reduced interest from the government to reimburse the hospital, reduced interest from the investors and the community and altogether reduced ability to improve the quality outcomes. In other words, there is a possibility for the current HCAHPS scores to damage the image of the hospital and to further decrease its future quality outcomes. C.

Potential cause of the HCAHPS scores The main cause of the low HCAHPS score of the Los Angeles Community Hospital is represented by low financial resources. This virtually translates in low resources to run and operate a high-quality and highly rated medical facility. It also translates into staff shortages, decreased technological equipments to efficient identify and treat illnesses and all the rest of the quality topics in the HCAHPS scores. Another potential cause could be constituted by the inability to efficiently collect the Medicaid reimbursements from the state.

And also, another potential cause could be an operational and/or managerial inefficiency in running the hospital.

Some other potential causes could include: Low discounts negotiated with the suppliers, as opposed to larger hospitals which can negotiate better The absence of an ability to create operational efficiencies through economies of scale Decreased ability to access and receive governmental reimbursements -- also lower with smaller hospitals than with bigger institutions High costs with accreditation and compliance Decreased access to financing from investors or other sources Inability to innovate and take risks that bring the hospital forward Inability to provide high-end medical care that would appeal to more profitable patients Low staff levels and the loss of the better physicians to bigger hospitals Lack of visionary leadership (Page, 2010).

D. Organizational strategic plan for improvement of the HCAHPS scores 1. The beneficial impact of organizational change on the hospital's HCAHPS scores An initial temptation would be to reassess the HCAHPS scores and to target the specific issues identified and improve them. For instance, one could consider training bed side manners to the doctors in order for this to improve the quality issue of doctor-patient communication.

Still, all HCAHPS scores reveal a more serious and deeply rooted problem at the Los Angeles Community Hospital -- lack of resource and lack of efficient usage of the existent and potential resources. Therefore, the plan will seek to address the root causes of the low quality medical act provided at the LACH and this will, in turn, lead to an increase of the HCAHPS.

As the scores are improved, the circle of profitability will be generated, in the meaning that better scores will attract more patients, which will lead to more resources, which will be further used in development, to further improve quality and the HCAHPS scores, and then to continue to attract more patients and allow the Los Angeles Community Hospital to operate in a more sustainable manner, providing higher quality patient services. 2.

Structure, process and outcomes of the strategic plan The strategic plan aims to strengthen and consolidate a better internal position for the Los Angeles Community Hospital at multiple levels. The expected outcome is that of an improved hospital, better able to manage itself and better able to provide quality medical services for its patients, as well as better employment conditions for its staffs. Ultimately, the objective is that of becoming a better hospital, able to generate more benefits for the community in which it operates.

As this position is consolidated, the HCAHPS scores of the hospital will subsequently improve. In order to attain these objectives, a plan is devised targeting the following: A change in the leadership of the hospital in order to make it more visionary. To create a new vision which aims to help the community but to do so in a new means, in which the hospital and its members are able to welcome and generate positive change.

And the new leadership vision seeks to inspire people in the community to embrace this change. The creation of a campaign to attract stakeholders in the change process, since the hospital depends on the community to generate the necessary change; this will be completed after the marketing team is identified and a collaboration is initiated The creation of operational efficiencies at multiple levels, including the creation of a better image of the hospital through marketing efforts, but also a better management of the resources through sustainable business practices. 3.

Evidence-based practice and shared governance towards organizational quality In a 2011 article written by Rachel Fields for Becker's Hospital Review -- a reputable and trustworthy source of information within the medical community -- the author found five most common problems within community hospitals, and proposed the adjacent solutions. All of these problems are also present at the Los Angeles Community Hospital and part of the solutions presented below will also be integrated in the plan to improve the performances at the LACH: Problem no. 1: Patients admitted for periods longer than necessary.

The solution which was implemented for this problem included patients being released on the weekends as well, not only on week days, as had been accustomed. Then, the hospital collaborated with care centers and other hospitals to transfer its patients in more efficient conditions. Also, the means in which doctors treated the same diseases and the number of days for admittances was also assessed in order to identify redundancies and eliminate them.

The LACH will also assess the length of stay, identify inefficiencies and redundancies and seek to eliminate them by reducing unnecessary stay. Problem no. 2: Few employed physicians -- This is a problem in all community hospitals and the article suggested responding to it by creating co-management collaboration with physicians, which allowed them more to say in how the hospital was run, but also more motivation to provide quality care and to improve the hospital's image and through this attain their personal and professional objectives.

This aspect will be further discussed in the improvement plan, but LACH will not share management with the doctors, but provide them with flexibility in order to increase their motivation. Problem no. 3: An unhealthy community -- this concern is observable in most societies, yet it is even more common in lower economically developed segments, where the interest in health care is decreased, as is education, healthy eating and exercising and where the incidence of addictions is higher.

Hospitals are recommended to target the health issues in the community in order to reduce and prevent them before they cause bigger damages. This is a long-term objective at a global level, but the LACH does not currently possess the necessary resources to engage in such a struggle. It is, nevertheless, hoped that this issue will improve as the hospitals improves and is able to provide higher quality services to the community. Problem no.

4: Poor communication between the parties -- the proposed solution to this problem was that of hiring new nursing staffs that would better ensure communication and increase efficients by also reducing redundant work; emphasis on more efficient communication will also be applied at the LACH. Problem no.

5: Physician and nurse shortages -- common in all community hospitals, a proposed solution is that of collaborating with teaching institutions in order to allow students to train in the community hospitals; this creates teaching opportunities for the students, as well as staffs for the hospitals (Fields, 2011). This solution is not however, considered for the LACH at this stage since they are not a teaching hospital and becoming one would imply complex operations the institution does not afford right now. 4.

Shared accountability among different stakeholders The previous section has revealed an empirical finding that physicians who are granted more control and are given a voice in the way in which the hospital is run are more motivated to intensify their efforts in sustaining the hospital to attain its overall objectives. Still, while this is normally true, it is not a solution applicable at the Los Angeles Community Hospital.

At this institution, the recommendation is for centralized management and leadership, rather than shared with the medical doctors, since the situation is in dire need for business solutions and long-term financial sustainability. In such a context then, the collaboration and shared accountability of the medical doctors will be attained through flexible working schedules (Backhus, 2000). The hospital will seek to attract new physicians who already work at private hospitals and who would be interested in pro bono clinic work, in an effort to give back to the community.

The hospital would also remunerate the work of other doctors, but will seek to attract them not with financial arguments, but with arguments of social well-being generation, which will generate shared accountability from the staffs. The underlying approach in generating shared accountability among the different types of stakeholders will be that of generating benefits for the community, giving back to the community in order to improve the life and the access to health care to the population who least affords yet, yet most needs it.

This approach will be employed in dealing with potential donors, government officials, staff members as well as any other party involved in the process. Patient accountability will be promoted through their education and responsabilization for their own well-being. To generate shared accountability from suppliers and payers, the hospital will develop campaigns that send the message that their help is needed. 5. Technology trends incorporation Technology in itself is a necessity in today's medical treatment, but it is not however, often affordable for the community hospitals.

At this level then, the recommendation is for the LACH to approach the most developed hospitals in the state -- or even the country if this is possible -- and to ask them if they would consider donating their outdated technological equipments. Specifically, the high-end, hi-tech leading hospitals often replace their technologies in order to remain on top of development, to integrate all innovations and to continually improve the quality of their medical act.

While this process is laudable, it is also highly financially consuming and not a sustainable option for the community hospitals. Nevertheless, as the hi-tech hospitals replace their equipments, the old ones they no longer need are still functional and probably still better than the ones currently operated at the LACH -- which are outdated and insufficient.

In such a context then, receiving technological equipments through donations would allow the Los Angeles Community Hospital to significantly improve its equipments and therefore the quality of the medical act they provide to their patients. As arguments in convincing the hi-tech hospitals to donate the equipments they anyway replace, the managers at the LACH could propose to publicly thank the respective hospitals or even to post signs that the equipments were donated by the respective hospitals.

Such a measure would improve the public image of the donors and would support their organizational objectives of appealing to more patients. Additionally, another argument in favor of donating would be represented by the possibility of the donor hospitals to request tax deductions on account of the donations made. All in all, technology is a necessity in today's medical field and the Los Angeles Community Hospital has to make the most of its possibilities and integrate all technologies it can in order to provide better patient care. 6.

Improving the care delivery system The quality of the care delivery system is an issue deriving directly from the problems encountered at the internal level of the Los Angeles Community Hospital. It is expected that as these problems as addressed and improved through the strategic plan, the quality of the medical act to also improve as a direct result. Doctors will be more motivated and the hospital will have more resources, which will directly impact the quality of the care.

More patients will have access to the medical services and the costs of the hospital will be better managed by the new efficiency-focused managerial team. The staffs will be better able to focus on the patients, to provide them with higher quality attention, medication and investigations, as each patient comes to need it across time. 7.

Improving financial stability Financial instability is one of the main causes of concern at the Los Angeles Community Hospital and the current plan aims to address this issue at four specific levels, as follows: (1) Better negotiating with suppliers in order to obtain better deals on the necessary items, such as medicine, cleaning supplies and disinfectants, beds or the necessary medical equipment. (2) Donations Aside from negotiating better deals with the suppliers, the Los Angeles Community Hospital could strengthen its financial position by attracting more donations.

These donations would increase the necessary resources at the hospital while not generating additional new pressures on the already weak financial position of the institution. The donations could be financial, general items, medical items or well as medical technological equipments -- as has been presented previously. In order to attract donations, it will be necessary for the hospital to create awareness that it accepts donations, that it needs them and that it would use the respective donations to improve the well-being of the community in which it operates.

The hospital should, as such, create a campaign to convey this message. In order to create this campaign, the hospital needs the support of a specialized partner to provide marketing and public relations services. Such services are rather costly, so it is suggested for the hospital to seek cost-effective alternatives, such as develop lower priced.