The service industry has become increasingly competitive. This dissertation addresses a number of outstanding and fundamental questions of competitions in service operations and supply chains. The challenges are characterization of the equilibrium behaviors, estimating the impact of firms' interactions, and designing of efficient market mechanisms. The first chapter of this dissertation considers price competition models for oligopolistic markets, in which the consumer reacts to relative rather than absolute prices, where the relative price is defined as the difference between the absolute price and a given reference value. Such settings arise, for example, when the full retail price earned by the ``retailer" is reduced by virtue of a third party offering a subsidy or a rebate or in prospect theoretical models in which customers establish a reference price and base their choices on the differentials with respect to the reference price. When choosing among the various competing options, the consumer trades off the net price paid with various other product or service attributes, as in standard price competition models. The reference price may be exogenously specified and pre-announced to the competing firms. Alternatively, it may be endogenously determined, as a function of the set of absolute prices selected by the competing firms, for example the lowest or the second lowest price. We characterize the equilibrium behavior under a general reference value scheme of the above type; this in a base model, where we assume that the consumer choice model is of the general MultiNomialLogit (MNL) type. We also derive comparison results for the price equilibria that arise under alternative subsidy schemes. These comparisons have important implications for the design of subsidy schemes. The second chapter applies the results of the first chapter to the Medicare insurance market, both in terms of its existing structure, as well as in terms of various proposals to redesign the program. Based on an oligopoly price competition model tailored towards this market, and actual county-by-county data for the year 2010, we estimate the impact such reforms would have on the plans' market shares, equilibrium premia, the government's cost, and the out-of-pocket expenses of the beneficiaries. We employ two different methodologies to derive the parameters in the county-by-county competition models: (i) a calibration model, and (ii) parameter distributions obtained from models estimated in Curto et al. (2015). The predicted impacts on the above performance measures are remarkably consistent across the two methodologies and reveal, for example, that the government cost would decrease by 8% if the traditional fee-for-service(FFS) plans are kept out of competitive bidding process and by 16.5%-21% if they are part of the process. The third chapter studies a class of buy procurement mechanisms, framework agreements (FAs), that are commonly used by buying agencies around the world to satisfy demand that arises over a certain time horizon. We are one of the first in the literature that provides a formal understanding of FAs, with a particular focus on the cost uncertainty faced by bidders over the FA time horizon. We introduce a model that generalizes standard auction models to include this salient feature of FAs; we analyze this model theoretically and numerically. First, we show that FAs are subject to a sort of winner's curse that in equilibrium induces higher expected buying prices relative to running first-price auctions as needs arise. Then, our results provide concrete design recommendations that alleviate this issue and decrease buying prices in FAs, highlighting the importance of (i) monitoring the price charged at the open market by the FA winner and using it to bound the buying price; (ii) investing in implementing price indexes for the random part of suppliers' costs; and (iii) allowing suppliers the flexibility to reduce their prices to compete with the open market throughout the selling period. These prescriptions are already being used by the Chilean government procurement agency that buys US$2 billion worth of contracts every year using FAs. The fourth chapter considers the preference of contractual forms in supply chains. The supply chain contracting literature has focused on incentive contracts designed to align supply chain members' individual interests. A key finding of this literature is that members' preferences for contractual forms are often at odds: the upstream supplier prefers more complex contracts that can coordinate the supply chain; however, the downstream retailer prefers the wholesale price--only contract because it leaves more surplus (than a coordinating contract) that the retailer can get. This chapter addresses the following question: under what circumstances do suppliers and retailers prefer the same contractual form? We study supply chain members' preference for contractual forms in three different competitive settings in which multiple supply chains compete to sell substitutable products to the same market. Our analysis suggests that both upstream and downstream sides of the supply chains may prefer the same ``quantity discount'' contract, thereby eliminating the conflicts of interest that otherwise typify contracting situations. More interesting still is that both sides may also prefer the wholesale price--only contract, which offers a theoretical explanation to why the simple inefficient contract is widely adopted in supply chain transactions.

This dissertation examines the assessment and documentation of sexual orientation and gender identity in the home healthcare setting, specifically patient and nurse perceptions of such data collection, as well as what is documented in nurses’ narrative notes about patients’ sexual orientation and gender identity. Chapter One describes the problem of health disparities among lesbian, gay, bisexual and transgender (LGBT) patients and how lack of documentation contributes to this problem. In Chapter Two, an integrated review of the literature on patients’ attitudes and perceptions related to the collection of information about sexual orientation and gender identity in the healthcare setting is reported. In Chapter Three, a qualitative study to determine nurses’ experiences, attitudes, and perceptions related to collecting information about sexual orientation and gender identity in the home healthcare setting is reported, and emergent barriers and facilitators discussed. In Chapter Four, a data mining study to examine what is documented about sexual orientation and gender identity in narrative home care nurses’ notes in an electronic health record is described. Finally, in Chapter Five, the findings of the three studies are summarized, overarching conclusions reported and implications for policy, practice and research are discussed.

The U.S. health care system of the 21st century is in desperate need of reform. Patients are being harmed in the hundreds of thousands attributable to medical errors, identified as the third leading cause of death in hospitals. The need for health care reform is further validated by the trillions of dollars that are infused into the U.S. health care system, where quality of care benchmarks are among the worst in the world. The historical evolution of the U.S. health care system was predicated on nurses who served as advocates and innovators of safe workplace and patient care practices. The Code of Ethics and Nurse Practice Act(s) for registered nurses and the requirements of registered nurse licensure in the 21st century, partnered with an ethical barometer in the delivery of quality patient care, command that registered nurses maintain their historical role as advocates and innovators to promote and maintain safe workplace and patient care practices. Registered nurses in the 21st century are being stifled in the fulfillment of what is commanded of them professionally. It is the quagmire of fulfilling their advocate, innovator role and being penalized with unjust discipline shortly thereafter that is stifling. This “coincidence” is silencing registered nurses across the United States. The aim of this study was to employ a hermeneutic phenomenological research design utilizing Max van Manen’s phenomenology of practice to explore the lived experience of unjust discipline among registered nurses. Audio-recorded interviews were conducted with the participants of the study. Vivid descriptions of the participants’ lived experiences of unjust discipline were communicated. Transcripts were generated from the audio recordings. An interpretive analysis utilizing the hermeneutic circle disclosed nine essential themes among the participants’ experiences of unjust discipline. Respondent feedback augmented validity in the interpretive processes during data collection and thematic analysis. In the context of the study, it was evident that unjust discipline is a disruptive workplace behavior that potentiated physical workplace violence. Further, authentic social support may have precluded many of the elements of unjust discipline experienced by the participants during the lived experience of unjust discipline.

Nonclinical frontline employees (FLE) work in a complex role that provides critical administrative support to healthcare organizations and they are extremely vulnerable to workplace stress. These employees frequently encounter challenging situations and routinely interact and serve many demanding customers. The purpose of this exploratory study was to understand how FLEs have learned the abilities they utilized to cope with workplace stress and how these relate to emotional intelligence. Utilizing a comprehensive survey; comprised of a demographic questionnaire, three assessment instruments (PSS, Brief COPE and SSEIT), a critical incident series and individual interviews, this study sought to understand the learned strategies acquired through personal and professional experiences and how those experiences impacted coping tendencies. FLEs were found to perceive high self efficacy and routinely regulated emotions in an effort to manage stress. Employees also adeptly managed routine conflict and impromptu difficult interactions. Formal, Nonformal and informal learning were pivotal to cultivating the strategies utilized in the workplace. Despite unpredictable stress levels, role ambiguity and the desire for stress management training, FLEs were optimistic, demonstrated the ability to use emotional intelligence and coped relatively well in the workplace.

The constant evolution of medical technology has increased the demand for managing medical devices to ensure safety and effectiveness. In this paper I will investigate how biomedical engineering has addressed the issue of equipment management and identifies strategies to successfully maintain an inventory of medical devices. Through research, on-the-job experience, and in-depth discussions with various biomedical engineering managers, I have been able to document possible equipment strategies and best practices for managing medical devices. There is really no "one size fits all" to medical equipment management due to the various clinical environments, but there are many aspects that remain necessary to ensure proper equipment safety and function while meeting or exceeding various regulatory requirements.

There is a growing interest in understanding recruitment, retention, and turnover of allied health professionals considering employment trends and workforce mobility, an increased need to understand the healthcare delivery system, and the dynamic nature of the allied health workforce especially for rural areas. A survey was sent to allied health administrators across a variety of allied health disciplines from the state of Tennessee hospitals in order to gauge opinions on retention and recruitment strategies. Overall successful strategies for recruitment and retention of allied health professionals were reported as well as differences between urban and rural areas, differences among allied health disciplines perceptions of strategy effectiveness, and key strategies for rural allied health recruitment.

Shifting payment models from fee for service (FFS) to pay for performance (P4P) have fundamentally changed the environment of healthcare administration in the United States (Center for Medicaid and Medicare Services (CMS), 2011). Due to this shift, there has been an increase in demand for tracking and improving quality measures to ensure not only patient safety, but optimization of utilization. Constraints on resources and capacity, coupled with increasing safety measures has developed a new study of patient flow (Miró, Sánchez, Espinosa, et al., 2003). Decreasing patient room turnover times has the potential to maximize utilization while ensuring patient safety and quality (Dyrda, 2012). LEAN and A3 Methodology were applied to create a process improvement initiative at a 500-bed regional medical center (RMC). Using a Rapid Improvement Event (RIE), efforts were made to identify gaps and improve processes to address issues which prevented patients from being in the right place, for the appropriate amount of time, and patient rooms cleaned in a timely manner. These gaps prevented adequate patient flow in the RMC. After tracking the implemented improvements for a year, the RMC ceased following the newly designed process. This study examines the original RIE, factors that changed since the event, and additional process improvements made two years post-RIE.

Poor interprofessional communication has been linked to decreased quality of patient care and increased numbers of medical errors. Increased occupational stress due to lack of effective interprofessional communication can lead to poor job satisfaction and burnout. The purpose of this study was to identify barriers to interprofessional communication as perceived by radiologic technologists. In particular, how did demographic data influence these perceptions? The research was conducted during June of 2009. The population for this survey consisted of registered radiologic technologists employed at hospitals in Northeast Tennessee. A locally developed survey questionnaire covering the subject of interprofessional communication was distributed to a cluster sample directly involved in patient care. Participants indicated that interprofessional communication effects their occupational stress and job satisfaction in addition to the quality of patient care. This analysis revealed that radiographers experienced the most difficulty communicating with nurses.

Thesis (MBA.) -- University of Limpopo, 2015 / The health profiles and outcomes in South Africa are unsatisfactory, not seeming to improve appreciably, amid the robust reform efforts, policies and strategies. These health challenges comprise largely of preventable conditions, as demonstrated by the quadruple burden of disease. Community participation, including the use of community governance structures in improving community health profiles and outcomes, are alluded to be beneficial in improving these communities` health profiles and outcomes. The main aim of this study was to understand the current and the potential future role and the factors at play, of the community governance structures in managing their communities` health profiles and outcomes, in the Zebediela sub-district, Limpopo, South Africa. A qualitative study was conducted, using the Zebediela sub-district as a case study, where from six out of the potential nine governance structures were interviewed and recorded in focus groups, using a pre-determined discussion guide. The recordings were analysed in-depth for themes, using the consistency matrix and the N-vivo data analysis. The results indicate that, the community governance structures are aware of the unsatisfactory health profiles and outcomes in their communities, but are not doing anything specific towards intervening to improve the situation. However, they are keen and willing to participate in improving the situation and are able to identify the potential role they can play, the skills and resources in themselves and in the communities, including the factors that facilitate and those that impede, their participation together with the recommendations of what can facilitate their participation and efficiency in improving their communities` health profiles and outcomes. The community governance structures represent a good opportunity to improve community health profiles and outcomes, through a specific strategic focus that would empower, support, motivate, strengthen and reinforce their current level of skills, functioning and participation.

With the passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Congress made changes to several important federal health programs. First, MACRA reformed the Sustainable Growth Rate, a mechanism created under the Balanced Budget Act of 1997. Second, MACRA instituted the framework for the QPP which solidifies efforts to shift payments to value-based arrangements and streamline several existing programs under a single policy. This thesis aims to better understand how providers are responding to this new policy in four parts. First, I explain how MACRA passed in Congress with nearly unanimous bipartisan support. Second, I review the QPP and the two tracks offered under the program. Third, I review the literature on value-based payment arrangements, including the response of providers and health systems to these arrangements. Finally, I present original research on how major health systems and provider groups in the state of Iowa are preparing for MACRA implementation. I find several characteristics among health systems and provider groups that are associated with efforts to align payments to value-based measures. Across the tracks laid out under the QPP, there is consistency in the types of investments and operational changes being made. Work on these changes has been occurring for several years, and continued investment and reforms are likely.