Modern Management Practices and Hospital Admissions

TeamSTEPPS improves patient safety

BACKGROUND

Examine how Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) can be used to manage patient safety and improve the standard of care for patients.

METHODS

In order to improve key medical training in areas like surgical safety management, blood transfusion closed-loop management, drug safety management and identity recognition, we apply the TeamSTEPPS teaching methodology. We then examine the effects of this implementation on changes in pertinent indicators.

RESULTS

Our hospital's perioperative death rate dropped to 0.019%, unscheduled reoperations dropped to 0.11%, and defined daily doses fell to 24.85. Antibiotic usage among hospitalised patients declined to 40.59%, while the percentage of antibacterial medicine prescriptions for outpatient patients decreased to 13.26%. Identity recognition requirements were implemented at a rate of 94.5%, and the low-risk group's death rate dropped to 0.01%. Critical transfusion episodes were less common, with an incidence of 0.01%. The physician's TeamSTEPPS Teamwork Perceptions Questionnaire and Teamwork Attitudes Questionnaire scores dramatically improved following the TeamSTEPPS team instruction course.

CONCLUSION

An evidence-based team collaboration training programme called TeamSTEPPS combines clinical practice with team collaboration skills to enhance team performance in the healthcare industry and raise standards for medical quality, safety, and effectiveness.

Management practices in facilities providing HIV services to key populations in Kenya and Malawi: A descriptive analysis of management in community-based organizations

HIV services for key populations (KP) at higher risk of HIV infection are often delivered by community-based organizations. To achieve HIV epidemic control, countries need to scale up HIV services for KP. Little is known about the management practices of community-based organizations delivering health services. We explored the management practices and facility characteristics of community-based health facilities providing HIV services to key populations as part of the LINKAGES program in Kenya and Malawi. We collected information on management practices from 45 facilities called drop-in centers (DICs) during US Government FY 2019, adapting the World Management Survey to the HIV community-based health service delivery context. We constructed management domain scores for each facility. We then analyzed the statistical correlations between management domains (performance monitoring, people management, financial management, and community engagement) and facility characteristics (e.g., number of staff, organization maturity, service scale) using ordinary least square models. The lowest mean management domain scores were found for people management in Kenya (38.3) and financial management in Malawi (25.7). The highest mean scores in both countries were for performance monitoring (80.9 in Kenya and 82.2 in Malawi). Within each management domain, there was significant variation across DICs, with the widest ranges in scores (0 to 100) observed for financial management and community involvement. The DIC characteristics we considered explained only a small proportion of the variation in management domain scores across DICs. Community-based health facilities providing HIV services to KP can achieve high levels of management in a context where they receive adequate levels of above-facility support and oversight-even if they deliver complex services, rely heavily on temporary workers and community volunteers, and face significant financial constraints. The variation in scores suggests that some facilities may require more above-facility support and oversight than others.

Measuring healthcare payor management practices in England

Good management practice in healthcare payors and providers is considered central to ensuring health systems respond to population needs, contain costs, and improve both quality and outcomes. However, the evidence to support this assertion is sparce. While a quantitative link between better management practice and improved patient outcomes has been demonstrated for healthcare providers, no such link has been identified for healthcare payors. The lack of a robust tool to assess the management practices of healthcare payors has impeded such quantitative assessments. We report upon a novel tool developed to measure and assess 11 management practices in all 152 healthcare payors within England's National Health Service in 2010. We have tested the acceptability, reliability and validity of this tool using rigorous analytic methods and present four key findings. First, performance of the tool is strong and comparable to management practice scorecards used in other settings. Second, exploratory factor analysis indicates the tool measures two distinct latent factors of healthcare payor management practice with high internal consistency and reliability. Third, there is evidence of assessment and score validity. Fourth, payor management practice variations are associated with the degree of supervisory oversight. While deploying such a tool is challenging, these results suggest that healthcare payor management practices can be measured and assessed robustly. This could enable governments, and others, to identify how payor management practices influence health system performance and to estimate what health system performance improvements they should expect from interventions designed to improve the management practices of their local healthcare payors.

Management Practices and Quality of Care: Evidence from the Private Health Care Sector in Tanzania

We measure the adoption of management practices in over 220 private for-profit and non-profit health facilities in 64 districts across Tanzania and link these data to process quality-of-care metrics, assessed using undercover standardised patients and clinical observations. We find that better managed health facilities are more likely to provide correct treatment in accordance with national treatment guidelines, adhere to a checklist of essential questions and examinations, and comply with infection prevention and control practices. Moving from the 10th to the 90th percentile in the management practice score is associated with a 48% increase in correct treatment. We then leverage a large-scale field experiment of an internationally recognised management support intervention in which health facilities are assessed against comprehensive standards, given an individually tailored quality improvement plan and supported through training and mentoring visits. We find zero to small effects on management scores, suggesting that improving management practices in this setting may be challenging.

A validated survey to measure Chinese hospital management practices

Surveys are widely used to assess hospital management with the aim of understanding differences in management practices. However, survey measures with prior notice can make hospitals change their routine practices and are unable to reflect the actual hospital management level. The World Management Survey (WMS) methodology has been developed to ameliorate these issues. It uses a double-blinded method and open-ended question design. The Chinese Hospital Management Survey (CHMS) project is the first to adapt the WMS methodology in China, which it uses to measure hospital management level in 510 hospitals. This paper provides an instrument to better measure actual management practices, which makes it possible to compare the management level of hospitals in China and other countries.

Hospital management practices in county-level hospitals in rural China and international comparison

Background

Although management is important in healthcare, low- and middle-income countries (LMICs) have little experience measuring the competence of hospital management. While improving hospital management is the main focus of hospital reform in China, few studies have empirically documented the baseline situation to inform policy design.

Methods

We assessed the management practices of county-level hospitals in Guizhou in southwest China during 2015. We used the Development World Management Survey (D-WMS) instrument to interview 273 managers in 139 hospitals. We scored the management practices of the sampled hospitals, overall and in four dimensions (operations, monitoring, targets, personnel management) and three processes (implementation, usage, monitoring). We then converted the scores to the WMS scale and compared these with data from two other LMICs and seven high-income countries (HICs).

Results

On a scale of 1 (‘worst practice’) to 5 (‘best practice’), the mean (SD) hospital D-WMS scores were 2.57 (0.46) overall; 2.71 (0.48), 2.64 (0.58), 2.40 (0.64), and 2.56 (0.40) for operation, monitoring, target, and personnel, respectively; and 2.43 (0.48), 2.62 (0.48), and 2.66 (0.47) for implementation, usage, and monitoring, respectively. After conversion to WMS scores, China ranked seventh of 10 countries, after six HICs and higher than one HIC and two other LMICs (Brazil and India). China ranked higher than the two LMICs in each of the four dimensional scores.

Conclusions

Chinese county-level hospitals should improve their low quality of management by prioritizing target-setting and process implementation, particularly in personnel management. Meanwhile, modern management training should be given to most clinical managers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07396-y.

Medical disputes and patient satisfaction in China: How does hospital management matter?

OBJECTIVE

Satisfaction with healthcare may be captured by surveys of patients and staff, or in extreme cases, the number and severity of medical disputes. This study tries to investigate the relationship between satisfaction and hospital management as well as the role of good management in preventing medical disputes ex ante.

METHOD

We investigate this relationship using information on management practices collected from 510 hospitals in mainland China using the World Management Survey questionnaire and combined with medical malpractice litigation data and patient/staff satisfaction surveys. Multiple regression models were used to analyse the relationship between hospital management scores and medical litigation outcomes as well as patient and staff satisfaction during 2014-2016.

RESULTS

An increase of one standard deviation in the management score was related to 13.1% (p < 0.10) lower incidence of medical disputes, 12.4% (p < 0.05) fewer medical litigations, and 51.3% (p < 0.10) less compensation. Better management quality of hospitals was associated with higher inpatient satisfaction (p < 0.05) and staff well-being (p < 0.01).

CONCLUSION

Improving hospital management could reduce hospital costs generated by lawsuits, reduce potential harm to patients, and improve patient and staff satisfaction, thus leading to a better patient-physician relationship.

Characterizing health care provider knowledge: Evidence from HIV services in Kenya, Rwanda, South Africa, and Zambia

BACKGROUND

Identifying approaches to improve levels of health care provider knowledge in resource-poor settings is critical. We assessed level of provider knowledge for HIV testing and counseling (HTC), prevention of mother-to-child transmission (PMTCT), and voluntary medical male circumcision (VMMC). We also explored the association between HTC, PMTCT, and VMMC provider knowledge and provider and facility characteristics.

METHODS

We used data collected in 2012 and 2013. Vignettes were administered to physicians, nurses, and counselors in facilities in Kenya (66), Rwanda (67), South Africa (57), and Zambia (58). The analytic sample consisted of providers of HTC (755), PMTCT (709), and VMMC (332). HTC, PMTCT, and VMMC provider knowledge scores were constructed using item response theory (IRT). We used GLM regressions to examine associations between provider knowledge and provider and facility characteristics focusing on average patient load, provider years in position, provider working in another facility, senior staff in facility, program age, proportion of intervention exclusive staff, person-days of training in facility, and management score. We estimated three models: Model 1 estimated standard errors without clustering, Model 2 estimated robust standard errors, and Model 3 estimated standard errors clustering by facility.

RESULTS

The mean knowledge score was 36 for all three interventions. In Model 1, we found that provider knowledge scores were higher among providers in facilities with senior staff and among providers in facilities with higher proportions of intervention exclusive staff. We also found negative relationships between the outcome and provider years in position, average program age, provider working in another facility, person-days of training, and management score. In Model 3, only the coefficients for provider years in position, average program age, and management score remained statistically significant at conventional levels.

CONCLUSIONS

HTC, PMTCT, and VMMC provider knowledge was low in Kenya, Rwanda, South Africa, and Zambia. Our study suggests that unobservable organizational factors may facilitate communication, learning, and knowledge. On the one hand, our study shows that the presence of senior staff and staff dedication may enable knowledge acquisition. On the other hand, our study provides a note of caution on the potential knowledge depreciation correlated with the time staff spend in a position and program age.

Hospital management practices and medical device costs

OBJECTIVE

To determine whether the variation in prices paid for cardiac medical devices was associated with management practices in cardiac units.

STUDY SETTING

Cardiac units in US hospitals.

STUDY DESIGN

We regressed unit prices on management practice scores and other hospital characteristics, with and without controls for device fixed effects, for the 11 top-spending cardiac device categories.

DATA COLLECTION

A trusted third party that had entered into a confidentiality agreement combined de-identified medical device price data for N = 213 US hospitals from ECRI's Supply Guide benchmarking service, with survey responses regarding management practices in those hospitals' cardiac units; the resulting merged data were made available to researchers for analysis with hospital identifiers removed. N = 1980 hospitals with interventional cardiac catheterization laboratories and at least 25 annual acute myocardial infarction discharges in 2010 were eligible for inclusion; N = 648 responded to the management practices survey; N = 213 subscribed to Supply Guide and purchased at least one of 11 top cardiac medical device categories.

PRINCIPAL FINDINGS

Cardiac units with better management practices paid lower prices for cardiac devices (percent decrease in price for one standard deviation increase in management score = 1.33%, 95% confidence interval 0.99-1.67). This was comparable in magnitude to the price decrease associated with a one standard deviation increase in patient volume.

CONCLUSIONS

Better management practices were associated with lower device prices. This relationship is robust, but modest in magnitude. This modest magnitude is similar, though, to other events expected to lower input prices, such as transparency in the form of benchmarking information and hospital mergers.

The hospital management practices in Chinese county hospitals and its association with quality of care, efficiency and finance

Background

County hospitals as the backbone of the China’s healthcare system are providing services for over 70% of the total population. However, the hospital management practice (HMP) and its links with quality of care, efficiency and finance in these hospitals are unknown.

Methods

We did two cross-sectional surveys of HMP in 2013 and 2015 among 101 county hospitals across rural China. Three managing roles (hospital director, director of medical affairs office and director of cardiology) and a cardiologist were invited to the surveys. A novel HMP rating scale, with 100 as full score, was used to measure the HMP in 17 indicators under four dimensions (target, operation, performance, and talent management) for each hospital. We analyzed the association of HMP score with variables on quality of care, efficiency and finance using linear mixed models with and without adjustment for potential confounders.

Findings

A total of 95 hospitals participated in at least one survey and were included in the analysis. The overall mean HMP score varied dramatically across the hospitals and 84% of them scored less than 60. The dimension mean HMP score was 38.6 (target), 56.4 (operation), 53.2 (performance) and 55.7 (talent), respectively. The pattern of indicator mean HMP score, however, was almost identical between hospitals with high and low overall HMP score, showing the same ‘strength’ (staff satisfaction, staff performance appraisal, ‘hard wares’, patient-centered services, etc.) and ‘weakness’ (target balance, target setting, continuous quality improvement, penalties on staff with dissatisfied performance, etc.). The associations of overall mean HMP score with quality of care and efficiency variables and cost per hospitalization was not statistically significant. The statistical significance in the association with hospital annual total income disappeared after adjusting for region, teaching status, number of competitors, number of staff and number of beds in use.

Conclusion

The HMP in Chinese county hospitals scores low in general and was not significantly associated with hospital care quality, efficiency and finance. The current healthcare reform in China should address the micro level issues in hospital management practices.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06472-7.

An Examination of the Factors Associated With Implementation of Evidence-Based Management Practices for Improving Nurse Work Environments

BACKGROUND

Evidence-based management practices (EBMPs) that improve nurses' work environments have been linked to improvements in patient outcomes such as patient satisfaction and mortality. Yet, the extent to which nurse managers implement these EBMP or the factors associated with their implementation is not known.

AIMS

Guided by the Promoting Action on Research Implementation in Health Services (PARIHS) Framework, we examined individual, evidence, and organizational characteristics associated with nurse managers' implementation of the five EBMPs.

METHODS

A cross-sectional, correlational, survey design was used. Nurse managers from 10 public hospitals in New York City were recruited. Evidence and contextual variables were measured with the Organizational Readiness for Change Assessment instrument. EBMPs were measured with a modified version of the Practice Environment Scale of the Nursing Work Index. All multi-item scales were validated with confirmatory factors analysis in the studied sample. Additionally, the scales had Cronbach's alpha reliability greater than .8. A multivariate linear regression analysis with robust standard error correction was used to analyze the data and to adjust for clustering of managers in hospitals.

RESULTS

A total of 331 nurse managers responded for a 47.4% response rate. Bachelor's degree, number of staff supervised, managers' personal experience with evidence for EBMPs, staff culture, and organizational resources were significant predictors of nurse managers' implementation of EBMPs for NWE improvement (p < .05).

LINKING EVIDENCE TO ACTION

Staff culture was positively associated with implementation of all five EBMPs for improving nurses' work environments. Managers should prioritize nursing unit culture that encourages staff to innovate and change in order to improve care.

The impact of quality on hospital choice. Which information affects patients' behavior for colorectal resection or knee replacement?

Quality competition among hospitals, induced by patients freely choosing their hospital in a price regulated market, can only be realized if quality differences between hospitals are transparent, understandable, and thus influence patients' hospital choice. We use data from ~145,000 German patients and ~ 900 hospitals for colorectal resections and knee replacements to investigate whether patients value quality and specialization when choosing their hospital. Using a random utility choice model, we estimate patients' marginal utilities, willingness to travel and change in hospital demand for quality improvements. Patients respond to service quality and specialization and thus, quality competition seems to be present. Colorectal resection patients are willing to travel longer for more specialized hospitals (+9% for procedure volume, +9% for certification). Knee replacement patients travel longer for hospitals with better service quality (+6%) and higher procedure volume (+12%). However, clinical quality indicators, often difficult to access and interpret, barely play a role in patients' hospital choice. Furthermore, we find that competition on quality for colorectal resection is rather local, whereas for knee replacement we observe regional competition patterns.

Efficiency, quality, and management practices in health facilities providing outpatient HIV services in Kenya, Nigeria, Rwanda, South Africa and Zambia

Few studies have assessed the efficiency and quality of HIV services in low-resource settings or considered the factors that determine both performance dimensions. To provide insights on the performance of outpatient HIV prevention units, we used benchmarking methods to identify best-practices in terms of technical efficiency and process quality and uncover management practices with the potential to improve efficiency and quality. We used data collected in 338 facilities in Kenya, Nigeria, Rwanda, South Africa, and Zambia. Data envelopment analysis (DEA) was used to estimate technical efficiency. Process quality was estimated using data from medical vignettes. We mapped the relationship between efficiency and quality scores and studied the managerial determinants of best performance in terms of both efficiency and quality. We also explored the relationship between management factors and efficiency and quality independently. We found levels of both technical efficiency and process quality to be low, though there was substantial variation across countries. One third of facilities were mapped in the best-performing group with above-median efficiency and above-median quality. Several management practices were associated with best performance in terms of both efficiency and quality. When considering efficiency and quality independently, the patterns of associations between management practices and the two performance dimensions were not necessarily the same. One management characteristic was associated with best performance in terms of efficiency and quality and also positively associated with efficiency and quality independently: number of supervision visits to HIV units.

A systematic review of Lean in healthcare: a global prospective

Purpose

Fostered by a rapid spread beyond the manufacturing sector, Lean philosophy for continuous improvement has been widely used in service organizations, primarily in the healthcare sector. However, there is a limited research on the motivating factors, challenges and benefits of implementing Lean in healthcare. Taking this as a valuable opportunity, the purpose of this paper is to present the key motivating factors, limitations or challenges of Lean deployment, benefits of Lean in healthcare and key gaps in the literature as an agenda for future research.

Design/methodology/approach

The authors used the secondary data from the literature (peer-reviewed journal articles) published between 2000 and 2016 to understand the state of the art. The systematic review identified 101 articles across 88 journals recognized by the Association of Business Schools ranking guide 2015.

Findings

The systematic review helped the authors to identify the evolution, current trends, research gaps and an agenda for future research for Lean in healthcare. A bouquet of motivating factors, challenges/limitations and benefits of Lean in healthcare are presented.

Practical implications

The implications of this work include directions for managers and healthcare professionals in healthcare organizations to embark on a focused Lean journey aligned with the strategic objectives. This work could serve as a valuable resource to both practitioners and researchers for learning, investigating and rightly adapting the Lean in the healthcare sector.

Originality/value

This study is perhaps one of the comprehensive systematic literature reviews covering an important agenda of Lean in Healthcare. All the text, figures and tables featured here are original work carried by five authors in collaboration (from three countries, namely, India, the USA and the UK).

Top-tier emergency general surgery hospitals: Good at one operation, good at them all

BACKGROUND

There is a longstanding interest in the field of management science to study high performance organizations. Applied to medicine, research on hospital performance indicates that some hospitals are high performing, while others are not. The objective of this study was to identify a cluster of high-performing emergency general surgery (EGS) hospitals and assess whether high performance at one EGS operation was associated with high performance on all EGS operations.

METHODS

Adult patients who underwent one of eight EGS operations were identified in the California State Inpatient Database (2010-2011), which we linked to the American Hospital Association database. Beta regression was used to estimate a hospital's risk-adjusted mortality, accounting for patient- and hospital-level factors. Centroid cluster analysis grouped hospitals by patterns of mortality rates across the eight EGS operations using z scores. Multinomial logistic regression compared hospital characteristics by cluster.

RESULTS

A total of 220 acute care hospitals were included. Three distinct clusters of hospitals were defined based on assessment of mortality for each operation type: high-performing hospitals (n = 66), average performing (n = 99), and low performing (n = 55). The mortality by individual operation type at the high-performing cluster was consistently at least 1.5 standard deviations better than the low-performing cluster (p < 0.001). Within-cluster variation was minimal at high-performing hospitals compared with wide variation at low-performing hospitals. A hospital's high performance in one EGS operation type predicted high performance on all EGS operation types.

CONCLUSION

High-performing EGS hospitals attain excellence across all types of EGS operations, with minimal variability in mortality. Poor-performing hospitals are persistently below average, even for low-risk operations. These findings suggest that top-performing EGS hospitals are highly reliable, with systems of care in place to achieve consistently superior results. Further investigation and collaboration are needed to identify the factors associated with high performance.

LEVEL OF EVIDENCE

Prognostic, level III.

Relation Between Statewide Hospital Performance Reports on Myocardial Infarction and Cardiovascular Outcomes

Healthcare systems may be judged on quality of care and access to health services. Studies on the association of hospital quality of care scores and clinical outcomes have yielded mixed results. With the help of a richer and more representative database, the aim of our study was to shed light on these inconsistencies. We examined the association of 4 process of care scores (prescription of aspirin, β blocker, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker used for left ventricular systolic dysfunction, and an overall composite score) for acute myocardial infarction (AMI), reported in the Hospital Performance Reports, with 30-day and 1-year rates of readmission for AMI and cardiovascular (CV) death. Clinical outcomes were from the Myocardial Infarction Data Acquisition System, an administrative database that comprises all patient CV disease admissions to acute care hospitals in New Jersey. CV death was related with overall score (adjusted odds ratio [OR] 0.821, 95% confidence interval [CI] 0.726 to 0.930, p = 0.002) at 30 days and with all 4 scores at 1 year (OR ranging from 0.829 to 0.997, p <0.01). Readmission due to AMI was associated with the overall score (OR 0.789, 95% CI 0.691 to 0.902, p <0.0001) and the aspirin score (OR 0.995, 95% CI 0.990 to 1, p = 0.046) at 30 days. Low hospital performance scores for AMI were associated with increased CV death and readmission for AMI. In conclusion, healthcare providers should allocate their resources to improving hospital performance to decrease AMI case fatality, AMI readmissions, and CV-related healthcare spending.

Common challenges managing bed and staff availability on labor and delivery units in the United States: A qualitative analysis

BACKGROUND

Managers of labor and delivery units need to ensure that their limited supply of beds and nursing staff are adequately available, despite uncertainty with respect to patient needs. The ability to address this challenge has been associated with patient outcomes; however, best practices have not been defined.

METHODS

We conducted a secondary analysis of 96 interviews with nurse and physician managers from 48 labor and delivery units across the United States. Included units represented a diverse range of characteristics, but skewed toward higher volume teaching hospitals. The prior study scored management practice based on their proactiveness (ability to mitigate challenges before they occur). Based on emerging themes, we identified common challenges in managing bed and staff availability and performed an analysis of positive deviants to identify an additional criterion for effective management performance.

RESULTS

We identified four key challenges common to all labor and delivery units, (1) scheduling planned cases, (2) tracking patient flow, (3) monitoring bed and staff availability in the moment, and (4) adjusting bed and staff availability in the moment. We also identified "systematicness" (ability to address challenges in a consistent and reliable manner) as an emerging criterion for effective management. We observed that being proactive and systematic represented distinct characteristics, and units with both proactive and systematic practices appeared best positioned to effectively manage limited beds and staffing.

DISCUSSION

Labor and delivery unit managers should distinctly assess both the proactiveness and systematicness of their existing management practices and consider how their practices could be modified to improve care.

Choice of hospital: Which type of quality matters?

The implications of hospital quality competition depend on what type of quality affects choice of hospital. Previous studies of quality and choice of hospitals have used crude measures of quality such as mortality and readmission rates rather than measures of the health gain from specific treatments. We estimate multinomial logit models of hospital choice by patients undergoing hip replacement surgery in the English NHS to test whether hospital demand responds to quality as measured by detailed patient reports of health before and after hip replacement. We find that a one standard deviation increase in average health gain increases demand by up to 10%. The more traditional measures of hospital quality are less important in determining hospital choice.