Contextual factors associated with hospitals’ decision to operate freestanding emergency departments

Factors driving differences in the adoption of quality management practices among hospitals: A two-phase, sequential mixed-methods analysis

BACKGROUND

Although all hospitals aim to deliver high-quality care, there is considerable variation in their adoption of quality management (QM) practices. Organizational and environmental factors are known to drive strategic decision-making in hospitals, but their impact on the adoption of QM practices remains unclear.

PURPOSE

Our study aims to identify multiple organizational and environmental factors that explain variation in the adoption of QM practices among hospitals and to explore mechanisms underlying these relationships.

METHODOLOGY

We conducted a two-phase, sequential mixed-methods study of German acute care hospitals. The quantitative phase used between-effects regressions to identify factors explaining variation in the number of QM practices adopted by hospitals from 2015 to 2019. The qualitative phase used semistructured interviews with quality managers to gain in-depth insights.

RESULTS

The number of QM practices adopted by a hospital was significantly associated with factors like hospital size and the presence of an emergency department or QM steering committee. Our qualitative findings highlighted potential mechanisms such as the presence of an emergency department serving as a proxy for organizational complexity or urgency of case-mix.

CONCLUSION

We provide an overview of factors driving QM adoption in hospitals, extending beyond the focus on single factors in previous research. Future studies could explore additional factors highlighted by our interviewees.

PRACTICE IMPLICATIONS

Our results can inform interventions to strengthen QM in hospitals and guide future research on this topic.

Market Factors Associated with Comprehensive Behavioral Health Crisis Care Availability: A Resource Dependence Theory Study

Behavioral health crisis care (BHCC) is a care delivery model for individuals experiencing acute distress related to a mental health or substance use disorder. We examined market factors associated with comprehensive BHCC availability using 2022 data on mental health treatment facilities (n = 9385) obtained from the Substance Abuse and Mental Health Services Administration. We aggregated facility-level data by county (n = 3142) and merged with county-level market factors. Logistic regression models were used to examine the adjusted associations between market factors and BHCC availability. We found that 468 (14.9%) counties had at least one mental health treatment facility offering comprehensive BHCC services. Specifically, counties with more mental health providers (Adjusted Odds Ratio = 2.26, Confidence Interval = 1.32-3.86) and metropolitan counties (AOR = 3.26, CI = 1.95-5.43) had higher odds of having a comprehensive BHCC facility. Our findings highlight the importance of developing the mental health workforce to increase BHCC availability and a need to address disparities in rural counties.

A Conceptual Framework for Optimizing the Equity of Hospital-Based Emergency Care: The Structure of Hospital Transfer Networks

Policy Points Current pay-for-performance and other payment policies ignore hospital transfers for emergency conditions, which may exacerbate disparities. No conceptual framework currently exists that offers a patient-centered, population-based perspective for the structure of hospital transfer networks. The hospital transfer network equity-quality framework highlights the external and internal factors that determine the structure of hospital transfer networks, including structural inequity and racism.

CONTEXT

Emergency care includes two key components: initial stabilization and transfer to a higher level of care. Significant work has focused on ensuring that local facilities can stabilize patients. However, less is understood about transfers for definitive care. To better understand how transfer network structure impacts population health and equity in emergency care, we proposea conceptual framework, the hospital transfer network equity-quality model (NET-EQUITY). NET-EQUITY can help optimize population outcomes, decrease disparities, and enhance planning by supporting a framework for understanding emergency department transfers.

METHODS

To develop the NET-EQUITY framework, we synthesized work on health systems and quality of health care (Donabedian, the Institute of Medicine, Ferlie, and Shortell) and the research framework of the National Institute on Minority Health and Health Disparities with legal and empirical research.

FINDINGS

The central thesis of our framework is that the structure of hospital transfer networks influences patient outcomes, as defined by the Institute of Medicine, which includes equity. The structure of hospital transfer networks is shaped by internal and external factors. The four main external factors are the regulatory, economic environment, provider, and sociocultural and physical/built environment. These environments all implicate issues of equity that are important to understand to foster an equitable population-based system of emergency care. The framework highlights external and internal factors that determine the structure of hospital transfer networks, including structural racism and inequity.

CONCLUSIONS

The NET-EQUITY framework provides a patient-centered, equity-focused framework for understanding the health of populations and how the structure of hospital transfer networks can influence the quality of care that patients receive.

The perceived impact of physician shortages on human resource strategies in German hospitals - a resource dependency perspective

PURPOSE

Like other European countries, Germany is facing regional physician shortages, which have several consequences on patient care. This study analyzes how hospitals perceive physician shortages and which strategies they adopt to address them. As a theoretical framework, the resource dependency theory is chosen.

DESIGN/METHODOLOGY/APPROACH

The authors conducted 20 semi-structured expert interviews with human resource officers, human resource directors, and executive directors from hospitals in the northwest of Germany. Hospitals of different ownership types, of varying sizes and from rural and urban locations were included in the sample. The interviews were analyzed by using qualitative content analysis.

FINDINGS

The interviewees reported that human resource departments in hospitals expand their recruiting activities and no longer rely on one single recruiting instrument. In addition, they try to adapt their retaining measures to physicians' needs and offer a broad range of employment benefits (e.g. childcare) to increase attractiveness. The study also reveals that interviewees from small and rural hospitals report more difficulties with attracting new staff and therefore focus on recruiting physicians from abroad.

PRACTICAL IMPLICATIONS

Since the staffing situation in German hospitals will not change in the short term, the study provides suggestions for hospital managers and health policy decision-makers in dealing with physician shortages.

ORIGINALITY/VALUE

This study uses the resource dependency theory to explain hospitals' strategies for dealing with healthcare staff shortages for the first time.

Impact of External Environmental Dimensions on Financial Performance of Major Teaching Hospitals in the U.S

Teaching hospitals have a unique mission to not only deliver graduate medical education but to also provide both inpatient and ambulatory care and to conduct clinical medical research; therefore, they are under constant financial pressure, and it is important to explore what types of external environmental components affect their financial performance. This study examined if there is an association between the short-term and long-term financial performance of major teaching hospitals in the United States and the external environmental dimensions, as measured by the Resource Dependence Theory. Data for 226 major teaching hospitals spanning 46 states were analyzed. The dependent variable for short-term financial performance was days cash on hand, and dependent variable for long-term financial performance was return on assets, both an average of most recently available 4-year data (2014-2017). Utilizing linear regression model, results showed significance between outpatient revenue and days cash on hand as well as significant relationship between population of the metropolitan statistical area, unemployment rate of the metropolitan statistical area, and teaching hospital's return on assets. Additionally, system membership, type of ownership/control, and teaching intensity also showed significant association with return on assets. By comprehensively examining all major teaching hospitals in the U.S. and analyzing the association between their short-term and long-term financial performance and external environmental dimensions, based upon Resource Dependence Theory, we found that by offering diverse outpatient services and novel delivery options, administrators of teaching hospitals may be able to increase organizational liquidity.

Factors that Determine Comprehensive Categorical Classification of EHR Implementation Levels

Electronic Health Records (EHRs) have the potential to alleviate patient safety mistakes. Of the various levels of EHR, advanced or higher-level functionalities of EHR are designed to improve patient safety. Certain organizational and environmental factors may pose as barriers toward implementing all of the functionalities, leaving certain hospitals intermediate between basic and comprehensive levels of implementation. This study identifies a comprehensive categorical classification that includes hospitals that have functionalities between basic and comprehensive levels of EHR and determines the organizational and environmental factors that may influence hospitals to implement one or more combinations of these categories. A longitudinal panel design was used. Ordinal logistic regression with random effects model was fitted with robust cluster standard errors. Our sample consisted of non-federal general acute care hospitals utilizing a panel design from 2010 to 2016 with 17 586 hospital-year observations (or an average of 2600 hospitals per year). Larger size hospitals, ones with higher total margin, metropolitan and urban hospitals, system affiliated hospitals, and those in higher managed care penetration areas have higher odds of belonging in one of the higher categories of EHR implementation. Hospitals that can access a greater amount of human resources and financial assets from their environments, may implement higher levels of EHR. Initial and maintenance costs of EHR, interoperability issues, and inability to distribute high costs of training across facilities may stymie implementation of higher EHR functionalities. Policymaking to encourage competition among vendors may possibly lower the implementation price for hospitals with limited resources.

Factors associated with Interhospital transfers of emergency general surgery patients from emergency departments

BACKGROUND

Emergency general surgery (EGS) conditions account for over 3 million or 7.1% of hospitalizations per year in the US. Patients are increasingly transferred from community emergency departments (EDs) to larger centers for care, and a growing demand for treating EGS conditions mandates a better understanding of how ED clinicians transfer patients. We identify patient, clinical, and organizational characteristics associated with interhospital transfers of EGS patients originating from EDs in the United States.

METHOD

We analyze data from the Agency for Healthcare Research and Quality Nationwide Emergency Department Sample (NEDS) for the years 2010-2014. Patient-level sociodemographic characteristics, clinical factors, and hospital-level factors were examined as predictors of transfer from the ED to another acute care hospital. Multivariable logistic regression analysis includes patient and hospital characteristics as predictors of transfer from an ED to another acute care hospital.

RESULTS

Of 47,442,892 ED encounters (weighted) between 2008 and 2014, 1.9% resulted in a transfer. Multivariable analysis indicates that men (Odds ratio (OR) 1.18 95% Confidence Interval (95% CI) 1.16-1.21) and older patients (OR 1.02 (95% CI 1.02-1.02)) were more likely to be transferred. Relative to patients with private health insurance, patients covered by Medicare (OR 1.09 (95% CI 1.03-1.15) or other insurance (OR 1.34 (95% CI 1.07-1.66)) had a higher odds of transfer. Odds of transfer increased with a greater number of comorbid conditions compared to patients with an EGS diagnosis alone. EGS diagnoses predicting transfer included resuscitation (OR 36.72 (95% CI 30.48-44.22)), cardiothoracic conditions (OR 8.47 (95% CI 7.44-9.63)), intestinal obstruction (OR 4.49 (95% CI 4.00-5.04)), and conditions of the upper gastrointestinal tract (OR 2.82 (95% CI 2.53-3.15)). Relative to Level I or II trauma centers, hospitals with a trauma designation III or IV had a 1.81 greater odds of transfer. Transfers were most likely to originate at rural hospitals (OR 1.69 (95% CI 1.43-2.00)) relative to urban non-teaching hospitals.

CONCLUSION

Medically complex and older patients who present at small, rural hospitals are more likely to be transferred. Future research on the unique needs of rural hospitals and timely transfer of EGS patients who require specialty surgical care have the potential to significantly improve outcomes and reduce costs.

Hospitalists, two decades later: Which US hospitals utilize them?

Hospitalists, or specialists of hospital medicine, have long been practicing in Canada and Europe. However, it was not until the mid-1990s, when hospitals in the U.S. started widespread adoption of hospitalists. Since then, the number of hospitalists has grown exponentially in the U.S. from a few hundred to over 50,000 in 2016. Prior studies on hospitalists have well documented benefits hospitals gain from adopting this innovative staffing strategy. However, there is a dearth of research documenting predictors of hospitals' adoption of hospitalists. To fill this gap, this longitudinal study (2003-2015) purposes to determine organizational and market characteristics of U.S. hospitals that utilize hospitalists. Our findings indicate that private not-for-profit, system affiliated, teaching, and urban hospitals, and those located in higher per capita income markets have a higher probability of utilizing hospitalists. Additionally, large or medium, profitable hospitals, and those that treat sicker patients have a higher probability of adoption. Finally, hospitals with a high proportion of Medicaid patients have a lower probability of utilizing hospitalists. Our results suggest that hospitals with greater slack resources and those located in munificent counties are more likely to use hospitalists, while their under-resourced counterparts may experience more barriers in adopting this innovative staffing strategy.

Environmental and Organizational Factors Associated with Hospital Use of GPO Services

Given the potential benefits of Group Purchasing Organizations in cost-containment efforts for hospitals on supplies and purchased services, an important question that remains unanswered is what conditions support or hinder the utilization of GPOs by hospitals. Therefore, this study explores the relationship between GPO use by hospitals and their market and organizational characteristics. Data on hospital GPO utilization and other organizational characteristics were combined with secondary hospital market characteristics. Panel logistic regression with random effects and state and year fixed effects analysis was used to examine the relationship between hospitals' utilization of GPO services and hospitals' organizational and market characteristics. Overall, the majority of hospitals utilized the services of GPOs. Specifically, the number of hospitals utilizing the services of GPOs increased slightly from 3290 (72.2%) in 2004 to 3337 (74.4%) in 2013. In regression analyses, hospitals utilizing the services of GPOs operated in an external environment with mixed levels of munificence, more dynamism, and less competition. Specifically, hospitals operating in a less munificent environment are more likely to utilize the services of GPOs. The study findings provide organizational decision-makers and policymakers' insights into how certain market and organizational factors influence hospital strategy choice, in this case, the use of GPOs.

Hospital staff shortages: Environmental and organizational determinants and implications for patient satisfaction

Recent discussions and previous research often indicate that German hospitals are affected by a shortage of healthcare personnel on the labor market. However, until now, research has provided only limited insights into how environmental and organizational factors explain variations in staff shortages, how staff shortage measures relate to staffing ratios, and what relevance staff shortages have for patients. Regression analyses based on survey data of 104 German hospitals from 2015 to 2016, combined with labor market and patient satisfaction data, show that several environmental and organizational factors are significantly related to hospital staff shortages, measured by self-reports, vacancies, and turnover. These three measures of staff shortage do not correlate to the same degree for physicians and nurses, and none of the three significantly relate to nursing ratios, which indicates that the latter is a distinct concept rather than a direct consequence of staff shortage. The analyses further show that hospital staff shortages relate significantly to patient satisfaction with physician and nursing care. The findings suggest that hospitals are, to a certain extent, able to influence the degree to which they are affected by staff shortages and that hospitals' decisions about staffing levels depend on more than staff availability.

Rural Hospital Mergers Increased Between 2005 and 2016-What Did Those Hospitals Look Like?

The objective of this study is to determine whether key hospital-level financial and market characteristics are associated with whether rural hospitals merge. Hospital merger status was derived from proprietary Irving Levin Associates data for 2005 through 2016 and hospital-level characteristics from HCRIS, CMS Impact File Hospital Inpatient Prospective Payment System, Hospital MSA file, AHRF, and U.S. Census data for 2004 through 2016. A discrete-time hazard analysis using generalized estimating equations was used to determine whether factors were associated with merging between 2005 and 2016. Factors included measures of profitability, operational efficiency, capital structure, utilization, and market competitiveness. Between 2005 and 2016, 11% (n = 326) of rural hospitals were involved in at least one merger. Rural hospital mergers have increased in recent years, with more than two-thirds (n = 261) occurring after 2011. The types of rural hospitals that merged during the sample period differed from nonmerged rural hospitals. Rural hospitals with higher odds of merging were less profitable, for-profit, larger, and were less likely to be able to cover current debt. Additional factors associated with higher odds of merging were reporting older plant age, not providing obstetrics, being closer to the nearest large hospital, and not being in the West region. By quantifying the hazard of characteristics associated with whether rural hospitals merged between 2005 and 2016, these findings suggest it is possible to determine leading indicators of rural mergers. This work may serve as a foundation for future research to determine the impact of mergers on rural hospitals.

A Geospatial Analysis of Freestanding and Hospital Emergency Department Accessibility via Public Transit

Introduction

Emergency departments (ED) are an important source of care for underserved populations and represent a significant part of the social safety net. In order to explore the effect of freestanding emergency departments (FSED) on access to care for urban underserved populations, we performed a geospatial analysis comparing the proximity of FSEDs and hospital EDs to public transit lines in three United States (U.S.) metropolitan areas: Houston, Denver, and Cleveland.

Methods

We used publicly available U.S. Census data, public transportation maps obtained from regional transit authorities, and geocoded FSED and hospital ED locations. Euclidean distance from each FSED and hospital ED to the nearest public transit line was calculated in ArcGIS. We calculated the odds ratio (OR) of an FSED, relative to a hospital ED, being located within 0.5 miles (mi) of a public transit line using logistic regression, adjusting for population density and median household income and with error clustered at the metropolitan statistical area (MSA) level.

Results

The median distance from FSEDs to public transit lines was significantly greater than from hospital EDs across all three markets. In Houston, Denver, and Cleveland, the median distance between FSEDs and public transit lines was greater than from hospital EDs by 1.0 mi, 0.2 mi, and 1.6 mi, respectively. The OR of a public transit line being located within 0.5 mi of an FSED, as compared with a hospital ED, across all three MSAs was 0.21 (95% confidence interval [CI], 0.13–0.34) unadjusted and 0.20 (95% CI, 0.11–0.40) adjusted for population density and median household income.

Conclusion

In comparison with hospital EDs, FSEDs are located farther from public transit lines and are less likely to be within walking distance of public transportation. These findings suggest that FSEDs are unlikely to directly increase access to care for patients without private means of transportation. Further research is necessary to explore both the direct and indirect impact of FSEDs on access to care, potentially through effects on hospital ED crowding and overall healthcare expenditures, as well as the ultimate role and responsibility of FSEDs in improving access to care for underserved populations.

Explaining variations in hospitals' use of strategic human resource management: How environmental and organizational factors matter

BACKGROUND

Against the background of increasing workforce-related challenges such as staff shortages, strategic human resource management (SHRM) has gained importance in hospitals. Although the positive implications of SHRM for hospital performance are well known and commonly accepted in research and practice, hospitals still vary in its use. However, the sources of variations in hospitals' use of SHRM are largely unknown.

PURPOSE

Various organizational and environmental factors were used in this study to explain the variations in hospitals' use of SHRM for physicians and nurses.

METHODOLOGY

Data were obtained from a hospital survey (n = 172) on topics related to human resource management in hospitals and linked to different secondary data sets. We apply multiple linear regression modeling to investigate the association between organizational and environmental characteristics and hospitals' use of SHRM for nurses and physicians.

FINDINGS

Our results suggest that organizational factors such as private for-profit and nonprofit ownership (compared to public ownership), academic teaching status, and the strategic involvement of the human resource administration are positively associated with hospitals' use of SHRM. None of the environmental factors investigated in this study was significantly related to hospitals' use of SHRM.

PRACTICAL IMPLICATIONS

The study results increase our understanding of variations in hospitals' use of SHRM. Although organizational characteristics were found to explain variations in SHRM, environmental factors seem unrelated with hospitals' use of SHRM. Our results inform both hospital managers and policy makers about possible approaches to enhance SHRM use in hospitals. Furthermore, profound knowledge about factors associated with SHRM will help to enhance our understanding of anticipating changes in hospitals' use of SHRM through organizational- and environmental-oriented interventions.

Freestanding Emergency Departments Are Associated With Higher Medicare Costs: A Longitudinal Panel Data Analysis

The number of freestanding emergency departments (FSEDs) is growing rapidly in the United States. Proponents of FSEDs cite potential benefits of FSEDs including lower waiting time and reduced travel distance for needed emergency care. Others have suggested that increased access to emergency care may lead to an increase in the use of emergency departments for lower acuity patients, resulting in higher overall health care expenditures. We examined the relationship between the number of FSEDs in each county and total Medicare expenditures between 2003 and 2009. Our results show that each additional FSED in a county is associated with an expenditure increase of $55 per Medicare beneficiary. This finding suggests that even if FSEDs may increase access to emergency care, it may result in higher overall Medicare expenditures.