Organization and Performance of US Health Systems

IMPORTANCE

Health systems play a central role in the delivery of health care, but relatively little is known about these organizations and their performance.

OBJECTIVE

To (1) identify and describe health systems in the United States; (2) assess differences between physicians and hospitals in and outside of health systems; and (3) compare quality and cost of care delivered by physicians and hospitals in and outside of health systems.

EVIDENCE REVIEW

Health systems were defined as groups of commonly owned or managed entities that included at least 1 general acute care hospital, 10 primary care physicians, and 50 total physicians located within a single hospital referral region. They were identified using Centers for Medicare & Medicaid Services administrative data, Internal Revenue Service filings, Medicare and commercial claims, and other data. Health systems were categorized as academic, public, large for-profit, large nonprofit, or other private systems. Quality of preventive care, chronic disease management, patient experience, low-value care, mortality, hospital readmissions, and spending were assessed for Medicare beneficiaries attributed to system and nonsystem physicians. Prices for physician and hospital services and total spending were assessed in 2018 commercial claims data. Outcomes were adjusted for patient characteristics and geographic area.

FINDINGS

A total of 580 health systems were identified and varied greatly in size. Systems accounted for 40% of physicians and 84% of general acute care hospital beds and delivered primary care to 41% of traditional Medicare beneficiaries. Academic and large nonprofit systems accounted for a majority of system physicians (80%) and system hospital beds (64%). System hospitals were larger than nonsystem hospitals (67% vs 23% with >100 beds), as were system physician practices (74% vs 12% with >100 physicians). Performance on measures of preventive care, clinical quality, and patient experience was modestly higher for health system physicians and hospitals than for nonsystem physicians and hospitals. Prices paid to health system physicians and hospitals were significantly higher than prices paid to nonsystem physicians and hospitals (12%-26% higher for physician services, 31% for hospital services). Adjusting for practice size attenuated health systems differences on quality measures, but price differences for small and medium practices remained large.

CONCLUSIONS AND RELEVANCE

In 2018, health system physicians and hospitals delivered a large portion of medical services. Performance on clinical quality and patient experience measures was marginally better in systems but spending and prices were substantially higher. This was especially true for small practices. Small quality differentials combined with large price differentials suggests that health systems have not, on average, realized their potential for better care at equal or lower cost.

Identification and assessment of a comprehensive set of structural factors associated with hospital costs in Switzerland

Structural factors can influence hospital costs beyond case-mix differences. However, accepted measures on how to distinguish hospitals with regard to cost-related organizational and regional differences are lacking in Switzerland. Therefore, the objective of this study was to identify and assess a comprehensive set of hospital attributes in relation to average case-mix adjusted costs of hospitals. Using detailed hospital and patient-level data enriched with regional information, we derived a list of 23 cost predictors, examined how they are associated with costs, each other, and with different hospital types, and identified principal components within them. Our results showed that attributes describing size, complexity, and teaching-intensity of hospitals (number of beds, discharges, departments, and rate of residents) were positively related to costs and showed the largest values in university (i.e., academic teaching) and central general hospitals. Attributes related to rarity and financial risk of patient mix (ratio of rare DRGs, ratio of children, and expected loss potential based on DRG mix) were positively associated with costs and showed the largest values in children's and university hospitals. Attributes characterizing the provision of essential healthcare functions in the service area (ratio of emergency/ ambulance admissions, admissions during weekends/ nights, and admissions from nursing homes) were positively related to costs and showed the largest values in central and regional general hospitals. Regional attributes describing the location of hospitals in large agglomerations (in contrast to smaller agglomerations and rural areas) were positively associated with costs and showed the largest values in university hospitals. Furthermore, the four principal components identified within the hospital attributes fully explained the observed cost variations across different hospital types. These uncovered relationships may serve as a foundation for objectifying discussions about cost-related heterogeneity in Swiss hospitals and support policymakers to include structural characteristics into cost benchmarking and hospital reimbursement.

Improving patient flow during infectious disease outbreaks using machine learning for real-time prediction of patient readiness for discharge

BACKGROUND

Delays in patient flow and a shortage of hospital beds are commonplace in hospitals during periods of increased infection incidence, such as seasonal influenza and the COVID-19 pandemic. The objective of this study was to develop and evaluate the efficacy of machine learning methods at identifying and ranking the real-time readiness of individual patients for discharge, with the goal of improving patient flow within hospitals during periods of crisis.

METHODS AND PERFORMANCE

Electronic Health Record data from Oxford University Hospitals was used to train independent models to classify and rank patients' real-time readiness for discharge within 24 hours, for patient subsets according to the nature of their admission (planned or emergency) and the number of days elapsed since their admission. A strategy for the use of the models' inference is proposed, by which the model makes predictions for all patients in hospital and ranks them in order of likelihood of discharge within the following 24 hours. The 20% of patients with the highest ranking are considered as candidates for discharge and would therefore expect to have a further screening by a clinician to confirm whether they are ready for discharge or not. Performance was evaluated in terms of positive predictive value (PPV), i.e., the proportion of these patients who would have been correctly deemed as 'ready for discharge' after having the second screening by a clinician. Performance was high for patients on their first day of admission (PPV = 0.96/0.94 for planned/emergency patients respectively) but dropped for patients further into a longer admission (PPV = 0.66/0.71 for planned/emergency patients still in hospital after 7 days).

CONCLUSION

We demonstrate the efficacy of machine learning methods at making operationally focused, next-day discharge readiness predictions for all individual patients in hospital at any given moment and propose a strategy for their use within a decision-support tool during crisis periods.

Humanizing the Morbidity and Mortality Conference

Morbidity and mortality conferences (MMCs) are a long-held legacy institution in academic medicine that enable medical providers and hospital administrators to learn from systemic and individual errors, thereby leading to improved medical care. Originally, this forum had 1 major role-education. The MMC evolved and a second key role was added: quality improvement. In the wake of the 2020 COVID-19 pandemic, a second evolution-one that will humanize the MMC-is required. The pandemic emphasizes the need to use MMCs not only as a place to discuss errors but also as a place for medical providers to reflect on lives lost. The authors' review of the literature regarding MMCs indicates that most studies focus on enabling MMCs to become a forum for quality improvement, while none have emphasized the need to humanize MMCs to decrease medical provider burnout and improve patient satisfaction. Permitting clinicians to be human on the job requires restructuring the MMC to provide a space for reflection and, ultimately, defining a new purpose and charge for the MMC. The authors have 3 main recommendations. First, principles of humanism such as compassion, empathy, and respect, in particular, should be incorporated into traditional MMCs. Second, shorter gatherings devoted to giving clinicians the opportunity to focus on their humanity should be arranged. Third, an MMC focused entirely on the human aspects of medical care should be periodically arranged to provide an outlet for storytelling, artistic expression, and reflection. Humanizing the MMC-a core symposium in clinical medicine worldwide-could be the first step in revitalizing the spirit at the heart of medicine, one dedicated to health and healing. This spirit, which has been eroding as the field of medicine becomes increasingly corporate in structure and mission, is as essential during peaceful times in health care as during a pandemic.

Investigating Hospital Supervision: A Case Study of Regulatory Inspectors' Roles as Potential Co-creators of Resilience

OBJECTIVES

The aim of this study was to explore if, and in what ways, there has been changes in the supervisory approach toward Norwegian hospitals due to the implementation of a new management and quality improvement regulation (Regulation on Management and Quality Improvement in the Healthcare Services, hereinafter referred to as "Quality Improvement Regulation"). Moreover, we aimed to understand how inspectors' work promotes or hampers resilience potentials of adaptive capacity and learning in hospitals.

METHODS

The study design is a case study of implementation and impact of the Quality Improvement Regulation. We performed a document analysis, and conducted and analyzed 3 focus groups and 2 individual interviews with regulatory inspectors, recruited from 3 county governor offices who are responsible for implementation and supervision of the Quality Improvement Regulation in Norwegian regions.

RESULTS

Data analysis resulted in 5 themes. Informants described no substantial change in their approach owing to the Quality Improvement Regulation. Regardless, data pointed to a development in their practices and expectations. Although the Norwegian Board of Health Supervision, at the national level, occasionally provides guidance, supervision is adapted to specific contexts and inspectors balance trade-offs. Informants expressed concern about the impact of supervision on hospital performance. Benefits and disadvantage with positive feedback from inspectors were debated. Inspectors could nurture learning by improving their follow-up and add more hospital self-assessment.

CONCLUSIONS

A nondetailed regulatory framework such as the Quality Improvement Regulation provides hospitals with room to maneuver, and self-assessment might reduce resource demands. The impact of supervision is scarce with an unfulfilled potential to learn from supervision. The Government could contribute to a shift in focus by instructing the county governors to actively reflect on and communicate positive experiences from, and smart adaptations in, hospital practice.

Supporting the Quadruple Aim Using Simulation and Human Factors During COVID-19 Care

The health care sector has made radical changes to hospital operations and care delivery in response to the coronavirus disease (COVID-19) pandemic. This article examines pragmatic applications of simulation and human factors to support the Quadruple Aim of health system performance during the COVID-19 era. First, patient safety is enhanced through development and testing of new technologies, equipment, and protocols using laboratory-based and in situ simulation. Second, population health is strengthened through virtual platforms that deliver telehealth and remote simulation that ensure readiness for personnel to deploy to new clinical units. Third, prevention of lost revenue occurs through usability testing of equipment and computer-based simulations to predict system performance and resilience. Finally, simulation supports health worker wellness and satisfaction by identifying optimal work conditions that maximize productivity while protecting staff through preparedness training. Leveraging simulation and human factors will support a resilient and sustainable response to the pandemic in a transformed health care landscape.

Analysis of factors and corresponding interactions influencing clinical management assistant ability using competency model in China

The clinical management assistant (CMA) is an innovative and practical way to help manage a hospital, so the selection of CMA is important. This research is to find the influencing factors on the competency of CMA and help to select proper candidate of CMA.Based on the items of competency theory using the structural equation model, the data of 600 hospital managers from Shanghai, Guangzhou and Wuhan were identified by exploratory factor analysis and confirmatory factor analysis. In further analysis, the interactions among the factors were evaluated.A total of 20 items were identified as critical to CMA capability, which were further tested and divided into 3 factors: (1) personal characteristics; (2) competence; (3) thinking. The subsequent analysis showed that all factors had significant impact on CMA's ability, and competence contributed the most to the formation of CMA's ability, while the intermediary role of personal characteristics and thinking could not be ignored in practice. The results showed that the competency model contained these 3 factors and had the same structure as the classic competency model.This study presented a tentative approach for assessing CMA's competency, as well as provided the criteria to find and evaluate a CMA.

Delinquent Medical Records: Who Are the Stakeholders for Timely Medical Documentation?

The explosion of electronic documentation associated with Meaningful Use-certified electronic health record systems has led to a massive increase in provider workload for completion and finalization of patient encounters. Delinquency of required documentation affects multiple areas of hospital operations. We present the major stakeholders affected by delinquency of the electronic medical record and examine the differing perspectives to gain insight for successful engagement to reduce the burden of medical record delinquency.

Value of new performance information in healthcare: evidence from Japan

Mandatory measurement and disclosure of outcome measures are commonly used policy tools in healthcare. The effectiveness of such disclosures relies on the extent to which the new information produced by the mandatory system is internalized by the healthcare organization and influences its operations and decision-making processes. We use panel data from the Japanese National Hospital Organization to analyze performance improvements following regulation mandating standardized measurement and peer disclosure of patient satisfaction performance. Drawing on value of information theory, we document the absolute value and the benchmarking value of new information for future performance. Controlling for ceiling effects in the opportunities for improvement, we find that the new patient satisfaction measurement system introduced positive, significant, and persistent mean shifts in performance (absolute value of information) with larger improvements for poorly performing hospitals (benchmarking value of information). Our setting allows us to explore these effects in the absence of confounding factors such as incentive compensation or demand pressures. The largest positive effects occur in the initial period, and improvements diminish over time, especially for hospitals with poorer baseline performance. Our study provides empirical evidence that disclosure of patient satisfaction performance information has value to hospital decision makers.

Pillars of Hospital Preparedness in Radiation Emergency Management

Human beings have always suffered and have incurred irreparable damages from different disasters. The most logical way to deal with disaster is to be comprehensively prepared. In line with this, the readiness of hospitals in the vicinity of nuclear centers is of great importance, as this could lead to reduced injuries and damage. In this study, we aimed to develop a model by which hospitals could effectively react to nuclear incidents. This is a comparative study using library studies, including examining existing patterns, recommended policies and instructions of WHO and IEAE, and articles and documents of selected countries that have models for radiation disaster management. The primary developed model was discussed in expert panels and, ultimately, with some modifications, was finalized. The findings of the research indicated that the most important factors in the success of crisis management are skill in predicting a crisis and having a preparation plan for necessary measures at the time of an incident. Different countries have developed various approaches toward radiation incident management that are mostly focused on human resources, medical equipment, and physical space. The model plan developed here includes a two-part foundation with seven pillars. Intra- and intersectorial arrangements are considered as the foundation, and the pillars are physical structure, medical equipment, human resources, process and instructions, intra- and intrasectorial coordination, information systems, and organizational structure. Having an appropriate model for coping with radiation incidents is pivotal for hospitals active in areas with nuclear centers. Undoubtedly, existence of an effective and comprehensive model could reduce the consequences of radiation crises.

Challenges around COVID-19 at a tertiary-level healthcare facility in South Africa and strategies implemented for improvement

SARS-CoV-2 has resulted in a global pandemic within months following its initial detection. South Africa (SA), like many other countries, was not prepared for the impact this novel infection would have on the healthcare system. In this paper, the authors discuss the challenges experienced while facing COVID-19 at a tertiary-level institution in Gauteng province, SA, and the dynamic strategies implemented to deal with the epidemic.

Prevention of health care associated venous thromboembolism through implementing VTE prevention clinical practice guidelines in hospitalized medical patients: a systematic review and meta-analysis

BACKGROUND

Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in hospitalized patients. Numerous VTE prevention clinical practice guidelines are available but not consistently implemented. This systematic review explored effectiveness of implementing VTE prevention clinical practice guidelines on VTE risk assessment and appropriateness of prophylaxis in hospitalized adult medical patients and identified the interventions followed to improve the adherence to these guidelines.

METHODS

Six electronic databases were searched for randomized controlled trials, clinical controlled trials, or pre/post evaluation studies up to January 2019. Studies identified were screened for eligibility by two reviewers independently. Data were extracted by two reviewers using a standardized form. Risk of bias was assessed using MINORS and the certainty of evidence for each outcome using the GRADE approach.

RESULTS

Of the 3537 records identified, 36 were eligible; eight studies were included for qualitative synthesis and four for meta-analysis. The meta-analysis of the studies assessing the impact of implementing VTE clinical practice guidelines favored appropriate prophylaxis (RR 1.67, 95% CI 1.41 to 1.97, 552 patients). Potential risk of bias was assessed to be low for 28% of the studies. However, using GRADE, the certainty of the evidence of all outcomes was rated very low quality.

CONCLUSIONS

The lack of randomized controlled trials in this area reduces the quality of the evidence available. The evidence from before-after studies suggests that the implementation of VTE clinical practice guidelines may increase the practice of VTE risk assessment and appropriate prophylaxis in hospitalized medical patients.

TRIAL REGISTRATION

PROSPERO CRD42018085506.

[Complete information technology blackout in hospitals : Development of a concept for maintaining patient care]

The complete blackout of information technology (IT) in a hospital represents a major incident with acute loss of functionality. The immediate consequence is a rapidly progressive loss of treatment capacity. The major priority for the acute management of such an event is to keep patients safe and prevent life-threatening situations. A possibility to channel the uncontrolled loss of treatment capacity in order to achieve the aforementioned protective target is the immediate organization of an analog system for baseline emergency medical care. The switch over from a fully operational routinely functioning system to a reduced emergency state occurs daily in hospitals (night shift, weekends, public holidays) and reflects the controlled reduction of the treatment capacity. This process and the procedures associated with it are universally known, the functions are clearly defined and planned in advance by duty rotas and the interplay of clinics in the organizational schedule is regulated in detail. In order to accomplish this strategy analog instruments are necessary. These must all be conceived, established, practiced and evaluated in advance with the clinics and departments. Ultimately, all isolated IT blackout concepts must be amalgamated into a compatible and functioning total framework. This structure must be maintained for as long as a partially or totally functioning IT has been reinstated.

Evaluation results of national hospital accreditation program in Iran: The view of hospital managers

BACKGROUND

Accreditation programs have a crucial role in improving the safety and effectiveness of hospital services. Many factors contribute to achieve accreditation goals. This study evaluated the national Iranian hospital accreditation program from the view of hospital managers in Iran.

METHODS

The study was conducted in 2015 using a validated questionnaire designed to collect feedback concerning accreditation processes and impacts. In total, 547 managers were surveyed using a stratified random sampling method. A 5-degree scale Likert from totally disagree=1 to totally agree=5 has been used for the evaluation. Descriptive and inferential statistics were used to analyze the data.

RESULTS

Approximately half of hospital managers were satisfied with the accreditation standards and surveying methods. The reason for their dissatisfaction was the high number of measures (2.38). The main challenges to the accreditation method were reported inadequate surveyor training (2.94) their satisfaction with the infrastructure was low because of a lack of hospital resources. Nonetheless, the accreditation program was perceived as being successful in improving patient safety (3.80), patient compliance (3.72), and error reduction (3.53).

CONCLUSION

An effective accreditation program requires reducing the number of standards and making them clearer as well as the infrastructure for the implementation of accreditation such as sufficient and sustainable funds, enough human resources and equipment should be provided. Appropriate surveyors should be selected and trained professionally to ensure inter-rater reliability among them.

Improving Patient behavioral Consent through Different Service Quality Dimensions: Assessing the Mediating Role of Patient Satisfaction

This study aimed to examine the impact of the five-dimensional health care service quality (SQ) on patient behavioral consent (PBC). This study further explored the mediating role of patient satisfaction (PS) on the SQ–PBC relationship. A survey questionnaire was used to collect the data from public sector hospitals situated in Bahawalpur division, Punjab, Pakistan. We used confirmatory factor analysis (CFA) and structural equation modeling (SEM) to test the hypotheses. This study found positive and significant relationships between SQ and PBC, SQ and PS, and PS and PBC. Our results further revealed that PS partially mediates the relationship between SQ and PBC. Our study offers a comprehensive theoretical framework of several service quality attributes (SQs) affecting patient behavioral consent (PBC) and patient satisfaction (PS) in health care institutions. Testing these above relationships via a mediation approach is novel and contributed to the current study on service quality.

A Framework for Performance Comparison among Major Electronic Health Record Systems

While nearly all hospitals have adopted electronic health record (EHR) systems, some are dissatisfied and considering replacement systems to better address unique organizational needs and priorities. With more than 4,000 certified health information technology products available, comparing the vast number of EHR options is complex. This study tested the hypothesis that various EHR systems demonstrate different financial and quality performance and presented a framework for comparison. Using a subscribed database containing US hospitals' observations from 2011 to 2016, we estimated an ordinary least squares regression model with robust standard errors and clustered by year. We regressed the selected finance and quality measures as dependent variables with the vendors' indicators as independent variables, with control variables. This study demonstrated an approach for analyzing performance data to help hospitals distinguish EHR systems on the basis of several organizational outcomes: return on assets, bed utilization rate, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) summary star rating, and value-based purchasing Total Performance Score. This framework will help EHR acquisition teams make informed decisions.

Study and implementation of a performance set of indicators for the nurse manager in a frailty hospital

INTRODUCTION

Hospitals are known to be the most complex entities to manage. In fact, the main problem in healthcare are the expensive needs with limited resources. During the last years the complexity of the nurse manager role has gradually changed from assistance to management. However, nowadays the methods for quantifying the nurse managers' skills and performance are not available. The aim of this study is to implement a method to assess and measure the skills of the nurse managers. An innovative indicator to globally evaluate the features, the professional skills and their performance is described.

METHODS

The authors started with an interview with the directors of all the nurses as the top experts of the nurse managers' technical skills. The purpose of this step was to understand what were the features of a valuable nurse manager. The methods identified three different aspects (qualitative, quantitative and relational) that were transformed in a single indicator. These parameters also enable to identify the strengths and weaknesses of each professional. An important implication of this score is the possible improvement of loss-making skills.

RESULTS

A total of 18 centres, with their nurse managers, were evaluated in this study. All the results confirmed the judgment of the Healthcare Professions Structure Manager.

CONCLUSIONS

This assessment method, validated with these tests, evaluated the nurse manager's ability to deal with personnel, resources and patients and to quantify his/her organizational and welfare performances. It is useful for planning actions that allow nurse managers to improve their skills.

Hospital Survey on Patient Safety Culture (HSPSC): a systematic review of the psychometric properties of 62 international studies

OBJECTIVE

To carry out a systematic review of the psychometric properties of international studies that have used the Hospital Survey on Patient Safety Culture (HSPSC).

DESIGN

Literature review and an analysis framework to review studies.

SETTING

Hospitals and other healthcare settings in North and South America, Europe, the Near East, the Middle East and the Far East.

DATA SOURCES

A total of 62 studies and 67 datasets made up of journal papers, book chapters and PhD theses were included in the review.

PRIMARY AND SECONDARY OUTCOME MEASURES

Psychometric properties (eg, internal consistency) and sample characteristics (eg, country of use, participant job roles and changes made to the original version of the HSPSC).

RESULTS

Just over half (52%) of the studies in our sample reported internal reliabilities lower than 0.7 for at least six HSPSC dimensions. The dimensions 'staffing', 'communication openness', 'non-punitive response to error', 'organisational learning' and 'overall perceptions of safety' resulted in low internal consistencies in a majority of studies. The outcomes from assessing construct validity were reported in 60% of the studies. Most studies took place in a hospital setting (84%); the majority of survey participants (62%) were drawn from nursing and technical staff. Forty-two per cent of the studies did not state what modifications, if any, were made to the original US version of the instrument.

CONCLUSIONS

While there is evidence of a growing worldwide trend in the use of the HSPSC, particularly within Europe and the Near/Middle East, our review underlines the need for caution in using the instrument. Future use of the HSPSC needs to be sensitive to the demands of care settings, the target population and other aspects of the national and local healthcare contexts. There is a need to develop guidelines covering procedures for using, adapting and translating the HSPSC, as well as reporting findings based on its use.

Spread tools: a systematic review of components, uptake, and effectiveness of quality improvement toolkits

BACKGROUND

The objective was to conduct a systematic review of toolkit evaluations intended to spread interventions to improve healthcare quality. We aimed to determine the components, uptake, and effectiveness of publicly available toolkits.

METHODS

We searched PubMed, CINAHL, and the Web of Science from 2005 to May 2018 for evaluations of publicly available toolkits, used a forward search of known toolkits, screened references, and contacted topic experts. Two independent reviewers screened publications for inclusion. One reviewer abstracted data and appraised the studies, checked by a second reviewer; reviewers resolved disagreements through discussion. Findings, summarized in comprehensive evidence tables and narrative synthesis addressed the uptake and utility, procedural and organizational outcomes, provider outcomes, and patient outcomes.

RESULTS

In total, 77 studies evaluating 72 toolkits met inclusion criteria. Toolkits addressed a variety of quality improvement approaches and focused on clinical topics such as weight management, fall prevention, vaccination, hospital-acquired infections, pain management, and patient safety. Most toolkits included introductory and implementation material (e.g., research summaries) and healthcare provider tools (e.g., care plans), and two-thirds included material for patients (e.g., information leaflets). Pre-post studies were most common (55%); 10% were single hospital evaluations and the number of participating staff ranged from 17 to 704. Uptake data were limited and toolkit uptake was highly variable. Studies generally indicated high satisfaction with toolkits, but the perceived usefulness of individual tools varied. Across studies, 57% reported on adherence to clinical procedures and toolkit effects were positive. Provider data were reported in 40% of studies but were primarily self-reported changes. Only 29% reported patient data and, overall, results from robust study designs are missing from the evidence base.

CONCLUSIONS

The review documents publicly available toolkits and their components. Available uptake data are limited but indicate variability. High satisfaction with toolkits can be achieved but the usefulness of individual tools may vary. The existing evidence base on the effectiveness of toolkits remains limited. While emerging evidence indicates positive effects on clinical processes, more research on toolkit value and what affects it is needed, including linking toolkits to objective provider behavior measures and patient outcomes.

TRIAL REGISTRATION

PROSPERO registration number: PROSPERO 2014: CRD42014013930 .

The impact mechanism of the controlling system in hospitals on quality of care: A study on clinical practice in China

BACKGROUND

Quality control system is one of the hospital information systems. The adoption of quality control system increases the work efficiency; however, to some extent, it also increases the workload for physicians.

OBJECTIVE

The purpose of this study is to investigate the impacts of the quality control system on quality of care (e.g., process and outcome performance).

METHODS

Our study collected physicians' behavior information from a large urban hospital in China. We constructed the fixed-effect model to examine the relationship between the quality control system adoption and quality of care.

RESULTS

Using the quality control system has a significant (p< 0.001) and negative effect on patients' stay length in the hospital (process performance). Furthermore, using the quality control system has a significant (p< 0.001) and positive effect on the trends of cure rate in the hospital (outcome performance). The coefficient of the dependent variable from the patients' stay length (process performance) is lower than the trends of cure rate (outcome performance).

CONCLUSIONS

The controlling system can improve medical quality even though it limits physician behavior to some extent. The controlling system improves both the process performance and outcome performance, and it brings more benefits to outcome performance rather than process performance which means the reflection of the new technology may have more evident on outcome variables.

Improving the quality of administration of the Surgical Safety Checklist: a mixed methods study in New Zealand hospitals

While the WHO Surgical Safety Checklist (the Checklist) can improve patient outcomes, variable administration can erode benefits. We sought to understand and improve how operating room (OR) staff use the Checklist. Our specific aims were to: determine if OR staff can discriminate between good and poor quality of Checklist administration using a validated audit tool (WHOBARS); to determine reliability and accuracy of WHOBARS self-ratings; determine the influence of demographic variables on ratings and explore OR staff attitudes to Checklist administration.

DESIGN

Mixed methods study using WHOBARS ratings of surgical cases by OR staff and two independent observers, thematic analysis of staff interviews.

PARTICIPANTS

OR staff in three New Zealand hospitals.

OUTCOME MEASURES

Reliability of WHOBARS for self-audit; staff attitudes to Checklist administration.

RESULTS

Analysis of scores (243 participants, 2 observers, 59 cases) supported tool reliability, with 87% of WHOBARS score variance attributable to differences in Checklist administration between cases. Self-ratings were significantly higher than observer ratings, with some differences between professional groups but error variance from all raters was less than 10%. Key interview themes (33 interviewees) were: Team culture and embedding the Checklist, Information transfer and obstacles, Raising concerns and 'A tick-box exercise'. Interviewees felt the Checklist could promote teamwork and a safety culture, particularly enabling speaking up. Senior staff were of key importance in setting the appropriate tone.

CONCLUSIONS

The WHOBARS tool could be useful for self-audit and quality improvement as OR staff can reliably discriminate between good and poor Checklist administration. OR staff self-ratings were lenient compared with external observers suggesting the value of external audit for benchmarking. Small differences between ratings from professional groups underpin the value of including all members of the team in scoring. We identified factors explaining staff perceptions of the Checklist that should inform quality improvement interventions.

[The prevention of psychosocial risks in hospital]

The best way to prevent psychosocial risk is to support the teams in terms of their dynamics and their difficulties. We need to take care of caregivers and other hospital staff. Management has an essential role to play to achieve this objective.

Development of a Balanced Scorecard for the monitoring of hospital performance in the countries of the Greater Maghreb. Systematic Review

BACKGROUND

Despite the wealth of knowledge on hospital performance, the majority of health facilities in the Maghreb don't have yet a Balanced Scorecard for its measurement.

OBJECTIVE

Elaborate, through a systematic review of the biomedical literature, a Balanced Scorecard for hospital performance, consisting of indicators of quality of care, highly recommended and suitable for the professional and managerial contexts of Greater Maghreb health systems.

MATERIALS AND METHODS

  This is a "systematic review" study on the topic of indicators to measure hospital performance. A documentary query combining the "Mesh Major Topic" for the two following descriptors "hospitals" and "health quality indicators", has been applied to the "Medline" database over a period of ten years (2004-2013). A focus group composed of clinicians, managers and representatives of civil society, was formed for the selection of a Balanced Scorecard of health facilities in Maghreb, composed of 20 systemic indicators.

RESULTS

An in-depth reading of 166 articles included in the study identified 926 quality of care assessment indicators. It is in one of three cases "systemic" indicators applicable to multi-purpose health facilities, and in one case of two, it is"process"indicators focused on a health care activity. Following the work of the focus group, a Balanced Scorecard for hospital performance was developed in a consensual manner. Among these indicators, 18 explored the "care" dimension (average length of stay, bed occupancy rates, turnover beds rates, occupational blood exposure rates, unplanned admission rates, discharge rates, prolonged admissions rates, antibiotic prescription rates, mortality rates, health care-associated infection rates, readmission rates, pressure ulcer rates, patient / staff ratio, staff turnover rates, maintenance of medical records, time sending of the report of hospitalization, staff burnout rates, patients' satisfaction rates), and two indicators were related to training functions and research (number of hours of staff training, publication rates).

CONCLUSION

The use, by health care facilities, of this Balanced Scorecard, based on the current data from the literature and adapted to the specific professional context of Greater Maghreb, would be a preliminary condition for the start-up of a strategy to measure and improve hospital performance in the Maghreb countries.

Hospital CIO Explains Blockchain Potential: An Interview with Beth Israel Deaconess Medical Center's John Halamka

Work is already underway to bring blockchain technology to the healthcare industry, and hospital administrators are trying to figure out what it can do for them, their clinicians, and their patients. That includes administrators at Beth Israel Deaconess Medical Center, a leading academic medical center located in Boston.

[EFQM Model in the hospitals of Madrid Regional Health Service: full self-assessment cycle]

AIM

To analyse a complete cycle of self-assessment using the European Foundation for Quality Management (EFQM) Model in the hospitals of the Madrid Health Service as regards the fundamental concepts of excellence (FCE).

METHOD

Descriptive study of the EFQM self-assessments of the entire public hospital sector identifying the methodology and the information on strengths, weaknesses, evidence, RADAR matrix (Results, Approach, Deployment, Assessment and Review), and the related FCEs in the enabling criteria and in the prioritised action plans.

RESULTS

The self-assessment was carried out in 85% of the hospitals (29/34), 86% of them required specific training (25/29), with a total of 329 teaching hours and 833 people in training. Multidisciplinary working groups were required in 83% of the hospitals (24/29), with 123 groups and 857 people involved. There were 3,686 strengths and 3,197 weaknesses identified: strengths and weaknesses were 78% (2,869) and 74% (2,355), respectively, for the enabling criteria and 22% (817) and 26% (842), respectively, for the results criteria. The mean score was 404 points with a median of 399. The main FCEs were managing with agility, developing organisational capability, sustaining outstanding results, creating a sustainable future, succeeding through the talent of people, and adding value for customers, with harnessing creativity/innovation and leading with vision, inspiration and integrity being placed in lower positions. A total of 113 action plans were identified for all the hospitals.

CONCLUSION

A complete EFQM self-assessment cycle of the entire public hospital sector of a Regional Health Service is provided, linking the analysis and action plans with the FCE of the EFQM Model.

Building a cloud-based data sharing model for the Saudi national registry for implantable medical devices: Results of a readiness assessment

BACKGROUND

Implantable medical device registries are used as a medium to conduct post-marketing surveillance. Little information is available on the development and implementation of implantable biomedical device registries in general and specifically in Saudi Arabia and the Middle East.

OBJECTIVES

This study presents the experiences of building an implantable medical device registry in the Kingdom of Saudi Arabia. The work specifically addresses the early experiences of the Saudi Food and Drug Authority in the planning and development of a data sharing model for the implementation of a medical device registry at different hospital sites within the country.

METHODS

A two-year case study in which 60 health professionals from 5 hospitals in Saudi Arabia participated in a readiness assessment survey. The readiness assessment examined system-level capacity, hospital workflow and operations, clinical staff-level engagement, and technological assessment as they relate to the implementation of the Implantable Medical Device Registry (IMDR). Both subjective and objective data were collected as part of the readiness assessment survey at each hospital site. Data was collected from participants either individually or as part of a group at each hospital site. Using Microsoft Excel, Microsoft Word, flip charts, and back-and-forth discussion, the data was descriptively summarized and synthesized to provide an overview of hospital readiness for IMDR implementation.

RESULTS

Results show that there are large differences among Saudi hospitals in terms of their readiness for IMDR implementation due to a variety of factors relating to differences in hospital-wide organizational systems, clinical practice, technological infrastructure, and data sharing capabilities. Each of the hospitals surveyed in this study had differences in how clinical biomedical implantation policies and procedures were utilized. Manual entry into the cloud-based IMDR was recommended as the most optimal data sharing model that would mitigate the differences between hospital readiness for IMDR implementation.

CONCLUSION

Registries play a major role in monitoring the effectiveness of implantable biomedical devices. National standardized policies, enforced regulations, and information technology infrastructure are needed to achieve this goal. Furthermore, due to differences in hospital readiness, building a cloud-based registry system through manual data entry into the IMDR was found to be the most appropriate data sharing model that can be implemented at the national level.

Self-assessment of health promoting Hospital's activities in the largest heart Hospital of Northwest Iran

BACKGROUND

Health Promoting Hospitals are among the major health promoters of the society. To acquire Health Promoting Hospital (HPH) status, a hospital must self-assess to know their inadequacies and then lay the foundation for improvements. This study has been performed with the aim of assessing readiness of the largest heart hospital of northwestern Iran regarding the HPH standards.

METHODS

This cross-sectional study was conducted through the participation of 270 administrative and clinical staff of the largest heart hospital of northwestern Iran. Data were gathered using self-assessment tool for health promoting hospitals including demographics and the HPH standards. HPH standards' dimensions were Management policy, Patient assessment, Patient information and intervention, Promoting a healthy workplace, and Continuity and cooperation. Analysis was performed by SPSS v. 16 with a significance level of 0.05.

RESULTS

The participants included clinical (67.4%) and administrative (32.6%) staff. Among the HPH standards, the lowest score belonged to the management policy (1.44 ± 0.53) and the highest one to the patient information and intervention (1.72 ± 0.47). The average score of compliance with the HPH standards was 1.60 ± 0.40 which shows moderate progress of the hospital towards the HPH standards.

CONCLUSION

Regarding the moderate situation of the hospital in HPH standards and the low score of the management policy, the studied hospital should enforce the standards, especially in the management policy. Also, there is a need for health promotion programs in all three levels of prevention with the participation of the staff and the patients as much as possible.

1,300 Days and Counting: A Risk Model Approach to Preventing Retained Foreign Objects (RFOs)

BACKGROUND

A retained foreign object (RFO) is a devastating surgical complication that typically results in additional surgeries, increased length of stay, and risk of infections and is potentially fatal. Memorial Sloan Kettering Cancer Center (MSKCC) convened a multidisciplinary task force to undertake an improvement initiative to reduce the frequency of RFO incidents.

METHODS

A needs assessment was undertaken using focus group interviews, review of past RFOs, and operating room (OR) observations, and a comprehensive intervention plan was initiated. Items at risk of retention were reclassified and new tracking sheets were developed. A probabilistic risk model was developed based on aviation industry methodology, an RFO risk projection, and the retention risk classification of surgical items. Training initiatives were launched to shift organizational culture and staff behaviors toward greater awareness of RFO risk and proactive prevention.

RESULTS

Since the implementation of our task force's recommendations on March 24, 2014, there have been no RFO incidents at our institution to this day. The last RFO occurred in August 2013-more than 1,300 days ago (as of March 28, 2017). The RFO incident frequency was reduced from 1.69 per year to a risk model estimate of 1 in 22 years. Ongoing training maintains the staff's behavioral changes as well as the improved OR and organizational culture.

CONCLUSION

Implementation of a multidisciplinary approach to preventing RFOs was successful at MSKCC. The use of an RFO risk model enabled the creation of a robust system for RFO prevention. Support from leadership, participation by all stakeholders, education, training, and cooperation from frontline staff are all important contributors to RFO prevention success.

[Sharing internal audit results with the Inspectorate; interviews on the possibility and preconditions]

OBJECTIVE

To study to what extent internal audit results of hospitals can be shared with external supervisors and the necessary preconditions for this.

DESIGN

Qualitative interview research.

METHOD

In 2013-2015, we interviewed 36 individuals from six hospitals: 12 department heads (all medical specialists), 10 department managers; five members of the Board of Directors; five members of the Supervisory Board and the four account-holding hospital inspectors. We also performed a focus group interview with six other hospital inspectors of the Health and Youth Care Inspectorate. The interview data were analysed thematically.

RESULTS

The interviewees pointed out that there is no coordination between internal and external supervision. They were in favour of sharing internal audit results with external supervisors to reduce the supervisory burden. They stated that internal audits give insight into quality improvements, how hospital directors govern quality and safety and the culture of improvement within healthcare provider teams. With this information, the Inspectorate can assess to what extent hospitals are learning organisations. The interviewees mentioned the following preconditions for sharing audit results: reliable and risk-based information about quality and safety, collected by expert, trained auditors and careful use of this information by the Inspectorate in order to maintain openness among audited healthcare providers.

CONCLUSION

Internal audit results can be shared conditionally with external supervisors like the Health and Youth Care Inspectorate. When internal audit results show that hospitals are open, learning and self-cleansing organisations, the Inspectorate can supervise the hospitals remotely and supervisory burden will probably be reduced.

Interactional Resources for Quality Improvement: Learning From Participants Through a Qualitative Study

BACKGROUND

Implementing quality improvement in hospitals requires a multifaceted commitment from leaders, including financial, material, and personnel resources. However, little is known about the interactional resources needed for project implementation. The aim of this analysis was to identify the types of interactional support hospital teams sought in a surgical quality improvement project.

METHODS

Hospital site visits were conducted using a combination of observations, interviews, and focus groups to explore the implementation of a surgical quality improvement project. Twenty-six site visits were conducted between October 2012 and August 2014 at a total of 16 hospitals that agreed to participate. All interviews were recorded, transcribed, and coded for themes using inductive analysis.

RESULTS

We interviewed 321 respondents and conducted an additional 28 focus groups. Respondents reported needing the following types of interactional support during implementation of quality improvement interventions: (1) a critical outside perspective on their implementation progress; (2) opportunities to learn from peers, especially around clinical innovations; and (3) external validation to help establish visibility for and commitment to the project.

CONCLUSIONS

Quality improvement in hospitals is both a clinical endeavor and a social endeavor. Our findings show that teams often desire interactional resources as they implement quality improvement initiatives. In-person site visits can provide these resources while also activating emotional energy for teams, which builds momentum and sustainability for quality improvement work.

IMPLICATIONS

Policymakers and quality improvement leaders will benefit from developing strategies to maximize interactional learning and feedback for quality improvement teams. Further research should investigate the most effective methods for meeting these needs.

Psychometric Evaluation of the Hospital Culture of Transitions Survey

BACKGROUND

Ineffective or inefficient transitions threaten patient safety, hinder communication, and worsen patient outcomes. The Hospital Culture of Transitions (H-CulT) survey was designed to assess a hospital's organizational culture related to within-hospital transitions in care involving patient movement. In this article, psychometric properties of the H-CulT survey were examined to assess and refine the hospital culture of transitions.

METHODS

A cross-sectional, multicenter, multidisciplinary correlational design and survey methods were used to examine the psychometric properties of the H-CulT survey. Exploratory factor analysis was used to quantify the accuracy of the previously identified structure. Specifically, the analysis involved the principal axis factor method with an oblique rotation, based on a polychoric correlation matrix.

RESULTS

A sample of 492 respondents from 13 diverse hospitals participated. Cronbach's alpha for the instrument was 0.88, indicating strong internal consistency. Seven subscales emerged and were labeled: Hospital Leadership, Unit Leadership, My Unit's Culture, Other Units' Culture, Busy Workload, Priority of Patient Care, and Use of Data. Correlations between subscales ranged from 0.07 to 0.52, providing evidence that the subscales did not measure the same construct. Subscale correlations with the total score were near or above 0.50 (p <0.001). Use of a factor-loading cutoff of 0.40 resulted in the elimination of 12 items because of weak associations with the topic.

CONCLUSION

The H-CulT is a psychometrically sound and practical survey for assessing hospital culture related to patient flow during transitions in care. Survey results may prompt quality improvement interventions that enhance in-hospital transitions and improve staff satisfaction and patient satisfaction with care.

Medical leadership, a systematic narrative review: do hospitals and healthcare organisations perform better when led by doctors?

INTRODUCTION

Despite common assumptions that doctors are well placed to lead hospitals and healthcare organisations, the peer-reviewed literature contains little evidence on the performance of doctors in leadership roles in comparison with that of non-medical managers.

OBJECTIVES

To determine whether there is an association between the leader's medical background and management performance in terms of organisational performance or patient outcomes.

METHODS

We searched for peer-reviewed, English language studies using Medline, Embase and Emerald Management between 2005 and 2017. We included quantitative, qualitative and mixed method empirical studies on the performance of senior healthcare managers where participants were described as doctors or leaders and where comparative performance data were provided on non-medical leaders. Studies without full text available, or no organisational, leadership behaviour or patient measures, were excluded.

RESULTS

The search, conducted in Medline (n=3395), Embase (n=1913) and Emerald Management (n=454) databases, yielded 3926 entries. After the application of inclusion and exclusion criteria, 16 studies remained. Twelve studies found that there were positive differences between medical and non-medical leaders, and eight studies correlated those findings with hospital performance or patient outcomes. Six studies examined the composition of boards of directors; otherwise, there were few common areas of investigation. Five inter-related themes emerged from a narrative analysis: the impact of medical leadership on outcomes; doctors on boards; contribution of qualifications and experience; the medical leader as an individual or part of a team and doctors transitioning into the medical leadership role.

DISCUSSION AND CONCLUSION

A modest body of evidence supports the importance of including doctors on organisational governing boards. Despite many published articles on the topic of whether hospitals and healthcare organisations perform better when led by doctors, there were few empirical studies that directly compared the performance of medical and non-medical managers. This is an under-researched area that requires further funding and focus.

Diagnosing and Resolving Conflict Created by Strategic Plans: Where Outreach Strategies and Execution Meet at an Academic Health Center

The imperative for strategic change at academic health centers has never been stronger. Underpinning the success of strategic change is an effective process to implement a strategy. Healthcare organizations, however, often fail to execute on strategy because they do not activate the requisite capabilities and management processes. The University of Kentucky HealthCare recently defined its 2020 strategic plan to adapt to emerging market conditions. The authors outline the strategic importance of strengthening partnership networks and the initial challenges faced in executing their strategy. The findings are a case study in how one academic health center has approached strategy implementation.

Developing an evaluation framework for clinical redesign programs: lessons learnt

Purpose The purpose of this paper is to present lessons learnt through the development of an evaluation framework for a clinical redesign programme - the aim of which was to improve the patient journey through improved discharge practices within an Australian public hospital. Design/methodology/approach The development of the evaluation framework involved three stages - namely, the analysis of secondary data relating to the discharge planning pathway; the analysis of primary data including field-notes and interview transcripts on hospital processes; and the triangulation of these data sets to devise the framework. The evaluation framework ensured that resource use, process management, patient satisfaction, and staff well-being and productivity were each connected with measures, targets, and the aim of clinical redesign programme. Findings The application of business process management and a balanced scorecard enabled a different way of framing the evaluation, ensuring measurable outcomes were connected to inputs and outputs. Lessons learnt include: first, the importance of mixed-methods research to devise the framework and evaluate the redesigned processes; second, the need for appropriate tools and resources to adequately capture change across the different domains of the redesign programme; and third, the value of developing and applying an evaluative framework progressively. Research limitations/implications The evaluation framework is limited by its retrospective application to a clinical process redesign programme. Originality/value This research supports benchmarking with national and international practices in relation to best practice healthcare redesign processes. Additionally, it provides a theoretical contribution on evaluating health services improvement and redesign initiatives.

Development and Validation of a Cross-Country Hospital Patient Quality of Care Assessment Tool in Europe

BACKGROUND

Patient perceptions of quality of care (QoC) are directly linked with patient safety and clinical effectiveness. We need patient-designed QoC instruments that work across languages and countries to optimise studies across systems in this area. Few QoC measurement tools exist that assess all aspects of QoC from the patient perspective. This paper describes the development and validation of a comprehensive measure to assess patient perceptions of QoC that incorporates technical and interpersonal aspects of care and is grounded in the established Institute of Medicine (IOM) QoC framework.

DESIGN

We conducted a multi-country cross-sectional study.

METHODS

Following a literature review and patient focus groups, an expert panel generated questionnaire items. Following a pilot study, item numbers were reduced. The final questionnaire consisted of three sections: demographics, perceived QoC and one open-ended question. Data was collected from patients (n = 531) discharged from hospitals across seven countries in South East Europe (languages: Turkish, Greek, Portuguese, Romanian, Croatian, Macedonian and Bulgarian). Reliability and validity of the measure were assessed.

RESULTS

Confirmatory factor analysis was used to compare various factor models of patient-perceived QoC. Good model fit was demonstrated for a two-factor model: communication and interpersonal care, and hospital facilities.

CONCLUSIONS

The ORCAB (Improving quality and safety in the hospital: The link between organisational culture, burnout and quality of care) Patient QoC questionnaire has been collaboratively and exhaustively developed between healthcare professionals and patients. It enables patient QoC data to be assessed in the context of the IOM pillars of quality, considering both technical and interpersonal dimensions of care. It represents an important first step in including the patient perspective.

Re-thinking barriers to organizational change in public hospitals

Public hospitals are well known to be difficult to reform. This paper provides a comprehensive six-part analytic framework that can help policymakers and managers better shape their organizational and institutional behavior. The paper first describes three separate structural characteristics which, together, inhibit effective problem description and policy design for public hospitals. These three structural constraints are i) the dysfunctional characteristics found in most organizations, ii) the particular dysfunctions of professional health sector organizations, and iii) the additional dysfunctional dimensions of politically managed organizations. While the problems in each of these three dimensions of public hospital organization are well-known, and the first two dimensions clearly affect private as well as publicly run hospitals, insufficient attention has been paid to the combined impact of all three factors in making public hospitals particularly difficult to manage and steer. Further, these three structural dimensions interact in an institutional environment defined by three restrictive context limitations, again two of which also affect private hospitals but all three of which compound the management dilemmas in public hospitals. The first contextual limitation is the inherent complexity of delivering high quality, safe, and affordable modern inpatient care in a hospital setting. The second contextual limitation is a set of specific market failures in public hospitals, which limit the scope of the standard financial incentives and reform measures. The third and last contextual limitation is the unique problem of generalized and localized anxiety, which accompanies the delivery of medical services, and which suffuses decision-making on the part of patients, medical staff, hospital management, and political actors alike. This combination of six institutional characteristics - three structural dimensions and three contextual dimensions - can help explain why public hospitals are different in character from other parts of the public sector, and the scale of the challenge they present to political decision-makers.

Studer Group® ' s evidence-based leadership initiatives

PURPOSE

The purpose of this paper is to analyze the implementation of an organizational change initiative--Studer Group®'s Evidence-Based Leadership (EBL)--in two large, US health systems by comparing and contrasting the factors associated with successful implementation and sustainability of the EBL initiative.

DESIGN/METHODOLOGY/APPROACH

This comparative case study assesses the responses to two pairs of open-ended questions during in-depth qualitative interviews of leaders and managers at both health systems. Qualitative content analysis was employed to identify major themes.

FINDINGS

Three themes associated with success and sustainability of EBL emerged at both health systems: leadership; culture; and organizational processes. The theme most frequently identified for both success and sustainability of EBL was culture. In contrast, there was a significant decline in salience of the leadership theme as attention shifts from success in implementation of EBL to sustaining EBL long term. Within the culture theme, accountability, and buy-in were most often cited by interviewees as success factors, while sense of accountability, buy-in, and communication were the most reported factors for sustainability.

ORIGINALITY/VALUE

Cultural factors, such as accountability, staff support, and communication are driving forces of success and sustainability of EBL across both health systems. Leadership, a critical factor in several stages of implementation, appears to be less salient as among factors identified as important to longer term sustainability of EBL.

A Study of the Readiness of Hospitals for Implementation of High Reliability Organizations Model in Tehran University of Medical Sciences

Creating a safe of health care system requires the establishment of High Reliability Organizations (HROs), which reduces errors, and increases the level of safety in hospitals. This model focuses on improving reliability through higher process design, building a culture of accreditation, and leveraging human factors. The present study intends to determine the readiness of hospitals for the establishment of HROs model in Tehran University of Medical Sciences from the viewpoint of managers of these hospitals. This is a descriptive-analytical study carried out in 2013-2014. The research population consists of 105 senior and middle managers of 15 hospitals of Tehran University of Medical Sciences. The data collection tool was a 55-question researcher-made questionnaire, included six elements of HROs to assess the level of readiness for establishing HROS model from managers' point of view. The validity of the questionnaire was calculated through the content validity method using 10 experts in the area of hospitals' accreditation, and its reliability was calculated through test-retest method with a correlation coefficient of 0.90. The response rate was 90 percent. The Likert scale was used for the questions, and data analysis was conducted through SPSS version 21 Descriptive statistics was presented via tables and normal distributions of data and means. Analytical methods, including t-test, Mann-Whitney, Spearman, and Kruskal-Wallis, were used for presenting inferential statistics. The study showed that from the viewpoint of senior and middle managers of the hospitals considered in this study, these hospitals are indeed ready for acceptance and establishment of HROs model. A significant relationship was showed between HROs model and its elements with demographic details of managers like their age, work experience, management experience, and level of management. Although the studied hospitals, as viewed by their managers, are capable of attaining the goals of HROs, it seems there are a lot of challenges in this way. Therefore, it is suggested that a detailed audit is conducted among hospitals' current status regarding different characteristics of HROs, and workshops are held for medical and non-medical employees and managers of hospitals as an influencing factor; and a re-assessment process afterward, can help moving the hospitals from their current position towards an HROs culture.

Where is the pilot? The changing shapes of governance in the European hospital sector

Hospital governance refers to the complex of checks and balances that determine how decisions are made within the top structures of hospitals. This article explores the essentials of the concept by analysing the root notion of governance and comparing it with applications in other sectors. Recent developments that put pressure on the decision-making system within hospitals are outlined. Examples from the UK, France and the Netherlands are presented.

Based on an evaluation of the current state of affairs, a research framework is developed, focusing on the determinants of governance configurations within the national healthcare systems and the wider legal and socio-economic context, as well as on the impact of governance configurations on the efficiency of the governing bodies and overall hospital performance.

The article concludes with a preview of the European Hospital Governance Project, which follows the outlines of the described research framework. New techniques of data mining that are used in this project are explained by means of a real data example.

Determining Hospital Performance Based on Rank Ordering: Is It Appropriate?

An increasing number of "pay for performance" initiatives for hospitals and physicians ascribe performance by ranking hospitals or physicians on quality of care measures. Payment is subsequently based on where a hospital or physician ranks among peers. This study examines the variability of ranking hospitals on quality of care measures and its impact on comparing hospital performance. Variability in the ranks of 3 quality of care measures was examined: discharge instruction for congestive heart failure, use of beta-blockers at discharge for heart attack, and timing of initial antibiotic therapy within 4 hours of admission to the hospital for pneumonia. The data are available on the Centers for Medicare and Medicaid Services Web site as part of the Hospital Quality Alliance project. We found that considerable uncertainty exists in ranking of hospitals on these measures, which calls into question the use of rank ordering as a determinant of performance.

It Isn't Just about Choice: The Potential of a Public Performance Report to Affect the Public Image of Hospitals

Can a well-designed public performance report affect the public image of hospitals? Using a pre/postdesign and telephone interviews, consumer views and reports of their use of public hospital report are examined. The findings show that the report did influence consumer views about the quality of individual hospitals in the community 2 to 4 months after the release of the report.

Toward the Creation of an Institutional Logic for the Management of Hospitals: Efficiency in the Early Nineteen Hundreds

This research focuses on the creation of an institutional logic—efficiency—and on its organizing principles of standardization and business practices through a study of the American Hospital Association and its publication, the Modern Hospital. In the early years of the 20th century, efficiency began to emerge as a first institutional logic for the management of hospitals. The term was defined broadly, encompassing not only economy but also quality and breadth of services, as well as access to care. This early emphasis on efficiency foreshadowed three issues that affect health policy and hospital management to this day: the pressure on hospitals to introduce new technology while containing cost, the assumption that hospitals should act like businesses, and the practice of offering large hospitals as the model for other providers.