Dissertations / Theses on the topic 'Hospital Administration/*methods'

Military health care organizations need competent frontline managers with knowledge and skills to manage health care complexity and ensure evidence-based practice. With systematic, planned turn over of military managers, more civilian managers are needed to fill permanent positions in military hospitals. The purpose of this project was to provide a better understanding of the competencies perceived by nurse managers at a military medical center and whether they differed by military or civilian status. The American Organization of Nurse Executives competency model and framework provided the theoretical framework for the project. The design was nonexperimental, with an observational, descriptive, cross-sectional approach. The Chase Nurse Manager Competency Instrument was used to collect data from 53 military and civilian nurse managers who ranked the top 10 competencies needed for effective leadership. The top competencies chosen by the managers were the knowledge and ability to use effective communication, decision making, problem solving, nursing practice standards, time management, and effective staffing strategies. Using t test statistics, only minimal differences were identified between military and civilian nurse managers' perceptions of the top competencies, which allows the medical center to create one integrated leadership curriculum to assist in the development of a competent, unified leadership team of civilian and military managers. Social change to improve patient outcomes can occur within military health care organizations by assessing and developing leadership competencies in all nurse managers to ensure reliable cultures of safety, quality, and value-based productivity within their military hospital environments.

Relaying information from a Chief Communications Officer (CIO), or centralized communications departments to hospital employees is not always efficient or effective. Employees may not be informed of important changes to department protocols or hospital policies. The purpose of the study was to determine the most efficient and effective forms of internal communications in the hospital setting. A total of 83 surveys were mailed to communication officers working in Tennessee hospitals in and east of Nashville. Sixteen communication officers responded. This low response rate may be attributed to poor designation of communication responsibilities and an abdication of responsibilities to an off campus (corporate) source. One significant difference was found regarding the preference of supervisor contact to relay feedback in the age groups of 31-40 and 51-60. Those 31-40 were less likely to prefer direct supervisor contact as their favored communications channel as opposed to 51-60 year olds who favored this method.

Employee turnover is costly in service-intensive organizations where employee-customer interactions directly affect the organization's success. The purpose of this multiple case study was to identify strategies community hospital leaders use to reduce frontline support employee turnover. The study population consisted of leaders of a community hospital in southeast Louisiana. The conceptual framework for this study is Kahn's model of employee engagement. Semistructured interviews were conducted with eight hospital leaders in southeast Louisiana who were selected through census sampling. Interview transcripts were analyzed and coded following Yin's case study analysis process. Methodological triangulation allowed for a comparison of the findings of the interviews with information derived from exit interviews and employee engagement survey results. Four themes emerged from the interviews and document review: leadership, hiring and onboarding strategies, pay and compensation, and organizational-related factors. Reducing turnover among frontline hospital support employees can positively affect the quality of care provided to patients, and improve the level of service provided by the hospital to the community it serves. Beyond increasing organizational efficiency, the findings of this study can contribute to social change benefits for employees as continued employment allows individuals to provide for themselves and their families.

Hospital performance metrics are an indicator of leadership performance. However, there is inadequate research on whether physician or nonphysician chief executive officers (CEOs) perform better in the U.S. hospitals. The purpose of this study was to examine which type of leaders is better. Leadership trait, situational leadership, and leadership behavior theories constituted the theoretical foundation. The key research question examined the relationship between a hospital’s outcomes, which in this study, included hospital net income, patient experience ratings, and mortality rates, and the type of CEO in that hospital: physician or non-physician. A quantitative, causal comparative design was used to answer this question. Three hypotheses were tested using multivariate analysis of variance. The dependent variable was hospital outcomes: hospital net income, patient experience ratings, and mortality rates. The independent variable was the type of hospital CEO: physician and nonphysician. Datasets from 2014-2015 were used, which were publically available on the websites of U.S. based hospitals, research organizations, and journals. A sample of 60 hospitals was drawn from U.S. non-federal, short-term, acute care hospitals, based on number of staffed beds (n = 60). No significant differences were found between nonphysician and physician CEOs on hospitals’ net income (p = .911), patient experience ratings (p = .166), or mortality rates ( p = .636). Thus, the null hypotheses were retained. Findings suggest that physician and non-physician CEOs may produce similar outcomes in the hospitals they lead. Based on these findings, hospital boards can view CEO applicants equally when considering whom to hire and understanding U.S. hospital leadership.

This project study addressed the problem of frequent turnover of nurse managers at a Northeastern community hospital. The lack of retention of nurse managers has led to attenuated support for the nursing staff who continued to hold the front line in patient care. The purpose of this qualitative bounded case study was to explore nurse managers' experiences with turnover in order to identify strategies for enhancing retention. Work empowerment and servant leadership theories served as the frameworks for the study. Research questions focused on nurse managers' perceptions of empowerment and servant leadership characteristics that were important in decisions to assume and remain in a management/leadership role. Data collection included audio-recorded interviews with seven current or past full-time nurse managers, and observation of three of the participants at a leadership meeting. Interview transcripts were open coded and thematically analyzed. Observation data were categorized according to empowerment and servant leadership characteristics. Five themes were identified that related to research questions: struggling in management transition, seeking opportunity for transformation, being committed but powerless, embarking unprepared on an unplanned journey, and having the presence to lead others by serving. The findings of this study guided development of a 12-month program for new nurse managers that integrated characteristics of servant leadership to empower leaders and others. These contributions may promote positive social change by preparing new nurse managers for their role and developing their skills to become successful nurse managers.

As sondas de alimentação constituem uma via alternativa para a administração de medicamentos em pacientes cuja situação clínica impede a utilização da via oral. É sabido que a utilização de medicamentos nesses pacientes requer cuidados especiais, tanto na seleção da forma farmacêutica quanto no preparo e na administração dos mesmos. Para se conhecer as características dos pacientes internados usando sondas de nutrição enteral (SNE) no Hospital de Clínicas de Porto Alegre, bem como os medicamentos prescritos e utilizados via SNE, foram analisados 315 prontuários médicos na primeira etapa do estudo. A maioria dos pacientes era formada por adultos (51%) do sexo masculino (59%), com diagnóstico de câncer (32%) ou doença neurológica (21%). A média de uso da SNE foi de 15 dias. Noventa e cinco por cento dos pacientes utilizaram algum fármaco na forma farmacêutica sólida, principalmente comprimidos (72%), cápsulas (12%) e drágeas (9%). A taxa de troca de sonda correspondeu a 32%. Na segunda etapa do estudo, auxiliares de enfermagem foram observados em suas rotinas de trabalho no hospital, visando analisar o processo de preparo e administração dos medicamentos aos pacientes. Foi observado que esses profissionais não utilizavam técnicas adequadas nos momentos de preparo dos medicamentos e administração dos mesmos aos pacientes com SNE. A alta incidência do uso de formas farmacêuticas sólidas, o número de medicamentos prescritos, os dias de uso da sonda e a diversidade de métodos de trabalho utilizados no momento da derivação, diluição e administração dos medicamentos pelos auxiliares de enfermagem mostram que, apesar da ampla informação disponível na literatura sobre o uso de medicamentos em pacientes com SNE, a prática clínica está sendo realizada de modo inconsistente em relação aos dados disponíveis, trazendo assim dificuldades para o tratamento dos pacientes.
The tube feeding constitutes an alternative way for patients with a clinic situation that the oral way is hindered. It is known that these patients require particular methods in the drug utilization process, even in the selection of the pharmaceutical form of the medicine as in the preparation and administration of these drugs. To understand the patient characteristics using enteral tube feeding (ETF) in the Hospital de Clínicas de Porto Alegre as well as the drugs prescribed by ETF way, the medical records of 315 interned patients were analyzed in the first stage of the research. The majority of patients was adults (51%) of male gender (59%) with cancer (32%) or neurological disease (21%) diagnostic. The ETF using average was 15 days. Ninety five per cent of the analyzed patients used some kind of drug in the solid pharmaceutical form, mainly tablets (72%), capsule (12%) and coated tablet (9%). The ETF using average was 15 days. Ninety five per cent of the analyzed patients used some kind of drug in the solid pharmaceutical form, mainly tablets (72%), capsule (12%) and coated tablet (9%). The average of ETF changing was 32%. In the second stage of this research, nurse assistants were observed in their routine of working in the hospital to analyze the process of preparation and administration of the drugs to patients with ETF. It was observed that the nurses assistant neither use proper techniques in the moment of the drugs preparation nor in the administration of these drugs to patients with ETF. The high incidence of using solid pharmaceutical forms; the number of drugs prescribed, the using days of ETF and the diversity of working methods used in the derivation, dilution and administration moment by the nurse assistants showed that despite good amount of information in the literature about the administration of drugs in patients using ETF, the clinical practice is being carried out in a way that is inconsistent with the data available, causing difficulties for the patient treatment.

Over 80 rural hospitals have closed in the United States since 2010, representing about half of all hospital closures during this period, and another 600-700 rural hospitals are at risk of closing shortly. The purpose of this qualitative exploratory multiple case study, which was based on transformational leadership and diffusion of innovation theories, was to gain a common understanding of financial problems and operational inefficiencies that may be impacting rural hospital leaders in the state of Texas. Data collection involved semi-structured interviews with 4 senior healthcare leaders from 3 separate regions in Texas. Data analysis included compiling, sorting, fragmenting, and reassembling of the data into 19 common themes. The 4 most common themes included poor payer mix and uninsured population, inconsistency with evidence-based measures, costs of providing care exceeding reimbursement, and the movement of inpatient procedures to outpatient. The study findings may help advance the practice of leadership in both rural and urban healthcare. This study may contribute to positive social change by creating awareness of how rural hospitals are in danger of closures, and how these closures can affect urban hospitals and overall quality of life for rural Americans.

The debate about healthcare reform revolves around a triple aim of improving the health of populations, improving the patient experience, and reducing the cost of care. A major tool discussed in this debate has been the adoption of electronic health record (EHR) systems to record and guide care delivery. Due to low adoption rates and limited examples of success, the problem was a lack of understanding by healthcare organizations of how the EHR fundamentally changes an organization through the interactions of people, processes, and technology over time. The purpose of this case study was to explore the people, processes, and technology factors that change as a result of an EHR implementation. Complexity theory was used as the lens to evaluate the effects of the EHR on the holistic system of healthcare. Data were collected using semistructured interviews and observations of physicians, nurses, and administrators, as well as document reviews of organizational documents related to the EHR. Data were analyzed using open coding to identify themes and patterns of usage that redesign or restructure institutional resources. The results of this study demonstrated positive changes in the interactions of healthcare providers with increasing collaboration on process changes and reliance on EHR for communication. These findings may positively affect government policy and the organizational approach to adoption and ongoing use of EHRs to create organizational change beyond the implementation of such systems, thus benefiting both health care employees and patients.

Abstract Amidst the worst disaster to impact a major U.S. city in one hundred years, New Orleans’ main trauma and safety net medical center, the Reverend Avery C. Alexander Charity Hospital, was permanently closed. Charity’s administrative operator, Louisiana State University (LSU), ordered an end to its attempted reopening by its workers and U.S. military personnel in the weeks following the August 29, 2005 storm. Drawing upon rigorous review of literature and an exhaustive analysis of primary and secondary data, this case study found that Charity Hospital was closed as a result of disaster capitalism. LSU, backed by Louisiana state officials, took advantage of the mass internal displacement of New Orleans’ populace in the aftermath of Hurricane Katrina in an attempt to abandon Charity Hospital’s iconic but neglected facility and to supplant its original safety net mission serving the poor and uninsured for its neoliberal transformation to favor LSU’s academic medical enterprise.

Hospital electronic prescribing and medicines administration (HEPMA) system implementation is advocated by national e-health strategies to produce patient safety benefits. No previous study has evaluated HEPMA implementation impacting discharge information communication or assessed discharge prescribing errors. The aims were to assess HEPMA system implementation impact on medicines related discharge communication and prescribing errors, and to gain the perspective of hospital staff involved in the communication process. Following a narrative literature review, a convergent parallel mixed methods was selected, consisting of interpretative phenomenology and experimental before and after study design. Face-to-face semi-structured interviews of a purposive sample of hospital staff involved in discharge information communication were undertaken using the Theoretical Domains Framework (TDF) as a theoretical lens. In addition a quasi experimental retrospective case notes review, both before and after implementation was completed. Pre-implementation, staff described patient safety concerns with traditional discharge communication processes. They cited frequent prescribing errors, and associated adverse events and hospital readmissions. HEPMA implementation was anticipated to improve patient safety and create more efficient discharge communication. Post-implementation staff articulated improved information quality highlighting fewer omitted medicines and improved patient safety. TDF findings of behaviour change highlighted behavioural alteration including adaption of processes to improve discharge quality. Quantitative data collection (n=159 before and after) confirmed qualitative findings; increased compliance with discharge documentation, for example staff grade recorded increased from 40% to 100% (p<0.001). Prescribing error quantity and severity were reduced; errors reduced from 99% to 23% of patients (p<0.001); only 22% of identified errors likely to cause harm. Omitted medicines decreased from 42% to 11% of patients (p<0.001). The findings contribute original knowledge concerning HEPMA implementation impacting discharge information communication and prescribing errors. The study demonstrated reduced prescribing errors and improved patient safety which potentially impacted health and wellbeing. Qualitative findings and quantitative results are transferable and applicable to other NHS organisations or similar healthcare settings.

OBJETIVOS: O estudo explorou diferentes métodos de séries temporais visando desenvolver um modelo para a previsão do volume diário de pacientes no Pronto Socorro do Instituto Central do Hospital das Clínicas da Faculdade de Medicina da USP. MÉTODOS: Foram explorados seis diferentes modelos para previsão do número diário de pacientes no pronto socorro de acordo com algumas variáveis relacionadas ao calendário e à temperatura média diária. Para a construção dos modelos, utilizou-se a contagem diária de pacientes atendidos no pronto socorro entre 1° de janeiro de 2008 a 31 de dezembro de 2010. Os primeiros 33 meses do banco de dados foram utilizados para o desenvolvimento e ajuste dos modelos, e os últimos três meses foram utilizados para comparação dos resultados obtidos em termos da acurácia de previsão. A acurácia foi medida a partir do erro médio percentual absoluto. Os modelos foram desenvolvidos utilizando-se três diferentes métodos: modelos lineares generalizados, equações de estimação generalizadas e modelos sazonais autorregressivos integrados de média móvel (SARIMA). Para cada método, foram testados modelos que incluíram termos para controlar o efeito da temperatura média diária e modelos que não incluíram esse controle. RESULTADOS: Foram atendidos, em média, 389 pacientes diariamente no pronto socorro, número que variou entre 166 e 613. Observou-se uma sazonalidade semanal marcante na distribuição do volume de pacientes ao longo do tempo, com maior número de pacientes às segundas feiras e tendência linear decrescente ao longo da semana. Não foi observada variação significante no volume de pacientes de acordo com os meses do ano. Os modelos lineares generalizados e equações de estimação generalizada resultaram em melhor acurácia de previsão que os modelos SARIMA. No primeiro horizonte de previsão (outubro), por exemplo, os erros médios percentuais absolutos dos modelos lineares generalizados e de equação de estimação generalizada foram ambos 11,5% e 10,8% (modelos que incluíram e que não incluíram termo para controlar o efeito da temperatura, respectivamente), enquanto os erros médios percentuais absolutos para os modelos SARIMA foram 12,8% e 11,7% (modelos que incluíram e que não incluíram termo para controlar o efeito da temperatura, respectivamente). Para todos os modelos, incluir termos para controlar o efeito da temperatura média diária não resultou em melhor acurácia de previsão. A previsão a curto prazo (7 dias) em geral resultou em maior acurácia do que a previsão a longo prazo (30 dias). CONCLUSÕES: Este estudo indica que métodos de séries temporais podem ser aplicados na rotina do serviço de pronto socorro para a previsão do provável volume diário de pacientes no serviço. A previsão realizada para o curto prazo tem boa acurácia e pode ser incorporada à rotina do serviço, de modo a subsidiar seu planejamento e colaborar com a adequação de recursos materiais e humanos. Os modelos de previsão baseados unicamente em variáveis relacionadas ao calendário foram capazes de prever a variação no volume diário de pacientes, e os métodos aqui aplicados podem ser automatizados para gerar informações com antecedência suficiente para decisões de planejamento do serviço de pronto socorro
OBJECTIVES: This study aims to develop different models to forecast the daily number of patients seeking emergency department (ED) care in a general hospital according to calendar variables and ambient temperature readings and to compare the models in terms of forecasting accuracy. METHODS: We developed and tested six different models of ED patient visits using total daily counts of patient visits to the Instituto Central do Hospital das Clínicas Emergency Department from January 1, 2008 to December 31, 2010. We used the first 33 months of the dataset to develop the ED patient visits forecasting models (the training set), leaving the last 3 months to measure each model\'s forecasting accuracy by the mean absolute percentage error. Forecasting models were developed using 3 different time series analysis methods: generalized linear models, generalized estimating equations and seasonal autoregressive integrated moving average (SARIMA). For each method, we explored models with and without the effect of mean daily temperature as a predictive variable. RESULTS: Daily mean number of ED visits was 389, ranging from 166 to 613. Data showed a weekly seasonal distribution, with highest patient volumes on Mondays and lowest patient volumes on weekends. There was little variation in daily visits by month. Generalized linear models and generalized estimating equation models showed better forecasting accuracy than SARIMA models. For instance, the mean absolute percentage errors from generalized linear models and generalized estimating equations models at the first month of forecasting (October, 2012), were 11.5% and 10.8% (models with and without control for the temperature effect, respectively), while the mean absolute percentage errors from SARIMA models were 12.8% and 11.7% (models with and without control for the temperature effect, respectively). For all models, controlling for the effect of temperature resulted in worse or similar forecasting ability than models with calendar variables alone, and forecasting accuracy was better for the short term horizon (7 days in advance) than for the longer term (30 days in advance). CONCLUSIONS: Our study indicates that time series models can be developed to provide forecasts of daily ED patient visits, and forecasting ability was dependent on the type of model employed and the length of the time-horizon being predicted. In our setting, generalized linear models and generalized estimating equation models showed better accuracy, and including information about ambient temperature in the models did not improve forecasting accuracy. Forecasting models based on calendar variables alone did in general detect patterns of daily variability in ED volume, and thus could be used for developing an automated system for better planning of personnel resources

The Patient Protection and Affordable Care Act, which promoted quality of care, started the transformation of healthcare systems in the United States. The purpose of this qualitative multiple case study was to explore clinical practice innovation strategies used by hospital middle managers to improve quality of care and profitability. Pettigrew's theory was the conceptual framework for this study. Participants were 8 middle managers from 2 high-performing hospitals in the southwestern region of the United States. Data were collected from semistructured interviews, personal notes, and review of the hospital's publicly reported documents and literature. Member checking and methodological triangulation increased the credibility, validity, reliability, and trustworthiness of the study findings. Content and thematic data analysis provided the basis for coding the findings. Data analysis resulted in the emergence of 4 themes: organizational culture, leadership, systematic approach to management by objectives, and staff engagement. The findings showed the interactions among internal context, content, and process constructs of Pettigrew's theory as relevant to clinical practice innovation strategies for improving the quality of care and organizational profitability. The implications for positive social change include the potential for hospital middle managers to implement innovative strategies to improve patients' quality of care and save lives and the overall health and wellness of individuals in the communities they serve.

Healthcare spending in the United States has continued to rise with annual healthcare cost of $3.8 trillion in 2014. While costs and the population continue to rise, resources continue to dwindle. Consequently, Congress has imposed various price controls and healthcare reform measures over the past 20 years, including the recent Patient Protection and Affordable Care Act (PPACA), which aims to decrease spending while enhancing quality and safety of care delivery. As a result of the implementation of the PPACA, 34 million additional Americans may be eligible for healthcare in a system already needing additional resources, increased access to care, and strategies to offset increasing operational and fiscal challenges. The purpose of this descriptive study was to explore what strategies and changes 10 executive leaders of the nonprofit hospitals in Maryland used to address the operational and fiscal challenges of the PPACA. The conceptual framework for this study was built upon the general systems theory. The data were collected through semistructured interviews, cataloged and coded, analyzed using a modified van Kaam method, and reviewed by participants as part of member checking process. The findings revealed 3 emergent themes: investment in IT resources to support an EMR system, strategies to address healthcare workforce challenges, and strategies for sustainability for managed care outpatient services and patient safety and quality of care. The findings impact social change by presenting policies and processes that medical professionals can use to support local and national health care reform.

Members of the healthcare industry have not fully understood organizational climate factors that enhance organizational citizenship behaviors (OCBs). This lack of understanding can result in negative patient outcomes. The purpose of this cross-sectional quantitative study was to examine the relationships between organizational climate factors and OCBs of employees at hospitals via person-organization fit theory. More, specifically, the purpose of this research was to explore (a) the relationships between organizational climate variables (i.e., welfare, autonomy, involvement, effort, training, integration, and supervisory support) and OCBs (n = 218), (b) differences in OCB scores between hospital leaders (n = 72) and followers (n = 146), and (c) differences in OCB scores between clinical (n = 167) and nonclinical (n = 51) hospital employees. The data were collected from alumni of healthcare degree programs via an anonymous online questionnaire. Results indicated that effort and integration were statistically significant predictors of OCBs. Independent t-test results indicated no significant differences in OCB scores between leaders and followers and between clinical and nonclinical employees. To increase OCBs, a cultural shift is required that includes rewarding actions that align with organizational goals and engaging in interdepartmental collaboration. Implications include increased organizational sustainability; more efficient use of healthcare resources; positive, data-driven decision making regarding healthcare policy; and an increase in aggregate displays of OCBs. Emphasizing effort and integration can promote positive social change that results in enhanced patient care, alignment between employee actions and organizational goals, and improved overall societal health.

Recent changes in the Centers for Medicare and Medicaid Services (CMS) reimbursement programs resulted in $1 billion in payments to hospitals based on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores. Approximately 50% of the 3,000 hospitals currently receiving Medicare supplements may receive increases in reimbursement payments while 50% will receive decreases in payments. This case study explored how one hospital team in North Texas achieved high HCAHPS scores. The primary provider theory, Deming's model of plan-do-study-act (PDSA), and disruptive innovation theory framed the study. The data collection process included administrator interviews (n = 7), hospital document analysis (n = 13), and observations of staff conducting care (n = 8). Through method triangulation, themes emerged on the constructs required to achieve high HCAHPS scores. Themes included caregiver-patient interactions, hospital services, hospital environment, hospital technology, and hospital governance. Although this was a single case study, other healthcare leaders may explore the findings to determine how the information contained within might transfer to other healthcare organizations. Improved patient outcomes resulting from education, communication, and technology in the continuum of care might enhance the patient experience and patients' overall health and wellness.

Nurses experiencing bullying or witnessing other nurses bullied may choose to vacate their hospital positions. Nurse attrition negatively impacts a hospital's bottom line, which can lead to insolvency and a lack of access to healthcare by patients. The purpose of this phenomenological study was to understand the choices nurses made regarding their careers after experiencing or witnessing bullying and to calculate a hospital's cost of loss. Freire's oppressed group theory provided the conceptual framework for the study. The basis of the research questions was to understand how the nurse felt when bullied or observing a coworker bullied, the actions taken, and the financial impact to the hospital. The snowball technique secured 11 RN participants for this phenomenological study with data collection consisting of a demographic questionnaire and semistructured interviews. Data analysis followed Maxwell's plan of initial analysis, transcribing and coding, theme identification, a final coding review, and the final abstraction. The findings in this study demonstrated that based on the lived experiences of the participants, demographics did not influence who or how nurses were bullied; and after leaving the employer, bullied nurses and witnesses displayed various emotions that encompassed nonchalance, anger, tears, or relief. Over half said they would have stayed if they had not been bullied or witnessed it. An additional theme demonstrated that the results of bullying significantly affected a hospital's bottom line in revenue and reputation. Eleven suggestions have been recommended for future studies. Academics, hospital administrators, nurses, and the community at large can use the study findings to effect changes in the hospital environment through conversations, grass-roots efforts, and collaboration.

Depending on their needs for enhancing and sustaining their business and market values, some firms choose to operate with a corporate governance structure of CEO duality, in which an executive serves as the CEO and the chairperson of the board of directors. The problem addressed in this study is that past empirical and theoretical studies of the relationship between CEO duality and firm performance of organizations across different industries have generated ambiguous results, and no studies have focused specifically on the relationship between CEO duality and financial performance of not-for-profit hospitals. Based on agency and stewardship theories, and considering that CEO duality's effects on firms' financial performance are contextually specific to each type of industry and dependent on certain industry conditions, the purpose of this quantitative study was to answer 3 research questions that examine the relationship between CEO duality, presence of physicians on governance board, hospital size, hospital age, board size, and financial performance of not-for-profit hospitals. This study used multiple regression analyses of data of financial indicators from 146 U.S. not-for-profit hospitals selected from the Office of Statewide Health Planning and Development database of California, for the period from 2009 to 2012. The results of this study suggested CEO duality and presence of physicians on healthcare governance were not related to financial performance of not-for-profit hospitals. The outcomes of this study can promote positive social change by bringing awareness of appropriate healthcare governance structures that enhance organizational effectiveness and sustain hospitals' charitable missions of provision of community services and transformation of communities and society.

Hospital leaders set quality and safety as high priorities in their strategic goals. Improving the quality and safety of patient care requires improving internal processes that have direct implications for patient care. Hospital leaders need to improve health care providers' communication as part of improving quality and safety. The problem addressed in this study was the lack of strategies health care administrators use to guide nurse-physician communication patterns in a university medical center in the Middle East. The purpose of this qualitative case study was to explore communication strategies that health care administrators use to guide nurse-physician communication. Relational coordination informed the conceptual framework of the study. The research question was designed to identify strategies health care administrators use to guide nurse-physician communication patterns. Data were collected and thematically analyzed through semistructured interviews with 5 administrators, 3 nurses, and 3 physicians, and the hospital policy manual. Analysis revealed 4 major themes: nurses' empowerment, nurses and physicians' accountability, multidisciplinary care delivery, and mutual respect. Strategies were identified through the exploration and analysis of the 4 themes. The key findings included that administrators considered holding nurses and physicians accountable for their work to be a key strategy that guides communication, and that effective communication is directly connected to mutual respect among different teams and individuals. The implications for social change include improved patient care and safety, and increased job satisfaction through health care leaders applying the identified strategies to enhance nurse-physician communication.

Cardiovascular (CV) patients receive one-third of the care and account for $444 billion of the health care costs in the United States. The cardiovascular service line (CVSL) in hospitals contributes to the profitability influenced by elements of resource dependence theory (RDT). The purpose of this study was to understand whether the regression model of hospital characteristics and outcomes would predict profitability in a CVSL through the cost-to-charge ratio (CCR). The use of a general linear model and multiple regression analysis to examine the 2012 National Inpatient Sample from the Healthcare Cost and Utilization Project allowed estimates from a weighted sample of discharges from all hospitals in participating states. Transformation to dichotomous, independent variables preceded analysis of CV-conditions by discharges. An analysis of variance included in the validated model of grouped strata predicted a level of profitability through the CCR, (4, 509) = 129.83, p < .001, R2 = .505. Mortality was not a significant predictor in the regression model. The 3 characteristic variables with an inverse relationship to the CCR, which resulted in favorable profitability for CVSL, included large, academic, and private for-profit institutions. Prior research aligns well to the study, which emphasized the importance of RDT. Leaders in health care organizations may choose to employ decision making that is dependent upon big data and reference to internal resources to achieve reform expectations. Predictive modeling may aid in the strategic direction of health care organizations. Social implications of this study include hospitals striving to enhance the value proposition by centering care activities around the person over rationing finite resources by condition.

Foi descrita e analisada a implantação de um processo de gestão da qualidade total na Divisão de Laboratório Central entre 1996 e 97. O sistema de garantia da qualidade com descrição e análise efetuadas, apoiou-se na Norma ISO 9002. Seu desempenho foi monitorizado por indicadores, tendo as suas repercussões discutidas. Os resultados indicaram que processos similares são viáveis em laboratórios clínicos públicos. Demonstrando-se um envolvimento dos funcionários, com diminuição do absenteísmo e do número de licenças do trabalho. A produtividade e o faturamento aumentaram, mantendo-se o custo médio por exame. As pesquisas de opinião apontaram mudanças no conceito dos médicos sobre o laboratório e mais satisfaçào dos pacientes com os serviços prestados. Este sistema obteve reconhecimento externo em 1997
The implementing process of a total quality management system in the DLC was described and analyzed from 1996-97. A quality assurance system was established base don the rules of the ISO 9002. The steps of the establishing process were described, analyzed and a set of the indicators were used in order to monitor the performance of the introduced system, through the analysis of its follow-up. The results demonstrated that employees´ commitment resulted in a decrease in absenteeism, leave of absence and accidents related to work. There was an increase in productivity and billing with the upkeep of the cost per exam. Public opinion polls disclosed a better concept of the laboratory by the clinical staff and the patients. This system got external certification in 1997

Les systèmes hospitaliers sont des lieux de soins caractérisés par la variété des activités et des situations auxquelles ils sont confrontés. Ceci engendre des interactions induisant des situations imprévues liées à plusieurs risques.La gestion des risques apparaît donc comme une préoccupation importante pour les décideurs. Plus particulièrement, la gestion des risques dans les blocs opératoires est d’une grande importance étant donné que ces derniers présentent des lieux hautement stratégiques par rapport aux nombreuses activités qu’ils regroupent et des coûts qu’ils engendrent. Le risque zéro n’existe pas, il peut néanmoins être réduit.Ce travail de recherche a pour objectif de maîtriser la gestion des risques dans les blocs opératoires. Cette recherche s’intègre dans le cadre d’une collaboration entre l’Ecole Centrale de Lille et le CHU Sahloul de Sousse, terrain d’étude choisi pour mettre en œuvre l’approche proposée. Étant donné qu’aucun système de gestion des risques n’a été mis en place dans cet établissement, ce travail représenté un apport important et original pour le CHU Sahloul.Notre démarche se déroule en plusieurs étapes. Tout d’abord, suite à une comparaison entre les méthodes de gestion des risques existantes, nous avons choisi d’adapter la méthode de gestion des risques AMDEC (Analyse des Modes de Défaillances, de leurs Effets et de leurs Criticités) aux blocs opératoires du CHU Sahloul de Sousse.Nous proposons ensuite un système d’aide à la décision pour la gestion des risques GRAMA (Gestion des Risques par une Approche Multi - Agent) afin d’orienter les intervenants dans les blocs opératoires vers les meilleures décisions pour minimiser les risques pouvant survenir. Enfin, une simulation basée sur l’approche proposée est mise en œuvre au CHU Sahloul
The hospital systems are a place of health care distinguished by the variety of activities and situations with which they are confronted. This creates interactions leading into unexpected situations related to several risks.The risk management appears as an important concern for the decisions makers. More particularly, the risk management in the operating theatres has a major importance given that they are about a highly strategic in relation to the many activities they include and the costs they generate. The zero risk does not exist. Never theless, it can be reduced.This research aims to control risk management in operating rooms. This research gets in collaboration between l’Ecole Centrale de Lille and the University Hospital (UH) of Sousse Sahloul, field of study chosen to implement the proposed approach. Since non system of risk management has been implemented in this establishment, this work is significant and original for the UH Sahloul.Our approach is made up of several steps. First, following a comparison between the existing methods of risk management, we chose to adapt the method of risk management FMECA (Failure Modes, Effects and Criticality Analysis) in operating rooms of UH Sahloul, Sousse. We propose a decision support system for risk management based on multi-agent approach in order to guide contributors in the operating rooms making the best decisions to minimize risks which occur in UH Sahloul. Finally, a simulation based on the proposed approach is implemented in the UH Sahloul

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INTRODUCTION: Patients are increasingly being thought of as central to patient safety. A small but growing body of work suggests that patients may have a role in reporting patient safety problems within a hospital setting. This review considers this disparate body of work, aiming to establish a collective view on hospital-based patient reporting. STUDY OBJECTIVES: This review asks: (a) What can patients report? (b) In what settings can they report? (c) At what times have patients been asked to report? (d) How have patients been asked to report? METHOD: 5 databases (MEDLINE, EMBASE, CINAHL, (Kings Fund) HMIC and PsycINFO) were searched for published literature on patient reporting of patient safety 'problems' (a number of search terms were utilised) within a hospital setting. In addition, reference lists of all included papers were checked for relevant literature. RESULTS: 13 papers were included within this review. All included papers were quality assessed using a framework for comparing both qualitative and quantitative designs, and reviewed in line with the study objectives. DISCUSSION: Patients are clearly in a position to report on patient safety, but included papers varied considerably in focus, design and analysis, with all papers lacking a theoretical underpinning. In all papers, reports were actively solicited from patients, with no evidence currently supporting spontaneous reporting. The impact of timing upon accuracy of information has yet to be established, and many vulnerable patients are not currently being included in patient reporting studies, potentially introducing bias and underestimating the scale of patient reporting. The future of patient reporting may well be as part of an 'error detection jigsaw' used alongside other methods as part of a quality improvement toolkit.

This thesis study evaluates access to care at an internal medicine unit with solely semi-private rooms at Baystate Medical Center (BMC). Patients are divided into two types: Type I patient consumes one bed; Type II patient occupies two beds or an entire semi-private room as a private space for clinical reasons, resulting in one empty but unavailable (blocked) bed per Type II patient. Because little data is available on blocked beds and Type II patients, unit-level hospital bed planning studies that consider blocked beds have been lacking. This thesis study bridges that gap by building a single-stream and a two-stream discrete micro-simulation model in Excel VBA to describe unit-level bed queue dynamics at hourly granularity in the next 48-hour time horizon, using historical arrival rates and census-dependent discharge rates, supplemented with qualitative results on complexity of patient-level discharge prediction. Results showed that while we increase additional semiprivate beds, there was notable difference between the traditional single-stream model and the two-stream model concerning improvement in bed queue size. Possible directions for future research include patient-level discharge prediction considering both clinical and nonclinical milestones, and strategic redesign of hospital unit(s) considering overflows and internal transfers.

This study explores how formal and informal social networks and decision making about resources in the hospital setting are related. Over the last few years, tensions between new public management of hospitals and increased demands has led to an increase in bottlenecks, stagnation of patient flow, and overcrowded emergency departments. These problems have led to an increase in access block for patients attempting to access the public hospital system. The introduction of Patient Flow Units has instigated the formalisation of a nurse manager function to coordinate patient flow. Nurses in such a pivotal position and who greatly influence hospital operations, tend to have special characteristics and use these to “get things done”. This thesis investigates interpersonal associations between professional (e.g. doctors and nurses) and functional groups (e.g. clinicians and managers), when making clinical and operational decisions when transferring a patient from the emergency department to a ward bed. By employing a mixed methodology, this thesis first sought to establish a snapshot of organisational culture in three hospitals. Drawing on Degeling et al. (1998) and Fitzgerald (2002), an organisational cultural survey was distributed to a total of 1750 participants. The response rate was 11.65% This survey particularly addressed five cultural constructs including a sense of organisational commitment, perceptions of managerial role characteristics, perceptions of currently pursued organisational goals, perceptions of orientation to work values when choosing a job, and interactions with various professional constituencies. In addition, 18 interviews were conducted and a total of 150 hours of observation of work processes, interactions between staff and environmental conditions were studied. This investigation largely confirmed earlier studies by Degeling (2002) and Fitzgerald (2002) that professional groups believed that their organisation primarily exhibited an Elite style of management, that financial viability is the most important goal their organisation is pursuing, and staff welfare was a low priority. In addition, it found significant differences in cultural footprints between the small hospital, which had a more integrated culture, and the large hospital, which was more fragmented in nature. However, the major contribution of this investigation is demonstrated in the qualitative chapter. This thesis found that the role of “who matters the most” in relation to decision making about patient flow, changes depending on the stage of the decision making process. It also found that non-managerial nursing staff with no formal power or legitimacy could affect urgency. The thesis comprises eight chapters. Following the introductory chapter, Chapter 2 considers the literature associated with the public health system in Australia with a focus on public hospitals in NSW. Chapter 3 critically examines the literature describing organisational culture, with an emphasis on subcultures. Chapter 4 contains a review of professional identity and roles, networks and alliances, social capital, deep smarts, and stakeholder theory. Description and justification of the research method selected to explore the thesis proposition follows in Chapter 5. Chapter 6 contains an outline of the findings concerning the analysis of the survey questionnaire to determine a cultural footprint of the three hospitals studied. Chapter 7 considers the different roles of professional groups (doctors, nurses, and others) and functional groups (clinicians and managers) in the operational phase of patient flow and in doing so contributes to knowledge. Finally, in Chapter 8, a discussion summarises the thesis findings, describes the implications, acknowledges limitations of the study and identifies avenues for future research.
Doctor of Philosophy (PhD)

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PURPOSE/OBJECTIVES: To assess and improve the safety of hospital-based adult chemotherapy administration. DESIGN: Prospective, systems-focused clinical risk assessment. SETTING: An adult inpatient and outpatient oncology unit in a large urban hospital in the United Kingdom. SAMPLE: 8-person nurse-led multidisciplinary team, which included managerial staff and patient safety researchers. METHODS: Failure mode and effects analysis (FMEA), a prospective, systems-focused risk assessment methodology, was undertaken in biweekly team meetings and included mapping the chemotherapy administration process, identifying and numerically prioritizing potential errors (failure modes) for each process step, and generating remedial strategies to counteract them. MAIN RESEARCH VARIABLES: The analysis aimed to identify chemotherapy administration failure modes and to generate remedial strategies to address them. User feedback on the FMEA process also was collected. FINDINGS: Several specific chemotherapy failure modes were identified, the majority of which had not previously been recognized, and several novel strategies to counteract them were generated. Many of the strategies were specific, environment-focused actions, which are simple, quick, and inexpensive to implement; however, more substantive, longer-term initiatives also were generated. User feedback generally was very positive, and the process of undertaking the analysis improved multidisciplinary teamwork and communication. CONCLUSIONS: Although time and resource intensive, FMEA is a useful safety improvement tool. IMPLICATIONS FOR NURSING: Nurses should be aware of and informed about FMEA as a tool they can use in partnership with management and other disciplines to proactively and collectively improve the safety of high-risk oncology procedures such as chemotherapy administration.