Effects of Internal and External Factors on Hospital Data Breaches: Quantitative Study.

BACKGROUND: Health care data breaches are the most rapidly increasing type of cybercrime; however, the predictors of health care data breaches are uncertain. OBJECTIVE: This quantitative study aims to develop a predictive model to explain the number of hospital data breaches at the county level. METHODS: This study evaluated data consolidated at the county level from 1032 short-term acute care hospitals. We considered the association between data breach occurrence (a dichotomous variable), predictors based on county demographics, and socioeconomics, average hospital workload, facility type, and average performance on several hospital financial metrics using 3 model types: logistic regression, perceptron, and support vector machine. RESULTS: The model coefficient performance metrics indicated convergent validity across the 3 model types for all variables except bad debt and the factor level accounting for counties with >20% and up to 40% Hispanic populations, both of which had mixed coefficient directionality. The support vector machine model performed the classification task best based on all metrics (accuracy, precision, recall, F1-score). All the 3 models performed the classification task well with directional congruence of weights. From the logistic regression model, the top 5 odds ratios (indicating a higher risk of breach) included inpatient workload, medical center status, pediatric trauma center status, accounts receivable, and the number of outpatient visits, in high to low order. The bottom 5 odds ratios (indicating the lowest odds of experiencing a data breach) occurred for counties with Black populations of >20% and <40%, >80% and <100%, and >40% but <60%, as well as counties with ≤20% Asian or between 80% and 100% Hispanic individuals. Our results are in line with those of other studies that determined that patient workload, facility type, and financial outcomes were associated with the likelihood of health care data breach occurrence. CONCLUSIONS: The results of this study provide a predictive model for health care data breaches that may guide health care managers to reduce the risk of data breaches by raising awareness of the risk factors.

A reason to renovate: The association between hospital age of plant and value-based purchasing performance.

BACKGROUND/PURPOSE: Value-based purchasing (VBP) is increasing in influence in the health care industry; however, questions remain regarding the structural factors associated with improved performance. This study evaluates the association between age of hospital infrastructure and VBP outcomes. METHODOLOGY: Data on 1,911 hospitals from three sources (the American Hospital Association Annual Survey Database, the American Hospital Association DataViewer Financial Module, and the Centers for Medicare & Medicaid Services Hospital VBP Total Performance Scores data set) were evaluated. Age of health care facilities was represented by the "average age of plant" financial ratio. VBP performance was measured by an aggregate Total Performance Score composed of four equally weighted domains, including Efficiency and Cost Reduction, Clinical Care, Patient- and Caregiver-Centered Experience, and Patient Safety. We hypothesize that average age of plant is negatively correlated with each of these measures. RESULTS: Hospitals within the lowest quartile of average age of plant (0-8.13 years) were found to have a total Performance Score of 2.35 points higher than hospitals with a an average age of plant in the fourth quartile (14.63 years and above; R = 21.5%; p < .001) while controlling for hospital ownership, size, teaching status, geographic location, service mix, case mix, length of stay, community served, and labor force relative cost. Comparable results were found within the VBP domains, specifically for Clinical Care (ß = 4.09, p < .001) and Patient Experience (ß = 3.41, p < .001). Findings for the Patient Safety and Efficiency domains were not significant. A secondary and more granular examination of capitalized assets indicates organizations with higher building asset accumulated depreciation per bed in service were associated with lower total performance (ß = -.25, p < .001), Clinical Care (ß = -.31, p < .05), and Patient Experience scores (ß = -.45, p < .001). CONCLUSIONS: The results of this study provide evidence of an inverse association between a hospital's age of plant and specific elements of VBP performance. PRACTICE IMPLICATIONS: To date, no studies have investigated the relationship between hospital age of plant and value-based care. The results of our study may serve as supportive foundational evidence for health care leaders to target future capital investments to improve VBP outcomes.

Does Patient Safety Pay? Evaluating the Association Between Surgical Care Improvement Project Performance and Hospital Profitability.

EXECUTIVE SUMMARY: Financial issues are top concerns for hospital executives. Evolving reimbursement structures focused on value provide an incentive to fully understand how patient safety performance and financial outcomes are connected. To that end, this study examines the relationships between Surgical Care Improvement Project (SCIP) measurements and hospital financial performance.Using multinomial logistic regression, we determined the association between hospital patient safety performances via analysis of eight prophylaxis data elements drawn from the archived Hospital Compare data. The measures are SCIP-Inf-1 (prophylactic antibiotic prophylaxis received within 1 hr prior to surgical incision), SCIP-Inf-2 (prophylactic antibiotic selection for surgical patients), SCIP-Inf-3 (prophylactic antibiotics discontinued within 24 hr after surgery end time), SCIP-Inf-4 (cardiac surgery patients with controlled 6 A.M. postoperative serum glucose management), SCIP-Inf-9 (urinary catheter removal postsurgery), SCIP-Inf-Card-2 (beta-blocker during the perioperative period), and SCIP-Inf-VTE-2 (venous thromboembolism prophylaxis). Data from the American Hospital Association provided two dimensions of organizational profitability: operating margin and net patient revenue. Our results indicate that improved hospital safety performance is associated with a relative risk of higher operating margin and net patient revenue, with some variation noted among the measures of patient safety. Our findings suggest that targeted improvement in patient safety performance, as evaluated in the Hospital Compare data, is associated with improved financial performance at the hospital level. Increased attention to safe care delivery may allow hospitals to generate additional patent care earnings, improve margins, and create capital to advance hospital financial position.

Doing well by doing good: Evaluating the influence of patient safety performance on hospital financial outcomes.

BACKGROUND: As financial pressures on hospitals increase because of changing reimbursement structures and heightened focus on quality and value, the association between patient safety performance and financial outcomes remains unclear. PURPOSE: The purpose of this study is to investigate if hospitals with higher patient safety performance are associated with higher levels of profitability than those with lower safety performance. METHODOLOGY/APPROACH: Using multinomial logistic regression, we analyzed data from the spring 2014 Leapfrog Hospital Safety Score and the 2014 American Hospital Association to determine the association between Leapfrog Hospital Safety Score performance and three dimensions of organizational profitability: operating margin, net patient revenue, and operating income. RESULTS: Our findings suggest that improved hospital safety scores are associated with a relative risk of being in the top versus bottom quartile of financial performance: 5.41 times greater (p < .001) for operating margin, 10.98 times greater (p < .001) for net patient revenue, and 4.03 times greater (p < .001) for operating income. PRACTICE IMPLICATIONS: Our findings suggest that improved patient safety performance, as evaluated within the Leapfrog Hospital Safety Score, is associated with improved financial performance at the hospital level. Targeted focus on patient safety may allow hospitals to improve financial performance, maximize scarce resources, and generate additional capital to continue to positively evolve care.

Fix These First: How the World's Leading Companies Point the Way Toward High Reliability in the Military Health System.

EXECUTIVE SUMMARY: The 2014 Military Health System Review calls for healthcare system leaders to implement effective strategies used by other high-performing organizations. The authors state, " the [military health system] MHS can create an optimal healthcare environment that focuses on continuous quality improvement where every patient receives safe, high-quality care at all times" (Military Health System, 2014, p. 1). Although aspirational, the document does not specify how a highly reliable health system is developed or what systemic factors are necessary to sustain highly reliable performance. Our work seeks to address this gap and provide guidance to MHS leaders regarding how high-performing organizations develop exceptional levels of performance.The authors' expectation is that military medicine will draw on these lessons to enhance leadership, develop exceptional organizational cultures, onboard and engage employees, build customer loyalty, and improve quality of care. Leaders from other segments of the healthcare field likely will find this study valuable given the size of the military healthcare system (9.6 million beneficiaries), the United States' steady progression toward population-based health, and the increasing need for highly reliable systems and performance.

Assessing Risk Literacy Skills: Enhancing Healthcare Management among University Students.

The purpose of this study was to explore the determinants of risk literacy among university students in the United States by utilizing the Berlin Numeracy Test. Risk literacy skills are essential for decision-making and communication of risks, but few studies consider university students. This study aims to evaluate the association of sociodemographic factors with individual risk literacy levels. An observational cross-sectional survey study was used with a convenience sample of 184 undergraduate and graduate university students. Statistical analysis revealed significant differences for demographics at risk for negative outcomes associated with lower risk literacy. For this group of students, the majority had below-average numeracy. These findings can guide healthcare professionals to focus on college-age individuals with low-risk literacy scores to enhance patient understanding, facilitate communication, and promote healthier behaviors.

An Exploratory Analysis of the Association between Healthcare Associated Infections & Hospital Financial Performance.

Purpose: Healthcare-associated infections (HAIs) place a significant financial burden on United States hospitals. HAI treatments extend hospital lengths of stay and increase hospital operational costs while significantly reducing hospital profit margins. Given these challenges, the research aim of this study was to explore the association between HAIs and hospital financial performance. A better understanding of this relationship can assist hospital leaders in optimizing the use of scarce financial resources to reduce HAI prevalence. Methods: Data for calendar year 2022 for active short-term acute care hospitals (n = 1454) in the US were analyzed using multiple linear regression analysis. We explored two derived dependent variables, operating expense per staffed bed and operating expense per discharge. The independent variables included four healthcare-associated infection rates: methicillin-resistant Staphylococcus aureus (MRSA) infection rate, Clostridium difficile (C. diff) infection rate, Catheter-Associated Urinary Tract Infection (CAUTI) rate, and Central Line Associated Blood Stream Infections (CLABSI). Appropriate organizational and market-level variables that may independently influence hospital financial performance were included as control variables. Results: The results revealed that C. diff (ß: 0.037, p < 0.05) and CAUTI (ß: 0.031, p < 0.05) rates were positively associated with an increase in operating expense per staffed bed, while increases in MRSA (ß: 0.042, p < 0.001), C. diff (ß: 0.062, p < 0.001), and CAUTI rates (ß: 0.039, p < 0.001) were correlated with increased operating expenses per discharge. Conclusions: This study demonstrates that specific HAIs may be associated with increased hospital expenses. Proactively targeting these infections through tailored interventions may lead to reduced hospital costs, improved financial performance, and economic stability.

Examining the Effect of Contactless Intergenerational Befriending Intervention on Social Isolation Among Older Adults and Students' Attitude Toward Companionship: Content Analysis.

BACKGROUND: Intergenerational friendship, a mechanism of social support, is an effective intervention to reduce the increasing risk of social isolation (SI) and develop companionship in the older adult population. The COVID-19 pandemic provided a unique opportunity to examine the psychosocial intervention of befriending via technology use as a primary form of contactless socialization. OBJECTIVE: The study aims to explore the effectiveness of the befriending intervention through a contactless, intergenerational service-learning project on older adult emotions, especially boredom and loneliness as the key attributes of SI, and on students' attitude toward companionship. METHODS: During the months of January to April 2022 , undergraduate students enrolled in a health administration course with a special focus on culture were asked to be involved in a contactless, intergenerational service-learning project (n=46). In this study, contactless intervention meant communication using the telephone and apps such as FaceTime and Zoom. Students were paired with older adults to have at least a 30-minute weekly conversation, for 8 weeks, via telephone or an internet-based app such as FaceTime. Students were asked to write a half-page diary after each interaction and a 1-page reflection at the end of the fourth week and at the end of the service-learning project. At the completion of the project, the researchers also surveyed the older adults to assess the impact of the project using a 5-item open-ended questionnaire. Following a heuristic approach and content analysis, student artifacts (110,970 words; 118-page, single-spaced Microsoft Word document) and the older adult surveys were analyzed using MAXQDA, (VERBI GmbH). Qualitative data were extracted to assess the impact of service learning on SI by measuring the attributes of boredom and loneliness among 46 older adults. Students' attitudes toward companionship were also assessed using data from their diaries and reflections. RESULTS: Overall, three major constructs were identified: (1) meaningful engagement, defined as feeling safe, having increased confidence, and having reduced boredom; (2) internal motivation to participate in the weekly interaction, defined as discussion about daily life experience, level of happiness, and ability to exert personal control over the situation; and (3) intergenerational befriending, defined as perceived benefits from the friendly nature of the interaction, ability to comfortably connect with students, and positive feeling and attitude toward the student. CONCLUSIONS: The contactless, intergenerational befriending intervention reduced boredom and loneliness among older adults and enhanced positive attitude and confidence among university students. Students helped older adults to develop digital skills for the use of apps and social media. Older adults showed interest in the intervention and shared their daily life experiences with the students, which helped to reduce the gap between generations. Findings indicate the effectiveness of an intergenerational service-learning intervention on SI reduction and increased positive attitude among college students.

The effect of COVID-19 on cancer incidences in the U.S.

Fundamental data analysis assists in the evaluation of critical questions to discern essential facts and elicit formerly invisible evidence. In this article, we provide clarity into a subtle phenomenon observed in cancer incidences throughout the time of the COVID-19 pandemic. We analyzed the cancer incidence data from the American Cancer Society [1]. We partitioned the data into three groups: the pre-COVID-19 years (2017, 2018), during the COVID-19 years (2019, 2020, 2021), and the post-COVID-19 years (2022, 2023). In a novel manner, we applied principal components analysis (PCA), computed the angles between the cancer incidence vectors, and then added lognormal probability concepts in our analysis. Our analytic results revealed that the cancer incidences shifted within each era (pre, during, and post), with a meaningful change in the cancer incidences occurring in 2020, the peak of the COVID-19 era. We defined, computed, and interpreted the exceedance probability for a cancer type to have 1000 incidences in a future year among the breast, cervical, colorectal, uterine corpus, leukemia, lung & bronchus, melanoma, Hodgkin's lymphoma, prostate, and urinary cancers. We also defined, estimated, and illustrated indices for other cancer diagnoses from the vantage point of breast cancer in pre, during, and post-COVID-19 eras. The angle vectors post the COVID-19 were 72% less than pre-pandemic and 28% less than during the pandemic. The movement of cancer vectors was dynamic between these eras, and movement greatly differed by type of cancer. A trend chart of cervical cancer showed statistical anomalies in the years 2019 and 2021. Based on our findings, a few future research directions are pointed out.

An Exploratory Analysis of the Association between Hospital Quality Measures and Financial Performance.

Hospitals are perpetually challenged by concurrently improving the quality of healthcare and maintaining financial solvency. Both issues are among the top concerns for hospital executives across the United States, yet some have questioned if the efforts to enhance quality are financially sustainable. Thus, the aim of this study is to examine if efforts to improve quality in the hospital setting have a corresponding association with hospital profitability. Recent and directly relevant research on this topic is very limited, leaving practitioners uncertain about the wisdom of their investments in interventions which enhance quality and patient safety. We assessed if eight different quality measures were associated with our targeted measure of hospital profitability: the net patient revenue per adjusted discharge. Using multivariate regression, we found that improving quality was significantly associated with our targeted measure of hospital profitability: the net patient revenue per adjusted discharge. Significant findings were reported for seven of eight quality measures tested, including the HCAHPS Summary Star Rating (p < 0.001), Hospital Compare Overall Rating (p < 0.001), All-Cause Hospital-Wide Readmission Rate (p < 0.01), Total Performance Score (p < 0.001), Safety Domain Score (p < 0.01), Person and Community Engagement Domain Score (p < 0.001), and the Efficiency and Cost Reduction Score (p < 0.001). Failing to address quality and patient safety issues is costly for US hospitals. We believe our findings support the premise that increased attention to the quality of care delivered as well as patients' perceptions of care may allow hospitals to accentuate profitability and advance a hospital's financial position.

An Exploratory Analysis of the Association Between Hospital Labor Costs and the Quality of Care.

Introduction: The competent healing touch of a caregiver is a critical component to the care patients receive. The more skilled the provider, the higher the likelihood outcomes will be delivered in a safe and effective manner. Unfortunately, in recent years, hospitals in the United States have faced immense financial pressures that are threatening their economic sustainability and patients' access to care in the future. Through the recent COVID-19 pandemic, the cost of delivering healthcare has continued to escalate, while the demand for patient care has exceeded many hospitals' capacity. Most troubling is the impact that the pandemic has had on the healthcare workforce, which has resulted in many hospitals struggling to fill vacancies at ever-increasing cost - all while under immense pressure to deliver quality patient care. What remains uncertain is whether the increase in labor costs has been matched with a commensurate rise in the quality of care or if quality has deteriorated as the labor force mix has changed to include more contract and temporary staff. Thus, in the enclosed study, we sought to determine what association, if any, exists between hospitals' cost of labor and the quality of care delivered. Methods and Models: Drawing from a representative national sample of nearly 3214 short-term acute care hospitals' common quality measures from the year 2021, we examined the labor cost-quality relationship via multivariate linear and logistic regression and found there is a persistent negative association across all quality outcome variables studied. Discussion: These findings lead us to believe simply paying more for hospital labor does not, by itself, ensure a positive patient outcome. We contend cautious use of temporary staff, measured adoption of short-term financial incentives, and robust staff development all should be considered as features of future workforce planning.

Renovating Healthcare Facility Maintenance Planning: A Case Study From Walter Reed National Military Medical Center (WRNMMC).

PURPOSE: This article documents the development and implementation of a new approach for health facilities construction and maintenance planning, the use of a Facilities and Clinical Coordination (FCC) Council, at Walter Reed National Military Medical Center (WRNMMC). BACKGROUND: WRNMMC is preparing for the largest and most complex renovation project in recent Department of Defense history. There is sparse documentation demonstrating stepwise frameworks for the implementation of effective and efficient health facilities maintenance management tools and techniques. METHOD: This study discusses the development and evaluation of the FCC Council. Clarity to the literature sources guiding the development of the FCC Council is provided, followed by the survey approach undertaken to assess Council efficacy based on participants' perceptions. Data are analyzed using descriptive and inferential statistics. RESULTS: Our study suggests routine cross-functional synchronous FCC Council meetings improve perceptions of safety and communication, encourage teamwork, and are more productive when conducted using synchronous rather than asynchronous communication. Clinician participants strongly supported the face-to-face meeting approach and considered such meetings more effective as they are perceived to maintain staff and patient safety as a constant organizational focus. CONCLUSION: The FCC's perceived effectiveness toward improving healthcare facilities maintenance planning centers on engaged leadership, the inclusion of diverse subject matter experts, and structured group facilitation. Our results inform health facilities planners of the value the FCC Council brings to an organization by helping to develop organizational buy-in for major facilities renovation projects.

Testing Kissick's Iron Triangle-Structural Equation Modeling Analysis of a Practical Theory.

BACKGROUND/PURPOSE: The purpose of this research is to determine if the tradeoffs that Kissick proposed among cost containment, quality, and access remain as rigidly interconnected as originally conceived in the contemporary health care context. Although many have relied on the Kissick model to advocate for health policy decisions, to our knowledge the model has never been empirically tested. Some have called for policy makers to come to terms with the premise of the Kissick model tradeoffs, while others have questioned the model, given the proliferation of quality-enhancing initiatives, automation, and information technology in the health care industry. One wonders whether these evolutionary changes alter or disrupt the originality of the Kissick paradigms themselves. METHODS: Structural equation modeling (SEM) was used to evaluate the Kissick hypothetical relationships among the unobserved constructs of cost, quality, and access in hospitals for the year 2018. Hospital data were obtained from Definitive Healthcare, a subscription site that contains Medicare data as well as non-Medicare data for networks, hospitals, and clinics (final n = 2766). RESULTS: Reporting significant net effects as defined by our chosen study variables, we find that as quality increases, costs increase, as access increases, quality increases, and as access increases, costs increase. Policy and Practice Implications: Our findings lend continued relevance to a balanced approach to health care policy reform efforts. Simultaneously bending the health care cost curve, increasing access to care, and advancing quality of care is as challenging now as it was when the Kissick model was originally conceived.

A Report Card on Prevention Efforts of COVID-19 Deaths in US.

COVID-19 (otherwise known as coronavirus disease 2019) is a life-threatening pandemic that has been combatted in various ways by the government, public health officials, and health care providers. These interventions have been met with varying levels of success. Ultimately, we question if the preventive efforts have reduced COVID-19 deaths in the United States. To address this question, we analyze data pertaining to COVID-19 deaths drawn from the Centers for Disease Control and Prevention (CDC). For this purpose, we employ incidence rate restricted Poisson (IRRP) as an underlying analysis methodology and evaluate all preventive efforts utilized to attempt to reduce COVID-19 deaths. Interpretations of analytic results and graphical visualizations are used to emphasize our various findings. Much needed modifications of the public health policies with respect to dealing with any future pandemics are compiled, critically assessed, and discussed.

Accreditation and Certification: Do They Improve Hospital Financial and Quality Performance?

The relationship between healthcare organizational accreditation and their leaders' professional certification in healthcare management is of specific interest to institutions of higher education and individuals in the healthcare management field. Since academic program accreditation is one piece of evidence of high-quality education, and since professional certification is an attestation to the knowledge, skills, and abilities of those who are certified, we expect alumni who graduated from accredited programs and obtained professional certification to have a positive impact on the organizations that they lead, compared with alumni who did not graduate from accredited programs and who did not obtain professional certification. The authors' analysis examined the impact of hiring graduates from higher education programs that held external accreditation from the Commission on Accreditation of Healthcare Management Education (CAHME). Graduates' affiliation with the American College of Healthcare Executives (ACHE) professional healthcare leadership organization was also assessed as an independent variable. Study outcomes focused on these graduates' respective healthcare organization's performance measures (cost, quality, and access) to assess the researchers' inquiry into the perceived value of a CAHME-accredited graduate degree in healthcare administration and a professional ACHE affiliation. The results from this study found no effect of CAHME accreditation or ACHE affiliation on healthcare organization performance outcomes. The study findings support the need for future research surrounding healthcare administration professional graduate degree program characteristics and leader development affiliations, as perceived by various industry stakeholders.

Predictors of Death Rate during the COVID-19 Pandemic.

Coronavirus (COVID-19) is a potentially fatal viral infection. This study investigates geography, demography, socioeconomics, health conditions, hospital characteristics, and politics as potential explanatory variables for death rates at the state and county levels. Data from the Centers for Disease Control and Prevention, the Census Bureau, Centers for Medicare and Medicaid, Definitive Healthcare, and USAfacts.org were used to evaluate regression models. Yearly pneumonia and flu death rates (state level, 2014-2018) were evaluated as a function of the governors' political party using a repeated measures analysis. At the state and county level, spatial regression models were evaluated. At the county level, we discovered a statistically significant model that included geography, population density, racial and ethnic status, three health status variables along with a political factor. A state level analysis identified health status, minority status, and the interaction between governors' parties and health status as important variables. The political factor, however, did not appear in a subsequent analysis of 2014-2018 pneumonia and flu death rates. The pathogenesis of COVID-19 has a greater and disproportionate effect within racial and ethnic minority groups, and the political influence on the reporting of COVID-19 mortality was statistically relevant at the county level and as an interaction term only at the state level.

Overpriced? Are Hospital Prices Associated with the Quality of Care?

In most consumer markets, higher prices generally imply increased quality. For example, in the automobile, restaurant, hospitality, and airline industries, higher pricing generally conveys a signal of complexity and superiority of a service or product. However, in the healthcare industry, there is room to challenge the price-quality connection as both health prices and health quality can be difficult to interpret. In the best of circumstances, health care costs, prices, and quality can often be difficult to isolate and measure. Recent efforts by the Trump Administration and the Center for Medicare and Medicaid Services (CMS) have required the pricing of hospital services to be more transparent. Specifically, hospital chargemaster (retail) prices must now be available to the public. However, many continue to question if the pricing of health care services reflects the quality of service delivery. This research focuses on investigating the prices hospitals charge for their services in relation to the costs incurred and the association with the quality of care provided. By analyzing data from a nationwide sample of U.S. hospitals, this study considers the relationship between hospital pricing (as measured by the charge-to-cost ratio) and hospital quality performance as measured by the Value Based Purchasing Total Performance Score (TPS) and its associated sub-domains. Results of the study indicate that hospital prices, as measured by our primary independent variable of interest, the charge-to-cost ratio, are significantly and negatively associated with Total Performance Score, Patient Experience, and the Efficiency and Cost Reduction domains. A marginal statistically significant positive association is shown in the Clinical Care domain. The findings indicate that unlike most other industries, in medicine, higher pricing compared to cost does not necessarily associate with higher quality and, in fact, might indicate the opposite. The results of this study suggest that purchasers of healthcare, at all levels, have justification in challenging the pricing of healthcare services considering the quality scores available in the public domain.

Quality Indicators Associated With the Level of NCQA Accreditation.

The National Committee for Quality Assurance (NCQA) is the most widely used accrediting body of health plans, but no study has explored how differences in health quality affect the accreditation level. Consumers may benefit as they guide health insurance purchasing decisions toward a cost-quality evaluation. The authors conducted a multinomial logistic regression analysis using data from the 2015 NCQA Quality Compass of 351 health plans. This study's outcome variable represented NCQA accreditation at 3 levels: accredited, commendable, and excellent. The authors examined the relationship of patient satisfaction, monitoring and prevention activities, appropriate care, and readmission rates on accreditation level. Satisfaction and monitoring and prevention activities were significantly associated with higher levels of accreditation in all analyses, but readmission was not. The expanded coverage of the Affordable Care Act provides an opportunity for health plans to market to consumers the benefits of accreditation to foster higher quality care.

The Effects of Nursing Satisfaction and Turnover Cognitions on Patient Attitudes and Outcomes: A Three-Level Multisource Study.

OBJECTIVE: To explore antecedents and outcomes of nurse self-reported job satisfaction and dissatisfaction-based turnover cognitions, theorizing (using Self-Determination Theory) that leaders can foster work conditions that help fulfill innate needs, thereby fostering satisfaction of nurses and patients, and reducing adverse events. DATA SOURCES/STUDY SETTING: Primary and secondary data were collected within a 4-month period in 2015, from 2,596 nurses in 110 Army treatment facilities (hospitals and clinics) across 35 health care systems. DATA COLLECTION/EXTRACTION: We collected individual nurse responses to the Practice Environment Scale-Nursing Work Index, in addition to aggregated archival data from the same timeframe, including both facility-level patient satisfaction records (the Army Provider Level Satisfaction Survey) and health care system-level adverse events records (provided by the Army Programming, Analysis, and Evaluation office). PRINCIPAL FINDINGS: Five predictors of nurse satisfaction and turnover cognitions emerged-supportive leadership, staffing levels, nurse-physician teamwork, adoption of nursing care practice, and advancement opportunities. Aggregated nurse satisfaction was the most consistent predictor of both patient satisfaction and adverse events. CONCLUSION: These findings provide evidence of the importance of nurse attitudes in improving perceived and actual performance across facilities and health care systems; in addition to practical steps, managers can take to improve satisfaction and retention.

Finance at the front line. The effects of financial slack on community health center clinical process quality.

As the number of health centers increases through a federal initiative, questions remain about these primary care providers' capacity to provide sufficient care to the underserved. In the current study, the authors hypothesize that health centers with greater financial latitude or "slack" will provide medically appropriate primary care to greater proportions of their patients. Annual data from all US federally funded community health centers between 1998 and 2004 provide unusually rich data through which to test this hypothesis. Multilevel model results indicate positive associations between higher levels of net revenue and percentages of patients receiving preventive health care at baseline, as well as between initial net revenue and increases over time in post partum care access. Contrary to expectation, higher net revenue was also negatively associated with percentages of women getting post partum care at baseline. Also contrary to expectation, higher baseline levels of net revenue were associated with decreasing preventive care access over time. These mixed results imply that organizations' financial slack can affect quality, but in ways that vary across outcomes and over time.