Co-designing a theory-informed intervention to increase shared decision-making in maternity care.

BACKGROUND: Shared decision-making (SDM) has been shown to improve healthcare outcomes and is a recognized right of patients. Policy requires health services to implement SDM. However, there is limited research into what interventions work and for what reasons. The aim of the study was to develop a series of interventions to increase the use of SDM in maternity care with stakeholders. METHODS: Interventions to increase the use of SDM in the setting of pregnancy care were developed using Behaviour Change Wheel and Theoretical Domains Framework and building on findings of an in-depth qualitative study which were inductively analysed. Intervention development workshops involved co-design, with patients, clinicians, health service administrators and decision-makers, and government policy makers. Workshops focused on identifying viable SDM opportunities and tailoring interventions to the local context (the Royal Women's Hospital) and salient qualitative themes. RESULTS: Pain management options during labour were identified by participants as a high priority for application of SDM, and three interventions were developed including patient and clinician access to the Victorian Government's maternity record via the patient portal and electronic medical records (EMR); a multi-layered persuasive communications campaign designed; and clinical champions and SDM simulation training. Factors identified by participants for successful implementation included having alignment with strategic direction of the service, support of leaders, using pre-standing resources and workflows, using clinical champions, and ensuring equity. CONCLUSION: Three interventions co-designed to increase the use of SDM for pain management during labour address key barriers and facilitators to SDM in maternity care. This study exemplifies how health services can use behavioural science and co-design principles to increase the use of SDM. Insights into the co-design of interventions to implement SDM in routine practice provide a framework for other health services, policy makers and researchers.

The continued decline of plasma transfusions in Taiwan: An 11-year population-based study.

BACKGROUND AND OBJECTIVES: In Taiwan, plasma use per capita ranks among the highest in the world. We aimed to describe the trends in usage after the introduction of new hospital accreditation standards that evaluate compliance with institutional plasma transfusion guidelines. MATERIALS AND METHODS: We identified hospitalizations receiving plasma between 2007 and 2017 from the national health insurance database. We estimated plasma transfusions per thousand capita. The risk ratio of transfusion rates among hospitalizations in 2017 compared to 2007 was estimated using logistic regression. RESULTS: The total number of plasma transfusions declined from 964,408 in 2007 to 659,828 in 2017, yielding a rate of 28.00 per thousand capita. The proportion of hospitalizations receiving plasma declined by 38%, from 3.89% (95% confidence interval: 3.86%-3.91%) to 2.62% (2.61%-2.64%). Gastroenterology (16.4%) and general surgery (15.3%) accounted for the largest proportions of plasma usage. Within these two services, liver diseases were the top diagnoses needing plasma use. For hospitalized patients with liver diseases, approximately 40% of plasma units were administered to patients with neither noticeable bleeding nor red blood cells transfusions. Among these patients, almost 50% received plasma with an international normalized ratio trigger of less than 1.50. The use of potential alternative therapies or anticoagulants remained quite low during this period. CONCLUSION: Plasma utilization rates during hospitalizations continuously declined over 11 years. However, inappropriate plasma use remained high, while the use of alternative therapies remained low in services such as gastroenterology. To improve the appropriateness of plasma transfusions, patient blood management should be implemented in the near future.

Consecutive cycles of accreditation and quality of in-hospital care: a Danish population-based study.

BACKGROUND: Little is known about whether repeated cycles of hospital accreditation are a robust method to improve quality of care continuously. OBJECTIVE: We aimed to examine the association between compliance with consecutive cycles of accreditation and quality of in-hospital care. METHODS: We conducted a Danish nationwide population-based study including patients aged 18 years treated for acute stroke, chronic obstructive pulmonary disease, diabetes, heart failure or hip fracture at public, non-psychiatric hospitals. From 2012 to 2015, two cycles of national hospital accreditation were completed, resulting in 12 high and 14 low compliant hospitals (Low = partially accredited in both cycles). Our outcome measure was quality of in-hospital care measured by 39 process performance measures (PPMs), reflecting recommendations from the national clinical guidelines by adherence to (i) individual PPMs and (ii) the full bundle of PPMs (all-or-none). We computed adjusted odds ratios (ORs) using logistic regression based on robust standard error estimation for cluster sampling of data at hospital level. RESULTS: In total, 78 387 patient pathways covering 508 816 processes were included, of which 47% had been delivered at high compliant hospitals and 53% at low compliant hospitals, respectively. Compliance with consecutive cycles was not associated with improved quality of in-hospital care (individual: OR = 0.92, 95% confidence interval (CI): 0.77-1.10; All-or-none: OR = 0.87, 95% CI: 0.66-1.15). However, in the second cycle alone, patients treated at partially accredited hospitals had a lower adherence than patients treated at fully accredited hospitals (Individual: OR = 0.84, 95% CI: 0.71-0.99; All-or-none: OR = 0.78, 95% CI: 0.59-1.03). The association was particularly strong among patients treated at partially accredited hospitals required to submit additional documentation. CONCLUSION: Compliance with consecutive cycles of hospital accreditation in Denmark was not associated with improved quality of in-hospital care. However, compliance with the second cycle alone was associated with improved quality of in-hospital care.

National accreditation programmes for hospitals in the Eastern Mediterranean Region: Case studies from Egypt, Jordan, and Lebanon.

BACKGROUND: Many countries use external evaluation programmes such as accreditation in order to improve quality and safety in their healthcare settings. Hospital accreditation has developed in many low-and-middle-income countries (LMICs); however, the implementation and sustainability of these programmes vary in each country. This study addresses design and implementation issues of national hospital accreditation programmes. It identifies factors which may explain why programmes can be implemented successfully in one country but not in another and derives lessons for the design and implementation of national accreditation programmes in poor-resource settings. METHODS: A multiple case study design was used, comprising three countries in the Eastern Mediterranean Region: Egypt, Lebanon and Jordan. In-depth semi-structured interviews were conducted with 27 key stakeholders in the three countries and experts from international organisations concerned with accreditation activities in LMICs. RESULTS: The hospital accreditation programme was successful and sustainable in Jordan but experienced some difficulties in Egypt and Lebanon. The premature end of external funding and devastating political instability after the Arab Spring were problematic for the programmes in Egypt and Lebanon, but continuous funding and strong political will supported the implementation and sustainability of the programme in Jordan. CONCLUSIONS: LMICs striving to improve their hospitals' performance through accreditation programmes should consider their vulnerability to a scarcity of financial resources and political instability. An important factor underpinning sustainability is recognising that the accreditation programme is an ongoing and developing quality improvement process that needs continuing and careful attention from funders and political systems if it is to survive and thrive.

Iran hospital accreditation standards: challenges and solutions.

OBJECTIVE: The purpose of this study was to identify the challenges of Iranian hospital accreditation standards and provide solutions. DESIGN: A qualitative research design was used in this study. Open and semi-structured interviews were conducted in 2018. Thematic analysis was used to analyse qualitative data. SETTING: Public, private, semi-public, charity and military hospitals in Tehran, Iran. PARTICIPANTS: A pluralistic evaluation approach was employed and 151 participants including policy makers, hospital management and staff, accreditation surveyors and university professors participated in this study. RESULTS: Challenges of hospital accreditation standards were grouped into two groups: standards development process and standards content. Lack of an independent standards development committee, insufficient expertise of committee members, inconsistencies among the standards' constructs, inappropriate standard classification, ambiguity of standards, unmeasurable standards, vague and inflexible scoring system, and inability to use some standards were the main challenges of Iran hospital accreditation standards. Establishing a scientific committee consisting of representative from hospitals, health insurance companies, professional and scientific associations and universities for standard development, training the committee members, and utilizing hospital's feedback will help address these problems. CONCLUSION: Iran's hospital accreditation standards face challenges that prevent them from achieving their goals, that is, improving the quality, safety, effectiveness and efficiency of hospital services. Necessary measures should be taken to solve these problems.

Contextual factors favouring success in the accreditation process in Colombian hospitals: a nationwide observational study.

BACKGROUND: To identify context factors associated with and predicting success in the hospital accreditation process, and to contribute to the understanding of the relative relevance of context factors and their organizational level in the success of QI initiatives. METHODS: Analytical study of cases and controls in a sample of hospitals of medium and high complexity in Colombia. Cases (n = 16) are accredited hospitals by the time of preparation of the study (2016) and controls (n = 38) are similar facilities, which have not succeeded to obtain accreditation. Eligibility criteria for both groups included complexity (medium and high), having emergency services, an official quality assurance license, and being in operation for at least 15 years. Besides eligibility criteria, geographical location, and type of ownership (public/private) are used to select controls to match cases. Context measures are assessed using a survey instrument based on the MUSIQ model ("Model for Understanding Success in Quality") adapted and tested in Colombia. Statistical analysis includes descriptive measures for twenty-three context factors, testing for significant statistical differences between accredited and non-accredited hospitals, and assessing the influence and strength of association of context factors on the probability of success in the accreditation process. A multivariate model assesses the predictive probability of achieving accreditation. RESULTS: Eighteen (78.3%) of the twenty-three context factors are significantly different when comparing cases and controls hospitals, particularly at the Microsystem level; all factors are statistically significant in favor of accredited hospitals. Five context factors are strongly associated to the achievement of accreditation but in the logistic multivariable model, only two of them remain with significant OR, one in the Macrosystem, "Availability of economic resources for QI" (OR: 22.1, p: 0,005), and the other in the Microsystem, "Involvement of physicians" (OR: 4.9, p: 0,04). CONCLUSION: This study has applied an instrument, based on the MUSIQ model, which allows assessing the relevance of different context factors and their organizational level in hospitals, to explain success in the accreditation process in Colombia. Internal macrosystem and microsystem seem to be more relevant than external environment factors.

Creating a pathway for public hospital accreditation in Rwanda: progress, challenges and lessons learned.

QUALITY PROBLEM: Weaknesses in the quality of care delivered at hospitals translates into patient safety challenges and causes unnecessary harm. Low-and-middle-income countries disproportionately shoulder the burden of poor quality of hospital care. INITIAL ASSESSMENT: In the early 2000s, Rwanda implemented a performance-based financing (PBF) system to improve quality and increase the quantity of care delivered at its public hospitals. PBF evaluations identified quality gaps that prompted a movement to pursue an accreditation process for public hospitals. CHOICE OF SOLUTION: Since it was prohibitively costly to implement an accreditation program overseen by an external entity to all of Rwanda's public hospitals, the Ministry of Health developed a set of standards for a national 3-Level accreditation program. IMPLEMENTATION: In 2012, Rwanda launched the first phase of the national accreditation system at five public hospitals. The program was then expected to expand across the remainder of the public hospitals throughout the country. EVALUATION: Out of Rwanda's 43 public hospitals, a total of 24 hospitals have achieved Level 1 status of the accreditation process and 4 have achieved Level 2 status of the accreditation process. LESSONS LEARNED: Linking the program to the country's existing PBF program increased compliance and motivation for participation, especially for those who were unfamiliar with accreditation principles. Furthermore, identifying dedicated quality improvement officers at each hospital has been important for improving engagement in the program. Lastly, to improve upon this process, there are ongoing efforts to develop a non-governmental accreditation entity to oversee this process for Rwanda's health system moving forward.

Hospital accreditation impact on healthcare quality dimensions: a systematic review.

PURPOSE: To systematically review the impact of hospital accreditation on healthcare quality indicators, as classified into seven healthcare quality dimensions. DATA SOURCE: We searched eight databases in June 2020: EBSCO, PubMed, Web of Science, Emerald, ProQuest, Science Direct, Scopus and Virtual Health Library. Search terms were conceptualized into three groups: hospitals, accreditation and terms relating to healthcare quality. The eligibility criteria included academic articles that applied quantitative methods to examine the impact of hospital accreditation on healthcare quality indicators. STUDY SELECTION: We applied the PICO framework to select the articles according to the following criteria: Population-all types of hospitals; Intervention-hospital accreditation; Comparison-quantitative method applied to compare accredited vs. nonaccredited hospitals, or hospitals before vs. after accreditation; Outcomes-regarding the seven healthcare quality dimensions. After a critical appraisal of the 943 citations initially retrieved, 36 studies were included in this review. RESULTS OF DATA SYNTHESIS: Overall results suggest that accreditation may have a positive impact on efficiency, safety, effectiveness, timeliness and patient-centeredness. In turn, only one study analyzes the impact on access, and no study has investigated the impact on equity dimension yet. CONCLUSION: Mainly due to the methodological shortcomings, the positive impact of accreditation on healthcare dimensions should be interpreted with caution. This study provides an up-to-date overview of the main themes examined in the literature, highlighting critical knowledge-gaps and methodological flaws. The findings may provide value to healthcare stakeholders in terms of improving their ability to assess the relevance of accreditation processes.

Knowledge mapping of hospital accreditation research: a coword analysis.

PURPOSE: Hospital accreditation has been adopted internationally as a way and solution for healthcare quality improvement in hospitals. The purpose of this study was to review and knowledge mapping of bibliographic data about "Hospital Accreditation" and assess the current quantitative trends. DESIGN/METHODOLOGY/APPROACH: Scientometric methods and knowledge visualization using the coword analysis techniques conducted in three steps based on the data related to the field of hospital accreditation from 1975 to 2018 obtained from the MEDLINE database. Bibliographic data for titles, abstracts and keywords articles were saved in CSV format and MEDLINE templates by applying filters. Data extracted were exported into an Excel spreadsheet and were preprocessed. The authors applied the text mining and visualization using VOSviewer software. FINDINGS: Hospital accreditation studies have been increased rapidly over the past 30 years. 6,661 documents in the field of hospital accreditation had been published from 1975 to 2018. Hospitals or organizations active in the field of hospital accreditation were in the United States, Italy and Canada. The 10 most productive authors identified in the area of hospital accreditation with a higher influence were identified. "The United States", "accreditation", "Joint commission on accreditation" and "quality assurance, healthcare" had, respectively, the highest frequency. The cluster analysis identified and categorized them into four major clusters. Hospital accreditation field had a close relationship with the quality improvement, patient safety, risk and standards. ORIGINALITY/VALUE: Hospital accreditation had focused on the scopes of implementation of accreditation programs, adherence to JCI standards, and focus on safety and quality improvement. Future studies are recommended to be conducted on design interventions and paying attention to all dimensions of hospital accreditation.

Effects of National Hospital Accreditation in Acute Coronary Syndrome on In-Hospital Mortality and Clinical Outcomes.

BACKGROUND: Acute coronary syndrome (ACS) is a life-threatening medical condition that accounts for an annual expenditure of more than $300 billion in the United States. Hospital accreditation has been shown to improve patient and hospital outcomes for various conditions. OBJECTIVES: This study aimed to determine the benefits of hospital accreditation in patients with ACS. METHODS: This nationwide population-based cohort study used Taiwan's National Health Insurance Research Database from 1997 to 2011 (n = 249,354). Multivariable logistic regression was used to analyze the risk of in-hospital events among those treated in accredited and non-accredited hospitals, and to compare outcomes in hospitals before and after accreditation. The effect of accreditation on these events was also stratified by accreditation grade. RESULTS: A total of 823 hospitals were included, of which 2.4% were medical centers, 13.7% were regional hospitals, and 83.8% were district hospitals. The in-hospital mortality [odds ratio (OR), 0.82; 95% confidence interval (CI), 0.79-0.85; p < 0.001] and recurrent acute myocardial infarction (AMI) admission (OR, 0.81; 95% CI, 0.71-0.93; p = 0.003) rates were significantly lower in the after-accreditation group than in the before-accreditation group. There was a substantial and marked decrease in the in-hospital mortality rate after accreditation in 2008. CONCLUSIONS: This cohort study demonstrated that ACS accreditation was associated with better in-hospital mortality and recurrent AMI admission rates in ACS patients.

Impulse response function analysis of the impacts of hospital accreditations on hospital efficiency.

Improving hospital efficiency is an emerging area of interest among policy makers in the new global economy's healthcare system. To ensure accurate efficiency analyses, we consider the nonhomogeneous input/output characteristics of various hospital departments, particularly the Department of Medicine, Department of Surgery, and Department of Other Specialist Medicine. These departments employ co-inputs to produce nonhomogeneous outputs. Specifically, we employ data envelopment analysis to evaluate the efficiency of 15 veterans hospitals in Taiwan. Empirical results show that the performance of the Department of Surgery has higher quality than that of the Department of Medicine and Department of Other Specialist Medicine. In addition, we include another data science technique, namely, impulse response function analysis. The findings indicate that "the New Hospital Accreditation" introduced in 2007 and revised in 2011 improved the efficiency of all departments in their respective first year of introductions. By contrast, the efficiencies of the Department of Surgery and Department of Other Specialist Medicine immediately decreased in the second year after the introductions.

Hospitals accreditation status in Indonesia: associated with hospital characteristics, market competition intensity, and hospital performance?

BACKGROUND: Hospital accreditation is widely adopted as a visible measure of an organisation's quality and safety management standards compliance. There is still inconsistent evidence regarding the influence of hospital accreditation on hospital performance, with limited studies in developing countries. This study aims to explore the association of hospital characteristics and market competition with hospital accreditation status and to investigate whether accreditation status differentiate hospital performance. METHODS: East Java Province, with a total 346 hospitals was selected for this study. Hospital characteristics (size, specialty, ownership) and performance indicator (bed occupancy rate, turnover interval, average length of stay, gross mortality rate, and net mortality rate) were retrieved from national hospital database while hospital accreditation status were recorded based on hospital accreditation report. Market density, Herfindahl-Hirschman index (HHI), and hospitals relative size as competition indicators were calculated based on the provincial statistical report data. Logistic regression, Mann-Whitney U-test, and one sample t-test were used to analyse the data. RESULTS: A total of 217 (62.7%) hospitals were accredited. Hospital size and ownership were significantly associated with of accreditation status. When compared to government-owned, hospital managed by ministry of defense (B = 1.705, p = 0.012) has higher probability to be accredited. Though not statistically significant, accredited hospitals had higher utility and efficiency indicators, as well as higher mortality. CONCLUSIONS: Hospital with higher size and managed by government have higher probability to be accredited independent to its specialty and the intensity of market competition. Higher utility and mortality in accredited hospitals needs further investigation.

An international systems-theoretic comparison of hospital accreditation: developing an implementation typology.

OBJECTIVE: The integration of quality indicators into the accreditation process has been recognized as a promising strategy worldwide. This study was to explore the implementation patterns of hospital accreditation through the lens of a systems-theory based model, and determine an international accreditation implementation typology. DESIGN: A qualitative comparative study of five established international hospital accreditation systems was undertaken based on a systems-theoretic holistic healthcare systems relationship model. A set of key attributes relevant to three systems-theoretic model relationships guided data collection, comparison and synthesis. SETTING: Hospital accreditation systems in five countries: America, Canada, Australia, Taiwan and France. RESULTS: An accreditation implementation typology was developed based on the data synthesis of the similarities and differences among the relationships. A typology including five implementation types of hospital accreditation systems (TYPE I-V) was induced. TYPE I is a basic stand-alone accreditation system. The higher types represent stronger relationships among accreditation system, healthcare organizations and quality measurement systems. The five settings have shifted their accreditation approaches from the basic type (TYPE I). CONCLUSIONS: The implementation typology of hospital accreditation could serve as a roadmap for refining hospital accreditation systems toward an integrative approach for continuous quality improvement.

Role of a hospital accreditation program in developing a process management system.

PURPOSE: The purpose of this paper is to clarify the effects of the Iranian Hospital Accreditation Program (IHAP) on hospital processes from the viewpoint of the staff charged with establishing the program. DESIGN/METHODOLOGY/APPROACH: This qualitative study is based on the data collected in semi-structured interviews conducted in 2016, which involved eight questions. Interviews were held with 70 staff members at 14 hospitals. Managerial staff were purposively interviewed based on their familiarity and involvement with the program. The hospitals were divided into five groups, comprising public, private, charity, military and social service hospitals. A thematic analysis was carried out using the collected data. FINDINGS: Three themes emerged from the data, which together comprise a process management cycle: the establishment, implementation, and control phases of the program. For each phase, various positive trends, as well as hurdles for establishing the program, declared which were framed two sub-themes as positive effects and challenges. ORIGINALITY/VALUE: The findings contribute to the body of evidence used by policy-makers and hospital managers to improve the change management processes related to the Iranian IHAP. Although positive changes in the process management cycles at Iranian hospitals were noted, successful implementation of the program demands a thorough assessment of the hospitals' technical and financial needs (taking into account disparities between hospitals), and there is an urgent requirement for a plan to meet these needs.

[Psychometric validation of an instrument to evaluate the context of quality improvement and accreditation of hospitals]. / Validación psicométrica de instrumento para evaluar contexto de mejora de calidad y acreditación de hospitales.

OBJECTIVE: To adapt and validate an instrument to measure the context factors which favor quality improvement initiatives and accreditation of hospitals. MATERIALS AND METHODS: The model and questionnaire Model for Understanding Success in Quality (MUSIQ) is adapted and validated for application in Spanish-speaking countries and its specific use in hospital accreditation projects. The theoretical construct of its dimensions is assessed by confirmatory factor analysis (Bartlett test and Kaiser-Meyer-Olkim index) and internal consistency (Cronbach's a), in a study carried out in a sample of 54 hospitals of medium and high complexity in Colombia. RESULTS: Instrument with four dimensions of context (environment, macrosystem, microsystem, quality team), composed of 23 elements that are measured through 35 variables. Factor analysis showed statistical significance and adequacy of the dimensions, which had also good internal consistency. CONCLUSIONS: Adapted instrument with useful- ness for measurement of context elements that can promote initiatives of improvement and accreditation in hospitals.

OBJETIVO: Adaptar y validar instrumento para medir elementos del contexto que pueden favorecer iniciativas de mejoramiento de la calidad y acreditación de hospitales. MATERIAL Y MÉTODOS: Se adaptó y validó modelo y cuestionario Model for Understanding Success in Quality (MUSIQ) para aplicación en países hispanoparlantes y uso específico para proyectos de acreditación de hospitales. Se realizó un análisis factorial confirmatorio (test de Bartlett e índice Kaiser-Meyer-Olkim) del constructo teórico de sus dimensiones y se comprueba consistencia interna en estudio realizado en muestra de 54 hospitales de mediana y alta complejidad en Colombia. RESULTADOS: Instrumento con cuatro dimensiones de contexto (ambiente, macrosistema, microsistema, equipo de calidad), compuestas por 23 elementos medidos a través de 35 variables. El análisis factorial mostró significancia estadística y adecuación de las dimensiones que tuvieron también buena consistencia interna. CONCLUSIONES: Instrumento adaptado con utilidad para monitorizar elementos del contexto que pueden favorecer iniciativas de mejora y acreditación en hospitales.

Residents' perception of duty hour limits through teaching hospital accreditation status-experience in Taiwan.

Residents' work overload is a rising issue in Taiwan. Duty hours of the residents in the United States have been limited by the Accreditation Council for Graduate Medical Education Common Program Requirements since 2003; similar standards were not implemented in Taiwan until 2013. Taiwanese duty hour standards are the work hour limits adopted as part of the required teaching hospital accreditation status. In January 2015, the Ministry of Health and Welfare conducted a national survey for all house officers in Taiwan. We collected data including those on demographics and perceptions of residents regarding duty hour limits. Most respondents reported positive perceptions of the duty hour standards. They felt that these limits will improve resident education, quality of life, and patient safety. The strong incentive to follow the regulations (through teaching hospital accreditation) could help protect residents (and patients) from unsafe working conditions. However, further studies on the influence of shortened duty hour on professional development are necessary for future improvement.

Mortality and cost of radiation therapy for oesophageal cancer according to hospital accreditation level: a nationwide population-based study.

This study examined and analysed the relationship between the cost-effectiveness and outcome of radiotherapy for oesophageal cancer among hospitals with varying accreditation levels. We selected 428 oesophageal cancer patients from medical and non-medical centres using the National Health Insurance Research Database, which is maintained by the Taiwanese National Health Research Institutes, and compared their medical expenditure and the outcome of their radiotherapy treatment. In this study cohort of patients with oesophageal cancer, 278 patients were treated in medical centres (mean age: 60.1 years) and 150 patients were treated in non-medical centres (mean age: 62.0 years, P = 0.16). The medical centre group exhibited significantly lower medical expenses, mortality and risk of death compared with the non-medical centre group (adjusted hazard ratio = 1.38, 95% confidence interval = 1.11-1.71). Our study determined that radiotherapy for oesophageal cancer costs significantly less, and medical centres had lower mortality rates than non-medical centres. These findings could provide professional organisations and healthcare policy makers with essential information for allocation of resources.

[Centennial retrospective on the evolution and development of the nursing practice environment in Taiwan].

The practice environment for nurses has seen tremendous change over the past century due to the dedication and trailblazing work of nursing pioneers. This article describes how the nursing practice environment in Taiwan has evolved over this period. References used include nursing narratives, hospital accreditation standards, standard operating procedures, workplace safety standards, and worksite-related values and expectations. The efforts of the professional nursing community to realize a positive practice environment are further discussed. Over this century of change, the only thing that has remained unchanged is the commitment of nurses to "treat patients as one's own family". In the current as well as the previous periods of manpower shortages in nursing, the nursing community has managed to turn crisis into opportunity by using the situation to enhance pay and benefits. Nursing professionalism is widely respected and recognized throughout Taiwan society. The rapidly changing needs of the 21st century in aspects such as the advancement of high technology, the rapid growth of the elderly population, and the fast rate of social change seriously impact the development of the nursing profession. How to effectively apply high technology, simplify workflows, provide high quality and humanistic nursing care, build safe and quality workplaces, attract bright nursing students, and provide healthcare for the entire population will remain the responsibilities of nursing for generations to come.

Geographic distance to Commission on Cancer-accredited and nonaccredited hospitals in the United States.

PURPOSE: The Commission on Cancer (CoC) establishes standards to support multidisciplinary, comprehensive cancer care. CoC-accredited cancer programs diagnose and/or treat 73% of patients in the United States. However, rural patients may experience diminished access to CoC-accredited cancer programs. Our study evaluated distance to hospitals by CoC accreditation status, rurality, and Census Division. METHODS: All US hospitals were identified from public-use Homeland Infrastructure Foundation-Level Data, then merged with CoC-accreditation data. Rural-Urban Continuum Codes (RUCC) were used to categorize counties as metro (RUCC 1-3), large rural (RUCC 4-6), or small rural (RUCC 7-9). Distance from each county centroid to the nearest CoC and non-CoC hospital was calculated using the Great Circle Distance method in ArcGIS. FINDINGS: Of 1,382 CoC-accredited hospitals, 89% were in metro counties. Small rural counties contained a total of 30 CoC and 794 non-CoC hospitals. CoC hospitals were located 4.0, 10.1, and 11.5 times farther away than non-CoC hospitals for residents of metro, large rural, and small rural counties, respectively, while the average distance to non-CoC hospitals was similar across groups (9.4-13.6 miles). Distance to CoC-accredited facilities was greatest west of the Mississippi River, in particular the Mountain Division (99.2 miles). CONCLUSIONS: Despite similar proximity to non-CoC hospitals across groups, CoC hospitals are located farther from large and small rural counties than metro counties, suggesting rural patients have diminished access to multidisciplinary, comprehensive cancer care afforded by CoC-accredited hospitals. Addressing distance-based access barriers to high-quality, comprehensive cancer treatment in rural US communities will require a multisectoral approach.

How Professional and Market Logics and the Conflict between Institutional Demands Affect Hospital Accreditation Compliance: A Multiple-Case Study in Brazil.

Hospital accreditation has become ubiquitous in developing countries. While research acknowledges that accreditation can enhance healthcare quality, efficiency, and safety, concerns persist regarding hospitals' management of conflicts stemming from the diverse institutional logic inherent in this process. Therefore, this study aimed to investigate how professional and market logic, alongside conflicts arising from institutional demands, affect compliance with hospital accreditation. To this end, we conducted a multiple-case study in four Brazilian hospitals employing in-depth interviews and on-site observations. The triangulation of narrative analysis and the outcomes of multiple correspondence analysis revealed that when professional logic predominates, there is a greater propensity to tailor accredited activities by segmenting the tasks between physicians and nurses with the intention of mitigating existing conflicts. Conversely, when conflicts occur over established goals between professionals and orientated marked logic executives, the accreditation process is impeded, resulting in non-compliance. Ultimately, the findings underscore the alignment between the pursuit of legitimacy and efficiency within the accreditation process. We conclude by delineating the theoretical and practical implications of scrutinizing the internal dynamics of institutional logic.