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

BACKGROUND: Although all hospitals aim to deliver high-quality care, there is considerable variation in their adoption of quality management (QM) practices. Organizational and environmental factors are known to drive strategic decision-making in hospitals, but their impact on the adoption of QM practices remains unclear. PURPOSE: Our study aims to identify multiple organizational and environmental factors that explain variation in the adoption of QM practices among hospitals and to explore mechanisms underlying these relationships. METHODOLOGY: We conducted a two-phase, sequential mixed-methods study of German acute care hospitals. The quantitative phase used between-effects regressions to identify factors explaining variation in the number of QM practices adopted by hospitals from 2015 to 2019. The qualitative phase used semistructured interviews with quality managers to gain in-depth insights. RESULTS: The number of QM practices adopted by a hospital was significantly associated with factors like hospital size and the presence of an emergency department or QM steering committee. Our qualitative findings highlighted potential mechanisms such as the presence of an emergency department serving as a proxy for organizational complexity or urgency of case-mix. CONCLUSION: We provide an overview of factors driving QM adoption in hospitals, extending beyond the focus on single factors in previous research. Future studies could explore additional factors highlighted by our interviewees. PRACTICE IMPLICATIONS: Our results can inform interventions to strengthen QM in hospitals and guide future research on this topic.

Measuring patients' experience of nursing quality in acute hospitals: review of existing scales and development and psychometric validation of a new scale.

OBJECTIVE: To provide an overview of existing instruments measuring patient-perceived quality of nursing care and to develop and psychometrically evaluate a new multidimensional scale applicable to the German acute care sector. DESIGN: We conducted a scale development and validation study involving the following phases: (1) performing a structured literature search to identify existing scales, (2) generating an initial pool of items using the results of the literature search and expert interviews, (3) coding/categorising the item pool, (4) organising a peer researcher workshop to select relevant items, (5) drafting the survey questionnaire and conducting cognitive pretesting, (6) pilot testing the survey questionnaire, (7) administering the survey to a large sample of hospital patients and (8) conducting a psychometric evaluation comprising exploratory factor analysis using the survey results, followed by confirmatory factor analysis and reliability and validity assessment of the resulting draft scale. SURVEY PARTICIPANTS: 17 859 recently hospitalised patients discharged from non-intensive care in non-paediatric and non-psychiatric hospital units in Germany between May and October 2019. RESULTS: We identified 32 instruments comprising 635 items on nursing care quality. Alongside 135 indicators derived from expert interviews, these formed our initial item pool, which we coded into 15 categories. From this pool, 36 items were selected in the peer researcher workshop for pretesting and psychometric evaluation. Based on the results of our exploratory and confirmatory factor analyses, we propose a second-order scale to measure Patients' Experience of Nursing Quality in Acute Hospitals (PENQuAH), including the two higher-order dimensions 'patients' perception of direct nursing care activities' and 'patients' perception of guidance provided by nurses'. The results of various tests suggest the scale has sufficient goodness of fit, reliability and validity. CONCLUSIONS: The PENQuAH scale is promising in terms of its psychometric properties, the plausibility and meaningfulness of its dimensions, and its ease of use.

Factors Influencing the Acceptability, Acceptance, and Adoption of Conversational Agents in Health Care: Integrative Review.

BACKGROUND: Conversational agents (CAs), also known as chatbots, are digital dialog systems that enable people to have a text-based, speech-based, or nonverbal conversation with a computer or another machine based on natural language via an interface. The use of CAs offers new opportunities and various benefits for health care. However, they are not yet ubiquitous in daily practice. Nevertheless, research regarding the implementation of CAs in health care has grown tremendously in recent years. OBJECTIVE: This review aims to present a synthesis of the factors that facilitate or hinder the implementation of CAs from the perspectives of patients and health care professionals. Specifically, it focuses on the early implementation outcomes of acceptability, acceptance, and adoption as cornerstones of later implementation success. METHODS: We performed an integrative review. To identify relevant literature, a broad literature search was conducted in June 2021 with no date limits and using all fields in PubMed, Cochrane Library, Web of Science, LIVIVO, and PsycINFO. To keep the review current, another search was conducted in March 2022. To identify as many eligible primary sources as possible, we used a snowballing approach by searching reference lists and conducted a hand search. Factors influencing the acceptability, acceptance, and adoption of CAs in health care were coded through parallel deductive and inductive approaches, which were informed by current technology acceptance and adoption models. Finally, the factors were synthesized in a thematic map. RESULTS: Overall, 76 studies were included in this review. We identified influencing factors related to 4 core Unified Theory of Acceptance and Use of Technology (UTAUT) and Unified Theory of Acceptance and Use of Technology 2 (UTAUT2) factors (performance expectancy, effort expectancy, facilitating conditions, and hedonic motivation), with most studies underlining the relevance of performance and effort expectancy. To meet the particularities of the health care context, we redefined the UTAUT2 factors social influence, habit, and price value. We identified 6 other influencing factors: perceived risk, trust, anthropomorphism, health issue, working alliance, and user characteristics. Overall, we identified 10 factors influencing acceptability, acceptance, and adoption among health care professionals (performance expectancy, effort expectancy, facilitating conditions, social influence, price value, perceived risk, trust, anthropomorphism, working alliance, and user characteristics) and 13 factors influencing acceptability, acceptance, and adoption among patients (additionally hedonic motivation, habit, and health issue). CONCLUSIONS: This review shows manifold factors influencing the acceptability, acceptance, and adoption of CAs in health care. Knowledge of these factors is fundamental for implementation planning. Therefore, the findings of this review can serve as a basis for future studies to develop appropriate implementation strategies. Furthermore, this review provides an empirical test of current technology acceptance and adoption models and identifies areas where additional research is necessary. TRIAL REGISTRATION: PROSPERO CRD42022343690; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=343690.

The contagious leader: a panel study on occupational stress transfer in a large Danish municipality.

Occupational stress has immense economic and health-related consequences for individuals, organizations, and societies. In this context, the question of whether and how stress among managers transmits to their subordinates is highly interesting, yet not profoundly researched. This study aims to empirically investigate the effect of manager occupational stress on the development of subordinate stress and for how long such effects last in time. We exploit a unique panel dataset based on three different surveys among employees from a large Danish municipality, covering 5,688 employees and their 473 immediate managers between 2016 and 2020. We analyze this data using a fixed effects estimator with clustered robust standard errors, allowing us to significantly reduce potential endogeneity issues. The study shows that managers do in fact 'transmit' stress onto their employees, that the relationship is detectable a full year after the initial transmission of stress occurred, and that such an effect fades within additional two years. Our study serves to emphasize the great importance of the psychosocial wellbeing of managers as 'nerve centers' for entire job teams and urges organizations to treat stress among personnel on management levels with a high degree of concern.

What is the impact of introducing a non-clinical community health advice and navigation service on the demand for primary care in socially deprived areas? Evidence from an observational panel study with difference-in-differences design.

OBJECTIVES: To examine the effect of introducing a non-clinical community health advice and navigation service on the demand for primary care in a socially deprived area. DESIGN: Observational panel study with difference-in-differences design. We conducted fixed-effects negative binomial regressions to compare changes in the number of visits to general practitioners (GPs) in individuals who visited the health advice and navigation service and a matched control group of individuals who did not visit the service. In addition, we analysed the effects of visiting the service multiple times. SETTING AND PARTICIPANTS: Our empirical setting is a socially deprived urban area in Germany with a multicultural population of about 110 000 people. Our analyses are based on patient data (N=1044) from a non-clinical community health advice and navigation service and from two statutory health insurers. OUTCOME MEASURES: Patient demand for primary care measured as the number of visits to GPs before and after the first visit to the health advice and navigation service. RESULTS: Visiting the service for the first time significantly decreased the number of GP visits compared with the control group (ß=-0.113, p<0.1). Each additional visit to the service, however, significantly decreased the effect of the first visit (ß=0.037, p<0.05). CONCLUSIONS: Our findings suggest that non-clinical community health advice and navigation services can serve as a low-threshold first point of contact. As first point contact, such services might possibly reduce the burden of primary care physicians in socially deprived areas. At the same time, such services might function as a gateway to accessing the health system, reducing unmet care needs and stimulate demand. Ongoing counselling in the service can identify medical needs that require a physician visit. Our findings may be useful for policymakers and healthcare leaders seeking to reduce the demand on the primary care workforce and can stimulate further research in this area.

Treatment and Coronary Artery Aneurysm Formation in Kawasaki Disease: A Per-Day Risk Analysis.

OBJECTIVE: To assess whether 'treatment day' is a significant predicting factor in Kawasaki disease and imposes a risk for coronary artery aneurysms (CAAs) in a per-day analysis. CAA formation can be reduced from 25% to 10% when treated with intravenous immunoglobulin (IVIG). STUDY DESIGN: Patient data from (n = 1016) a single center were collected for an observational cohort study. After exclusions, we retrospectively analyzed 776 patients in total. A multivariate analysis was performed with treatment day as a continuous variable (n = 691). Patients were categorized as no enlargement, small CAA, medium CAA, and giant CAA. RESULTS: Late treatment per-day was a significant predicting factor for the development of larger CAAs. ORs for medium and giant CAAs per delayed day were 1.1 (95% CI 1.1-1.2) P < .05 and 1.2 (95% CI 1.1-1.2) P < .05, respectively. CONCLUSION: We showed that every day of delay in treatment of patients with Kawasaki disease inherently carries a risk of medium and giant aneurysm formation. There was no cut-off point for treatment day that could mark a safe zone.

Nurse staffing and patient-perceived quality of nursing care: a cross-sectional analysis of survey and administrative data in German hospitals.

OBJECTIVE: To examine the impact of nurse staffing on patient-perceived quality of nursing care. We differentiate nurse staffing levels and nursing skill mix as two facets of nurse staffing and use a multidimensional instrument for patient-perceived quality of nursing care. We investigate non-linear and interaction effects. SETTING: The study setting was 3458 hospital units in 1017 hospitals in Germany. PARTICIPANTS: We contacted 212 554 patients discharged from non-paediatric, non-intensive and non-psychiatric hospital units who stayed at least two nights in the hospital between January and October 2019. Of those, 30 174 responded, yielding a response rate of 14.2%. Our sample included only those patients. After excluding extreme values for our nurse staffing variables and removing observations with missing values, our final sample comprised 28 136 patients ranging from 18 to 97 years of age (average: 61.12 years) who had been discharged from 3458 distinct hospital units in 1017 hospitals. PRIMARY AND SECONDARY OUTCOME MEASURES: Patient-perceived quality of nursing care (general nursing care, guidance provided by nurses, and patient loyalty to the hospital). RESULTS: For all three dimensions of patient-perceived quality of nursing care, we found that they significantly decreased as (1) nurse staffing levels decreased (with decreasing marginal effects) and (2) the proportion of assistant nurses in a hospital unit increased. The association between nurse staffing levels and quality of nursing care was more pronounced among patients who were less clinically complex, were admitted to smaller hospitals or were admitted to medical units. CONCLUSIONS: Our results indicate that, in addition to nurse staffing levels, nursing skill mix is crucial for providing the best possible quality of nursing care from the patient perspective and both should be considered when designing policies such as minimum staffing regulations to improve the quality of nursing care in hospitals.

The impact of nurse staffing levels on nursing-sensitive patient outcomes: a multilevel regression approach.

The goal of this study is to provide empirical evidence of the impact of nurse staffing levels on seven nursing-sensitive patient outcomes (NSPOs) at the hospital unit level. Combining a very large set of claims data from a German health insurer with mandatory quality reports published by every hospital in Germany, our data set comprises approximately 3.2 million hospital stays in more than 900 hospitals over a period of 5 years. Accounting for the grouping structure of our data (i.e., patients grouped in unit types), we estimate cross-sectional, two-level generalized linear mixed models (GLMMs) with inpatient cases at level 1 and units types (e.g., internal medicine, geriatrics) at level 2. Our regressions yield 32 significant results in the expected direction. We find that differentiating between unit types using a multilevel regression approach and including postdischarge NSPOs adds important insights to our understanding of the relationship between nurse staffing levels and NSPOs. Extending our main model by categorizing inpatient cases according to their clinical complexity, we are able to rule out hidden effects beyond the level of unit types.

Staffing levels and nursing-sensitive patient outcomes: Umbrella review and qualitative study.

OBJECTIVE: To derive a comprehensive list of nursing-sensitive patient outcomes (NSPOs) from published research on nurse staffing levels and from expert opinion. DATA SOURCES/STUDY SETTING: Published literature reviews and their primary studies analyzing the link between nurse staffing levels and NSPOs and interviews with 16 experts on nursing care. STUDY DESIGN: Umbrella review and expert interviews. DATA COLLECTION/EXTRACTION METHODS: We screened three electronic databases for literature reviews on the association between nurse staffing levels and NSPOs. After screening 430 potentially relevant records, we included 15 literature reviews, derived a list of 22 unique NSPOs from them, and ranked these in a systematic fashion according to the strength of evidence existing for their association with nurse staffing. We extended this list of NSPOs based on data from expert interviews. PRINCIPAL FINDINGS: Of the 22 NSPOs discussed in the 15 included literature reviews, we rated the strength of evidence for four as high, for five as moderate, and for 13 outcomes as low. Four additional NSPOs that have not been considered in literature were identified through expert interviews. CONCLUSIONS: We identified strong evidence for a significant association between nurse staffing levels and NSPOs. Our results may guide researchers in selecting NSPOs they might wish to prioritize in future studies. In particular, rarely studied NSPOs as well as NSPOs that were only identified through expert interviews but have not been considered in literature so far should be subject to further research.

One-Year COMBO Stent Outcomes in Acute Coronary Syndrome: from the COMBO Collaboration.

PURPOSE: The COMBO biodegradable polymer sirolimus-eluting stent includes endothelial progenitor cell capture (EPC) technology for rapid endothelialization, which may offer advantage in acute coronary syndromes (ACS). We sought to analyze the performance of the COMBO stent by ACS status and ACS subtype. METHODS: The COMBO collaboration (n = 3614) is a patient-level pooled dataset from the MASCOT and REMEDEE registries. We evaluated outcomes by ACS status, and ACS subtype in patients with ST segment elevation myocardial infarction (STEMI) or non-STEMI (NSTEMI) versus unstable angina (UA). The primary endpoint was 1-year target lesion failure (TLF), composite of cardiac death, target vessel myocardial infarction, or clinically driven target lesion revascularization. Secondary outcomes included stent thrombosis (ST). RESULTS: We compared 1965 (54%) ACS and 1649 (46.0%) non-ACS patients. ACS presentations included 40% (n = 789) STEMI, 31% (n = 600) NSTEMI, and 29% (n = 576) UA patients. Risk of 1-year TLF was greater in ACS patients (4.5% vs. 3.3%, HR 1.51 95% CI 1.01-2.25, p = 0.045) without significant differences in definite/probable ST (1.1% vs 0.5%, HR 2.40, 95% CI 0.91-6.31, p = 0.08). One-year TLF was similar in STEMI, NSTEMI, and UA (4.8% vs 4.8% vs. 3.7%, p = 0.60), but definite/probable ST was higher in STEMI patients (1.9% vs 0.5% vs 0.7%, p = 0.03). Adjusted outcomes were not different in MI versus UA patients. CONCLUSIONS: Despite the novel EPC capture technology, COMBO stent PCI was associated with somewhat greater risk of 1-year TLF in ACS than in non-ACS patients, without significant differences in stent thrombosis. No differences were observed in 1-year TLF among ACS subtypes.

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

BACKGROUND: Against the background of increasing workforce-related challenges such as staff shortages, strategic human resource management (SHRM) has gained importance in hospitals. Although the positive implications of SHRM for hospital performance are well known and commonly accepted in research and practice, hospitals still vary in its use. However, the sources of variations in hospitals' use of SHRM are largely unknown. PURPOSE: Various organizational and environmental factors were used in this study to explain the variations in hospitals' use of SHRM for physicians and nurses. METHODOLOGY: Data were obtained from a hospital survey (n = 172) on topics related to human resource management in hospitals and linked to different secondary data sets. We apply multiple linear regression modeling to investigate the association between organizational and environmental characteristics and hospitals' use of SHRM for nurses and physicians. FINDINGS: Our results suggest that organizational factors such as private for-profit and nonprofit ownership (compared to public ownership), academic teaching status, and the strategic involvement of the human resource administration are positively associated with hospitals' use of SHRM. None of the environmental factors investigated in this study was significantly related to hospitals' use of SHRM. PRACTICAL IMPLICATIONS: The study results increase our understanding of variations in hospitals' use of SHRM. Although organizational characteristics were found to explain variations in SHRM, environmental factors seem unrelated with hospitals' use of SHRM. Our results inform both hospital managers and policy makers about possible approaches to enhance SHRM use in hospitals. Furthermore, profound knowledge about factors associated with SHRM will help to enhance our understanding of anticipating changes in hospitals' use of SHRM through organizational- and environmental-oriented interventions.

Once is rarely enough: can social prescribing facilitate adherence to non-clinical community and voluntary sector health services? Empirical evidence from Germany.

BACKGROUND: Non-clinical health interventions provided by the voluntary and community sector can improve patients' health and well-being and reduce pressure on primary and secondary care, but only if patients adhere to them. This study provides novel insights into the impact of doctor referrals to such services, known as social prescribing, on patients' adherence to them. METHODS: Using a negative binomial model, we analysed electronic visitor records from a community health advice and navigation service in Germany between January 2018 and December 2019 to determine whether social prescribing was associated with greater adherence to the service (measured in terms of return visits) compared to patients who self-referred. We also explored whether this effect differed according to patient characteristics. RESULTS: Based on 1734 observations, we found that social prescribing was significantly associated with a greater number of return visits compared to patient self-referrals (p < 0.05). For patients who visited the service because of psychological concerns, the effect of social prescribing was lower. For all other patient characteristics, the effect remained unchanged, suggesting relevance to all other patient groups. CONCLUSIONS: The results of our study indicate that social prescribing may be an effective way to facilitate adherence to non-clinical community and voluntary sector health services. This knowledge is important for policy makers who are deciding whether to implement or expand upon social prescribing schemes.

Public managers' role in creating workplace social capital (WSC) and its effect on employees' well-being and health: a protocol of a longitudinal cohort study (PUMA-WSC).

INTRODUCTION: Workplace social capital (WSC) has been shown to affect employees' well-being and health, yet it is not clear how public managers can create WSC and which forms of WSC are most important. This study is the first prospective cohort study to examine the relationship between management behaviour, WSC, well-being and sickness absence. It uses a validated and detailed scale on WSC, which can distinguish between bonding, bridging, linking and organisational WSC over time. The study thereby provides rich data giving a much-needed detailed image of how WSC impacts on public employees' well-being and health. Additionally, the study pays special attention to the fact that these relationships can be different for different types of employees and therefore tests a set of relevant employee and context-related variables. METHODS AND ANALYSIS: Project preparations in terms of agreements and data preparation of existing data started in 2019. This prospective cohort study considers and collects organisational data from 2016 to 2025. Annual employee surveys of more than 8000 employees (in a large Danish municipality) will be combined with register data in all years. This generates a unique cohort of public employees in different professions that are traceable over several years. The annual surveys include information on the management behaviour, WSC and employee outcomes. Fine-grained information on sickness absences will be matched for all employees and years under study. Moreover, confounders and the nested nature of the data will be considered. ETHICS AND DISSEMINATION: Approval has been obtained from The Regional Committee on Health Research Ethics from Southern Denmark and from the University of Southern Denmark. The results will be presented at conferences and published in international peer-reviewed journals and in a practice-oriented monography targeted at public managers. The result will furthermore be disseminated to the involved employees through seminars and workshops in the participating organisations.

1-Year Outcomes with COMBO Stents in Small-Vessel Coronary Disease: Subgroup Analysis From the COMBO Collaboration.

BACKGROUND: Small vessel diameter is associated with higher risk of target lesion revascularization (TLR) after percutaneous coronary intervention (PCI). The COMBO sirolimus-eluting biodegradable-polymer stent has a proprietary anti-CD34 antibody layer to enhance homogeneous endothelialization, which may be advantageous in treating small vessels. OBJECTIVE: We examined for differences in 1-year clinical outcomes after PCI by maximum implanted stent diameter from the COMBO collaboration. METHODS: The COMBO collaboration (n = 3614) is a patient-level pooled dataset of patients undergoing PCI with COMBO stents in the MASCOT and REMEDEE multicenter registries. Stent diameter was available in 3590 (99.3%) patients. We compared patients receiving COMBO stents <3 mm versus ≥3 mm. The primary endpoint was 1-year target lesion failure (TLF), composite of cardiac death, target vessel-myocardial infarction (TV-MI) or clinically driven TLR. Secondary outcomes included stent thrombosis (ST). Adjusted outcomes were assessed using Cox regression methods. RESULTS: The study included 792 (22%) patients with small stents <3 mm and 2798 (78%) patients with large stents ≥3 mm. Small stent patients included more women with lower body mass index and higher prevalence of diabetes but similar prevalence of acute coronary syndrome. Risk of 1-year TLF was similar in small and large stent groups (4.4% vs. 3.8%, HR 1.12, 95% CI 0.74-1.72, p = 0.58). There were no differences in the rates of cardiac death (1.7% vs. 1.5%, p = 0.74), TV-MI (1.4% vs. 1.2%, p = 0.58) or TLR (2.7% vs. 2.1%, p = 0.31). Definite or probable ST occurred in 1.3% of the small stent and 0.7% of the large stent PCI patients, p = 0.14, HR 2.13, 95% CI 0.93-5.00, p = 0.07. CONCLUSIONS: One-year ischemic outcomes after COMBO PCI were similar irrespective of stent diameter in this all-comers international cohort.

A Systematic Review of the Association Between Hospital Cost/price and the Quality of Care.

BACKGROUND: Limited empirical evidence exists regarding the effect of price changes on hospital behavior and, ultimately, the quality of care. Additionally, an overview of the results of prior literature is lacking. OBJECTIVE: This study aims to provide a synthesis of existing research concerning the relationship between hospital cost/price and the quality of care. METHODS: Searches for literature related to the effect of hospital cost and price on the quality of care, including studies published between 1990 and March 2019, were carried out using four electronic databases. In total, 47 studies were identified, and the data were extracted and summarized in different tables to identify the patterns of the relationships between hospital costs/prices and the quality of care. RESULTS: The study findings are highly heterogenous. The proportion of studies detecting a significant positive association between price/cost and the quality of care is higher when (a) price/reimbursement is used (instead of cost); (b) process measures are used (instead of outcome measures); (c) the focus is on acute myocardial infarction, congestive heart failure, and stroke patients (instead of patients with other clinical conditions or all patients); and (d) the methodological approach used to address confounding is more sophisticated. CONCLUSION: Our results suggest that there is no general relationship between cost/price and the quality of care. However, the relationship seems to depend on the condition and specific resource utilization. Policy makers should be prudent with the measures used to reduce hospital costs to avoid endangering the quality of care, especially in resource-sensitive settings.

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

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

Board characteristics, governance objectives, and hospital performance: An empirical analysis of German hospitals.

BACKGROUND: There is a growing need for hospital supervisory boards to support hospital management in different areas, including (financial) monitoring, resource provision, stakeholder relationships, and strategic decision-making. Little is currently known about how boards' emphases on these various governance objectives contribute to performance. PURPOSE: Using a dominant logics perspective, this article aims to detect the governance logics that hospital boards emphasize, to determine whether there are distinct clusters of hospitals with the same sets of emphases, and to show how cluster membership relates to board characteristics and financial performance. METHODOLOGY: Using factor analysis, we identify latent classes of governance objectives and use hierarchical cluster analysis to detect distinct clusters with varying emphasis on the classes. We then use multinomial regression to explore the associations between cluster membership and board characteristics (size, gender diversity, and occupational diversity) and examine the associations between clusters and financial performance using OLS regression. RESULTS: Classes of objectives reflecting three governance theories-agency theory, stewardship theory, and stakeholder theory-can be distinguished, and hospitals can be divided into four clusters based on their board's relative emphasis on the classes. Cluster membership is significantly associated with board characteristics. There is also a significant association between cluster membership and hospital financial performance, with two of three groups performing significantly better than the reference group. CONCLUSION: High performance in hospitals can be the result of governance logics, which, compared to simple board characteristics, are associated with better financial outcomes. PRACTICE IMPLICATIONS: Hospitals can influence the emphasis placed on different governance objectives and enhance organizational success by creating boards that are small enough to be effective yet diverse enough to profit from a wide variety of expertise and experience.

Job demands, job resources, and behavior in times of sickness: An analysis across German nursing homes.

BACKGROUND: The concept of presenteeism, that is, employees coming to work despite being sick, has recently received more attention in the literature. Presenteeism not only threatens employees' health but also substantially drains productivity and drives considerable costs. When they are sick, employees have the choice of whether to go to work or to stay at home. Therefore, determinants of (sickness) absenteeism and presenteeism should be examined simultaneously. Nursing homes are faced with a particularly high prevalence of both absenteeism and presenteeism and are therefore a relevant object of investigation. PURPOSE: The aim of our study is to analyze the effect of job demands and job resources on absenteeism, presenteeism, and the tendency to choose one behavior (being absent or being present in times of sickness) rather than the other over the last 12 months. To do so, we identify the determinants of absenteeism and/or presenteeism behavior based on theory and existing research about absenteeism, presenteeism, and job demands and job resources. After our empirical analysis, we provide explanations for our findings and offer practical suggestions for how to decrease the frequencies of absenteeism and presenteeism. METHODOLOGY: In this study, a sample of 212 nurses from German nursing homes was used for an ordinal logistic regression analysis. RESULTS: Our results show that role overload significantly increases the frequencies of both absenteeism and presenteeism. A good team climate decreases absenteeism and increases the tendency to choose presenteeism rather than absenteeism, whereas strategic training and development opportunities decrease presenteeism and increase the tendency to choose absenteeism rather than presenteeism.

Operating Room Efficiency before and after Entrance in a Benchmarking Program for Surgical Process Data.

Operating room (OR) efficiency continues to be a high priority for hospitals. In this context the concept of benchmarking has gained increasing importance as a means to improve OR performance. The aim of this study was to investigate whether and how participation in a benchmarking and reporting program for surgical process data was associated with a change in OR efficiency, measured through raw utilization, turnover times, and first-case tardiness. The main analysis is based on panel data from 202 surgical departments in German hospitals, which were derived from the largest database for surgical process data in Germany. Panel regression modelling was applied. Results revealed no clear and univocal trend of participation in a benchmarking and reporting program for surgical process data. The largest trend was observed for first-case tardiness. In contrast to expectations, turnover times showed a generally increasing trend during participation. For raw utilization no clear and statistically significant trend could be evidenced. Subgroup analyses revealed differences in effects across different hospital types and department specialties. Participation in a benchmarking and reporting program and thus the availability of reliable, timely and detailed analysis tools to support the OR management seemed to be correlated especially with an increase in the timeliness of staff members regarding first-case starts. The increasing trend in turnover time revealed the absence of effective strategies to improve this aspect of OR efficiency in German hospitals and could have meaningful consequences for the medium- and long-run capacity planning in the OR.

Evaluating the link between human resource management decisions and patient satisfaction with quality of care.

BACKGROUND: Patient satisfaction with quality of care is becoming increasingly important in the competitive hospital market. Simultaneously, the growing shortage of clinical staff poses a considerable challenge to ensuring a high quality of care. In this context, a question emerges regarding whether and how human resource management (HRM) might serve as a means to reduce staff shortage problems and to increase patient satisfaction. Although considerable efforts have been devoted to understanding the concepts of patient satisfaction and HRM, little is known about the interrelationships between these concepts or about the link between staff shortage problems and patients' satisfaction with quality of care. PURPOSE: The aim of this study was to investigate the relationship between strategic human resource management (SHRM), staff shortage problems, and patients' satisfaction with care. Furthermore, we analyze how the HRM decision to fill short-term vacancies through temporary staffing affects patient satisfaction. We differentiate between physicians and nurses. METHODOLOGY: We develop and empirically test a theoretical model. The data (n = 165) are derived from a survey on SHRM that was sent to 732 German hospitals and from a survey on patient satisfaction that comprises 436,848 patient satisfaction ratings. We use a structural equation modeling approach to test the model. FINDINGS: The results indicate that SHRM significantly reduces staff shortage problems for both occupational groups. Having fewer physician shortage problems is significantly associated with higher levels of patient satisfaction, whereas this effect is not significant for nurses. Furthermore, the use of temporary staffing considerably reduces patients' satisfaction with care. PRACTICE IMPLICATIONS: Hospital managers are advised to consider the effects of HRM decisions on patients' satisfaction with care. In particular, investments in SHRM targeted at physicians have significantly positive effects on patient satisfaction, whereas the temporary staffing of physicians and nurses should be avoided.