Critical Access Hospital Leaders Beat Challenges to Support Their Communities and Staffs.

SUMMARY: Critical access hospitals (CAHs) serve their rural communities as the main access points and communication centers for healthcare, typically with very limited financial, staffing, and support resources. Local residents rely on their CAHs as the only providers for many miles around. When the COVID-19 pandemic hit in early 2020, CAH leaders had to rethink operations and priorities, both internally with staffs and externally with community leaders and organizations. Few critical care beds were available when the need was greatest. Testing was problematic, and cultural barriers complicated care. Now, as virus variants strike where vaccination numbers are low, CAH leaders remain wary of financial hits to elective procedure income, limited resources, and added stress for their staffs. Working with community service organizations and larger regional healthcare centers is a crucial strategy for CAHs as they address care delivery issues and ensure that their caregivers can do their jobs now and in the future.

Profit distribution and managers' behaviour in vertical integrated medical delivery systems - an experimental economics study.

BACKGROUND: The vertical integration of medical delivery systems (VIMDSs) is a reform direction both in China and worldwide. We conducted a controlled economic experiment to explore decision-making by managers of medical institutions with respect to profits and what influences the distribution mechanism in VIMDSs. METHODS: Students and hospital staff were recruited to make choices regarding the role of directors of institutions. z-Tree software was used to design the experimental program. Ninety-six subjects participated in the experiment. We gathered 479 valid contracts. RESULTS: Of the subjects, 66.39% chose flexible contracts. The median of the bidding distribution rate to community health service centres of all auctions was 18.50%. The final distribution rate was approximately 3 percentage points higher than the bidding distribution rate. The median effort level was 9.00. There was a significant correlation between the improvement rate and the choice of effort level (P<0.05) in flexible contracts. CONCLUSIONS: Hospital managers have a preference for flexible contracts because of uncertainty in the medical system. A community health service centre director may behave perfunctorily by engaging in shading in the integration. Flexible contracts and sharing rates beyond the participants' expectations motivate managers to engage in more cooperative behaviours.

Effect of public hospital managers' risk and gain perception on their attitude towards physician dual practice: a cross-national study in 31 provinces of China.

BACKGROUND: This study aims to explore the effect of public hospital managers' risk and gain perception on their attitude towards physician dual practice (PDP). METHODS: A cross-sectional study enrolling 1513 managers from public hospitals in the East, Middle and West of China was conducted. Generalized linear mixed models (GLMM) were used to identify the determinants of managers' support for PDP. RESULTS: The rate of managers' support for allowing PDP or implementing PDP with restriction, was 94.3% (95% CI: 0.93, 0.95). The mean score of managers' risk perception was 67.7 ± 14.46, and the mean score of managers' gain perception was 24.0 ± 5.56. After controlling for individual and institutional characteristics, the GLMM presented the score for risk perception increased 1 score and the rate of managers' support for PDP decreased by 5% (OR = 0.95, 95% CI: 0.93, 0.97); while the score for gain perception increased 1 score and the rate of managers' support increased by 18% (OR = 1.18, 95% CI: 1.12, 1.24). CONCLUSIONS: Our data demonstrate that the majority of Chinese public hospital managers are in favor of allowing or implementing PDP with restrictions. Although gain perception is comparatively weaker than risk perception, a stronger influence in determining public hospital managers' support for PDP is demonstrated.

Exploring the potential for collective leadership in a newly established hospital network.

PURPOSE: Achieving integrated care is a key focus for health systems and has resulted in various structures between and within organisations. The reorganisation of the Irish health system into hospital networks/groups aims to encourage work across hospitals to integrate care. This study evaluated if collective leadership emerged over time through increased interaction and collaboration following the organisation of hospitals into a network. A secondary aim was to elucidate the potential for collective leadership, through understanding the barriers and enablers perceived by participants. DESIGN/METHODOLOGY/APPROACH: This study employed social network analysis and qualitative interviews. Leaders across the hospital group were invited to participate in an online network survey and interviews (analysed using thematic analysis) at three time points over an 18-month period. FINDINGS: Although there was evidence that some parts of network were beginning to operate collectively, the structures observed were more typical of a hierarchical network. Disruption in the network and uncertainty regarding permanence of the organisational structure had a negative impact on the potential for collective leadership. Yet, progress was evident in terms of establishing building blocks for collective leadership and integration, including developing trust, mutual understanding and creating space for change. PRACTICAL IMPLICATIONS: This study contributes to the literature by reflecting on the mechanisms and initiatives perceived as enabling/inhibiting collective leadership. Based on this research, it is important to communicate a clear and consistent message about the plans for the organisations involved and be clear regarding the roles and expectations for those involved in introducing new approaches to leadership and integration. Honest collaboration, openness and certainty in communication will likely be important in order to help create the contextual conditions to enable collective and system approaches to introduce "stepping stones" to change. These conditions include developing interpersonal relationships between leaders, creating time and space for deep and shared reflection, and enhancing trust among colleagues. ORIGINALITY/VALUE: A key strength of this study is the linking of leadership-as-networks theory with social network methods to investigate collective leadership in practice. This study contributes to the literature by reflecting on the mechanisms and initiatives perceived as enabling/inhibiting collective leadership.

Accreditation as a management tool: a national survey of hospital managers' perceptions and use of a mandatory accreditation program in Denmark.

BACKGROUND: This study aimed to examine managers' attitudes towards and use of a mandatory accreditation program in Denmark, the Danish Healthcare Quality Program (Den Danske Kvalitetsmodel [DDKM]) after it was terminated in 2015. METHODS: We designed a nationwide cross-sectional online survey of all senior and middle managers in the 31 somatic and psychiatric public hospitals in Denmark. We elicited managers' attitudes towards and use of DDKM as a management using 5-point Likert scales. Regression analysis examined differences in responses by age, years in current position, and management level. RESULTS: The response rate was 49% with 533 of 1095 managers participating. Overall, managers' perceptions of accreditation were favorable, highlighting key findings about some of the strengths of accreditation. DDKM was found most useful for standardizing processes, improving patient safety, and clarifying responsibility in the organization. Managers were most negative about DDKM's ability to improve their hospitals' financial performance, reshape the work environment, and support the function of clinical teams. Results were generally consistent across age and management level; however, managers with greater years of experience in their position had more favorable attitudes, and there was some variation in attitudes towards and use of DDKM between regions. CONCLUSION: Future attention should be paid to attitudes towards accreditation. Positive attitudes and the effective use of accreditation as a management tool can support the implementation of accreditation, the development of standards, overcoming disagreements and boundaries and improving future quality programs.

Case-studies of displacement effects in Dutch hospital care.

BACKGROUND: Under a constrained health care budget, cost-increasing technologies may displace funds from existing health services. However, it is unknown what services are displaced and how such displacement takes place in practice. The aim of our study was to investigate how the Dutch hospital sector has dealt with the introduction of cost-increasing health technologies, and to present evidence of the relative importance of three main options to deal with cost-increases in health care: increased spending, increased efficiency, or displacement of other services. METHODS: We conducted six case-studies and interviewed 84 professionals with various roles and responsibilities (practitioners, heads of clinical department, board of directors, insurers, and others) to investigate how they experienced decision making in response to the cost pressure of cost-increasing health technologies. Transcripts were analyzed thematically in Atlas.ti on the basis of an item list. RESULTS: Direct displacement of high-value care due to the introduction of new technologies was not observed; respondents primarily pointed to increased spending and efficiency measures to accommodate the introduction of the cost-increasing technologies. Respondents found it difficult to identify the opportunity costs; partly due to limited transparency in the internal allocation of funds within a hospital. Furthermore, respondents experienced the entry of new technologies and cost-containment as two parallel processes that are generally not causally linked: cost containment was experienced as a permanent issue to level costs and revenues, independent from entry of new technologies. Furthermore, the way of financing was found important in displacement in the Netherlands, especially as there is a separate budget for expensive drugs. This budget pressure was found to be reallocated horizontally across departments, whereas the budget pressure of other services is primarily reallocated vertically within departments or divisions. Respondents noted that hospitals have reacted to budget pressures primarily through a narrowing in the portfolio of their services, and a range of (other) efficiency measures. The board of directors is central in these processes, insurers are involved only to a limited extent. CONCLUSIONS: Our findings indicate that new technologies were generally accommodated by greater efficiency and increased spending, and that hospitals sought savings or efficiency measures in response to cumulative cost pressures rather than in response to single cost-increasing technologies.

Simulation educators in clinical work: the manager's perspective.

PURPOSE: Information is scarce on healthcare managers' understanding of simulation educators' impact on clinical work. Therefore, the aim of this study was to explore healthcare managers' perceptions of the significance of clinically active simulation educators for the organisation. DESIGN/METHODOLOGY/APPROACH: Healthcare managers were invited to be interviewed in a semi-structured manner. Inductive thematic analysis was used to identify and analyse patterns of notions describing the managers' perceptions of simulation educators' impact as co-workers on their healthcare organisations. FINDINGS: The identified relevant themes for the healthcare unit were: (1) value for the manager, (2) value for the community and (3) boundaries. Simulation educators were perceived to be valuable gatekeepers of evidence-based knowledge and partners in leadership for educational issues. Their most prominent value for the community was establishing a reflective climate, facilitating open communication and thereby improving the efficacy of teamwork. Local tradition, economy, logistics and staffing of the unit during simulation training were suggested to have possible negative impacts on simulation educators' work. PRACTICAL IMPLICATIONS: The findings might have implications for the implementation and support of simulation training programs. SOCIAL IMPLICATIONS: Healthcare managers appreciated both the personal value of simulation educators and the effect of their work for their own unit. Local values were prioritised versus global. Simulation training was valued as an educational tool for continual professional development, although during the interviews, the managers did not indicate the importance of employment of pedagogically competent and experienced staff. ORIGINALITY/VALUE: The study provided new insights about how simulation educators as team members affect clinical practice.

Decision-Making on New Non-Drug Health Technologies by Hospitals and Health Authorities in Canada.

INTRODUCTION: Unlike those for publicly funded drugs in Canada, coverage decision-making processes for non-drug health technologies (NDTs) are not well understood. OBJECTIVES: This paper aims to describe existing NDT decision-making processes in different healthcare organizations across Canada. METHODS: A self-administered survey was used to determine demographic and financial characteristics of organizations, followed by in-depth interviews with senior leadership of consenting organizations to understand the processes for making funding decisions on NDTs. RESULTS: Seventy-three and 48 organizations completed self-administered surveys and telephone interviews, respectively (with 45 participating in both ways). Fifty-five different processes were identified, the majority of which addressed capital equipment. Most involved multidisciplinary committees (with medical and non-medical representation), but the types of information used to inform deliberations varied. Across all processes, decision-making criteria included local considerations such as alignment with organizational priorities. CONCLUSIONS: NDT decision-making processes vary in complexity, depending on characteristics of the healthcare organization and context.

Barriers to cardiac rehabilitation delivery in a low-resource setting from the perspective of healthcare administrators, rehabilitation providers, and cardiac patients.

BACKGROUND: Despite clinical practice guideline recommendations that cardiovascular disease patients participate, cardiac rehabilitation (CR) programs are highly unavailable and underutilized. This is particularly true in low-resource settings, where the epidemic is at its' worst. The reasons are complex, and include health system, program and patient-level barriers. This is the first study to assess barriers at all these levels concurrently, and to do so in a low-resource setting. METHODS: In this cross-sectional study, data from three cohorts (healthcare administrators, CR coordinators and patients) were triangulated. Healthcare administrators from all institutions offering cardiac services, and providers from all CR programs in public and private institutions of Minas Gerais state, Brazil were invited to complete a questionnaire. Patients from a random subsample of 12 outpatient cardiac clinics and 11 CR programs in these institutions completed the CR Barriers Scale. RESULTS: Thirty-two (35.2%) healthcare administrators, 16 (28.6%) CR providers and 805 cardiac patients (305 [37.9%] attending CR) consented to participate. Administrators recognized the importance of CR, but also the lack of resources to deliver it; CR providers noted referral is lacking. Patients who were not enrolled in CR reported significantly greater barriers related to comorbidities/functional status, perceived need, personal/family issues and access than enrollees, and enrollees reported travel/work conflicts as greater barriers than non-enrollees (all p < 0.01). CONCLUSIONS: The inter-relationship among barriers at each level is evident; without resources to offer more programs, there are no programs to which physicians can refer (and hence inform and encourage patients to attend), and patients will continue to have barriers related to distance, cost and transport. Advocacy for services is needed.

Potential of innovations in hygiene management - a managerial perspective.

Background: Assessment of the current situation is crucial before introducing innovative infection prevention measures. According to the literature, hospital managers should take on the role of "power promoters" in adopting infection prevention measures due to their position and decision-making authority. However, there is no empirical evidence for whether or not this assumption is valid. This paper reports German hospital managers' perceptions of current challenges in infection prevention and control and innovative prevention measures. We analysed the managerial promoters and barriers of adopting innovations in order to derive recommendations for improving the innovation process in hospitals using the novel AHOI-approach to actively involve patients and their relatives in anti-infection measures. Methods: All 3877 medical, nursing and administrative managers of German hospitals were invited to participate in an online survey. The first set of questions intended to determine their perception of problems of hygiene management in their institution and in particular in the interaction with patients and their relatives. The second set of questions was asked to identify potential challenges and barriers to combating nosocomial infections and involving patients and their relatives in infection prevention. Results: Two hundred six managers from German hospitals participated in the survey. Transmission of pathogens was seen as the main problem in the inpatient area, especially in acute care hospitals and stationary geriatric care. Barriers to the implementation of novel infection prevention concepts were primarily perceived as lack of time and refinancing by health insurance providers. The surveyed hospital managers assessed that the active involvement of patients and their relatives in infection prevention could strengthen the infection prevention of their institution. Conclusions: Hospital managers are open to innovative hygiene interventions. In particular, they welcome the active involvement of patients and their relatives in infection prevention. Therefore, financial and institutional barriers, such as insufficient funding of hygiene management, must be overcome.

Who owns responsibility? An administrator's take on implementing time-variable medical training in teaching hospitals.

Introduction: Developments in outcome-based medical education led to the introduction of time-variable medical training (TVMT). Although this idea of training may be a consequence of competency-based training that calls for individualized learning, its implementation has posed significant challenges. As a new paradigm it is likely to have repercussions on the organization of teaching hospitals. The purpose of this study is therefore to explore how hospital administrators cope with this implementation process. Methods: We conducted an exploratory qualitative study for which we interviewed administrators of hospitals who were actively implementing TVMT in their postgraduate programs. Results: Several problems of implementation were identified: existing governance structures proved unfit to cope with the financial and organizational implications of TVMT. Administrators responded to these problems by delegating responsibilities to departments, reallocating tasks, learning from other hospitals and scaling up their teaching facilities. Conclusions: Hospital administrators perceived the implementation of TVMT as challenging. TVMT affects the existing equilibrium between education and clinical service. Administrators' initial attempts to regain control, using steering strategies that were based on known concepts and general outcomes, including cutting departmental budgets did not work, nor did their subsequent wait-and-see approach of leaving the implementation to the individual departments.

Hybrid clinical-managers in Kenyan hospitals.

PURPOSE: The purpose of this paper is to explore the way "hybrid" clinical managers in Kenyan public hospitals interpret and enact hybrid clinical managerial roles in complex healthcare settings affected by professional, managerial and practical norms. DESIGN/METHODOLOGY/APPROACH: The authors conducted a case study of two Kenyan district hospitals, involving repeated interviews with eight mid-level clinical managers complemented by interviews with 51 frontline workers and 6 senior managers, and 480 h of ethnographic field observations. The authors analysed and theorised data by combining inductive and deductive approaches in an iterative cycle. FINDINGS: Kenyan hybrid clinical managers were unprepared for managerial roles and mostly reluctant to do them. Therefore, hybrids' understandings and enactment of their roles was determined by strong professional norms, official hospital management norms (perceived to be dysfunctional and unsupportive) and local practical norms developed in response to this context. To navigate the tensions between managerial and clinical roles in the absence of management skills and effective structures, hybrids drew meaning from clinical roles, navigating tensions using prevailing routines and unofficial practical norms. PRACTICAL IMPLICATIONS: Understanding hybrids' interpretation and enactment of their roles is shaped by context and social norms and this is vital in determining the future development of health system's leadership and governance. Thus, healthcare reforms or efforts aimed towards increasing compliance of public servants have little influence on behaviour of key actors because they fail to address or acknowledge the norms affecting behaviours in practice. The authors suggest that a key skill for clinical managers in managers in low- and middle-income country (LMIC) is learning how to read, navigate and when opportune use local practical norms to improve service delivery when possible and to help them operate in these new roles. ORIGINALITY/VALUE: The authors believe that this paper is the first to empirically examine and discuss hybrid clinical healthcare in the LMICs context. The authors make a novel theoretical contribution by describing the important role of practical norms in LMIC healthcare contexts, alongside managerial and professional norms, and ways in which these provide hybrids with considerable agency which has not been previously discussed in the relevant literature.

Pregnant-puerperal care in Network: the experience of nurses, doctors and administrators.

OBJECTIVE: Understand the experience of nurses, doctors and administrators of pregnancy-puerperal cycle care to women in the Rede Mãe Paranaense (Freely translated as Paranaense Mother Network). METHOD: Qualitative research according to social phenomena with 44 professionals from 10 municipalities of the Regional of Health, in Paraná State, Brazil. The testimonies were recorded until converge and were analyzed following the steps established from the background. RESULTS: It was understood a content of meaning experienced among different professional classes. The "motives why" in which the Network was a reasoned proposal to improve the mother care quality, although there is disarticulation in the planning and application. The expectation for "motives for" proved fragility and challenges to reach the goals and aims of the Network in the Primary Health Care practice. FINAL CONSIDERATIONS: The Network reorganization was carried out, but there are gaps in the reference and counter-reference system, especially for the pregnancy and high risky childbirth and puerperal cycle.

Exploring perceptions, motivations, and practices regarding outsourcing support services by general hospitals in Uganda: A mixed methods study.

Research on outsourcing in a developing country using a mixed methods approach can provide insights on outsourcing decisions and practices. This study investigated motivations, practices, perceived benefits, and barriers to outsourcing by general hospitals in Uganda. An explanatory sequential mixed methods design was used. Quantitative data were collected using a self-administered questionnaire from managers in 32 randomly selected hospitals. Qualitative data were latter collected from eight purposively selected managers using an interview guide. Quantitative data were statistically analyzed using SAS 9.3. Qualitative data were managed using ATLAS ti 7 and coded manually, and content analysis was conducted. Quantitative findings indicate that outsourcing of support services was prevalent (72% of hospitals). The key motivation for outsourcing was to gain access to quality service (68%). Limited availability of service providers was a key challenge during outsourcing (57%). Managers perceive improved productivity and better services as key benefits of outsourcing (90%). The main barrier to outsourcing is limited financing. These findings were confirmed and explained by the qualitative data. Findings and recommendations from this study are critical in developing interventions to encourage effective outsourcing by hospitals in Uganda and other developing countries.

Exploring medical residents' perceived need for negotiation skills training.

OBJECTIVES: This study explores the optimal focus for negotiation skills development training by investigating how often medical residents negotiate in practice, and how they perceive the effectiveness of their negotiation capabilities. METHODS: An exploratory study was performed using a questionnaire regarding the medical residents' working environment, negotiation frequency, knowledge and skills using a 5-point Likert scale, multiple choice questions and open questions. Exploratory factor analysis with principal component analysis, varimax rotation, reliability analysis, and content analysis were used to reduce the number of variables. Descriptive and interferential statistics and multiple regression analysis were used to analyze the data. RESULTS: We analyzed the responses of 60 medical residents. The findings showed that the perceived development of their negotiation knowledge (M=3.06, SD=0.83) was less than their negotiation skills (M=3.69, SD=0.47). Their attitude during negotiations, especially females, differed substantially in the interactions with nurses than with their supervisors. Medical residents with more working experience, better negotiation skills or who worked in hierarchical environments negotiated more frequently with their supervisors. Medical residents with better collaboration skills and negotiation knowledge demonstrated better negotiation skills. CONCLUSIONS: This study underlines medical residents' need for negotiation training. In addition to the basic negotiation knowledge and skills, training programs in negotiation should focus on the medical residents' awareness of their attitudes during negotiations, combining the assertiveness shown in interactions with supervisors with the empathy and emotional engagement present in interactions with nurses.  Furthermore, attention should be paid to the influence of the environmental hierarchy on negotiation skill development.

Public hospital reforms in China: the perspective of hospital directors.

BACKGROUND: To understand the attitudes and opinions of directors of large public hospitals in China on reform policies of public hospital. METHOD: A cross-sectional survey utilizing questionnaires of the Survey of Attitudes to Public Hospital Reform by Directors was conducted in 2014. The respondents were randomly selected in 100 tertiary public hospitals in 62 cities of 31 provinces in China by stratified multistage random cluster sampling method. 178 directors and associate directors working in tertiary public hospitals were involved. Standard descriptive statistics were used to describe and summarize the data. RESULTS: The measure of increasing government subsidies ranked first in the list of concerns expressed by responders (N = 149, 83.7%); while implementing clinical pathways ranked lowest in the list of concerns (N = 34, 19.7%). More associate directors (N = 64, 70.3%) were concerned over the measures of removing drug mark-ups than directors (N = 45, 51.7%) (χ2 = 6.49, p = 0.01). In addition, 75.8% of responders were concerned over the policy of salary system reform, while only 14.5% of them were satisfied with their current income level. What's more, more than half responders were concerned over the policy of adjusting pricing policies (N = 127, 71.4%) and removing drug markups (N = 109, 61.2%). CONCLUSION: In healthcare reform, the financial security for the hospitals should be considered as a priority by the policy-makers, without the reform goals cannot be achieved. Thus, an incentive mechanism needs to be established in China to guide the director to focus on the medical quality.

A comparison of leadership competencies among doctors practicing in public and private hospitals in Jos metropolis of Plateau State, Nigeria.

Aim: This study aimed at assessing and comparing perceived leadership competencies of doctors occupying managerial positions in a public and various private hospitals in Jos metropolis of Plateau state, Nigeria. Materials and Methods: This was a cross-sectional, comparative multicenter study. It involved self-assessment by 27 doctors occupying managerial positions in public and private hospitals within Jos metropolis and peer-assessments by 89 health and nonhealth professionals who worked with the doctor-managers at the time of the study. The National Center for Healthcare Leadership competency model was used as the assessment tool. Results: We found that perceived leadership competencies were low for all doctor-managers irrespective of their hospital affiliation. Distributions of these competencies varied with the private sector showing superiority for certain competencies. Conclusion: Perceived leadership competencies were low for the doctor-managers assessed. This calls for an innovative approach to the training and practice of health management in Jos Metropolis.

RésuméObjectif: Cette étude visait à évaluer et à comparer les compétences de leadership perçues des médecins occupant des postes de direction dans divers hôpitaux du public et privé dans la métropole de Jos, Plateau state, Nigeria. Matériaux et méthode: C'était une étude tranversale comparative multicentrique. I'll s'agissait d'une auto évaluation par 29 médecins occupant des postes managériaux dans la l'hôpitaux public et privés dans la métropole de Jos et d'une évaluation par 89 professionnels de la santé et de la non-santé qui ont travailler avec les médecin-gestionnaires au moment de l'étude. Résultats: Nous avons constaté que les compétences de leadership perçues étaient faibles pour tous les médecins-gestionnaires, indépendamment de leur affiliation à l'hôpital. Les répartitions de ces compétences variaient avec le secteur privé montrer de la supériorité pour certaines compétences. Conclusion: Les compétences en leadership perçues étaient faibles pour les médecins-gestionnaires évalués. Cela nécessite une approche innovante de la formation et de la pratique de la gestion de la santé à Jos métropole.