Bayesian logistic regression approaches to predict incorrect DRG assignment.

Episodes of care involving similar diagnoses and treatments and requiring similar levels of resource utilisation are grouped to the same Diagnosis-Related Group (DRG). In jurisdictions which implement DRG based payment systems, DRGs are a major determinant of funding for inpatient care. Hence, service providers often dedicate auditing staff to the task of checking that episodes have been coded to the correct DRG. The use of statistical models to estimate an episode's probability of DRG error can significantly improve the efficiency of clinical coding audits. This study implements Bayesian logistic regression models with weakly informative prior distributions to estimate the likelihood that episodes require a DRG revision, comparing these models with each other and to classical maximum likelihood estimates. All Bayesian approaches had more stable model parameters than maximum likelihood. The best performing Bayesian model improved overall classification per- formance by 6% compared to maximum likelihood, with a 34% gain compared to random classification, respectively. We found that the original DRG, coder and the day of coding all have a significant effect on the likelihood of DRG error. Use of Bayesian approaches has improved model parameter stability and classification accuracy. This method has already lead to improved audit efficiency in an operational capacity.

Public-private partnerships in non-profit hospitals: Case study of China.

The gap between supply and demand for health care services is expanding rapidly in China. In order to resolve this problem, the government has implemented supply-side reforms in the health care sector by inviting private capital to increase supply quantity and improve quality. However, health care institutions have high complexity and particular needs, while non-profit hospitals have very strong public interests. This gives rise to complications in the implementation of public-private partnerships (PPPs) for health care services. In this paper, the authors have selected one case each from three different models of non-profit hospital PPP projects in the national PPP project database, operated by the Ministry of Finance, and compared how these projects were operated to identify the differences among them. A content analysis of the vital project documents is the primary analysis technique used for this comparison. Key issues investigated include reasons for model selection, requirements for private sectors and market competition level in different models, risk identification and sharing, design of payment mechanism, operation supervision, and performance appraisal of the project. Based on the comparison, some key lessons and recommendations are discussed to act as a useful reference for future non-profit hospital PPP projects in China.

Evaluation for learning and improvement at the right time: an example from the field.

Evaluation expertise to assist with identifying improvements, sourcing relevant literature and facilitating learning from project implementation is not routinely available or accessible to not-for-profit organisations. The right information, at the right time and in an appropriate format, is not routinely available to program managers. Program management team members who were implementing The Fred Hollows Foundation's Indigenous Australia Program's Trachoma Elimination Program required information about what was working well and what required improvement. This article describes a way of working where the program management team and an external evaluation consultancy collaboratively designed and implemented an utilisation-focused evaluation, informed by a developmental evaluation approach. Additionally, principles of knowledge translation were embedded in this process, thereby supporting the evaluation to translate knowledge into practice. The lessons learned were that combining external information and practice-based knowledge with local knowledge and experience is invaluable; it is useful to incorporate evaluative information from inception and for the duration of a program; a collaborative working relationship can result in higher quality information being produced and it is important to communicate findings to different audiences in different formats.

The Progress of US Hospitals in Addressing Community Health Needs.

OBJECTIVES: To identify how US tax-exempt hospitals are progressing in regard to community health needs assessment (CHNA) implementation following the Patient Protection and Affordable Care Act. METHODS: We analyzed data on more than 1500 tax-exempt hospitals in 2013 to assess patterns in CHNA implementation and to determine whether a hospital's institutional and community characteristics are associated with greater progress. RESULTS: Our findings show wide variation among hospitals in CHNA implementation. Hospitals operating as part of a health system as well as hospitals participating in a Medicare accountable care organization showed greater progress in CHNA implementation whereas hospitals serving a greater proportion of uninsured showed less progress. We also found that hospitals reporting the highest level of CHNA implementation progress spent more on community health improvement. CONCLUSIONS: Hospitals widely embraced the regulations to perform a CHNA. Less is known about how hospitals are moving forward to improve population health through the implementation of programs to meet identified community needs.

Hospital-ownership status and cesareans in the United States: The effect of for-profit hospitals.

BACKGROUND: Given the increasing proportion of United States hospitals that are for-profit, we examined whether women who give birth in for-profit hospitals are more likely to have cesareans than women who give birth in not-for-profit hospitals. We hypothesized that cesareans are more likely to occur in for-profit hospitals because of the organizational emphasis on short-term financial indicators, including payment of shareholder dividends. METHODS: We used logistic regression and difference of means tests to analyze data from the Listening to Mothers III survey of women who gave birth in the United States in 2011 and 2012. RESULTS: Controlling for patient-level characteristics, we found that the odds of a woman's having a cesarean were two times higher in for-profit hospitals than in not-for-profit hospitals. We also found for-profit hospitals were significantly more likely to be members of multihospital systems and to have fewer full-time registered nurses and staff members per hospital bed. CONCLUSION: This research suggests that women who give birth in for-profit hospitals are more likely to have cesareans than women who give birth in not-for-profit hospitals. This information is important to women when deciding where to give birth. Knowing which hospital characteristics are associated with a greater likelihood of cesarean is helpful since hospital cesarean rates may be difficult to find. These findings are also informative for obstetric professionals, who can implement improvement initiatives to decrease cesarean rates and improve the overall quality of care for childbearing women in the United States.

Health workers' perceptions of private-not-for-profit health facilities' organizational culture and its influence on retention in Uganda.

BACKGROUND: An in-depth understanding of how organizational culture is experienced by health workers (HWs), and influences their decisions to leave their jobs is a fundamental, yet under-examined, basis for forming effective retention strategies. This research examined HWs' working experiences and perceptions of organisational culture within private-not-for-profit, largely mission-based hospitals, and how this influenced retention. METHODS: Thirty-two HWs, including managers, in 19 health facilities in Uganda were interviewed using a semi-structured topic guide. Interview transcripts were analysed using thematic content analysis. RESULTS: Interviews showed that the organizational culture was predominantly hierarchical, with non-participative management styles which emphasized control and efficiency. HWs and managers held different perceptions of the organizational culture. While the managers valued results and performance, HWs valued team work, recognition and participative management. CONCLUSIONS: The findings of this study indicate that organizational culture influences retention of HWs in health facilities and provide a useful context to inform health care managers in the PNFP sub-sector in Uganda and similar contexts. To improve retention of HWs, a gradual shift in organizational culture will be necessary, focussing on the values, beliefs and perceptions which have the greatest influence on observable behaviour.

The Power of Community Voices for Enhancing Community Health Needs Assessments.

As required by the Affordable Care Act, Community Health Needs Assessments (CHNAs) are formalized processes nonprofit hospitals must perform at least every 3 years. CHNAs are designed to help hospitals better tailor health services to the needs of local residents. However, CHNAs most often use quantitative, population-level data, and rarely incorporate the actual voices of local community members. This is particularly a problem for meeting the needs of residents who are also racial or ethnic minorities. This article discusses one model for integrating residents' voices into the CHNA process. In this model, we videotaped interviews with community members and then coded and analyzed interview data to identify underlying themes. We created a short video aimed at starting conversations about community members' concerns. In addition to demonstrating how other nonprofit hospitals may use qualitative data in the CHNA process, this article illustrates how adding qualitative data may change how we think about health promotion. We find that community members requested that health care providers view culture as a health resource, foster community connections, and be present in the community.

Changes in nursing practice to improve patient safety. / Mudanças na prática de enfermagem para melhorar a segurança do paciente.

OBJECTIVE: To identify changes in nursing practice to improve the quality of care and patient safety. METHOD: A case study conducted at an inpatient unit with professionals from the patient safety centre and a nursing team, totalling 31 participants. Data were collected from May to December 2015 through interviews, observations recorded in a field journal, and documentary analysis, followed by content analysis. RESULTS: The changes observed in the nursing practice included the identification of care and physical risks, especially the risk of falls and pressure injury, with the use of personal forms and the Braden scale; notification of adverse events; adoption of protocols; effective communication with permanent education and multiprofessional meetings. CONCLUSIONS: Changes were observed in the nursing practice, chiefly focused on risk management.

Applying Community Organizing Principles to Assess Health Needs in New Haven, Connecticut.

The Affordable Care Act added requirements for nonprofit hospitals to conduct community health needs assessments. Guidelines are minimal; however, they require input and representation from the broader community. This call echoes 2 decades of literature on the importance of including community members in all aspects of research design, a tenet of community organizing. We describe a community-engaged research approach to a community health needs assessment in New Haven, Connecticut. We demonstrate that a robust community organizing approach provided unique research benefits: access to residents for data collection, reliable data, leverage for community-driven interventions, and modest improvements in behavioral risk. We make recommendations for future community-engaged efforts and workforce development, which are important for responding to increasing calls for community health needs assessments.

Tax-exempt hospitals and community benefit: new directions in policy and practice.

The current community benefit standard for nonprofit hospital tax exemption has been the subject of mounting criticism. Many different constituencies have advanced the view that in its present form it fails to ensure that nonprofit hospitals provide adequate benefits to their communities in exchange for their tax exemption. In contrast, hospitals have often expressed the concern that the community benefit standard in its current form is vague and therefore difficult to comply with. Various suggestions have been made regarding how the existing community benefit standard could be improved or even replaced. In this article, we first discuss the historical and legal development of the community benefit standard. We then present the key controversies that have emerged in recent years and the policy responses attempted thus far. Finally, we evaluate possible future policy directions, which reform efforts could follow.

Nonprofit hospitals' approach to community health needs assessment.

OBJECTIVES: We sought a better understanding of how nonprofit hospitals are fulfilling the community health needs assessment (CHNA) provision of the 2010 Patient Protection and Affordable Care Act to conduct CHNAs and develop CHNA and implementation strategies reports. METHODS: Through an Internet search of an estimated 179 nonprofit hospitals in Texas conducted between December 1, 2013, and January 5, 2014, we identified and reviewed 95 CHNA and implementation strategies reports. We evaluated and scored reports with specific criteria. We analyzed hospital-related and other report characteristics to understand relationships with report quality. RESULTS: There was wide-ranging diversity in CHNA approaches and report quality. Consultant-led CHNA processes and collaboration with local health departments were associated with higher-quality reports. CONCLUSIONS: At the time of this study, the Internal Revenue Service had not yet issued the final regulations for the CHNA requirement. This provides an opportunity to strengthen the CHNA guidance for the final regulations, clarify the purpose of the assessment and planning process and reports, and better align assessment and planning activities through a public health framework.

The Nurse-Patient Assignment: Purposes and Decision Factors.

OBJECTIVE: Identify purposes and decision factors of the nurse-patient assignment process. BACKGROUND: Nurse-patient assignments can positively impact patient, nurse, and environmental outcomes. METHODS: This was an exploratory study involving interviews with 14 charge nurses from 11 different nursing units in 1 community hospital. RESULTS: Charge nurses identified 14 purposes and 17 decision factors of the nurse-patient assignment process. CONCLUSIONS: The nurse-patient assignment is a complex process driven by the patient, nurse, and environment. Further study is needed to identify factors linked to patient safety, nurse, and environmental outcomes.

Community benefits provided by religious, other nonprofit, and for-profit hospitals: a longitudinal analysis 2000-2009.

BACKGROUND: Nonprofit hospitals (NFPs) are expected to provide community benefits to justify the tax benefits they receive, but recent budgetary constraints have called into question the degree to which the tax benefits are justified. The empirical literature comparing community benefits provided by NFPs and their for-profit counterparts is mixed. However, NFPs are not a homogenous group and can include religious hospitals, community-owned hospitals, or academic medical centers. PURPOSE: This longitudinal study examines how religious hospitals compare with other NFPs and for-profit hospitals with respect to providing community benefits and how the provision of community benefits by hospitals has changed over time. METHODOLOGY: Using a pooled cross-sectional design, we examine two summated scores based on questions from the American Hospital Association annual survey that focus on community orientation among hospitals. We analyze two regressions with year, facility, and market controls to determine how religious hospitals compare with the other groups over time. FINDINGS: Overall, 11% of U.S. hospitals are religious. Religious hospitals were more likely to engage in each individual community benefit activity examined. In addition, the mean values of community benefits provided by religious hospitals, as measured on two summated scores, were significantly higher than those provided by other hospital types in bivariate and regression analyses. Overall, community benefits provided by all hospitals increased over time and then leveled off during the start of the recent economic downturn. PRACTICE IMPLICATIONS: As the debate continues regarding federal tax exemption status, policymakers should consider religious hospitals separately from NFPs. Managers at religious hospitals should consider how their increased levels of community benefits are related to their missions and set benchmarks that recognize and communicate those achievements.

Preparing for section 501(r).

Steps hospitals should take to prepare for Section 501(r) requirements include the following: Prepare the board for its role in approving updated financial assistance, billing and collections, and emergency medical care policies. Revisit financial assistance policy eligibility requirements. Conduct a policy gap analysis. Review how the current financial assistance policy is publicized and make adjustments where necessary.

Memorial Hermann: high reliability from board to bedside.

BACKGROUND: In 2006 the Memorial Hermann Health System (MHHS), which includes 12 hospitals, began applying principles embraced by high reliability organizations (HROs). Three factors support its HRO journey: (1) aligned organizational structure with transparent management systems and compressed reporting processes; (2) Robust Process Improvement (RPI) with high-reliability interventions; and (3) cultural establishment, sustainment, and evolution. METHODS: The Quality and Safety strategic plan contains three domains, each with a specific set of measures that provide goals for performance: (1) "Clinical Excellence;" (2) "Do No Harm;" and (3) "Saving Lives," as measured by the Serious Safety Event rate. MHHS uses a uniform approach to performance improvement--RPI, which includes Six Sigma, Lean, and change management, to solve difficult safety and quality problems. RESULTS: The 9 acute care hospitals provide multiple opportunities to integrate high-reliability interventions and best practices across MHHS. For example, MHHS partnered with the Joint Commission Center for Transforming Healthcare in its inaugural project to establish reliable hand hygiene behaviors, which improved MHHS's average hand hygiene compliance rate from 44% to 92% currently. Soon after compliance exceeded 85% at all 12 hospitals, the average rate of central line-associated bloodstream and ventilator-associated pneumonias decreased to essentially zero. CONCLUSION: MHHS's size and diversity require a disciplined approach to performance improvement and systemwide achievement of measurable success. The most significant cultural change at MHHS has been the expectation for 100% compliance with evidence-based quality measures and 0% incidence of patient harm.

Hospital ownership and community benefit: looking beyond uncompensated care.

Not-for-profit (NFP) hospitals have come under increased public scrutiny for management practices that are inconsistent with their charitable focus. Of particular concern is the amount of community benefit provided by NFP hospitals compared to for-profit (FP) hospitals given the substantial tax benefits afforded to NFP hospitals. This study examines hospital ownership and community benefit provision beyond the traditional uncompensated care comparison by using broader measures of community benefit that capture charitable services, community assessment and partnership, and community-oriented health services. The study sample includes 3,317 nongovernment, general, acute care, community hospitals that were in operation in 2006. Data for this study came from the 2006 American Hospital Association Hospital Survey and the 2006 Area Resource File. We used multivariate regression analyses to examine the relationship between hospital ownership and five indicators of community benefit, controlling for hospital characteristics, market demand, hospital competition, and state regulations for community benefit. We found that NFP hospitals report more community benefit activities than do FP hospitals that extend beyond uncompensated care. Our findings underscore the importance of defining and including activities beyond uncompensated care when evaluating community benefit provided by NFP hospitals.

The use and role of open source software applications in public and not-for-profit hospitals in the United States.

BACKGROUND: The potential cost savings and customizability of open source software (OSS) may be particularly attractive for hospitals. However, numerous health-care-specific OSS applications exist, the adoption of OSS health information technology (HIT) applications is not widespread in the United States. PURPOSE: This disconnect between the availability of promising software and low adoption raises the basic question: If OSS HIT is so advantageous, why are more health care organizations not using it? METHODOLOGY: We interviewed the chief information officer, or equivalent position, at 17 not-for-profit and public hospitals across the United States. Through targeted recruitment, our sample included nine hospitals using OSS HIT and eight hospitals not using OSS HIT. The open-ended interview questions were guided by domains included in the fit-viability theory, an organizational-level innovation adoption framework, and those suggested by a review of the literature. Transcripts were analyzed using an inductive and comparative approach, which involved an open coding for relevant themes. FINDINGS: Interviews described the state of OSS use in hospitals. Specifically, general OSS applications were widely used by IT professionals. In addition, hospitals using OSS HIT still relied heavily on vendor support. In terms of why decisions arose to use OSS HIT, several hospitals using OSS HIT noted the cost advantages. In contrast, hospitals avoiding OSS HIT were clear, OSS as a class did not fit with clinical work and posed too much risk. PRACTICE IMPLICATIONS: Perceptions of OSS HIT ranged from enthusiastic embracement to resigned adoption, to refusal, to abandonment. Some organizations were achieving success with their OSS HIT choices, but they still relied on vendors for significant support. The decision to adopt OSS HIT was not uniform but contingent upon views of the risk posed by the technology, economic factors, and the hospital's existing capabilities.

The relationship between transformational leadership and social capital in hospitals--a survey of medical directors of all German hospitals.

CONTEXT: The German hospital market has been undergoing major changes in recent years. Success in this new market is determined by a multitude of factors. One is the quality of the social relationships between staff and the presence of shared values and rules. This factor can be considered an organization's "social capital." OBJECTIVE: This study investigates the relationship between social capital and leadership style in German hospitals using a written survey of medical directors. DESIGN AND SETTING: In 2008, a cross-sectional representative study was conducted with 1224 medical directors from every hospital in Germany with at least 1 internal medicine unit and 1 surgery unit. Among the scales included in the standardized questionnaire were scales used to assess the medical directors' evaluation of social capital and transformational leadership in the hospital. We used a multiple linear regression model to examine the relationship between social capital and internal coordination. We controlled for hospital ownership, teaching status, and number of beds. PARTICIPANTS: In total, we received questionnaires from 551 medical directors, resulting in a response rate of 45.2%. The participating hospitals had an average of 345 beds. The sample included public (41.3%), not-for-profit (46.9%), and for-profit (11.7%) hospitals. RESULTS: The data, which exclusively represent the perceptions of the medical directors, indicate a significant correlation between a transformational leadership style of the executive management and the social capital as perceived by medical directors. A transformational leadership style of the executive management accounted for 36% of variance of the perceived social capital. CONCLUSION: The perceived social capital in German hospitals is closely related to the leadership style of the executive management. A transformational leadership style of the executive management appears to successfully strengthen the hospital's social capital.