The impact of health needs assessment and prioritisation on District Health Board planning in New Zealand

Objectives District Health Boards (DHBs) in New Zealand are mandated to assess and prioritise the health needs of their resident populations. This paper evaluates the impact of those health needs assessments (HNAs) and prioritisation practices on health service planning and purchasing in the first 3 years of the DHBs (2001–2003). Methods DHB HNAs, 5‐yearly strategic plans, and annual plans were evaluated using document analysis to determine the impact of needs assessments on prioritisation and planning by boards. Key informant interviews with DHB senior managers were used to identify differences between boards. Results HNAs had relatively little influence on the direction of planning and purchasing. HNAs conducted in DHBs that focussed on planning at the service level and in relation to population subgroups using a ‘mixed‐scanning’ approach and ‘service planning groups’ had a greater impact on planning and purchasing than more comprehensive approaches. DHBs found prioritisation difficult due to the level of control exercised by central government over their actions. Conclusions HNAs in New Zealand need to be less ambitious, more focussed and more closely institutionally linked to prioritisation, service planning and purchasing processes if they are to have an impact on the allocation of resources. Copyright © 2009 John Wiley & Sons, Ltd.     

The effect of the MassHealth hospital pay-for-performance program on quality

Objective

To test the effect of Massachusetts Medicaid''s (MassHealth) hospital-based pay-for-performance (P4P) program, implemented in 2008, on quality of care for pneumonia and surgical infection prevention (SIP).

Data

Hospital Compare process of care quality data from 2004 to 2009 for acute care hospitals in Massachusetts (N = 62) and other states (N = 3,676) and American Hospital Association data on hospital characteristics from 2005.

Study Design

Panel data models with hospital fixed effects and hospital-specific trends are estimated to test the effect of P4P on composite quality for pneumonia and SIP. This base model is extended to control for the completeness of measure reporting. Further sensitivity checks include estimation with propensity-score matched control hospitals, excluding hospitals in other P4P programs, varying the time period during which the program was assumed to have an effect, and testing the program effect across hospital characteristics.

Principal Findings

Estimates from our preferred specification, including hospital fixed effects, trends, and the control for measure completeness, indicate small and nonsignificant program effects for pneumonia (−0.67 percentage points, p>.10) and SIP (−0.12 percentage points, p>.10). Sensitivity checks indicate a similar pattern of findings across specifications.

Conclusions

Despite offering substantial financial incentives, the MassHealth P4P program did not improve quality in the first years of implementation.     

Health planning and the closure of a community hospital.

The overall purpose of the research reported in this article is two-fold: firstly, to describe the efforts of a regional health planning agency in the United States to reduce the size of acute care facilities in its planning area; and, secondly, to frame these events into a general theory of structural problems of state interventions in the American health care sector. Specifically, a case study is presented that documents--over time--the process of decision making, in seeking to close a community hospital against strong, and vocal, local interests. This analysis supports the view that, in the real world of health planning, power is exercised through a process of bargaining between health care providers and government, and between health care providers. Overall, the study illustrates the constraints upon the American health planning agencies to steer a relatively autonomous health care sector.     

Approaches to optimize patient and family engagement in hospital planning and improvement: Qualitative interviews

BackgroundPatient engagement (PE) in health‐care planning and improvement is a growing practice. We lack evidence‐based guidance for PE, particularly in hospital settings. This study explored how to optimize PE in hospitals.MethodsThis study was based on qualitative interviews with individuals in various roles at hospitals with high PE capacity. We asked how patients were engaged, rationale for approaches chosen and solutions for key challenges. We identified themes using content analysis.ResultsParticipants included 40 patient/family advisors, PE managers, clinicians and executives from 9 hospitals (2 < 100 beds, 4 100 + beds, 3 teaching). Hospitals most frequently employed collaboration (standing committees, project teams), followed by blended approaches (collaboration + consultation), and then consultation (surveys, interviews). Those using collaboration emphasized integrating perspectives into decisions; those using consultation emphasized capturing diverse perspectives. Strategies to support engagement included engaging diverse patients, prioritizing what benefits many, matching patients to projects, training patients and health‐care workers, involving a critical volume of patients, requiring at least one patient for quorum, asking involved patients to review outputs, linking PE with the Board of Directors and championing PE by managers, staff and committee/team chairs.ConclusionThis research generated insight on concrete approaches and strategies that hospitals can use to optimize PE for planning and improvement. On‐going research is needed to understand how to recruit diverse patients and best balance blended consultation/collaboration approaches.Patient or public contributionThree patient research partners with hospital PE experience informed study objectives and interview questions.     

The effect of hospital discharge price increases on publicly reported measures of quality

Objective

To determine if increases in hospital discharge prices are associated with improvements in clinical quality or patient experience.

Data Sources

This study used Medicare cost report data and publicly available Medicare.gov Care Compare quality measures for approximately 3000 short-term care general hospitals between 2011 and 2018.

Study Design

We separately regressed quality measure scores on a lag of case mix adjusted discharge price, hospital fixed effects, and year indicators. Clinical quality measures included 30-day readmission rates for acute myocardial infarction, chronic obstructive pulmonary disease, heart failure, hip and knee replacement, and pneumonia; risk-adjusted 30-day mortality rates for acute myocardial infarction, chronic obstructive pulmonary disease, heart failure, and stroke; and 90-day complication rate for hip and knee replacement. Patient experience measures included the summary star rating and 10 domain measures reported through the Hospital Consumer Assessment of Healthcare Providers and Systems survey. We tested for heterogeneous effects by hospital ownership, number of beds, the commercial share of overall discharges, and market concentration.

Data Collection/Extraction Methods

We linked hospitals identified in Medicare cost reports to Medicare.gov Care Compare quality measures. We excluded hospitals for which we could not identify a discharge price or that had an unrealistic price.

Principal Findings

There was no positive association between lagged discharge price and any clinical quality measure. For patient experience measures, a 2% increase in discharge price was not associated with overall patient satisfaction but was associated with small, statistically significant increases ranging from 0.01% to 0.02% (relative to mean scores) for seven of ten domain measures. There was a positive association for five of ten patient experience measures in competitive markets and one measure in both moderately concentrated and heavily concentrated markets.

Conclusions

We found no evidence that hospitals use higher prices to make investments in clinical quality; patient experience improved, but only negligibly.     

The 2017 reform of the hospital sector in Poland – The challenge of consistent design

Beginning in October 2017 a system of basic hospital service provision, popularly called the ‘hospitals network’ was implemented in Poland. It covered 594 hospitals out of a total number of approx. 920 operating in 2017. The regulation’s official objectives were to: “(1) improve the organization of services delivered by hospitals; (2) improve access to hospital care; (3) optimize the number of specialist wards; (4) improve coordination of in- and out-patient care; (5) facilitate hospital management”. The aim of this paper is to describe the background of the reform planning and its formal objectives, content and implementation process, as well as to assess the preliminary results and discuss the possible limitations and implications. Although the official term ‘hospitals network’ is used to describe the reform, in practice it does not involve an element of cooperation between hospitals. The regulation’s main feature was changing the financing methods for a pre-defined scope of services (from per-case to global budget).The reform was planned and implemented on a rather ad-hoc basis while its major controversy is the lack of quality of care, health outcome and population health need measures in the network inclusion criteria. The assessment of the reform’s impact on service provision requires long-term analysis and access to detailed quantitative data.     

The impact of a complex care clinic in a children's hospital

Background The number of medically complex and fragile children (MCFC) cared for in children's hospitals is growing, necessitating the need for optimal care co‐ordination. The purpose of this study was to describe the impact of a nurse practitioner/paediatrician‐run complex care clinic in a tertiary care hospital on healthcare utilization, parental and primary care provider (PCP) perceptions of care and parental quality of life. Methods MCFC and their parents were recruited for ambulatory follow‐up by the hospital team to complement care provided by the PCP in this mixed methods single centre pre‐ or post‐evaluative study. Parents participated in semi‐structured interviews within 48 h of discharge; further data were collected at 6 and 12 months. Healthcare utilization was compared with equal time periods pre‐enrolment. Parental health was assessed with the SF‐36; parental perceptions of care were assessed using the Larsen's Client Satisfaction Questionnaire and the Measure of Processes of Care; PCPs completed a questionnaire at 12 months. Parental and PCP comments were elicited. Comparisons were made with baseline data. Results Twenty‐six children and their parental caregivers attended the complex care clinic. The number of days that children were admitted to hospital decreased from a median of 43 to 15 days, and outpatient visits increased from 2 to 8. Mean standardized scores on the SF‐36 increased (improved) for three domains related to mental health. A total of 24 PCPs responded to the questionnaire (92% response); most found the clinic helpful for MCFC and their families. Parents reported improvements in continuity of care, family‐centredness of care, comprehensiveness and thoroughness of care, but still experienced frustrations with access to services and miscommunication with the team. Conclusion A collaborative medical home focused on integrating community‐ and hospital‐based services for MCFC is a promising service delivery model for future controlled evaluative studies.     

Analysing the use of hospital care services in Finland

Hospital care captures more than one half of the funds allocated for health care within municipalities in Finland. Municipal administrators perceive that there is little they can do as far the quantity and quality of services are concerned. This case study was to analyse the utilization of hospital care within a coalition of two municipalities (Paimio and Sauvo) for one year. By using the Diagnosis Related Groups and Main Diagnostic Categorizations and by comparing the data with the existing physician visits, health care decisions may be made regarding the general morbidity and the use of medical services. While the databases number among the most extensive in the world, the existing information has not been fully utilized for planning, implementation and evaluation of services within the municipalities.     

Implementing changes to hospital services: factors influencing the process and 'results' of reconfiguration

Objectives

Acute hospital reconfiguration is often presented as a problem to be solved by calculations of optimal design, a rational process amenable to influence by open and responsive consultation. We aimed to analyse factors in the process and ‘results’ of hospital reconfiguration in three case study sites in the English NHS.

Methods

In-depth semi-structured interviews were conducted with internal and external stakeholders at each site. Analysis within each case was complemented by cross-case analysis focusing on the relationships between the features of the origins and process of reconfiguration and progress in the implementation of plans.

Findings

We identified a number of inter-related factors operating in the process of implementation which influenced the ‘results’: the drivers for change, the reconfiguration, its content (particularly the extent to which services are withdrawn or made less accessible), the influence of stakeholders, such as local politicians, financial pressures, and the role of the management team.

Conclusions

We argue that the differences in reconfiguration implementation between the three cases reflected the nature of the proposed changes and local politics, rather than the strength of the ‘evidence’ for change. National policy has tended to over-emphasise the importance of consultation using ‘evidence’ and underplays these influencing factors.     

基于门诊病人流量优化医院床位数量：理论模型及政策含义

从理论假设出发,本文认为基于门(急)诊病人流量的多少,可以推算出住院病人数量,再根据住院病人的平均住院天数,可以估算出医院需要的最优床位数量。通过分析、论证及检验,表明这是我国医院设置病床普遍采用的一种方法。所以,我国公立医院床位扩张的直接原因,是由于医院病人流量过多。解决大型公立医院规模过大问题,相关管理部门应从根本上进行合理的区域卫生规划,加强多元化办医,促使医疗资源的合理分配及利用。否则,直接的、盲目的控制医院的床位规模,并不能使医疗资源得到合理配置,而且会加重患者看病难的问题。     

Optimizing the role of social workers in advance care planning within an academic hospital: an educational intervention program

Advance Care Planning (ACP) promotes communication to help patients express future health-care preferences and goals for their medical care. Social workers (SWs) are trained to facilitate complex conversations and assist in various ACP tasks across clinical settings. This three-part mixed-method interventional study implemented a comprehensive education and training program for SWs of a large academic hospital, which used pre- and post-training evaluations, chart review, and qualitative data from debrief sessions to examine ACP skills and confidence, and assess the number of ACP conversations initiated with patients. Self-reported level of preparation to facilitate ACP conversations improved significantly (n = 26; pre 36% versus post 82%; p < .05). A 4-month post-intervention chart audit showed an 8.69 fold increase in the number of initiated ACP conversations. Qualitative analysis identified key themes regarding barriers and enablers of initiating ACP conversations during standard care from the perspective of SWs.     

On the use of planning models in the operating theatre: results of a survey in Flanders

This paper presents an overview of the operating theatre planning and scheduling practice of hospitals in Flanders (Belgium). An electronic survey was sent to 95 hospitals in which surgeries are performed, which eventually resulted in a response set of 52 hospitals (55%). The questionnaire did not only focus on issues related to the elective (inpatient and outpatient) planning and scheduling process, but also questioned how hospitals currently deal with the occurrence of non‐elective surgeries (urgencies and emergencies). We indicate what goals health managers try to achieve and how this planning is established. We furthermore pay attention to some possible disruptions to the schedule and the corresponding anticipatory methods. Despite the proliferation of computerized planning and scheduling procedures proposed by the scientific community, the implementation rate of satisfying technological planning or evaluation systems still seems to be low. In order to increase the operating theatre efficiency, a closer cooperation between the academic institutions and the practitioners should be encouraged. Copyright © 2010 John Wiley & Sons, Ltd.