Patient assessments of hospital maternity care: a useful tool for consumers?

OBJECTIVE: To examine three issues related to using patient assessments of care as a means to select hospitals and foster consumer choice-specifically, whether patient assessments (1) vary across hospitals, (2) are reproducible over time, and (3) are biased by case-mix differences. DATA SOURCES/STUDY SETTING: Surveys that were mailed to 27,674 randomly selected patients admitted to 18 hospitals in a large metropolitan region (Northeast Ohio) for labor and delivery in 1992-1994. We received completed surveys from 16,051 patients (58 percent response rate). STUDY DESIGN: Design was a repeated cross-sectional study. DATA COLLECTION: Surveys were mailed approximately 8 to 12 weeks after discharge. We used three previously validated scales evaluating patients' global assessments of care (three items)as well as assessments of physician (six items) and nursing (five items) care. Each scale had a possible range of 0 (poor care) to 100 (excellent care). PRINCIPAL FINDINGS: Patient assessments varied (p<.001) across hospitals for each scale. Mean hospital scores were higher or lower (p<.01) than the sample mean for seven or more hospitals during each year of data collection. However, within individual hospitals, mean scores were reproducible over the three years. In addition, relative hospital rankings were stable; Spearman correlation coefficients ranged from 0.85 to 0.96 when rankings during individual years were compared. Patient characteristics (age, race, education, insurance status, health status, type of delivery) explained only 2-3 percent of the variance in patient assessments, and adjusting scores for these factors had little effect on hospitals' scores. CONCLUSIONS: The findings indicate that patient assessments of care may be a sensitive measure for discriminating among hospitals. In addition, hospital scores are reproducible and not substantially affected by case-mix differences. If our findings regarding patient assessments are generalizable to other patient populations and delivery settings, these measures may be a useful tool for consumers in selecting hospitals or other healthcare providers.     

Medical guidelines: a valid and reliable management tool?

Medical practice guidelines are one instrument to improve either quality care or to encourage efficient health care production. To achieve these goals they have to be valid, reliable, clinically applicable, clear, and timely revised. This article checks whether current efforts to develop and establish guidelines meet these criteria. Unfortunately, it turns out that especially the compliance of the first two criteria is problematic. It is concluded that medical guidelines are, as yet, neither a scientifically sound way to improve quality care nor a ready means to improve efficient care production. Approaches to complement these efforts are therefore discussed.     

NHS reforms and resource management: whither the hospital?

This paper considers whether resource management (RM) as currently constituted in the National Health Service (NHS) is likely to fulfil its aim of efficiency. For the individual hospital RM has two key features: changes in managerial structure and changes in information systems. The paper assesses the extent to which the hospital behavioural model that implicitly underlies RM can be judged to reflect well the actual behaviour of hospitals. It is noteworthy that in the RM literature there is no explicit statement about the assumed underlying behaviour of the NHS hospital. Here the author selects the Harris model of hospital behaviour as providing the best explanation of internal hospital organisation. Harris represents the two lines of authority, physicians and administrators (managers in the present-day NHS), as two firms within the hospital structure, each with its own managers, objectives and constraints, making this model particularly appealing as a basis for analysing RM. Using this model the paper concludes that RM alone and as currently constituted will not be successful in promoting efficiency, because the structural and cultural mechanisms put in place by RM will not sufficiently affect physician behaviour.     

Is hospital case management a rationalized myth?

In this article the adoption of case management processes in US hospitals is discussed. While such process change is prevalent, there is a paucity of systematic empirical evidence that hospital case management improves efficiency or effectiveness. Using an institutional theoretical framework, motivations other than improved efficiency and effectiveness are proposed that may drive hospitals to adopt change to their technical core processes, in the form of case management. Further research using these propositions as an adjunct to cost-benefit analyses would be important to validate the rationale behind the widespread adoption of hospital case management processes.     

Is the quality of hospital care a function of leadership?

Multiple regression analysis was used to evaluate the relationship between hospital quality and independent variables of interest. While past studies have analyzed hospital efficiency to evaluate organizational performance, this study is unique because it evaluates the relationship between quality and efficiency. The study incorporates an independent variable, "efficiency," calculated using a variable returns-to-scale, input-oriented, data envelopment analysis methodology. This article provides an innovative approach to measuring cost and quality as the federal government attempts to realign scarce health care resources to better meet local community needs. Data for 143 hospitals in 2000 were analyzed using multiple regression and data envelopment analysis to evaluate hospital quality. These results have managerial implications related to improving hospital quality as well as enhancing organizational performance. The study has policy implications on the relationship between quality and efficiency and supports current initiatives related to pay-for-performance in the health care industry. This study clearly documents the positive relationship between quality and efficiency, which supports the premise that hospital leadership through the effective allocation of resources and development of high-performance work processes is important to improve quality of care.     

Accessing the Ethics of Complex Health Care Practices: Would a “Domains of Ethics Analysis” Approach Help?

This paper explores how using a “domains of ethics analysis” approach might constructively contribute to an enhanced understanding (among those without specialized ethics training) of ethically-complex health care practices through the consideration of one such sample practice, i.e., deep and continuous palliative sedation (DCPS). For this purpose, I select four sample ethics domains (from a variety of possible relevant domains) for use in the consideration of this practice, i.e., autonomous choice, motives, actions and consequences. These particular domains were choosen because of their relevance to the analysis of DCPS and their relative ease of access to those without ethics training. The analysis demonstrates that such an approach could facilitate the emergence of accessible arguments and discussion points that could enhance the understanding and appreciation of this and other health care practices with strong ethics dimensions.     

Tissue engineering of the gastrointestinal tract for surgical replacement: a nutrition tool of the future?

Optimal nutrition depends on the multiple complex functions performed by the gastrointestinal tract, which range from basic functions such as storage, conduit and mechanical processing to more finely regulated capabilities such as vectorial transport, immune defence and cell signalling. Surgical strategies to supply lacking gastrointestinal tract tissues have relied on either replacement by proxy (surgical substitution) or the introduction of prostheses. Tissue engineering seeks to replace missing tissues with engineered tissues that more accurately reproduce the native physiological and anatomical milieu. It is now possible to engineer several areas of the gastrointestinal tract with high fidelity, and to employ tissue-engineered bowel in replacement in animal models. These replacement models have reflected excellent anatomical and physiological recapitulation of native bowel by the tissue-engineered constructs in vivo.     

Motivational profile of nurses working in a general hospital in the state of São Paulo

The present study aimed at identifying the motivational profile of nurses who work in a public general hospital as well as at finding out the motivations that lead nurse in their work and correlating attitudes and beliefs verified in the responses of the subjects to work and their motivations. Data were collected through three instruments, two of them were scales of Likert type (MOSE e ACTRA) and one questionnaire with data to characterize the sample that was formed by 184 nurses. Results enabled the author to delineate a motivational profile based on the three social motivations and conclude that the majority of nurses studied are working in order to overcome the underdevelopment.     

Does case management matter as a hospital cost-control strategy?

Using an evidence-based model for management research, we examine the relationship of case management adoption and the expected nonclinical outcomes in nationwide hospitals operating continuously between 1994 and 2000. Although case management may be beneficial for certain populations, institution-wide effects in the form of decreased costs or decreased length of stay do not appear to be present in the study hospitals.     

What is the nature and value of a risk management tool in a large-scale complex programme of collaborative applied health research?

In this article we examine a risk management tool that was used in a pilot programme of applied health research in the south-west of England funded by the National Institute for Health Research (NIHR). During a wider internal evaluation of the NIHR Collaboration for Leadership in Applied Health Research and Care for the South West Peninsula, we became interested in how risk was being defined and managed in the programme. Our search of the empirical literature showed that little attention had been given to risk governance within large-scale organisational change programmes in the health field. Through analysis of official documents and interviews with senior managers, we examined the nature and the value of the risk tool that was used by the programme managers. This highlighted that the programme was believed to be a ‘relatively risky’ initiative that required active management. The senior managers developed a risk tool for this purpose, which was regularly used throughout the pilot. It was perceived to have value in three main ways – providing assurance to members of the collaboration, responsiveness to the wider context and acceptability as part of routine programme implementation. Our analysis also highlighted intentional risk-taking within a complex partnership programme that sought to facilitate the translation of evidence into everyday practice. We discuss the implications of our insights for the further development of risk tools and the potential value of ‘edgework’ as a theoretical framework to inform further research of risk management in complex programmes.