J Healthc Manag
· 2023 Jul-Aug 01 · PMID 37410989
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GOAL: The COVID-19 pandemic has left a significant impact on hospitals' operations, expenses, and revenues. However, little is known about the pandemic's financial impact on rural and urban hospitals. Our main objective...GOAL: The COVID-19 pandemic has left a significant impact on hospitals' operations, expenses, and revenues. However, little is known about the pandemic's financial impact on rural and urban hospitals. Our main objective was to analyze how hospital profitability changed during the first year of the pandemic. We specifically studied the association between COVID-19 infections and hospitalizations and county-level variables with operating margins (OMs) and total margins (TMs). METHODS: We obtained data from Medicare Cost Reports, the American Hospital Association Annual Survey Database, and the Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry (CDC/ATSDR) for 2012-2020. Our final dataset consisted of an unbalanced panel with 17,510 observations for urban hospitals and 17,876 observations for rural hospitals. We estimated separate hospital fixed-effects models for urban and rural hospitals' OMs and TMs. The fixed-effects models controlled for time-invariant differences across hospitals. PRINCIPAL FINDINGS: In our review of the early impact of the COVID-19 pandemic on rural and urban hospitals' profits as well as trends in OMs and TMs from 2012 to 2020, we found that OMs were inversely related to the duration of hospitals' exposure to infections in urban and rural locations. In contrast, TMs and hospitals' exposures had a positive relationship. Government relief funds, a source of nonoperating revenue, apparently allowed most hospitals to avoid financial distress from the pandemic. We also found a positive relationship between the magnitude of weekly adult hospitalizations and OMs in urban and rural hospitals. Size, participation in group purchasing organizations (GPOs), and occupancy rates were positively related to OMs, with size and participation in GPOs relating to scale economies and occupancy rates reflecting capital efficiencies. PRACTICAL APPLICATIONS: Hospitals' OMs have been declining since 2014. The pandemic made this decline worse, especially for rural hospitals. Federal relief funds, along with investment income, helped hospitals remain financially solvent during the pandemic. However, investment income and temporary federal aid are insufficient to sustain financial well-being. Executives need to explore cost-saving opportunities such as joining a GPO. Small rural hospitals with low occupancy and low community COVID-19 hospitalization rates have been particularly vulnerable to the financial impact of the pandemic. Although federal relief funds have limited hospital financial distress induced by the pandemic, we maintain that the funds should have been more effectively targeted, as the mean TM increased to its highest level in a decade. The disparate results of our analysis of OMs and TMs illustrate the utility of using multiple measures of profitability.
The Internet of Medical Things (IoMT) and interoperable technologies have transformed how patient data affect medical care; such technological innovations revolutionize how healthcare organizations (HCOs) improve cost, q...The Internet of Medical Things (IoMT) and interoperable technologies have transformed how patient data affect medical care; such technological innovations revolutionize how healthcare organizations (HCOs) improve cost, quality, and access. New cyber risks, however, accompany developing cyber ecosystems. Although immediate data exchange is beneficial, risk arises from the IoMT's increased susceptibility to human influence. The success of quality care relies on protecting health information technology (HIT) against newly developing cyber vulnerabilities. Therefore, managers must be just as invested in their HCO's cybersecurity protocols as cybercriminals are in bypassing those protocols. This essay proposes a healthcare cyber resiliency model that leverages human and technical factors through a cycle of feedback and process improvement. It intends to equip healthcare administrators with the foundational philosophy necessary to secure their emerging technologies.
Climate change poses global challenges as rising temperatures, recurring natural disasters, and the resulting increase in the prevalence of acute and long-term climate-related diseases threaten the health and safety of p...Climate change poses global challenges as rising temperatures, recurring natural disasters, and the resulting increase in the prevalence of acute and long-term climate-related diseases threaten the health and safety of populations worldwide. The healthcare sector, one of the largest sources of greenhouse gas emissions globally, both exacerbates and suffers from these effects. As leaders in their local communities and the national economy, hospitals and health systems have a responsibility to not only build climate resilience to withstand disaster events but also implement sustainability initiatives that will reduce the healthcare sector's carbon footprint. A wide variety of initiatives that can meet all financial plans and timelines are available. This discussion focuses on three of the most impactful areas for opportunity: building resilience through community, operating room sustainability, and renewable energy sources.
Minga I, Balasubramanian S, Adum JPS
… +7 more, Kwak E, Macrinici V, Schwartz A, Spiro A, Shtein Y, Tafur A, Lampert M
J Healthc Manag
· 2023 Jul-Aug 01 · PMID 37326622
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GOAL: Readmissions are a significant financial burden for payers. Cardiovascular-related discharges are particularly prone to readmission. Posthospital discharge support can impact patient recovery and probably reduce pa...GOAL: Readmissions are a significant financial burden for payers. Cardiovascular-related discharges are particularly prone to readmission. Posthospital discharge support can impact patient recovery and probably reduce patient readmissions. This study aimed to address the underlying behavioral and psychosocial factors that can negatively affect patients after discharge. METHODS: The study population was adult patients admitted to the hospital with a cardiovascular diagnosis who had a plan to discharge home. Those who consented to participate were randomized to intervention or control groups on a 1:1 basis. The intervention group received behavioral and emotional support, whereas the control group received usual care. Interventions included motivational interviewing, patient activation, empathetic communication, addressing mental health and substance use, and mindfulness. PRINCIPAL FINDINGS: Observed total readmission costs were significantly lower in the intervention group than in the control group ($1.1 million vs. $2.0 million) as was the observed mean cost per readmitted patient ($44,052 vs. $91,278). The mean expected cost of readmission after adjustment for confounding variables was lower in the intervention group than in the control group ($8,094 vs. $9,882, p = .011). PRACTICAL APPLICATIONS: Readmissions are a costly spend category. In this study, posthospital discharge support addressing the psychosocial factors contributing to patients' readmissions resulted in a lower total cost of care for those with a cardiovascular diagnosis. We describe an intervention that is reproducible and can be scaled broadly through technology to reduce readmission costs.
Quigley DD, Predmore Z, Martino S
… +2 more, Qureshi N, Hays RD
J Healthc Manag
· 2023 Jul-Aug 01 · PMID 37326612
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GOAL: Patient experience survey data are used to examine the patient-centeredness of care, identify areas for improvement, and monitor interventions aimed to enhance the patient experience. Most healthcare organizations...GOAL: Patient experience survey data are used to examine the patient-centeredness of care, identify areas for improvement, and monitor interventions aimed to enhance the patient experience. Most healthcare organizations measure patient experience using Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. Studies have documented the use of CAHPS closed-ended survey responses for completing public reports, monitoring internal feedback and performance, identifying areas of improvement, and evaluating interventions to improve care. However, limited evidence exists on the utility of patients' comments on CAHPS surveys for evaluating provider-level interventions. To explore this potential, we examined comments on the CAHPS Clinician and Group (CG-CAHPS) 2.0 visit survey before and after a provider intervention. The "shadow coaching" intervention had been shown to improve provider performance and patient experience scores on the CG-CAHPS overall provider rating and provider communication composite. METHODS: We examined how patient comments on the CG-CAHPS survey differed before and after shadow coaching of 74 providers. We described the valence (tone), content, and actionability of 1,935 comments-1,051 collected before coaching and 884 collected after coaching-to see how these aspects changed before and after providers were coached. PRINCIPAL FINDINGS: Patient comments reflected improved CG-CAHPS scores after shadow coaching. The proportion of positive comments increased, and comments about doctors were more positive. Comments about time spent in the examination room decreased, apparently reflecting the decreased proportion of negative comments after coaching. Comments regarding three of the four aspects of provider communication asked on the CG-CAHPS survey were more positive after coaching (provider listens carefully, shows respect, spends enough time); the valence of comments about the fourth aspect (provider explains things in a way that is easy to understand) did not change. Also, comments describing an overall positive evaluation of the practice increased. Comments were generally less actionable after coaching, perhaps reflecting the increased positivity of the comments. PRACTICAL APPLICATIONS: Patient comments collected before the provider intervention reflected overall improvements in provider behavior, as indicated by medium-to-large statistically significant improvements in CG-CAHPS composite scores. These results suggest that patient comments from the CG-CAHPS survey can be used as input for quality improvement or an evaluation of provider-level interventions. Tracking the valence and content of comments about providers before and after an intervention to improve care is a practical method to learn how provider behavior changes.
GOAL: We explored how readmissions may result from patients' lack of access to aftercare services, failure to adhere to psychotropic medication plans, and inability to understand and follow hospital discharge recommendat...GOAL: We explored how readmissions may result from patients' lack of access to aftercare services, failure to adhere to psychotropic medication plans, and inability to understand and follow hospital discharge recommendations. We also investigated whether insurance status, demographics, and socioeconomic status are associated with hospital readmissions. This study is important because readmissions contribute to increased personal and hospital expenses and decreased community tenure (the ability to maintain stability between hospital admissions). Addressing hospital readmissions will promote optimal discharge practices beginning on day one of hospital admission. METHODS: The study examined the differences in hospital readmission rates for patients with a primary psychotic disorder diagnosis. Discharge data were drawn in 2017 from the Nationwide Readmissions Database. Inclusion criteria included patients aged 0-89 years who were readmitted to a hospital between less than 24 hr and up to 30 days from discharge. Exclusion criteria were principal medical diagnoses, unplanned 30-day readmissions, and discharges against medical advice. The sampling frame included 269,906 weighted number of patients diagnosed with a psychotic disorder treated at one of 2,355 U.S. community hospitals. The sample size was 148,529 unweighted numbers of patients discharged. PRINCIPAL FINDINGS: In a logistic regression model, weighted variables were calculated and used to determine an association between the discharge dispositions and readmissions. After controlling for hospital characteristics and patient demographics, we found that the odds for readmission for routine and short-term hospital discharge dispositions decreased for home health care discharges, which indicated that home health care can prevent readmissions. The finding was statistically significant when controlling for payer type and patient age and gender. PRACTICAL APPLICATIONS: The findings support home health care as an effective option for patients with severe psychosis. Home health care reduces readmissions and is recommended, when appropriate, as an aftercare service following inpatient hospitalization and may enhance the quality of patient care. Improving healthcare quality involves optimizing, streamlining, and promoting standardized processes in discharge planning and direct transitions to aftercare services.
GOAL: Positive patient experience is associated with less healthcare utilization, better treatment adherence, increased likelihood of returning to the same hospital, and fewer complaints. However, hospitals have been abl...GOAL: Positive patient experience is associated with less healthcare utilization, better treatment adherence, increased likelihood of returning to the same hospital, and fewer complaints. However, hospitals have been able to collect few insights into the experiences of pediatric patients due to age limitations. As an exception to that reality, adolescents (aged 12-20 years) are able to share their experiences and recommend improvements, yet little is known about their hospital experiences with traumatic injuries. We examined the patient experience of adolescents with traumatic injuries and collected their recommendations for improving care. METHODS: We conducted 28 semistructured interviews with English-speaking adolescents hospitalized at two trauma Level 1 hospitals (pediatric and adult) for physical injuries from July 2018 to June 2021. Interviews were transcribed and analyzed using modified thematic analysis. PRINCIPAL FINDINGS: The patients expressed three basic desires: (1) autonomy and active involvement in their care, (2) human connections with their clinicians, and (3) minimal discomfort. Study participants provided actionable recommendations for improving the patient experience for adolescents with traumatic injuries. PRACTICAL APPLICATIONS: Hospital administrators and clinicians can improve the patient experience for adolescents in their care by sharing information, expectations, and goals with them. Hospital administrators can also empower the clinical staff to connect with adolescents with traumatic injuries on a personal level.
GOAL: The purpose of this study was to examine nurse staffing while describing the relationships that exist in staffing and quality associated with nursing care during the COVID-19 pandemic, a significantly challenging t...GOAL: The purpose of this study was to examine nurse staffing while describing the relationships that exist in staffing and quality associated with nursing care during the COVID-19 pandemic, a significantly challenging time for nurse staffing. We examined the relationship between permanent registered nurse (RN) and travel RN staffing during the pandemic and the nursing-sensitive outcomes of catheter-associated urinary tract infections (CAUTIs), central line-associated bloodstream infections (CLABSIs), falls, and hospital-acquired pressure injuries (HAPIs) and length of stay and compared the cost of CAUTIs, CLABSIs, falls, and HAPIs in fiscal years 2021 and 2022. METHODS: We used a descriptive, observational design to retrospectively examine permanent nurse staffing volume and CAUTI, CLABSI, HAPI, and fall counts from October 1, 2019, to February 28, 2022, and travel nurse volume for the most current 12 months, April 1, 2021, to March 31, 2022. Descriptive statistics, Pearson correlation, and statistical process control analyses were completed. PRINCIPAL FINDINGS: Pearson correlation showed a statistically significant, moderately strong negative correlation (r = -0.568, p = .001) between the active registered nurse full-time equivalents (RN FTEs) and average length of stay (ALOS), and a moderately strong positive correlation (r = 0.688, p = .013) between the travel RN FTEs and ALOS. Pearson correlations were not statistically significant, with low to moderate negative correlations for CAUTIs (r = -0.052, p = .786), CLABSIs (r = -0.207, p = .273), and falls (r = -0.056, p = .769). Pearson correlation for active RN and HAPI showed a moderately strong, statistically significant positive correlation (r = 0.499, p = .003). We observed common cause variation in CAUTIs and CLABSIs, with HAPIs and falls showing special cause variation via statistical process control. PRACTICAL APPLICATIONS: Despite the challenges associated with the lack of available nurse staffing accompanied by increasing responsibilities including unlicensed tasks, positive clinical outcomes can be maintained by staff adherence to evidence-based quality improvement.
GOAL: Span of control is a multidimensional concept requiring a comprehensive definition that captures the complexities of the nurse manager's role in acute care settings. This concept analysis aimed to identify factors...GOAL: Span of control is a multidimensional concept requiring a comprehensive definition that captures the complexities of the nurse manager's role in acute care settings. This concept analysis aimed to identify factors associated with span of control and provide a comprehensive definition outlining the breadth of this concept. METHODS: ProQuest, PubMed, and Scopus databases were used to search peer-reviewed literature addressing the span of control in acute care nurse management. The search produced 185 articles; 177 titles and abstracts were screened for eligibility. Data from 22 articles were included in this analysis. PRINCIPAL FINDINGS: This analysis includes antecedents, attributes, and consequences of expanded nurse manager spans of control. Work-related factors such as staff and manager experience levels, work complexity, and patient acuity are attributes of a nurse manager's span of control. Our findings suggest that expanded spans of control can have negative consequences on nurse managers such as role overload and burnout. Low satisfaction among staff and patients can result from excessive spans of control. PRACTICAL IMPLICATIONS: An awareness of span of control can promote sustainable nursing practices by improving workplace conditions, staff satisfaction, and patient care quality. Our findings may translate across other health disciplines and thus contribute to scientific knowledge that can support changes in job designs and encourage more manageable workloads.
GOAL: Clinical physician leaders have become an increasingly important asset to hospitals and hospital systems in a changing healthcare environment. Specifically, the role of the chief medical officer (CMO) has expanded...GOAL: Clinical physician leaders have become an increasingly important asset to hospitals and hospital systems in a changing healthcare environment. Specifically, the role of the chief medical officer (CMO) has expanded and evolved amid the shift to value-based payment models and sharpened focus on patient safety, quality, community engagement, and equity in healthcare, as well as a global pandemic. In light of these changes, this study examined the transformation of CMOs and similar roles and evaluated the current needs, challenges, and responsibilities of clinical leaders today. METHODS: The primary data source used in this analysis was a survey fielded to 391 clinical leaders in 290 Association of American Medical Colleges-member hospitals and health systems in 2020. In addition, this study compared responses to the 2020 survey with findings from two prior iterations of the survey from 2005 and 2016. The surveys collected information regarding demographics, compensation, administrative titles, qualifications for the position, and the scope of the role, among other questions. All surveys consisted of multiple-choice, free response, and rating questions. The analysis was conducted using frequency counts and percentage distributions. PRINCIPAL FINDINGS: Thirty percent of eligible clinical leaders responded to the 2020 survey. Twenty-six percent of the clinical leader respondents identified as female. Ninety-one percent of the CMOs were members of the senior management team in their hospital or health system. CMOs reported that they were responsible for five hospitals, on average, with 67% indicating they were responsible for more than 500 physicians. PRACTICAL APPLICATIONS: This analysis provides hospital and health systems with insight into the expanding scope and complexity of CMOs as they take on greater leadership responsibilities within their institutions amidst a shifting healthcare landscape. In reflecting on our results, hospital leaders can understand the current needs, barriers, and responsibilities of today's clinical leaders.
GOAL: Patient experiences affect the competitiveness and financial viability of a hospital. The purpose of this research was to ascertain the factors that contribute to positive inpatient experiences by using empirical e...GOAL: Patient experiences affect the competitiveness and financial viability of a hospital. The purpose of this research was to ascertain the factors that contribute to positive inpatient experiences by using empirical evidence from national databases and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey data. METHODS: Data were assembled from four publicly available U.S. government datasets. The HCAHPS national survey responses (n = 2,472) were based on four consecutive quarters of patient surveys. Measures of clinical complications obtained from the Centers for Medicare & Medicaid Services were used to assess hospital quality. Social determinants of health were incorporated into the analysis by including data from the Social Vulnerability Index as well as zip code-level information from the Office of Policy Development and Research. PRINCIPAL FINDINGS: The study results show that hospital quietness, nurse communication, and care transition positively affected patient experience ratings and the patient's likelihood to recommend the hospital. In addition, findings show that hospital cleanliness positively influenced patient experience ratings. However, hospital cleanliness had little impact on the likelihood of a patient's recommending the hospital, and staff responsiveness had a negligible impact on both patient experience ratings and the likelihood to recommend the hospital. The results also revealed that hospitals with better clinical outcomes received better patient experience ratings and recommendation scores, whereas hospitals that serve more vulnerable populations received worse patient experience ratings and recommendation scores. PRACTICAL APPLICATIONS: Findings from this research demonstrate that managing the physical surroundings by providing a clean and quiet environment, providing relationship-centered care through interactions with medical personnel, and working to engage patients in their health as they transition out of care contributed to positive inpatient experiences.
J Healthc Manag
· 2023 Mar-Apr 01 · PMID 36892452
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GOAL: We examined the variation in community benefit and charity care reporting standards mandated by states to determine whether state-mandated community benefit and charity care reporting is associated with greater pro...GOAL: We examined the variation in community benefit and charity care reporting standards mandated by states to determine whether state-mandated community benefit and charity care reporting is associated with greater provision of these services. METHODS: We used 2011-2019 data from IRS Form 990 Schedule H for 1,423 nonprofit hospitals to create a sample of 12,807 total observations. Random effects regression models were used to examine the association between state reporting requirements and community benefit spending by nonprofit hospitals. Specific reporting requirements were analyzed to determine whether certain requirements were associated with increased spending on these services. PRINCIPAL FINDINGS: Nonprofit hospitals in states that required reports spent a higher percentage of total hospital expenditures on community benefits (9.1%, SD = 6.2%) compared to states without these requirements (7.2%, SD = 5.7%). A similar association between the percentage of charity care and total hospital expenditures (2.3% and 1.5%) was found. The greater number of reporting requirements was associated with lower levels of charity care provision, as hospitals allocated more resources to other community benefits. PRACTICAL APPLICATIONS: Mandating the reporting of specific services is associated with greater provision of certain specific services, but not all. A concern is that when many services must be reported, the provision of charity care might be reduced as hospitals choose to allocate their community benefit dollars to other categories. As a result, policymakers may want to focus their attention on the services they most want to prioritize.