A growing interest in evaluating quality of healthcare services has led to several initiatives geared towards quality improvement and increased efficiency by focusing on patient needs and collected evidence. Efforts designed to standardize quality healthcare delivery are difficult because of variation in perspectives and disagreement as to what actually indicates quality healthcare. To help bring more clarity to the topic of quality care this study performed a secondary analysis on data gathered from the ‘provider morale’ section of the ‘Managing Quality in Canadian Hospitals’ project. The purpose of this study was to address how nurses’ perceptions of distress, work place recognition and satisfaction influenced their assessment of quality care in Saskatoon hospitals. The conservation of resources (COR) theory was used as a theoretical framework to guide the development of an understanding of nurses’ perceptions through a focus on occupational distress, recognition, and job satisfaction as a potential means of observing environmental effects on quality of care. This research established that there were significant positive relationships between recognition-quality, satisfaction-quality and recognition-satisfaction; suggesting that recognition and satisfaction can be viewed as work related resources and indicators of nurses’ perceptions of quality care delivery. Significant negative relationships were found between distress-recognition and distress-satisfaction; suggesting that distress levels have an effect on perceptions of nursing work resources. The research findings also indicated that there was a significant difference in how nursing units perceived quality and distress, but no significant difference in perceptions of recognition or satisfaction; suggesting that work place resources have different effects, that there are other resources in play on units which affect perceptions, and that the impact of recognition and satisfaction on quality and distress perceptions differs between nursing units. The results of this study provide nurses, nursing managers, and healthcare organizations with a deeper understanding of how resources and stress processes in work environments effect the perception of quality care delivery.

The purpose of this study is to investigate medical tourism in Jordan through the international patients‘ perspective. The aim is to contribute to a better understanding of international patients‘ consumption behaviour to seek medical treatment, and while at the destination. And also to better understand the medical tourists‘ perceptions of quality of healthcare services. This research was designed to facilitate the identification of the characteristics of medical tourists, their visit, their sources of information and the main pull/push factors influencing their decision to travel. Moreover, it was designed to identify the level of satisfaction held by medical tourists towards their patient experience and their satisfaction predictors, by translating, adapting and validating a patient-centred quality of care instrument and assessing its psychometric properties amongst them. This research used a mixed-methods case study approach. It was conducted in 7 private hospitals with a primary quantitative research method through 302 interviewer-administered questionnaires and descriptive quantitative statistics, Mann-Whitney U Non-Parametric Significance Tests, Principal Component Analysis (PCA) and Factor Analysis. As a complement, qualitative research through 20 semi-structured interviews and content analysis was conducted in order to provide further insights into this area of research. The findings suggest that word-of-mouth recommendations and reputation have the utmost role in informing international patients of healthcare options in Jordan. Furthermore, recommendations from family and friends are the second most important after availability of specialized treatments in influencing the 3 international patients‘ decision to seek international healthcare. Moreover, significant differences in these terms exist between first and repeat visitors, which hold important implications for tourism marketers. Further marketing implications also exist as most patients shift in the type of activities they and their companions undertake after the main treatment period is completed. In terms of satisfaction, Factor Analysis suggest that medical tourists satisfaction of quality of services in Jordan‘s hospitals is based on six predictors including nutritional care, nursing care, physician care, room atmosphere, the procedure for incoming patients and other hospital services. Both quantitative and qualitative analyses show that medical tourists are satisfied with the quality of health care services rendered to them. However, minor areas show less satisfaction. The findings raise issues regarding the recruitment of non-Arab speaking nurses. Drawing together these findings presents implications for medical tourism management, international healthcare marketing, policy-making, and continuous improvement of the services they provide.

This dissertation seeks to investigate how hospital reimbursement policy affects the quality of care provided to patients when providers compete for healthcare labor that is limited in supply. Cost payment systems fully reimburse a provider’s the total cost of healthcare provided, fixed reimbursements are predetermined at a fixed amount and mixed reimbursements have a cost and fixed component. The first chapter investigates how government reimbursement schemes that induce quality competition among health providers affects the choice of quality of care provided to patients and how these choices depend on the labor supply constraints in the healthcare labor market. We build a theoretical model that explicitly incorporates the healthcare labor supply into a framework of a hospital cournot competition, to show how a hospitals' choice of quality of patient care will be directly influenced when there is a shortage of health personnel in a regulated reimbursement system. We find that multiple equilibria can arise in healthcare markets depending on the consumers’ sensitivity to quality and hospitals’ share of cost when investing in quality. Contrary to existing findings, we are able to show that the effects of reimbursement schemes can vary in different equilibria and in different labor market situations. For instance, in high patient quality sensitivity hospital markets under a high hospital quality equilibrium, we can show that a cost payment scheme decreases a provider’s quality of care while a fixed reimbursement scheme increases quality. More importantly we find that the labor market constraint increases or decreases the effect of the reimbursement system on quality of care. Consequently, the labor constraint changes the quality choice of the provider as compared to the quality level that would have been induced by a particular reimbursement’s policy incentive for quality. In the second chapter, we carry out some of the testable implications of the theoretical finding from the first chapter. This paper investigates how higher Medicare payments brought about by geographical reclassification affects a provider’s quality of care as captured by registered nurses (RN) and licensed practical nurses (LPN) staffing, as well as patient outcomes (mortality, urinary tract infections, pneumonia, peptic ulcer deep vein thrombosis) and length of stay when hospitals compete for nurses. In contrast with past literature, we specifically allow for asymmetry in the hospital’s choice of quality, by permitting coefficients to differ across reclassified hospitals in response to the higher Medicare payments. This asymmetry is based on the relativity of the labor cost faced by the hospital due to competition for nurses in the healthcare labor market. Using Healthcare Cost and Utilization Project (HCUP) and the Center for Medicare and Medicaid (CMS) data from the period 2001 to 2011, we find that hospitals who face relatively higher labor costs will post reclassification increase their RN to LPN staffing ratio as compared to hospitals in their post geographical reclassification areas. A higher RN staffing by these hospitals will result in an improvement of quality of care as the incidence of patient complications due to Pneumonia, Peptic Ulcer and Deep Vein Thrombosis reduces for hospitals that were reclassified after allowing for asymmetry in response to the higher Medicare payment due to differences in labor costs (Pneumonia and Peptic Ulcer complications improve as compared to pre re-class area hospitals and DVT in both pre/post re-class area hospitals). Length of stay also increases for hospitals that faced a higher labor cost while mortality and UTI complications remain unchanged post reclassification. Finally, in the third chapter, we examine how the for profit (FP) or not for profit (NFP) status of hospitals impact the choice of nurse staffing and patient outcomes when there is an increase in provider reimbursement due geographical reclassification. Most of the past studies focus on mortality and length of stay in FPs and NFPs, we extend these studies by investigating the impact of geographical reclassification on patient outcomes that have been established as outcomes sensitive to nursing care. From our regression results, with reference to the ratio of RN to LPN staffing, we find evidence that an increase in Medicare payments will have a greater impact in FPs than in NFPs as compared to their pre re-class geographical area control hospitals. We also find that in hospitals that face a relatively higher labor cost as compared to their controls; (1) There is no difference in the impact of reclassification between FPs and NFPs (2) There is a better response from FPs than NFPs to geographical reclassification when the outcome considered is DVT as evidenced by a decreases in cases of DVT (3) NFPs decrease length of stay whiles FPs increase length of stay as compared to their post re-class geographical area hospitals.

Preventable medical errors are the third leading cause of death in the United States. Healthcare leaders must consistently promote the delivery of quality and safe care of patients to reduce unnecessary errors and prevent harm. The purpose of this case study was to explore human resource strategies for improving organizational performance to reduce medical errors. The study included face-to-face interviews with 5 healthcare clinical managers who work within a multifaceted health system in the Midwestern region of the United States. Complex adaptive systems theory was used to frame this study. Interview notes, publicly available documents, and audio recordings were transcribed and analyzed to identify themes regarding strategies used by managers to find effective ways for improvement. Four themes emerged: addressing seminal/never events, ongoing training programs, communication/collaboration, and promoting a culture of safety and quality. Results may directly benefit healthcare managers by facilitating successful strategies to reduce preventable medical errors through education, feedback, innovation, and leadership. Implications for social change for healthcare managers include continued training, building a culture of safety, and using collaborative and communicative efforts while making contributions to the best practices within healthcare organizations to reduce the likelihood of medical errors.

The purpose of this study was to determine case managers’ understanding of their role in a managed care organisation and to develop recommendations for the improvement of case management practice. Quantitative descriptive research was conducted to explore perceptions of case managers regarding their role. A self-administered questionnaire was used as a formal data collection instrument and 25 respondents participated in the study. The findings revealed that the majority of case managers know what is expected of them in their job but that they do experience some barriers. There appears to be uncertainty with quite a number of respondents regarding certain aspects of their role. Recommendations were made for improved case management practice.

The purpose of this study was to determine case managers’ understanding of their role in a managed care organisation and to develop recommendations for the improvement of case management practice. Quantitative descriptive research was conducted to explore perceptions of case managers regarding their role. A self-administered questionnaire was used as a formal data collection instrument and 25 respondents participated in the study. The findings revealed that the majority of case managers know what is expected of them in their job but that they do experience some barriers. There appears to be uncertainty with quite a number of respondents regarding certain aspects of their role. Recommendations were made for improved case management practice.