Healthcare is an organizational field that has undergone profound change in the last few decades, an era characterized by market reform. Healthcare production has revealed both economic and quality problems in past eras, and reporting on these problems can be seen to have contributed to pressures for social reform. Yet, the move toward more market-oriented governance structures and design solutions also reflects a wider isomorphic institutional tendency for organizing social order.The conceptual frame work of this study takes a pessimistic stance on whether the market reform has achieved the intended goals with respect to advancing organizational quality performance. The framework draws on institutional theory and complementary collective action notions in organization theory concerned with boundedly rational decision-making to reason that healthcare evidences certain contextual characteristics that are not a good fit with the market enterprise model of organizing organizations. Specifically, hazards to the efficient market thesis were considered to include uncertain outcomes, a high degree of technical and coordination complexity, and the need to account for intertemporal process transformations of significant duration.A longitudinal design was used to test efficient market thesis propositions. Inpatient administrative data was used to develop two latent hospital quality performance variables, a Mortality quality indicator and an Errors quality indicator. The two latent variables were derived from three selected AHRQ patient safety indicators and an inpatient mortality rate. The measurement model was validated as evidencing significant systematic between-hospital variation. Audited survey data, along with inpatient discharge data was used to develop hospital economic performance variables and process control variables.A set of predictive supply-and-demand models were used to test: 1) whether there is evidence of any trend in quality performance, and how market competition relates to observations of improvement; 2) whether quality cost more; and, 3) whether preferences for better quality outcomes related to hospital economic performance. A hierarchical linear model growth-curve design was employed to assess the predicted relationships and to account for unmeasured organizational dependent relations determinant of hospital quality performance. The unaccounted for systematic between-hospital variance was taken to estimate an "unspecified" hospital-specific institutional effect, independent of material-resource factors. The measurement model results for each of the quality indicators selected evidenced construct validity for patient-level risk-adjustment. Each quality indicator demonstrated a significant systematic between-group variance component in all of the four years studied. The two latent hospital quality performance variables also demonstrated systematic between-hospital variance in growth trajectories in the linear growth-curve model.The predictive models evidenced no significant growth rate trend for either of the quality indicators, indicating the competitive bar on quality performance was unaffected during this period of market reform. Neither was there any evidence that pricing mechanism were able to price the utility of better outcomes, as higher quality did not cost more. Neither was there evidence that consumer preferences for better quality related to better hospital economic performance, as measured by hospital operating margins.

Excess inpatient length of stay (LOS) varies between hospitals and is burdensome to patients and the overall healthcare system. Variation in LOS has often been associated with hospital-level factors, such as hospital efficiency and quality. Clostridium difficile infection (CDI) is an increasingly common hospital-acquired (HA) infection. This thesis explores the connection between hospital incidence of CDI and excess LOS in patients without a CDI. It is hypothesized that HA-CDI incidence may act as a "proxy variable" to capture unobserved hospital characteristics, such as hospital quality or efficiency, associated with prolonged LOS. In addition, hospitals with longer LOS may tend to observe more HA-CDI cases prior to discharge. This thesis analyzes the ability of CDI incidence to capture excess LOS variation across hospitals, while controlling for CDI cases that occur after discharge. We use data on hospital inpatient visits, spanning the years 2005-2011, from three data sources distributed by the Healthcare Cost and Utilization Project: the Nationwide Inpatient Sample (NIS), and the State Inpatient Databases (SID) for California and New York. The NIS provides discharge records from a nationwide sampling of hospitals in a given year. The SIDs are longitudinal populations of inpatient records in each state, and patient records can be linked across stays. We compute a variety of different measures of hospital CDI incidence and identify HA-CDI cases that occur after a patient is discharged. Various multivariable regression models are analyzed to predict LOS at an individual patient level. A generalized linear modeling approach is used, and different distributions and link functions are compared using the Akaike information criterion. A multilevel modeling approach is also used to estimate the amount of between-hospital variation in LOS that can be explained by HA-CDI incidence. We find CDI incidence to be a strong predictive factor for explaining a patient's LOS and is one of the strongest predictive variables we identified. Moreover, CDI incidence appears to primarily capture between-hospital variation in excess LOS. Although we find evidence that present-on-admission indicators may underreport cases of HA CDI, our findings suggest the connection between CDI incidence and excess LOS is driven primarily by CDI cases that are HA. In addition, when we account for HA-CDI cases that occur post-discharge, the relationship between CDI incidence and LOS appears even stronger. Our results suggest that CDI incidence may be a powerful tool for making comparisons of excess LOS across hospitals.

This dissertation discusses three problems from different areas of medical research and their machine learning solutions. Each solution is a distinct type of decision support system. They show three common properties: personalized healthcare decision support, reduction of the use of medical resources, and improvement of outcomes. The first decision support system assists individual hospital selection. This system can help a user make the best decision in terms of the combination of mortality, complication, and travel distance. Both machine learning and optimization techniques are utilized in this type of decision support system. Machine learning methods, such as Support Vector Machines, learn a decision function. Next, the function is transformed into an objective function and then optimization methods are used to find the values of decision variables to reach the desired outcome with the most confidence. The second decision support system assists diagnostic decisions in a sequential decision-making setting by finding the most promising tests and suggesting a diagnosis. The system can speed up the diagnostic process, reduce overuse of medical tests, save costs, and improve the accuracy of diagnosis. In this study, the system finds the test most likely to confirm a diagnosis based on the pre-test probability computed from the patient's information including symptoms and the results of previous tests. If the patient's disease post-test probability is higher than the treatment threshold, a diagnostic decision will be made, and vice versa. Otherwise, the patient needs more tests to help make a decision. The system will then recommend the next optimal test and repeat the same process. The third decision support system recommends the best lifestyle changes for an individual to lower the risk of cardiovascular disease (CVD). As in the hospital recommendation system, machine learning and optimization are combined to capture the relationship between lifestyle and CVD, and then generate recommendations based on individual factors including preference and physical condition. The results demonstrate several recommendation strategies: a whole plan of lifestyle changes, a package of n lifestyle changes, and the compensatory plan (the plan that compensates for unwanted lifestyle changes or real-world limitations).

The primary motivation of this PhD by publication has been the apparent disconnect between the metrics of hospital quality of care at national and board level and patients’ experiences. Exploration of the gap led to the realisation of two key points. Firstly, the concept of healthcare quality continually evolves. Secondly, the NHS Scotland Measurement Framework does not include a measure of patient experience at the microsystem level (e.g. hospital ward). This is needed to counterbalance easier to obtain metrics of quality (e.g. waiting times). Resource tends to follow measurement. Papers 1 and 2 were exploratory, investigating theoretical and practical aspects of measuring quality of hospital care at the clinical microsystem level. With the associated Chapters, they highlighted both the necessity and the possibility of measuring the patient experience at the micro level of the healthcare system. They also drew attention to the inadequacy of “satisfaction” as a metric, leading to closer examination of “experience” as the decisive metric. This required the development of a systematic review protocol (Paper Three), then a systematic review (Paper Four). The review (Paper Four) examined the utility (validity, reliability, cost efficiency, acceptability and educational impact) of questionnaires to measure the patient experience of hospital quality of care, with a newly devised matrix tool. Findings highlighted a gap for an instrument with high utility for use at the clinical microsystem level of healthcare. Paper Five presents the development and preliminary psychometric testing of such an instrument; the Care Experience Feedback Improvement Tool (CEFIT). The thesis provides, as well as the matrix tool and CEFIT, theoretical and methodological contributions in the field of healthcare quality. It contributes to an aspiration that the patient’s voice can be heard and acknowledged, in order to direct improvements in the quality of hospital care.

This is a quantitative study of archival data that examines Merger and Acquisition (M&A) activity using currently established healthcare quality and financial performance metrics. The research seeks to explicate the relationship between M&A activity and M&A experience in the healthcare industry as it relates to initiatives aimed at improving the quality and decreasing the cost of healthcare. The Affordable Care Act (ACA) legislation appears to be contributing to a trend toward M&A consolidation; by illuminating how this trend potentially impacts healthcare quality and cost reduction initiatives, this study’s contribution is both useful and practical. The units of analysis are Medicare reporting hospitals, hospital systems, and related healthcare providers that have or have not experienced an M&A or multiple M&As. The study shows a statistically significant improvement in quality each year from 2006–2014, which is reflected in higher scores for the four quality metrics measured. M&A activity, as measured by acquisition status and acquirer experience, did not appear to influence these quality metrics, with the exception of the heart failure measure, which showed a statistically significant positive influence of acquirer experience across all specifications. M&A activity’s possible effects on hospital financial performance was assessed through operating-cost-to-charge and capital-cost-to-charge ratios (CCRs). The operating CCR appears to be positively influenced by both acquisition status and acquirer experience, while the capital CCR was positively influenced only by acquirer experience. A positive influence is reflected in a decreasing ratio. Results on quality improvement over time, both before and after the ACA, suggest that the ACA itself may not be the driver for quality improvement. Similarly, decreases in OCCR occurred consistently and statistically significantly over time, both pre- and post-ACA, while CCCR showed statistically significant decreases in 2006–2008, 2013, and 2014. These results appear to support the notion that the trend was ongoing before the ACA was enacted and gave these measures high-profile exposure. This is a quantitative study of archival data that examines Merger and Acquisition (M&A) activity using currently established healthcare quality and financial performance metrics. The research seeks to explicate the relationship between M&A activity and M&A experience in the healthcare industry as it relates to initiatives aimed at improving the quality and decreasing the cost of healthcare. The Affordable Care Act (ACA) legislation appears to be contributing to a trend toward M&A consolidation; by illuminating how this trend potentially impacts healthcare quality and cost reduction initiatives, this study’s contribution is both useful and practical. The units of analysis are Medicare reporting hospitals, hospital systems, and related healthcare providers that have or have not experienced an M&A or multiple M&As. The study shows a statistically significant improvement in quality each year from 2006–2014, which is reflected in higher scores for the four quality metrics measured. M&A activity, as measured by acquisition status and acquirer experience, did not appear to influence these quality metrics, with the exception of the heart failure measure, which showed a statistically significant positive influence of acquirer experience across all specifications. M&A activity’s possible effects on hospital financial performance was assessed through operating-cost-to-charge and capital-cost-to-charge ratios (CCRs). The operating CCR appears to be positively influenced by both acquisition status and acquirer experience, while the capital CCR was positively influenced only by acquirer experience. A positive influence is reflected in a decreasing ratio. Results on quality improvement over time, both before and after the ACA, suggest that the ACA itself may not be the driver for quality improvement. Similarly, decreases in OCCR occurred consistently and statistically significantly over time, both pre- and post-ACA, while CCCR showed statistically significant decreases in 2006–2008, 2013, and 2014. These results appear to support the notion that the trend was ongoing before the ACA was enacted and gave these measures high-profile exposure.

Darbo tikslas: Įvertinti Lietuvos regioninių stacionarinių asmens sveikatos priežiūros įstaigų teikiamų paslaugų kokybę ir jos netolygumus, remiantis statistiniais kokybės rodikliais. Darbo uždaviniai: 1. Įvertinti Lietuvos regioninių stacionarinių asmens sveikatos priežiūros įstaigų paslaugų kokybę remiantis statistiniais paslaugų kokybės vertinimo rodikliais. 2. Išanalizuoti Lietuvos regioninių stacionarinių asmens sveikatos priežiūros įstaigų paslaugų kokybės rodiklių svyravimus priklausomai nuo amžiaus, lyties, dienos pobūdžio, paslaugos rūšies. 3. Įvertinti atvejų skaičiaus įtaką stacionarinių asmens sveikatos priežiūros įstaigų paslaugų kokybei Tyrimo metodika: Tyrime vertintos 6 regioninės ligoninės. Kokybės rodikliai: Cezario pjūvio (CPO) operacijų dažnis, hospitalinis mirštamumas dėl ūmaus miokardo infarkto per 30 ir per 2 d. (ŪMI 30d. ir 2d.) ir dėl galvos smegenų insulto (GSI 30d. ir ŪMI 2d.). Papildomi rodikliai: vidutinės gulėjimo trukmės (VGT) analizė pagal gimdymo būdą ir tarp ligoninių, vertinta atvejų skaičiaus koreliacija su pasirinktų rodiklių rezultatais ir analizuotas perkeltų į kitą ligoninę tolimesniam gydymui pacientų srautai. Statistinė duomenų analizė atlikta SAS programa. Rezultatai: Bendras CPO dažnis regioninėse ligoninėse buvo 18,45 proc. Amžiaus grupėse svyravo: <25 m. 15,38 proc., 25–35 m. 20,06 proc., >35 m. 20,55 proc. (p<0,05). CPO dažnis darbo dienomis buvo 19,82 proc., laisvadieniais 13,82 proc. (p<0,05). Lyginant tarp ligoninių:... [toliau žr. visą tekstą] / Aim of the study. To measure the quality of care in Lithuanian regional hospitals and its variations with statistical quality indicators. Objectives. 1. to assess the quality of care in Lithuanian regional hospitals with statistical quality indicators. 2. To analyse the variations of quality indicators of Lithuanian regional hospitals depending on age, sex, nature of day, and type of delivery. 3. To assess the influence of case volume on service quality of hospitals. Methods. 6 regional hospitals were assessed during the research period from 2010 to 2012. Quality indicators: Caesarean section (CS) rate, in-hospital 30-day and 2-day mortality rates due to Acute Myocardial Infarction (AMI) and in-hospital 30-day and 2-day mortality rates following stroke. Additional indicators: analysis of average length of stay (ALS) according to the mode of childbearing and among hospitals; assessment of correlation of the results between selected indicators and patient case volume; and the analysis of patient flows transferred to another hospital for further treatment. Statistical analysis was performed by means of SAS program. Results. The overall rate of CS in regional hospitals was 18.45 %. Ages in the groups ranged as follows: <25 y.o. - 15.38 %; 25-35 y.o. - 20.06 %; > 35 y.o. - 20.55 % (p <0.05). CS rate on weekdays was 19.82 %, at weekends - 13.82 % (p <0.05). Comparing among hospitals: the rate of CS in hospital performing least CS was 13.19 %; the highest indicator value was 28.9 %... [to full text]

Bibliografický záznam WINZBERGEROVÁ, Alžběta. 2015. Odborný a osobnostní profil manažerů kvality fakultních nemocnic v České republice. Praha: Univerzita Karlova, Fakulta humanitních studií, Katedra řízení a supervize v sociálních a zdravotnických organizacích. 85 stran. Vedoucí diplomové práce Mgr. Petr Vrzáček. Abstract The thesis is focused on the quality management in the healthcare organizations. Quality management is perceived as a process or a set of processes, which are coordinated by a responsible person - a quality manager. The thesis summarizes the expert theoretical knowledge about the historical development of the quality requirements, about the quality management systems in healthcare and it introduces the institutional framework of quality and safety in healthcare organizations in the Czech Republic. The emphasis is especially given to the profile and job description of quality managers. The objective of this thesis is to create a professional and personal profile of quality managers working at the Czech university hospitals. The method of data collection used is semi structured interview. The results from the analysis show that quality managers were educated in different fields, but still they have similar personal characteristics. They perceive their job as exhausting, but they keep being...

Submitted by JOSIANE SANTOS DE OLIVEIRA (josianeso) on 2017-09-22T13:25:26Z No. of bitstreams: 1 Fabricio Colvero Avini_.pdf: 3377321 bytes, checksum: b18160c29f04c7b1de74a9b4ccdf5f40 (MD5) / Made available in DSpace on 2017-09-22T13:25:26Z (GMT). No. of bitstreams: 1 Fabricio Colvero Avini_.pdf: 3377321 bytes, checksum: b18160c29f04c7b1de74a9b4ccdf5f40 (MD5) Previous issue date: 2017-06-01 / Nenhuma / A saúde apresenta enorme desafio de conciliar qualidade com viabilidade financeira. Como premissa, é uma área que demanda fazer mais, com menos recursos e com resultados que podem impactar na vida das pessoas. No Brasil, hospitais de excelência têm iniciativas muito próximas as internacionais de destaque, visando atender requisitos de qualidade elevada, medindo sua performance, como os hospitais da ANAHP (Associação Nacional de Hospitais Privados), mas a principal questão desta pesquisa é em relação a quais indicadores representam melhor a área de atenção hospitalar e poderia ser aplicada para todos perfis de hospitais do país. Os indicadores avaliados neste estudo foram agrupados nas dimensões do BSC (Balanced Scorecard), onde foram considerados processos de gestão e assistenciais, além de aspectos financeiros, recursos humanos e percepção de qualidade pelo cliente. O trabalho propõe, a partir de 7 referências nacionais e internacionais, um conjunto de 30 indicadores, com preocupação de cobrir não apenas processos estratégicos de gestão, mas também assistenciais, menos avaliado em hospitais fora do grupo de excelência. Este conjunto de indicadores foi validado por especialistas em gestão e assistência, não apenas ligados a hospitais de excelência, mas também ao perfil de hospitais identificados como futuros “adopters”, mais prevalente no brasil, como os filantrópicos, na tentativa de explorar a percepção de viabilidade futura de adoção de uma plataforma nacional de bencharming hospitalar. Após validado o conjunto de indicadores, foi apresentado um protótipo não-funcional em uma plataforma tecnológica em ambiente web, disponível no domínio benchealth.com.br e realizada a avaliação sobre a viabilidade de importar estas informações a partir dos Sistemas de Informação Hospitalar (SIH) presentes no mercado e de acordo com o nível de sistematização, com intuito de avaliar a viabilidade de extração destes indicadores. O resultado deste estudo demonstrou aderência aos indicadores propostos, porém ficou evidente as dificuldades de obtenção de alguns indicadores, principalmente relacionados a processos assistenciais, menos sistematizados nos hospitais. Também entende-se como necessidade futura, avaliar viabilidade de outros indicadores que possuem representatividade em ambientes de excelência e ainda não fizeram parte deste estudo inicial. / The health area presents huge challenge of reconciling quality with financial viability. As a premise is an area that demands to do more, with fewer resources and with results that can impact lives of people. In Brazil, hospitals of excellence have initiatives that are very close to the most important international ones, aiming to meet high quality requirements, measuring their performance, such as hospitals members of ANAHP (National Association of Private Hospitals), which has a collection of indicators and comparison between participants, but the main question of this research is in relation to which Indicators better represent the area of hospital care and could be applied to all profiles of hospitals in the country. The indicators evaluated in this study were grouped into the BSC (Balanced Scorecard) dimensions, mainly related within management and assistance process, besides financial aspects, human resources and customer perception of quality. The work proposes, from 7 national and international references, a set of 30 indicators, with concern to cover not only strategic processes of management, but also assistance, less evaluated in hospitals outside the group of excellence. This set of indicators was validated by a group of management and healthcare specialists, not only linked to hospitals of excellence, but also to the widespread profile of hospitals, identified as future adopters, more prevalent in Brazil, such as non-profit, in an attempt to exploring the perception of future feasibility of adopting a national hospital benchmarking platform. After validating the set of indicators, a non-functional prototype was presented in a web-based technology platform, available in the benchealth.com domain, and an assessment was made to visualize the feasibility of importing this information from the Hospital Information Systems (HIS) most used in market, considering systematization level within HIT, in order to evaluate the viability of extracting these indicators. The result of this study showed adherence to the proposed indicators, but also signaled difficulties in obtaining some indicators, mainly related to care processes, less systematized in hospitals. It is also clear the need to assess the viability of other indicators that have representativeness in environments of excellence and have not yet been part of this initial study.

The topic of this work - social work in palliative care - is very up-to-date because in the last three years, thanks to the "Together until the end" program of the Avast Foundation Fund, specialized palliative care has been introduced in eighteen Czech hospitals, which is a response to the fact that 78% of the citizens of the Czech Republic die in healthcare facilities. The goal of the thesis was to answer the research question: "How do social workers at the Central Military Hospital in Prague who have experience with clients in the terminal stage of illness describe the means to achieve the goals of social work in palliative care in the hospital?" To find out the answer to this question, we have used the Grounded theory research method and realized a research in the CMH in Prague. The main findings of the research consist in describing the objectives of social work in palliative care in the hospital as understood by the respondents, and in the description of the means used to achieve these goals and the links between them. These objectives are: the client's wishes and the quality of life with dignified dying and among the means is the relationship between the social worker, the client and the family; social counselling and family care. Other findings include a description of the needs of those...