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Catholic Ownership, Physician Leadership and Operational Strategies: Evidence from German Hospitals
(2022)
Previous research has revealed that Catholic hospitals are more likely follow a strategy of horizontal diversification and maximization of the number of patients treated, whereas Protestant hospitals follow a strategy of horizontal specialization and focus on vertical differentiation. However, there is no empirical evidence pertaining to this mechanism. We conduct an empirical study in a German setting and argue that physician leadership mediates the relationship between ownership and operational strategies. The study includes the construction of a model combining data from a survey and publicly available information derived from the annual quality reports of German hospitals. Our results show that Catholic hospitals opt for leadership structures that ensure operational strategies in line with their general values, i.e., operational strategies of maximizing volume throughout the overall hospital. They prefer part-time positions for chief medical officers, as chief medical officers are identified to foster strategies of maximizing the overall number of patients treated. Hospital owners should be aware that the implementation of part-time and full-time leadership roles can help to support their strategies. Thus, our results provide insights into the relationship between leadership structures at the top of an organization, on the one hand, and strategic choices, on the other.
Background: To improve interprofessional collaboration between registered nurses (RNs) and general practitioners (GPs) for nursing home residents (NHRs), the interprof ACT intervention package was developed. This complex intervention includes six components (e.g., shared goal setting, standardized procedures for GPs’ nursing home visits) that can be locally adapted. The cluster‑randomized interprof ACT trial evaluates the effects of this intervention on the cumulative incidence of hospital admissions (primary outcome) and secondary outcomes (e.g., length of hospital stays, utilization of emergency care services, and quality of life) within 12 months. It also includes a process evaluation which is subject of this protocol. The objectives of this evaluation are to assess the implementation of the interprof ACT intervention package and downstream effects on nurse–physician collaboration as well as preconditions and prospects for successive implementation into routine care.
Methods: This study uses a mixed methods triangulation design involving all 34 participating nursing homes (clusters). The quantitative part comprises paper‑based surveys among RNs, GPs, NHRs, and nursing home directors at baseline and 12 months. In the intervention group (17 clusters), data on the implementation of preplanned implementation strategies (training and supervision of nominated IPAVs, interprofessional kick‑off meetings) and local implementation activities will be recorded. Major outcome domains are the dose, reach and fidelity of the implementation of the intervention package, changes in interprofessional collaboration, and contextual factors. The qualitative part will be conducted in a subsample of 8 nursing homes (4 per study group) and includes repeated non‑participating observations and semistructured interviews on the interaction between involved health professionals and their work processes. Quantitative and qualitative data will be descriptively analyzed and then triangulated by means of joint displays and mixed methods informed regression models.
Discussion: By integrating a variety of qualitative and quantitative data sources, this process evaluation will allow comprehensive assessment of the implementation of the interprof ACT intervention package, the changes induced in interprofessional collaboration, and the influence of contextual factors. These data will reveal expected and unexpected changes in the procedures of interprofessional care delivery and thus facilitate accurate conclusions for the further design of routine care services for NHRs.
Background
Maternal postpartum depression has an impact on mother-infant interaction. Mothers with depression display less positive affect and sensitivity in interaction with their infants compared to non-depressed mothers. Depressed women also show more signs of distress and difficulties adjusting to their role as mothers than non-depressed women. In addition, depressive mothers are reported to be affectively more negative with their sons than with daughters.
Methods
A non-clinical sample of 106 mother-infant dyads at psychosocial risk (poverty, alcohol or drug abuse, lack of social support, teenage mothers and maternal psychic disorder) was investigated with EPDS (maternal postpartum depressive symptoms), the CARE-Index (maternal sensitivity in a dyadic context) and PSI-SF (maternal distress). The baseline data were collected when the babies had reached 19 weeks of age.
Results
A hierarchical regression analysis yielded a highly significant relation between the PSI-SF subscale "parental distress" and the EPDS total score, accounting for 55% of the variance in the EPDS. The other variables did not significantly predict the severity of depressive symptoms. A two-way ANOVA with "infant gender" and "maternal postpartum depressive symptoms" showed no interaction effect on maternal sensitivity.
Conclusions
Depressive symptoms and maternal sensitivity were not linked. It is likely that we could not find any relation between both variables due to different measuring methods (self-reporting and observation). Maternal distress was strongly related to maternal depressive symptoms, probably due to the generally increased burden in the sample, and contributed to 55% of the variance of postpartum depressive symptoms.
Background:
This study examined the extent to which regulatory problems in infants at 4 and 6 months influence childhood development at 12 months. The second aim of the study was to examine the influence maternal distress has on 4-month-old children’s subsequent development as well as gender differences with regard to regulatory problems and development.
Methods:
153 mother-child dyads enrolled in the family support research project “Nobody slips through the net” constituted the comparison group. These families faced psychosocial risks (e.g. poverty, excessive demands on the mother, and mental health disorders of the mother, measured with the risk screening instrument Heidelberger Belastungsskala - HBS) and maternal stress, determined with the Parental Stress Index (PSI-SF). The children’s developmental levels and possible early regulatory problems were evaluated by means of the Ages and Stages Questionnaires (ASQ) and a German questionnaire assessing problems of excessive crying along with sleeping and feeding difficulties (SFS).
Results:
A statistically significant but only low, inverse association between excessive crying, whining and sleep problems at 4 and 6 months and the social development of one-year-olds (accounting for 5% and 8% of the variance respectively) was found. Feeding problems had no effect on development. Although regulatory problems in infants were accompanied by increased maternal stress level, these did not serve as a predictor of the child’s social development at 12 months. One-year-old girls reached a higher level of development in social and fine motor skills. No gender differences were found with regard to regulatory problems, nor any moderating effect of gender on the relation between regulatory problems and level of development.
Conclusions:
Our results reinforce existing knowledge pertaining to the transactional association between regulatory problems in infants, maternal distress and dysfunctionality of mother-child interactions. They also provide evidence of a slight but distinct negative influence of crying and sleeping problems on children’s subsequent social development. Easily accessible support services provided by family health visitors (particularly to the so-called “at-risk families”) are strongly recommended to help prevent the broadening of children’s early regulatory problems into other areas of behavior.
Background: Continuity of care is associated with many benefits for patients and health care systems. Therefore measuring care coordination - the deliberate organization of patient care activities between two or more participants - is especially needed to identify entries for improvement. The aim of this study was the translation and cultural adaptation of the Medical Home Care Coordination Survey (MHCCS) into German, and the examination of the psychometric properties of the resulting German versions of the MHCCS-P (patient version) and MHCCS-H (healthcare team version).
Methods: We conducted a paper-based, cross-sectional survey in primary care practices in three German federal states (Schleswig-Holstein, Hamburg, Baden-Württemberg) with patients and health care team members from May 2018 to April 2019. Descriptive item analysis, factor analysis, internal consistency and convergent, discriminant and predictive validity of the German instrument versions were calculated by using SPSS 25.0 (Inc., IBM).
Results: Response rates were 43% (n = 350) for patients and 34% (n = 141) for healthcare team members. In total, 300 patient questionnaires and 140 team member questionnaires could be included into further analysis. Exploratory factor analyses resulted in three domains in the MHCCS-D-P and seven domains in the MHCCS-D-H: “link to community resources”, “communication”, “care transitions”, and additionally “self-management”, “accountability”, “information technology for quality assurance”, and “information technology supporting patient care” for the MHCCS-D-H. The domains showed acceptable and good internal consistency (α = 0.838 to α = 0.936 for the MHCCS-D-P and α = 0.680 to α = 0.819 for the MHCCS-D-H).
As 77% of patients (n = 232) and 63% of health care team members denied to have or make written care plans, items regarding the “plan of care” of the original MHCCS have been removed from the MHCCS-D.
Conclusions: The German versions of the Medical Home Care Coordination Survey for patients and healthcare team members are reliable instruments in measuring the care coordination in German primary care practices. Practicability is high since the total number of items is low (9 for patients and 27 for team members).
Background
In Germany, up to 50% of nursing home residents are admitted to a hospital at least once a year. It is often unclear whether this is beneficial or even harmful. Successful interprofessional collaboration and communication involving general practitioners (GPs) and nurses may improve medical care of nursing home residents. In the previous interprof study, the six-component intervention package interprof ACT was developed to facilitate collaboration of GPs and nurses in nursing homes. The aim of this study is to evaluate the effectiveness of the interprof ACT intervention.
Methods
This multicentre, cluster randomised controlled trial compares nursing homes receiving the interprof ACT intervention package for a duration of 12 months (e.g. comprising appointment of mutual contact persons, shared goal setting, standardised GPs’ home visits) with a control group (care as usual). A total of 34 nursing homes are randomised, and overall 680 residents recruited. The intervention package is presented in a kick-off meeting to GPs, nurses, residents/relatives or their representatives. Nursing home nurses act as change agents to support local adaption and implementation of the intervention measures. Primary outcome is the cumulative incidence of hospitalisation within 12 months. Secondary outcomes include admissions to hospital, days admitted to hospital, use of other medical services, prevalence of potentially inappropriate medication and quality of life. Additionally, health economic and a mixed methods process evaluation will be performed.
Discussion
This study investigates a complex intervention tailored to local needs of nursing homes. Outcomes reflect the healthcare and health of nursing home residents, as well as the feasibility of the intervention package and its impact on interprofessional communication and collaboration. Because of its systematic development and its flexible nature, interprof ACT is expected to be viable for large-scale implementation in routine care services regardless of local organisational conditions and resources available for medical care for nursing home residents on a regular basis. Recommendations will be made for an improved organisation of primary care for nursing home residents. In addition, the results may provide important knowledge and data for the development and evaluation of further strategies to improve outpatient care for elderly care-receivers.
Background: Given both the increase of nursing home residents forecast and challenges of current interprofessional interactions, we developed and tested measures to improve collaboration and communication between nurses and general practitioners (GPs) in this setting. Our multicentre study has been funded by the German Federal Ministry of Education and Research (FK 01GY1124).
Methods: The measures were developed iteratively in a continuous process, which is the focus of this article. In part 1 “exploration of the situation”, interviews were conducted with GPs, nurses, nursing home residents and their relatives focusing on interprofessional interactions and medical care. They were analysed qualitatively. Based on these results, in part 2 “development of measures to improve collaboration”, ideas for improvement were developed in nine focus groups with GPs and nurses. These ideas were revisited in a final expert workshop. We analysed the focus groups and expert workshop using mind mapping methods, and finally drew up the compilation of measures. In an exploratory pilot study "study part 3" four nursing homes chose the measures they wanted to adopt. These were tested for three months. Feasibility and acceptance of the measures were evaluated via guideline interviews with the stakeholders which were analysed by content analyses.
Results: Six measures were generated: meetings to establish common goals, main contact person, standardised pro re nata medication, introduction of name badges, improved availability of nurse/GP and standardised scheduling/ procedure for nursing home visits. In the pilot study, the measures were implemented in four nursing homes. GPs and nurses reviewed five measures as feasible and acceptable, only the designation of a “main contact person” was not considered as an improvement.
Conclusions: Six measures to improve collaboration and communication could be compiled in a multistep qualitative process respecting the perspectives of involved stakeholders. Five of the six measures were positively assessed in an exploratory pilot study. They could easily be transferred into the daily routine of other nursing homes, as no special models have to exist in advance. Impact of the measures on patient oriented outcomes should be examined in further research.
Trial registration: Not applicable.
Objectives
Quality of care largely depends on successful teamwork, which in turn needs effective communication between health professionals. To communicate successfully in a team, health professionals need to strive for the same goals. However, it has been left largely unaddressed which goals professionals consider to be important. In this study, we aim to identify these goals and analyse whether differences between (1) personal and organisational goals, (2) different professions and (3) hierarchical levels exist in neonatal intensive care units (NICUs).
Design
Goals were identified based on a literature review and a workshop with health professionals and tested in a pilot study. Subsequently, in the main study, a cross-sectional employee survey was undertaken.
Setting and participants
1489 nurses and 537 physicians from 66 German NICUs completed the
questionnaire regarding personal and organisational goal importance between May and July 2013. Answers were given based on a 7-point Likert scale varying between none and exceptionally high importance.
Results
Results show that the goals can be subdivided into three main goal dimensions: patients, parents and staff. Furthermore, our results reveal significant differences between different professions and different hierarchical level: physicians rated patient goals with a
mean (95% CI) importance of 6.37 (3.32 to 6.43), which is significantly higher than nurses with a mean (95% CI) importance of 6.15 (6.12 to 6.19) (p<0.01). Otherwise, nurses classified parental goals as more important (p<0.01). Furthermore, professionals in leading positions rate patient goals significantly higher than professionals that are not in leading positions (6.36 (3.28 to 6.44) vs 6.19 (6.15 to 6.22), p<0.01).
Conclusions
Different employee goals need to be considered in decision-making
processes to enhance employee motivation and the effectiveness of teamwork.
Background:
In order to prevent child abuse, instruments measuring child abuse potential (CAP) need to be appropriate, reliable and valid.
Objective:
This study aimed to confirm the 6-factor structure of the Brief Child Abuse Potential Inventory (BCAPI) in a German sample of mothers and fathers, and to examine longitudinal predictors of CAP.
Participants and setting:
Two waves of data were collected from 197 mothers and 191 fathers of children aged 10–21 months for the “Kinder in Deutschland–KiD 0–3” in-depth study. Families were stratified based on prior self-report data for screening purposes.
Methods:
138 fathers and 147 mothers were included in the analysis (invalid: 25% mothers, 30% fathers). First, validity of reporting was examined. Second, confirmatory factor analysis (CFA) was employed to assess factor structure. Third, internal reliability and criterion validity were examined. Finally, multivariate poisson regressions investigated longitudinal predictors of CAP in mothers.
Results:
A previously established six-factor structure was confirmed for mothers but not fathers. CFA failed for fathers due to large numbers of variables with zero variance. For mothers, internal consistency and criterion validity were good. BCAPI score at follow-up was associated with baseline BCAPI score (β= 00.08), stress (β= 0.06), education (β=-0.19) and alcohol use(β= .58).
Conclusions:
Findings confirm the six-factor structure of the BCAPI among German mothers. The clinical use of the BCAPI in fathers is not recommended as it might produce data that are hard to interpret. Further research with fathers is needed to establish if this is due to limitations with this dataset or with the questionnaire.
Since child maltreatment has highly negative effects on child adjustment, early identification of at-risk families is important. This study focuses on longitudinal risk factors for child maltreatment and associations between abuse risk and occurrence. It also examines whether abuse risk and involvement in early childhood intervention are associated. The sample comprises 197 German caregivers with children under 3 years of age. Data was collected in two waves. The Brief Child Abuse Potential Inventory assessed abuse risk. Socio-demographic, parent, child and family-related risk factors were measured using screening tools. The analysis revealed that parental characteristics (psychopathology, own maltreatment experiences etc.) were associated with concurrent abuse risk. Longitudinal changes in abuse risk were linked to caregiver education and child-related factors. Cumulative risk did not explain more variance than specific risk factors. Significant associations with caregiverreported abuse were found, and data suggest that some burdened families cannot be reached by early childhood intervention.