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The purpose of this study is to evaluate the determinants of health outcomes of dialysis patients, while specifically focusing on the role of dialysis process measures and dialysis practice characteristics. The dialysis industry is facing a major transition from a volume-based health care system to a value-based cost-efficient care model, in the USA. Under the bundled Prospective Payment System, the treatment-based payment model is subject to meeting quality thresholds as defined by clinical process measures including dialysis adequacy and anemia management. Few studies have focused on studying these two processes and their association with the quality of patient health outcomes.

In this study, the authors focus on identifying the determinants of patient health outcomes among freestanding dialysis clinics, using a large cross-sectional data set of 4,571 dialysis clinics in the USA. The authors use econometric analyses to estimate the association between dialysis facility characteristics and practice patterns and their association with dialysis process measures and hospitalization risk.

The authors find that reusing dialyzers and increasing the number of dialysis stations is associated with higher levels of clinical quality. This research indicates that deploying more nurses on-site allows patients to avail adequate dialysis, while increasing the supply of physicians can hurt anemia control process. In addition, the authors report that offering peritoneal dialysis and late night shifts are not beneficial practices in terms of their impact on the hospitalization risk.

While early studies of dialysis care mainly focused on the associations between practice patterns and patient outcomes, this research reveals the underlying mechanisms of these relationships by exploring the mediation effects of clinical dialysis processes on patient outcomes. The results indicate that dialysis process measures mediate the impact of the operational characteristics of dialysis centers on patient hospitalization rates.

This study offers several managerial insights for owners and operators of dialysis clinics with respect to the association between managerial and clinical practices that they deploy within dialysis clinics and their impact on clinical quality measures as well as hospitalization risk of patients. Managers can draw on this study to optimize staffing levels in their dialysis clinics, and implement innovative clinical practices.

Considering the growth in healthcare expenditures in developing and developed countries, and specifically for costly diagnoses such as dialyses, this study offers several insights related to the inter-relationships between dialysis practice patterns and their clinical quality measures.

This study makes several major contributions. First, the authors address the extant gap in the literature on the relationships between dialysis facility and practice characteristics and clinical outcomes, while specifically highlighting the role of clinical process measures as antecedents of patient hospitalization ratio, a key metric used to measure performance of dialysis clinics. Second, this study sheds light on the underlying mechanisms that serve as enablers of the dialysis adequacy and anemia management. To the best of the authors’ knowledge, this is the first study to explore these relationships in the dialysis industry. The authors’ approach provides a new direction for future studies to explore the pathways that may impact clinical quality measures in the delivery of dialysis services.

The purpose of this paper is to empirically explore and conceptualize how healthcare professionals and managers give shape to the increasing call for compassionate care as an alternative for system-based quality management systems. The research demonstrates how quality rebels craft deviant practices of good care and how they account for them.

Ethnographic research was conducted in three Dutch hospitals, studying clinical groups that were identified as deviant: a nursing ward for infectious diseases, a mother–child department and a dialysis department. The research includes over 120 h of observation, 41 semi-structured interviews and 2 focus groups.

The research shows that rebels’ quality practices are an emerging set of collaborative activities to improving healthcare and meeting (individual) patient needs. They conduct “contexting work” to achieve their quality aims by expanding their normative work to outside domains. As rebels deviate from hospital policies, they are sometimes forced to act “under the radar” causing the risk of groupthink and may undermine the aim of public accounting.

The research shows that in order to come to more compassionate forms of care, organizations should allow for more heterogeneity accompanied with ongoing dialogue(s) on what good care yields as this may differ between specific fields or locations.

This is the first study introducing quality rebels as a concept to understanding social deviance in the everyday practices of doing compassionate and good care.

The purpose of this paper is to increase knowledge of the role organizational factors have in how health personnel make efficiency-thoroughness trade-offs, and how these trade-offs potentially affect clinical quality dimensions.

The paper is a thematic synthesis of the literature concerning health personnel working in clinical, somatic healthcare services, organizational factors and clinical quality.

Identified organizational factors imposing trade-offs were high workload, time limits, inappropriate staffing and limited resources. The trade-offs done by health personnel were often trade-offs weighing thoroughness (e.g. providing extra handovers or working additional hours) in an environment weighing efficiency (e.g. ward routines of having one single handover and work-hour regulations limiting physicians' work hours). In this context, the health personnel functioned as regulators, balancing efficiency and thoroughness and ensuring patient safety and patient centeredness. However, sometimes organizational factors limited health personnel's flexibility in weighing these aspects, leading to breached medication rules, skipped opportunities for safety debriefings and patients being excluded from medication reviews.

Balancing resources and healthcare demands while maintaining healthcare quality is a large part of health personnel's daily work, and organizational factors are suspected to affect this balancing act. Yet, there is limited research on this subject. With the expected aging of the population and the subsequent pressure on healthcare services' resources, the balancing between efficiency and thoroughness will become crucial in handling increased healthcare demands, while maintaining high-quality care.

The purpose of this paper is to describe and analyse two approaches to paramedic service clinical governance and quality management from the perspective of two groups of paramedics and paramedic managers working in North America.

A case study approach was utilised to describe and analyse paramedic service medical direction in North America and contrast this with the professional self-governance and clinical governance systems operating in other high-income countries. Researchers interviewed participants at two remote North American sites, then completed transcription and thematic analysis.

Participants identified three themes: first, resourcing, regulatory frameworks and fragmentation; second, independent practice facilitators and barriers; and third, paramedic roles and professionalisation. Those trained outside North America tended to identify self-regulation and clinical governance as the preferred approach to quality management. Few participants had considered paramedicine becoming a self-regulating health profession.

In North America, the “medical direction” model is the dominant approach employed to ensure optimal patient outcomes in paramedic service delivery. In contrast, other comparable countries employ paramedic self-regulatory systems combined with clinical governance to achieve the same ends. This is one of two studies to examine medical direction from the perspective of paramedics and paramedic managers.

The purpose of this study is to present a quality improvement approach titled “Picture-Understanding-Action” used in Ireland to enhance the role of healthcare boards in the oversight of healthcare quality and its improvement.

The novel and practical “Picture-Understanding-Action” approach was implemented using the Model for Improvement to iteratively introduce changes across three quality improvement projects. This approach outlines the concepts and activities used at each step to support planning and implementation of processes that allow a board to effectively achieve its role in overseeing and improving quality. This approach matured over three quality improvement projects.

The “Picture” included quantitative and qualitative aspects. The quantitative “Picture” consisted of a quality dashboard/profile of board selected outcome indicators representative of the health system using statistical process control (SPC) charts to focus discussion on real signals of change. The qualitative picture was based on the experience of people who use and work in health services which “people-ised” the numbers. Probing this “Picture” with collective grounding, curiosity and expert training/facilitation developed a shared “Understanding”. This led to “Action(s)” from board members to improve the “Picture” and “Understanding” (feedback action), to ask better questions and make better decisions and recommendations to the executive (feed-forward action). The Model for Improvement, Plan-Do-Study-Act cycles and a co-design approach in design and implementation were key to success.

To the authors’ knowledge, this is the first time a board has undertaken a quality improvement (QI) project to enhance its own processes. It addresses a gap in research by outlining actions that boards can take to improve their oversight of quality of care.

The primary objective of this paper is to show a systematic and methodological approach for the digitalization of critical clinical pathways (CPs) within the healthcare domain.

The methodology entails the integration of service design (SD) and action research (AR) methodologies, characterized by iterative phases that systematically alternate between action and reflective processes, fostering cycles of change and learning. Within this framework, stakeholders are engaged through semi-structured interviews, while the existing and envisioned processes are delineated and represented using BPMN 2.0. These methodological steps emphasize the development of an autonomous, patient-centric web application alongside the implementation of an adaptable and patient-oriented scheduling system. Also, business processes simulation is employed to measure key performance indicators of processes and test for potential improvements. This method is implemented in the context of the CP addressing transient loss of consciousness (TLOC), within a publicly funded hospital setting.

The methodology integrating SD and AR enables the detection of pivotal bottlenecks within diagnostic CPs and proposes optimal corrective measures to ensure uninterrupted patient care, all the while advancing the digitalization of diagnostic CP management. This study contributes to theoretical discussions by emphasizing the criticality of process optimization, the transformative potential of digitalization in healthcare and the paramount importance of user-centric design principles, and offers valuable insights into healthcare management implications.

The study’s relevance lies in its ability to enhance healthcare practices without necessitating disruptive and resource-intensive process overhauls. This pragmatic approach aligns with the imperative for healthcare organizations to improve their operations efficiently and cost-effectively, making the study’s findings relevant.

Audit and feedback (A&F) often underlie implementation projects, described as a circular process; i.e. an A&F cycle. They are widely used, but effect varies with no apparent explanation. We need to understand how A&F work in real-life situations. The purpose of this paper, therefore, is to describe and explore mental healthcare full A&F cycle experiences.

This is a naturalistic qualitative study that uses four focus groups and qualitative content analysis.

Staff accepted the initial A&F stages, perceiving it to enhance awareness and reassure them about good practice. They were willing to participate in the full cycle and implement changes, but experienced poor follow-up and prioritization, not giving them a chance to own to the process. An important finding is the need for an A&F cycle facilitator.

Research teams cannot be expected to be involved in implementing clinical care. Guidelines will keep being produced to improve service quality and will be expected to be practiced. This study gives insights into planning and tailoring A&F cycles.

Tools to ease implementation are not enough, and the key seems to lie with facilitating a process using A&F. This study underscores leadership, designated responsibility and facilitation throughout a full audit cycle.

Previous research provides adequate evidence on performance management (PM) for hospitals and healthcare providers; however, less is known about their individual and PM appraisal process. Additionally, there is limited research exploring PM in the Middle Eastern context. This study investigates PM practices in the Middle Eastern healthcare industry.

This study adopts the qualitative research methodology through semi-structured interviews of healthcare professionals in Kingdom of Saudi Arabia and the United Arab Emirates. Thematic analysis was adopted for analyzing this qualitative data.

The main findings have uncovered different facets of appraisal challenges for both the appraiser (i.e. manager) and the appraisee (i.e. employee). These challenges include communication deficits, lack of goal setting standards and regular meeting updates in order to ensure employee satisfaction and motivation in the workplace.

This study has significant implications for policymakers in Middle Eastern hospitals in terms of implementing PM for their staff. Moreover, future studies can conduct in-depth analysis and provide comparison between public and private sectors in the Gulf countries.

This study is one of the first to portray challenges involved in conducting PM in the Middle East healthcare sector specifically in the UAE and Kingdom of Saudi Arabia (KSA), both from the perspectives of the appraiser and appraisee.

In North America, delegated practice “medical direction” models are often used as a proxy for clinical quality and safety in paramedic services. Other developed countries favor a combination of professional regulatory boards and clinical governance frameworks that feature paramedics taking lead clinician roles. The purpose of this paper is to bring together the evidence for medical direction and clinical governance in paramedic services through the prism of paramedic self-regulation.

This narrative synthesis critically examines the long-established North American Emergency Medical Services medical direction model and makes some comparisons with the UK inspired clinical governance approaches that are used to monitor and manage the quality and safety in several other Anglo-American paramedic services. The databases searched were CINAHL and Medline, with Google Scholar used to capture further publications.

Synthesis of the peer-reviewed literature found little high quality evidence supporting the effectiveness of medical direction. The literature on clinical governance within paramedic services described a systems approach with shared responsibility for quality and safety. Contemporary paramedic clinical leadership papers in developed countries focus on paramedic professionalization and the self-regulation of paramedics.

The lack of strong evidence supporting medical direction of the paramedic profession in developed countries challenges the North American model of paramedics practicing as a companion profession to medicine under delegated practice model. This model is inconsistent with the international vision of paramedicine as an autonomous, self-regulated health profession.

Value-based healthcare suggested using patient-reported information to complement the information available in the medical records and administrative healthcare data to provide insights into patients' perceptions of satisfaction, experience and self-reported outcomes. However, little attention has been devoted to questions about factors fostering the use of patient-reported information to create value at the system level.

Action research design is carried out to elicit possible triggers using the case of patient-reported experience and outcome data for breast cancer women along their clinical pathway in the clinical breast network of Tuscany (Italy).

The case shows that communication and engagement of multi-stakeholder representation are needed for making information actionable in a multi-level, multispecialty care pathway organized in a clinical network; moreover, political and managerial support from higher level governance is a stimulus for legitimizing the use for quality improvement. At the organizational level, an external facilitator disclosing and discussing real-world uses of collected data is a trigger to link measures to action. Also, clinical champion(s) and clear goals are key success factors. Nonetheless, resource munificent and dedicated information support tools together with education and learning routines are enabling factors.

Current literature focuses on key factors that impact performance information use often considering unidimensional performance and internal sources of information. The use of patient/user-reported information is not yet well-studied especially in supporting quality improvement in multi-stakeholder governance. The work appears relevant for the implications it carries, especially for policymakers and public sector managers when confronting the gap in patient-reported measures for quality improvement.