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Lean Six Sigma in public and private healthcare organisations has received considerable attention over the last decade. Nevertheless, such process improvement methodologies are not generalizable, and their effective implementation relies on contextual variables. The purpose of this study is to explore the readiness of Italian hospitals for Lean Six Sigma and Quality Performance Improvement (LSS&QPI), with a focus on gender differences.

A survey comprising 441 healthcare professionals from public and private hospitals was conducted. Multivariate analysis of variance was used to determine the mean scores on the LSS&QPI dimensions based on hospital type, gender and their interaction.

The results showed that public healthcare professional are more aware of quality performance improvement initiatives than private healthcare professionals. Moreover, gender differences emerged according to the type of hospital, with higher awareness for men than women in public hospitals, whereas for private hospitals the opposite was true.

This study contributes to the Lean Six Sigma literature by focusing on the holistic assessment of LSS&QPI implementation.

This study informs healthcare managers about the revolution within healthcare organisations, especially public ones. Healthcare managers should spend time understanding Lean Six Sigma as a strategic orientation to promote the “lean hospital”, improving processes and fostering patient-centredness.

This is a preliminary study focussing on analysing inter-relationship between perceived importance of soft readiness factors such as gender dynamics as a missing jigsaw in the current literature. In addition, the research advances a holistic assessment of LSS&QPI, which sets it apart from the studies on single initiatives that have been documented to date.

The purpose of this paper is to analyze to what extent and in what ways signaling theory has been explored within the field of international marketing. This paper systematically reviews the use of signaling theory in the field of international marketing. Communication is a core aspect of the international marketing process. Research in this field has explored effective and unique ways of improving the communication flow to reduce the asymmetry of information between international consumers and the firm. This notion is adopted, enhanced and strengthened by signaling theory. Signaling theory has recently received the attention of international marketing scholars.

The systematic review methodology was applied for the purpose of identifying the relevant studies. We extracted academic articles over the last 23 years from the domain of international marketing that directly contribute to signaling theory based on 57 journal articles extracted through the systematic review process.

Based on systematic research the results reveal that the topic has grown and continues to expand within the broader international marketing field. We offer a theoretical conceptual framework to better understand signaling theory in the context of international marketing.

The authors map and critically evaluate the use of signaling theory in international marketing. Relevance of signaling theory in international marketing is growing and authors present an integrative framework that organizes the existing literature, and provides scholars to further expand on emerging themes of the domain. The paper offers some useful future research directions.

This study aims to evaluate the quality of a speech and language therapy (SLT) swallow service provided to adults with intellectual disability (ID) by exploring the process and outcome factors; to explore the process of what is done to and for the patient including identifying dysphagia, choking and pneumonia risk, typical interventions and management; examine clinical outcomes; and explore the relationship of outcomes with risk factors, satisfaction with the service and the impact of the service on the number of choking incidents and admissions to acute hospital with swallow concerns.

There were three specific work packages: (1) collecting and scrutinising patient data from the clinical record for adults with ID referred to the SLT swallow service over a six-month period. The researcher created aims, defined the limits to achieve the aims, designed a standardised data collection form, set out where data was in the clinical record, piloted, set limits for collection and trained reviewers; (2) gathering experience and satisfaction surveys from patients, caregivers and referrers over the six-month study period; and (3) monitoring choking adverse incident reports and hospital admission with swallow concerns for the whole ID population.

Choking and hospital admission were the main reasons for referral, and pneumonia risk significantly predicted dysphagia impairment. The research highlighted common dysphagia risk factors, interventions and recommendations for this population. The SLT swallow service is a quality service that is highly valued by patients, their caregivers and referrers. The service achieves significant clinical improvements, helps identify dysphagia and provides management to reduce associated risks.

This study found common dysphagia risk factors, interventions and recommendations; it also found that the therapy outcome measures/Royal College of Speech and Language Therapy online outcome tool was a meaningful outcome measure, and that pneumonia risk significantly predicted dysphagia impairment, all of which could inform the identified dysphagia research priorities for this population.

Naming usual care in treatment and recommendations could help ensure a fair service and could help form quality indicators. People with ID, their caregivers and staff generated valuable ideas for improvement, and further involvement work could create a logic model for the service. Other future work could explore the use of screening tools, increase multidisciplinary team working, improve access to instrumental assessments, raise awareness of swallowing and promote important oral health and medication reviews. By using this information to shape quality improvement work and policies, one can work toward addressing high health-related inequalities and preventable deaths associated with dysphagia in this vulnerable population.

It may be useful to raise awareness that adults with ID age earlier and that one should not exclude them from older people’s services because of an age threshold, often set higher than their life expectancy. This study highlighted a possible inequality of access issue for adults with ID who do not have direct care or day care staff. There is a need to increase access to awareness training so caregivers and general practitioners can recognise swallow difficulties and know how to make a referral for a swallow assessment.

Overall, the evaluation of the swallow service to adults with ID suggests that SLT have a quality service for adults with ID that is highly valued and provides significant clinical improvements. By building on these strengths, SLT could extend the reach, influence and impact of their services to help those adults with ID who have emerging swallow difficulties or who do not access the service.

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.

This study aims to investigate the influence of cognitive and affective trust on the revisit intention of medical tourists to a developing country like India, focusing on the role of country image as a moderator.

This study used partial least square-based structural equation modelling to test the hypotheses using data from 297 medical tourists visiting India from abroad for treatment.

The findings of this study confirmed that all the dimensions of cognitive trust, namely, perceived expertise, performance and reputation of the health-care service providers, have a positive and significant impact on the revisit intention of medical tourists to India. In contrast, none of the two dimensions of affective trust have a significant effect on the revisit intention of medical tourists to India. This study also confirmed that country image significantly moderates the relationship between performance dimensions of cognitive trust and medical tourists’ revisit intention to India.

The study’s findings have significant theoretical and managerial implications as they explore the effect of cognitive and affective trust on medical tourists’ the revisit intention to visit an emerging economy, considering the country’s image as a moderator.

本研究旨在调查认知和情感信任对印度等发展中国家医疗游客重游意愿的影响, 重点关注国家形象的调节作用。

本研究采用基于偏最小二乘的结构方程模型, 使用 297 名从国外到印度接受治疗的医疗游客的数据来检验假设。

本研究的结果证实, 认知信任的所有维度, 即医疗服务提供者的专业知识、绩效和声誉, 对印度医疗游客的重游意愿产生积极且显着的影响。相比之下, 情感信任的两个维度都没有对印度医疗游客的重游意愿产生显着影响。这项研究还证实, 国家形象显着调节认知信任绩效维度与医疗游客重访印度意愿之间的关系。

该研究的结果具有重要的理论和管理意义, 因为他们探讨了认知和情感信任对医疗游客重访新兴经济体的意愿的影响, 并考虑到该国作为调节者的形象。

Este estudio tiene como objetivo investigar la influencia de la confianza cognitiva y afectiva en la intención de volver a visitar a un país en desarrollo como la India por parte de turistas médicos, centrándose en el papel de la imagen del país como moderador.

Este estudio empleó un modelo de ecuaciones estructurales parcial basado en mínimos cuadrados para probar las hipótesis utilizando datos de 297 turistas médicos que visitaron la India desde el extranjero para recibir tratamiento.

Los hallazgos de este estudio confirmaron que todas las dimensiones de la confianza cognitiva, es decir, la experiencia percibida, el desempeño y la reputación de los proveedores de servicios de atención médica, tienen un impacto positivo y significativo en la intención de volver a visitar a la India por parte de los turistas médicos. Por el contrario, ninguna de las dos dimensiones de la confianza afectiva tiene un efecto significativo en la intención de volver a visitar la India por parte de los turistas médicos. Este estudio también confirmó que la imagen del país modera significativamente la relación entre las dimensiones de desempeño de la confianza cognitiva y la intención de los turistas médicos de volver a visitar la India.

Los hallazgos del estudio tienen importantes implicaciones teóricas y administrativas, ya que exploran el efecto de la confianza cognitiva y afectiva en la intención de los turistas médicos de visitar una economía emergente, considerando la imagen del país como moderador.

Value-based health care (VBHC) argues that health-care needs to re-focus to maximise value creation, defining value as the quota when dividing the outcomes important for the patient, by the cost for health care to deliver such outcomes. This study aims to explore the perception of value among different stakeholders involved in the process of implementing VBHC at a Swedish hospital to support leaders to be more efficient and effective when developing health care.

Participants comprised 19 clinicians and non-clinicians involved in the implementation of VBHC. Semi-structured interviews were conducted and content analysis was performed.

The clinicians described value as a dynamic concept, dependent on the patient and the clinical setting, stating that improving outcomes was more important than containing costs. The value for non-clinicians appeared more driven by the interplay between the outcome and the cost. Non-clinicians related VBHC to a strategic framework for governance or for monitoring different continuous improvement processes, while clinicians appreciated VBHC, as they perceived its introduction as an opportunity to focus more on outcomes for patients and less on cost containment.

There is variation in how clinicians and non-clinicians perceive the key concept of value when implementing VBHC. Clinicians focus on increasing treatment efficacy and improving medical outcomes but have a limited focus on cost and what patients consider most valuable. If the concept of value is defined primarily by clinicians’ own assumptions, there is a clear risk that the foundational premise of VBHC, to understand what outcomes patients value in their specific situation in relation to the cost to produce such outcome, will fail. Health-care leaders need to ensure that patients and the non-clinicians’ perception of value, is integrated with the clinical perception, if VBHC is to deliver on its promise.

The resource crisis in healthcare can be alleviated by engaging external stakeholders and resources in healthcare delivery. The authors use value and open innovation concepts to understand what motivates the stakeholders to join the healthcare innovation ecosystem and what value such an ecosystem brings to healthcare.

A systematic literature review following the PRISMA framework method was applied to reach the research objective. Out of a total of 509 identified articles published till 2021, 25 were selected as relevant for this review.

Six categories of actors were identified, including innovation intermediaries, which were so far neglected in the healthcare innovation literature. Furthermore, patients, healthcare providers, innovation suppliers, investors and influencers were described. The authors also distinguished internal and external stakeholders. The authors show why and how open innovation projects contribute to involving external stakeholders and resources in healthcare delivery by contributing to patient autonomy, relationship building, knowledge transfer, improving collaborative mindset and culture, advancing know-how and bringing additional finances.

This article is the first one to systematically describe the value of open innovation in healthcare. The authors challenge the positivist approach in value presented by value-based healthcare. The authors show how openness contributes to addressing the resource crisis by involving new stakeholders and resources in the care delivery process.

This study aims to investigate how institutional and organisational factors affect case management of patients with mental disorders by GPs in Italy and Spain. The paper highlights the importance of improving the effectiveness of primary care to ensure easy access to mental health services, which is crucial in responding to the increasing incidence of mental disorders and preventing negative outcomes.

This article details a qualitative research study that examines the management of patients with mental disorders by general practitioners (GPs) in Italy and Spain, using cross-national comparison and in-depth interviews with GPs as research methods.

The study revealed that Italian self-employed GPs have more scheduling autonomy than Spanish Health Centre GPs. Both face high work pressure and resource scarcity, highlighting the need for targeted training. The COVID-19 pandemic led to a rise in phone consultations.

This study provides novel insights into mental health management by examining the case management of patients with mental disorders by GPs in Italy and Spain, with a focus on the impact of institutional and organisational factors. The cross-national comparison and in-depth interviews enhance the originality of the study, offering a nuanced understanding of the constraints faced by GPs in their work context. Furthermore, the comparison of the similar primary care frameworks of Italy and Spain may offer insight into their evolution.