Bita A. Kash

Nursing home spending, staffing and turnover

Background: Recent work on nursing home staffing and turnover has stressed the importance of ownership and resources. However, few studies have examined spending behaviors, which might also influence staffing levels and staff turnover rates. Purpose: This study investigates whether spending behaviors measured by financial ratios are associated with staffing levels and staff turnover in nursing homes. Methodology: We analyzed cross-sectional data from 1,014 Texas homes. Data were from the 2002 Texas Nursing Facility Medicaid Cost Report and the 2003 Area Resource File. First, we examined differences in financial ratios by ownership type. Next, the effect of 10 financial ratios on staffing levels and turnover rates for registered nurses, licensed vocational nurses, and certified nursing assistants was examined using robust regression models. Findings: Descriptive data indicated that expense ratios related to resident care activities and staff development were significantly higher among not-for-profit than for-profit homes. Higher profits were associated with lower staffing levels, but not higher turnover rates. Administrative expenses (a measure of management capacity) had a negative impact both on staffing levels and staff turnover for licensed vocational nurses and certified nursing assistants, but they did not affect registered nurse staffing. Employee benefit expenses exhibited a positive impact on registered nurse and licensed vocational nurse staffing levels. The addition of information on financial ratios to models predicting staffing indicators reduced the effect of ownership on these indicators. Practice Implications: Solutions to the staffing and turnover problem should focus on more effective management practices. Certain levels of administrative and staff benefit expenses may be necessary to improve professional staff recruitment and reduce both staffing and turnover costs. Differences in these financial ratios may partially explain the role played by ownership in determining staffing levels and turnover.

Exploring Factors Associated With Turnover Among Registered Nurse (RN) Supervisors in Nursing Homes

Because most turnover studies focus on certified nursing assistants (CNAs), licensed vocational nurses (LVNs), and administrators, little is known about registered nurses’ (RNs) higher turnover. This study builds on the current body of knowledge about turnover among RN supervisors in nursing homes. The article discusses a survey of RN nurse supervisors administered in more than 1,000 nursing homes that was merged with the 2003 Texas Medicaid cost report and the area resource file. Two 2-stage models are developed to predict RN turnover rates. RNs’ intent to leave predicts RN turnover through job satisfaction, perceived empowerment, and education level. High LVN and CNA turnover and high Medicare census are associated with higher turnover. Implications are that participation in management decisions and perceived wage competitiveness are an important determinant of RN retention in nursing homes. Future research should focus why RN supervisors with higher levels of education leave nursing homes.

Success Factors for Strategic Change Initiatives: A Qualitative Study of Healthcare Administrators' Perspectives

EXECUTIVE SUMMARY Success factors related to the implementation of change initiatives are well documented and discussed in the management literature, but they are seldom studied in healthcare organizations engaged in multiple strategic change initiatives. The purpose of this study was to identify key success factors related to implementation of change initiatives based on rich qualitative data gathered from health leader interviews at two large health systems implementing multiple change initiatives. In‐depth personal interviews with 61 healthcare leaders in the two large systems were conducted and inductive qualitative analysis was employed to identify success factors associated with 13 change initiatives. Results from this analysis were compared to success factors identified in the literature, and generalizations were drawn that add significantly to the management literature, especially to that in the healthcare sector. Ten specific success factors were identified for the implementation of change initiatives. The top three success factors were (1) culture and values, (2) business processes, and (3) people and engagement. Two of the identified success factors are unique to the healthcare sector and not found in the literature on change models: service quality and client satisfaction (ranked fourth of 10) and access to information (ranked ninth). Results demonstrate the importance of human resource functions, alignment of culture and values with change, and business processes that facilitate effective communication and access to information to achieve many change initiatives. The responses also suggest opportunities for leaders of healthcare organizations to more formally recognize the degree to which various change initiatives are dependent on one another.

Organizational technologies for transforming care: measures and strategies for pursuit of IOM quality aims.

Progress on the Institute of Medicines (IOMs) 6 aims to bridge the “quality chasm” requires both measurement and the concerting of multiple organizational technologies. The basic thesis of this article is that rapid progress on the IOMs multiple aims calls for transformative change within and among healthcare organizations. The promise of a number of types of transformative approaches is closely linked to their ability to simultaneously build upon several organizational technologies: clinical, social, information, and administrative technologies. To encourage and advance such efforts, this article identifies illustrative measures of attainment of the IOMs 6 aims or targeted areas for improvement that reflect the contributions of the 4 organizational technologies. It discusses examples of relationships between the IOM aims and the organizational technologies considered. Finally, the article offers illustrations of the interplay of these organizational technologies and IOM aims—across an array of organizational innovations with transformative potential. Included among such innovations are information technology in the form of electronic medical records, computer-based physician order entry, and patient health records; organization-wide patient-centered cultural change such as Studers Hardwiring Excellence; Six Sigma and Toyota Production Management/LEAN; major clinical technology change, for example, minimally invasive cardiac surgery and broader treatment innovations such as disease management.

Individual factors associated with intentions to leave among directors of nursing in nursing homes.

BACKGROUND Although the importance of nurse leadership stability and participation in decision making in nursing homes is well established, scarce literature exists on determinants of intent to leave among directors of nursing (DONs) in nursing homes. PURPOSE : The purpose of this study was to examine factors associated with DON intent to leave in nursing homes. METHODOLOGY We examined potential factors associated with DON intent to leave at three levels: individual DON characteristics, facility, and county-level market factors. A survey of nurse supervisors in Texas nursing homes, the 2003 Texas Nursing Facility Medicaid Cost Report, and the Area Resource File were merged. We only included respondents who identified themselves as DONs in this study (572 observations). We examined bivariate differences in individual DON characteristics on the basis of facility ownership (for-profit versus not-for-profit homes) and geographic location (urban versus rural location). We constructed three alternative logit models to explore the relationships between DON intent to leave and DON, facility, and market characteristics. FINDINGS DONs working in for-profit homes were more inclined to leave, less satisfied with their job, and had lower levels of perceived empowerment in terms of autonomy. Educational level and intention to leave were significantly higher for DONs working in urban areas. Job satisfaction was significantly and inversely associated with intent to leave in all three models. Higher perceived salary competitiveness and level of empowerment were associated with reduced odds of intending to leave. Higher educational levels were associated with higher odds of intentions to leave. PRACTICE IMPLICATIONS Nursing homes should focus on improving DON job satisfaction, empowerment in decision making, and salary competitiveness when designing retention strategies for DONs.

Healthcare Strategic Management and the Resource Based View

Purpose – The purpose of this paper is to examine how two large health systems formulate and implement strategy with a specific focus on differences and similarities in the nature of strategic initiatives across systems. The aim is to gain a better understanding of the role of resource dependency theory (RDT) and resource based view (RBV) in healthcare strategic management.Design/methodology/approach – A comparative case study design is used to describe, categorize and compare strategic change initiatives within a children’s health and a multi-hospital system located in two competitive metropolitan markets. A total of 61 in-person semi-structured interviews with healthcare administrators were conducted during 2009. Summary statistics and qualitative content analysis were employed to examine strategic initiatives.Findings – The two health systems have as their top initiatives very similar pursuits, thus indicating that both utilize an externally oriented RDTmethod of strategy formulation. The relevance of the RBV becomes apparent during resource deployment for strategy implementation. The process of healthcarestrategic decision-making incorporates RDT and RBV as separate and compatible activities that are sequential.Research limitations/implications – Results from this comparative case study are based on only two health systems. Further, the RBV perspective only takes managerial resources and time into consideration.Practical implications – Given that external resources are likely to become more constrained, it is important that hospitals leverage relevant internal resources, in the identification of competitive advantages and effective execution of strategic initiatives.Originality/value – The author propose a refined healthcare strategic management framework that takes both RDT and RBV into consideration by systematically linking strategy formulation with deployment of resources.

Residency Board Certification Requirements and Preoperative Surgical Home Activities in the United States: Comparing Anesthesiology, Family Medicine, Internal Medicine, and Surgery

Better management of the perioperative process has come unto the spotlight in recent years as a way to possibly reduce costs while improving the quality of care. However, perioperative care is not a subject traditionally comprehensivelycovered in any 1 medical specialty. Various elements of perioperative care are included in each of the 4 residencies studied (anesthesiology, family medicine, internal medicine, and surgery), but many of the activities inherent to the PSH are not required for board certification in any of the specialties, particularly in the intraoperative and postoperative phases. All 4 specialties appear to have room for improvement by expanding perioperative care education.

Advertising expenditures in the nursing home sector: evaluating the need for and purpose of advertising.

Marketing and advertising activities in the nursing home sector have increased in recent years, following the example of hospitals and health systems. The reasons for this trend may be related to the growth in competition but are not clearly identified yet. Theoretically, advertising becomes necessary to gain an advantage over the competition. The purpose of this study was to identify the reasons for the variation in advertising expenditures among nursing homes in Texas. For this study, we merged 2003 data from the Texas Medicaid Nursing Facility Cost Report, the Texas Nursing Home Quality Reporting System, and the Area Resource File for Texas. Using the Herfindahl-Hirschman Index, we then examined the correlations between advertising expenses and the level of market concentration. We evaluated the association between advertising expenditures and market competition using two logistic and four linear regression models. Total advertising expenses in Texas nursing homes ranged from

Review of successful hospital readmission reduction strategies and the role of health information exchange

0 to

Organizational capacity for change in health care: Development and validation of a scale.

165,000 per year. Higher advertising expenditures were associated with larger facilities, higher occupancy, and high Medicare census. Market competition, however, was not a significant predictor of such expenses. Advertising seems to be more resource-driven than market-driven. Therefore, some advertising expenditures may be unnecessary, may lack impact, and may even be wasteful. Reducing unnecessary advertising costs could free up resources, which may be allocated to necessary resident care activities.