Jeroen Trybou

The impact of organizational support and leader–member exchange on the work‐related behaviour of nursing professionals: the moderating effect of professional and organizational identification

AIM The aim of this study was to examine the relations between perceived organizational support, the quality of leader-member exchange, in-role and extra-role behaviour, professional identification and organizational identification among registered nurses and nurse assistants. BACKGROUND Theoretically, employees will reciprocate received beneficial treatment with positive attitudes and behaviour. Recently, it has been shown that this principle may be more complex than originally anticipated. DESIGN A quantitative, cross-sectional survey design was used. The quality of social exchange and identification was scored by the involved registered nurses and nurse assistants; in-role and extra-role behaviour was rated by the head nurse. METHODS The survey was administered to nurses and nurse assistants (n = 196) working in five Belgian nursing homes. Data were collected from February-March 2012. Pearson correlation analyses, t-test analyses and hierarchical regression were used to analyse the data. RESULTS Our results showed no relationship between perceived organizational support and leader-member exchange and in-role behaviour. A positive relationship was found between perceived organizational support and extra-role behaviour and a trend towards significance between leader-member exchange and extra-role behaviour. Organizational and professional identification moderated the relationship between perceived organizational support and extra-role behaviour. CONCLUSIONS Our study demonstrates the importance of social exchange to nurses and nurse assistants and therefore nursing administrators and leaders. When registered nurses and nurse assistants perceive high-quality social exchange, they are more likely to go the extra mile on behalf of the organization. Fostering social identification could enhance this.

The ties that bind: an integrative framework of physician-hospital alignment

BackgroundAlignment between physicians and hospitals is of major importance to the health care sector. Two distinct approaches to align the medical staff with the hospital have characterized previous research. The first approach, economic integration, is rooted in the economic literature, in which alignment is realized by financial means. The second approach, noneconomic integration, represents a sociological perspective emphasizing the cooperative nature of their relationship.DiscussionEmpirical studies and management theory (agency theory and social exchange theory) are used to increase holistic understanding of physician hospital alignment. On the one hand, noneconomic integration is identified as a means to realize a cooperative relationship. On the other hand, economic integration is studied as a way to align financial incentives. The framework is developed around two key antecedent factors which play an important role in aligning the medical staff. First, provider financial risk bearing is identified as a driving force towards closer integration. Second, organizational trust is believed to be important in explaining the causal relation between noneconomic and economic integration.SummaryHospital financial risk bearing creates a greater need for closer cooperation with the medical staff and alignment of financial incentives. Noneconomic integration lies at the very basis of alignment. It contributes directly to alignment through the norm of reciprocity and indirectly by building trust with the medical staff, laying the foundation for alignment of financial incentives.

Effects of physician-owned specialized facilities in health care: A systematic review

BACKGROUND Multiple studies have investigated physician-owned specialized facilities (specialized hospitals and ambulatory surgery centres). However, the evidence is fragmented and the literature lacks cohesion. OBJECTIVES To provide a comprehensive overview of the effects of physician-owned specialized facilities by synthesizing the findings of published empirical studies. METHODS Two reviewers independently researched relevant studies using a standardized search strategy. The Institute of Medicines quality framework (safe, effective, equitable, efficient, patient-centred, and accessible care) was applied in order to evaluate the performance of such facilities. In addition, the impact on the performance of full-service general hospitals was assessed. RESULTS Forty-six studies were included in the systematic review. Overall, the quality of the included studies was satisfactory. Our results show that little evidence exists to confirm the advantages attributed to physician-owned specialized facilities, and their impact on full-service general hospitals remains limited. CONCLUSION Although data is available on a wide variety of effects, the evidence base is surprisingly thin. There is no compelling evidence available demonstrating the added value of physician-owned specialized facilities in terms of quality or cost of the delivered care. More research is necessary on the relative merits of physician-owned specialized facilities. In addition, their corresponding impact on full-service general hospitals remains unclear. The development of physician-owned specialized facilities should thus be monitored carefully.

HOSPITAL-ACQUIRED INFECTIONS IN BELGIAN ACUTE-CARE HOSPITALS: FINANCIAL BURDEN OF DISEASE AND POTENTIAL COST SAVINGS

Abstract Introduction: Hospital Acquired Infections (HAIs) are considered to be one of the most serious patient safety issues in healthcare today. It has been shown that HAIs contribute significantly not only to morbidity and mortality, but also to excessive costs for the health care system and for hospitalized patients. Since possibilities of prevention and control exist, hospital quality can be improved while simultaneously the cost of care is reduced. The objectives of this study were to examine the prevalence and the excess costs associated with HAIs. Methods: A retrospective observational study was performed to estimate costs associated with hospital– acquired infections in Belgian hospitals, both in procedural admissions and in medical admissions. Hospital, diagnosisrelated group, age and gender were used as matching factors to compare stays associated with HAIs and stays without HAIs. Data were obtained from the Minimum Basic Data Set 2008 used by Belgian hospitals to register casemix data for each admission to obtain reimbursement from the authorities. Data included information from 45 hospitals representing 16,141 beds and 2,467,698 patient stays. Using the 2008 national feedback programme of the Belgian government, cost data were collected (prolonged length of stay, additional pharmaceuticals and procedures) and subsequently linked to the data set. By means of a sensitivity analysis we estimated potential monetary savings when a reduction in the incidence of HAIs in hospitals having a higher rate of hospital-acquired infections in comparison to other hospitals would be realized. Results: In our sample 5.9% of the hospital stays were associated with a hospital-acquired infection. In the procedural admission subset this was the case for 4.7% of the hospital stays. The additional mean cost of the hospital-acquired infection was € 2,576 for all stays (P < 0.001) and € 3,776 for procedural stays (P < 0.001). The total burden of disease in Belgium is estimated at € 533,076,110 for all admissions and € 235,667,880 for the subset of procedural admissions. The excess length of stay varied between hospitals from 2.52 up to 8.06 days (Md 4.58, SD 1.01), representing an associated cost of € 355,060,174 (66,61% of the total cost). The cost of additional medical procedures and additional pharmaceutical products was estimated at € 62,864,544 (11.97%) and € 115,151,939 (21.60%) respectively. Overall, our results showed that considerable variability between hospitals regarding the incidence of HAIs (3.77-9.78%) for all hospital stays is present, indicating a potential for improvement. We provide a full overview of the potential monetary savings when reductions in HAIs are realized by applying different thresholds. For instance, if all Belgian hospitals having a higher rate of hospital-acquired infections improve their rate to the level of the hospital corresponding to percentile 75 (= 7.5% HAI) savings would be € 17,799,326. Conclusion: HAIs are associated with important additional healthcare costs. Although not all hospital-acquired infections can be prevented, an opportunity to increase cost-effectiveness of hospital care delivery presents itself. This study is the first to estimate the annual economic burden of HAIs for Belgium at a national level, incorporating all associated hospital costs. Apart from the fact that the cost of prolonged length of stay is of major importance, we have also shown that the cost of additional procedures and pharmaceutical products cannot be neglected when estimating the financial burden of HAIs.

Nursing staff and their team: Impact on intention to leave

AIM The aim was to examine the relationship between the quality of team-member exchange experienced by nursing staff and their intention to leave. Job satisfaction and affective organizational commitment are considered as mediators. BACKGROUND While the shortage of nurses is a management and policy priority, few studies have studied the relationships between nursing staff and their team, key organizational attitudes, and intentions to leave the organization. METHOD A questionnaire was administered to 217 registered nurses and nurse assistants in Belgium. Data were collected in 2012. To analyse the data, descriptive statistics, correlation, regression and path analyses were conducted. FINDINGS Team-member exchange has a positive impact on nursing staff satisfaction and affective commitment. Job satisfaction and affective organizational commitment fully mediated the impact of team-member exchange on nursing staffs intention to leave. CONCLUSION AND IMPLICATIONS FOR NURSING AND HEALTH POLICY This study illustrates the potential benefits of the positive influence of team-member exchange on key organizational attitudes of nursing staff, and the negative influence on intention to leave through affective commitment and job satisfaction.

The impact of economic and noneconomic exchange on physicians' organizational attitudes: the moderating effects of the Chief Medical Officer

Background: Hospital–physician relationships are critical to hospitals’ organizational success. A distinction can be drawn between economic and noneconomic physician–hospital exchange. Physician senior leadership could be an important component of managerial strategies aimed at optimizing hospital–physician relationships. Purpose: The purpose of this study was to investigate the moderating role of the quality of exchange with the Chief Medical Officer (CMO) in the relationship between economic and noneconomic exchange and physicians’ key organizational attitudes. Methodology: Self-employed physicians practicing at six Belgian hospitals were surveyed. Economic exchange was conceptualized by the concepts of distributive and procedural justice, whereas noneconomic exchange was conceptualized by the concepts of administrative and professional psychological contract. Our outcomes comprise three key organizational attitudes identified in the literature (job satisfaction, affective organizational commitment, and intention to leave). The moderating role of leader–member exchange with the CMO in these relationships was assessed. Findings: Our results showed a relationship between both psychological contract breach and organizational justice and physicians’ organizational attitudes. The quality of exchange with the CMO buffered the negative effect of psychological contract breach and reinforced the positive effects of organizational justice with respect to physicians’ organizational attitudes. Practice Implications: Our results demonstrate that both economic and noneconomic aspects are important when considering physicians’ key organizational attitudes. The reciprocity dynamic between physician and hospital can be enhanced by high-quality exchange with the CMO.

Cost-effectiveness and budget impact analysis of a population-based screening program for colorectal cancer

BACKGROUND Colorectal cancer (CRC) is one of the leading causes of cancer mortality in Belgium. In Flanders (Belgium), a population-based screening program with a biennial immunochemical faecal occult blood test (iFOBT) in women and men aged 56-74 has been organised since 2013. This study assessed the cost-effectiveness and budget impact of the colorectal population-based screening program in Flanders (Belgium). METHODS A health economic model was conducted, consisting of a decision tree simulating the screening process and a Markov model, with a time horizon of 20years, simulating natural progression. Predicted mortality and incidence, total costs, and quality-adjusted life-years (QALYs) with and without the screening program were calculated in order to determine the incremental cost-effectiveness ratio of CRC screening. Deterministic and probabilistic sensitivity analyses were conducted, taking into account uncertainty of the model parameters. RESULTS Mortality and incidence were predicted to decrease over 20years. The colorectal screening program in Flanders is found to be cost-effective with an ICER of 1681/QALY (95% CI -1317 to 6601) in males and €4,484/QALY (95% CI -3254 to 18,163). The probability of being cost-effective given a threshold of €35,000/QALY was 100% and 97.3%, respectively. The budget impact analysis showed the extra cost for the health care payer to be limited. CONCLUSION This health economic analysis has shown that despite the possible adverse effects of screening and the extra costs for the health care payer and the patient, the population-based screening program for CRC in Flanders is cost-effective and should therefore be maintained.

In the eye of the beholder: A qualitative study of mutual obligations and areas of ambiguity in the hospital–physician relationship

Abstract Hospitals and physicians have been working together for years in providing specialized health services. However, hospital–physician relationships are considered lukewarm at the best. We build on psychological contract theory to develop an in-depth understanding of how physicians (N = 15) and hospital executives (N = 15) in Belgium experience and interpret obligations in their working relationship. Our analysis yielded a rich understanding of mutual obligations and areas of ambiguity. Two major themes emerged from the analysis. A distinction should be made between administrative obligations (adequate support and responsive decision making) and professional obligations (clinical excellence and physician autonomy). Two areas of ambiguity could be identified reflecting both dimensions. An economic trade-off exists in the day-to-day interaction and therefore views on how the care should be organized differ. In addition, the extent to which medical decisions should take into account the corresponding impact on hospital finance varies.

The impact of professional and organizational identification on the relationship between hospital–physician exchange and customer-oriented behaviour of physicians

BackgroundHospitals face increasingly competitive market conditions. In this challenging environment, hospitals have been struggling to build high-quality hospital–physician relationships. In the literature, two types of managerial strategies for optimizing relationships have been identified. The first focuses on optimizing the economic relationship; the second focuses on the noneconomic dimension and emphasizes the cooperative structure and collaborative nature of the hospital–physician relationship. We investigate potential spillover effects between the perceptions of physicians of organizational exchange and their customer-oriented behaviors.MethodsA cross-sectional study was conducted on 130 self-employed physicians practicing at six Belgian hospitals. Economic exchange was measured using the concept of distributive justice (DJ); noneconomic exchange was measured by the concept of perceived organizational support (POS). Our outcomes consist of three types of customer-oriented behaviours: internal influence (II), external representation (ER), and service delivery (SD).ResultsOur results show a positive relationship between DJ and II (adjusted R2 = 0.038, t = 2.35; p = 0.028) and ER (adjusted R2 = 0.15, t = 4.59; p < 0.001) and a positive relationship between POS and II (adjusted R2 = 0.032, t = 2.26; p = 0.026) and ER (adjusted R2 = 0.22, t = 5.81; p < 0.001). No relationship was present between DJ (p = 0.54) or POS (p = 0.57) and SD. Organizational identification positively moderates the relationship between POS and ER (p = 0.045) and between DJ and ER (p = 0.056). The relationships between POS and II (p = 0.54) and between DJ and II (p = 0.99) were not moderated by OI. Professional identification did not moderate the studied relationships.ConclusionOur results demonstrate that both perceptions of economic and noneconomic exchange are important to self-employed physicians’ customer-oriented behaviours. Fostering organizational identification could enhance this reciprocity dynamic.

How to govern physician–hospital exchanges: contractual and relational issues in Belgian hospitals

Objective Our aim was to investigate contractual mechanisms in physician–hospital exchanges. The concepts of risk-sharing and the nature of physician–hospital exchanges – transactional versus relational – were studied. Methods Two qualitative case studies were performed in Belgium. Hospital executives and physicians were interviewed to develop an in-depth understanding of contractual and relational issues that shape physician–hospital contracting in acute care hospitals. The underlying theoretical concepts of agency theory and social exchange theory were used to analyse the data. Results Our study found that physician–hospital contracting is highly complex. The contract is far more than an economic instrument governing financial aspects. The effect of the contract on the nature of exchange – whether transactional or relational – also needs to be considered. While it can be argued that contractual governance methods are increasingly necessary to overcome the difficulties that arise from the fragmented payment framework by aligning incentives and sharing financial risk, they undermine the necessary relational governance. Relational qualities such as mutual trust and an integrative view on physician–hospital exchanges are threatened, and may be difficult to sustain, given the current fragmentary payment framework. Conclusions Since health care policy makers are increasing the financial risk borne by health care providers, it can be argued that this also increases the need to share financial risk and to align incentives between physician and hospital. However, our study demonstrates that while economic alignment is important in determining physician–hospital contracts, the corresponding impact on working relationships should also be considered. Moreover, it is important to avoid a relationship between hospital and physician predominantly characterized by transactional exchanges thereby fostering an unhealthy us-and-them divide and mentality. Relational exchange is a valuable alternative to contractual exchange, stimulating an integrated hospital–physician relationship. Unfortunately, the fragmented payment framework characterized by unaligned incentives is perceived as an obstacle to realize effective collaboration.