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This article looks at the alignment of performance management system with the strategy, structure, and organizational outcome in Canadian health care organizations. In this study, balanced scorecard is the framework adopted for assessing the health care organization's performance management system (PMS) and outcome. CEO and clinical unit managers were surveyed for their perceptions on their organization's strategy, autonomy structure, PMS, and organizational performance. Path analysis was the methodology used in examining the relationship about the above organizational variables. The results indicate that patient satisfaction is the primary and most significant perspective of the depicted balanced scorecard in organizational performance. Patient satisfaction and research criteria, on the other hand, are the significant perspectives of a balanced scorecard in an organization's PMS, which are linked to strategy, autonomy structure, and organizational performance. Moreover, the results show that the strategy/structure links operated as suggested. Surprisingly, strategy on service innovation has a negative impact on the organizational outcome of patient satisfaction. Uncertainty from continuous development and organizational change in pursuing service innovation and cost-cutting measures in response to fiscal constraints are plausible explanations of the adverse impact reported.

The article features a study based on postal questionnaires and structured interviews, targeting senior members of the hospital pharmacy profession. The aim was to examine the potential of practice and performance benchmarking as a means of improving competence and capabilities within the clinical pharmacy service of NHS Trust hospitals. Postulation of models and analysis of data is followed by discussion of results. This leads to a number of suggestions and conclusions with respect to the potential role of benchmarking including an assessment of its suitability, limitations, and implementation issues associated with this particular service sector.

This study aims to investigate the hybridization practices that medical managers engage with to promote accounting and performance measurement in the hybrid setting of healthcare. In doing so, the authors explore how medical managers enact and become practitioners of hybridity.

The authors adopt a practice lens to conceptualize hybridization as an emergent, situated practice and capture the micro-activities that medical managers engage with when they enact hybridity. The authors conducted semi-structured interviews with medical managers, business managers and coding professionals and collected documents at an English National Health Service (NHS) hospital over the course of five years.

The findings accentuate two emergent practices through which medical managers instill hybridity to individuals who are hesitant or resistant to hybridization. Medical managers engage in equivocalizing and de-stigmatizing practices to broaden the understandings, further diversify or reconcile the teleologies of clinicians in non-managerial roles. In doing so, the authors signal the merits of accounting in improving care outcomes and remove the stigma associated to clinical engagement with costs.

The study contributes to hybridization and practice theory literature via capturing how hybridity is enacted in practice in a healthcare setting. As medical managers engage with and promote accounting information and performance measurement technologies in their practice environment, they transcend professional boundaries and hybridize the professional spaces that surround them.

This study aims to unravel the dynamic nature of the process of self-regulated learning (SRL) of medical specialists as it actually unfolds over time in the authentic clinical environment.

A longitudinal multiple case-study design was used, combining multiple data-collection techniques. Long-term observations offered evidence on overt SRL strategies. Physicians’ observed behaviours were used as cues for in loco stimulated recall interviews, asking about covert SRL strategies and their thoughts regarding a situation at hand. Field notes and audiotaped stimulated recall interviews were transcribed verbatim and integrated in a longitudinal database to map SRL as it actually unfolds moment-by-moment. The transcripts were analysed from an inter- and intra-individual perspective using Nvivo 12.

Results show a variety of strategies that initiate, advance and evaluate the process of SRL. Different SRL strategies not included in contemporary frameworks on SRL are found and classified as a new category which the authors labelled “learning readiness”. Exemplary for an SRL strategy in this category is awareness of learning needs. Results show that SRL in the clinical environment is found as an interrelated, dynamic process unfolding in time with feedback loops between different SRL strategies. Performance is found to play a leading role in driving SRL.

This study contributes empirically to the conceptual understanding of SRL in the clinical environment. The use of a situated, longitudinal methodology, which goes beyond the common path of retrospective self-report questionnaires, adds to the disentanglement of the process of SRL as it actually unfolds in the work environment.

The purpose of this paper is to assess the performance measurement in the UK NHS ambulance service documenting various unintended consequences of the current performance framework and to suggest a future research agenda.

The paper reviews the literature on ambulance performance targets and documents several unintended consequences of the current performance system through an in‐depth case study analysis based on interviews with Trust staff and policy experts along with observation of performance review meetings in the chosen Trust. Ethical approval for the study was obtained from a local NHS research ethics committee.

Significant unintended consequences of the ambulance performance targets based on response times have been systematically documented, which are likely to put the target under spotlight, especially that of the eight‐minute response. The current policy focus to reform the eight‐minute target by making it more stringent has the potential of jeopardising the reform agenda based on developing clinical skills of the paramedics and introducing clinical management in the service.

The paper makes an objective assessment of the sustainability of the current policy framework and identifies future lines of enquiry for further research.

This paper makes an original contribution in identifying and documenting the disjuncture between stated and unintended consequences of ambulance performance measurement, which will be of value to academics, practitioners and policy makers.

The purpose of this paper is to describe the design and construction of a privilege mapping system (clinical and organizational competences) of the medical staff of the Niguarda Hospital in Milan, Italy. The second aim is to measure and assess the impact of implementing an evaluation process of clinical competences at the same hospital.

The paper retraces the development and implementation of the evaluation of the privilege system, highlighting the subjects involved, the phases and outputs. Moreover, a questionnaire was distributed to 50 heads of unit involved in the planning, building and implementation of competences mapping. Five areas were investigated: competences evaluation for professional development; the impact on work organization and professional roles; professional collaboration; its impact according to context (hospital or unit) and time scale (short or long term); and ability to evaluate clinical outcome.

Results reveal success factors for the development and implementation of a privilege mapping system. Furthermore, the survey revealed that clinical leaders are aware of the importance of competences evaluation. In particular, they consider it as a management tool useful for professional development, for identifying excellence and planning operational activities.

Literature and practical evidence recognize the need to assess the clinical and organizational competences in order to assign tasks and responsibilities. However, there are no studies that describe the construction of systems of evaluation of privileges, as it has never been investigated as professionals perceive these tools.

Clinical governance (CG) is crucial for healthcare quality of care improvement and safeguarding high standards of care. Little is known about CG in sub-Saharan Africa. The authors assessed health workers' perceptions of CG and hospital performance in Ghana's psychiatric hospitals.

A cross-sectional survey was conducted among 230 health workers across two psychiatric hospitals in Ghana. Data were collected with a structured questionnaire and analyzed with Statistical Package for Social Sciences (SPSS), version 23.0.

The majority (59.5%) of the respondents were females. The authors found that less than five in ten respondents felt that the hospitals have adopted measures to promote quality assurance (43.2%) and research and development (43.7%). However, a little above half of the respondents felt that the hospitals have adopted measures to promote education and training (57.7%); clinical audit (52.7%); risk management (50.7%) and clinical effectiveness (68.6%). The authors also found a statistically significant association between CG and hospital performance (p < 0.05).

There was a positive relationship between CG and hospital performance. Therefore, investing in CG may help to increase hospital performance.

This is the maiden study to investigate CG and hospital performance in Ghana's psychiatric hospitals and one of the few studies in Africa. This study makes a modest contribution to the global discourse on the subject matter.

This paper attempts to define quality (particularly in terms of evidence‐based health care) and considers the incentives available to bring about improvements in quality. It examines the contribution that economics, as a discipline, can make to the debate on clinical governance. It considers the nature and importance of clinical governance, measuring quality, objectives and behaviour in questions raised concerning objectives and individual and team behaviour.

The performance of NHS UK hospitals is under continuous scrutiny as they are constantly under pressure to perform well. A recent document published by an independent body has recommended a host of clinical indicators to assess non‐financial performance of hospitals. This study aims to critically analyse the performance of a single UK hospital against several of these recommended indicators.

Data presented to the Hospital Trust Board for 12 months were used for this study. Previous years' data were used wherever available.

Based on data analysis, this hospital's performance is extremely difficult to calculate. The indicators use complex ratios and due to lack of standardisation, the hospital performance could be interpreted as better, worse or indifferent.

This study analyses most of the recommended indicators. Literature review did not reveal a similar analysis of another hospital against these indicators which precludes comparison.

This study highlights the difficulty in comparing the performance of hospitals due to the inherent lack of consistency. Therefore it is apparent that any reward‐rebuke system linked to performance should interpret the data with caution. It is therefore suggested that easy to control single value activities and standardised routine activities could be used to measure hospital performance. Alternatively, the hospital could compare with its own statistics from previous years.

Literature acknowledges the difficulties in measuring clinical performance. This paper elucidates these difficulties applied to the NHS and suggests alternatives.

The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) program is known to improve team and clinical performance, but the relationship to psychological stress has not been clarified. The purpose of this paper is to evaluate team performance, clinical performance and psychological stress simultaneously in a simulation-based training combined with or without the TeamSTEPPS program.

This randomized, controlled, prospective pilot study was performed to reveal TeamSTEPPS impact on psychological stress. The course included an emergency care training course, the TeamSTEPPS program, and a scenario simulation. Ten medical student teams were randomly allocated two groups: a TeamSTEPPS group and a non-TeamSTEPPS group. Team performance, clinical performance and psychological stress were evaluated simultaneously in the course; i.e., questionnaire evaluation and an observational evaluation for team performance; an assessor’s evaluation and a simulator’s evaluation for clinical performance. Autonomic nervous activity, represented by salivary amylase levels and heart rate variability, were measured as psychological stress indicators.

Team performance and clinical performance were significantly better in the TeamSTEPPS group, while psychological stress did not differ between the groups.

This is the first study to examine the relationship between TeamSTEPPS and psychological stress. Although only preliminary conclusions can be drawn from this small-scale study, results suggest that the TeamSTEPPS program improved team and clinical performance without increasing psychological stress.

This article explores professional self‐regulation in the context of clinical governance. It begins by explaining clinical governance’s origins before setting out a framework in which the Department of Health expects managers and practitioners to work. Description, analysis and synthesis of professional self‐regulation issues, operating within a clinical governance framework, are greatly enhanced by comment drawn from the theoretical and empirical literature.

The purpose of this paper is to assess the relationship between patient satisfaction and a variety of clinical quality measures in an ambulatory setting to determine if there is significant overlap between patient satisfaction and clinical quality or if they are separate domains of overall physician quality. Assessing this relationship will help to determine whether there is congruence between different types of clinical quality performance and patient satisfaction and therefore provide insight to appropriate financial structures for physicians.

Ordered probit regression analysis is conducted with overall rating of physician from patient satisfaction responses to the Clinician and Groups Consumer Assessment of Healthcare Providers and Systems survey as the dependent variable. Physician clinical quality is measured across five composite groups based on 26 Healthcare Effectiveness Data and Information Set (HEDIS) measures aggregated from patient electronic health records. Physician and patient demographic variables are also included in the model.

Better physician performance on HEDIS measures are correlated with increases in patient satisfaction for three composite measures: antibiotics, generics, and vaccination; it has no relationship for chronic conditions and is correlated with decrease in patient satisfaction for preventative measures, although the negative relationship for preventative measures is not robust in sensitivity analysis. In addition, younger physicians and male physicians have higher satisfaction scores even with the HEDIS quality measures in the regression.

There are four primary limitations to this study. First, the data for the study come from a single hospital provider organization. Second, the survey response rate for the satisfaction measure is low. Third, the physician clinical quality measure is the percent of the physician’s relevant patient population that met the HEDIS measure rather than if the measure was met for the individual patient. Finally, it is not possible to distinguish if the significant coefficient estimates on the physician age and gender variables are capturing systematic differences in physician behavior or capturing patient bias.

The results suggest patient satisfaction and physician clinical quality may be complementary, capturing similar aspects of overall physician quality, across some clinical quality measures but for other measures satisfaction and clinical quality are unrelated or negatively related. Therefore, for some clinical quality metrics, it will be important to separately compensate clinical quality and satisfaction and understand the relationship between metrics. Finally, the strong relationship between the level of patient satisfaction and physician age, physician gender, and patient age are important to consider when designing a physician compensation package based on patient satisfaction; if these differences reflect patient bias they could increase inequality among medical staff if compensation is based on patient satisfaction.

This study is the first to use physician organization data to examine patient satisfaction and physician performance on a variety of HEDIS quality metrics.

The purpose of this paper is to evaluate clinical departments' performance per clinical sector in the context of the Greek public hospital care system.

The sample consisted of 96 internal pathology and surgical clinical departments in 15 hospitals in Greece and their technical efficiency was assessed by the use of data envelopment analysis. The proposed model used the number of nursing staff, medical specialists and department beds, pharmaceutical expenditure and clinical leadership job satisfaction as inputs while the number of hospitalized patients was selected as an output. Clinical leadership job satisfaction was captured by the use of a specialized questionnaire. The methodology applied investigated variations in technical efficiency in the presence or absence of job satisfaction. The model proposed an efficiency improvement through the possible reduction of inputs (input oriented) variable returns to scale.

Processing the results revealed variations in the way clinical leadership job satisfaction affects efficiency assessments per clinical sector. The impact of job satisfaction is verified for the surgical sector and rejected marginally for the pathology sector. Applied methodology results proposed reductions in pharmaceutical expenditure, human resources and available beds. These are indications towards implementing rational economic and human resources management and productive factors development.

This research effort uses job satisfaction as a quantitative variable to assess efficiency, focusing on clinical efficiency per clinical sector. In all efforts to restrain health expenditure, measuring clinical department efficiency is critical for health policy makers.

Principal-agent theory (PAT) has been used to understand relationships among different professional groups and explain performance management between organisations, but is rarely used for research within primary care. The purpose of this paper is to explore whether PAT can be used to attain a better understanding of performance management in primary care.

Purposive sampling was used to identify a range of general practices in the North-west of England. Interviews were carried out with directors, managers and clinicians in commissioning and regional performance management organisations and within general practices, and the data analysed using matrix analysis techniques to produce a case study of performance management.

There are various elements of the principal-agent framework that can be applied in primary care. Goal alignment is relevant, but can only be achieved through clear, strategic direction and consistent interpretation of objectives at all levels. There is confusion between performance measurement and performance management and a tendency to focus on things that are easy to measure whilst omitting aspects of care that are more difficult to capture. Appropriate use of incentives, good communication, clinical engagement, ownership and trust affect the degree to which information asymmetry is overcome and goal alignment achieved. Achieving the right balance between accountability and clinical autonomy is important to ensure governance and financial balance without stifling innovation.

The principal-agent theoretical framework can be used to attain a better understanding of performance management in primary care; although it is likely that only partial goal alignment will be achieved, dependent on the extent and level of alignment of a range of factors.

The performance construct may be one of the most elusive in organization theory. Health care organizations are particularly complex owing to their dual lines of accountability, i.e. professional and administrative. This article examines the factors affecting performance indicator development and use at the technical/managerial and institutional levels, including the accreditation process and the relationship between levels. Using institutional and rational/goal theory, the motivations behind performance measurement behavior at different organizational levels was explored. Results show that the institutional level is motivated by legitimacy while the technical/managerial level is motivated by rationality. Tensions exist between the two levels and between indicator development and use.

The clinical team’s recovery performance for the failures in the patient care processes plays a crucial role in leveraging the healthcare service quality. The purpose of this paper is to investigate the relationship between collective job crafting and team service recovery performance via the mediation mechanism of team work engagement.

Clinicians including physicians and nurses from hospitals in Ho Chi Minh City of Vietnam were recruited as sources of data for the current study. Structural equation modeling was utilized to conduct the data analysis.

The data analysis demonstrated the role of team work engagement as a mediator for the positive link between collective job crafting and team service recovery performance. Serving culture was also found to have an interaction effect with collective job crafting in predicting team work engagement.

The current research extends service recovery research by examining service recovery performance at the team level as well as collective job crafting as its team-level antecedent.

The European Union (EU) Medical Device Regulations (MDR) 2017/745 entered into force on May 2021 with changes related to strengthening the clinical evaluation requirements, particularly for high-risk devices. This study aims to investigate the impact of these strengthened requirements on medical device manufacturers by investigating the challenges they encounter while generating an MDR-compliant clinical evaluation report.

A systematic literature review was carried out using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses method of peer-reviewed literature and various government jurisdictional reports and legislation.

The findings from the study understanding what constitutes sufficient clinical evidence poses the biggest challenge to the generation of an MDR-compliant clinical evaluation report. Resulting from the challenges they are facing, manufacturers of certain CE-marked medical devices are planning to remove (and have removed) devices from the EU market upon expiration of their certificate, and in the case of new and innovative devices, some manufacturers are planning to launch in other markets ahead of the EU. These challenges will lead to a potential shortage of certain medical devices in the EU and a delay in access to new devices, thereby negatively impacting patients’ quality of life.

This study provides a unique insight into the challenges currently experienced by medical device manufacturers as they transition to the MDR clinical evaluation requirements and the subsequent impact on the continued availability of medical devices in the EU. A limitation is the lack of literature analysing the regulations and their effects.

This study has both theoretical contributions in that, to the best of the authors’ knowledge, it is the first detailed and systematic review of the new MDR Regulations and has implications for practice as manufacturers and policymakers can leverage it alike to understand the challenges of the new MDR.

The purpose of this paper, based on a nation‐wide survey, is to explore how clinical governance managers in the English NHS are seeking to engage with the culture(s) of their organisation to support quality improvement.

All English NHS primary and acute trusts, a total of 325, were contacted for R&D approval between March and September 2006. Clinical governance leads of organisations which gave their approval, 276 (or 85 per cent), were targeted in a nation‐wide postal survey between October 2006 and February 2007. A response rate of 77 per cent was obtained. The questionnaire contained mostly closed questions about the role and importance of culture in clinical governance and the use of tools for culture assessment. The questionnaire was piloted with eight respondents, seven in clinical governance from both primary care and acute trusts, and one from the National Patient Safety Agency. Useful feedback was received from five of the respondents, which was used to revise and refine the questionnaire. Confidence in the reliability and validity of the results is based on a high degree of consistency and similarity in the responses, both with respect to a few questions which were closely related and the two categories of respondents from primary care trusts and acute trusts.

There was found to be clear interest among clinical governance managers in culture renewal and management, in line with the growing national policy interest in promoting culture change as a lever for health system reform. Nearly, all clinical governance managers (98 per cent) saw the need to measure local culture in order to foster change for improved performance; 85 per cent, indicated that culture assessment should satisfy a formative purpose, whereas 64 per cent believed that it should serve summative ends. While nearly all clinical governance managers (99 per cent) acknowledge the importance of understanding and shaping local cultures, the majority are also conscious that there are many challenges to overcome in their efforts to implement and sustain beneficial culture change.

This research highlights the widespread practical interest in assessing and managing local health care cultures to support clinical governance and quality improvement activities. It also highlights the need for culture assessment tools that better reflect the needs and interests of clinical governance managers.

After implementing an internal quality control (IQC) programme, the purpose of this paper is to maintain the requisite analytical performance for clinical laboratory staff, thereby safeguarding patient test results for their intended medical purpose.

The authors address how quality can be maintained and if lost, how it can be regained. The methodology is based on the experience working in clinical laboratory diagnostics and is in accord with both international accreditation requirements and laboratory best practice guidelines.

Monitoring test performance usually involves both prospective and retrospective IQC data analysis. The authors present a number of different approaches together with software tools currently available and emerging, that permit performance monitoring at the level of the individual analyser, across analysers and laboratories (networks). The authors make recommendations on the appropriate response to IQC rule warnings, failures and metrics that indicate analytical control loss, that either precludes further analysis, or signifies deteriorating performance and eventual unsuitability. The authors provide guidance on systematic troubleshooting, to identify undesirable performance and consider risk assessment preventive measures and continuous quality improvement initiatives; e.g., material acceptance procedures, as tools to help regain and maintain analytical control and minimise potential for patient harm.

The authors provide a template for use by laboratory scientific personnel that ensures the optimal monitoring of analytical test performance and response when it changes undesirably.

The proposed template has been designed to meet the International Organisation for Standardisation for medical laboratories ISO15189:2012 requirements and therefore includes the use of External Quality Assessment and patient results data, as an adjunct to IQC data.

Healthcare services in the USA have been described as being fragmented and uncoordinated. Integrated delivery systems are frequently promoted as being instrumental in efforts to improve the coordination of care and, thus, enhancing the quality of clinical care and patient services while ensuring optimum cost‐efficiencies. This study seeks to analyze and compare the performance of hospitals participating in highly integrated systems with non‐integrated hospitals based on outcome measures involving hospital performance.

The study compares the performance of 50 flagship hospitals participating in the most highly integrated delivery systems in the USA with a representative sample of non‐system hospitals utilizing one‐way analysis of variance. The comparative analysis was based on three key performance measures; clinical quality of medical care, patient satisfaction, and cost‐efficiency considerations.

The results of the review demonstrate that there is a statistically significant positive difference between the clinical quality performance of the highly integrated hospitals compared with the quality performance of non‐highly integrated facilities. No difference was identified between the two sample groups of hospitals for the performance measures related to patient satisfaction or cost‐efficiencies.

The study is an attempt to evaluate the implications and effectiveness of integration within the health care delivery system. It suggests that integrated delivery systems may provide the organization structure appropriate to help support and enhance the quality of clinical care for patients.

Introducing change is a difficult issue facing all health care systems. The use of various clinical governance levers can facilitate change in health care systems. The purpose of this paper is to define clinical governance levers, and to illustrate their use in a large-scale transformation.

The empirical analysis deals with the in-depth study of a specific case, which is the organizational model for Ontario’s cancer sector. The authors used a qualitative research strategy and drew the data from three sources: semi-structured interviews, analysis of documents, and non-participative observations.

From the results, the authors identified three phases and several steps in the reform of cancer services in this province. The authors conclude that a combination of clinical governance levers was used to transform the system. These levers operated at different levels of the system to meet the targeted objectives.

To exercise clinical governance, managers need to acquire new competencies. Mobilizing clinical governance levers requires in-depth understanding of the role and scope of clinical governance levers.

This study provides a better understanding of clinical governance levers. Clinical governance levers are used to implement an organizational environment that is conducive to developing clinical practice, as well as to act directly on practices to improve quality of care.

The purpose of this paper is to overview, background and context to clinical governance in Australia, areas for further development and potential learnings for other jurisdictions.

Commentary; non-systematic review of clinical governance literature; review of web sites for national, state and territory health departments, quality and safety organisations, and clinical colleges in Australia.

Clinical governance in Australia shows variation across jurisdictions, reflective of a fragmented health system with responsibility for funding, policy and service provision being divided between levels of government and across service streams. The mechanisms in place to protect and engage with consumers thus varies according to where one lives. Information on quality and safety outcomes also varies; is difficult to find and often does not drill down to a service level useful for informing consumer treatment decisions. Organisational stability was identified as a key success factor in realising and maintaining the cultural shift to deliver ongoing quality.

Comparison of quality indicators with clinical governance systems and processes at a hospital level will provide a more detailed understanding of components most influencing quality outcomes.

The information reported will assist health service providers to improve information and processes to engage with consumers and build further transparency and accountability.

In this paper the authors have included an in depth profile of the background and context for the current state of clinical governance in Australia. The authors expect the detail provided will be of use to the international reader unfamiliar with the nuances of the Australian Healthcare System. Other studies (e.g. Russell and Dawda, 2013; Phillips et al., n.d.) have been based on deep professional understanding of clinical governance in appraising and reporting on initaitives and structures. This review has utilised resources available to an informed consumer seeking to understand the quality and safety of health services.

The cumulative cart of data piling through the empirical journey around hospitals in Vietnam provides the clue on whether corporate social responsibility (CSR) influences clinical governance, which in turn catalyzes team processes and knowledge sharing. This paper aims to discuss these issues.

Structural equation modeling (SEM) approach served as an analyst for 341 responses returned from self‐administered structured questionnaires sent to 504 hospital members in the middle‐management position.

A model of clinical governance and knowledge sharing evolved along the process of hypothesis testing. Ethical CSR was found to nourish clinical governance in the healthcare service organizations.

The research findings shed light on the CSR‐based model of knowledge sharing which underscores the role of ethical CSR initiatives in the activation of chain effects from clinical governance through team processes to knowledge sharing.

Digital transformation in nursing education is crucial for enhancing pedagogical practices and preparing future healthcare professionals for the rapidly evolving healthcare landscape. This chapter explores how the integration of digital technologies in higher education has revolutionising teaching methodologies and offered new opportunities to enhance learning experiences. It identifies gaps in digital learning modalities for undergraduate and postgraduate nursing students and discusses strategies to strengthen online literacy preparation and transition into the healthcare sector's digital transformation landscape and the 4th industrial era economy. The chapter examines best practices and challenges in digital transformation in nursing education such as blended learning environments, simulation and virtual reality, mobile learning applications and gamification strategies. Additionally, it addresses challenges in curriculum development including insufficient technological infrastructure, faculty training and development, assessment strategies and resistance to change among faculty and students. This chapter aims to provide insights and recommendations for educators, curriculum developers and policymakers in implementing successful digital transformation in nursing education.

The purpose of this paper is to review the accreditation research in specific to its effect on the performance of healthcare organizations.

A comprehensive search and analysis of literature on the effect of healthcare accreditation were conducted between June 2017 and May 2018. The study identified 62 empirical research studies that examined the effect of healthcare accreditation programmes. Study particulars such as year of publication, objectives, focus of the study, research settings and key findings were recorded. A content analysis was performed to identify the frequency of the main themes in the literature. Knowledge gaps needing further examination were identified.

Majority of the accreditation impact studies were carried out in the developed nations (n = 49). The thematic categories, that is the impact on “patient safety and healthcare quality” (n = 26), “healthcare professionals’ views” (n = 28) and “clinical process and outcomes” (n = 17) were addressed more times. Whereas the other two thematic categories “organizational performance” and “consumers’ views or satisfaction,” each was examined less than 10 instances. This review reveals mixed views on effect of healthcare accreditation. The varied quality of studies and the availability of a few studies on consumers’ perception of accreditation effectiveness were the important limiting factors of this review.

The findings are valuable to healthcare managers and hospital administrators in accreditation decisions, whereas findings are of value to researchers and academicians in terms of gaps identified for future research studies pertaining to the impact of healthcare accreditation. Future studies need to consider holistic theoretical frameworks for assessing the effect of accreditation on performance of healthcare organizations to achieve precise results.

Risk management is an essential cornerstone of any effective unit. The maternity dashboard has been found to be an efficient governance tool, but there is no such scorecard in gynaecology. The paper aims to conceptualise and implement an acute gynaecology dashboard in a teaching hospital over a period of two years and review the changes brought in practice as a result of the dashboard.

This acute gynaecology dashboard was designed in line with the existing maternity dashboard. Goals and benchmarks were determined on the basis of available national guidelines, expert opinions and local policies. The dashboard was prospectively implemented, updated monthly and presented in the relevant forums. A retrospective overview of the changes brought in the practice is presented in this paper.

Through the use of the dashboard significant problems related to workforce, training and clinical activity were identified. A number of changes were subsequently executed to improve patient management, service provision and training. This paper provides empirical insights about how positive changes in clinical practice could be brought in by the implementation of the acute gynaecology dashboard. The acute gynaecology dashboard was found to be a valuable governance tool to monitor performance and improve training and patient care.

The acute gynaecology dashboard can be used as an effective clinical governance tool to monitor performance and leads to improvement in clinical practice in other acute gynaecology units.

Though the maternity dashboard is widely in use, there has been no previous description of an acute gynaecology dashboard and this is the first paper in this area. With the increasing demand of acute gynaecology services, the dashboard becomes an essential tool for clinical governance.

This paper seeks to study the process of clinical audit to improve tubercolosis (TB) diagnosis in Cuba, Peru and Bolivia. It aims to present the lessons learned in implementing clinical audit in the three specific study sites and highlight what may be relevant to low‐income settings in general.

The lessons are based on observations and qualitative data collected from 22 health centres that completed a minimum of two audit cycles in the three study countries. Local audit committees selected audit criteria, collected relevant data, compared their performance against the agreed standards and proposed ways for improvement.

Lessons for the development of clinical audit for TB diagnosis in the study countries include the difficulties in setting achievable standards based on appropriate criteria; the need to establish clinical guidelines and routine data; and the need to address patients' beliefs and attitude. Lessons for the development of clinical audit in low‐income countries include the need for preparation (e.g. through clinical guidelines) before introducing quality improvement tools and the importance of a visible relationship between audit activity and patient care. Crucially, local clinicians struggle in developing evidence‐based audit criteria that should be developed at national level.

The lessons learned presented here are derived from interviews, document analysis and participant observation. Such techniques are liable to observers' and informants' bias. Similarly, conclusions drawn from an inquiry into contextual factors also threaten their external validity. The paper used chronological analysis and explanation building to overcome these limitations.

In low‐income countries, audit needs to be fully integrated in the national and local disease control programmes. The lessons presented here provide practical guidance for those considering developing or improving clinical audit in low‐income countries.

Clinical audit has major potential for improving health care delivery in low‐income countries within existing resource constraints. The lessons presented here have relevance to audit across the entirety of health systems in low‐income countries.

The aims of this paper are to understand the links between work transitions and doctors' performance and to identify the implications for policy, regulation, practice and research.

The paper explains transitions in terms of the inseparability of learning, practice and performance and introduces the concept of the transition as a critically intensive learning period to draw attention to this phenomenon. It also identifies implications for practice, research and regulation

Drawing on empirical data in relation to prescribing and case management, the paper will show that, in contrast to current assumptions of, understanding about and practice in doctors' transitions, doctors can never be fully prepared in advance for aspects of their work.

Transitions are explained in terms of the inseparability of learning, practice and performance and we introduce the concept of the transition as a critically intensive learning period to draw attention to this phenomenon. Also identified are implications for practice, research and regulation.

The purpose of this study was to evaluate the status of US hospital Laboratory Information Systems. Laboratory Information Systems are critical to high quality healthcare service provision. Data show that the need for these systems is growing to meet accompanying technological and workload demands. Additionally, laboratory tests provide the majority of information for clinical decision‐making. Laboratory processes automation, including patient result verification, has greatly improved laboratory test throughput while decreasing turn‐around‐times, enabling critical results to reach physicians rapidly for improved clinical outcomes.

Data were drawn from the 2007 Healthcare Information and Management Systems Society (HIMSS) Analytics Database, which includes over 5,000 US healthcare organizations and provides extensive data on the hardware, software, and information technology infrastructure within healthcare organizations.

US hospitals are actively involved in laboratory systems planning to improve health service quality. Specifically, data show 76 new laboratory information systems are currently being installed in 2007 with another 399 under contract for future installation. As a result, increasing investment in laboratory information systems is providing state‐of‐the‐art clinical laboratory support, which enhances clinical care processes and improves quality. These state‐of‐the‐art Laboratory Information Systems, when linked with other clinical information systems such as Computerized Physician Order Entry and Electronic Medical Record, will support further healthcare quality improvement.

This article includes the most current information available on the US hospital laboratory information system applications.

The research analyzes good practices in health care “management experimentation models,” which fall within the broader range of the integrative public–private partnerships (PPPs). Introduced by the Italian National Healthcare System in 1991, the “management experimentation models” are based on a public governance system mixed with a private management approach, a patient-centric orientation, a shared financial risk, and payment mechanisms correlated with clinical outcomes, quality, and cost-savings. This model makes public hospitals more competitive and efficient without affecting the principles of universal coverage, solidarity, and equity of access, but requires higher financial responsibility for managers and more flexibility in operations.

In Italy the experience of such experimental models is limited but successful. The study adopts the case study methodology and refers to the international collaboration started in 1997 between two Italian hospitals and the University of Pittsburgh Medical Center (UPMC – Pennsylvania, USA) in the field of organ transplants and biomedical advanced therapies.

The research allows identifying what constitutes good management practices and factors associated with higher clinical performance. Thus, it allows to understand whether and how the management experimentation model can be implemented on a broader basis, both nationwide and internationally. However, the implementation of integrative PPPs requires strategic, cultural, and managerial changes in the way in which a hospital operates; these transformations are not always sustainable.

The recognition of ISMETT’s good management practices is useful for competitive benchmarking among hospitals specialized in organ transplants and for its insights on the strategies concerning the governance reorganization in the hospital setting. Findings can be used in the future for analyzing the cross-country differences in productivity among well-managed public hospitals.

The purpose of this article is to analyze and compare between the frameworks of performance measurement in primary health care in the world. The subject of search is to compare if the frameworks of performance measurement in primary health care have an influence on performances of health centers.

We conducted a systematic review of the literature to (1) identify the conceptual framework for measuring quality management systems, (2) assess the effects of conceptual framework on quality improvement and quality of care outcomes. We opted for the frameworks that are more cited in the literature and we analyzed and compared between these frameworks.

Eight dimensions were identified for assessing performance in Primary Health Care Facilities “PHCF” in more than 50% frameworks: Effectiveness, Safety, Accessibility, Equity, Efficiency, Acceptability, Patient Centeredness and Timeliness.

The limits of this study can be represented by the following elements: (1) lack of exhaustiveness with regard to the current Frameworks. (2) The evaluation of reliability and validity of the qualitative studies remains difficult to appreciate. (3) Most of the evaluation tools of the primary health care are not validated yet. (4) The difference in performance levels between countries, especially for the developed countries and the multitude of the frames of measure of performance, limits the comparability of the results.

This study provides a conceptual and descriptive literature on the different conceptual frameworks for performance measurement in primary health care, and a practical and useful tool for comparison between the different conceptual frameworks. Several organisations of accreditation or certification introduced, developed, incorporated and checked the indicators of clinical quality in the organizations of health care. Some studies revealed links with the governance, the access, the continuity, the coordination, the efficiency and the strength primary care (Dionne Kringos, 2018). Improvements in the quality of care have been observed in the results of accreditation and certification bodies regarding hospital infection control infrastructure, organization and performance.

Even if the links are not established within the framework of a scientific research, quality approaches are generally recognized as an essential tool to help establishments to improve the quality and the safety of the patients. Until now, it is not still common to make evaluation of the quality of care in the “PHCF” to obtain the relevant information. The necessity of having performance measurement tools, which puts in coherence the piloting of the operational level with the strategy, to integrate the organizational objectives into the measures of operational performances and make estimate its structures towards a real management by the quality.

The objective of this research is to synthesize evidence on the relationship between context, strategies and performance in the context of federally qualified health centers (FQHCs), a core safety net health services provider in the United States. The research also identifies prior approaches to measure contextual factors, FQHC strategy and performance. Gaps in the research are identified, and directions for future research are provided.

A systematic review of peer-reviewed journal articles published between the years 1997 and 2017 was conducted using a bibliographic search of PubMed, Business Source Premier and ABI/Inform databases.

28 studies were selected for the analysis. Results supported associations among contextual factors (organizational and environmental) and FQHC strategy and FQHC performance. The research also indicates that previous research was primarily emphasized on clinical performance with less focus on other types of FQHC performance. In addition, there exists a wide variability in terms of measuring context, FQHC strategy and performance.

Operating in resource-scarce and highly constraining environments, FQHCs have demonstrated the ability to stay innovative and competent as serving often unhealthier and costlier patient populations. To date, there has been no study that reviewed the relationships between context, FQHC strategy and FQHC performance. In addition, there is an absence of consensus on how context, FQHC strategy and FQHC performance are measured. This study is the first that examined context–strategy–performance relationships in the context of FQHCs.

The purpose of this paper is to explore how the clinical governance policy and its main component, patient satisfaction, turned into practice and what they look like on the ground in the centralised health system of Iran.

A qualitative research stance was adopted incorporating three main sources of information: face to face in‐depth interviews and focus groups conducted with hospital senior managers at the teaching hospitals in Kerman city, Iran, as well as documentary analysis of key policy texts. Nine hospital senior managers were purposefully selected for face‐to‐face interviews as well as a purposeful sample of 15 hospital senior managers for focus groups.

The documentary analysis revealed how clinical policy has been put into practice. The interview and focus group data analysis also disclosed four key themes with respect to how policy implementers in the Iranian centralised health system perceive nationally developed policies towards clinical governance and patient satisfaction. These include: a paper exercise; opaque, ambiguous policies; unstable policies; and separation of policy making from policy implementation.

The study revealed a perceived mismatch between the official proposals for clinical governance and their application in practice. The findings of this research lend support to the idea that there should be no separation between policy making process and its implementation; they are inseparable and should be treated in parallel, rather than in sequence. The study further suggests more accountability of the state towards its policies and public alike as a better governance of the health system. State‐level sustainability followed by allocating proper resources to implementation fields and empowering policy implementers coupled with good systems of performance control are the keys to keep patient focus a top priority.

Clinical governance is an organisational approach to improving the quality of clinical services. A survey was conducted of 33/40 NHS trusts 2.5 to three years after a baseline survey of the 46 trusts was conducted in the West Midlands region. Reported outcomes were achieved more often than expected at baseline. Patient outcomes and documented changes in clinical behaviour were both expected and reported in over three quarters at both periods. A more open culture was expected in 65 per cent at baseline and achieved in 84 per cent at time 2. Strategies for change continued to rely on both periods in optional, educative, audit and protocol procedures. The new approaches of critical incident review and consultant appraisal were welcomed. External review and league tables had adverse impacts where results were poor, but minimal impact if results were positive. Conclusions are drawn about more effective means of catalysing change.

Performance metrics have become widely used and much lamented – about tools for measuring healthcare quality. In this paper, the authors reflect on the development and use of performance metrics in healthcare regulation and clinical practice. Studying multi-actor settings of performance measurement systems in healthcare in Sweden and the Netherlands, the authors show how regulatory agencies (i.e., the inspectorate and national registries), patients, hospitals, and practitioners engage in the constitution of healthcare practices through developing performance indicators that form the input for ranking, ensuing intensive dialogues on what should be measured and accounted for, and to what effects. The authors analyze this process as caring for numbers. The authors discern two practices of caring for numbers: validating and contexting. Validating refers to the practices of making numbers reflect those practices they intend to depict; contexting is about how with the use of numbers specific contexts of healthcare are built. These processes together emphasize the performative character of numbers as well as the reflexive uses of performativity. The paper shows how collaborative and rather pragmatic practices of caring for numbers co-construct specific practices of healthcare. Though this reflexive entanglement of production and use of numbers actors not only constitute specific performance metrics and ranking practices but also perform healthcare.

The purpose of this paper is to propose a practical conceptualization of the balanced scorecard (BSC) to describe the mechanism producing creation of monetary value for hospitals in the territorial context of Lombardy region (Italy).

The authors propose a model‐building strategy that assigns key indicators to key performance areas, and identifies causal relationships between key performance areas. Second, the authors utilize a suitable statistical approach to estimate causal relationships among involved latent variables, taking into account the hierarchical structure of data. Utilizing a suitable data decomposition, the causal model is applied separately to the within data (hospitals) and to the between data (local health agencies).

In the measurement model a new latent construct (medical human capital) was found that resumes the amount of formal training and the performance of surgical staff in hospitals. The estimated causal models reflect the usual directional assumptions, supposed in a typical BSC causal scheme, with some differences. For local health agencies, fruits (financial measures) are strongly related to clinical processes (leaves) for which the medical human capital constitutes its unique trunk. However, for hospitals, fruits (financial measures) are directly linked to clinical processes and Patient Satisfaction.

The main limitations of this study are the lack of new independent data to validate the obtained causal structures and the limited number of indicators that reflect the deficiency of available information in regional administrative archives.

The present study may be useful to guide further efforts which attempt to conceptualize BSC in the health sector. As more information can be made available, other performance indicators can prove to be linked with this structure using the same methodology.

The use of clinical performance data is increasing rapidly. Yet, substantial variation exists across indicators designed to measure the same clinical event. We compared indicators from several indicator measurement systems to determine the consistency of results. Five measurement systems with well‐defined indicators were selected. They were applied to 24 hospitals. Indicators for mortality from coronary artery bypass graft surgery and mortality in the perioperative period were chosen from these measurement systems. Analyses results and concludes that it is faulty to assume that clinical indicators derived from different measurement systems will give the same rank order. Widespread demand for external release of outcome data from hospitals must be balanced by an educational effort about the factors that influence and potentially confound reported rates.

Two-thirds of medical decisions are based on laboratory test results. Therefore, laboratories should practice strict quality control (QC) measures. Traditional QC processes may not accurately reflect the magnitude of errors in clinical laboratories. Six Sigma is a statistical tool which provides opportunity to assess performance at the highest level of excellence. The purpose of this paper is to evaluate performance of the coagulation laboratory utilizing Sigma metrics as the highest level of quality.

Quality indicators of the coagulation laboratory from January 1, 2009, to December 31, 2015, were evaluated. These QIs were categorized into pre-analytical, analytical and post-analytical. Relative frequencies of errors were calculated and converted to Sigma scale to determine the extent of control over each process. The Sigma level of 4 was considered optimal performance.

During the study period, a total of 474,655 specimens were received and 890,535 analyses were performed. These include 831,760 (93.4 percent) routine and 58,775 (6.6 percent) special tests. Stat reporting was requested for 166,921 (18.7 percent). Of 7,535,146 total opportunities (sum of the total opportunities for all indicators), a total of 4,005 errors were detected. There were 2,350 (58.7 percent) pre-analytical, 11 (0.3 percent) analytical and 1,644 (41 percent) post-analytical errors. Average Sigma value obtained was 4.8 with 12 (80 percent) indicators achieving a Sigma value of 4. Three (20 percent) low-performance indicators were: unacceptable proficiency testing (3.8), failure to inform critical results (3.6) and delays in stat reporting (3.9).

This study shows that a small number of errors can decrease Sigma value to below acceptability limits. If clinical laboratories start using Sigma metrics for monitoring their performance, they can identify gaps in their performance more readily and hence can improve their performance and patient safety.

This study provides an opportunity for the laboratorians to choose and set world-class goals while assessing their performance.

To the best of the authors’ knowledge and belief, this study is the first of its kind that has utilized Sigma metrics as a QC tool for monitoring performance of a coagulation laboratory.

The purpose of this paper is to describe the parameters for the development of performance measurement of the quality of medical care behind bars, drawing from widely‐published free‐world clinical guidelines and aspects of care that are unique to the criminal justice arena.

One way to help assure that prisoners receive timely and appropriate health care is through independent review of health care services, to identify strengths of programs and opportunities for improvement. This is a quality of medical care assessment. When done in a systematic way, this has the potential to reduce risk of harm and enhance the personal health of the prisoner and improve the public health. Independent external review provides the best opportunity to identify and remedy opportunities for improvement. “External” can mean wholly independent or “corporate,” that is, review by agency staff that has no vested interest in the findings at the individual facility. Recently, the methodology for assessment of the quality of medical care in the community has blossomed, yet there is little guidance on how to adapt this methodology to the prison setting.

This paper introduces a prison‐oriented method for assessing clinical performance. To the extent possible, the author cites references to the scientific basis for the recommendations. Where there is no science, the author relies as much as possible on consensus, and in a few cases resorts to “wisdom and experience,” as unreliable as this might be. This is a conceptual paper with a viewpoint.

The paper provides guidance on reducing risk of harm and promoting improved health and health care for prisoners.

Focuses on the critical role played by professionals in the management of health‐care institutions in the UK and Canada. Using empirical data, examines the structural models of clinical management, the roles of clinical managers and their relationships with colleague professionals. Compares the approaches taken in the UK and Canada, and explores issues of context, history and relative power. Questions the extent to which professionals are losing autonomy to other professions and management. In particular examines whether the sharing of power inter‐professionally may lead to greater, overall collective professional autonomy. Develops themes of the contextual influences on the process of change, and whether professionals are more effectively managed by internal or external processes of control.

This paper aims to contribute to the existing literature in the field of hospital governance by exploring the relationship between the attributes and performance of hospital boards and hospital performance in terms of quality of healthcare.

A survey of board performance in public hospitals in Morocco was carried out, in which we surveyed all board members of the 13 hospitals in the Casablanca-Settat region. A total of 82 members responded (82% response rate) to the previously adapted and validated self-evaluation questionnaire on board self-assessment questionnaire (BSAQ) board member performance.

On average, the hospital boards studied had eight members. In terms of clinical expertise, half the members were physicians and 17% were nurses. In addition, positive correlations were found between certain board characteristics, notably age, seniority, members' perceptions of their impact on the quality of healthcare and several dimensions of board performance. In parallel, the results showed strong and significant associations between turnover rate and BSAQ score. Negative correlations were also found between average length of stay and BSAQ score. With regard to mortality parameters, it should be noted that we were unable to establish a strong empirical correlation between hospital boards' self-assessed performance and other hospital mortality indicators.

The present study offers a rigorous rationale for the use of the French-translated BSAQ in the hospital context, and we hope that others will use this tool in future work within the framework of evidence-based research. In addition, the BSAQ tool’s focus on board competencies (and not just structure, composition or processes) provides valuable insights into what boards need to learn in order to function effectively. However, despite the insistence of the authors of this study on the need for a comprehensive census of public hospital board members in the region, several obstacles were encountered. Firstly, there were difficulties related to vacancies within the hospitals, which had the effect of restricting the representativeness of the sample. Secondly, access to hospital board members proved complex due to their busy schedules and the confidential nature of their meetings. Finally, it is important to note that national performance indicators in Morocco may not be as reliable as in other countries, which could complicate the identification of high-performing hospital systems and, consequently, make inference difficult.

This study provides large-scale empirical evidence of processes related to the governance of quality of healthcare and elucidates the existence of an association between hospital board performance and clinical performance. The use of validated tools such as the BSAQ should therefore help improve the performance of boards and governance in public hospitals.

The experience of implementing clinical governance in Bradford South and West Primary Care Group illustrates how an emphasis on cultural change rather than on target setting, scrutiny and enforcement is both more consistent with the primary care context and more likely to create lasting improvements. The emerging focus on governance is reviewed and its implementation in one PCG via baseline assessment, strategic planning and innovative practice is presented. Linking clinical governance with a reduction in medical autonomy, as some commentators have done, does not allow for the complexity of power and responsibility characteristic of primary care. Alternative analytic models that draw on organizational theory and on sociology are offered.

The purpose of this paper is to explore the experiences and opinions of mental health professionals working in two rehabilitation wards to a clinical dashboard system.

Following the creation of the clinical dashboards, a questionnaire was developed and sent to staff and patients across two clinical wards involved in the clinical dashboard mental health pilot.

The clinical dashboards were viewed as being useful tools for clinicians, supporting engagement. They can offer rapid access to large volumes of clinically useful information, in a palatable format. The pilot suggested that they could be presented in different ways to make them easier to engage with however they could also result in more paperwork for clinicians.

The main limitations included the sample size, responder bias and the limited sampling period. It would have been helpful to have obtained further responses to understand why individuals came to their conclusions.

The development and use of clinical dashboards in a psychiatric rehabilitation setting offered the opportunity to improve quality, collect and respond to relevant clinical data trends: which is regarded positively by staff and patients.

This study represents the first study to examine the use of clinical dashboards within a UK long stay adult mental health ward setting. The results suggest a positive response from both staff and patients and illustrates the potential benefits relating to clinical quality.

The purpose of this paper is to review critically the published research investigating how guided practice into the profession contributes to increased professional confidence in health care students, with a view to identifying its impact on the development of professional confidence.

A literature search was performed using MEDLINE and ERIC (1980‐2009), which identified guided practice into the profession as being the most commonly examined educational opportunity increasing professional confidence. Empirical studies that had rigorous research design and methods were selected for in‐depth review. However, in light of the paucity of the extant research, a few studies reporting anecdotal accounts of the development of professional confidence through guided practice were also included.

The review revealed how guided practice into the profession can contribute significantly to students' development of professional confidence. The review also points to arguable relationships between confidence and competence and the importance of better understanding and addressing the issue of under‐ and over‐confidence. The review highlights when evidence of the effectiveness of learning opportunities was insufficient or unreliable, with some directions for future research.

The review was based on a selection of papers most representative of research examining the effectiveness of guided professional practice learning opportunities to promote the development of professional confidence, and therefore is not a systematic review of all the extant literature.

It provides insight into the conditions under which guided practice into the profession can contribute to enhancing professional confidence, which is important, given the nature of its relationship with professional competence.

This study examines the relationship between CEO compensation and patient satisfaction in Ontario, Canada. The purpose of this paper is to determine what impact hospital CEO compensation has on hospital patient satisfaction.

The analyses in this study were based on data of 261 CEO-hospital-year observations in a sample of 103 nonprofit hospitals. A number of linear regressions were conducted, with patient satisfaction as the dependent variable and CEO compensation as the independent variable of interest. Controlling variables included hospital size, type of hospital, and frequency of adverse clinical outcomes.

CEO compensation does not significantly influence hospital patient satisfaction. Both patient satisfaction and CEO compensation appear to be driven primarily by hospital size. Patient satisfaction decreases, while CEO compensation increases, with the number of acute care beds in a hospital. In addition, CEO compensation does not even appear to moderate the influence of hospital size on patient satisfaction.

There are several limitations to this study. First, observations of CEO-hospital-years in which annual nominal CEO compensation was below $100,000 were excluded, as they were not publicly available. Second, this research was limited to a three-year range. Third, this study related the compensation of individual CEOs to a measure of performance based on a multitude of patient satisfaction surveys. Finally, this research is restricted to not-for-profit hospitals in Ontario, Canada.

The findings seem to suggest that hospital directors seeking to improve patient satisfaction may find their efforts frustrated if they focus exclusively on the hospital CEO. The findings highlight the need for further research on how CEOs may, through leading and supporting those hospital clinicians and staff that interact more closely with patients, indirectly enhance patient satisfaction.

To the best of the authors’ knowledge, no research has examined the relationship between hospital CEO compensation and patient satisfaction. This research fills the gap and provides a basis for future research.

To compare and contrast the cultural characteristics of “high” and “low” performing hospitals in the UK National Health Service (NHS).

A multiple case study design incorporating a purposeful sample of “low” and “high” performing acute hospital Trusts, as assessed by the star performance rating system.

These case studies suggest that “high” and “low” performing acute hospital organisations may be very different environments in which to work. Although each case possessed its own unique character, significant patternings were observed within cases grouped by performance to suggest considerable cultural divergence. The key points of divergence can be grouped under four main headings: leadership and management orientation; accountability and information systems; human resources policies; and relationships within the local health economy.

As with any study, interpretation of findings should be tempered with a degree of caution because of methodological considerations. First, there are the limitations of case study which proceeds on the basis of theoretical rather than quantitative generalisation. Second, organisational culture was assessed by exploring the views of middle and senior managers. While one should in no way suggest that such an approach can capture all important cultural characteristics of organisations, it is believed that it may be at least partially justified, given the agenda‐setting powers and influence of the senior management team. Finally “star” performance measures are far from a perfect measure of organisational performance. Despite such reservations, the findings indicate that organisational culture is associated in a variety of non‐trivial ways with the measured performance of hospital organisations.

Highlights considerable cultural divergence within UK NHS hospitals.

An increasing amount of data on the quality and clinical performance of NHS hospital Trusts is entering the public domain, however there has been no research looking at how this information is used by general practitioners. A telephone questionnaire survey using a random sample of general practitioners found that less than a quarter of general practitioners used published clinical outcomes data to inform their assessments of the quality of hospital services. Only a small proportion discussed these data with their patients. Nevertheless, some latent demand for this type of information was detected. Those responsible for publishing such data should develop data sets and design dissemination strategies that are capable of engaging the attention of general practitioners. Given the sheer volume of information targeted at general practice it is advisable that the views and opinions of general practitioners are incorporated in future developments.

Purpose – In light of the recent report on regulation by the CMO of England and Wales and the subsequent Department of Health White Paper, this paper aims to consider the nexus between revalidation, appraisal and clinical governance. It provides a summary of the history of revalidation in the UK and explores how revalidation is linked to annual appraisal. It further considers the implications of this relationship and its potential impact on clinical governance and practise. Design/methodology/approach – This is a policy review related to revalidation and appraisal including primary sources from the Department of Health, the GMC, Fifth report of the Shipman Inquiry and published journal articles. Findings – Local clinical governance will be a significant part of the route to re‐licensing for the vast majority of doctors working in the NHS and many of the larger private sector hospitals. Although it will be used for two different purposes, it is generally accepted that the information collected by doctors for their annual appraisal will also form the basis of evidence for revalidation. If appraisal is to be effective, robust and consistent, it is important that the clinical governance framework within which it operates is appropriately designed for its increased role within the regulatory system. Originality/value – This paper is a valuable summary and introduction to the concept of revalidation in the UK, its history and its impact on clinical governance and regulation. It provides a timely review and analysis of the proposed changes to clinical governance at the local, SHA level and the strengthened connection between consultant appraisal and revalidation, contained in both the Department of Health White Paper – Trust, Assurance and Safety and the report – Good Doctors, Safer Patients, by the Chief Medical Officer for England and Wales.

To a rapidly changing environment, health‐care organizations are adopting a variety of value enhancement strategies. Typically characterized as quality improvement activities, these strategies generally include efforts to improve: clinical effectiveness; financial performance; consumer satisfaction; employee satisfaction; and risk management/quality assurance activities. Early efforts involved the use of continuous quality improvement (CQI) or total quality management (TQM) strategies with a focus on improving financial performance, while clinical effectiveness has been a greater emphasis more recently. This study examines the manner in which 14 US health‐care systems, noted for innovation in quality improvement and value enhancement, are utilizing these activities to promote productive organizational change. An interview format, for use with key informants in each organization, was developed using a model with four dimensions – strategic, cultural, technical, and structural.

CASPE Research and Brighton Health Authority have been working together to test a series of approaches to quality assurance in healthcare. In this paper, they give an account of the results of the quality assurance techniques used; discuss the key requirements for successful quality assurance in the NHS environment; and consider the need for systematic evaluation of quality assurance programmes.