Physician compliance with quality and patient safety regulations: The role of perceived enforcement approaches and commitment.

The implementation of a quality and patient safety accreditation system is crucial for hospitals. Although control systems-such as accreditation-can contribute to quality improvements, they also run the risk of unintended consequences. As a result, ways should be found to avoid or reduce these undesirable consequences. This study aims to answer this call by exploring the association of different approaches to the enforcement of rules (punishment, based on monitoring and threats of sanctions; and persuasion, based on dialog and suggestion) with compliance. To test the relation between perceived enforcement and compliance, this study used survey data collected from medical specialists (N = 92) of a large academic medical center. The findings indicate that the same system is interpreted differently and that only a perceived persuasion approach is related to higher levels of compliance. This effect is fully mediated by affective commitment. No direct or indirect effects on compliance were found for a perceived coercive approach. These results suggest that control systems can be perceived in different ways and that the implementation of a control system does therefore not automatically lead to negative and unintended outcomes.

Using regulatory enforcement theory to explain compliance with quality and patient safety regulations: the case of internal audits.

BACKGROUND: Implementing an accredited quality and patient safety management system is inevitable for hospitals. Even in the case of an obligatory rule system, different approaches to implement such a system can be used: coercive (based on monitoring and threats of punishment) and catalytic (based on dialogue and suggestion). This study takes these different approaches as a starting point to explore whether and how implementation actions are linked to compliance. By doing so, this study aims to contribute to the knowledge on how to increase compliance with obligatory rules and regulations. METHODS: The internal audit system (the 'tracer system') of a large Dutch academic hospital is used as a case to investigate different implementation approaches and their effect on compliance. This case allowed us to use a multi-actor and multi-method approach for data collection. Internal audits (N = 16) were observed, audit reports were analyzed, and semi-structured interviews were conducted with both the internal auditors (N = 23) and the ward leaders (N = 14) responsible for compliance. Framework analysis was used to analyze the data. RESULTS: Although all auditors use catalytic enforcement actions, these do not lead to (intended) compliance of all ward leaders. Rather, the catalytic actions contribute to (intended) compliance of ward leaders that are motivated, whereas they do not for the ward leaders that are not motivated. For the motivated ward leaders, catalytic enforcement actions contribute to (intended) compliance by increasing ward leaders' knowledge of the rules and how to comply with them. CONCLUSIONS: Our findings suggest that the effectiveness of implementation actions depends not only on the actions themselves, but also on the pre-existing motivation to comply. These findings imply that there is not one 'best' approach to the implementation of obligatory rules. Rather, the most effective approach depends on the willingness to comply with rules and regulations.

Financial performance, employee well-being, and client well-being in for-profit and not-for-profit nursing homes: A systematic review.

BACKGROUND: Expanding the opportunities for for-profit nursing home care is a central theme in the debate on the sustainable organization of the growing nursing home sector in Western countries. PURPOSES: We conducted a systematic review of the literature over the last 10 years in order to determine the broad impact of nursing home ownership in the United States. Our review has two main goals: (a) to find out which topics have been studied with regard to financial performance, employee well-being, and client well-being in relation to nursing home ownership and (b) to assess the conclusions related to these topics. The review results in two propositions on the interactions between financial performance, employee well-being, and client well-being as they relate to nursing home ownership. METHODOLOGY/APPROACH: Five search strategies plus inclusion and quality assessment criteria were applied to identify and select eligible studies. As a result, 50 studies were included in the review. Relevant findings were categorized as related to financial performance (profit margins, efficiency), employee well-being (staffing levels, turnover rates, job satisfaction, job benefits), or client well-being (care quality, hospitalization rates, lawsuits/complaints) and then analyzed based on common characteristics. FINDINGS: For-profit nursing homes tend to have better financial performance, but worse results with regard to employee well-being and client well-being, compared to not-for-profit sector homes. We argue that the better financial performance of for-profit nursing homes seems to be associated with worse employee and client well-being. PRACTICAL IMPLICATIONS: For policy makers considering the expansion of the for-profit sector in the nursing home industry, our findings suggest the need for a broad perspective, simultaneously weighing the potential benefits and drawbacks for the organization, its employees, and its clients.