Is the grass any greener? Canada to United States of America nurse migration.

AIM: Little or no attempt has been made to determine why nurses leave Canada, remain outside of Canada, or under what circumstances might return to Canada. The purpose of this study was to gain an understanding of Canadian-educated registered nurses working in the USA. DATA SOURCES: Data for this study include the 1996, 2000 and 2004 USA National Sample Survey of Registered Nurses and reports from the same time period from the Canadian Institute for Health Information. FINDINGS: This research demonstrates that full-time work opportunities and the potential for ongoing education are key factors that contribute to the migration of Canadian nurses to the USA. In addition, Canada appears to be losing baccalaureate-prepared nurses to the USA. DISCUSSION: These findings underscore how health care policy decisions such as workforce retention strategies can have a direct influence on the nursing workforce. Policy emphasis should be on providing incentives for Canadian-educated nurses to stay in Canada, and obtain full-time work while continuing to develop professionally. CONCLUSION: Findings from this study provide policy leaders with important information regarding employment options of interest to migrating nurses. STUDY LIMITATIONS: This study describes and contrasts nurses in the data set, thus providing information on the context of nurse migration from Canada to the USA. Data utilized in this study are cross-sectional in nature, thus the opportunity to follow individual nurses over time was not possible.

Hospital efficiency and patient satisfaction.

The objective of this study was to investigate the relationship between efficiency and patient satisfaction for a sample of general, acute care hospitals in Ontario, Canada. A measure of patient satisfaction at the hospital level was constructed using data from a province-wide survey of patients in mid-1999. A measure of efficiency was constructed using data from a cost model used by the Ontario Ministry of Health, the primary funder of hospitals in Ontario. In accordance with previous studies, the model also included measures of hospital size, teaching status and rural location. Based on the results of this study, at a 95% confidence level, there does appear to be evidence to suggest that an inverse relationship between hospital efficiency and patient satisfaction exists. However, the magnitude of the effect appears to be small. Hospital size and teaching status also appear to affect satisfaction, with lower satisfaction scores reported among non-teaching and larger hospitals. This study did not find any evidence to suggest that hospital location (rural versus urban) or religious affiliation contributed to reports of patient satisfaction in any way not explained by the other measures included in the study. The findings imply that low patient satisfaction cannot be explained by excessive management concentration on efficiency. Managers should analyse some of the underlying causes of patient dissatisfaction before reconfiguring resources. It may be beneficial in larger hospitals to study the aspects of care that patients have reported they prefer in small hospitals.

Supply and demand for cardiac nurses in Ontario: perceptions of CNOs.

This article presents the results of a nursing survey of cardiac care hospitals undertaken by a Cardiac Care Network of Ontario Consensus Panel on Cardiovascular Human Resources. The focus of the Panel was to identify areas of current or pending shortages in human resources and make recommendations to the Ministry of Health and Long-Term Care about human resource management in adult cardiac care in Ontario. The article presents the number and mix of full-time, part-time and casual nursing staff, the age distribution of RNs, and the number of vacant Registered Nurse (RN) positions for a sample of cardiac care hospitals in Ontario. Next a sample of Chief Nursing Officer opinions about factors contributing to current difficulties in recruiting RNs and the outlook for future shortages are presented. Implications for nurse managers are offered, including development of new recruitment and retention strategies, identification of further efficiencies in care provision, and a need for nurse manager involvement in debates about the future of how health care is provided in Canada.

Creating a balanced scorecard for a hospital system.

In 1999, hospitals in Ontario, Canada, collaborated with a university-based research team to develop a report on the relative performance of individual hospitals in Canada's most populated province. The researchers used the balanced-scorecard framework advocated by Kaplan and Norton. Indicators of performance were developed in four areas: clinical utilization and outcomes, patient satisfaction, system integration and change, and financial performance and condition. The process of selecting, calculating, and validating meaningful indicators of financial performance and condition is outlined. Lessons learned along the way are provided. These lessons may prove valuable to other finance researchers and practitioners who are engaged in performance measurement endeavors.

Development of a nursing management practice atlas. Part 2, Variation in use of nursing and financial resources.

Developing mechanisms for making benchmark comparisons among hospital organization is a challenge that has been embraced by nurse executives. A methodologic approach for ensuring data congruency when using available secondary data bases for making benchmark comparisons was detailed in part one (July/August) of this two-part series. This second article analyzes nursing management data using a set of nursing and financial resource variables identified by senior nurse executives of the hospital sites involved in this study.

Developing a nursing management practice atlas: Part 1, Methodological approaches to ensure data consistency.

Challenges associated with the use of secondary data sources for benchmarking in nursing administration research are identified. A methodological approach for ensuring data consistency is presented in part one of this two-part series. Part two (September 2000) will provide an analysis of the nursing management data, based on a set of nursing and financial resource benchmarking variables identified by the senior nurse executives of these sites. Initial findings show evidence of data consistency across similar hospitals.

Developing guidelines for allocating catheterization laboratory resources: lessons from an Ontario Consensus Panel. Consensus Panel on Cardiac Catheterization Laboratory Services in Ontario and the Steering Committee of the Cardiac Care Network of Ontario.

In March 1997, the Ontario Ministry of Health asked the Cardiac Care Network of Ontario (CCN) to develop guidelines for allocating cardiac catheterization laboratory resources. A consensus panel of providers and planners used findings from the literature and expert opinion to recommend guidelines for the operation of cardiac catheterization laboratories and criteria to be considered when allocating additional cardiac catheterization laboratory resources. This article summarizes the consensus panel's major findings that may be of value to other jurisdictions, including need identification, clinical practice, system issues, location criteria and cost considerations. The article reflects the advice given to the Ontario Ministry of Health by the CCN and is not an official position paper of the Canadian Cardiovascular Society.

Integrated delivery systems: has their time come in Canada?

In the 1990s every Canadian province is struggling to reduce health care expenditures without jeopardizing access to health care or quality of care. The authors propose a new model for health care delivery: the Canadian Integrated Delivery System (CIDS). A CIDS is a network of health care organizations; it would provide, or arrange to provide, a coordinated continuum of services to a defined population and would be held clinically and fiscally accountable for the outcomes in and health status of that population. A CIDS would serve 100,000 to 2 million people; the care it would provide would be funded on a capitation basis. For providers, there would be explicit financial incentives to minimize costs. At the same time, service quality and consumer choice of primary care practitioner would be maintained. Primary care physicians and specialists would work with other health care service providers to offer a full spectrum of care. CIDS providers would form strategic alliances with community agencies, hospitals, the private sector and other health care services not managed by the CIDS, as needed. For physicians, affiliation with a CIDS that provided strong clinical leadership could be beneficial to their income stability and autonomy. Pilot projects of this model in several communities would determine whether this concept is feasible in the Canadian health care context.

A balanced scorecard for Canadian hospitals.

Managing a health care organization on the basis of one set of information alone (e.g., financial information) does not give a full view of the impact of changes on the organization. A balanced scorecard approach can provide management with a comprehensive framework that turns an organization's strategic objectives into a coherent set of performance measures. This approach has been used extensively in industry, but seldom in health care organizations. By developing a scorecard approach, these organizations could obtain feedback providing a balanced view of organizational performance, letting them see if improvements in one area may have been achieved at the expense of another. It also demands that managers translate their general mission statement on customer service into specific measures that reflect the factors that really matter to customers.

Issues in the use of the Alberta Patient Classification System to fund Ontario long term care.

The purpose of this paper is to assess some of the issues surrounding the use of the Alberta Patient Classification System for Long Term Care Facilities (APCS) to fund Ontario long term care by attempting to answer the following questions: 1) Is the APCS valid for classifying Ontario long term care patients?; 2) Is it appropriate to use the APCS to fund Ontario long term care?, and; 3) What is required to develop a valid long term care patient classification and funding system appropriate for Ontario? The paper discusses why it may be inappropriate to use the APCS to classify Ontario long term care patients, some of the important financial consequences to a long term care facility if the APCS is inappropriate, and what might be necessary for a better patient classification and funding strategy. The potential and pitfalls of adopting patient classification systems developed in a different health system should be of interest to nurse managers in all provinces.

Two methods for allocating pharmacy cost per patient case.

The consequences of two different methods of allocating pharmacy costs per patient case were studied. The study was conducted using cost data from Sunnybrook Health Science Centre (SHSC), a 1205-bed teaching hospital in Toronto, Canada. A sample of the 1991-1992 cases for the three case mix groups (CMGs) with the highest total pharmacy cost and the three CMGs with the highest pharmacy cost per case were examined. Information was obtained from patient records and used to produce two sets of data: pharmacy prescription unit costs and pharmacy costs per case using the relative value unit (RVU) method, and pharmacy prescription unit costs and pharmacy costs per case using the workload measurement system (WMS) method. For each case, the difference between the RVU and WMS pharmacy costs was determined. The RVU method consistently produced higher pharmacy costs per case for the CMGs with the highest pharmacy cost per case. If these CMGs are typical of other CMGs with high pharmacy costs per case, then case reimbursement based on the WMS method of cost allocation would result in underfunding of hospitals whose case mix has a high proportion of CMGs with high pharmacy costs per case and overfunding of hospitals whose case mix has a high proportion of CMGs with low pharmacy costs per case. However, the RVU method of cost allocation, although it appears to be more accurate, places a greater data collection burden on pharmacy managers. The RVU and WMS methods of pharmacy cost allocation gave significantly different pharmacy costs per case for the six CMGs studied.

Physicians in health care management: 4. Case Mix Groups and Resource Intensity Weights: physicians and hospital funding.

In the second of two articles on Case Mix Groups (CMGs) and Resource Intensity Weights (RIWs) the authors describe how these measures are used to adjust the funding of hospitals in Ontario. Because CMGs and RIWs are based on medical chart information concerning diagnoses, concurrent illnesses and main procedures the role of physicians in recording this information is important to the outcome for hospital funding. CMGs and RIWs provide the basis for the calculations of the average cost per weighted case for hospitals and for groups of comparable hospitals. The Ontario Ministry of Health originally gave equity adjustment payments to hospitals with low average costs per weighted case to raise their funding toward norms of comparable hospitals. However, it is now proposed that hospitals with high average costs per weighted case be targeted for budget cuts. In the face of greater case-mix-based hospital funding in the future physician recording of information will be ever more critical.

Physicians in health care management: 3. Case Mix Groups and Resource Intensity Weights: an overview for physicians.

In the first of two articles on the subject, the authors explain what Case Mix Groups (CMGs) and Resource Intensity Weights (RIWs) are and how they are used. The former categorize hospital patients into groups. The latter are ratios showing the relative use of hospital resources for a typical case (successful course of treatment in an acute care hospital and discharge when the patient no longer requires the hospital's services) and atypical cases (death, transfer, sign-out and substantially longer than average stay) in each CMG. As such, CMGs and RIWs define the relation between the medical and financial dimensions of hospital cases for use in planning and management. Ontario and Alberta are the first provinces to use them to adjust hospital funding. CMGs are limited by the number of diagnoses contained in each category, and RIWs are limited by the use of New York cost data due to the lack of Canadian data.

Managing health services organizations with an educational mission: the case of Canada.

Teaching hospitals represent a major segment of the Canadian health system, accounting for a disproportionate number of beds, patient days, and separations. Thus, although only six percent of hospitals are classified as teaching hospitals, they are responsible for about 36 percent of total hospital operating expenses. While affiliation with a medical school presents unique opportunities for the teaching hospital and increases its prestige, there are clear costs associated with affiliation. Administrators have less control over resource allocation decisions, including the types of teaching programs offered. Teaching hospitals cannot unilaterally design their own teaching programs around specialties and subspecialties of their own choosing; decisions related to teaching programs have a direct impact on the services provided by the hospital and may negatively affect the hospital's ability to fulfill its patient care mission. As education budgets are constrained, teaching hospitals are expected to assume outstanding teaching-related expenses. Teaching hospitals are also expected to shift some of their teaching to alternative settings, such as the community. Thus, teaching hospital administrators will require a strong background in finance as well as negotiation and political skills.

Innovative revenue generation.

Innovative revenue generation by Canadian hospitals is drawing increasing attention. After a critical examination of the literature, we classified these into six areas: clinical/diagnostic insured services, clinical/diagnostic non-insured services, hotel services, retail services, administrative services and financial activities. We concluded that many Canadian hospitals are engaging in innovative revenue generation activities, the success of such activities has been mixed, there are many factors to consider when selecting revenue generation activities, many aspects of innovative revenue generation involve sophisticated business and risk management skills not traditionally required in hospital management, and implementation of many such activities requires support from the hospital board, hospital staff and medical staff.

Relative performance evaluation of non-profit hospitals.

In this paper, we use the relative performance evaluation model of Gibbons and Murphy (1990) to examine the relationship between management compensation and the absolute and relative financial performance of 223 non-profit hospitals in Ontario, Canada for the year 1985-86. We find support for the hypothesis of a positive relationship between absolute hospital performance and management compensation and a negative relationship between relative hospital performance and management compensation. Management compensation is also influenced by the size, teaching status, and religious affiliation of the hospital.

Are managers compensated for hospital financial performance?

Management compensation in a sample of 213 nonprofit hospitals in Ontario, Canada, is examined. Management compensation is determined first and foremost by hospital size and teaching status. Results indicate only a weak relationship between management compensation and hospital financial performance.

The Canadian Hospital Executive Simulation System (CHESS).

The Canadian Hospital Executive Simulation System (CHESS) is a computer-based management decision-making game designed specifically for Canadian hospital managers. The paper begins with an introduction on the development of business and health services industry-specific simulation games. An overview of CHESS is provided, along with a description of its development and a discussion of its educational benefits.