Similarities and differences in the associations between patient safety culture dimensions and self-reported outcomes in two different cultural settings: a national cross-sectional study in Palestinian and Belgian hospitals.

OBJECTIVES: To investigate the relationships between patient safety culture (PSC) dimensions and PSC self-reported outcomes across different cultures and to gain insights in cultural differences regarding PSC. DESIGN: Observational, cross-sectional study. SETTING: Ninety Belgian hospitals and 13 Palestinian hospitals. PARTICIPANTS: A total of 2836 healthcare professionals matched for profession, tenure and working hours. PRIMARY AND SECONDARY OUTCOME MEASURES: The validated versions of the Belgian and Palestinian Hospital Survey on Patient Safety Culture were used. An exploratory factor analysis was conducted. Reliability was tested using Cronbach's alpha (α). In this study, we examined the specific predictive value of the PSC dimensions and its self-reported outcome measures across different cultures and countries. Hierarchical regression and bivariate analyses were performed. RESULTS: Eight PSC dimensions and four PSC self-reported outcomes were distinguished in both countries. Cronbach's α was α≥0.60. Significant correlations were found between PSC dimensions and its self-reported outcome (p value range <0.05 to <0.001). Hierarchical regression analyses showed overall perception of safety was highly predicted by hospital management support in Palestine (ß=0.16, p<0.001) and staffing in Belgium (ß=0.24, p<0.001). The frequency of events was largely predicted by feedback and communication in both countries (Palestine: ß=0.24, p<0.001; Belgium: ß=0.35, p<0.001). Overall grade for patient safety was predicted by organisational learning in Palestine (ß=0.19, p<0.001) and staffing in Belgium (ß=0.19, p<0.001). Number of events reported was predicted by staffing in Palestine (ß=-0.20, p<0.001) and feedback and communication in Belgium (ß=0.11, p<0.01). CONCLUSION: To promote patient safety in Palestine and Belgium, staffing and communication regarding errors should be improved in both countries. Initiatives to improve hospital management support and establish constructive learning systems would be especially beneficial for patient safety in Palestine. Future research should address the association between safety culture and hard patient safety measures such as patient outcomes.

A multicenter record review of in-hospital adverse drug events requiring a higher level of care.

OBJECTIVE: Adverse drug events (ADEs) are a worldwide concern, particularly when leading to a higher level of care. This study defines a higher level of care as an unplanned (re)admission to an intensive care unit or an intervention by a Medical Emergency Team. The objectives are to describe the incidence and preventability of ADEs leading to a higher level of care, to assess the types of drug involved, and to identify the risk factors. METHODS: A three-stage retrospective review was performed in six Belgian hospitals. Patient records were assessed by a trained clinical team consisting of a nurse, a physician, and a clinical pharmacist. Descriptive statistics, univariate, and multiple logistic regressions were used. RESULTS: In this study, 830 patients were detected for whom a higher level of care had been needed. In 160 (19.3%) cases, an ADE had occurred; 134 (83.8%) of these were categorized as preventable adverse drug events (pADEs). The overall incidence rate of patients transferred to a higher level of care because of a pADE was 33.9 (95% CI: 28.5-39.3) per 100,000 patient days at risk. Antibiotics and antithrombotic agents accounted both for one-fifth of all pADEs. Multivariate analysis indicated American Society of Anaesthesiologists physical status score as a risk factor for pADEs. CONCLUSIONS: The high number of pADE with patient harm shows that there is a need for structural improvement of pharmacotherapeutic care. Detection of these pADEs can be the basis for the implementation of these improvements.

Incidence and outcome of inappropriate in-hospital empiric antibiotics for severe infection: a systematic review and meta-analysis.

INTRODUCTION: The aims of this study were to explore the incidence of in-hospital inappropriate empiric antibiotic use in patients with severe infection and to identify its relationship with patient outcomes. METHODS: Medline (from 2004 to 2014) was systematically searched by using predefined inclusion criteria. Reference lists of retrieved articles were screened for additional relevant studies. The systematic review included original articles reporting a quantitative measure of the association between the use of (in)appropriate empiric antibiotics in patients with severe in-hospital infections and their outcomes. A meta-analysis, using a random-effects model, was conducted to quantify the effect on mortality by using risk ratios. RESULTS: In total, 27 individual articles fulfilled the inclusion criteria. The percentage of inappropriate empiric antibiotic use ranged from 14.1% to 78.9% (Q1-Q3: 28.1% to 57.8%); 13 of 27 studies (48.1%) described an incidence of 50% or more. A meta-analysis for 30-day mortality and in-hospital mortality showed risk ratios of 0.71 (95% confidence interval 0.62 to 0.82) and 0.67 (95% confidence interval 0.56 to 0.80), respectively. Studies with outcome parameter 28-day and 60-day mortality reported significantly (P ≤0.02) higher mortality rates in patients receiving inappropriate antibiotics. Two studies assessed the total costs, which were significantly higher in both studies (P ≤0.01). CONCLUSIONS: This systematic review with meta-analysis provides evidence that inappropriate use of empiric antibiotics increases 30-day and in-hospital mortality in patients with a severe infection.

Risk factors for unplanned hospital re-admissions: a secondary data analysis of hospital discharge summaries.

RATIONALE, AIMS AND OBJECTIVES: To identify patient groups at risk for unplanned hospital re-admissions and risk factors for re-admission. METHOD: We analysed the Belgian Hospital Discharge Dataset including data from 1 130 491 patients discharged in 2008. Patient and hospital factors contributing to re-admission rate were analysed using a multivariable model for logistic regression. RESULTS: The overall unplanned re-admission rate was 5.2%. Cardiovascular and pulmonary diagnoses were the most common reasons for re-admission. We found that 10.4% of all re-admissions were due to complications. A high number of previous emergency department (ED) visits proved to be a predictor for re-admission [odds ratio (OR) for patients with at least four ED visits in the past 6 months 4.65; 95% confidence interval (CI) 4.25-5.08]. Patients discharged on Friday (OR 1.05; 95% CI 1.01-1.08) and patients with a long length of stay (OR 1.19; 95% CI 1.15-1.23) also had a higher risk for re-admission. Patients with short lengths of stay were not at risk for re-admission (OR 0.99; 95% CI 0.95-1.02). CONCLUSIONS: Actions to reduce re-admissions can be targeted to patient groups at risk, and should be aimed at the caring for chronic cardiovascular or pulmonary diseases, preventing complications and multiple ED visits, and ensuring continuity of care after discharge, especially for patients discharged on Friday.

One fourth of unplanned transfers to a higher level of care are associated with a highly preventable adverse event: a patient record review in six Belgian hospitals.

OBJECTIVE: The objectives of this study are to determine the prevalence and preventability of adverse events requiring an unplanned higher level of care, defined as an unplanned transfer to the ICU or an in-hospital medical emergency team intervention, and to assess the type and the level of harm of each adverse event. DESIGN: A three-stage retrospective review process of screening, record review, and consensus judgment was performed. SETTING: Six Belgian acute hospitals. PATIENTS: During a 6-month period, all patients with an unplanned need for a higher level of care were selected. INTERVENTIONS: The records 6-month period, the records of all patients with an unplanned need for a higher level of care were assessed by a trained clinical team consisting of a research nurse, a physician, and a clinical pharmacist. MEASUREMENTS AND MAIN RESULTS: Adverse events were found in 465 of the 830 reviewed patient records (56%). Of these, 215 (46%) were highly preventable. The overall incidence rate of patients being transferred to a higher level of care involving an adverse event was 117.6 (95% CI, 106.9-128.3) per 100,000 patient days at risk, of which 54.4 (95% CI, 47.15-61.65) per 100,000 patient days at risk involving a highly preventable adverse event. This means that 25.9% of all unplanned transfers to a higher level of care were associated with a highly preventable adverse event. The adverse events were mainly associated with drug therapy (25.6%), surgery (23.7%), diagnosis (12.4%), and system issues (12.4%). The level of harm varied from temporary harm (55.7%) to long-term or permanent impairment (19.1%) and death (25.2%). Although the direct causality is often hard to prove, it is reasonable to consider these adverse events as a contributing factor. CONCLUSION: Adverse events were found in 56% of the reviewed records, of which almost half were considered highly preventable. This means that one fourth of all unplanned transfers to a higher level of care were associated with a highly preventable adverse event.

Staffing levels and the use of physical restraints in nursing homes: a multicenter study.

There is an unclear relation between staffing levels and the use of physical restraints in nursing homes (NHs). A survey design was used in 570 older adults (median age = 86; 77.2% women), living on 23 wards within seven NHs. Restraint use was high (50% of residents, of which 80% were restrained on a daily basis). Multivariate analysis was conducted at the level of the individual wards. Neither staff intensity nor staff mix was a determinant of restraint use. Bathing dependency, transfer difficulties, risk for falls, frequent restlessness/agitation, and depression were independent predictors of restraint use. Patient characteristics have significant greater impact on physical restraint use than staffing levels. Therefore, improving knowledge and skills of NH staff to better deal with restlessness/agitation, mobility problems, and risk for falls is encouraged to decrease the use of physical restraints in NH residents.

The Global Trigger Tool shows that one out of seven patients suffers harm in Palestinian hospitals: challenges for launching a strategic safety plan.

OBJECTIVE: The aim of this study was to evaluate patient safety levels in Palestinian hospitals and to provide guidance for policymakers involved in safety improvement efforts. DESIGN: Retrospective review of hospitalized patient records using the Global Trigger Tool. SETTING: Two large hospitals in Palestine: a referral teaching hospital and a nonprofit, non-governmental hospital. PARTICIPANTS: A total of 640 random records of discharged patients were reviewed by experienced nurses and physicians from the selected hospitals. INTERVENTION: Assessment of adverse events. MAIN OUTCOME MEASURES: Prevalence of adverse events, their preventability and harm category. Descriptive statistics and Cohen kappa coefficients were calculated. RESULTS: One out of seven patients (91 [14.2%]) suffered harm. Fifty-four (59.3%) of these events were preventable; 64 (70.4%) resulted in temporary harm, requiring prolonged hospitalization. Good reliability was achieved among the independent reviewers in identifying adverse events. The Global Trigger Tool showed that adverse events in Palestinian hospitals likely occur at a rate of 20 times higher than previously reported. Although reviewers reported that detecting adverse events was feasible, we identified conditions suggesting that the tool may be challenging to use in daily practice. CONCLUSION: One out of seven patients suffers harm in Palestinian hospitals. Compromised safety represents serious problems for patients, hospitals and governments and should be a high priority public health issue. We argue that direct interventions should be launched immediately to improve safety. Additional costs associated with combating adverse events should be taken into consideration, especially in regions with limited resources, as in Palestine.

The Arabic version of the hospital survey on patient safety culture: a psychometric evaluation in a Palestinian sample.

BACKGROUND: A growing global interest in patient safety culture has increased the development of validated instruments to asses this phenomenon. The aim of this study is to investigate the psychometric properties of the Hospital Survey on Patient Safety Culture (HSOPSC) and its appropriateness for Arab hospitals. METHODS: The 7-step guideline of the Agency for Healthcare Research and Quality was used to translate and validate the HSOPSC. A panel of experts evaluated the face and content validity indexing of the Arabic version. Data were collected from 13 Palestinian hospitals including 2022 healthcare professionals who had direct or indirect interaction with patients, hospital supervisors, managers and administrators. Descriptive statistics and psychometric evaluation (a split-half validation technique) were then used to test and strengthen the validity and reliability of the instrument. RESULTS: With respect to face and content validity, the CVI analysis showed excellent results for the Arab context (CVI = 0.96). As to construct validity, the 12 original dimensions could not be applied to the Palestinian data. Furthermore, three of the 12 original dimensions were not reliable (α <0.6). The split-half technique resulted in an optimal 11-factor model. CONCLUSIONS: Our study is the first study in the Arab world to provide an evaluation of the HSOPSC using Arabic data from Palestine. The Arabic translation of the HSOPSC comprises an 11-factor structure showing good validity and acceptable reliability. Despite the similarity between the Arab factor structure of the HSOPSC and that of the original one, and taking into account that our version may be applied in Arabic hospitals, there is a need for caution in comparing HSOPSC data between countries.

Health care professionals as second victims after adverse events: a systematic review.

Adverse events within health care settings can lead to two victims. The first victim is the patient and family and the second victim is the involved health care professional. The latter is the focus of this review. The objectives are to determine definitions of this concept, research the prevalence and the impact of the adverse event on the second victim, and the used coping strategies. Therefore a literature research was performed by using a three-step search procedure. A total of 32 research articles and 9 nonresearch articles were identified. The second victim phenomenon was first described by Wu in 2000. In 2009, Scott et al. introduced a detailed definition of second victims. The prevalence of second victims after an adverse event varied from 10.4% up to 43.3%. Common reactions can be emotional, cognitive, and behavioral. The coping strategies used by second victims have an impact on their patients, colleagues, and themselves. After the adverse event, defensive as well as constructive changes have been reported in practice. The second victim phenomenon has a significant impact on clinicians, colleagues, and subsequent patients. Because of this broad impact it is important to offer support for second victims. When an adverse event occurs, it is critical that support networks are in place to protect both the patient and involved health care providers.

Supporting involved health care professionals (second victims) following an adverse health event: a literature review.

BACKGROUND: One out of seven patients is involved in an adverse event. The first priority after such an event is the patient and their family (first victim). However the involved health care professionals can also become victims in the sense that they are traumatized after the event (second victim). They can experience significant personal and professional distress. Second victims use different coping strategies in the aftermath of an adverse event, which can have a significant impact on clinicians, colleagues, and subsequent the patients. It is estimated that nearly half of health care providers experience the impact as a second victim at least once in their career. Because of this broad impact it is important to offer support. OBJECTIVE: The focus of this review is to identify supportive interventional strategies for second victims. STUDY DESIGN: An extensive search was conducted in the electronic databases Medline, Embase and Cinahl. We searched from the start data of each database until September 2010. RESULTS: A total of 21 research articles and 10 non-research articles were identified in this literature review. There are numerous supportive actions for second victims described in the literature. Strategies included support organized at the individual, organizational, national or international level. A common intervention identified support for the health care provider to be rendered immediately. Strategies on organizational level can be separated into programs specifically aimed at second victims and more comprehensive programs that include support for all individuals involved in the adverse event including the patient, their family, the health care providers, and the organization. CONCLUSION: Second victim support is needed to care for health care workers and to improve quality of care. Support can be provided at the individual and organizational level. Programs need to include support provided immediately post adverse event as well as on middle long and long term basis.

Design of a medical record review study on the incidence and preventability of adverse events requiring a higher level of care in Belgian hospitals.

BACKGROUND: Adverse events are unintended patient injuries that arise from healthcare management resulting in disability, prolonged hospital stay or death. Adverse events that require intensive care admission imply a considerable financial burden to the healthcare system. The epidemiology of adverse events in Belgian hospitals has never been assessed systematically. FINDINGS: A multistage retrospective review study of patients requiring a transfer to a higher level of care will be conducted in six hospitals in the province of Limburg. Patient records are reviewed starting from January 2012 by a clinical team consisting of a research nurse, a physician and a clinical pharmacist. Besides the incidence and the level of causation and preventability, also the type of adverse events and their consequences (patient harm, mortality and length of stay) will be assessed. Moreover, the adequacy of the patient records and quality/usefulness of the method of medical record review will be evaluated. DISCUSSION: This paper describes the rationale for a retrospective review study of adverse events that necessitate a higher level of care. More specifically, we are particularly interested in increasing our understanding in the preventability and root causes of these events in order to implement improvement strategies. Attention is paid to the strengths and limitations of the study design.

Retrospective medical record evaluation: reliability in assessing causation, preventability, and disability of adverse events.

PURPOSE: The purpose of this article is to assess the reliability of an in-depth analysis on causation, preventability, and disability by two separate review teams on five selected adverse events in acute hospitals: pressure ulcer, postoperative pulmonary embolism or deep vein thrombosis, postoperative sepsis, ventilator-associated pneumonia and postoperative wound infection. DESIGN/METHODOLOGY/APPROACH: The analysis uses a retrospective medical record review of 1,515 patient records by two independent teams in eight acute Belgian hospitals for the year 2005. The Mann-Whitney U-test is used to identify significant differences between the two review teams regarding occurrence of adverse events as well as regarding the degree of causation, preventability, and disability of found adverse events. FINDINGS: Team 1 stated a high probability for health care management causation in 95.5 per cent of adverse events in contrast to 38.9 per cent by Team 2. Likewise, high preventability was considered in 83.1 per cent of cases by Team 1 versus 51.7 per cent by Team 2. Significant differences in degree of disability between the two teams were also found for pressure ulcers, postoperative pulmonary embolism or deep vein thrombosis and postoperative wound infection, but not for postoperative sepsis and ventilator-associated pneumonia. ORIGINALITY/VALUE: New insight on the degree of and reasons for the huge differences in adverse event evaluation is provided.

Monitoring quality in a federal state with shared powers in healthcare: the case of Belgium.

The Belgian healthcare system consists of a complex of more or less autonomous groups of healthcare providers. It is the responsibility of the government to ensure that the fundamental right to qualitative healthcare is secured through the services they provide. In Belgium, the regulatory powers in healthcare are divided between the federal state and the three communities. Both levels, within their area of competence, monitor the quality of healthcare services. Unique to the Belgian healthcare system is that the government that providers are accountable to is not always the same as the government that is competent to set the criteria. The goal of this article is to provide an overview of the main mechanisms that are used by the federal government and the government of the Flemish community to monitor healthcare quality in hospitals. The Flemish community is Belgian's largest community (6.2 million inhabitants). The overview is followed by a critical analysis of the dual system of quality monitoring.

Improving patient safety culture.

PURPOSE: Improving hospital patient safety means an open and stimulating culture is needed. This article aims to describe a patient safety culture improvement approach in five Belgian hospitals. DESIGN/METHODOLOGY/APPROACH: Patient safety culture was measured using a validated Belgian adaptation of the Hospital Survey on Patient Safety Culture (HSOPSC) questionnaire. Studies before (autumn 2005) and after (spring 2007) the improvement approach was implemented were completed. Using HSOPSC, safety culture was measured using 12 dimensions. Results are presented as evolving dimension scores. FINDINGS: Overall, 3,940 and 3,626 individuals responded respectively to the first and second surveys (overall response rate was 77 and 68 percent respectively). After an 18 to 26 month period, significant improvement was observed for the "hospital management support for patient safety" dimension--all main effects were found to be significant. Regression analysis suggests there is a significant difference between professional subgroups. In one hospital the "supervisor expectations and actions promoting safety" improved. The dimension "teamwork within hospital units" received the highest scores in both surveys. There was no improvement and sometimes declining scores in the lowest scoring dimensions: "hospital transfers and transitions", "non-punitive response to error", and "staffing". RESEARCH LIMITATIONS/IMPLICATIONS: The five participating hospitals were not randomly selected and therefore no representative conclusions can be made for the Belgian hospital sector as a whole. Only a quantitative approach to measuring safety culture was used. Qualitative approaches, focussing on specific safety cultures in specific parts of the participating hospitals, were not used. PRACTICAL IMPLICATIONS: Although much needs to be done on the road towards better hospital patient safety, the study presents lessons from various perspectives. It illustrates that hospital staff are highly motivated to participate in measuring patient safety culture. Safety domains that urgently need improvement in these hospitals are identified: hospital transfers and transitions; non-punitive response to error; and staffing. It confirms that realising progress in patient safety culture, demonstrating at the same time that it is possible to improve management support, is complex. ORIGINALITY/VALUE: Safety is an important service quality aspect. By measuring safety culture in hospitals, with a validated questionnaire, dimensions that need improvement were revealed thereby contributing to an enhancement plan.

Increasing nurse staffing levels in Belgian cardiac surgery centres: a cost-effective patient safety intervention?

AIM: This paper is a report of a cost-effectiveness analysis from a hospital perspective of increased nurse staffing levels (to the level of the 75th percentile) in Belgian general cardiac postoperative nursing units. BACKGROUND: A previous study indicated that increasing nurse staffing levels in Belgian general cardiac postoperative nursing units was associated with lower mortality rates. Research is needed to compare the costs of increased nurse staffing levels with benefits of reducing mortality rates. METHOD: Two types of average national costs were compared. A first calculation included the simulation of an increase in the number of nursing hours per patient day to the 75th percentile for nursing units staffed below that level. For the second calculation (the comparator) we used a 'do nothing' alternative. The most recent available data sources were used for the analysis. Results were expressed in the form of the additional costs per avoided death and the additional costs per life-year gained. The analysis used 2007 costing data. FINDINGS: The costs of increasing nurse staffing levels to the 75th percentile in Belgian general cardiac postoperative nursing units amounted to euro1,211,022. Such nurse staffing levels would avoid an estimated number of 45.9 (95% confidence interval: 22.0-69.4) patient deaths per year and generate 458.86 (95% confidence interval: 219.93-693.79) life-years gained annually. This corresponds with incremental cost-effectiveness ratios of euro26,372 per avoided death and euro2639 per life-year gained. CONCLUSION: Increasing nurse staffing levels appears to be a cost-effective intervention as compared with other cardiovascular interventions.

Validation of Hospital Administrative Dataset for adverse event screening.

OBJECTIVE: To assess whether the Belgian Hospital Discharge Dataset (B-HDDS) is a valid source for the detection of adverse events in acute hospitals. DESIGN, SETTING AND PARTICIPANTS: Retrospective review of 1515 patient records in eight acute Belgian hospitals for the year 2005. MAIN OUTCOME MEASURES: Predictive value of the B-HDDS and medical record reviews and degree of correspondence between the B-HDDS and medical record reviews for five indicators: pressure ulcer, postoperative pulmonary embolism or deep vein thrombosis, postoperative sepsis, ventilator-associated pneumonia and postoperative wound infection. RESULTS: Postoperative wound infection received the highest positive predictive value (62.3%), whereas postoperative sepsis and ventilator-associated pneumonia were rated as only 44.2% and 29.9% respectively. Excluding present on admission from the screening substantially decreased the positive predictive value of pressure ulcer from 74.5% to 54.3%, as pressure ulcers present on admission were responsible for more B-HDDS-medical record mismatches than any other indicator. Over half (56.8%) of false-positive cases for postoperative sepsis were due to a lack of specificity of the ICD-9-CM code, whereas in 58.6% of false-positive cases for ventilator-associated pneumonia, clinical criteria appeared to be too stringent. CONCLUSIONS: The B-HDDS has the potential to accurately detect some but not all adverse events. Adding a code 'present on admission' and improving the ICD-9-CM codes might already partially improve the correspondence between the B-HDDS and the medical record review.

The relationship between inpatient cardiac surgery mortality and nurse numbers and educational level: analysis of administrative data.

BACKGROUND: In most multicenter studies that examine the relationship between nurse staffing and patient safety, nurse-staffing levels are measured per hospital. This can obscure relationships between staffing and outcomes at the unit level and lead to invalid inferences. OBJECTIVE: In the present study, we examined the association between nurse-staffing levels in nursing units that treat postoperative cardiac surgery patients and the in-hospital mortality of these patients. DESIGN-SETTING-PARTICIPANTS: We illustrated our approach by using administrative databases (Year 2003) representing all Belgian cardiac centers (n=28), which included data from 58 intensive care and 75 general nursing units and 9054 patients. METHODS: We used multilevel logistic regression models and controlled for differences in patient characteristics, nursing care intensity, and cardiac procedural volume. RESULTS: Increased nurse staffing in postoperative general nursing units was significantly associated with decreased mortality. Nurse staffing in postoperative intensive care units was not significantly associated with in-hospital mortality possibly due to lack of variation in ICU staffing across hospitals. CONCLUSION: This study, together with the international body of evidence, suggests that nurse staffing is one of several variables influencing patient safety. These findings further suggest the need to study the impact of nurse-staffing levels on in-hospital mortality using nursing-unit-level specific data.

Nurse staffing and patient outcomes in Belgian acute hospitals: cross-sectional analysis of administrative data.

BACKGROUND: Studies have linked nurse staffing levels (number and skill mix) to several nurse-sensitive patient outcomes. However, evidence from European countries has been limited. OBJECTIVES: This study examines the association between nurse staffing levels (i.e. acuity-adjusted Nursing Hours per Patient Day, the proportion of registered nurses with a Bachelor's degree) and 10 different patient outcomes potentially sensitive to nursing care. DESIGN-SETTING-PARTICIPANTS: Cross-sectional analyses of linked data from the Belgian Nursing Minimum Dataset (general acute care and intensive care nursing units: n=1403) and Belgian Hospital Discharge Dataset (general, orthopedic and vascular surgery patients: n=260,923) of the year 2003 from all acute hospitals (n=115). METHODS: Logistic regression analyses, estimated by using a Generalized Estimation Equation Model, were used to study the association between nurse staffing and patient outcomes. RESULTS: The mean acuity-adjusted Nursing Hours per Patient Day in Belgian hospitals was 2.62 (S.D.=0.29). The variability in patient outcome rates between hospitals is considerable. The inter-quartile ranges for the 10 patient outcomes go from 0.35 for Deep Venous Thrombosis to 3.77 for failure-to-rescue. No significant association was found between the acuity-adjusted Nursing Hours per Patient Day, proportion of registered nurses with a Bachelor's degree and the selected patient outcomes. CONCLUSION: The absence of associations between hospital-level nurse staffing measures and patient outcomes should not be inferred as implying that nurse staffing does not have an impact on patient outcomes in Belgian hospitals. To better understand the dynamics of the nurse staffing and patient outcomes relationship in acute hospitals, further analyses (i.e. nursing unit level analyses) of these and other outcomes are recommended, in addition to inclusion of other study variables, including data about nursing practice environments in hospitals.

Do non-profit nursing homes separate governance roles? The impact of size and ownership characteristics.

Separation between operational responsibilities and those of oversight is an important point of discussion in governance. Novel to the literature, this paper not only offers direct evidence on the degree of separation, but also shows its relationship with size (ceteris paribus efficiency prescribes that large organizations implement more separation) and ownership characteristics of non-profit institutions. Using a sample of Belgian (Flemish) nursing homes, we find that in private nursing homes this separation increases with size while this is not the case in public homes. We document that this lack in flexibility in governance practices explains the micro-monitoring in public institutions. We formulate policy implications and suggest solutions to create more flexibility and likely also better governance.