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Theses/dissertations from 2023 2023.

Factors Associated with the Difficulty of Computerized Tasks Among Office-Based Physicians in the United States , Khalid Alshehri

Reducing Oral Health Disparities: Effectiveness of Preventive Dental Care on Treatment Use, Expenditures and Determinants of Service Utilization , Rashmi Lamsal

'The Very Structure of Opportunities Has Collapsed': How Taxation Policies Enhance, Decay, and Otherwise Affect the Distribution of Health & Health Services in the United States , Valerie Pacino

An Exploration of Policies, Equity, and Emerging Threats to the Traffic Safety Environment in the U.S. , Sachi Verma

Theses/Dissertations from 2022 2022

The State of Oral Health in People with Disabilities and the Impact of Family-Centered Care on the Oral Health of Children with Special Health Care Needs , Bedant Chakraborty

Theses/Dissertations from 2021 2021

The Ecology of Mental Health and the Impact of Barriers on Mental Health Service Utilization , Alisha Aggarwal

Health Service Utilization and Expenditure in Cardio-Metabolic Conditions in the United States Adults , Kavita Mosalpuria

Impact of Prescription Drug Monitoring Program on Drug Misuse and Drug-related Fatal Vehicle Crashes , Moosa Tatar

Theses/Dissertations from 2020 2020

Essays on rehospitalization under the Hospital Readmission Reduction Program , Yangyuna Yang

Theses/Dissertations from 2019 2019

Impact of Healthcare Delivery and Policies on Children's Outcomes after the Affordable Care Act of 2010 , Shreya Roy

Examining the Effects of Approaches on Reducing Hospital Utilization: The Patient-Centered Medical Home, Continuity of Care, and the Inpatient Palliative Consultation at the End-of-Life , Xiaoting Sun

Theses/Dissertations from 2018 2018

Essays on the Patient-Centered Medical Home in the United States Military Health System , Glen N. Gilson

A Multi-Level Assessment of Healthcare Facilities Readiness, Willingness, and Ability to Adopt and Sustain Telehealth Services , Jamie Larson

Healthcare Utilization for Behavioral Health Disorders: Policy Implications on Nationwide Readmissions, and Outcomes in the States of Nebraska and New York , Rajvi J. Wani

Theses/Dissertations from 2017 2017

Structural violence and gender-based violence in the United States , Sarbinaz Z. Bekmuratova

Community Benefits Spending by Private Tax-Exempt Hospitals in the U.S. , Wael ElRayes

Patient-Centered Medical Home Adoption in School-Based Health Centers , Abbey Gregg

Meaningful Use of Electronic Health Records for Population Health Management in U.S. Acute Care Hospitals , Niodita Gupta

Hospital Based Emergency Department Visits With Dental Conditions: Outcomes and Policy Implications in the States of California, Nebraska and New York , Sankeerth Rampa

Theses/Dissertations from 2016 2016

Adoption of Medication Management Technologies by U.S. Acute Care Hospitals after the HITECH Act , Aastha Chandak

The Impact of Electronic Health Records on Healthcare Service Delivery, Patient Safety, and Quality , Kate Elizabeth Trout

Essays on Immigration-Related Disparities in Health Behavior and Health Care Utilization , Yang Wang

Theses/Dissertations from 2015 2015

The Impact of Gasoline Prices on Medical Care and Costs of Motor Vehicle Injuries , He Zhu

Theses/Dissertations from 2014 2014

Provision, cost, and quality of robot-assisted radical prostatectomies in the United States , Soumitra Sudip Bhuyan

Organizational factors associated with the implementation of evidence-based public health interventions in local health department settings , Janelle J. Jacobson

Hospital cost shifting in the United States , Tao Li

Patient-centered medical home readiness in the veterans health administration: an organizational perspective , Anh T. Nguyen

Organizational and environmental correlates of electronic health records implementation and performance in acute care hospitals in the United States , Diptee Ojha

Assessing geographic variation and migration behaviors of foreign-born medical graduates in the United States , Samuel Tawiah Yaw Opoku

Theses/Dissertations from 2013 2013

Organizational and environmental correlates of strategic behavior and financial performance in the US hospice industry , Bettye Appiah Apenteng

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Main factors affecting perceived quality in healthcare: a patient perspective approach

The TQM Journal

ISSN : 1754-2731

Article publication date: 20 July 2021

Issue publication date: 17 December 2021

Delivering patient-centered healthcare is now seen as one of the basic requirements of good quality care. In this research, the impact of the perceived quality of three experiential dimensions (Physical Environment, Empowerment and Dignity and Patient–Doctor Relationship) on patient's Experiential Satisfaction is assessed.

Design/methodology/approach

259 structured interviews were performed with patients in private and public hospitals across Italy. The research methodology is based in testing mediation and moderation effects of the selected variables.

The study shows that: perceived quality of Physical Environment has a positive impact on patient's Experiential Satisfaction; perceived quality of Empowerment and Dignity and perceived quality of Patient–Doctor Relationship mediate this relationship reinforcing the role of Physical Environment on Experiential Satisfaction; educational level is a moderator in the relationship between perceived quality of Patient–Doctor Relationship and overall Satisfaction: more educated patients pay more attention to relational items. Subjective Health Frailty is a moderator in all the tested relationships with Experiential Satisfaction: patients who perceive their health as frail are more reactive to the quality of the above-mentioned variables.

Originality/value

Physical Environment items are enablers of both Empowerment and Dignity and Patient–Doctor Relationship and these variables must be addressed all together in order to improve the value proposition provided to patients. Designing a hospital, beyond technical requirements that modern medicine demands and functional relationships between different medical departments, means dealing with issues like the anxiety of the patient, the stressful working environment for the hospital staff and the need to build a sustainable and healing building.

• Healthcare marketing
• Patient experience
• Patient satisfaction
• Patient empowerment

Bellio, E. and Buccoliero, L. (2021), "Main factors affecting perceived quality in healthcare: a patient perspective approach", The TQM Journal , Vol. 33 No. 7, pp. 176-192. https://doi.org/10.1108/TQM-11-2020-0274

Emerald Publishing Limited

Copyright © 2021, Elena Bellio and Luca Buccoliero

Published by Emerald Publishing Limited. This article is published under the Creative Commons Attribution (CC BY 4.0) licence. Anyone may reproduce, distribute, translate and create derivative works of this article (for both commercial and non-commercial purposes), subject to full attribution to the original publication and authors. The full terms of this licence may be seen at http://creativecommons.org/licences/by/4.0/legalcode

Today patient experience is recognized as one of the key elements of quality control within healthcare organizations ( James, 2013 ), becoming crucial for a competitive growth strategy ( Needham, 2012 ; Ismail et al. , 2014 ; Larson et al. , 2019 ).

Delivering patient-centered healthcare is now seen as one of the basic requirements of good quality care ( Ismail et al. , 2014 ). From 2000 to 2009, more than 400 articles were published on patient experience ( Lecroy, 2010 ) showing that positive patient experiences are associated with improved health outcomes, patient loyalty and satisfaction ( Murante et al. , 2014 ).

With the term “experience” usually people refer to all the elements of the patient journey: Needham (2012) uses the term “roller-coaster” to synthetize the alternation of different emotional and physical status that patient experience while going through the healthcare treatments. Other authors ( Bowling et al. , 2012 ) define the patient experience as the main output coming from all the different healthcare-related elements that patients observe. More in general different studies relate the patient experience to two main domains: the physical ambience and the human interactions ( Frampton, 2012 ), as they can be perceived by both patients and caregivers in any medical touch point ( Weiss and Tyink, 2009 ). Human interaction in this specific field is further analyzed with a focus on both interactions with medical staff and on the patient empowerment dimension ( Hewitson et al. , 2014 ).

With the term “satisfaction” it is common to refer to all patient opinions with regards to the received assistance ( Bate and Robert, 2007 ; Tsianakas et al. , 2012 ; Health Foundation, 2013 ; Crow et al. , 2002 ). Studies in the healthcare setting provide some evidence that hospitals' service quality has a positive influence on patient satisfaction ( Nor Khasimah and Wan Normila, 2013 ; Murti et al. , 2013 ; Alrubaiee and Alkaa'ida, 2011 ; Helena Vinagre and Neves, 2008 ; Wu, 2011 ; Cham et al. , 2015 ), it means that healthcare providers should adopt a marketing approach to deeply understand patients' needs and expectations in order to meet them ( Lee et al. , 2010 ). It is also common to consider patient experiences as an indicator of the quality of a specific hospital ( Wilson and Strong, 2014 ; Health Foundation, 2013 ) as experience evaluation is a fundamental instrument to be able to reach expectations ( Shannon, 2013 ; AbuDagga and Weech-Maldonado, 2016 ). Bright and beautiful lobbies, rooms with big windows and access to outdoor gardens, dining options and innovative hospital designs have changed patients' experiences and expectations of what a hospital should be. Research has shown that hospitals that feature new designs and amenities positively affect patient satisfaction ( Goldman and Romley, 2008 ), improve therapeutic benefits ( Marcus and Barnes, 1995 ), reduce pain and allow a shorter hospital stay ( Roger et al. , 2004 ).

Studies about patient experience have often been found to be of poor quality since patients' involvement has not been fully considered and the effects on quality of care have not been reported ( Crawford et al. , 2002 ). Moreover also hospital strategic planning was rarely linked with patient involvement ( Daykin et al. , 2007 ). Until now, research on patients' satisfaction has been focused on environmental or relational items of the patient experience while a comprehensive and holistic approach to the mutual interdependencies of these dimensions has been mostly ignored both by the scientific research and by the health managerial practice ( Beattie et al. , 2014 ). The present study aims at providing this incremental value, by analyzing the interdependencies between the main patients' experiential items and how they can be combined in order to maximize the positive impacts on patients' experiential satisfaction.

Adopting an experiential marketing approach: the items of patient experience

It is currently argued that patients' opinions should supplement traditional indicators of quality in the healthcare domain ( Wilson and Strong, 2014 ; Health Foundation, 2013 ) because they provide information on the ability to meet their expectations ( Shannon, 2013 ).

Through a literature review it was possible to identify several elements of patient experience, which largely influence the perceived quality of care. Those elements and their measurements vary depending on the study considered ( Health Foundation, 2013 ). Researchers have proposed various instruments as the “Customer Quality Index Cataract Questionnaire”, the “Picker Patient Experience Questionnaire” ( Jenkinson et al. , 2002 ), the “Hospital Consumer Assessment of Healthcare Providers and Systems” ( Raman and Tucker, 2011 ). Both qualitative and quantitative approaches are utilized.

Starting from the available scientific literature, we identified three main dimensions of the inpatients' healthcare experience as follows:

Physical Environment . A key component of customer experience is related to aesthetic sensory and physical aspects of the healthcare facilities ( Eroglu and Machleit, 1993 ). Research has highlighted how physical environmental elements directly affect customers ( Baraban and Durocher, 2001 ; Siberil, 1994 ), evoking internal responses ( Lin, 2004 ) and indirectly influencing their behaviors ( Plichon, 1999 ; Bitner, 1992 ). Literature (summarized in Table 1 ) suggests that environmental aspects of the experience can include variables such as ambience/atmosphere, color ( Bellizzi and Hite, 1992 ; Gorn et al. , 1997 ), shape ( Zhang et al. , 2006 ), sound ( Lichtle et al. , 2002 ; Yalch and Spangenberg, 1990 ; Dubé et al. , 1995 ), cleanliness ( Bitner et al. , 2000 ), waiting time ( Burt, 2006 ), comfort and services ( Reese, 2009 ; Meyers, 2009 ), food quality ( Calderoni et al. , 1999 ; Webb, 2007 ), lighting ( Golden and Zimmerman, 1986 ) and smell ( Bitner et al. , 2000 ; Bitner, 1992 ; Chebat and Michon, 2003 ; Joy and Sherry, 2003 ; Baker et al. , 1992 ; Baraban and Durocher, 2001 ; Donovan and Rossiter, 1982 ). Focusing on the role of the experience in healthcare, studies show that some of the above-mentioned factors also improve inpatient's experience ( Nemetz, 2010 ) and satisfaction ( Susilo et al. , 2020 ). Although some of the above-described elements are recurring in patient experience research, they have been analyzed separately so far. Hence, it appears difficult to find studies that jointly examine those items and provide a unique classification of the key experiential components related to the environment.

Empowerment and dignity

Respect for the patients' dignity;

Privacy with regards to medical information;

Autonomy of the patient in deciding about his own healthcare.

Patients' respect is related to how the hospital staff interacts with patients, specifically with regards to the level of empathy, relationship skills, listening skills and the interest toward the patient as a person ( Dawood and Gallini, 2010 ; Wu, 2011 ; Şener ; Melotti et al. , 2009 ; Avis et al. , 1995 ). Other important elements are represented by spiritual care, staff's willingness to listen to patients' fears ( Puchalski et al. , 2009 ), the focus on pain management ( Darr, 2001 ) and the privacy that patient experience through the different phases of his medical treatments ( Piper et al. , 2012 ; Bate and Robert, 2007 ; Melotti et al. , 2009 ). The concept of empowerment means inclusion of patients in the decision-making process, as well as the degree of such participation ( Andrade et al. , 2013 ; Kjeken et al. , 2006 ) by considering it a bricolage of tactical interactions with social environments rather than as the consequence of an external strategic process ( Schneider-Kamp and Askegaard, 2020 ). Contradicting the traditional paternalistic approach, today it is important to give patients the ability to get personal information about their disease (for instance through an easy access to their Personal Health Record also during the hospitalization), understand and rationally analyze the available options and apply their personal beliefs to the medical decisions ( Buccoliero et al. , 2016a ). As a result, patients are nowadays more involved in the healthcare decision-making process while having to decide which medical treatments to undergo ( Bos et al. , 2008 ; Stump and Coustasse, 2012 ) and medical consultations are becoming increasingly based on mutuality, meaning that patients are gaining a greater control over that relationship with a clear link between physician relationship and patient involvement determining satisfying patient empowerment ( Ippolito et al. , 2019 ).

Patients – patients assume an active role in their own healthcare choices ( Bellio et al. , 2009 );

Caregivers and family members – patients' relatives involvement in the care process ( Conway et al. , 2006 );

Medical staff – increased control of clinicians over both the content and context of their practice ( Meyers, 2009 ) and also to the continuity of care, meaning that they are able to take care of the patient even after their hospital journey ( Webb, 2007 ).

Patient–Doctor relationship . Communication between doctors and patients is one of the most complex relationships among inter-personal ones and is thus attracting more attention within healthcare studies ( Chaitchik et al. , 1992 ).

A traditional or paternalistic approach with regards to that relationship usually involved high physician control compared to patients' one and can thus be described as a model where the doctor is dominant and acts as a “parent” figure who decides the care process on patients' place. However, nowadays medical consultations are becoming increasingly based on mutuality, meaning that patients are gaining a greater control over that relationship. In fact, the patient–doctor relationship has been described in economic terms as an “agency relationship” where informed agents make decisions for uninformed clients. In the context of the above-mentioned trends of patient empowerment, patient loyalty to a medical doctor does not seem to be guaranteed and it is thus becoming more important to change the traditional agency relationship into a more collaborative one ( Einwiller, 2003 ; McKnight and Chervany, 2001 ). In that direction moves the consumerist approach, that involves a situation in which the roles are reversed, the patient interpret the active role and the doctor adopts a fairly passive role, acceding to the patient's requests for a second opinion, referral to hospital, a sick note and so on ( Morgan, 2003 ).

On one hand, patients complain that many of their questions to doctors go unanswered. The need of more detailed information is arising ( Buccoliero et al. , 2016b ), patients are becoming less reliant on doctors as Internet acts as an alternative source of information ( Charles et al. , 2003 ; Godolphin, 2003 ). On the other hand, patients express the need of reaching a positive relationship with doctors as they miss the warmth and trust in the interaction.

The quality of the relationship can be improved by perceiving the staff team as a harmonious group ( Borrill et al. , 2000 ) where the professional role of each member can be easily identified by the patient. This is normally obtained by the use of different colors in employees uniforms. Courtesy, attention, empathy capabilities, professionalism of staff members and their ability to establish and maintain a positive relation with their patients affect patients' satisfaction ( Avis et al. , 1995 , Şener ).

Certain aspects of doctor–patient communication seem to have an influence on patients' behavior and well-being, for example satisfaction with care, adherence to treatment, recall and understanding of medical information, coping with the disease, quality of life and even state of health ( Smith et al. , 1981 ; Ong et al. , 1995 ). The assessment of these impacts is very often based on small samples, given the need to implement controlled clinical trials to this extent. Otherwise, subjective perceptions are considered instead.

Research objectives

As we stated above, the interdependencies between the three main pillars of patient experience (environment, relation and empowerment) have not been analyzed or implemented so far. Consequently, there is a lack of knowledge about the joint impact of these health service dimensions in shaping patients' experience and affecting their satisfaction. There is, therefore, a clear gap in the existing literature with reference to the above-mentioned three patient experience dimensions' if based on their relevance from patients' viewpoint. Through this study we want to provide a detailed analysis of the value elements of an inpatients experience, by combining the three dimensions and assessing their strengths for different cluster of patients (with a specific focus on different patients' subjective perceptions on their current health conditions) (see Figure 1 ).

Variables considered for the assessment of the different dimensions of the model are listed in Table 2 .

Perceived quality of Physical Environment is positively related to Experiential Satisfaction.

Perceived quality of Empowerment and Dignity and perceived quality of Patient–Doctor Relationship are positively related to Experiential Satisfaction.

Perceived quality of Empowerment and Dignity is positively related to Experiential Satisfaction.

Perceived quality of Patient–Doctor Relationship is positively related to Experiential Satisfaction.

Perceived quality of Physical Environment is positively related to perceived quality of Empowerment and Dignity and perceived quality of Patient–Doctor Relationship.

Perceived quality of Physical Environment is positively related to perceived quality of Empowerment and Dignity.

Perceived quality of Physical Environment is positively related to perceived quality of Patient–Doctor Relationship.

The positive relationship between perceived quality of Physical Environment and Experiential Satisfaction is mediated by perceived quality of Empowerment and Dignity and perceived quality of Patient–Doctor Relationship. The assumption is that perceived quality of Physical Environment does not affect directly Experiential Satisfaction. Rather, these perceptions become stronger according to perceived quality of Empowerment and Dignity and perceived quality of Patient–Doctor Relationship.

The positive relationship between perceived quality of Physical Environment and Experiential Satisfaction is mediated by perceived quality of Empowerment and Dignity.

The positive relationship between perceived quality of Physical Environment and Experiential Satisfaction is mediated by perceived quality of Patient–Doctor Relationship.

With reference to socio-demographic factors, literature allows to identify some specific clusters of patients defined by gender, age and education ( Fox et al. , 2000 ; Fox, 2006 ), while there is no significant evidence of the effect of income on behaviors ( Fox et al. , 2000 ; Ha and Cohen, 2008 ). Results show that as education level increases, patient satisfaction decreases, while as the age of the patient increases, so does the satisfaction level of the patient.

Gender moderates the relationship between perceived quality of Empowerment and Dignity and perceived quality of Patient–Doctor Relationship and Experiential Satisfaction.

Gender will moderate the relationship between perceived quality of Empowerment and Dignity and Experiential Satisfaction; specifically, perceived quality of Empowerment and Dignity will be more strongly related to Experiential Satisfaction in females rather than in males.

Gender will moderate the relationship between perceived quality of Patient–Doctor Relationship and Experiential Satisfaction; specifically, perceived quality of Patient–Doctor Relationship will be more strongly related to Experiential Satisfaction in females rather than in males.

Age moderates the relationship between perceived quality of Empowerment and Dignity and perceived quality of Patient–Doctor Relationship and Experiential Satisfaction.

Age will moderate the relationship between perceived quality of Empowerment and Dignity and Experiential Satisfaction; specifically, perceived quality of Empowerment and Dignity will be more strongly related to Experiential Satisfaction in young patients rather than in older ones.

Age will moderate the relationship between perceived quality of Patient–Doctor Relationship and Experiential Satisfaction; specifically, perceived quality of Patient–Doctor Relationship will be more strongly related to Experiential Satisfaction in young patients rather than in older ones.

Education level moderates the relationship between perceived quality of Empowerment and Dignity and perceived quality of Patient–Doctor Relationship and Experiential Satisfaction.

Education level will moderate the relationship between perceived quality of Empowerment and Dignity and Experiential Satisfaction; specifically, perceived quality of Empowerment and Dignity will be more strongly related to Experiential Satisfaction in well educated patients rather than in less-educated ones.

Education level will moderate the relationship between perceived quality of Patient–Doctor Relationship and Experiential Satisfaction; specifically, perceived quality of Patient–Doctor Relationship will be more strongly related to Experiential Satisfaction in well educated patients rather than in less educated ones.

Subjective Health Frailty moderates the relationship between perceived quality of Empowerment and Dignity and perceived quality of Patient–Doctor Relationship and Satisfaction.

Subjective Health Frailty will moderate the relationship between perceived quality of Empowerment and Dignity and Experiential Satisfaction; specifically, perceived quality of Empowerment and Dignity will be more strongly related to Experiential Satisfaction in higher levels of Subjective Health Frailty.

Subjective Health Frailty will moderate the relationship between perceived quality of Patient–Doctor Relationship and Experiential Satisfaction; specifically, perceived quality of Patient–Doctor Relationship will be more strongly related to Experiential Satisfaction in higher levels of Subjective Health Frailty.

Subjective Health Frailty moderates the relationship between perceived quality of Physical Environment and perceived quality of Patient–Doctor Relationship and Experiential Satisfaction in higher levels of Subjective Health Frailty.

Sample and interviews

The research methodology is quantitative, based on the use of standardized structured interviews with patients staying in five departments: surgery, oncology, orthopedics, gynecology and general internal medicine from four different private and public hospitals across Italy (two based in Milan, one in Cagliari and one in Caserta). All the considered Hospitals operate within the Italian National Health Service (public funding and universal access).

Socio-demographic information;

Perceived quality of Physical Environment;

Perceived quality of Empowerment and Dignity;

Perceived quality of Doctor–Patient Relationship;

Experiential Satisfaction;

Internet use in accessing health information.

This study is based on part of the collected data. For instance section 6 and other items have not been used in this paper.

Questions used for the assessment of patients' experience were adapted from the following questionnaires “Patient-Perceived Total Quality Service (TQS)” ( Duggirala et al. , 2008 ) and “Patient Satisfaction Questionnaire (PSQ)” ( Marshall and Hays, 1994 ); while the assessment of Subjective Health Frailty was based on the VOICE questionnaire ( Evans et al. , 2012 ) and items selected by the SWB model ( Sun et al. , 2016 ).

259 interviews were carried out. Once the data was collected, descriptive statistics were calculated.

Statistical analysis

Statistical Package for the Social Sciences Program (SPSS) version 21 is used for the statistical analysis. An early investigation of the sample composition is made through descriptive statistics. Respondents' Experiential Satisfaction is investigated by testing the mediating role of Empowerment and Dignity and of Patient–Doctor Relationship. According to Baron and Kenny (1986) suggestions, there are four steps to examine this effects, in which several regression analyses are conducted and significance of the coefficients is examined at each step. Regression analysis is also performed in the light of various socio-demographic variables tested as moderators ( MacKinnon and Dwyer, 1993 ).

Sample description

The average age of the sample is 50.37 years (youngest respondent 16 y.o.; oldest 94 y.o.). Females represent 60.2% of the sample; males represent 39.8%. When asked to specify their educational level, 23.6% said primary school, 29.7% middle school, 36.3% high school and 10.4% declared to have an academic degree. The 95% of respondents were Italian citizens. Finally, regarding their job status, the 28.2% of patients indicated retired and 23.6% housewife, 8.5% employee, 8.1% freelance professional, 5.8% worker, 3.1% student and 22.7% other.

Hypothesis testing

The experiential items are derived in this study through an aggregation of various items, Cronbach's alpha coefficients were performed to test their reliability ( Cronbach, 1951 ). Test scores exhibit a good internal consistency reliability with all Cronbach's alpha higher than 0.7 as shown in Table 3 .

The study uses simple regression analysis to examine the relationship among PE, E&D, PDR and SAT by considering age, gender and education level as control variables.

As shown in Table 4 , perceived quality of Physical Environment (Beta 0.899 Sig. 0.000), perceived quality of Empowerment and Dignity (Beta 0.666 Sig. 0.000) and perceived quality of Patient–Doctor Relationship (Beta 0.642 Sig. 0.000) are positively and significantly related to Experiential Satisfaction. In addition, perceived quality of Physical Environment is positively and significantly related to perceived quality of Empowerment and Dignity (Beta 0.907 Sig. 0.000) and perceived quality of Patient–Doctor Relationship (Beta 0.879 Sig. 0.000). This allows to state that H1 , H2a , H2b , H3a , H3b are all supported .

The impact of perceived quality of Physical Environment elements above Experiential Satisfaction was further analyzed by testing a mediation effect for the two variables perceived quality of Empowerment and Dignity ( H4a ) and perceived quality of Patient–Doctor Relationship ( H4b ). In the two analyses we controlled for age, gender and education level.

H4a (see Table 5 ): the study first lets perceived quality of Physical Environment be the independent variable, and perceived quality of Empowerment and Dignity the dependent one. Results show that perceived quality of Physical Environment significantly and positively affects perceived quality of Empowerment and Dignity (Beta 0.907 Sig. 0.000).

Furthermore, we considered perceived quality of Physical Environment as the independent variable, and Experiential Satisfaction the dependent one. In this scenario, results indicate that perceived quality of Physical Environment significantly and positively affects Experiential Satisfaction (Beta 0.899 Sig. 0.000). Moreover, perceived quality of Empowerment and Dignity significantly and positively accounts for Experiential Satisfaction (Beta 0.666 Sig. 0.000). Once obtained the above-mentioned results, the study regresses perceived quality of Physical Environment toward Experiential Satisfaction by adding as mediating variable perceived quality of Empowerment and Dignity. Perceived quality of Empowerment and Dignity significantly and positively affects Experiential Satisfaction. Results demonstrate that Beta value for Experiential Satisfaction in model 3 is lower than in the second model (Beta 0.516 lower than Beta 0.899): therefore, a partial mediation effect is registered thus H4a is confirmed .

H4b (see Table 6 ): the study first lets perceived quality of Physical Environment be the independent variable, and perceived quality of Patient–Doctor Relationship the dependent one. Results show that perceived quality of Physical Environment significantly and positively affects perceived quality of Patient–Doctor Relationship (Beta 0.879 Sig. 0.000). Then perceived quality of Physical Environment is considered the independent variable, and Experiential Satisfaction the dependent one. Results indicate that perceived quality of Physical Environment significantly and positively affects Experiential Satisfaction (Beta 0.899 Sig. 0.000). Moreover, perceived quality of Patient–Doctor Relationship significantly and positively accounts for Experiential Satisfaction (Beta 0.642 Sig. 0.000). Once obtained the above-mentioned results, the study regresses with Experiential Satisfaction on perceived quality of Physical Environment by adding as the mediating variable perceived quality of Patient–Doctor Relationship. Perceived quality of Patient–Doctor Relationship significantly and positively affects Experiential Satisfaction. Results demonstrate that Beta value for Experiential Satisfaction in model 3 is lower than in the second model (Beta 0.520 lower than Beta 0.899): therefore, a partial mediation effect is registered thus H4b is confirmed .

In order to test H5 , H6 , H7 , H8 and H9 a moderator effect was evaluated for Gender, Age, Educational Level and Subjective Health Frailty.

H5 : first the moderator role was considered in the relationship between perceived quality of Empowerment and Dignity and Experiential Satisfaction for gender. In this case H5a (Sig. 0.749) is refused, then the moderator role was considered in the relationship between perceived quality of Patient–Doctor Relationship and Experiential Satisfaction for gender. In this case, H5b (Sig. 0.220) is also refused .

H6 : first the moderator role was considered in the relationship between perceived quality of Empowerment and Dignity and Experiential Satisfaction for age. In this case H6a (Sig. 0.184) is refused , then the moderator role was considered in the relationship between perceived quality of Patient–Doctor Relationship and Experiential Satisfaction for age. In this case, H6b (Sig. 0.402) is also refused.

H7 : first the moderator role was considered in the relationship between perceived quality of Empowerment and Dignity and Experiential Satisfaction for education level. In this case H7a (Sig. 0.989) is refused . Consequently, the moderator role was considered in the relationship between perceived quality of Patient–Doctor Relationship and Experiential Satisfaction for education level. In this case, H7b (Sig. 0.036) is accepted in fact the effect of perceived quality of Patient–Doctor Relationship on Experiential Satisfaction is stronger when the patient is more educated.

H8 : first the moderator role was considered in the relationship between perceived quality of Empowerment and Dignity and Experiential Satisfaction for Subjective Health Frailty. In this case H8a (Sig. 0.015) is accepted, then the moderator role was considered in the relationship between perceived quality of Patient–Doctor Relationship and Experiential Satisfaction for Subjective Health Frailty. In this case, H8b (Sig. 0.000) is also accepted .

H9 : the moderator role was considered in the relationship between perceived quality of Physical Environment and Experiential Satisfaction for Subjective Health Frailty. In this case H9 (Sig. 0.032) is accepted.

Discussion and conclusion

Our results allow to state that the three identified patient experience dimensions significantly impact on patient Experiential Satisfaction, thus establishing the relevance of the considered variables. The analyses provide a clear evidence that patients' satisfaction is determined by a blend of positive patient experiential items.

A perceived high quality of Physical Environment enables an improvement of both Empowerment and Dignity and Patient–Doctor Relationship, and positively affects the Experiential patients' Satisfaction. Moreover, increased levels of Empowerment and Dignity and Patient–Doctor Relationship further reinforce (as shown through their mediation role) the impact of Physical Environment on Experiential Satisfaction. These relationships are qualified as even stronger for two selected clusters of patients (as shown through the moderation analyses): patients who perceived their health as frail and people with higher levels of education.

Therefore, we demonstrate that an improvement in hospital Physical Environment creates a better context in terms of perceived quality of patient empowerment and relationship and increases the Experiential Satisfaction in a sort of “virtual circle”. People who are more afraid of their health condition show to be even more sensitive to these “circular” relationships as they need a better understanding of their conditions and fears.

In order to satisfy patients' experiential needs, a greater attention is required in renewing the different physical elements of the hospital, as from our study this dimension is confirmed to be relevant in affecting patients' Experiential Satisfaction. Moreover, we also demonstrate that the relations with patients and the perceived patient empowerment could take significant benefits from these environmental improvements. Experiential marketing interventions on selected items of physical environment (shown in Table 1 with references to existing scientific literature) could play an important role to this extent. For instance, the insights collected during our study clearly show that colors and music are among the most effective factors. As for the colors, 212 respondents out of 236 declared to appreciate the presence of different colors inside the hospital. As for the music, 60% of the sample stated to prefer the presence of music inside the hospital environment also in order to filter out typical hospital noises.

Evidence from our study also suggest that the best impact on patients' Experiential Satisfaction is achieved when these environmental projects are linked to the improvement of the relational skills and of the overall patient empowerment (by providing patients with better information and with the opportunity to play an active role in the care process).

The introduction in the healthcare sector of the managerial role of the Chief Experience Officer might contribute to the development and improvement of the patient journey ( Needham, 2012 ). A strong cooperation between the Chief Experience Officer and the Hospital Chief Architects could enrich the overall value provided to patients instead of focusing only on organizational and functional needs.

This current study could be further developed by including the assessment of the clinical outcome of patients (monitored through controlled clinical studies), in order to measure potential impacts of the considered variables also on this dimension (improvements in patients' compliance or long term health outcomes). Furthermore, also the value of the digital patient experiential items could be investigated.

The main strength of this study is measuring hospital performance from the patients' perspective rather than from the providers' point of view. This perspective has been so far missing especially in the public healthcare sector in Italy which should get rid of its traditional bureaucratic organizational approach, focusing instead on customers' experience and activating customer oriented developments in accordance with the competitive environment ( Hsiao and Lin, 2008 ).

The research model

Physical environment elements

Variables and dimensions of the model

Reliability analysis

Regression analysis

Mediating test of perceived quality of Empowerment and Dignity

Mediating test of perceived quality of Patient–Doctor relationship

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Busse R, Klazinga N, Panteli D, et al., editors. Improving healthcare quality in Europe: Characteristics, effectiveness and implementation of different strategies [Internet]. Copenhagen (Denmark): European Observatory on Health Systems and Policies; 2019. (Health Policy Series, No. 53.)

Improving healthcare quality in Europe: Characteristics, effectiveness and implementation of different strategies [Internet].

1 an introduction to healthcare quality: defining and explaining its role in health systems.

Reinhard Busse , Dimitra Panteli , and Wilm Quentin .

1.1. The relevance of quality in health policy

Quality of care is one of the most frequently quoted principles of health policy, and it is currently high up on the agenda of policy-makers at national, European and international levels (EC, 2016 ; OECD, 2017 ; WHO, 2018 ; WHO/OECD/World Bank, 2018 ). At the national level, addressing the issue of healthcare quality may be motivated by various reasons – ranging from a general commitment to high-quality healthcare provision as a public good or the renewed focus on patient outcomes in the context of popular value-based healthcare ideas to the identification of specific healthcare quality problems ( see Box 1.1 ).

Reasons for (re)focusing on quality of care.

At the European level, the European Council’s Conclusions on the Common Values and Principles in European Union Health Systems highlight that “the overarching values of universality, access to good quality care, equity, and solidarity have been widely accepted in the work of the different EU institutions” (European Council, 2006 ). The European Commission (EC, 2014 ; EC, 2016 ) also recognizes quality as an important component of health system performance (i.e. the extent to which health systems meet their goals; we return to the link between quality and performance later in the chapter).

At the international level, quality is receiving increasing attention in the context of the Sustainable Development Goals (SDGs), as the SDGs include the imperative to “achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all”. This is reflected in two World Health Organization (WHO) reports published in 2018, a handbook for national quality policies and strategies (WHO, 2018 ) and a guide aiming to facilitate the global understanding of quality as part of universal health coverage aspirations (WHO/OECD/World Bank, 2018 ).

A previous study on quality of care by the European Observatory on Health Systems and Policies (Legido-Quigley et al., 2008 ) noted that the literature on quality of care in health systems was already very extensive and difficult to systematize ten years ago – and this is even truer today. Research is available on a vast range of approaches or strategies for assuring or improving quality of care, often focusing on certain organizations (hospitals, health centres, practices) or particular areas of care (emergency care, maternal care, etc.) (Flodgren, Gonçalves & Pomey, 2016 ; Ivers et al., 2014 ; Houle et al., 2012 ; Gharaveis et al., 2018 ). This body of evidence has contributed to a better understanding of the effectiveness of particular interventions in particular settings for particular groups of patients. However, the available literature rarely addresses the question of the superiority of individual strategies and usually does not provide guidance to policy-makers on which strategy to implement in a particular setting.

In addition, despite the vast literature base and the universal acknowledgement of its importance in health systems, there is no common understanding of the term “quality of care”, and there is disagreement about what it encompasses. The definition of quality often differs across contexts, disciplinary paradigms and levels of analysis. Yet, as prescribed by the seminal work of Avedis Donabedian ( 1980 ), assessing and improving quality predicates an understanding of what it entails. Therefore, the aim of this chapter is to provide clarity about the definition of quality and its relation to health system performance as well as introduce the level of analysis adopted in this book. The chapter concludes with a brief introduction to the aims and the structure of the book.

1.2. Definitions of healthcare quality

Early definitions of healthcare quality were shaped almost exclusively by health professionals and health service researchers. However, there has been increasing recognition that the preferences and views of patients, the public and other key players are highly relevant as well (Legido-Quigley et al., 2008 ). Table 1.1 summarizes some of the most influential definitions of healthcare quality from different contexts, starting with the definition of Donabedian ( 1980 ) and ending with the definition provided by WHO’s handbook for national quality policy and strategy (WHO, 2018 ).

Selected definitions of quality, 1980–2018.

Donabedian defined quality in general terms as “the ability to achieve desirable objectives using legitimate means”. This definition reflects the fact that the term “quality” is not specific to healthcare and is used by many different people in various sectors of society. People use the term quality when they describe a range of positive aspects of hospitals and doctors – but also when they speak about food or cars. In fact, the widespread use of the term quality explains part of the confusion around the concept of healthcare quality when policy-makers or researchers use the term for all kinds of positive or desirable attributes of health systems. However, Donabedian also provides a more specific definition of quality of care, stating that it is “care which is expected to maximize an inclusive measure of patient welfare, after one has taken account of the balance of expected gains and losses that attend the process of care in all its parts” (Donabedian, 1980 ).

Donabedian’s definition is interesting because it specifies that quality of care is related to the process of care in all its parts and that the goal of high-quality care is to maximize patient welfare. Patient welfare certainly includes the health status of the patient (later specified as encompassing physical, physiological and psychological dimensions; see also Donabedian, Wheeler & Wyszewianski, 1982 ). However, the concept of patient welfare is also in line with an approach that considers what patients find important. Furthermore, Donabedian’s definition recognizes the natural limits of quality and its improvement, by highlighting that gains and losses are expected in the process of care.

A decade later the Institute of Medicine (IOM) in the US defined quality of care as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” ( see Table 1.1 ). At first glance, the IOM’s definition’s focus on “health outcomes” seems to be more restrictive than Donabedian’s notion of “patient welfare”. However, in their elaboration of the definition, the IOM specified that these “desired” health outcomes were expected to reflect patient satisfaction and well-being next to broad health status or quality-of-life measures. The IOM’s definition has inspired the understanding of quality by many other organizations in the USA and internationally.

In contrast to other popular definitions of quality in healthcare around that time (including Donabedian’s), which mainly referred to medical or patient care, the IOM’s definition set the focus on health services in general (as “health care implies a broad set of services, including acute, chronic, preventive, restorative, and rehabilitative care, which are delivered in many different settings by many different health care providers”) and on individuals and populations (rather than patients), thus strengthening the link of quality with prevention and health promotion. Finally, the concept of “current professional knowledge” both reinforced the movement for evidence-based care and highlighted that the concept of quality is dynamic and continuously evolving. In that sense, providers can only be assessed against the current state of knowledge as a service that is considered “good quality” at any given time may be regarded as “poor quality” twenty years later in light of newer insights and alternatives.

The definition of quality by the Council of Europe included in Table 1.1 , published seven years after the IOM’s definition as part of the Council’s recommendations on quality improvement systems for EU Member States, is the first to explicitly include considerations about the aspect of patient safety. It argues that quality of care is not only “the degree to which the treatment dispensed increases the patient’s chances of achieving the desired results”, which basically repeats the IOM definition, but it goes on to specify that high-quality care also “diminishes the chances of undesirable results” (The Council of Europe, 1997 ). In the same document the Council of Europe also explicitly defines a range of dimensions of quality of care – but, surprisingly, does not include safety among them.

The final two definitions included in Table 1.1 are from the European Commission ( 2010 ) and from WHO ( 2018 ). In contrast to those discussed so far, both of these definitions describe quality by specifying three main dimensions or attributes: effectiveness, safety and responsiveness or patient-centredness. It is not by chance that both definitions are similar as they were both strongly influenced by the work of the OECD’s Health Care Quality Indicators (HCQI) project (Arah et al., 2006 ; see below). These final two definitions are interesting also because they list a number of further attributes of healthcare and healthcare systems that are related to quality of care, including access, timeliness, equity and efficiency. However, they note that these other elements are either “part of a wider debate” (EC, 2010 ) or “necessary to realize the benefits of quality health care” (WHO, 2018 ), explicitly distinguishing core dimensions of quality from other attributes of good healthcare.

In fact, the dimensions of quality of care have been the focus of considerable debate over the past forty years. The next section focuses on this international discussion around the dimensions of quality of care.

1.3. Dimensions of healthcare quality

As mentioned earlier, Donabedian posited that assessing and improving quality of care presupposes an understanding of what it does and does not entail. Different definitions of quality often specify relatively long lists of various attributes that they recognize as part of quality. Table 1.2 provides an overview of the dimensions of quality mentioned by ten selected definitions (including those in Table 1.1 ).

Quality dimensions in ten selected definitions of quality, 1980–2018.

The table shows that effectiveness, patient safety and responsiveness/patient-centredness seem to have become universally accepted as core dimensions of quality of care. However, many definitions – also beyond those shown in Table 1.2 – include attributes such as appropriateness, timeliness, efficiency, access and equity. This is confusing and often blurs the line between quality of care and overall health system performance. In an attempt to order these concepts, the table classifies its entries into core dimensions of quality, subdimensions that contribute to core dimensions of quality, and other dimensions of health system performance.

This distinction is based on the framework of the OECD HCQI project, which was first published in 2006 (Arah et al., 2006 ). The purpose of the framework was to guide the development of indicators for international comparisons of healthcare quality. The HCQI project selected the three dimensions of effectiveness, safety and patient-centredness as the core dimensions of healthcare quality, arguing that other attributes, such as appropriateness, continuity, timeliness and acceptability, could easily be accommodated within these three dimensions. For example, appropriateness could be mapped into effectiveness, whereas continuity and acceptability could be absorbed into patient-centredness. Accessibility, efficiency and equity were also considered to be important goals of health systems. However, the HCQI team argued – referring to the IOM ( 1990 ) definition – that only effectiveness, safety and responsiveness are attributes of healthcare that directly contribute to “increasing the likelihood of desired outcomes”.

Some definitions included in Table 1.2 were developed for specific purposes and this is reflected in their content. As mentioned above, the Council of Europe ( 1997 ) definition was developed to guide the development of quality improvement systems. Therefore, it is not surprising that it includes the assessment of the process of care as an element of quality on top of accessibility, efficacy, effectiveness, efficiency and patient satisfaction.

In 2001 the IOM published “Crossing the Quality Chasm”, an influential report which specified that healthcare should pursue six major aims: it should be safe, effective, patient-centred, timely, efficient and equitable. These six principles have been adopted by many organizations inside and outside the United States as the six dimensions of quality, despite the fact that the IOM itself clearly set them out as “performance expectations” (“a list of performance characteristics that, if addressed and improved, would lead to better achievement of that overarching purpose. To this end, the committee proposes six specific aims for improvement. Health care should be …”; IOM, 2001 ). For example, WHO ( 2006b ) adapted these principles as quality dimensions in its guidance for making strategic choices in health systems, transforming the concept of timeliness into “accessibility” to include geographic availability and progressivity of health service provision. However, this contributed to the confusion and debate about quality versus other dimensions of performance.

The European Commission’s Expert Panel on Effective Ways for Investing in Health Care also opted for a broad consideration of quality, including the dimensions of appropriateness, equity and efficiency in its recommendations for the future EU agenda on quality of care in 2014 (EC, 2014 ). Similarly, WHO ( 2016 ) used timeliness (as originally described by the IOM) instead of accessibility (as used by WHO in 2006b ), and added integration in healthcare provision as a dimension of high-quality care, in line with the approach taken by the Health Care Council of Canada (Health Care Council of Canada, 2013 ). The understanding of integrated care as part of patient-centredness can also be found in the updated version of the HCQI framework published by the OECD in 2015 (Carinci et al., 2015 ).

This long and inconsistent list of different dimensions inevitably contributes to the confusion about the concept of quality of care. However, conceptual clarity about quality is crucial, as it will influence the types of healthcare policies and strategies that are adopted to improve it. Part of the confusion around the demarcation between quality of care and health system performance originates from insufficiently distinguishing between intermediate and final goals of health systems and between different levels at which quality can be addressed.

The next section aims to provide more clarity about the role of quality in health systems and health systems performance assessment by highlighting the difference between healthcare service quality and healthcare system quality. In so doing, the section sets the background for the way quality is understood in the remainder of the book.

1.4. The role of quality in health systems and health system performance assessment

Numerous frameworks have been developed over the past 20 years with the aim of facilitating a better understanding of health systems and enabling health system performance assessments (Papanicolas, 2013 ; Fekri, Macarayan & Klazinga, 2018 ). Most of these frameworks implicitly or explicitly include quality as an important health system goal but they differ in how they define quality and how they describe its contribution to overall health system goals. A particularly influential framework is the WHO ( 2006a ) “building blocks” framework for health systems strengthening ( see Fig. 1.1 ). The framework conceptualizes health systems in terms of building blocks, including service delivery, health workforce, information, medical products, financing and leadership/governance. In addition, the framework defines quality and safety as intermediate goals of health systems, together with access and coverage. Achievement of these intermediate goals will ultimately contribute to achieving overall health system goals of improved health, responsiveness, financial protection and improved efficiency.

Quality is an intermediate goal of health systems. Source: WHO, 2006

It is worth noting that quality and safety are mentioned separately in the framework, while most of the definitions of quality discussed above include safety as a core dimension of quality. For more information about the relationship between quality and safety, see also Chapter 11 .

As mentioned above, Donabedian defined quality in general terms as “the ability to achieve desirable objectives using legitimate means” (Donabedian, 1980 ). Combining Donabedian’s general definition of quality with the WHO building blocks framework ( Fig. 1.1 ), one could argue that a health system is “of high quality” when it achieves these (overall and intermediate) goals using legitimate means. In addition, Donabedian highlighted that it is important to distinguish between different levels when assessing healthcare quality (Donabedian, 1988 ). He distinguished between four levels at which quality can be assessed – individual practitioners, the care setting, the care received (and implemented) by the patient, and the care received by the community. Others have conceptualized different levels at which policy developments with regard to quality may take place: the health system (or “macro”) level, the organizational (“meso”) level and the clinical (“micro”) level (Øvretveit, 2001 ).

While the exact definition of levels is not important, it is essential to recognize that the definition of quality changes depending on the level at which it is assessed. For simplicity purposes, we condense Donabedian’s four tiers into two conceptually distinct levels ( see Fig. 1.2 ). The first, narrower level is the level of health services, which may include preventive, acute, chronic and palliative care (Arah et al., 2006 ). At this level, there seems to be an emerging consensus that “quality of care is the degree to which health services for individuals and populations are effective, safe and people-centred” (WHO, 2018 ).

Two levels of healthcare quality.

The second level is the level of the healthcare system as a whole. Healthcare systems are “of high quality” when they achieve the overall goals of improved health, responsiveness, financial protection and efficiency. Many of the definitions of healthcare quality included in Table 1.2 seem to be concerned with healthcare system quality as they include these attributes among stated quality dimensions. However, such a broad definition of healthcare quality can be problematic in the context of quality improvement: while it is undoubtedly important to address access and efficiency in health systems, confusion about the focus of quality improvement initiatives may distract attention away from those strategies that truly contribute to increasing effectiveness, safety and patient-centredness of care.

To avoid confusion and achieve conceptual clarity, we therefore propose reserving the use of the term “healthcare quality” for the first level, i.e. the healthcare services level. Concerning the second level, i.e. the health(care) system level, there seems to be an international trend towards using the term “health system performance” to describe the degree to which health systems achieve their overall and intermediate goals.

Frameworks to assess health system performance by the OECD (Carinci, 2015 ) and the European Commission ( 2014 ) include healthcare quality at the service level as a core dimension – besides other elements of performance such as accessibility, efficiency and population health. In other words, health system performance is a better term for health system “quality” (according to Donabedian’s broad definition of the term), and healthcare service quality is one of its core components.

The relationship between quality and the achievement of final health system goals is aptly illustrated in another, relatively recent framework for health system performance comparisons ( Fig. 1.3 ). The framework has condensed the four intermediate goals of the WHO building blocks model into only two: access (including coverage) and quality (including safety). It posits that population health outcomes and system responsiveness depend on the extent to which the entire population has access to care and the extent to which health services are of good quality (i.e. they are effective, safe and patient-centred). The resources, financial or otherwise, required to produce final health system goals determine efficiency in the system.

The link between health system performance and quality of healthcare services. Source: Busse, 2017. Note: *Financial protection is both an enabling condition for access as well as a final outcome.

The framework highlights that health systems have to ensure both access to care and quality in order to achieve the final health system goals. However, it is important to distinguish conceptually between access and quality because very different strategies are needed to improve access (for example, improving financial protection, ensuring geographic availability of providers) than are needed to improve quality of care. This book focuses on quality and explores the potential of different strategies to improve it.

1.5. What are quality improvement strategies? Aims and structure of this book

As mentioned in the Preface, the purpose of the book is to provide a framework for understanding, measuring and ultimately improving the quality of healthcare through a variety of strategies. In general, a strategy can be viewed as an approach or plan that is designed or selected to achieve a desired outcome (for example, attain a goal or reach a solution to a problem). The 2018 WHO Handbook for National Quality Policy and Strategy differentiates between the two titular concepts by underlining that policy refers to an agreed ambition for the health system with an explicit statement of intention, i.e. a “course of action”. Accordingly, it would usually mainly outline broad priorities to be addressed rather than the concrete steps to address them. The corresponding strategy, on the other hand, provides a clear roadmap for achieving these priorities (WHO, 2018 ). In this conceptualization, a number of tools, or interventions, can be used to implement the strategy and aid in the attainment of its milestones.

For the purpose of this book, we use the term “strategy” more narrowly and in a sectoral way to denote a mechanism of action geared towards achieving specific quality assurance or improvement goals by addressing specific targets within healthcare provision (for example, health professionals, provider organizations or health technologies). For example, we consider accreditation of healthcare providers and clinical practice guidelines as quality strategies, whereas the same concepts would be described as “quality interventions”, “quality initiatives”, “quality improvement tools” or “quality improvement activities” elsewhere.

Table 1.3 summarizes a range of selected quality strategies (or interventions) and clusters them into system level strategies, institutional/organizational strategies and patient/community level strategies. This categorization follows the one used by the OECD in its Country Quality Reviews and the recent report on the economics of patient safety (OECD, 2017 ; Slawomirksi, Auraaen & Klazinga, 2017 ). Table 1.3 also includes strategies listed in the 2018 WHO Handbook (WHO, 2018 ), as well as a few others. The strategies discussed in more detail in the second part of this book are marked in grey in the table.

A selection of prominent quality strategies (marked in grey are the strategies discussed in Chapters 5 to 14 of this book).

As becomes evident in Table 1.3 , the focus of this book is on system level and organizational/institutional level strategies. Its aim is to provide guidance to policy-makers who have to make choices about investing political and economic resources into the implementation or scale-up of different options from this vast number of different strategies. The book does not attempt to rank the best quality strategies to be implemented across countries, because different strategies will need to be prioritized depending on the motivation, the identified quality improvement needs and the existing structures or initiatives already in place. Instead, it hopes (1) to provide an overview of the experience with the selected strategies to date in Europe and beyond, (2) to summarize the available evidence on their effectiveness and – where available – cost-effectiveness and the prerequisites for their implementation, and (3) to provide recommendations to policy-makers about how to select and actually implement different strategies.

The book is structured in three parts. Part I includes four chapters and deals with cross-cutting issues that are relevant for all quality strategies. Part II includes ten chapters each dealing with specific strategies. Part III focuses on overall conclusions for policy-makers.

The aim of Part I is to clarify concepts and frameworks that can help policy-makers to make sense of the different quality strategies explored in Part II . Chapter 2 introduces a comprehensive framework that enables a systematic analysis of the key characteristics of different quality strategies. Chapter 3 summarizes different approaches and data sources for measuring quality. Chapter 4 explores the role of international governance and guidance, in particular at EU level, to foster and support quality in European countries.

Part II , comprising Chapters 5 to 14 , provides clearly structured and detailed information about ten of the quality strategies presented in Table 1.3 (those marked in grey). Each chapter in Part II follows roughly the same structure, explaining the rationale of the strategy, exploring its use in Europe and summarizing the available evidence about its effectiveness and cost-effectiveness. This is followed by a discussion of practical aspects related to the implementation of the strategy and conclusions for policy-makers. In addition, each chapter is accompanied by an abstract that follows the same structure as the chapter and summarizes the main points on one or two pages.

Finally, Part III concludes with the main findings from the previous parts of the book, summarizing the available evidence about quality strategies in Europe and providing recommendations for policy-makers.

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• Cite this Page Busse R, Panteli D, Quentin W. An introduction to healthcare quality: defining and explaining its role in health systems. In: Busse R, Klazinga N, Panteli D, et al., editors. Improving healthcare quality in Europe: Characteristics, effectiveness and implementation of different strategies [Internet]. Copenhagen (Denmark): European Observatory on Health Systems and Policies; 2019. (Health Policy Series, No. 53.) 1.
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Frankema, Sander Pieter Gerard. "Quality in trauma care systems." [S.l.] : Rotterdam : [The Author] ; Erasmus University [Host], 2007. http://hdl.handle.net/1765/10548.

Mongado, Blair Coja. "Essays in Child Care Quality." Diss., Virginia Tech, 2007. http://hdl.handle.net/10919/26186.

Yildiz, Ozkan. "A Comprehensive Model For Measuring Health Care Process Quality: Health Care Process Quality Measurement Model (hpqmm)." Phd thesis, METU, 2012. http://etd.lib.metu.edu.tr/upload/12614318/index.pdf.

Fortune, Darla. "An Examination of Quality of Work Life And Quality of Care Within a Health Care Setting." Thesis, University of Waterloo, 2006. http://hdl.handle.net/10012/2798.

Steel, Nicholas. "National Population Evaluation Of Quality Of Health Care: Developing And Using Quality Of Health Care Indicators." Thesis, University of East Anglia, 2008. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.490364.

Svartbo, Boo. "The elusive quality of health care." Doctoral thesis, Umeå universitet, Institutionen för samhällsmedicin och rehabilitering, 2000. http://urn.kb.se/resolve?urn=urn:nbn:se:umu:diva-96909.

Hebert, Christopher J. "Measuring Quality of Care for Hypertension." Case Western Reserve University School of Graduate Studies / OhioLINK, 2009. http://rave.ohiolink.edu/etdc/view?acc_num=case1231883022.

Cronsioe, Carl. "Optimization of Quality in Home Care." Thesis, KTH, Optimeringslära och systemteori, 2017. http://urn.kb.se/resolve?urn=urn:nbn:se:kth:diva-209671.

Kirkegaard, Amy J. "Quality Management in Primary Care Dietetics." Thesis, Griffith University, 2022. http://hdl.handle.net/10072/420903.

Fickel, Jacqueline Jean. "Quality of care assessment : state Medicaid administrators' use of quality information." Full text (PDF) from UMI/Dissertation Abstracts International Access restricted to users with UT Austin EID, 2002. http://wwwlib.umi.com/cr/utexas/fullcit?p3077639.

Chavez, Maria Magdalena. "Improving Diabetes Care in Family Care Practice: A Quality Improvement Project." Diss., The University of Arizona, 2015. http://hdl.handle.net/10150/593612.

Flores, Cristina. "The quality of care in residential care facilities for the elderly." Diss., Search in ProQuest Dissertations & Theses. UC Only, 2007. http://gateway.proquest.com/openurl?url_ver=Z39.88-2004&rft_val_fmt=info:ofi/fmt:kev:mtx:dissertation&res_dat=xri:pqdiss&rft_dat=xri:pqdiss:3261238.

Youn, Kyung II. "ORGANIZATIONAL SLACK, EFFICIENCY, AND QUALITY OF CARE IN ACUTE CARE HOSPITALS." VCU Scholars Compass, 1995. https://scholarscompass.vcu.edu/etd/5059.

Kiessling, Anna. "Quality of care and quality of life in coronary artery disease /." Stockholm, 2005. http://diss.kib.ki.se/2005/91-7140-205-5/.

Habjanic, A. (Ana). "Quality of institutional elderly care in Slovenia." Doctoral thesis, University of Oulu, 2009. http://urn.fi/urn:isbn:9789514291869.

Chana, Navtej. "Quality of care amongst hospital nursing staff." Thesis, University of Oxford, 2010. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.531831.

Williams, Cynthia. "Home Care Quality Effects of Remote Monitoring." Doctoral diss., University of Central Florida, 2014. http://digital.library.ucf.edu/cdm/ref/collection/ETD/id/6383.

Jackson, Anne Margaret. "Explaining hydrotherapy outcomes : quality in health care." Thesis, University of Surrey, 2000. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.324076.

Symons, Nicholas. "Quality of care in emergency general surgery." Thesis, Imperial College London, 2014. http://hdl.handle.net/10044/1/18617.

Lee, Yuna Swatlian Hiratsuka. "Fostering creativity to improve health care quality." Thesis, Yale University, 2017. http://pqdtopen.proquest.com/#viewpdf?dispub=10633255.

Eliciting and evaluating new ideas to improve the quality of health care are important processes for health care organizations. Creativity, which refers to the generation of novel and useful ideas, is required for innovation and is valued by many organizations. Health care staff (e.g., primary care providers, nurses and medical assistants) can be an important source of creative ideas. In my dissertation, I conducted a longitudinal, mixed methods study of 220 improvement ideas generated over 18 months by improvement team members from 12 federally qualified community health centers. I also analyzed the experiences of 2,201 patients cared for by these individuals. I used data from patient surveys, quality improvement team meeting transcripts, staff surveys and wearable sociometric sensors.

Part one of this research draws on organizational theory to develop hypotheses and tests empirically the impact of creative idea implementation on patient care experiences, the relationship between idea creativity and implementation, and moderators of this relationship. Results suggest that the implementation of creative ideas is positively associated with better patient care experiences, but such ideas are less likely to be implemented. Three staff-level characteristics - more collaborative relationships, longer organizational tenure, and higher network centrality (a more central position in the organization's social network) – increase the likelihood that staff's creative ideas will be implemented. Part two of this research assesses the health care staff characteristics associated with idea creativity. The results show that staff with a peripheral perspective on care delivery (behavioral health provider and medical assistant), and staff with lower satisfaction and who have a shorter organizational tenure, are significant correlates of idea creativity. Part three of this dissertation focuses on the tactics that quality improvement leaders use to foster idea creativity, evolution, and implementation in their groups. The results suggest that the leader tactic of brainstorming is associated with groups having more creative, rapidly implemented, low-engagement ideas, which might be an effective tactic for leaders seeking disruptive change. The tactic of group reflection on process is associated with slower implemented, high-engagement ideas, which might help leaders elicit well-considered and deliberated solutions. I develop a conceptual framework for understanding creativity in health care organizations based on these findings, which may help scholars and health care professionals improve their understanding of health care innovation and how better to facilitate the expression and implementation of creative ideas.

This dissertation contributes to health services and organizational research by elucidating how creativity in health care organizations is fostered and facilitated, and how it affects outcomes. Understanding how creative ideas may improve the organization and delivery of quality care could facilitate efforts to discover and evaluate new ideas regarding the quality of health care delivery.

Mee, Jenny. "Australian home care quality : a political tango." Thesis, Federation University Australia, 2020. http://researchonline.federation.edu.au/vital/access/HandleResolver/1959.17/179509.

Lynch, Dorine A. "Basic Quality Care Blood Pressure Teaching Plan." ScholarWorks, 2019. https://scholarworks.waldenu.edu/dissertations/7821.

Magner, MaryBeth. "The Effects of Managed Care on the Quality of Dental Hygiene Care." TopSCHOLAR®, 1998. http://digitalcommons.wku.edu/theses/344.

Daskein, Robyn. "Nursing Documentation and Quality of Care in Residential Aged Care in Queensland." Thesis, Griffith University, 2008. http://hdl.handle.net/10072/367277.

Glover, Gloria. "Relationships Between Nursing Resources, Uncompensated Care, Hospital Profitability, and Quality of Care." ScholarWorks, 2019. https://scholarworks.waldenu.edu/dissertations/7142.

Noble, Marilynn. "Integrating Health Care Systems to Maintain Quality Care and to Manage Cost." ScholarWorks, 2019. https://scholarworks.waldenu.edu/dissertations/6851.

Wallace, Amanda. "Effects of Telemedicine in the Intensive Care Unit on Quality of Care." ScholarWorks, 2015. https://scholarworks.waldenu.edu/dissertations/1612.

Gunnarsdottir, Sigrun. "Quality of working life and quality of care in Icelandic hospital nursing." Thesis, London School of Hygiene and Tropical Medicine (University of London), 2006. http://researchonline.lshtm.ac.uk/682349/.

English, Christine. "Judging quality : parents' perspectives of the quality of their child's hospital care." Thesis, Northumbria University, 2017. http://nrl.northumbria.ac.uk/31608/.

Senot, Claire. "Combining Conformance Quality and Experiential Quality in the Delivery of Health Care." The Ohio State University, 2014. http://rave.ohiolink.edu/etdc/view?acc_num=osu1397407599.

Prater, Laura C. prater. "Advance Care Planning: Implications for Health Care Quality at the End of Life." The Ohio State University, 2018. http://rave.ohiolink.edu/etdc/view?acc_num=osu1534344349446923.

Parand, Anam. "The role of acute care managers in quality of care and patient safety." Thesis, Imperial College London, 2013. http://hdl.handle.net/10044/1/11677.

Newell, Amy Noël Abell Ellen Elizabeth. "Quality in family child care the voice of the family child care provider /." Auburn, Ala, 2009. http://hdl.handle.net/10415/1632.

Kocman, David. "Quality matters : re-formatting the boundaries of care in Czech social care policy." Thesis, University of Kent, 2013. https://kar.kent.ac.uk/47654/.

O'Connor, Pauline. "Providing quality care : exploring contextual influences and ethical issues inherent in the delivery of quality care for people with dementia." Thesis, University of Edinburgh, 2006. http://hdl.handle.net/1842/29304.

Martin, Sedeeka. "Quality care during childbirth at a midwife obstetric unit in Cape Town, Western Cape: Women and midwives’ perceptions." University of the Western Cape, 2018. http://hdl.handle.net/11394/6892.

D'Ambruoso, Lucia. "Care in obstetric emergencies : quality of care, access to care and participation in health in rural Indonesia." Thesis, University of Aberdeen, 2011. http://digitool.abdn.ac.uk:80/webclient/DeliveryManager?pid=165859.

Plauché, Leneé Michele. "Eliminating waste in US health care: evaluating accountable care organizations as a model for quality sustainable care." Thesis, Boston University, 2013. https://hdl.handle.net/2144/12191.

Whiteford, Chrystal Michelle. "Early child care in Australia : quality of care, experiences of care and developmental outcomes for Australian children." Thesis, Queensland University of Technology, 2015. https://eprints.qut.edu.au/81298/1/Chrystal_Whiteford_Thesis.pdf.

Urassa, David Paradiso. "Quality Aspects of Maternal Health Care in Tanzania." Doctoral thesis, Uppsala : Acta Universitatis Upsaliensis : Univ.-bibl. [distrubutör], 2004. http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-4221.

Petersson, Håkan. "On information quality in primary health care registries /." Linköping : Univ, 2003. http://www.bibl.liu.se/liupubl/disp/disp2003/tek805s.pdf.

Ekström, Anette. "Amning och vårdkvalitet = Breastfeeding and quality of care /." Stockholm, 2005. http://diss.kib.ki.se/2005/91-7140-240-3/.

Murton, Catherine S. "Profiling the quality of end of life care." Connect to this title online, 2007. http://etd.lib.clemson.edu/documents/1202410105/.

Momanyi, Kevin. "Enhancing quality in social care through economic analysis." Thesis, University of Aberdeen, 2019. http://digitool.abdn.ac.uk:80/webclient/DeliveryManager?pid=240815.

Mycroft, Matthew. "An Information System for Health Care Quality Measures." Digital Commons at Loyola Marymount University and Loyola Law School, 2016. https://digitalcommons.lmu.edu/etd/426.

Scharpf, Tanya Pollack M. S. "Functional Status and Quality in Home Health Care." Case Western Reserve University School of Graduate Studies / OhioLINK, 2005. http://rave.ohiolink.edu/etdc/view?acc_num=case1112905040.

Minich, Lisa. "Quality of Diabetes Care: Linking Processes to Outcomes." University of Cincinnati / OhioLINK, 2010. http://rave.ohiolink.edu/etdc/view?acc_num=ucin1291051784.

Lee, Hyang Yuol. "Quality of care: Impact of nursing home characteristics." Diss., Search in ProQuest Dissertations & Theses. UC Only, 2009. http://gateway.proquest.com/openurl?url_ver=Z39.88-2004&rft_val_fmt=info:ofi/fmt:kev:mtx:dissertation&res_dat=xri:pqdiss&rft_dat=xri:pqdiss:3352465.

Mattila, Marja-Leena. "Quality-related outcome of pediatric dental health care." Turku : Turun Yliopisto, 2001. http://catalog.hathitrust.org/api/volumes/oclc/48714198.html.

Hutchinson, Allen. "Exploring safety, quality and resilience in health care." Thesis, University of Sheffield, 2014. http://etheses.whiterose.ac.uk/6574/.

Research Topics & Ideas: Healthcare

100+ Healthcare Research Topic Ideas To Fast-Track Your Project

Finding and choosing a strong research topic is the critical first step when it comes to crafting a high-quality dissertation, thesis or research project. If you’ve landed on this post, chances are you’re looking for a healthcare-related research topic , but aren’t sure where to start. Here, we’ll explore a variety of healthcare-related research ideas and topic thought-starters across a range of healthcare fields, including allopathic and alternative medicine, dentistry, physical therapy, optometry, pharmacology and public health.

NB – This is just the start…

The topic ideation and evaluation process has multiple steps . In this post, we’ll kickstart the process by sharing some research topic ideas within the healthcare domain. This is the starting point, but to develop a well-defined research topic, you’ll need to identify a clear and convincing research gap , along with a well-justified plan of action to fill that gap.

If you’re new to the oftentimes perplexing world of research, or if this is your first time undertaking a formal academic research project, be sure to check out our free dissertation mini-course. In it, we cover the process of writing a dissertation or thesis from start to end. Be sure to also sign up for our free webinar that explores how to find a high-quality research topic.

Overview: Healthcare Research Topics

• Allopathic medicine
• Alternative /complementary medicine
• Veterinary medicine
• Physical therapy/ rehab
• Optometry and ophthalmology
• Pharmacy and pharmacology
• Public health
• Examples of healthcare-related dissertations

Allopathic (Conventional) Medicine

• The effectiveness of telemedicine in remote elderly patient care
• The impact of stress on the immune system of cancer patients
• The effects of a plant-based diet on chronic diseases such as diabetes
• The use of AI in early cancer diagnosis and treatment
• The role of the gut microbiome in mental health conditions such as depression and anxiety
• The efficacy of mindfulness meditation in reducing chronic pain: A systematic review
• The benefits and drawbacks of electronic health records in a developing country
• The effects of environmental pollution on breast milk quality
• The use of personalized medicine in treating genetic disorders
• The impact of social determinants of health on chronic diseases in Asia
• The role of high-intensity interval training in improving cardiovascular health
• The efficacy of using probiotics for gut health in pregnant women
• The impact of poor sleep on the treatment of chronic illnesses
• The role of inflammation in the development of chronic diseases such as lupus
• The effectiveness of physiotherapy in pain control post-surgery

Topics & Ideas: Alternative Medicine

• The benefits of herbal medicine in treating young asthma patients
• The use of acupuncture in treating infertility in women over 40 years of age
• The effectiveness of homoeopathy in treating mental health disorders: A systematic review
• The role of aromatherapy in reducing stress and anxiety post-surgery
• The impact of mindfulness meditation on reducing high blood pressure
• The use of chiropractic therapy in treating back pain of pregnant women
• The efficacy of traditional Chinese medicine such as Shun-Qi-Tong-Xie (SQTX) in treating digestive disorders in China
• The impact of yoga on physical and mental health in adolescents
• The benefits of hydrotherapy in treating musculoskeletal disorders such as tendinitis
• The role of Reiki in promoting healing and relaxation post birth
• The effectiveness of naturopathy in treating skin conditions such as eczema
• The use of deep tissue massage therapy in reducing chronic pain in amputees
• The impact of tai chi on the treatment of anxiety and depression
• The benefits of reflexology in treating stress, anxiety and chronic fatigue
• The role of acupuncture in the prophylactic management of headaches and migraines

Topics & Ideas: Dentistry

• The impact of sugar consumption on the oral health of infants
• The use of digital dentistry in improving patient care: A systematic review
• The efficacy of orthodontic treatments in correcting bite problems in adults
• The role of dental hygiene in preventing gum disease in patients with dental bridges
• The impact of smoking on oral health and tobacco cessation support from UK dentists
• The benefits of dental implants in restoring missing teeth in adolescents
• The use of lasers in dental procedures such as root canals
• The efficacy of root canal treatment using high-frequency electric pulses in saving infected teeth
• The role of fluoride in promoting remineralization and slowing down demineralization
• The impact of stress-induced reflux on oral health
• The benefits of dental crowns in restoring damaged teeth in elderly patients
• The use of sedation dentistry in managing dental anxiety in children
• The efficacy of teeth whitening treatments in improving dental aesthetics in patients with braces
• The role of orthodontic appliances in improving well-being
• The impact of periodontal disease on overall health and chronic illnesses

Tops & Ideas: Veterinary Medicine

• The impact of nutrition on broiler chicken production
• The role of vaccines in disease prevention in horses
• The importance of parasite control in animal health in piggeries
• The impact of animal behaviour on welfare in the dairy industry
• The effects of environmental pollution on the health of cattle
• The role of veterinary technology such as MRI in animal care
• The importance of pain management in post-surgery health outcomes
• The impact of genetics on animal health and disease in layer chickens
• The effectiveness of alternative therapies in veterinary medicine: A systematic review
• The role of veterinary medicine in public health: A case study of the COVID-19 pandemic
• The impact of climate change on animal health and infectious diseases in animals
• The importance of animal welfare in veterinary medicine and sustainable agriculture
• The effects of the human-animal bond on canine health
• The role of veterinary medicine in conservation efforts: A case study of Rhinoceros poaching in Africa
• The impact of veterinary research of new vaccines on animal health

Topics & Ideas: Physical Therapy/Rehab

• The efficacy of aquatic therapy in improving joint mobility and strength in polio patients
• The impact of telerehabilitation on patient outcomes in Germany
• The effect of kinesiotaping on reducing knee pain and improving function in individuals with chronic pain
• A comparison of manual therapy and yoga exercise therapy in the management of low back pain
• The use of wearable technology in physical rehabilitation and the impact on patient adherence to a rehabilitation plan
• The impact of mindfulness-based interventions in physical therapy in adolescents
• The effects of resistance training on individuals with Parkinson’s disease
• The role of hydrotherapy in the management of fibromyalgia
• The impact of cognitive-behavioural therapy in physical rehabilitation for individuals with chronic pain
• The use of virtual reality in physical rehabilitation of sports injuries
• The effects of electrical stimulation on muscle function and strength in athletes
• The role of physical therapy in the management of stroke recovery: A systematic review
• The impact of pilates on mental health in individuals with depression
• The use of thermal modalities in physical therapy and its effectiveness in reducing pain and inflammation
• The effect of strength training on balance and gait in elderly patients

Topics & Ideas: Optometry & Opthalmology

• The impact of screen time on the vision and ocular health of children under the age of 5
• The effects of blue light exposure from digital devices on ocular health
• The role of dietary interventions, such as the intake of whole grains, in the management of age-related macular degeneration
• The use of telemedicine in optometry and ophthalmology in the UK
• The impact of myopia control interventions on African American children’s vision
• The use of contact lenses in the management of dry eye syndrome: different treatment options
• The effects of visual rehabilitation in individuals with traumatic brain injury
• The role of low vision rehabilitation in individuals with age-related vision loss: challenges and solutions
• The impact of environmental air pollution on ocular health
• The effectiveness of orthokeratology in myopia control compared to contact lenses
• The role of dietary supplements, such as omega-3 fatty acids, in ocular health
• The effects of ultraviolet radiation exposure from tanning beds on ocular health
• The impact of computer vision syndrome on long-term visual function
• The use of novel diagnostic tools in optometry and ophthalmology in developing countries
• The effects of virtual reality on visual perception and ocular health: an examination of dry eye syndrome and neurologic symptoms

Topics & Ideas: Pharmacy & Pharmacology

• The impact of medication adherence on patient outcomes in cystic fibrosis
• The use of personalized medicine in the management of chronic diseases such as Alzheimer’s disease
• The effects of pharmacogenomics on drug response and toxicity in cancer patients
• The role of pharmacists in the management of chronic pain in primary care
• The impact of drug-drug interactions on patient mental health outcomes
• The use of telepharmacy in healthcare: Present status and future potential
• The effects of herbal and dietary supplements on drug efficacy and toxicity
• The role of pharmacists in the management of type 1 diabetes
• The impact of medication errors on patient outcomes and satisfaction
• The use of technology in medication management in the USA
• The effects of smoking on drug metabolism and pharmacokinetics: A case study of clozapine
• Leveraging the role of pharmacists in preventing and managing opioid use disorder
• The impact of the opioid epidemic on public health in a developing country
• The use of biosimilars in the management of the skin condition psoriasis
• The effects of the Affordable Care Act on medication utilization and patient outcomes in African Americans

Topics & Ideas: Public Health

• The impact of the built environment and urbanisation on physical activity and obesity
• The effects of food insecurity on health outcomes in Zimbabwe
• The role of community-based participatory research in addressing health disparities
• The impact of social determinants of health, such as racism, on population health
• The effects of heat waves on public health
• The role of telehealth in addressing healthcare access and equity in South America
• The impact of gun violence on public health in South Africa
• The effects of chlorofluorocarbons air pollution on respiratory health
• The role of public health interventions in reducing health disparities in the USA
• The impact of the United States Affordable Care Act on access to healthcare and health outcomes
• The effects of water insecurity on health outcomes in the Middle East
• The role of community health workers in addressing healthcare access and equity in low-income countries
• The impact of mass incarceration on public health and behavioural health of a community
• The effects of floods on public health and healthcare systems
• The role of social media in public health communication and behaviour change in adolescents

Examples: Healthcare Dissertation & Theses

While the ideas we’ve presented above are a decent starting point for finding a healthcare-related research topic, they are fairly generic and non-specific. So, it helps to look at actual dissertations and theses to see how this all comes together.

Below, we’ve included a selection of research projects from various healthcare-related degree programs to help refine your thinking. These are actual dissertations and theses, written as part of Master’s and PhD-level programs, so they can provide some useful insight as to what a research topic looks like in practice.

• Improving Follow-Up Care for Homeless Populations in North County San Diego (Sanchez, 2021)
• On the Incentives of Medicare’s Hospital Reimbursement and an Examination of Exchangeability (Elzinga, 2016)
• Managing the healthcare crisis: the career narratives of nurses (Krueger, 2021)
• Methods for preventing central line-associated bloodstream infection in pediatric haematology-oncology patients: A systematic literature review (Balkan, 2020)
• Farms in Healthcare: Enhancing Knowledge, Sharing, and Collaboration (Garramone, 2019)
• When machine learning meets healthcare: towards knowledge incorporation in multimodal healthcare analytics (Yuan, 2020)
• Integrated behavioural healthcare: The future of rural mental health (Fox, 2019)
• Healthcare service use patterns among autistic adults: A systematic review with narrative synthesis (Gilmore, 2021)
• Mindfulness-Based Interventions: Combatting Burnout and Compassionate Fatigue among Mental Health Caregivers (Lundquist, 2022)
• Transgender and gender-diverse people’s perceptions of gender-inclusive healthcare access and associated hope for the future (Wille, 2021)
• Efficient Neural Network Synthesis and Its Application in Smart Healthcare (Hassantabar, 2022)
• The Experience of Female Veterans and Health-Seeking Behaviors (Switzer, 2022)
• Machine learning applications towards risk prediction and cost forecasting in healthcare (Singh, 2022)
• Does Variation in the Nursing Home Inspection Process Explain Disparity in Regulatory Outcomes? (Fox, 2020)

Looking at these titles, you can probably pick up that the research topics here are quite specific and narrowly-focused , compared to the generic ones presented earlier. This is an important thing to keep in mind as you develop your own research topic. That is to say, to create a top-notch research topic, you must be precise and target a specific context with specific variables of interest . In other words, you need to identify a clear, well-justified research gap.

Need more help?

If you’re still feeling a bit unsure about how to find a research topic for your healthcare dissertation or thesis, check out Topic Kickstarter service below.

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15 Comments

I need topics that will match the Msc program am running in healthcare research please

Hello Mabel,

I can help you with a good topic, kindly provide your email let’s have a good discussion on this.

Can you provide some research topics and ideas on Immunology?

Thank you to create new knowledge on research problem verse research topic

Help on problem statement on teen pregnancy

This post might be useful: https://gradcoach.com/research-problem-statement/

can you provide me with a research topic on healthcare related topics to a qqi level 5 student

Please can someone help me with research topics in public health ?

Hello I have requirement of Health related latest research issue/topics for my social media speeches. If possible pls share health issues , diagnosis, treatment.

I would like a topic thought around first-line support for Gender-Based Violence for survivors or one related to prevention of Gender-Based Violence

Please can I be helped with a master’s research topic in either chemical pathology or hematology or immunology? thanks

Can u please provide me with a research topic on occupational health and safety at the health sector

Good day kindly help provide me with Ph.D. Public health topics on Reproductive and Maternal Health, interventional studies on Health Education

may you assist me with a good easy healthcare administration study topic

May you assist me in finding a research topic on nutrition,physical activity and obesity. On the impact on children

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Health Spending

Quality of care.

Access & Affordability

Health & Wellbeing

• Price Transparency
• Affordability
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How does the quality of the U.S. health system compare to other countries?

By Imani Telesford,  Emma Wager Twitter ,  Krutika Amin , and  Cynthia Cox   KFF

October 23, 2023

• Introduction

Despite spending more money per capita on healthcare than any similarly large and wealthy nation, the United States has a lower life expectancy than peer nations and has seen worsening health outcomes since the onset of the COVID-19 pandemic.  

This chart collection combines various measures of quality of care in the United States and other large, high-income nations to show how the U.S. stacks up against its peers and how that has changed over time. While inconsistent and imperfect metrics make it difficult to firmly assess system-wide health quality, measures of long-term health outcomes, treatment outcomes, patient safety, and patient experiences suggest the U.S. health system provides lower-quality care than its peers. The U.S. performs worse in long- term health outcomes measures (such as life expectancy), certain treatment outcomes (such as maternal mortality and congestive heart failure hospital admissions), some patient safety measures (such as obstetric trauma with instrument and medication or treatment errors), and patient experiences of not getting care due to cost. The U.S. performs similarly to or better than peer nations in other  measures of treatment outcomes (such as mortality rates within 30 days of acute hospital treatment) and patient safety (such as rates of post – operative sepsis).  

Long-Term Health Outcomes

Life expectancy continued to drop in the u.s. in 2021 while rebounding in most peer countries.

As discussed in more detail in a   separate brief , life expectancy at birth was similar in the U.S. and peer countries on average in 1980 (73.7 and 74.5 years, respectively), but the gap has grown substantially in the following decades, as peer nations saw more rapid improvement in life expectancy than the U.S. The COVID-19 pandemic further widened this gap, and life expectancy in 2021 was 6 years shorter in the U.S. than in peer countries (76.4 years in the U.S. and averaged 82.3 years in comparable countries, on average).  

The above data are period life expectancy estimates, based on excess mortality observed in each year. The period life expectancy at birth represents the mortality experience of a hypothetical cohort if current conditions persisted into the future, not the mortality experience of a birth cohort.

Since the pandemic, the gap in mortality rates between the U.S. and comparable countries has widened

A ll-cause mortality rates — the number of deaths per 100,000 people, adjusted for age differences across countries — plateaued in the U.S. in the 2010s, while continuing to fall in other peer nations . From 19 80 to 2020 (the latest year with comparable data), the overall mortality rate from all causes of death in the U.S. fell by about 19%, compared to a 43% decline in peer countries.  

The COVID-19 pandemic resulted in increased mortality across most nations, though the U.S. saw a significantly higher increase than many other countries. The gap in mortality rates between the United States and peer nations was at its highest point in 2020.  

Premature death rates in the U.S. continue to be higher than in comparable countries

In addition to overall mortality rates, the “years of life lost” metric marks the extent of premature deaths within a population by providing more weight to deaths at younger ages. The U.S. and comparable OECD countries have made progress in  reducing years of life lost from 1990 to 2019 (down 24% and 42%, respectively), although the gap between the U.S. and comparable countries has increased over time.  

The U.S. had the highest increase in premature deaths due the pandemic in 2020 and 2021. The per capita premature excess death rate in the U.S. was over twice as high as the next closest peer country, the U.K. The higher rate of new premature deaths in the U.S. compared to peer countries was driven in part by racial disparities within the U.S. The premature excess death rates for American Indian and Alaska Native, Black, Hispanic, and Native Hawaiian and other Pacific Islander populations in the U.S. were 3 times higher than the rates among White or Asian populations . The U.S. health system consistently results in higher rates of mortality and premature deaths among people of color.  

Children and teens in the U.S. are less likely to make it to adulthood than in peer countries, with the U.S having higher rates of motor vehicle accidents, firearm deaths , and suicide deaths among children and teens.  

Disease burden, which accounts for both premature death and years living with disability, is often measured using disability adjusted life years (DALYs).  As of 2019 — the most recent year with available data — DALYs  have declined in the U.S. and comparable countries since 2000, though the U.S. continued to have higher age-adjusted disease burden rates than peer countries. In 2019, the DALY rate was 37% higher in the U.S. than in comparable countries, on average.  

Related Content:

COVID-19 leading cause of death ranking

Racial disparities in premature deaths during the COVID-19 pandemic

Treatment outcomes, 30-day mortality for strokes is lower in the u.s. than in comparable countries, on average.

Mortality within 30 days of being admitted to a hospital is not entirely preventable, but high quality of care can reduce the mortality rate for certain diagnoses. The 30-day mortality rates after hospital admissions for heart attacks (acute myocardial infarction) and hemorrhagic stroke (caused by bleeding) are similar in the U.S. and comparable countries average . The 30-day mortality rates for ischemic strokes (caused by blood clots) was 4. 3 deaths per 100 patients in the U.S. in 20 20 , compared to an average of 6. 2 deaths per 100 patients in similar countries. While the U.S. has lower rates of mortality due to these conditions than the average across peer nation s , it is important to note that several peer nations have lower rates than the U.S.  

Maternal mortality rates in the U.S. have risen over time and are much higher than in peer countries

While wealth and economic prosperity are highly correlated with lower maternal mortality rates, the U.S. is an outlier with the highest rate of pregnancy-related deaths (23.8 deaths per 100,000 live births in 2020) when compared to similar countries (3.6 deaths per 100,000 live births).  

Within the U.S., there are significant racial disparities in maternal mortality rates. The m aternal mortality rate for Black mothers is about 3 times the rate for White mothers — a disparity that persists across age and socioeconomic groups .  Every race and ethnicity, socioeconomic, and age group in the United States sees higher maternal mortality rates than the average in comparable countries. Maternal mortality in the U.S. has risen in recent years, sparking concern from the medical community and regulators.   

Premature mortality during COVID-19 in the U.S. and peer countries

Hospital admissions for diabetes and congestive heart failure were more frequent in the u.s. than average across comparable countries.

Hospital admissions for certain chronic diseases, such as cardiac conditions, chronic obstructive pulmonary diseases (COPD), asthma, and diabetes, can arise for a variety of reasons, but preventive services — or lack thereof — play a large role . Hospital admission rates in the U.S. are higher than in comparable countries for congestive heart failure and complications due to diabetes, and some admissions for these chronic conditions could be minimized with adequate primary care. Admission rates in 2020 are likely impacted by the COVID-19 pandemic —  patients were less likely to seek hospital treatment, and hospitals were at times overwhelmed and unable to admit pat ients who would have been admitted in a different year .     

More cesarean sections are performed in the U.S. than in comparable countries

Cesarean sections are one of the most commonly  performed surgical procedures in the U.S. and have become a key indicator of quality of care in maternal health. Cesarean sections can be lifesaving — however, when they are not medically indicated, they can pose unnecessary   risks   for mothers, including an increased chance of blood clots, infections, and other complications that require further surgery.  

The U.S. has consistently had higher cesarean section rates than most of its peers, though rates have decreased slightly in recent years. In 2021, the rate of cesarean sections per 1,000 live births was 321 in the U.S. and an average of 267 in comparable countries.  

Patient Safety

Obstetric trauma during vaginal delivery is more common in the u.s. than in most comparable countries, especially when instruments are involved.

Obstetric trauma is more likely to occur in deliveries where instruments are utilized (i.e., forceps). The rate of obstetric trauma during deliveries with an instrument in the U.S. was 11.7 per 100 vaginal deliveries in 2020, higher than most comparable countries with available data. The rate of obstetric trauma during deliveries without an instrument in the U.S. was 1.7 per 100 vaginal deliveries in 2020, on the lower end among comparable countries with available data.  

Post-operative complications — such as pulmonary embolism or deep vein thrombosis — are more common in the U.S. than most peer countries

Rates of post-operative complications are an important measure of hospital safety. Pulmonary embolisms and deep vein thrombosis are common complications after major surgeries, such as hip or knee replacement. The prevalence of post-operative clots for these procedures is higher in the U.S. than in the U.K., Sweden, Belgium, and the Netherlands, but lower than in Australia.  

Post-operative sepsis is less common in the U.S. than in most peer countries

Sepsis is a serious complication for patients with infections, and effects can range from organ failure and shock to death in severe cases. Rates of post-operative infections and sepsis are an important marker of care quality for patients undergoing surgery, because this is a major source of morbidity and mortality that can sometimes be prevented. Prevention is multifactorial and can involve proper operative techniques and training, hygiene and safety protocols, and antibiotic utilization , amongst other things. The rate of post-operative sepsis following abdominal surgery is just under 2 % in the U.S., lower than in most peer countries that report data.  

The U.S. has higher rates of reported medication and treatment errors than most comparable countries

Patients in the U.S. are more likely than those in comparable countries to report experiencing a medication or medical error at some point during their care, according to a  survey  by the Commonwealth Fund. In this case, medication errors include being given the wrong medication or dose, and treatment errors indicate that people thought a medical mistake had been made in their treatment or care. In 2020, 12.6% of patients in the U.S. experienced a medical error compared to 11.4% of patients in similar countries.  

Among peer countries, the U.S. had the lowest rate of retained surgical item or unretrieved device fragments in 2020

Unintentionally retained items or device fragments following surgical procedures can result in pain, infection and even life-threatening consequences for patients. The U.S. has the lowest rate of retained surgical item s or unretrieved device fragment s in 2020 , at 1.6 per 100,000 surgical hospital discharges,  compared to a n average rate of 8. 2 per 100,000 surgical hospital discharges in comparable countries.   

Patient Experiences

The u.s. has higher rates of consultations missed due to costs than comparable countries in 2020.

Patients in the U.S. are more likely to experience missed consultations with their provider due to costs. In 2020, the rate of consultations missed due to costs in the U.S. was 26.8 per 100 patients , compared to 7.0 per 100 patients on average in comparable nations for the same year. When patients choose not to meet with their physicians due to cost or any other reason, it can lead to worse health outcomes and more expensive care needed at later points in the patient’s life.   

There are limited comparable measures of quality available. Among measures we can compare, the U.S. performs similarly or better than its peers for when intensive, acute care is required, such as for 30-day mortality after heart attack or stroke admissions. However, for long-term health measures and conditions where care coordination or public health efforts may improve outcomes (for example, maternal outcomes or chronic condition hospitalization rates), the U.S. consistently falls short. Of particular concern, outcomes measures such as all-cause mortality, maternal mortality, and years of life lost have stagnated or worsened in the U.S. in recent years, even as peer nations have seen improvement in these metrics.   

Throughout this chart collection, measures such as long-term health outcomes, treatment outcomes, patient safety, and patient experiences are used as a proxy to analyze the quality of health systems in the U.S. and 11 other countries identified as similarly wealthy based on total GDP and GDP per capita. While these indicators allow for cross-country comparisons, they do not necessarily provide a comprehensive overview of the quality of each country’s respective health system. Additional indicators can be used to provide further insight into the quality of countries’ health systems. However, country specific differences in population health, payment systems, survey metrics/methods, and demographics present barriers to cross country comparisons.    

Most data used here are sourced from the Organization for Economic Co-operation and Development (OECD), which compiles health quality statistics and data from member nations.  

All cause age-adjusted mortality data was interpolated for the U.K. in 2000 and Australia in 2005 due to unavailable data.  

How does U.S. life expectancy compare to other countries?

The state of the U.S. health system in 2022 and the outlook for 2023

C-section data is not available for Belgium and Sweden from 2000-2004, Switzerland from 2000-2001, Belgium from 2015 and the Netherlands from 2011 and 2020; 2021 data is not yet available for Australia, Canada, the Netherlands and the United Kingdom. Data points are interpolated for the comparable country average in those years.  

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• Peter McCulloch
• Nuffield Department of Surgical Science , Oxford University , Oxford , UK
• Correspondence to Peter McCulloch, Nuffield Department of Surgery, Oxford University, Oxford OX3 9DU, UK; peter.mcculloch{at}nds.ox.ac.uk

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• Healthcare quality improvement
• Human factors

Reducing harm in hospital care using Human Factors and Quality Improvement approaches has proved harder than expected: better evaluation of our efforts, a more realistic understanding of the challenges we face and an intense focus on engaging staff are the key elements needed for progress.

Patient safety was not a recognised term in medical research parlance until the 1990s. Prior to this, avoidable harm from treatment was assumed to be rare, and failure was commonly attributed to the incompetence or lack of diligence of individuals. The emergence of convincing evidence that around 10% of hospital inpatients suffered serious harm from their treatment stimulated alarm, and a search for a rapid solution to this huge, previously unnoticed problem. 1 Analyses of adverse events showed that their causes were usually complex, system-based and to some extent stochastic, echoing the typical findings of professional accident investigations in the transport and energy sectors. It seemed likely that systematic analysis of the underlying problems would result in effective solutions which could drastically reduce harm from treatment, and the concept of the high reliability organisation became hugely popular. 2 Following the lead of civil aviation, healthcare professionals became enthusiastic about using ergonomics (Human Factors science) to solve the safety problem. Decades on, progress has been incremental, and studies of harm show results not dissimilar to those from the 1990s. 3 4

So why are we not there yet?

There are several answers to this question. I focus here on the ones I think are most important, respectfully recognising the subjectivity in my position. First, there is a difference in the commitment of management and policymakers at the most senior level in healthcare when compared with leaders in airline companies and fossil fuel producers, for whom the massive financial consequences of a major accident were ever-present in safety decision-making. Second, the Human Factors approaches we tried to adopt from other industries had developed organically over time to fit particular contexts, and over-literal translation to healthcare environments was often a poor fit. 5 Third, our evaluation of our own efforts has been consistently weak, making it hard to learn the right lessons. Finally and importantly, the modern healthcare industry, by its very nature, poses underlying wicked problems of interaction between structure and culture, which make change very hard. I describe each of these in turn below. Some points in this viewpoint are well-evidenced, while others are based on experience and perceptions, but I hope that the arguments provide a helpful and potentially creative opportunity for readers to react and reflect.

Management and relentless organisational pressures

Human factors: the can of worms.

Innovators cannot be held accountable for not finding the perfect solution immediately—this is rare in any context. Human Factors researchers started by standardising processes, adopting checklists and modifying a team training philosophy from civil aviation to improve team communication and co-operation. 7 8 They were immediately faced with questions to which only trial and error could provide answers. What is the correct dose and duration for team training? Should we try to standardise everything across the system or focus on key events? How do we measure success? How do we ensure compliance? Is there data to show change? Is it better to fix the system by standardising or to improve team relationships and effectiveness? We found that if we tried to fix every problem, the complexity of the solution and the resource requirements defeated us. If we focused too narrowly, our impact on patient outcome was small. Team training approaches designed for aviation produced measurable effects on internal team process and function, but the impact on patient outcomes remains hard to demonstrate. 9 A striking and repeated finding was that staff engagement with the intended changes was highly variable and often weak. 10

Some lessons learnt from other fields were applicable and helpful. The importance of codesign of changes with frontline staff and the value of short iterative cycles of experimentation were products of the ‘lean’ Quality Improvement philosophy, which had some remarkable successes and underpins the work of several successful healthcare quality and safety organisations. Not surprisingly, combining attempts to improve teamwork with systems redesign seemed to do better than either alone. 11 The research community gradually realised that we were dealing more with a sociocultural challenge than with a technical problem in process design. This refocused interest in the patient safety field onto culture and how to change it—but no reliably effective, evidence-based, generalisable solutions to this age-old question have yet emerged from our work.

(Not) doing the science right

Measuring the effects of complex interventions on human work processes is challenging by its nature, and we have not helped ourselves by doing it much less well than we could have. Changes to complex processes need first to be trialled and iteratively improved, then tested in a wide range of settings before they can undergo a definitive evaluation of their benefit, and we have rarely followed this kind of stepwise evaluation pathway in patient safety work. 12 The impact of some of the most important major initiatives has been blunted by study designs which have left the validity of their claims uncertain. The pivotal study on the WHO surgical checklist was a short term, open label, non-randomised before–after comparison with evaluation performed by the team carrying out the study. 7 , 12 13 A subsequent observational whole-system study in Canada showed no benefit, and a later, better designed study showed no significant mortality reduction. 13 14 The largest ever study of teamwork training compared trained and untrained units halfway through a multihospital programme, but selected units for training priority on the basis of ‘readiness’, thus introducing major bias. 15 Randomised studies have been dismissed as impossible by leading figures in this field, but several have been done—and like randomised studies in other fields have tended to disappoint their authors. This often reflects the lack of support for adequate stepwise preparatory studies to ensure that the RCT is feasible. 12 Even having an independent control group is uncommon—and in the rare cases, where it has been done has demonstrated its value in reducing overoptimistic interpretation of results. 16 The value of parallel qualitative process evaluation was initially ignored, but where it has been done, the insights into why things worked or did not have often been compelling. 17 Clearly, we need to do better science to make better progress. It may be more expensive, but if it yields more reliable answers, we may end up getting there faster in the long run.

The wicked problems: complexity, pressure and culture

This brings us to the wicked problems, which are interlinked. Healthcare staff attitudes, organisational structures and the stress of constant high demand can interact to produce a culture of fear, risk aversion, denial and arrogance, as reported in numerous investigations of systemic failures in hospital care. How does this happen? The rigid hierarchical management structure noted above is an understandable response to the need to maintain activity constantly near the theoretical maximum, and severely limits capacity for and interest in systems change. The cultural aspects of professional formation for clinical staff, however, may also have paradoxical negative effects on clinical engagement with systems change. Both medical and nursing training are steeped in an idealistic but very person-centred set of values including diligence, duty, perfectionism and selfless beneficence. 18

This has served the NHS enormously well, by inducing countless talented people to work far harder for far less reward than they would otherwise have done. But the implied converse side of this "heroic" model is the ‘shame and blame’ mindset in which adverse outcomes are attributed to individual failure, making staff fearful, defensive and judgemental, and inhibiting their acceptance of systems-based solutions. 19 20 Frontline clinical staff working in this kind of organisation learn that attempts to change the system encounter great difficulties, are disruptive to their normal work patterns and usually fail. Because of the risks to leaders who take on change management directly, projects are usually driven by external academics, experts or consultants, who are seen by staff (sometimes correctly) as remote and unfamiliar with the realities of work in their environment, and are clearly not acting under the direction of senior management. It is easy to see how apathy and cynicism can flourish in these circumstances. This symbiotic relationship between a defensive tribal culture and a change-resistant bureaucracy is incapable of delivering high-quality care but is very hard to change, and, therefore can be highly durable over long periods of time.

So what can be done?

The wicked problems are embedded in the system and culture so deeply that only radical reform of both will lead to sustainable major change. This may be necessary at an institutional or whole system level. Some examples of how this can be done, and can be transformative, exist but to experiment with and implement this kind of change across a large health system would take considerable boldness and change management skills. 21 22

If we cannot tackle the wicked problems, we should downgrade our expectations, but we can still achieve a good deal. We have learnt from our mistakes over the last 30 years, and we can incorporate the lessons into our work. Enabling organisational improvements needs to start with a thorough understanding of ‘work as done’ and the gap between this and ‘work as imagined’. 23 Systematic use of analytical tools to understand work processes is helpful in redesigning them. All changes need to be codesigned with frontline staff, whose implicit knowledge of the system is impossible for outsiders to reproduce. 24 Expecting a single intervention to transform performance is fantasy, but trying to change everything is a recipe for exhausted failure. In a complex interconnected system, the limits of intervention are difficult to define, and too narrow a focus may predestine failure. Hence, projects which concentrate efforts on the staff in a particular specialty area may need to widen their scope and include, for example, both their patients and the other departments whose help they need as partners. Finally, staff engagement will remain the greatest challenge. The importance of careful thought and detailed planning in enhancing engagement cannot be overemphasised. Much can be done by using professional approaches to communication and having well-liked and respected ambassadors. 25 Efforts to improve a sense of belonging and common purpose in the clinical team are logical as part of a strategy. The long-established principles of diffusion of innovations, and of social influence generally, need to be taken seriously as essential components of any project which intends to bring about change. 26 This is a key area for future research.

So when it comes to patient safety we are not nearly there yet, but we have travelled through the territory and learnt a lot on the journey. It is harder than we thought, but the lessons learnt do point to what success requires. The focus of our efforts needs to be directed far more towards finding out how to engage frontline staff actively in change management, since without their support, nothing works. Radical transformation will require fundamental reform of the system, but better science, which directly involves management in studies at a whole-institution scale can take us further, and perhaps provide the impetus to stimulate the necessary policy change.

Key messages

Harm and suboptimal outcomes due to imperfections in care remain stubbornly frequent in modern hospital care, despite three decades of study and attempts at intervention.

Efforts to improve safety using a Human Factors approach remain rational but have been impeded by over-reliance on modification of strategies from very different contexts, poor evaluation, lack of genuine management support and interdependent aspects of hospital staff culture and decision-making processes.

Frontline staff engagement is the key ingredient for success and is often difficult to generate. Understanding how to achieve it should be the main focus of our efforts.

Radical improvement may require radical reform of management structure and process in order to change staff culture.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

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X @McCullochP

Contributors This article draws on experience of the challenges of implementing quality and safety changes in healthcare organisations in England and the US. Professor PM is a surgeon by background and has led multiple research groups focused on improving the safety of surgical care and quality of surgical research. He would like to acknowledge the assistance of Ms Olivia Lounsbury, a US quality and safety practitioner and researcher focused on removing barriers to implementation of safety changes in healthcare organisations. The piece was first conceptualised from discussions between PM and Ms Lounsbury, and both consulted a variety of international healthcare journals for evidence on the topic. Ms Lounsbury commented on and edited drafts, but declined to be an author. Professor PM is the article’s guarantor, and declares that the opinions expressed in it are his alone.

Funding The author has not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

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A DEVELOPMENT PROCESS FRAMEWORK FOR ARTIFICIAL INTELLIGENCE/MACHINE LEARNING (AI/ML)-BASED CONNECTED HEALTH INFORMATICS

The use of connected health technology is becoming increasingly significant in the field of healthcare. Artificial Intelligence- augmented workflows connected to treatment guidelines promise more inclusive care delivery. The AI/ML-based connected health informatics plays an integral role in every stage of medical product development, from initial discovery to providing guidance to healthcare providers, and finally to delivering patient care. The exponential growth of meta data and the rapid advancement of connected health technologies provide greater opportunities for novel healthcare solutions, delivery mechanisms, and clinical trial designs.

However, it poses complexity of the AI/ML-specific challenges besides all the challenges SaMD products face. The regulations for AI/ML-based connected solutions have yet to mature. The AI/ML SaMD development process requires additional considerations such as data quality and management, continuous deployment, and validation.

This study delves into the integration of Machine Learning (ML) with medical software devices and how the current lifecycle models fit the needs of the AI industry. AI/ML-based SaMD development process artifacts are identified through the theory and AI/ML SaMD regulations and standards requirements. Moreover, this study analyzes collected data from interviews, surveys, and an experimental case study to identify success factors in building quality and agility for AI/ML-based SaMD development projects.

Incorporating of Artificial Intelligence (AI) in healthcare requires continuous deployment and validation processes, which may not be in line with the current workflow, capability, or authority of regulators. This research also highlights that model governance and technology access can be key challenges in implementing AI/ML development process artifacts, especially when integrated into connected health solutions.

This work sets the foundation for future research to reduce bottlenecks in the machine-learning process. The focus should be on aiding model governance to streamline development and ensure machine reliability. A suitable software toolchain is necessary for exploratory data analysis, data integration, documentation, model governance, monitoring, version control, and integration with other software and services within a connected health solution. Additionally, conducting more focused research on security and privacy in the context of connected health would be valuable.

Degree Type

• Doctor of Technology
• Technology Leadership and Innovation

Campus location

• West Lafayette

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Additional committee member 2, additional committee member 3, additional committee member 4, usage metrics.

• Information systems development methodologies and practice

• About company
• GENERAL CONTRACTOR

+7 (495) 526-30-40 +7 (49657) 0-30-99

THE HISTORY OF THE COMPANY CREATION

1993 how the construction company remstroy was created   the year 1993 was a period when a lot of construction companies, which had been working successfully during the soviet times and had rich staff capacity, were forced to cease their activity for various reasons. a lot of capable specialists either had to look for another job or change their field. but there were also those who were willing to realise their potential in the field of construction in accordance with the received degree and the experience they had accumulated. thus, in 1993 in elektrostal (moscow oblast) a group of specialists and people sharing each other’s ideas, who had enormous educational background and the highest degree in architecture, organized and registered ooo firm erg which began its rapid development and successful work, offering its service both on the construction market and other areas. 2000 industrial construction is the main area   seven years of successful work have shown that combining different types of activities in the same company is not always convenient. and in the year 2000 the founders of ooo firm erg decided to create and register a monoprofile construction company ooo remstroy construction company. industrial construction was chosen as the priority area. it was in this area that the directors of ooo sk remstroy began their working life and grew as specialists. in order to achieve the set goal, they selected a mobile team of professionals in the field of industrial construction, which allows us to cope with the tasks assigned to ooo sk remstroy throughout russia and the near abroad. 2010 manufacturing of metal structures   we possess modern equipment that allows us to carry out the entire cycle of works on the manufacture of metal structures of any complexity without assistance. designing – production – installation of metal structures. a staff of professionals and well-coordinated interaction of the departments let us carry out the work as soon as possible and in accordance with all customer’s requirements.” extract from the list of members of self-regulatory organizations, construction.

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40 Facts About Elektrostal

Written by Lanette Mayes

Modified & Updated: 01 Jun 2024

Reviewed by Jessica Corbett

Elektrostal is a vibrant city located in the Moscow Oblast region of Russia. With a rich history, stunning architecture, and a thriving community, Elektrostal is a city that has much to offer. Whether you are a history buff, nature enthusiast, or simply curious about different cultures, Elektrostal is sure to captivate you.

This article will provide you with 40 fascinating facts about Elektrostal, giving you a better understanding of why this city is worth exploring. From its origins as an industrial hub to its modern-day charm, we will delve into the various aspects that make Elektrostal a unique and must-visit destination.

So, join us as we uncover the hidden treasures of Elektrostal and discover what makes this city a true gem in the heart of Russia.

Key Takeaways:

• Elektrostal, known as the “Motor City of Russia,” is a vibrant and growing city with a rich industrial history, offering diverse cultural experiences and a strong commitment to environmental sustainability.
• With its convenient location near Moscow, Elektrostal provides a picturesque landscape, vibrant nightlife, and a range of recreational activities, making it an ideal destination for residents and visitors alike.

Known as the “Motor City of Russia.”

Elektrostal, a city located in the Moscow Oblast region of Russia, earned the nickname “Motor City” due to its significant involvement in the automotive industry.

Home to the Elektrostal Metallurgical Plant.

Elektrostal is renowned for its metallurgical plant, which has been producing high-quality steel and alloys since its establishment in 1916.

Boasts a rich industrial heritage.

Elektrostal has a long history of industrial development, contributing to the growth and progress of the region.

Founded in 1916.

The city of Elektrostal was founded in 1916 as a result of the construction of the Elektrostal Metallurgical Plant.

Located approximately 50 kilometers east of Moscow.

Elektrostal is situated in close proximity to the Russian capital, making it easily accessible for both residents and visitors.

Known for its vibrant cultural scene.

Elektrostal is home to several cultural institutions, including museums, theaters, and art galleries that showcase the city’s rich artistic heritage.

A popular destination for nature lovers.

Surrounded by picturesque landscapes and forests, Elektrostal offers ample opportunities for outdoor activities such as hiking, camping, and birdwatching.

Hosts the annual Elektrostal City Day celebrations.

Every year, Elektrostal organizes festive events and activities to celebrate its founding, bringing together residents and visitors in a spirit of unity and joy.

Has a population of approximately 160,000 people.

Elektrostal is home to a diverse and vibrant community of around 160,000 residents, contributing to its dynamic atmosphere.

Boasts excellent education facilities.

The city is known for its well-established educational institutions, providing quality education to students of all ages.

A center for scientific research and innovation.

Elektrostal serves as an important hub for scientific research, particularly in the fields of metallurgy , materials science, and engineering.

Surrounded by picturesque lakes.

The city is blessed with numerous beautiful lakes , offering scenic views and recreational opportunities for locals and visitors alike.

Well-connected transportation system.

Elektrostal benefits from an efficient transportation network, including highways, railways, and public transportation options, ensuring convenient travel within and beyond the city.

Famous for its traditional Russian cuisine.

Food enthusiasts can indulge in authentic Russian dishes at numerous restaurants and cafes scattered throughout Elektrostal.

Home to notable architectural landmarks.

Elektrostal boasts impressive architecture, including the Church of the Transfiguration of the Lord and the Elektrostal Palace of Culture.

Offers a wide range of recreational facilities.

Residents and visitors can enjoy various recreational activities, such as sports complexes, swimming pools, and fitness centers, enhancing the overall quality of life.

Provides a high standard of healthcare.

Elektrostal is equipped with modern medical facilities, ensuring residents have access to quality healthcare services.

Home to the Elektrostal History Museum.

The Elektrostal History Museum showcases the city’s fascinating past through exhibitions and displays.

A hub for sports enthusiasts.

Elektrostal is passionate about sports, with numerous stadiums, arenas, and sports clubs offering opportunities for athletes and spectators.

Celebrates diverse cultural festivals.

Throughout the year, Elektrostal hosts a variety of cultural festivals, celebrating different ethnicities, traditions, and art forms.

Electric power played a significant role in its early development.

Elektrostal owes its name and initial growth to the establishment of electric power stations and the utilization of electricity in the industrial sector.

Boasts a thriving economy.

The city’s strong industrial base, coupled with its strategic location near Moscow, has contributed to Elektrostal’s prosperous economic status.

Houses the Elektrostal Drama Theater.

The Elektrostal Drama Theater is a cultural centerpiece, attracting theater enthusiasts from far and wide.

Popular destination for winter sports.

Elektrostal’s proximity to ski resorts and winter sport facilities makes it a favorite destination for skiing, snowboarding, and other winter activities.

Promotes environmental sustainability.

Elektrostal prioritizes environmental protection and sustainability, implementing initiatives to reduce pollution and preserve natural resources.

Home to renowned educational institutions.

Elektrostal is known for its prestigious schools and universities, offering a wide range of academic programs to students.

Committed to cultural preservation.

The city values its cultural heritage and takes active steps to preserve and promote traditional customs, crafts, and arts.

Hosts an annual International Film Festival.

The Elektrostal International Film Festival attracts filmmakers and cinema enthusiasts from around the world, showcasing a diverse range of films.

Encourages entrepreneurship and innovation.

Elektrostal supports aspiring entrepreneurs and fosters a culture of innovation, providing opportunities for startups and business development .

Offers a range of housing options.

Elektrostal provides diverse housing options, including apartments, houses, and residential complexes, catering to different lifestyles and budgets.

Home to notable sports teams.

Elektrostal is proud of its sports legacy , with several successful sports teams competing at regional and national levels.

Boasts a vibrant nightlife scene.

Residents and visitors can enjoy a lively nightlife in Elektrostal, with numerous bars, clubs, and entertainment venues.

Promotes cultural exchange and international relations.

Elektrostal actively engages in international partnerships, cultural exchanges, and diplomatic collaborations to foster global connections.

Surrounded by beautiful nature reserves.

Nearby nature reserves, such as the Barybino Forest and Luchinskoye Lake, offer opportunities for nature enthusiasts to explore and appreciate the region’s biodiversity.

Commemorates historical events.

The city pays tribute to significant historical events through memorials, monuments, and exhibitions, ensuring the preservation of collective memory.

Promotes sports and youth development.

Elektrostal invests in sports infrastructure and programs to encourage youth participation, health, and physical fitness.

Hosts annual cultural and artistic festivals.

Throughout the year, Elektrostal celebrates its cultural diversity through festivals dedicated to music, dance, art, and theater.

Provides a picturesque landscape for photography enthusiasts.

The city’s scenic beauty, architectural landmarks, and natural surroundings make it a paradise for photographers.

Connects to Moscow via a direct train line.

The convenient train connection between Elektrostal and Moscow makes commuting between the two cities effortless.

A city with a bright future.

Elektrostal continues to grow and develop, aiming to become a model city in terms of infrastructure, sustainability, and quality of life for its residents.

In conclusion, Elektrostal is a fascinating city with a rich history and a vibrant present. From its origins as a center of steel production to its modern-day status as a hub for education and industry, Elektrostal has plenty to offer both residents and visitors. With its beautiful parks, cultural attractions, and proximity to Moscow, there is no shortage of things to see and do in this dynamic city. Whether you’re interested in exploring its historical landmarks, enjoying outdoor activities, or immersing yourself in the local culture, Elektrostal has something for everyone. So, next time you find yourself in the Moscow region, don’t miss the opportunity to discover the hidden gems of Elektrostal.

Q: What is the population of Elektrostal?

A: As of the latest data, the population of Elektrostal is approximately XXXX.

Q: How far is Elektrostal from Moscow?

A: Elektrostal is located approximately XX kilometers away from Moscow.

Q: Are there any famous landmarks in Elektrostal?

A: Yes, Elektrostal is home to several notable landmarks, including XXXX and XXXX.

Q: What industries are prominent in Elektrostal?

A: Elektrostal is known for its steel production industry and is also a center for engineering and manufacturing.

Q: Are there any universities or educational institutions in Elektrostal?

A: Yes, Elektrostal is home to XXXX University and several other educational institutions.

Q: What are some popular outdoor activities in Elektrostal?

A: Elektrostal offers several outdoor activities, such as hiking, cycling, and picnicking in its beautiful parks.

Q: Is Elektrostal well-connected in terms of transportation?

A: Yes, Elektrostal has good transportation links, including trains and buses, making it easily accessible from nearby cities.

Q: Are there any annual events or festivals in Elektrostal?

A: Yes, Elektrostal hosts various events and festivals throughout the year, including XXXX and XXXX.

Elektrostal's fascinating history, vibrant culture, and promising future make it a city worth exploring. For more captivating facts about cities around the world, discover the unique characteristics that define each city . Uncover the hidden gems of Moscow Oblast through our in-depth look at Kolomna. Lastly, dive into the rich industrial heritage of Teesside, a thriving industrial center with its own story to tell.

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Thankfully Business Insider Is Not Responsible for Healthcare Modernization

Clickbait (noun): “something (such as a headline) designed to make readers want to click on a hyperlink especially when the link leads to content of dubious value or interest.” [1]

“Oracle’s deadly gamble. Larry Ellison bet $28 billion he could revolutionize healthcare. So why are so many patients dying?” reads the hyperbolic, fantastical headline recently published by Business Insider (BI).

Wow. Clickbait? One would expect that following such a headline, Business Insider would follow through with…some semblance of news?

Instead, we get the typical Business Insider formulaic story: start with a vignette, take some widely reported old news, mix in a few anonymous quotes, take other quotes out of context, ignore all facts to the contrary, present other facts entirely backwards, add some irrelevant graphics, refuse to print the company’s response, throw in the obligatory layoffs…and you have your typical Business Insider preconceived “expose.”

What’s worse, this story is nearly identical to a story published by Business Insider nearly two years ago to the day here . The regurgitated story again centers around the Department of Veterans Affairs’ (VA) electronic health record modernization program, which is a complex technology modernization effort in search of a scandal. The reason the VA needs to modernize is because its current system—VistA—was implemented during the Carter Administration. We cover all the reasons VistA is long past its prime in a blog entitled “Veteran’s Deserve Better than VistA” here . Even BI acknowledges that VistA is “outdated and vulnerable to cyberattacks.” What could go wrong with a cyberattack on the Department of Veterans Affairs? Well, lots, as Larry Ellison and Seema Verma (EVP and General Manager of Oracle Health) recently articulated in the Wall Street Journal here .

Boiled down to the basics, VistA is on-premise, fragmented, insecure technology conceived decades before the Internet. Our veterans deserve better. The modernization effort is going to provide the men and women who serve the United States a single, interoperable, secure, longitudinal record from time of enlistment to end-of-life care, following them from the Pentagon to the VA. What BI misses this time around is that by every single measure, the system is vastly improved from when BI first “reported” this identical story in July 2022.

The palaeoloxodon in the room is that the Department of Defense (DoD) has now finished successfully implementing the Cerner electronic heath record system to rave reviews. We were unaware the internet had page limits, but BI could only see fit to include 20 words of Oracle’s 124-word statement in a nearly 4,500-word story. We include the entirety of the statement below (for ease of the reader we bold everything BI ignored):

“Our veterans and the people who care for them deserve a world-class EHR system, and Oracle is delivering it. Since Oracle took over the VA’s EHR modernization project two years ago, we have made thousands of improvements to enhance the performance, reliability, and usability of the system. The technology being deployed at the VA is the same technology helping doctors and nurses provide reliable, quality care at all 3,890 DoD locations—the largest EHR implementation in the world. The recent highly successful go-live at the joint DoD and VA operated Lovell Federal Health Care Center in Chicago is a powerful demonstration of our ability and commitment to provide veterans with unsurpassed care, and we look forward to extending this success across every VA facility. ”

You see from our statement the fact that Oracle/Cerner was successfully deployed at nearly 4,000 DoD facilities. That part of our statement inconveniently contradicts BI’s core thesis. So they ignored it.

This story chooses as its main antagonist a software feature called the unknown queue, a function specified by the VA in the system’s design and also present in VistA . But after some issues with the unknown queue were widely reported nearly 2 years ago , the issue was resolved by Oracle in…wait for it…10 days. From that point forward, the unknown queue has not been an issue at all, so it is beyond us as to why it would form the centerpiece of BI’s new “reporting.”

And to never let the truth get in the way of a good story, BI literally turns other facts inside out. It invents this paragraph from a puff piece it wrote about the largest EHR provider, Epic, in 2020. BI parrots Epic’s misinformation:

“Epic may have been a more obvious target for Oracle, since it had a larger share of the market and dominated among large hospitals and research facilities. But Cerner, the go-to EHR for small and midsize hospitals, had a quality that would have appealed to Ellison: It was widely seen as taking a more relaxed approach to data privacy.”

This version of the truth is particularly special since everyone in the industry understands that Epic’s CEO Judy Faulkner is the single biggest obstacle to EHR interoperability. She opposes interoperability because it threatens Epic’s franchise. By contrast, Oracle believes outcomes are easier to obtain when providers can collaborate and gain insights across systems, data, and application silos. Our strategy is to build everything in a modular way that is EHR agnostic. We are continuing to deliver on the industry’s most open, interoperable EHR system and increasing our APIs by more than 300%. Privacy? Epic’s contracts expressly appropriate all patient EHR data as Epic’s own, stretching HIPAA beyond recognition, while Oracle/Cerner’s explicitly state medical centers must opt-in to any data sharing.

Business Insider could have spent its 4,500 words reporting on all of the progress made at the VA as we transparently detail here : the fact that veterans using the new EHR have a complete medical record from their DoD service to care at the VA—and even care they receive in the community. Or the fact that the recent deployment in North Chicago has exceeded expectations and gone very well. Or the successful deployment at one of the most complex medical centers, Walter Reed. Or the fact that Oracle has a new generative AI clinical digital assistant feature for the EHR that will help providers spend less time in the EHR and more with patients.

Business Insider could have chosen to cover the successful deployment in March of the new EHR to the joint VA-DoD Lovell Federal Health Care Center (Lovell FHCC) in North Chicago, where patient volumes have already returned to 90 percent of pre-deployment numbers. The emergency department is seeing patients at a number equivalent to 110 percent of pre-deployment numbers. And pharmacists have returned to 99 percent of pre-deployment numbers for outpatient prescriptions.

Overlooked in the discussion of the Lovell FHCC deployment is the fact that Lovell is the first deployment to happen under Oracle’s watch since the Cerner acquisition. Lovell FHCC has benefitted from all the updates to both performance and stability, features and workflows, and training that have occurred in the last two years. Through the course of the current reset, much of this work has been done, and as VA provides direction on further simplifications or modifications to the EHR, we are ready to quickly implement.

Because of the new EHR, veterans who go into the community for care now have interoperability with more than 90 percent of community care provider EHRs. This means the care they receive in the community is in their VA record, and their community care providers know what is in their VA record. This only makes care safer, more efficient and better for the veteran.

Business Insider ignores important veteran safety enhancements in the EHR such as the visibility of Patient Record Flags that alert clinical staff to critical issues including suicide risk, disruptive behavior and missing veterans to enable timely intervention.

Now, to the point. Healthcare is one of the largest sectors of the global economy, and everyone acknowledges it is far behind in basic IT modernization. As the BI authors acknowledge, here we are in 2024 and basic healthcare decisions are made essentially without data and in a vacuum. There is more compute put on predictive lattes at Starbucks than predictive medicine. We are committed to changing that and investing dramatically in IT tools that promote positive patient outcomes. 

That’s why Oracle is just getting started and why it is so invigorating to have BI rooting against us. It is true—as BI points out – that others have tried to modernize healthcare and failed. What BI misses is that all these same factors that caused others to fail will also cause Epic to fail. And these factors will lead to Oracle’s success.

The biggest differentiator Oracle brings to this effort is Oracle Cloud Infrastructure—scaled, secured, and autonomous. If you want to start to modernize healthcare you need to start with a modern cloud, not by supergluing on-premise systems onto AWS in hosted environments and saying cloud quickly (read, Epic).

Oracle then adds decades of expertise building complex enterprise applications in pure SaaS models. You think EHRs are complicated? Try global accounting. Generative AI didn’t commercially exist when Oracle bought Cerner, yet we are already embedding generative AI into our healthcare systems to provide ease of use and reduce practitioner fatigue. Look no further than Oracle’s new Clinical Digital Assistant to see where we are headed.

We then layer in Oracle’s expertise in other critical areas of healthcare, such as supply chain, clinical, scheduling, HCM, payments, billing, inventory and many others, and before you know it, the healthcare sector will benefit from the exact same modern efficiencies, convenience—and, by the way, outcomes—that we see across the global economy in sector after sector from IT modernization.

By comparison, Oracle has the easy job. It is the researchers, biologists, chemists, and medical specialists tasked with curing diseases who have the hard job. There is nobody who believes that more data, more analytics, and more AI will not accelerate that process. All we are doing is modernizing IT systems—and wrapping those systems in AI—to facilitate much of that work. As BI knows because it purports to cover technology, complex system modernization takes time and effort. We have no doubt our so-called “gamble” will hit big. Coming back to Business Insider’s opening vignette, Crestor may or may not have been the right statin for Mr. Ellison’s condition. The point is, in 2024 it’s time we stop guessing.

1 https://www.merriam-webster.com/dictionary/clickbait

Goshen Health receives 5th magnet certification

GOSHEN, Ind. (WNDU) - Goshen Health is always working to improve its healthcare, and now they’re getting a little recognition for it.

Out of nearly 6,000 hospitals in the country, Goshen Health has achieved something less than 1% have: five magnet certifications.

What does that mean exactly? They are being recognized for quality patient care and nursing excellence.

This isn’t a little award either. It’s actually the highest distinction a health-care organization can receive.

“I have a lifetime of personal experience with Goshen Health through everything from the birth of my daughter to a lifetime of care of my grandparents to now my parents as well, and every step along the way I have been so impressed with the quality of care that was provided and by Goshen Health team,” said Goshen Mayor Gina Leichty.

Goshen Health received their first award in 2004.

Copyright 2024 WNDU. All rights reserved.

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Geographic coordinates of Elektrostal, Moscow Oblast, Russia

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Coordinates of Elektrostal in decimal degrees

Coordinates of elektrostal in degrees and decimal minutes, utm coordinates of elektrostal, geographic coordinate systems.

WGS 84 coordinate reference system is the latest revision of the World Geodetic System, which is used in mapping and navigation, including GPS satellite navigation system (the Global Positioning System).

Geographic coordinates (latitude and longitude) define a position on the Earth’s surface. Coordinates are angular units. The canonical form of latitude and longitude representation uses degrees (°), minutes (′), and seconds (″). GPS systems widely use coordinates in degrees and decimal minutes, or in decimal degrees.

Latitude varies from −90° to 90°. The latitude of the Equator is 0°; the latitude of the South Pole is −90°; the latitude of the North Pole is 90°. Positive latitude values correspond to the geographic locations north of the Equator (abbrev. N). Negative latitude values correspond to the geographic locations south of the Equator (abbrev. S).

Longitude is counted from the prime meridian ( IERS Reference Meridian for WGS 84) and varies from −180° to 180°. Positive longitude values correspond to the geographic locations east of the prime meridian (abbrev. E). Negative longitude values correspond to the geographic locations west of the prime meridian (abbrev. W).

UTM or Universal Transverse Mercator coordinate system divides the Earth’s surface into 60 longitudinal zones. The coordinates of a location within each zone are defined as a planar coordinate pair related to the intersection of the equator and the zone’s central meridian, and measured in meters.

Elevation above sea level is a measure of a geographic location’s height. We are using the global digital elevation model GTOPO30 .

Elektrostal , Moscow Oblast, Russia