Nonprofit Hospitals Research Articles

Influence of hospital ownership on patient outcomes in STEMI-induced cardiogenic shock undergoing revascularization: a retrospective cohort study

Abstract Background Investor-owned hospitals constitute an expanding segment of healthcare enterprises that frequently eschew the provision of non-profitable services. The implications of this disparity in costs on the mortality rates of patients experiencing cardiogenic shock (CS) subsequent to ST-Elevation Myocardial Infarction (STEMI) undergoing percutaneous coronary intervention (PCI) with drug-eluting stents (DES) or bare-metal stents (BMS) remain unknown. Methods In this retrospective analysis, data from the National Inpatient Sample (NIS) were examined, including acute care admissions for patients aged 18 years and above admitted due to cardiogenic shock secondary to ST-Elevation Myocardial Infarction (STEMI) who underwent percutaneous coronary intervention (PCI) with the placement of either drug-eluting stents (DES) or bare-metal stents (BMS) between 2016 and 2020. Multivariable logistic regression, multilinear regression, chi-square tests, and t-tests were used to compare mortality rates, length of stay (LOS), and healthcare costs, adjusting for potential confounders. The total charges were adjusted for inflation using the Consumer Price Index (CPI) from the Bureau of Labor Statistics to ensure consistency in financial evaluations. Results We analyzed 66,180 patients and divided them into two cohorts: admitted to investor-owned vs nonprofit institutions. The findings revealed no significant difference in mortality rates, with an adjusted odds ratio (aOR) of 1.03 (P=0.60; 95% CI: 0.91-1.16). However, treatment in investor-owned hospitals was associated with significantly higher healthcare costs, with a coefficient of 120,921 (P<0.001; 95% CI: 106,658.6–135,184.7), but without a significant difference in length of stay (LOS) (coefficient 0.04; P=0.81; 95% CI: -0.33 to 0.41). Key predictors of mortality included age, with each additional year increasing the odds of mortality by 3% (P<0.001; 95% CI: 1.02-1.03), and uninsured status, which was linked to a higher mortality risk (aOR 1.40; P<0.001; 95% CI: 1.16-1.70). Disparities in healthcare costs were observed across different races and insurance types, notably affecting Hispanic patients and those covered by Medicaid. A significant difference was noted in the average adjusted hospital charges between non-profit and investor-owned hospitals; the average charge at investor-owned hospitals was $314,633, compared to $220,227 at non-profit hospitals (P<0.01), marking a net difference of $94,406. Conclusion This retrospective cohort analysis demonstrated that investor-owned hospitals incurred, on average, over $94,406 more in healthcare costs than nonprofit hospitals, with no significant difference in mortality rates and only a marginal difference in length of stay (LOS). Higher expenses at investor-owned hospitals did not translate into improved patient outcomes, challenging the notion that increased healthcare spending necessarily results in better healthcare delivery.

Changes in hospital-supported substance use services across US nonprofit hospitals, 2015-2021.

Substance use remains a timely and important community need to understand and address. Nonprofit hospitals are in a unique position to identify needs and develop programs in response to substance use challenges in their communities. To better understand how nonprofit hospitals do this, we collected data from community health needs assessments and their corresponding implementation strategy (IS) to address these needs for a 20% random sample of hospitals in each state of the United States over 2 periods (2015-2018 and 2019-2021). The sample of nonprofit hospitals came from the American Hospital Association's (AHA) Annual Survey Database. Community health needs assessment and IS documents were coded for the inclusion of substance use programs using a systematic protocol and analyzed quantitatively. We found that the percentage of nonprofit hospitals in our sample with at least 1 substance use program increased from 66.5% in 2015-2018 to 73.6% in 2019-2021. Of the types of programs analyzed, harm reduction approaches saw the greatest increase in implementation in the time period studied, while primary care approaches decreased. This indicates that hospitals are continuing or even increasing their responses to community needs regarding substance use, but there is evidence that their approaches in doing so are shifting over time.

Community Benefit and Tax-Exemption Levels at Non-Profit Hospitals Across U.S. States.

To assess the association between state policies and sociodemographic characteristics and state mean fair share spending at non-profit hospitals. Fair share spending is a hospital's charity care and community investment less the estimated value of their tax-exempt status. Hospitals with non-profit status in the United States are exempt from paying taxes. In return, they are expected to provide community benefits by subsidizing medical care for those who cannot pay and investing in the health and social needs of their community. We used a multivariable linear regression model to determine the association of state-level sociodemographics and policies with state-level mean fair share spending in 2019. Fair share spending data was obtained from the Lown Institute. We found no association between the percentage of people living in poverty, in rural areas, or U.S. region and fair share spending. Similarly, there was no association found for state minimum community benefit and reporting requirements. The state percentage of racial/ethnic minorities was associated with higher mean fair share spending [+$1.48 million for every 10% increase (95% CI: 0.01 to 2.96 million)]. Medicaid expansion status was associated with a 6.9-million-dollar decrease (95% CI: -10.4 to -3.3 million). State-level community benefit policies have been ineffective at raising community benefit spending to levels comparable to the value of non-profit hospital tax-exempt status.

Perioperative Antibiotic Choice and Postoperative Infectious Complications in Pelvic Organ Prolapse Surgery

ObjectiveThe objective of this study was to determine how rates of postoperative infectious complications after pelvic organ prolapse surgery differ based on perioperative antibiotic administered. In particular, we sought to determine whether anaerobic coverage is associated with reduced rates of infectious complications. DesignThis was a retrospective cohort study. SettingPremier Healthcare U.S. national database, a comprehensive all-payer dataset capturing patients from urban and rural nonprofit, community, and teaching hospitals. ParticipantsAdult patients who underwent vaginal, laparoscopic, and/or abdominal prolapse surgery with or without hysterectomy from January 2000 to March 2020. Procedures with and without mesh were included. InterventionsRates of infectious complications were compared among patients who received guideline-concordant antibiotic regimens, including those with anaerobic coverage. The primary outcome was any surgical site infection within 30 days of surgery without mesh or 90 days of surgery involving mesh. ResultsAmong 130,198 prolapse surgeries, the most common antibiotic regimens were cefazolin (n = 97,058, 74.5%), second-generation cephalosporin (n = 16,442, 12.6%), clindamycin + aminoglycoside (n = 8,397, 6.4%) and cefazolin + metronidazole (n = 4,328, 3.3%). On multivariable logistic regression, only clindamycin + aminoglycoside was associated with a higher rate of surgical site infections (OR = 1.37; 95% CI 1.09–1.72) and other infectious morbidity (OR = 1.26; 95% CI 1.12–1.42) when compared to cefazolin alone. The addition of metronidazole to cefazolin was not associated with reduced rates of surgical site infections (OR = 1.09; 95% CI 0.82–1.45). Obesity (OR = 1.22; 95% CI 1.03–1.43), diabetes without complication (OR = 1.30; 95% CI 1.08–1.57), Charlson comorbidity score >0 (OR = 1.24; 95% CI 1.06–1.45), and tobacco use (OR = 1.22, 95% CI 1.05–1.40) were also associated with increased composite surgical site infection. ConclusionCompared with cefazolin alone, the use of alternative perioperative antibiotics, including those with anaerobic coverage, was not associated with reduced infectious complications after pelvic organ prolapse surgery in this U.S. national sample.

Mixed-Methods Analysis of Community-Building Activities in Minnesota Hospitals.

Nonprofit hospitals are required to annually report spending on community-building activities (CBAs) to the Internal Revenue Service. CBAs are actions that address root causes of community health problems such as housing and food insecurity. While addressing these issues is important regardless of location, CBA spending could particularly benefit rural residents who, on average, experience worse health outcomes. However, national CBA spending has historically been extremely low, potentially due to confusion surrounding reporting. This explanatory mixed-methods study sought to illuminate nonprofit hospital spending patterns on CBAs in one state, Minnesota, to understand why spending in this important category is so low. Authors first conducted quantitative analyses of publicly available tax return data for the year 2019' which revealed no statistically significant differences in CBA spending by rural location or hospital system affiliation. Authors then performed a case study of the top spending hospitals' narrative statements provided in nonprofit hospital tax return documents and found significant variation in what is reported as a CBA. We suggest CBA spending be reported differently to reduce confusion and render tax documents more accurate portrayals of nonprofit hospital spending, thereby providing policymakers with needed information to ensure nonprofit hospitals are financially supporting community health.

Estimation of Tax Benefit of US Nonprofit Hospitals

Nonprofit hospitals are under increasing scrutiny to justify the generous tax benefit they receive due to their tax-exempt status. Quantifying the value of the tax benefit they receive at the federal, state, and local levels is critical for designing informed public health policies and ensuring nonprofit hospitals' taxpayer accountability. To estimate the financial benefit that nonprofit hospitals derive from their tax-exempt status and assess how the benefit is distributed across state and local communities. Using methodologies and measures consistent with current tax law and practice and data from 2021 Medicare Cost Reports, this study calculated the total financial benefit from nonprofit hospitals' tax-exempt status for all US nonprofit hospitals with the required Cost Reports data. Nonprofit hospitals' total tax benefit, which equals the sum of federal and state income tax, sales tax, property tax, the fair market value of charitable contributions from donors, savings from tax exemptions on issued bonds, and federal unemployment tax. A total of 2927 US nonprofit hospitals received a $37.4 billion total tax benefit in 2021 from federal income tax ($11.5 billion; 31%), sales tax ($9.1 billion; 24%), property tax ($7.8 billion; 21%), state income tax ($3.7 billion; 10%), charitable contributions ($3.2 billion; 8%), bond financing ($2.1 billion; 6%), and federal unemployment tax ($200 million; <1%). Tax benefit varied substantially across states, from $25 098 (Delaware) to $159 464 (Massachusetts) per hospital bed and from $19 (Alabama) to $275 (Massachusetts) per capita. Tax benefit was highly concentrated, with 7% (n = 212) of hospitals accounting for half of the total amount. This study highlights the wide variation of nonprofit hospitals' tax benefit across states, its high concentration among a small number of hospitals, and the primary role played by state and local taxes. Policy efforts to strengthen nonprofit hospitals' taxpayer accountability are likely to be more effective when pursued at the local level. The detailed standardized estimation road map can be used by various stakeholders to estimate tax benefit for external valuation and reporting purposes, updated as laws change, and improved upon as better data sources become available.

Exploring the Hospital Performance during the COVID-19 Pandemic from the Perspective of Intellectual Capital: An Empirical Study of Taipei Hospital in Taiwan

The COVID-19 pandemic, starting in 2019, posed unprecedented challenges to global healthcare systems, with Taiwan's rapid response gaining notable attention (Cheng, Li, &amp; Yang, 2020). This paper examines how non-profit hospitals can improve crisis management capabilities, using Taipei Hospital as an empirical study. It proposes a framework for constructing an intellectual capital report based on the ARC model, enhancing traditional financial statements with a comprehensive view of the hospital's intangible assets. Employing Data Envelopment Analysis (DEA) to evaluate Taipei Hospital's operational performance from 2013 to 2023, the study finds that the hospital's operational efficiency during the pandemic exceeded pre-pandemic levels, demonstrating its ability to leverage the crisis for improvement. This supports the assertion that intellectual capital is crucial for research and development organizations, validating the proposed reporting framework.

More Money, More Problems? Implications of Excess Cash in Nonprofit Hospitals

This study examines the implications of excess cash in nonprofit hospitals. Using a nationally representative sample of hospitals, I benchmark nonprofit cash holdings against for-profit cash holdings, and find that nonprofit hospitals hold significantly more cash. I consider three potential uses of excess cash in nonprofit hospitals: (a) investment in fixed assets, (b) increased charity care provision, and (c) higher executive compensation. I find that excess cash is associated with investments in fixed assets but not with increased charity care provision. Moreover, I find a positive relationship between excess cash and growth in CEO compensation. The results suggest that while nonprofit hospitals may accumulate cash to finance fixed assets, some of the accumulated cash may be diverted toward executive compensation. Overall, concerns regarding agency problems in nonprofit organizations may not be unfounded.

The determinants of nonprofit hospital CEO compensation.

Hospital CEO salaries have grown quickly over the past two decades. We investigate correlates of rising nonprofit hospital CEO pay between 2012 and 2019 by merging compensation data from Candid's IRS 990 forms with hospital data from the National Academy for State Health Policy Hospital Cost Tool. Almost half of the measured increase in CEO compensation (44.5%) accrued to a "base case" CEO, who was leading a non-teaching hospital system or independent hospital with fewer than 100 beds that earned 0 profits and provided no charity care. Another 28.5% of the measured salary increase resulted from changes in the generosity with which observable metrics were rewarded, particularly the reward for heading a system with 500 or more beds. The remaining 27% resulted mostly from hospital systems or single hospitals that increased their profits or bed size over time. The increase in CEO compensation associated with leading larger healthcare systems and earning greater profits may explain the increase in healthcare system consolidation which has occurred over the last several years.

The Legitimizing Role of Outsider Board Members: The Case of the U.S. Nonprofit Health Care Sector

Establishing a Nonprofit Hospital’s (NPH’s) legitimacy is central to gaining the support of external stakeholders. Yet, institutional studies have long argued that smaller and less established organizations face a liabilities of smallness/newness problem where they lack the legitimacy of larger and more established organizations. This study develops an institutional explanation of board governance in which outside board members develop a legitimacy that overcomes these liabilities. A panel of 231 U.S. NPHs was used to examine this institutional explanation where Quantile Fixed Effect (QFE) estimations find that the proportion, tenure, and compensation of outside members offer a legitimacy that increases the performance of smaller/newer NPHs over their larger and more established counterparts. This institutional explanation offers a broadened view of board governance that addresses the legitimacy demands of NPHs.

Evaluating the Accuracy, Quality, and Readability of Online Breast Cancer Information.

To assess the accuracy, quality, and readability of patient-focused breast cancer websites using expert evaluation and validated tools. Ensuring access to accurate, high-quality, and readable online health information supports informed decision-making and health equity but has not been recently evaluated. A qualitative analysis on 50 websites was conducted; the first 10 eligible websites for the following search terms were included: "breast cancer," "breast surgery," "breast reconstructive surgery," "breast chemotherapy," and "breast radiation therapy." Websites were required to be in English and not intended for healthcare professionals. Accuracy was evaluated by 5 breast cancer specialists. Quality was evaluated through the DISCERN questionnaire. Readability was measured using 9 standardized tests. Mean readability was compared with the American Medical Association and National Institutes of Health 6th grade recommendation. Nonprofit hospital websites had the highest accuracy (mean = 4.06, SD = 0.42); however, no statistical differences were observed in accuracy by website affiliation (P = 0.08). The overall mean quality score was 50.8 ("fair"/"good" quality) with no significant differences among website affiliations (P = 0.10). Mean readability was at the 10th grade reading level, the lowest being for commercial websites with a mean 9th grade reading level (SD = 2.38). All websites exceeded the American Medical Association- and National Institutes of Health-recommended reading level by 4.4 levels (P < 0.001). Websites with higher accuracy tended to have lower readability levels, whereas those with lower accuracy had higher readability levels. As breast cancer treatment has become increasingly complex, improving online quality and readability while maintaining high accuracy is essential to promote health equity and empower patients to make informed decisions about their care.

Unveiling the Adoption and Barriers of Telemedicine in US Hospitals: A Comprehensive Analysis (2017-2022).

Telemedicine has emerged as a vital healthcare delivery model, especially pronounced during the COVID-19 pandemic. Our study uniquely focuses on an institutional lens, examining US hospitals to offer targeted policy implications. To investigate the trend in telemedicine adoption across US hospitals from 2017 to 2022 and analyze the institutional challenges they encounter, particularly in the realm of electronic health information exchange. Cross-sectional study leveraging data from the American Hospital Association's (AHA) annual surveys for the years 2017 to 2021 and the 2022 AHA IT Supplement Survey. The study includes a national sample of US hospitals, covering a diverse range of hospital types including large, nonprofit, teaching, and system-affiliated institutions. US hospitals form the study's participants, with a substantial response rate to the surveys. Key metrics include the number of telemedicine patient encounters, percentage of hospitals offering telemedicine services, and institutional challenges to electronic health information exchange. Telemedicine encounters saw a 75% increase, growing from approximately 111.4 million in 2020 to nearly 194.4 million in 2021. The percentage of hospitals offering at least one form of telemedicine service went from 46% in 2017 to 72% in 2021. Larger, nonprofit, and teaching hospitals were more prone to telehealth adoption, without notable urban-rural disparities. While over 90% of hospitals allow patients to view and download medical records, only 41% permit online data submission. Importantly, 25% of hospitals identified Certified Health IT Developers such as EHR vendor as frequent culprits in information blocking, with cost being the primary obstacle. The findings underscore the rapid yet uneven adoption of telemedicine services in U.S. hospitals. The results point to the need for comprehensive policy interventions to address the challenges identified and realize telemedicine's full potential in healthcare delivery and resilience.

Intrahospital Mortality Rate after the Implementation of the Second Phase of the Health Sector Reform in Comparison with Before that in Iran.

The second phase of the health sector reform, called the Health Sector Evolution Plan (HSEP), has been implemented in Iran since 2014, aims to improve the equity and quality of health services. In the present study, we aimed to measure the trend of hospitalization and the crude intrahospital mortality rate from 1 year before the HSEP implementation (2013) to 5 years after the HSEP implementation (2018) in public hospitals compared with profit, nonprofit, and charity hospitals, which are affiliated with the Isfahan University of Medical Sciences (MUI). In a prospective, cross-sectional study, the data related to the frequency of hospitalized patients and intrahospital mortality during the time of hospitalization were collected through census sampling from 39 public hospitals as the exposed hospitals and 20 profit, nonprofit, and charity hospitals as the control hospitals. After HSEP implementation, the frequency of hospitalization increased in public hospitals by 50.45% compared with the previous period. Although the crude intrahospital mortality rate increased from 12.61 to 12.93 per 1000 hospitalized patients (an increase of 2.54%) in public hospitals, the raise was not significant (P value = 0.348). The frequency of hospitalization increased in Social Security Organization's (SSO) hospitals as well as charity hospitals. However, the percent of decrease in the intrahospital mortality rates were -42.96%, -34.76%, and -18.47% in the private, charity, and SSO hospitals, respectively, but was not significant (P value > 0.05). The crude intrahospital mortality rates in public hospitals affiliated with MUI did not change significantly after the implementation of the HSEP.

Assessing the quality of public services: For-profits, chains, and concentration in the hospital market.

We examine variation in US hospital quality across ownership, chain membership, and market concentration. We propose a new measure of quality derived from penalties imposed on hospitals under the flagship Hospital Readmissions Reduction Program, and use regression models to risk-adjust for hospital characteristics and county demographics. While the overall association between for-profit ownership and quality is negative, there is evidence of substantial heterogeneity. The quality of for-profit relative to non-profit hospitals declines with increasing market concentration. Moreover, the quality gap is primarily driven by for-profit chains. While the competition result mirrors earlier findings in the literature, the chain result appears to be new: it suggests that any potential quality gains afforded by chains are mostly realized by not-for-profit hospitals.

Ethnicity and health insurance disparities in rectal carcinoma.

e13732 Background: Ethnicity and insurance coverage affect healthcare delivery in rectal carcinoma (RC). RC pts (pts) with Medicaid or no insurance are more likely to present with distant stage RC compared to Medicare/private insurance pts, and have a worse prognosis even when stage is accounted for. To combat such issues, federal law requires that non-profit hospitals, which make up 58% of all community hospitals, to provide charity care, or financial assistance, to those eligible. As insurance status, ethnicity and race have been found to independently affect colon cancer care, we expect similar results for RC in our limited but diverse cohort. Methods: Trinitas Medical Center RWJBH is an urban, community hospital that predominantly treats a minority population and provides financial assistance to eligible underinsured pts. Due to this assistance, or Charity Care, we can provide access to cancer care for many who would not ordinarily have such means. With institutional IRB approval, we completed a retrospective chart review of 59 pts diagnosed with Stage I-IV RC from 2017-2023. We assessed ethnicity, insurance carriers and treatment choices. Results: We reviewed 59 pts with the following ethnic distribution: 22 Hispanic (H), 21 White (W), 11 Black (B) and 5 Asian (A) pts. The median age at diagnosis with RC was 57 in H, 64 in B, 71 in W and 71 in A pts. B pts were found to be diagnosed with more advanced disease: 36% at Stage III and 45% at Stage IV, with none diagnosed at Stage I or II. H pts had comparatively fewer distant stage diagnoses (23% at Stage III, 18% at Stage IV). Neoadjuvant chemotherapy and radiation therapy to 20 of 59 pts treated at our center, 15 of whom subsequently received surgery. Four of five of these declined surgical intervention post neoadjuvant therapy. H pts had the following primary insurance carriers: 36% Medicaid, 36% Medicare, 27% Charity care. 62% of W pts had Medicare and 14% Medicaid. 27% had B pts had Medicare, 27% Medicaid and 9% had Charity care. 50% of the 59 pts had Charity care, with most pts in this group being H. Conclusions: Research suggests that immigrants utilize healthcare facilities less than U.S. citizens and programs like Charity care may be underutilized. In our RC cohort, 38 of 59 (64%) pts were racial minorities, of these 50% received Charity care. Most did not receive screening prior to a diagnosis of rectal cancer and many applied for Charity Care only after their diagnosis. Despite offering significant financial assistance to our pts, we suggest education to immigrants regarding insurance coverage, broader screening efforts and the ability to offer improved subspecialty care to RC pts. In particular, we look to target B and H who present at younger ages and are not Medicare eligible. We believe this will lead to earlier staging of RC, which should lead to improved survival for minority pts.

Ohio Presents Opportunities For Understanding Hospital Alignment With Public Health Agencies On Community Health Assessments.

Multisector collaboration is critical for improving population health. Improving alignment between nonprofit hospitals and local health departments is one promising approach to achieving health improvement, and a number of states are exploring policies to facilitate such collaboration. Using public documents, we evaluated the alignment between Ohio nonprofit hospitals and local health departments in the community health needs they identify and those they prioritize. The top three needs identified by hospitals and health departments were mental health, substance use, and obesity. Alignment across organizations was high among the top needs, but it varied more among less commonly identified needs. Alignment related to social determinants of health was low, with health departments being more responsive to social determinants than hospitals. Given the different strengths and capacities of hospitals and health departments, this divergence may be in the best interests of the communities they serve. Community benefit policies should consider how to promote collaboration between hospitals and health departments while also encouraging organizations to use their own expertise to meet community needs.

Hospital ownership changes and charge-to-cost shifts

We examine hospital-level CCR – charges to Medicare-allowable costs – from 2011 to 2022 among governmental, for-profit, and non-profit hospitals and identify hospitals that charged extreme CCR of over 1000% of the cost. We tracked hospitals that experienced ownership transitions and found that governmental and non-profit hospitals’ average CCR increased by 161% and 99.7%, respectively, after transitioning to become for-profits. These higher CCRs affect uninsured patients, out-of-network patients, and casualty and workers’ compensation insurers.

A framework and process for community-engaged, mixed-methods cancer needs assessments

PurposeCommunity health needs assessments are required for most state and local public health agencies and non-profit hospitals. Typically based on community health improvement planning models, these assessments encompass overall community health and multiple diseases to inform program planning. National Cancer Institute (NCI)-designated Cancer Centers and community-based cancer-focused programs share the goal of reducing cancer burden in the catchment areas they serve. However, to date, no published models exist to guide cancer-specific needs assessments for a determined geographic area that can inform both public health and research initiatives. The purpose of this article is to outline a cancer needs assessment (CNA) framework and community-engaged, mixed-methods process, along with a case study of how we applied it in Kentucky.MethodsWe convened a steering committee of key organizational partners to provide input throughout the process. We developed a conceptual framework of multi-level determinants affecting cancer-related outcomes. We incorporated both quantitative and qualitative data gathered through a variety of means, including a novel application of group concept mapping to guide definition of priorities.ResultsThe resulting CNA has helped guide strategic planning and priorities for Kentucky’s Cancer Action Plan, Markey Cancer Center, state agencies, and community-based organizations.ConclusionThis framework and process can be used collaboratively by cancer center Community Outreach and Engagement offices, public health agencies, oncology programs, and community partners to plan impactful cancer control programs and research in their catchment areas. Universities can also use them to inform the planning of community engagement and health equity research efforts.

New insights about community benefit evaluation: Using the Community Health Implementation Evaluation Framework to assess what hospitals are measuring.

Nonprofit hospitals are required to conduct community health needs assessments (CHNA) every 3 years and develop corresponding implementation plans. Implemented strategies must address the identified community needs and be evaluated for impact. Using the Community Health Implementation Evaluation Framework (CHIEF), we assessed whether and how nonprofit hospitals are evaluating the impact of their CHNA-informed community benefit initiatives. We conducted a content analysis of 83 hospital CHNAs that reported evaluation outcomes drawn from a previously identified 20% random sample ( n = 613) of nonprofit hospitals in the United States. Through qualitative review guided by the CHIEF, we identified and categorized the most common evaluation outcomes reported. A total of 485 strategies were identified from the 83 hospitals' CHNAs. Evaluated strategies most frequently targeted behavioral health ( n = 124, 26%), access ( n = 83, 17%), and obesity/nutrition/inactivity ( n = 68, 14%). The most common type of evaluation outcomes reported by CHIEF category included system utilization ( n = 342, 71%), system implementation ( n = 170, 35%), project management ( n = 164, 34%), and social outcomes ( n = 163, 34%). CHNA evaluation strategies focus on utilization (the number of individuals served), with few focusing on social or health outcomes. This represents a missed opportunity to (a) assess the social and health impacts across individual strategies and (b) provide insight that can be used to inform the allocation of limited resources to maximize the impact of community benefit strategies.

Psychiatric Mental Health Nurses' Perceptions and Experiences of Inpatient Mental Health Care Safety Culture in Saudi Arabia.

Although patient safety culture is gaining attention globally, more studies are needed to investigate its relevance to the nursing care of mental health (MH) patients. This study aimed to illustrate the perceptions and experiences of nurses who work in inpatient mental health care (IMHC) concerning the patient safety practices that are employed to avert safety hazards encountered during the provision of care in IMHC settings. Eighteen postgraduate students working as MH nurses in nonprofit hospitals comprised the study sample. The participants had a minimum of 2 years' nursing experience in IMHC settings. Each participant was interviewed individually using a guided interview technique. The inductive data underwent thematic analysis. Patient protection and a safety perspective were the overarching themes that emerged from the data. Three principal themes and 9 subthemes were illuminated: (a) patient care safety knowledge and background, (b) improving MH care, and (c) development of MH nursing care. The findings of this investigation may assist in providing guidance for the further research into and development of a patient safety culture appropriate for IMHC nursing practice, including increased structured educational experiences, judicious risk assessment, assignment of staff to include a mixture of skills and experience levels during assignments, use of standardized handoff procedures, engagement with multidisciplinary care providers, blame-free reflective information sharing and mentoring, and attention to the built environment with consideration of patient and staff safety needs.