Background: In 2019, Belgium introduced mandatory locoregional hospital networks to enhance collaboration, facilitate task distribution, improve care coordination and achieve rationalization.,Objective: to evaluate the implementation of the Belgian hospital networks five years after enactment and determine the extent to which intended policy objectives have been met in practice.,Methods: this study employed a qualitative multi-method design, combining a systematic content analysis and in-depth elite interviews involving hospital executives, network managers and policy officials. Data were analysed through the lenses of policy implementation and institutional theory.,Results: while formal compliance is high – all networks and their mandatory governance bodies are established – the functional impact remains limited. Collaboration is primarily restricted to low-risk areas such as logistics and procurements, with minimal clinical integration or strategic task allocation. However, in some regions, networks have served as a transition model for hospital mergers, after which clinical integration proved feasible. Implementation is hindered by a misalignment between network boundaries and natural patient flows, ”institutional void” stemming from shared but limited governmental authority and a ”mutual hesitation trap” between hospitals and policy makers which further perpetuates implementation inertia.,Conclusions: Formal legislative adoption has not yet translated into the intended functional transformation. To move beyond symbolic adoption, policy makers should reconsider coordination models. Shifting towards a population-based logic and aligning financial mechanisms seem essential.

This study introduces a novel general-purpose mixed-integer programming heuristic designed for problems decomposable into a column-based formulation. The method encompasses a hybrid primal heuristic that alternates between two phases, i.e., column generation and the iterative solving of hybrid optimization models using mixed-integer programming. The hybrid models incorporate original (compact) and column variables, leveraging the advantages of both. The elements of the compact model ensure flexibility and the generation of new columns for one of the subproblems in search for improved integer feasible solutions. For the other subproblems, the solution space is constrained by only considering previously generated columns, uplifting tractability of the optimization search. To demonstrate the benefits of this approach, it is applied to a complex operating room planning problem that determines the case-mix and capacity planning, integrating the strategic decision-making with tactical admission planning of patients and relevant operational considerations related to the sequencing of surgical procedures. For solving the problem under study efficiently, the algorithm is accelerated using dedicated optimization mechanisms. The methodology is assessed using a dataset inspired by real-life settings. In the computational experiments, we validate the algorithm design choices and demonstrate that the proposed heuristic consistently outperforms alternative primal heuristics and mathematical programming.

Introduction Shift-to-shift handovers are a critical aspect of communication in healthcare settings, particularly in mental healthcare, where the nature of the information being transferred is complex and dynamic. This study aims to develop a mnemonic to structure nursing handover content in diverse psychiatric settings, ensuring effective communication and continuity of patient care. To date, no mnemonic tool specifically tailored to psychiatric handovers exists, highlighting a significant gap in practice and research. Methods A qualitative co-design approach was used, involving individual interviews with healthcare professionals from five psychiatric units in Flanders and two focus group interviews. Data were analyzed using reflexive thematic analysis. Results The study led to the development of the IPSA2 mnemonic (Identification, Problem, Situation, Agreements, and Action). Key contextual factors contributing to efficient nursing handovers included understanding the purpose of the handover, minimizing debriefing and interruptions, and having a designated leader to guide the process. Discussion The IPSA2 mnemonic was created as a tool for organizing handover content in psychiatric settings. The findings support previous research highlighting the importance of structure, clarity, and leadership in handovers.

AIM:To explore factors influencing the implementation of a nursing care delivery model in a hospital setting. DESIGN:A qualitative evidence synthesis with a thematic synthesis was conducted. METHODS:The search string consisted of four 'cluster topics': (1) nursing, (2) care delivery models, (3) hospital setting, (4) qualitative and mixed methods designs. Four electronic databases were searched from January 2000 until July 2024: MEDLINE (PubMed interface), Embase (embase.com interface), CINAHL (EBSCOhost interface) and Web of Science. A thematic synthesis was conducted consisting of the following steps; the 'line-by-line' coding of the text, the development and allocation of 'descriptive themes' and the generation of 'analytical themes'. RESULTS:In total, 3976 references were screened, of which 25 were included in the qualitative evidence synthesis. Eight analytical themes were generated that influence the implementation of a nursing care delivery model in a hospital setting: shared understanding of the care delivery model, ownership of the change, scope of practice and role clarity, collaboration, communication, responsibility, a double-loop process and aggregated recommendations. The themes were categorised on four different levels: vision, process, interactional factors and contextual factors. CONCLUSION:The eight themes identified in this qualitative evidence synthesis showed that during the implementation of a nursing care delivery model, a clear implementation strategy is often missing. It is advised that future implementation processes have a clear guide and goal. IMPACT:The analytical themes can guide the future implementation of a new nursing care delivery model in a hospital setting. This review can support nurses, researchers, hospital management and policymakers when implementing organisational alternatives to reorganise nursing care in a hospital setting. REPORTING METHOD:The qualitative evidence synthesis was reported according to the enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) statement. PATIENT OR PUBLIC CONTRIBUTION:No patient or public contribution.

Introduction Patient participation and safety are pivotal in healthcare quality, internationally acknowledged for enhancing health services. This study examines the correlation between two assessment tools, the Patient Participation Culture Tool (PACT) and the Hospital Survey on Patient Safety Culture (HSPSC), using retrospective data from 2014 to 2021.Method For the main analysis, dimensional scores of the HSPSC and domain scores of the PACT were aggregated according to hospital and specific wards. In a second step, we used aggregated scores by hospital and profession. Descriptive statistics outlined the sociodemographic characteristics of participants. Spearman’s rank correlation coefficient was employed to evaluate relationships between continuous variables represented by PACT domain and HSPSC dimensional scores among study participants.Results Data from 17 hospitals were analysed. The participants were distributed across 43 wards, and a match based on staff positions resulted in 37 different groups, predominantly comprised of nurses (>89%). At ward level, five PACT domains correlated significantly with ten different HSPSC dimensions (p<0.05), while a significant correlation was found between four PACT domains and seven HSPSC dimensions based on function. The correlation graphs demonstrate strong internal coherence within safety and participation culture measurements, highlighting the distinctiveness and validity of each questionnaire in capturing intricacies within patient safety and participation culture, supporting their construct validity.Conclusions This study compared the PACT and the HSPSC, revealing their connections and unique features. Using Spearman’s correlation, it positively linked patient participation and safety culture, finding significant correlations, mainly moderate, between their specific aspects. It highlighted how patient involvement positively influences safety practices in healthcare, valuable for enhancing overall quality.

Background Multidisciplinary team meetings (MDTMs) are considered a cornerstone of oncology care, yet questions remain about their efficiency and patient-centeredness. While tools exist to guide and structure MDTMs, their integration into hospital settings is often inconsistent. Methods This feasibility study examined the use of two validated tools—the MDT-QuIC checklist and the MDT-MeDiC complexity tool—across ten Multidisciplinary Oncological Consultations (MOCs) in five Belgian hospitals. Baseline assessments were conducted using the validated MDT-MODe observational instrument. Implementation feasibility was evaluated through repeated observations at the MOCs and interviews with MOC chairs. Results Baseline data showed limited discussion of psychosocial information and patient preferences, and minimal nurse contribution. The MDT-QuIC was generally accepted as helpful for structure and role clarity, though not consistently applied due to time pressures. The MDT-MeDiC tool was considered too resource-intensive for routine use. Implementation success varied by existing structure, leadership style, and administrative support. Conclusion Structured tools can improve the organization of MOCs, but feasibility is dependent on local context. Broader uptake across health systems requires attention to team composition, preparatory workflows, and integration into supportive policy and digital frameworks. Policy summary Embedding structured MDTM tools into oncology policy, through digital integration, case complexity triaging, and incentives for psychosocial and nursing input enables efficient use of expert time while safeguarding patient-centredness.

Head nurses have diverse job content, including operational management, human resources management, patient care, and unit-level policy development. They act as leaders, coordinators, managers, monitors, liaisons, and negotiators, and thus require broad competencies. Measuring these competencies is challenging because of the absence of integrated instruments that measure multiple intertwined competencies. This study aimed to identify and map existing instruments used to measure head nurses’ competencies and analyze the specific competencies they address. A scoping review according to the five-stage framework of Arksey and O’Malley was conducted. Articles focusing on developing and psychometrically testing instruments to measure the competencies of head nurses with 24-hour first-line organizational and hierarchical responsibility for one or two units in a hospital setting were included. An electronic search was conducted via PubMed, Embase, and CINAHL. The Journal of Nursing Administration, Journal of Nursing Management, Journal of Healthcare Management, International Journal of Healthcare Management, Nursing Management, Nursing Administration Quarterly, and Nursing Outlook were screened manually to identify additional articles. This study included twelve articles published between 2006 and 2024. A total of 477 head nurse competencies were identified across 12 measurement instruments. Thematic analysis revealed four key competency areas, encompassing 20 related subthemes. First, strategic management competencies involve systemic thinking, research and evidence-based practices, change management, creative thinking, external liaison, and possessing an organizational view and political savviness. Second, operational management competencies focus on quality and safety management, process management, technology and information management, financial management, resource management, and staff planning. Third, clinical competencies encompass direct patient care, case management, customer service commitment, and diversity and ethical practices. Finally, human resources competencies include communication and interpersonal competencies, general staff management, professional development, and individual staff management. Nine instruments permitted self-assessment, two facilitated 360° assessment, and one enabled assessment by the head nurses’ superiors. This study highlights inconsistencies in the terminology and descriptions of the head nurse position, as well as the competencies outlined in instruments, leading to ambiguity. To address this, clearer and more standardized definitions are needed, ensuring that competencies can be effectively measured in practice.

Technology plays a growing role in allowing aging persons to live independently. However, it is often difficult to motivate aging persons to use these new technologies. Using 182 dyads of aging persons and their primary family caregiver, this study investigates how family members' beliefs about the capabilities of the aging person are associated with the aging person's engagement in using healthcare technology—a phenomenon known as the Pygmalion effect. A quantitative statistical method response-surface analysis (RSA) was performed. RSA is often employed to understand complex, nonlinear interactions within a data set. It was investigated how the level of fit (when both the aging person and his or her family caregiver hold similar beliefs about the technological capabilities of the aging person) and the direction of misfit (whether the abilities of the aging person are greater or worse than the family caregiver thinks) shape the aging person's intention to use healthcare technologies. The individual perception of capabilities is an important driver of the intention to use technology. In line with the Pygmalion effect, the effects of family members on aging persons drives their adoption of healthcare technology. The greatest intentions to use technology are observed when there is a fit in beliefs. In contrast, misfit leads to lower usage intentions. The direction of misfit further reveals that aging person's beliefs about their capabilities are more decisive than their family caregiver's beliefs in promoting their technology usage intentions. In addition, age, experience with technology, attitudes, social norms, and technological savviness in the family also have an impact on aging persons' intentions to use technology. This study extends the theoretical basis of the Pygmalion effect by including fit, misfit, and direction of (mis)fit.

BACKGROUND:Head nurses face challenging job content while executing their roles as nurses, managers and leaders. However, no European compilation for portraying head nurses' job content within a hospital setting is available. OBJECTIVES:This study aimed to develop and validate a compilation that portrays the job content of head nurses employed in European hospitals. METHODS:A scoping review was conducted according to Arksey and O'Malley's (2005) five-stage framework. Articles focusing on the job content of head nurses with 24-h first-line organizational and hierarchical responsibility for one or two units in a hospital setting were included. An electronic search was performed via PubMed, CINAHL and Embase. The Journal of Nursing Administration, Journal of Nursing Management, Journal of Healthcare Management and Nursing Management were screened manually to identify additional articles. Subsequently, a two-round multinational Delphi study following the methodology of Yussof (2019) was carried out. Eligible opinion leaders originated from Europe and included head nurses, as well as second-line nurse managers and hospital executives with head nurse experience. Twenty-three opinion leaders participated in the first round of the Delphi study, and 16 opinion leaders from the initial round subsequently participated in the second round. The item-level content validity index and scale-level content validity index based on the average method were calculated. RESULTS:The scoping review included 90 articles published between 1934 and 2024. In total, 64 terms were found to name the head nurse position. Job content could be categorized according to four main themes: operational management, patient care, human resources management and unit-level policy development. Fifteen subthemes were determined, namely quality and safety management, staff planning, administrative and financial management, resource and technology management, care planning, direct and indirect patient care, individual and general staff management, learning opportunities, strategic management, creative thinking, and change management. After two Delphi rounds, the final compilation comprises four main themes, 10 subthemes and 53 task descriptions, excluding staff planning, care planning, direct patient care, administrative management and financial management. CONCLUSIONS:Head nurses' job content mapped by international evidence differs from the job content considered relevant by European opinion leaders. Fragmentation in what European opinion leaders considered relevant within the head nurses' job content became apparent. The compilation can be tailored to different countries or types of hospitals and serve as a guide for second-line nurse managers and hospital executives to determine the key job content based on the priorities and strategic direction of the hospital.

Palliative care is becoming an essential component of healthcare, but there is insufficient research on how integration across different levels of care (micro, meso, and macro) is realized in practice. Without such integration, care may become fragmented, leading to suboptimal patient outcomes. While many studies have explored palliative care models, there is a gap in understanding how priorities for integrated care align across these levels within healthcare ecosystems. Specifically, it is unclear whether key actions at each level are shared, coordinated, and supported effectively, making it difficult to implement sustainable, cohesive care strategies. Our study aims to explore the extent to which important goals (i.e., priorities) are shared across the micro, meso, and macro levels of the palliative care ecosystem in Flanders, Belgium. We applied a multimethod study using the analytic hierarchy process method (AHP). This consists of three sequential steps: a broad literature search and interviews with Belgian stakeholders (n = 12) to determine the criteria for the organization of integrated care; focus groups (n = 8) with patients, their relatives and caregivers to establish the completeness and relevance of the criteria; and prioritization of the criteria using a questionnaire among 305 Flemish participants (patients, relatives, caregivers and policy makers). Our findings revealed that integration is imbalanced, with priorities being most emphasized at the micro level (57

To deal with the upcoming challenges and complexity of the nursing profession, it is deemed important to reflect on our current organization of care. However, before starting to rethink the organization of nursing care, an overview of important elements concerning nursing care organization, more specifically nursing models, is necessary. The aim of this study was to conduct a mapping review, accompanied by an evidence map to map the existing literature, to map the field of knowledge on a meta-level and to identify current research gaps concerning nursing models in a hospital setting. Next to nursing models, two other organizational correlates seem to be of importance when looking at the organization of nursing care: nurse staffing and skill mix. Although it seems that in recent research, the theoretical focus on the organization of nursing care has been left behind, the increasingly complex healthcare environment might gain from the use of nursing theory, or in this case, care delivery models. As almost no fundamental studies have been done toward the combination of care delivery models, nurse staffing, and skill mix, those elements should be taken into account to fully capture the organization of nursing care in future research.

INTRODUCTION:The COVID-19 pandemic required a significant response from global healthcare systems. In Belgium, the crisis began in March 2020, prompting quick action in hospitals. This study assesses the effectiveness of Belgium's hospital emergency plans and compares them with global standards for potential enhancements. METHODOLOGY:An online survey targeting CEOs of 60 Flemish general hospitals evaluated the deployment of hospital emergency coordination cells during the pandemic's first and fourth waves, utilizing various statistical analyses. RESULTS:Findings indicate a high establishment rate of COVID-19 coordination cells before the government's deadline. Despite this readiness, differences in leadership, involvement, and communication strategies were noted among hospitals. There was a notable shift towards hybrid meetings and an evolving role for coordination cells, highlighting the need for a more structured crisis management approach. CONCLUSION:The study concludes that while Flemish hospitals were quick to respond, the lack of a standardized framework suggests the potential for adopting models like the Hospital Incident Command System (HICS) for improved crisis management. Future research should examine the long-term effects of these strategies and the integration of comprehensive emergency management systems in Belgium's healthcare.

PurposeNurses are capable of acting as advocates for patients since they hold valuable knowledge on patient preferences and their psychosocial needs. Yet, in practice they tend to contribute little to multidisciplinary team meetings (MDTMs). This study analyses the factors that influence whether or not nurses will speak up and increase patient-centred decision-making in MDTMs.Design/methodology/approachA multiple case study with cross-case comparison of twelve tumour groups across two Belgian hospitals was conducted. Data collection involved fifty structured non-participant observations and 41 semi-structured interviews with participants from the twelve tumour groups.Originality/valueThis study yields factors that increase the opportunities for nurses to speak up in MDTMs to enhance patient-centred decision-making. The findings help in the design of future interventions concerning multidisciplinary teamwork, that address nurses' contributions to augment patient-centred care.

BACKGROUND:Critical care nurses (CCNs) around the globe face other health challenges compared to their peers in general hospital nursing. Moreover, the nursing workforce grapples with persistent staffing shortages. In light of these circumstances, developing a sustainable work environment is imperative to retain the current nursing workforce. Consequently, this study aimed to gain insight into the recalled experiences of CCNs in dealing with the physical and psychosocial influences of work-related demands on their health while examining the environments in which they operate. The second aim was to explore the complex social and psychological processes through which CCNs navigate these work-related demands across various CCN wards.METHODS:A qualitative study following Thorne's interpretive descriptive approach was conducted. From October 2022 to April 2023, six focus groups were organised. Data from a diverse sample of 27 Flemish CCNs engaged in physically demanding roles from three CCN wards were collected. The Qualitative Analysis Guide of Leuven was applied to support the constant comparison process.RESULTS:Participants reported being exposed to occupational physical activity, emotional, quantitative, and cognitive work-related demands, adverse patient behaviour, and poor working time quality. Exposure to these work-related demands was perceived as harmful, potentially resulting in physical, mental, and psychosomatic strain, as well as an increased turnover intention. In response to these demands, participants employed various strategies for mitigation, including seeking social support, exerting control over their work, utilising appropriate equipment, recognising rewards, and engaging in leisure-time physical activity.CONCLUSIONS:CCNs' health is challenged by work-related demands that are not entirely covered by the traditional quantitative frameworks used in research on psychologically healthy work. Therefore, future studies should focus on improving such frameworks by exploring the role of psychosocial and organisational factors in more detail. This study has important implications for workplace health promotion with a view on preventing work absenteeism and drop-out in the long run, as it offers strong arguments to promote sufficient risk management strategies, schedule flexibility, uninterrupted off-job recovery time, and positive management, which can prolong the well-being and sustainable careers of the CCN workforce.

Background: Belgium initiated a hospital pay for performance (P4P) programme after a decade of fixed bonus budgets for "quality and safety contracts". This study examined the effect of P4P on hospital incentive payments, performance on quality measures, and the association between changes in quality performance and incentive payments over time. Methods: The Belgian government provided information on fixed bonus budgets in 2013 - 2017 and hospital incentive payments as well as hospital performance on quality measures for the P4P programmes in 2018 - 2020. Descriptive analyses were conducted to map the financial repercussion between the two systems. A difference -in -difference analysis evaluated the association between quality indicator performance and received incentive payments over time. Results: Data from 87 acute -care hospitals were analyzed. In the transition to a P4P programme, 29% of hospitals received lower incentive payments per bed. During the P4P years, quality performance scores increased yearly for 55% of hospitals and decreased yearly for 5% of hospitals. There was a significant larger drop in incentive payments for hospitals that scored above median with the start of the P4P programme. Conclusions: The transition from fixed bonus budgets for quality efforts to a new incentive payment in a P4P programme has led to more hospitals being financially impacted, although the effect is marginal given the small P4P budget. Quality indicators seem to improve over the years, but this does not correlate with an increase in reward per bed for all hospitals due to the closed nature of the budget. (c) 2024 FECA. Published by Elsevier Espana, S.L.U. All rights reserved.

IntroductionInvolving mental healthcare patients in nursing handover practices seems a promising method for increasing patient participation, empowerment, and shared decision-making but is hardly found in practice.MethodAn explorative review on bedside handovers in mental health care was conducted. Searched databases included CINHAHL, Web of Science, PubMed, and Embase. The search strategy yielded 3126 articles. Nine articles met the inclusion criteria and were included in this review.ResultsPre- and post-implementation perspectives were described, as well as strategies for implementation. After the implementation of bedside handover, nurses and patients experienced more time spent together and a greater sense of involvement with the care plans could be noticed.DiscussionBeing involved in bedside handovers facilitates active participation and open dialogue between nurses and patients. This accelerates the opportunities for patients to take part in shared decision-making and feel recognised as experts in their illness experience. More research on possible differences in effectiveness across different patient diagnoses is recommended.ConclusionInvolving patients in mental health care in handover practices seems a promising method but limited research has been done to explore the meaning it has to mental healthcare nurses and patients.

Top-down and externally imposed quality requirements can lead to improvement but do not seem as sustainable as intended. There is a need for a quality model that intrinsically motivates healthcare professionals to contribute to quality and safe care in hospitals. This study shows how a quality model that matches the identity and the quality vision of the organization was developed. A multimethod design with three phases was used in the development of the model at a large teaching hospital in Belgium. In the first phase, 14 focus groups and 19 interviews with staff members were conducted to obtain an overview of the quality and safety challenges, complemented by a plenary discussion with the members of the patient advisory council. In the second phase, the challenges that had been captured were further assessed using a hospital-wide survey for all hospital staff. Finally, a newly established quality review board (with internal and external stakeholders) critically evaluated the input of Phases 1 and 2 and defined the basic quality standards to be implemented in the hospital. A first evaluation 2 years after the implementation was conducted based on (i) patients’ perceptions of quality of care and patient safety by publicly available indicators collected in 2016, 2019, and 2022 and (ii) staff experiences and perceptions regarding the acceptability of the new model gathered through (grouped) interviews and an open questionnaire. The quality model consists of eight broad themes, including norms for the hospital staff (n = 27), sustained with quality systems (n = 8), and organizational support (n = 6), with aid from adequate management and leadership (n = 6). The themes were converted into 46 standards. These should be supported within a safe, efficient, and caring work environment. The new model was launched in the hospital in June 2021. The evaluation shows a significant difference in quality and safety on different dimensions as perceived by hospitalized patients. The perceived added value of the participatory model is a better fit with the needs of employees and the fact that the model can be adjusted to the specific context of the different hospital departments. The lack of hard indicators is seen as a challenge in monitoring quality and safety. The participation of various stakeholders inside and outside the organization in defining the quality challenges resulted in the creation of a participatory quality model for the hospital, which leads towards a better-supported quality policy in the hospital.

AIM:To synthesize and assess the effectiveness of different care delivery models in a hospital setting, taking into account patient- and nurse-related outcomes. DESIGN:A systematic review with narrative synthesis in which a comparison was made between different care delivery models. METHODS:The search string consisted of four clusters: 'nursing', 'care delivery models', 'hospital setting' and 'quantitative research designs'. Four electronic databases were searched from the inception of the databases to January 2023: Medline, Embase, CINAHL and Web of Science. RESULTS:In total, 19 studies were included in the systematic review. The most commonly compared care delivery models were functional nursing to primary nursing (n = 6), patient allocation to team nursing (n = 4), team nursing to primary nursing (n = 3) and functional nursing to modular nursing (n = 3). Only one randomized crossover trial was found, other included studies were pretest-posttest designs or quasi-experimental designs. The implementation of a nursing care delivery model was the study intervention. The following aspects of the intervention were not reported or inadequately described by the majority of the authors; tailoring of an intervention, modifications to an intervention and the adherence or fidelity to the intervention. Job satisfaction and quality of nursing care were the most commonly reported nursing outcomes, while patient satisfaction was the most commonly reported patient outcome. Due to a high heterogeneity in outcome measures between the studies, a meta-analysis of the included studies was not possible. All included studies had a high risk of overall bias. CONCLUSION:This systematic review found mixed evidence, inconsistent reporting of certain elements of the interventions, high heterogeneity in outcome measures and low methodological quality. Although this systematic review could not answer which nursing care delivery model is the most effective or most promising, other important findings from this review may inform future research. IMPACT:There are differences in care delivery model descriptions and a lack of agreement on the strengths and weaknesses of the care delivery models. No clear-cut answer can be given about the effect of different care delivery models in a hospital setting on patient- and nurse-related outcomes. Job satisfaction and quality of nursing care were the most commonly reported nursing outcomes, while patient satisfaction was the most commonly reported patient outcome. This review can support the development of future care delivery redesign strategies. REPORTING METHOD:The systematic review was reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). PATIENT OR PUBLIC CONTRIBUTION:No patient or public contribution.

Objective To evaluate the agreement between nurse and dietician nutritional risk assessments when using the Nutritional Risk Screening 2002 (NRS2002) protocol, and to explore the relations of falsely labeling patients ‘not at risk‘ for malnutrition and the screening time difference (STD) between nurse and dietician with the length of stay (LoS). Methods Included are all patients hospitalized in a tertiary care center between January 2017 and December 2019 and screened for malnutrition by both a nurse and a dietician. The inter-rater reliability is evaluated using Cohen’s Kappa. The relation between STD and the patient classification (PCET) is assessed by a linear mixed effect model. The relation between the LoS and PCET is evaluated with the Kaplan–Meier method and multivariable Cox regression including STD with pathology group and severity of illness as random effect. Results 9085 patients are assessed by nurse and dietician. 72% of all assessments agree (Kappa = 0.44 [0.43–0.46]). The dietician is involved later for patients falsely labeled ‘not at risk’ (1.06 [0.92–1.20] days; p < 0.001). Compared to patients where the dietician is involved within 3 days, the LoS is 7.37 days (Hazard Ratio (HR): 0.51 [0.43–0.61]) longer for patients falsely labeled ‘not at risk’, while only 3.51 days (HR: 0.72 [0.64–0.80]) longer for patients correctly labeled ‘at risk’. Conclusions Agreement of screening for malnutrition between nurses and dieticians is weak. Avoiding falsely labeling patients ‘not at risk‘ should be a main concern upon patient admission as later involvement of dieticians is correlated with a longer LoS.

This chapter explores the challenges for boards within today’s changing healthcare environment. Leadership is the art of influencing people so they enthusiastically move towards the achievement of a goal. Beyond that, leaders must create the right environments to achieve successful outcomes. Based on their fiduciary duty, board members can be expected to be capable leaders. However, the right conditions are needed. The board is an entity with particular connections and responsibilities. For healthcare boards, their interconnectedness can cause controversies. This chapter discusses these controversies in hospital board governance practices, attention is also given to the conceptual framings for healthcare board governance. We conclude with suggested directions for future research.