The association between hospital financial performance and the quality of care—a scoping review protocol

Health systems around the world operate under constant pressure to contain costs and improve the quality of care [1‐4]. Hospitals constitute a cornerstone of health service provision with their share of total current health expenditures ranging from 28.3% in Germany to 53.2% in Turkey in 2017 and being above 35% in 21 OECD countries [5]. A review by Schwierz [2] indicated that among the European Union member states a range of policy options have been implemented with the objective to contain the growth of hospital sector costs. Studies from numerous countries have indicated that hospitals might often face challenges related to long-term financial deficits (e.g., in UK [6], Italy [7], and several Central and Eastern European countries [8]) and/or risk of bankruptcy (e.g., in Germany [9] and the USA [10]). At the same time, the quality of care has been an important health policy objective at both national and international levels [3, 11]. Diverse strategies aimed at quality assurance or improvement have been implemented throughout different countries, at both system and organizational/institutional levels [3]. Several literature reviews on quality improvement strategies in hospital care can be identified [12‐15], illustrating a variety of approaches in terms of the mechanisms used to improve quality as well as mixed results in terms of the effectiveness of particular approaches.

The literature suggests that there is an association between health care providers’ financial performance (FP) and the quality of care (QoC) [16]. On the one hand, providers that are more financially stable (e.g., generate profit) might provide better quality of care as they have better capacity to finance investments in new technology, pay higher wages (and/or attract more skilled staff), and maintain reliable systems and resources for quality improvement [17, 18]. On the other hand, a better quality of care might lead to financial gains in the form of increased revenues (e.g., higher reimbursement, bonuses under “pay for quality” (P4Q) programs [19]), and/or achieved savings (e.g., due to improved management or limited waste [20]). Nevertheless, the scope of available evidence on this two-way association has not been thoroughly analyzed yet.

We have identified two previous literature reviews on associations between hospital FP and QoC, yet they were focused solely on the national context of the US market [16] or conducted more than a decade ago [21]. Also, there are several published studies/reviews focusing on or including the evaluation of P4Q programs in hospital settings [19, 22‐24]. Yet, in the case of those, the researchers were mainly interested in the impact of participation in the incentive program on quality of care (e.g., patient outcomes) and not on how the improvement in quality affected the overall hospital financial standing.

This scoping review will be conducted based on the methodological framework outlined by Arksey and O’Malley [29] and further developed by Levac et al. [30]. This framework includes the following stages: (1) defining the research question; (2) identifying relevant literature; (3) study selection; (4) data extraction; (5) collating, summarizing, and reporting the results; and (6) the consultation process and engagement of knowledge users. The reporting will utilize the PRISMA extension for Scoping Reviews (PRISMA-ScR) checklist [31]. The search strategy will be finalized and the searches conducted in August 2021, while data screening, extraction, and synthesis will take place from September 2021 with the scoping review being finalized by late Autumn, 2021. This project has been registered through the Open Science Framework [32].

This scoping review will identify and map a broad spectrum of evidence on the association between hospital financial performance and the quality of care. The review process will apply a rigorous methodological approach while wide-ranging inclusion criteria (quantitative and qualitative empirical studies as well as theoretical papers, no date limit) should assure broad coverage of the available literature. In case this protocol needs to be amended following its publication, the date, detailed description, and justification for each amendment will be reported.

There are several potential limitations to be noted. Firstly, following guidance on conducting scoping reviews [35], no quality assessment and risk of bias assessment of included studies will be conducted. Secondly, due to language limitations of the review team, only publications in English will be considered. We are also aware that there is abundance of additional factors that may influence both the hospital FP and QoC and we might identify mostly observational studies (e.g., cross-sectional or longitudinal), which may identify associations but cannot answer questions of causality. Yet, we would be still able to define the strengths of these associations and describe the control variables used.

Despite the above-mentioned limitations, we believe that the results of this scoping review will be of interest for both researchers and policy-makers at the health system level, as well as hospital managers at the micro level. By providing a systematic overview of the existing literature, we aim to build a knowledge base around the topic of associations between hospital FP and QoC. We hope to answer the question whether there is a trade-off between these two areas and define more precise research questions for future investigations (e.g., a systematic review and meta-analysis). Our findings could also indicate that the relationship depends on the context, and future research would have to place a stronger emphasis on contextual factors. The findings will be published in a peer-reviewed journal. The paper will be circulated through relevant mailing lists and social media, as well as diverse research platforms. The findings will also be disseminated through conference presentations as well as summaries for key stakeholders (e.g., via the knowledge transfer platform of the leading author university).