Temporal trends in hospital technical quality under unified clinical governance: a nationwide multicenter...

Large private hospital networks operating under unified clinical governance are increasingly prevalent, yet evidence of sustained improvements in technical quality remains limited, particularly in middle-income countries. We assessed network-wide temporal trends in technical quality indicators, including hospital-acquired infections, falls, pressure injuries, and selected process measures, and examined their association with financial performance.

We conducted a nationwide multicentre longitudinal study of a private hospital network in Brazil from 2016 to 2024. Hospitals entered the cohort at different time points, yielding an unbalanced panel (25-57 hospitals). Network-level trends were estimated using volume-weighted linear regressions of annual means. Hospital-level analyses used mixed-effects models to estimate annual adjusted changes (modelled slopes), with adjustment for changes in earnings before interest, taxes, depreciation, and amortisation (EBITDA), net margin, annual surgical volume, intensive care unit beds, and staffed beds. Trajectories were compared according to hospital type at network entry (network-built versus acquired).

Network-level analyses showed statistically significant annual declines in central line-associated bloodstream infection (- 0·18 per 1,000 central line-days), catheter-associated urinary tract infection (- 0·15 per 1,000 catheter-days), pressure injury incidence density (- 0·05 per 1,000 patient-days), and overall inpatient fall incidence density (- 0·015 per 1,000 patient-days). Antibiotic administration within 1 h of sepsis or septic shock recognition increased by 0·78% per year (95% CI: 0·37 to 1·19), and door-to-wire time for primary percutaneous coronary intervention decreased by 4·0 min per year (95% CI: -6·66 to - 1·28). Most indicators improved or remained stable over time, with non-linear temporal patterns, including transient increases during the COVID-19 period. Trajectories were consistent across hospital entry types. Changes in EBITDA were not associated with annual changes in quality indicators, and net margin showed no association with most indicators but was inversely associated with fall-with-harm and pressure injury incidence.

In this nationwide hospital network, improvements in technical quality were observed over time without a consistent association with financial performance, although inverse associations were identified for selected indicators. These findings suggest that quality improvement and financial stability can coexist within large hospital networks operating under unified clinical governance.