funded by the european community ‘s seventh framework programme fp7/2007-2013 under grant...
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Funded by the European Community ‘s Seventh Framework Programme FP7/2007-2013 under grant agreement nª 24188
Deepening our Understanding of Quality
Improvement in Europe
Deepening our Understanding of Quality Improvement in
Europe Rosa Sunol and Oliver Groene
on behalf of the DUQuE Consortium
Funded by the European Community ‘s Seventh Framework Programme FP7/2007-2013 under grant agreement nª 24188
Deepening our Understanding of Quality
Improvement in Europe
Project coordination: Avedis Donabedian Institute, Autonomous University of Barcelona. Prof. Rosa Suñol; Co-IP: Oliver Groene, PhD Partners Academic Medical Centre, Netherlands Netherlands Institute of Health
Services Research, Netherlands Dr Foster Intelligence, England Department of Clinical Quality and
Patient Safety, Central Denmark Region Polish Society for Quality Promotion of
Health Care, Poland Institute for Medical Sociology, Health
Services Research and Rehabilitation Sciences, Germany
European Hospital and Healthcare Federation, Belgium
University of California, Los Angeles, USA
Avedis Donabedian Institute, Autonomous University of Barcelona, Spain
Country coordination Czech National Accreditation
Committee, Czech Republic Dr Foster Intelligence, England Haute Autorité de Santé, France Institute for Medical Sociology,
Health Services Research and Rehabilitation Sciences, Germany
Silesian Society for Quality in Health Care , Poland
General directorate of Health, Portugal
Foundation for the Accreditation and the Development of Health Services, Spain
Turkish Society for Quality Management, Turkey
Funded by the European Community ‘s Seventh Framework Programme FP7/2007-2013 under grant agreement nª 24188
Deepening our Understanding of Quality
Improvement in Europe
• Substantial amount of research in the last 30 years on assessing and improving the quality of health care
• Considerable progress in developing measurement tools and widespread application; however, quality and safety problems persist
• Debate on how to accelerate and sustain quality improvement is more up to date than ever
• Relevance for decision-makers at different levels:– Hospital, purchasing agencies, MS and EU level
Background
Funded by the European Community ‘s Seventh Framework Programme FP7/2007-2013 under grant agreement nª 24188
Deepening our Understanding of Quality
Improvement in Europe
Justification• At European level, there is currently no
comprehensive guidance for the hospitals on the development of their quality management systems
• Exploration of impact of quality improvement strategies on patient-level performance has not been performed at EU level
• DUQUE will aim at identifying the most effective quality and safety mechanisms
• This research will guide hospitals, and purchasers in contracting hospital services
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Funded by the European Community ‘s Seventh Framework Programme FP7/2007-2013 under grant agreement nª 24188
Deepening our Understanding of Quality
Improvement in Europe
Overall objective
To test whether organisational quality improvement and culture, professionals' involvement, and patient empowerment are associated with the quality of care in
European hospitals (as measured in terms of clinical effectiveness, patient
safety and patient involvement)
Funded by the European Community ‘s Seventh Framework Programme FP7/2007-2013 under grant agreement nª 24188
Deepening our Understanding of Quality
Improvement in Europe
1. To develop a classification model for organizational quality management systems in EU hospitals
2. To investigate associations between the development of quality management systems and hospital level measures of organizational culture, professional engagement and patient empowerment
3. To investigate associations between the development of quality management systems and patient level quality of care outcomes (clinical effectiveness, patient safety and patient involvement)
4. To identify factors influencing the uptake of quality management activities by hospitals, including external pressure as enforced by accreditation, certification or external assessment programs
5. To summarize and assess the different analysis in order to inform the development of the hospital and purchaser appraisal guide
Research Questions
Quality management system
Quality management systems index
Quality management compliance index
Clinical quality implementation index
Hospital governance
Quality orientation of the management board
External pressure
Perceived external pressure
External assessmentExte
rnal
Hosp
ital le
vel
Path
way level
Pati
en
t le
vel
Hospital cultureCompeting values
Social capital
Patient safety culture
Patient
Involvement in QM
Involvement in QM
Client council
Departmental quality strategies
Specialized expertise and responsibility
Evidence-based organization of pathways
Patient safety strategies
Clinical review
Pathway culturePatient safety culture
Teamwork culture
ProfessionalismAttitudes
Behavior
Hip fractureStroke
Clinical effectivenessPatient experience Perceived patient safety
Professional
involvement
Acute myocardial infarctionDeliveries
Patient
Involvement in QM
Involvement in QM
Patient information
Funded by the European Community ‘s Seventh Framework Programme FP7/2007-2013 under grant agreement nª 24188
Deepening our Understanding of Quality
Improvement in Europe
Overall design
• Cross-sectional study• Data collected at hospital, departmental,
professional and patient levels • Mixed methods:
– Measurement of the various constructs will entail both qualitative and quantitative techniques • Surveys• Chart review• Audit/observation• Routine data
Funded by the European Community ‘s Seventh Framework Programme FP7/2007-2013 under grant agreement nª 24188
Deepening our Understanding of Quality
Improvement in Europe
Countries participating in the field test
Criteria:
• They cover
different
European health
systems and
social variation
• They are big
enough to have
sufficient number
of hospitals for
the sampling
strategy.
Funded by the European Community ‘s Seventh Framework Programme FP7/2007-2013 under grant agreement nª 24188
Deepening our Understanding of Quality
Improvement in Europe
Applicable to ALL 30 hospitals> = 130 beds General hospitals /Provide care for the four conditions
studied Acute Myocardial Infarction (AMI) Stroke Hip Fracture Deliveries
Applicable only to the 12 hospitals for the in-depth study
Volume of care provided to ensure recruitment of patients in given timeframe (30 valid cases in 4-5months per condition)
Hospitals inclusion criteria
Funded by the European Community ‘s Seventh Framework Programme FP7/2007-2013 under grant agreement nª 24188
Deepening our Understanding of Quality
Improvement in Europe
Countries and Hospitals participation
Participation and Activities at country level
30 hospitals Activities: - Surveys to professionals
(management directors, quality coordinators and prof. leaders)
- Administrative Data
12 hospitals (from the previous 30)
Additionally performed the following
Activities: - Surveys to professionals (Chiefs of
Department and professionals
- Chart review (35 per condition) - Surveys to patients (30 per
condition’s pathway) - Visits
Countries
Czech Republic
England
France
Germany
Poland
Portugal
Spain
Turkey
Total hospitals (n=240) and patients (n=11520)
Funded by the European Community ‘s Seventh Framework Programme FP7/2007-2013 under grant agreement nª 24188
Deepening our Understanding of Quality
Improvement in Europe
Questionnaires expected to be completed in each type of hospital
Type of questionnaire Non in-depthhospital
In-depthhospital
Professional QuestionnairesA. Chair of the Board of Trustees 1 1B. Chief Executive Officer 1 1C. Chief Medical Officer 1 1M. Highest Ranking Nurse 1 1D. Quality Manager 1 1E. Leading Physicians and Nurses 20 20F. Manager of Care Pathways or Head of Department 0 4G. Professionals at pathway level 0 80Patient Questionnaires 0 120Chart Reviews 0 140Administrative Routine Data 1 1External visits 0 1TOTAL QUESTIONNAIRES 26 371
Funded by the European Community ‘s Seventh Framework Programme FP7/2007-2013 under grant agreement nª 24188
Deepening our Understanding of Quality
Improvement in Europe
Expected output
• Development of guidance for hospitals – an in-depth overview on the effectiveness of quality and safety strategies and how to integrate them at hospital and departmental level.
• Appraisal scheme for purchasers – identifying the core quality and safety strategies that should be in place in European hospitals.
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Funded by the European Community ‘s Seventh Framework Programme FP7/2007-2013 under grant agreement nª 24188
Deepening our Understanding of Quality
Improvement in Europe
Some questions …
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Funded by the European Community ‘s Seventh Framework Programme FP7/2007-2013 under grant agreement nª 24188
Deepening our Understanding of Quality
Improvement in Europe
Ethics, confidentiality and sampling
• Obtaining ethics approval in multicenter studies – different countries, different models.
• Confidentiality issues in accessing clinical records: internal/external audit.
• … and: what is a hospital actually?
• Random sampling: hospital lists / data base mergers.
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Funded by the European Community ‘s Seventh Framework Programme FP7/2007-2013 under grant agreement nª 24188
Deepening our Understanding of Quality
Improvement in Europe
Developing measures
• A wide range of measures exists, but:– Lack of gold standard measures– Lack of measures developed for
international use– Same measures across condition?– Balancing posibles biases and
• Feasibility• Homogenity
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Funded by the European Community ‘s Seventh Framework Programme FP7/2007-2013 under grant agreement nª 24188
Deepening our Understanding of Quality
Improvement in Europe
Analytical framework
Funded by the European Community ‘s Seventh Framework Programme FP7/2007-2013 under grant agreement nª 24188
Deepening our Understanding of Quality
Improvement in Europe
Analysis
• Focus at hospital level (effect of admission, and discharge policies?)
• Calibration of outcome measures to take into account population level metrics.
• Adjustment for multiple confounding factors.
• Multilevel analysis to account for hospital, department, and patient level effects.
• Use of resampling techniques for measure development and application.
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