funded by the european community ‘s seventh framework programme fp7/2007-2013 under grant...

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




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




• 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




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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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)




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




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




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.




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




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)




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




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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Some questions …

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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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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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Analytical framework




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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A big challenge to achieve !!

funded by the european community ‘s seventh framework programme fp7/2007-2013 under grant...

Documents

effective quality

development of health

quality improvement

european community s

framework programme

leading existing research

grant agreement n

existing research literature