Implementation of Departmental Quality Strategies Is Positively Associated with Clinical Practice: Results of a Multicenter Study in 73 Hospitals in 7 European Countries.

BACKGROUND: Given the amount of time and resources invested in implementing quality programs in hospitals, few studies have investigated their clinical impact and what strategies could be recommended to enhance its effectiveness. OBJECTIVE: To assess variations in clinical practice and explore associations with hospital- and department-level quality management systems. DESIGN: Multicenter, multilevel cross-sectional study. SETTING AND PARTICIPANTS: Seventy-three acute care hospitals with 276 departments managing acute myocardial infarction, deliveries, hip fracture, and stroke in seven countries. INTERVENTION: None. MEASURES: Predictor variables included 3 hospital- and 4 department-level quality measures. Six measures were collected through direct observation by an external surveyor and one was assessed through a questionnaire completed by hospital quality managers. Dependent variables included 24 clinical practice indicators based on case note reviews covering the 4 conditions (acute myocardial infarction, deliveries, hip fracture and stroke). A directed acyclic graph was used to encode relationships between predictors, outcomes, and covariates and to guide the choice of covariates to control for confounding. RESULTS AND LIMITATIONS: Data were provided on 9021 clinical records by 276 departments in 73 hospitals. There were substantial variations in compliance with the 24 clinical practice indicators. Weak associations were observed between hospital quality systems and 4 of the 24 indicators, but on analyzing department-level quality systems, strong associations were observed for 8 of the 11 indicators for acute myocardial infarction and stroke. Clinical indicators supported by higher levels of evidence were more frequently associated with quality systems and activities. CONCLUSIONS: There are significant gaps between recommended standards of care and clinical practice in a large sample of hospitals. Implementation of department-level quality strategies was significantly associated with good clinical practice. Further research should aim to develop clinically relevant quality standards for hospital departments, which appear to be more effective than generic hospital-wide quality systems

Measuring professionalism in medicine and nursing: results of a European survey.

BackgroundLeveraging professionalism has been put forward as a strategy to drive improvement of patient care. We investigate professionalism as a factor influencing the uptake of quality improvement activities by physicians and nurses working in European hospitals.ObjectiveTo (i) investigate the reliability and validity of data yielded by using the self-developed professionalism measurement tool for physicians and nurses, (ii) describe their levels of professionalism displayed, and (iii) quantify the extent to which professional attitudes would predict professional behaviors.Methods and materialsWe designed and deployed survey instruments amongst 5920 physicians and nurses working in European hospitals. This was conducted under the cross-sectional multilevel study "Deepening Our Understanding of Quality Improvement in Europe" (DUQuE). We used psychometric and generalized linear mixed modelling techniques to address the aforementioned objectives.ResultsIn all, 2067 (response rate 69.8%) physicians and 2805 nurses (94.8%) representing 74 hospitals in 7 European countries participated. The professionalism instrument revealed five subscales of professional attitude and one scale for professional behaviour with moderate to high internal consistency and reliability. Physicians and nurses display equally high professional attitude sum scores (11.8 and 11.9 respectively out of 16) but seem to have different perceptions towards separate professionalism aspects. Lastly, professionals displaying higher levels of professional attitudes were more involved in quality improvement actions (physicians: b = 0.019, P<0.0001; nurses: b = 0.016, P<0.0001) and more inclined to report colleagues' underperformance (physicians--odds ratio (OR) 1.12, 95% CI 1.01-1.24; nurses - OR 1.11, 95% CI 1.01-1.23) or medical errors (physicians--OR 1.14, 95% CI 1.01-1.23; nurses - OR 1.43, 95% CI 1.22-1.67). Involvement in QI actions was found to increase the odds of reporting incompetence or medical errors.ConclusionA tool that reliably and validly measures European physicians' and nurses' commitment to professionalism is now available. Collectively leveraging professionalism as a quality improvement strategy may be beneficial to patient care quality

Measuring professionalism in medicine and nursing: results of a European survey

Leveraging professionalism has been put forward as a strategy to drive improvement of patient care. We investigate professionalism as a factor influencing the uptake of quality improvement activities by physicians and nurses working in European hospitals. To (i) investigate the reliability and validity of data yielded by using the self-developed professionalism measurement tool for physicians and nurses, (ii) describe their levels of professionalism displayed, and (iii) quantify the extent to which professional attitudes would predict professional behaviors. We designed and deployed survey instruments amongst 5920 physicians and nurses working in European hospitals. This was conducted under the cross-sectional multilevel study "Deepening Our Understanding of Quality Improvement in Europe" (DUQuE). We used psychometric and generalized linear mixed modelling techniques to address the aforementioned objectives. In all, 2067 (response rate 69.8%) physicians and 2805 nurses (94.8%) representing 74 hospitals in 7 European countries participated. The professionalism instrument revealed five subscales of professional attitude and one scale for professional behaviour with moderate to high internal consistency and reliability. Physicians and nurses display equally high professional attitude sum scores (11.8 and 11.9 respectively out of 16) but seem to have different perceptions towards separate professionalism aspects. Lastly, professionals displaying higher levels of professional attitudes were more involved in quality improvement actions (physicians: b = 0.019, P <0.0001; nurses: b = 0.016, P <0.0001) and more inclined to report colleagues' underperformance (physicians--odds ratio (OR) 1.12, 95% CI 1.01-1.24; nurses - OR 1.11, 95% CI 1.01-1.23) or medical errors (physicians--OR 1.14, 95% CI 1.01-1.23; nurses - OR 1.43, 95% CI 1.22-1.67). Involvement in QI actions was found to increase the odds of reporting incompetence or medical errors. A tool that reliably and validly measures European physicians' and nurses' commitment to professionalism is now available. Collectively leveraging professionalism as a quality improvement strategy may be beneficial to patient care qualit

The associations between organizational culture, organizational structure and quality management in European hospitals

To better understand associations between organizational culture (OC), organizational management structure (OS) and quality management in hospitals. A multi-method, multi-level, cross-sectional observational study. As part of the DUQuE project (Deepening our Understanding of Quality improvement in Europe), a random sample of 188 hospitals in 7 countries (France, Poland, Turkey, Portugal, Spain, Germany and Czech Republic) participated in a comprehensive questionnaire survey and a one-day on-site surveyor audit. Respondents for this study (n = 158) included professional quality managers and hospital trustees. Extent of implementation of quality management systems, extent of compliance with existing management procedures and implementation of clinical quality activities. Among participating hospitals, 33% had a clan culture as their dominant culture type, 26% an open and developmental culture type, 16% a hierarchical culture type and 25% a rational culture type. The culture type had no statistically significant association with the outcome measures. Some structural characteristics were associated with the development of quality management systems. The type of OC was not associated with the development of quality management in hospitals. Other factors (not culture type) are associated with the development of quality management. An OS that uses fewer protocols is associated with a less developed quality management system, whereas an OS which supports innovation in care is associated with a more developed quality management system

The use of on-site visits to assess compliance and implementation of quality management at hospital level.

Objective: Stakeholders of hospitals often lack standardized tools to assess compliance with quality management strategies and the implementation of clinical quality activities in hospitals. Such assessment tools, if easy to use, could be helpful to hospitals, health-care purchasers and health-care inspectorates. The aim of our study was to determine the psychometric properties of two newly developed tools for measuring compliance with process-oriented quality management strategies and the extent of implementation of clinical quality strategies at the hospital level. Design: We developed and tested two measurement instruments that could be used during on-site visits by trained external surveyors to calculate a Quality Management Compliance Index (QMCI) and a Clinical Quality Implementation Index (CQII). We used psychometric methods and the cross-sectional data to explore the factor structure, reliability and validity of each of these instruments. Setting and Participants: The sample consisted of 74 acute care hospitals selected at random from each of 7 European countries. Main Outcome Measures: The psychometric properties of the two indices (QMCI and CQII). Results: Overall, the indices demonstrated favourable psychometric performance based on factor analysis, item correlations, internal consistency and hypothesis testing. Cronbach's alpha was acceptable for the scales of the QMCI (α: 0.74–0.78) and the CQII (α: 0.82–0.93). Inter-scale correlations revealed that the scales were positively correlated, but distinct. All scales added sufficient new information to each main index to be retained. Conclusion: This study has produced two reliable instruments that can be used during on-site visits to assess compliance with quality management strategies and implementation of quality management activities by hospitals in Europe and perhaps other jurisdictions. (aut.ref.

The associations between organizational culture, organizational structure and quality management in European hospitals.

ObjectiveTo better understand associations between organizational culture (OC), organizational management structure (OS) and quality management in hospitals.DesignA multi-method, multi-level, cross-sectional observational study.Setting and participantsAs part of the DUQuE project (Deepening our Understanding of Quality improvement in Europe), a random sample of 188 hospitals in 7 countries (France, Poland, Turkey, Portugal, Spain, Germany and Czech Republic) participated in a comprehensive questionnaire survey and a one-day on-site surveyor audit. Respondents for this study (n = 158) included professional quality managers and hospital trustees.Main outcome measuresExtent of implementation of quality management systems, extent of compliance with existing management procedures and implementation of clinical quality activities.ResultsAmong participating hospitals, 33% had a clan culture as their dominant culture type, 26% an open and developmental culture type, 16% a hierarchical culture type and 25% a rational culture type. The culture type had no statistically significant association with the outcome measures. Some structural characteristics were associated with the development of quality management systems.ConclusionThe type of OC was not associated with the development of quality management in hospitals. Other factors (not culture type) are associated with the development of quality management. An OS that uses fewer protocols is associated with a less developed quality management system, whereas an OS which supports innovation in care is associated with a more developed quality management system

Development and validation of an index to assess hospital quality management systems.

ObjectiveThe aim of this study was to develop and validate an index to assess the implementation of quality management systems (QMSs) in European countries.DesignQuestionnaire development was facilitated through expert opinion, literature review and earlier empirical research. A cross-sectional online survey utilizing the questionnaire was undertaken between May 2011 and February 2012. We used psychometric methods to explore the factor structure, reliability and validity of the instrument.Setting and participantsAs part of the Deepening our Understanding of Quality improvement in Europe (DUQuE) project, we invited a random sample of 188 hospitals in 7 countries. The quality managers of these hospitals were the main respondents.Main outcome measureThe extent of implementation of QMSs.ResultsFactor analysis yielded nine scales, which were combined to build the Quality Management Systems Index. Cronbach's reliability coefficients were satisfactory (ranging from 0.72 to 0.82) for eight scales and low for one scale (0.48). Corrected item-total correlations provided adequate evidence of factor homogeneity. Inter-scale correlations showed that every factor was related, but also distinct, and added to the index. Construct validity testing showed that the index was related to recent measures of quality. Participating hospitals attained a mean value of 19.7 (standard deviation of 4.7) on the index that theoretically ranged from 0 to 27.ConclusionAssessing QMSs across Europe has the potential to help policy-makers and other stakeholders to compare hospitals and focus on the most important areas for improvement

The use of on-site visits to assess compliance and implementation of quality management at hospital level.

ObjectiveStakeholders of hospitals often lack standardized tools to assess compliance with quality management strategies and the implementation of clinical quality activities in hospitals. Such assessment tools, if easy to use, could be helpful to hospitals, health-care purchasers and health-care inspectorates. The aim of our study was to determine the psychometric properties of two newly developed tools for measuring compliance with process-oriented quality management strategies and the extent of implementation of clinical quality strategies at the hospital level.DesignWe developed and tested two measurement instruments that could be used during on-site visits by trained external surveyors to calculate a Quality Management Compliance Index (QMCI) and a Clinical Quality Implementation Index (CQII). We used psychometric methods and the cross-sectional data to explore the factor structure, reliability and validity of each of these instruments.Setting and participantsThe sample consisted of 74 acute care hospitals selected at random from each of 7 European countries.Main outcome measuresThe psychometric properties of the two indices (QMCI and CQII).ResultsOverall, the indices demonstrated favourable psychometric performance based on factor analysis, item correlations, internal consistency and hypothesis testing. Cronbach's alpha was acceptable for the scales of the QMCI (α: 0.74-0.78) and the CQII (α: 0.82-0.93). Inter-scale correlations revealed that the scales were positively correlated, but distinct. All scales added sufficient new information to each main index to be retained.ConclusionThis study has produced two reliable instruments that can be used during on-site visits to assess compliance with quality management strategies and implementation of quality management activities by hospitals in Europe and perhaps other jurisdictions