Application of quality improvement strategies in 389 European hospitals: results of the MARQuIS project

Context: This study was part of the Methods of Assessing Response to Quality Improvement Strategies (MARQuIS) research project investigating the impact of quality improvement strategies on hospital care in various countries of the European Union (EU), in relation to specific needs of cross-border patients. Aim: This paper describes how EU hospitals have applied seven quality improvement strategies previously defined by the MARQuIS study: organisational quality management programmes; systems for obtaining patients' views; patient safety systems; audit and internal assessment of clinical standards; clinical and practice guidelines; performance indicators; and external assessment. Methods: A web-based questionnaire was used to survey acute care hospitals in eight EU countries. The reported findings were later validated via on-site survey and site visits in a sample of the participating hospitals. Data collection took place from April to August 2006. Results: 389 hospitals participated in the survey; response rates varied per country. All seven quality improvement strategies were widely used in European countries. Activities related to external assessment were the most broadly applied across Europe, and activities related to patient involvement were the least widely implemented. No one country implemented all quality strategies at all hospitals. There were no differences between participating hospitals in western and eastern European countries regarding the application of quality improvement strategies. Conclusions: Implementation varied per country and per quality improvement strategy, leaving considerable scope for progress in quality improvements. The results may contribute to benchmarking activities in European countries, and point to further areas of research to explore the relationship between the application of quality improvement strategies and actual hospital performanc

Differentiating between hospitals according to the “maturity” of quality improvement systems: a new classification scheme in a sample of European hospitals

Aim: This study, part of the Methods of Assessing Response to Quality Improvement Strategies (MARQuIS) research project focusing on cross-border patients in Europe, investigated quality policies and improvement in healthcare systems across the European Union (EU). The aim was to develop a classification scheme for the level of quality improvement (maturity) in EU hospitals, in order to evaluate hospitals according to the maturity of their quality improvement activities. Methods: A web-based questionnaire survey designed to measure quality improvement in EU hospitals was used as the basis for the classification scheme. Items included for the development of an evaluation tool-the maturity index-were considered important contributors to quality improvement. The four-stage quality cycle (plan, do, check and act) was used to determine the level of maturity of the various items. Psychometric properties of the classification scheme were assessed, and validation analyses were performed. Results: A total of 389 hospitals participated in a questionnaire survey; response rates varied by country. For a final sample of 349 hospitals, it was possible to construct a quality improvement maturity index which consisted of seven domains and 113 items. The results of independent analyses sustained the validity of the index, which was useful in differentiating between hospitals in the research sample according to the maturity of their quality improvement system (defined as the total of all quality improvement activities). Discussion: Further research is recommended to develop an instrument which for use in the future as a practical tool to evaluate the maturity of hospital quality improvement systems

Efforts, rewards and professional autonomy determine residents' experienced well-being

The well-being of residents, our future medical specialists, is not only beneficial to the individual physician but also conditional for delivering high-quality patient care. Therefore, the authors further explored how residents experience their own well-being in relation to their professional and personal life. The authors conducted a qualitative study based on a phenomenological approach. From June to October 2013, 13 in-depth interviews were conducted with residents in various training programs using a semi-structured interview guide to explore participants' experience of their well-being in relation to their professional life. The data were collected and analyzed through an iterative process using the thematic network approach. Effort-reward balance and perceived autonomy were dominant overarching experiences in influencing residents' well-being. Experiencing sufficient autonomy was important in residents' roles as caregivers, as learners and in their personal lives. The experienced effort-reward balance could both positively and negatively influence well-being. We found two categories of ways that influence residents' experience of well-being; (1) professional lives: delivering patient care, participating in teamwork, learning at the workplace and dealing with the organization and (2) personal lives: dealing with personal characteristics and balancing work-life. In residents' well-being experiences, the effort-reward balance and perceived autonomy are crucial. Additionally, ways that influence residents' well-being are identified in both their professional and personal lives. These dominant experiences and ways that influence well-being could be key factors for interventions and residency training adaptations for enhancing residents' well-being.</p

Volume and diagnosis: an approach to cross-border care in eight European countries

Objectives: Mobility of patients is a pertinent issue on the European Union's agenda. This study aimed to estimate the volume and main diagnoses of cross-border care in eight European countries, in order to provide policy makers with background information about the nature of patient mobility in Europe. Methods: This article reports the combined findings from three independent studies that compiled self-reported information on admissions data and main diagnoses from more than 200 hospitals in eight European countries. Results: The average volume of cross-border patients accounted for less than 1% of total admissions in the hospitals studied here. Diseases of the circulatory system (mainly acute myocardial infarction) and fractures were the most common reasons for hospitalisation of European patients abroad. Deliveries and other diagnoses related to pregnancy, pneumonia, appendicitis and other diseases of the digestive system, aftercare procedures, and disorders of the eye and adnexa were also common diagnoses for this population. Conclusions: Hospitals should reinforce their efforts to adapt the care provided to the needs of foreign patients in treatment areas that cover the most frequent pathologies identified in this populatio

Impact of quality strategies on hospital outputs

Context: This study was part of the Methods of Assessing Response to Quality Improvement Strategies (MARQuIS) research project on patients crossing borders, a study to investigate quality improvement strategies in healthcare systems across the European Union (EU). Aim: To explore the association between the implementation of quality improvement strategies in hospitals and hospitals' success in meeting defined quality requirements that are considered intermediate outputs of the care process. Methods: Data regarding the implementation of seven quality improvement strategies (accreditation, organisational quality management programmes, audit and internal assessment of clinical standards, patient safety systems, clinical practice guidelines, performance indicators and systems for obtaining patients' views) and four dimensions of outputs (clinical, safety, patient-centredness and cross-border patient-centredness) were collected from 389 acute care hospitals in eight EU countries using a web-based questionnaire. In a second phase, 89 of these hospitals participated in an on-site audit by independent surveyors. Pearson correlation and linear regression models were used to explore associations and relations between quality improvement strategies and achievement of outputs. Results: Positive associations were found between six internal quality improvement strategies and hospital outputs. The quality improvement strategies could be reasonably subsumed under one latent index which explained about half of their variation. The analysis of outputs concluded that the outputs can also be considered part of a single construct. The findings indicate that the implementation of internal as well as external quality improvement strategies in hospitals has beneficial effects on the hospital outputs studied here. Conclusion: The implementation of internal quality improvement strategies as well as external assessment systems should be promoted

The Surgical Hazardous Attitudes Reflection Profile (SHARP) Instrument - A Prototype Study

OBJECTIVE: There is growing recognition that surgeons’ non-technical skills are crucial in guaranteeing optimal quality and safety of patient care. However, insight in relevant attitudes underlying these behavioral skills is lacking. Hazardous attitudes potentially cause risky behavior, which can result in medical errors and adverse events. A questionnaire offering surgeons insight in their attitudinal profile is still missing and would be instrumental in risk reduction. Therefore, the aim of this study is to develop a prototype of a reliable and valid instrument to measure hazardous attitudes among surgeons. DESIGN: To measure hazardous attitudes, a prototype of the Surgical Hazardous Attitudes Reflection Profile (SHARP) tool was designed using a mixed methods approach, consisting of (1) 2 focus group discussions, (2) a modified Delphi analysis, and (3) a survey followed by (4) statistical analysis of the psychometric properties. Statistical analysis included exploratory factor analysis with varimax rotation, calculation of internal consistency reliability coefficients, and interscale correlations. SETTING: Fourteen hospitals across the Netherlands were recruited to guarantee demographic variety and the inclusion of academic, tertiary, and general hospitals. PARTICIPANTS: Nineteen experts participated in the 2 focus groups, and 19 in the modified Delphi study. In total, 302 surgeons (54.1%) completed the SHARP. RESULTS: In total, 302 surgeons (54.1%) completed the SHARP. Exploratory factor analysis resulted in 6 subscales measuring attitude towards (1) authority (α = 0.78), (2) self-performance (α = 0.69), (3) performance feedback (α = 0.61), (4) own fitness to perform (α = 0.54), (5) uncertainty (α = 0.51), and (6) planned procedures (α = 0.48). CONCLUSIONS: This study resulted in a prototype instrument identifying 6 potential hazardous attitudes in surgeons. Attitudes towards “authority” and “self-performance” can now be validly and reliably measured. Further research is required to optimize the prototype version of the instrument and could usefully explore the plausible relations between hazardous attitudes and clinical outcomes

New Tools for Systematic Evaluation of Teaching Qualities of Medical Faculty: Results of an Ongoing Multi-Center Survey

Background: Tools for the evaluation, improvement and promotion of the teaching excellence of faculty remain elusive in residency settings. This study investigates (i) the reliability and validity of the data yielded by using two new instruments for evaluating the teaching qualities of medical faculty, (ii) the instruments' potential for differentiating between faculty, and (iii) the number of residents' evaluations needed per faculty to reliably use the instruments. Methods and Materials: Multicenter cross-sectional survey among 546 residents and 629 medical faculty representing 29 medical (non-surgical) specialty training programs in the Netherlands. Two instruments-one completed by residents and one by faculty-for measuring teaching qualities of faculty were developed. Statistical analyses included factor analysis, reliability and validity exploration using standard psychometric methods, calculation of the numbers of residents' evaluations needed per faculty to achieve reliable assessments and variance components and threshold analyses. Results: A total of 403 (73.8%) residents completed 3575 evaluations of 570 medical faculty while 494 (78.5%) faculty self-evaluated. In both instruments five composite-scales of faculty teaching qualities were detected with high internal consistency and reliability: learning climate (Cronbach's alpha of 0.85 for residents' instrument, 0.71 for self-evaluation instrument, professional attitude and behavior (0.84/0.75), communication of goals (0.90/0.84), evaluation of residents (0.91/0.81), and feedback (0.91/0.85). Faculty tended to evaluate themselves higher than did the residents. Up to a third of the total variance in various teaching qualities can be attributed to between-faculty differences. Some seven residents' evaluations per faculty are needed for assessments to attain a reliability level of 0.90. Conclusions: The instruments for evaluating teaching qualities of medical faculty appear to yield reliable and valid data. They are feasible for use in medical residencies, can detect between-faculty differences and supply potentially useful information for improving graduate medical educatio

Structural equation modelling analysis on relationships of job demands and resources with work engagement, burnout and work ability: an observational study among physicians in Dutch hospitals

Objective: To investigate to what extent work engagement mediates the relationships of job resources with work ability, and to what extent burnout mediates the relationships of job demands and resources with work ability. Design: Multicentre observational study. Setting: Academic and non-academic hospitals in the Netherlands. Participants: Physicians (n=385) participated in this study. Primary and secondary outcome measures: We measured work ability with selected items from the validated Questionnaire of Experience and Evaluation of Work 2.0 (QEEW V.2.0), work engagement with the Utrecht Work Engagement Scale and burnout with the exhaustion subscale of the Oldenburg Burnout Inventory. The job demand ‘workload’ and job resources ‘development opportunities’, ‘participation in decision-making’, ‘inspirational leadership’ and ‘relationships with colleagues’ were measured using the QEEW V.2.0. The job demand ‘bureaucratic burden’ was measured with the Three Item Red Tape scale. A structural equation model was built to answer our research question. Results: Work engagement mediated relationships of job resources with physicians’ work ability, and burnout mediated relationships of job resources and demands with work ability. Development opportunities (β=0.39, SE=0.12, p<0.001), participation in decision-making (β=0.18, SE=0.08, p=0.028) and relationships with colleagues (β=0.19, SE=0.19, p=0.002) were positively related to work engagement. Development opportunities (β=−0.20, SE=0.08, p=0.004) were negatively related and workload (β=0.51, SE=0.19, p<0.001) was positively related to burnout. Work engagement (β=0.22, SE=0.04, p<0.001) was positively related and burnout (β=−0.56, SE=0.06, p<0.001) was negatively related to work ability. Conclusions: Physicians’ work engagement and burnout mediated the relationships of various job demands and resources with their work ability. More work-engaged and less burned-out physicians reported better work ability. Hospitals may attenuate excessive workloads and facilitate development opportunities, participation in decision-making and good collegial relationships to enhance physicians’ occupational well-being and performance

The Teacher, the Physician and the Person: How Faculty's Teaching Performance Influences Their Role Modelling

OBJECTIVE: Previous studies identified different typologies of role models (as teacher/supervisor, physician and person) and explored which of faculty's characteristics could distinguish good role models. The aim of this study was to explore how and to which extent clinical faculty's teaching performance influences residents' evaluations of faculty's different role modelling statuses, especially across different specialties. METHODS: In a prospective multicenter multispecialty study of faculty's teaching performance, we used web-based questionnaires to gather empirical data from residents. The main outcome measures were the different typologies of role modelling. The predictors were faculty's overall teaching performance and faculty's teaching performance on specific domains of teaching. The data were analyzed using multilevel regression equations. RESULTS: In total 219 (69% response rate) residents filled out 2111 questionnaires about 423 (96% response rate) faculty. Faculty's overall teaching performance influenced all role model typologies (OR: from 8.0 to 166.2). For the specific domains of teaching, overall, all three role model typologies were strongly associated with "professional attitude towards residents" (OR: 3.28 for teacher/supervisor, 2.72 for physician and 7.20 for the person role). Further, the teacher/supervisor role was strongly associated with "feedback" and "learning climate" (OR: 3.23 and 2.70). However, the associations of the specific domains of teaching with faculty's role modelling varied widely across specialties. CONCLUSION: This study suggests that faculty can substantially enhance their role modelling by improving their teaching performance. The amount of influence that the specific domains of teaching have on role modelling differs across specialties

Work-Related Well-Being Among Dutch Cardiologists - A National Survey

This is the first study to provide a holistic examination of cardiologists' well-being, investigating positive and negative dimensions, and its determinants. We conducted a national, multicenter, self-administered web-based questionnaire. We used frequencies to depict scores on three well-being indicators (professional fulfillment, work exhaustion and interpersonal disengagement) and performed three multiple regression analyses to elucidate their determinants. Cardiologists' mean scores (scale 1 to 5) were 3.85 (SD = 0.62) for professional fulfillment, 2.25 (SD = 0.97) for work exhaustion and 2.04 (SD = 0.80) for interpersonal disengagement. Workload, work-home interference and team atmosphere predicted the negative dimensions of well-being. Autonomy predicted cardiologists' professional fulfillment. Physician-patient interactions, person-job fit and individual resilience affected both dimensions. Dutch cardiologists score relatively high on professional fulfillment and average on work exhaustion and interpersonal disengagement. In order to foster cardiologists' well-being it is critical to increase energy providing work- and individual aspects