- Quality improvement (QI) strategies are widely used in European hospitals. The most widely applied QI strategy is external assessment of hospitals, whereas patient involvement in QI activities is the least widely applied
- Reported implementation varies per country. This leaves considerable room for progress in making QI in hospitals a reality
- Differences also suggest that, for various reasons, countries may prefer some QI strategies over others
Contribution to better patient care
- International comparisons of the use of QI strategies can promote learning and the spread of good practice
- The results of this study may be useful to national policy makers in monitoring the attainment of healthcare policy goals
Points for further research
Further research should focus on exploring the relationship between the use of QI strategies and the actual performance of hospitals, including the relative contribution of each of the seven QI strategies to performance
This study has some limitations. The response rates varied per country, and were particularly low in the UK and the Netherlands. This may be explained by the various approaches used to recruit hospitals for the MARQuIS project, and to the effect of questionnaire fatigue due to the over-application of questionnaire surveys to evaluate healthcare performance in general. We therefore cannot rule out participation bias. Also, accuracy of the information is always a limitation when using self-reported data. However, the results of our validation process strongly suggest that the reported results are fairly accurate. Further, translation of the questionnaire, the use of jargon, and the involvement of people from various healthcare systems may have caused differences in how the items were interpreted. Lastly, hospitals may use local QI approaches or tools not included in this questionnaire, in which case the application of QI strategies, as described in this article, may misrepresent the “maturity” of hospitals’ quality management systems. These limitations should be taken into account when interpreting results.
International comparisons can promote learning and the spread of good practice, and are one of the ways in which the European Community is expected to raise healthcare quality. This study of how European hospitals apply seven common QI strategies found considerable variation between the level of implementation of the different strategies—a finding that leaves considerable scope for progress in making QI a reality.
The use of QI strategies at the European level was determined or at least influenced by national and international policy making and regulation, as well as by national and local bottom-up actions initiated by professionals or others.35
In our study 88% of all hospitals reported having been externally assessed; the widespread application of the “external assessment” QI strategy can be ascribed to the fact that most countries have adopted one or more models of external assessment (ie, accreditation, certification or licensure) to ensure and improve hospital performance, which in turn has been related to financing healthcare delivery.
However, policies and regulations may not always be effective, as shown by the fact that in most hospitals (>90%), patient involvement in QI activities was lacking. This was despite the various legal and other efforts undertaken by the European Commission over the past decades to increase citizens’ participation in QI, and in the organisation and structure of health services in general.4 5
Future research should focus on detecting barriers to the implementation of these QI strategies. In this regard, efforts by the EU to facilitate improvements and foster European collaboration may help to further increase implementation.36 37
Legislation recently proposed by the European Commission stresses the values and principles of safe, high-quality health services that underpin European health systems. However, the question arises as to how these agreed-upon values and principles can be applied by member states.36
We believe our results may help national policy makers to monitor the attainment of healthcare policy goals. The application of more QI strategies, however, may not necessarily imply more positive effects on performance. Our findings would be even more valuable if the demonstrated use of QI strategies could be related to actual performance in hospitals. This would give EU policy makers direct input for monitoring the development of healthcare policies and regulations. Elsewhere in this supplement this relationship is explored in greater depth.