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1.  Limitations of using same-hospital readmission metrics 
Objective
To quantify the limitations associated with restricting readmission metrics to same-hospital only readmission.
Design
Using 2000–2009 California Office of Statewide Health Planning and Development Patient Discharge Data Nonpublic file, we identified the proportion of 7-, 15- and 30-day readmissions occurring to the same hospital as the initial admission using All-cause Readmission (ACR) and 3M Corporation Potentially Preventable Readmissions (PPR) Metric. We examined the correlation between performance using same and different hospital readmission, the percent of hospitals remaining in the extreme deciles when utilizing different metrics, agreement in identifying outliers and differences in longitudinal performance. Using logistic regression, we examined the factors associated with admission to the same hospital.
Results
68% of 30-day ACR and 70% of 30-day PPR occurred to the same hospital. Abdominopelvic procedures had higher proportions of same-hospital readmissions (87.4–88.9%), cardiac surgery had lower (72.5–74.9%) and medical DRGs were lower than surgical DRGs (67.1 vs. 71.1%). Correlation and agreement in identifying high- and low-performing hospitals was weak to moderate, except for 7-day metrics where agreement was stronger (r = 0.23–0.80, Kappa = 0.38–0.76). Agreement for within-hospital significant (P < 0.05) longitudinal change was weak (Kappa = 0.05–0.11). Beyond all patient refined-diagnostic related groups, payer was the most predictive factor with Medicare and MediCal patients having a higher likelihood of same-hospital readmission (OR 1.62, 1.73).
Conclusions
Same-hospital readmission metrics are limited for all tested applications. Caution should be used when conducting research, quality improvement or comparative applications that do not account for readmissions to other hospitals.
doi:10.1093/intqhc/mzt068
PMCID: PMC3842125  PMID: 24167061
readmissions; quality indicators; hospital quality
2.  Hospital readmission and parent perceptions of their child's hospital discharge 
Objective
To describe parent perceptions of their child's hospital discharge and assess the relationship between these perceptions and hospital readmission.
Design
A prospective study of parents surveyed with questions adapted from the care transitions measure, an adult survey that assesses components of discharge care. Participant answers, scored on a 5-point Likert scale, were compared between children who did and did not experience a readmission using a Fisher's exact test and logistic regression that accounted for patient characteristics associated with increased readmission risk, including complex chronic condition and assistance with medical technology.
Setting
A tertiary-care children's hospital.
Participants: A total of 348 parents surveyed following their child's hospital discharge between March and October 2010.
Intervention
None.
Main Outcome Measure
Unplanned readmission within 30 days of discharge.
Results
There were 28 children (8.1%) who experienced a readmission. Children had a lower readmission rate (4.4 vs. 11.3%, P = 0.004) and lower adjusted readmission likelihood [odds ratio 0.2 (95% confidence interval 0.1, 0.6)] when their parents strongly agreed (n = 206) with the statement, ‘I felt that my child was healthy enough to leave the hospital’ from the index admission. Parent perceptions relating to care management responsibilities, medications, written discharge plan, warning signs and symptoms to watch for and primary care follow-up were not associated with readmission risk in multivariate analysis.
Conclusions
Parent perception of their child's health at discharge was associated with the risk of a subsequent, unplanned readmission. Addressing concerns with this perception prior to hospital discharge may help mitigate readmission risk in children.
doi:10.1093/intqhc/mzt051
PMCID: PMC3786626  PMID: 23962990
hospital discharge; readmission; care transition; quality of care; children
3.  Do older patients and their family caregivers agree about the quality of chronic illness care?† 
Objective
Family caregivers often accompany patients to medical visits; however, it is unclear whether caregivers rate the quality of patients' care similarly to patients. This study aimed to (1) quantify the level of agreement between patients' and caregivers' reports on the quality of patients' care and (2) determine how the level of agreement varies by caregiver and patient characteristics.
Design
Cross-sectional analysis.
Participants
Multimorbid older (aged 65 and above) adults and their family caregivers (n = 247).
Methods
Quality of care was rated separately by patients and their caregivers using the Patient Assessment of Chronic Illness Care (PACIC) instrument. The level of agreement was examined using a weighted kappa statistic (Kw).
Results
Agreement of caregivers' and patients' PACIC scores was low (Kw = 0.15). Patients taking ten or more medications per day showed less agreement with their caregivers about the quality of care than patients taking five or fewer medications (Kw = 0.03 and 0.34, respectively, P < 0.05). Caregivers who reported greater difficulty assisting patients with health care tasks had less agreement with patients about the quality of care being provided when compared with caregivers who reported no difficulty (Kw = −0.05 and 0.31, respectively, P < .05). Patient–caregiver dyads had greater agreement on objective questions than on subjective questions (Kw = 0.25 and 0.15, respectively, P > 0.05).
Conclusion
Patient–caregiver dyads following a more complex treatment plan (i.e. taking many medications) or having more difficulty following a treatment plan (i.e. having difficulty with health care tasks) had less agreement. Future qualitative research is needed to elucidate the underlying reasons patients and caregivers rate the quality of care differently.
doi:10.1093/intqhc/mzt052
PMCID: PMC3786627  PMID: 23980119
quality of care; caregiver; primary care
4.  Impact evaluation of a quality improvement intervention on maternal and child health outcomes in Northern Ghana: early assessment of a national scale-up project 
Objective
To evaluate the influence of the early phase of Project Fives Alive!, a national child survival improvement project, on key maternal and child health outcomes.
Design
The evaluation used multivariable interrupted time series analyses to determine whether change categories tested were associated with improvements in the outcomes of interest.
Participants
The evaluation used program and outcome data from interventions focused on health-care staff in 27 facilities.
Setting
Northern Ghana.
Intervention
The project uses a quality improvement (QI) approach whereby process failures are identified by health staff and process changes are tested in the health facilities and corresponding communities to address those failures.
Main Outcome Measures
The maternal health outcomes were early antenatal care attendance and skilled delivery, and the child health outcomes were underweight infants attending child wellness clinics, facility-level neonatal mortality and facility-level infant mortality.
Results
Postnatal care changes for the first 1–2 days of life (β= 0.10, P = 0.07) and the first 6–7 days of life (β = 0.10, P = 0.07) were associated with a higher rate of visits by underweight infants to child wellness clinics. There was an association between the early pregnancy identification change category with increased skilled delivery (β = 1.36 P = 0.07). In addition, a greater number of change categories tested was associated with increased skilled delivery (β = 0.05, P = 0.01).
Conclusion
The QI approach of testing and implementing simple and low cost locally inspired changes has the potential to lead to improved health outcomes at scale both in Ghana and other low- and middle-income countries.
doi:10.1093/intqhc/mzt054
PMCID: PMC3888142  PMID: 23925506
quality improvement; impact evaluation; time series analysis; maternal and child health; mortality; Ghana
5.  Meeting the ambition of measuring the quality of hospitals' stroke care using routinely collected administrative data: a feasibility study 
Objective
To examine the potential for using routinely collected administrative data to compare the quality and safety of stroke care at a hospital level, including evaluating any bias due to variations in coding practice.
Design
A retrospective cohort study of English hospitals' performance against six process and outcome indicators covering the acute care pathway. We used logistic regression to adjust the outcome measures for case mix.
Setting
Hospitals in England.
Participants
Stroke patients (ICD-10 I60–I64) admitted to English National Health Service public acute hospitals between April 2009 and March 2010, accounting for 91 936 admissions.
Main Outcome Measure
The quality and safety were measured using six indicators spanning the hospital care pathway, from timely access to brain scans to emergency readmissions following discharge after stroke.
Results
There were 182 occurrences of hospitals performing statistically differently from the national average at the 99.8% significance level across the six indicators. Differences in coding practice appeared to only partially explain the variation.
Conclusions
Hospital administrative data provide a practical and achievable method for evaluating aspects of stroke care across the acute pathway. However, without improvements in coding and further validation, it is unclear whether the cause of the variation is the quality of care or the result of different local care pathways and data coding accuracy.
doi:10.1093/intqhc/mzt033
PMCID: PMC3723302  PMID: 23584363
quality indicators; measurement of quality; safety indicators; patient safety
6.  Utilization of non-US educated nurses in US hospitals: implications for hospital mortality 
Objectives
To determine whether, and under what circumstance, US hospital employment of non-US-educated nurses is associated with patient outcomes.
Design
Observational study of primary data from 2006 to 2007 surveys of hospital nurses in four states (California, Florida, New Jersey and Pennsylvania). The direct and interacting effects of hospital nurse staffing and the percentage of non-US-educated nurses on 30-day surgical patient mortality and failure-to-rescue were estimated before and after controlling for patient and hospital characteristics.
Participants
Data from registered nurse respondents practicing in 665 hospitals were pooled with patient discharge data from state agencies.
Main Outcomes Measure(s)
Thirty-day surgical patient mortality and failure-to-rescue.
Results
The effect of non-US-educated nurses on both mortality and failure-to-rescue is nil in hospitals with lower than average patient to nurse ratios, but pronounced in hospitals with average and poor nurse to patient ratios. In hospitals in which patient-to-nurse ratios are 5:1 or higher, mortality is higher when 25% or more nurses are educated outside of the USA than when <25% of nurses are non-US-educated. Moreover, the effect of having >25% non-US-educated nurses becomes increasingly deleterious as patient-to-nurse ratios increase beyond 5:1.
Conclusions
Employing non-US-educated nurses has a negative impact on patient mortality except where patient-to-nurse ratios are lower than average. Thus, US hospitals should give priority to achieving adequate nurse staffing levels, and be wary of hiring large percentages of non-US-educated nurses unless patient-to-nurse ratios are low.
doi:10.1093/intqhc/mzt042
PMCID: PMC3723304  PMID: 23736834
patient outcomes (health status, quality of life, mortality); measurement of quality; surveys; general Methodology; health policy; health care system; mortality; complications; hospital care; setting of care; nursing; professions; workforce and workload; human resources
7.  Integrated care programmes for adults with chronic conditions: a meta-review 
Objective
To review systematic reviews and meta-analyses of integrated care programmes in chronically ill patients, with a focus on methodological quality, elements of integration assessed and effects reported.
Design
Meta-review of systematic reviews and meta-analyses identified in Medline (1946–March 2012), Embase (1980–March 2012), CINHAL (1981–March 2012) and the Cochrane Library of Systematic Reviews (issue 1, 2012).
Main Outcome Measures
Methodological quality assessed by the 11-item Assessment of Multiple Systematic Reviews (AMSTAR) checklist; elements of integration assessed using a published list of 10 key principles of integration; effects on patient-centred outcomes, process quality, use of healthcare and costs.
Results
Twenty-seven systematic reviews were identified; conditions included chronic heart failure (CHF; 12 reviews), diabetes mellitus (DM; seven reviews), chronic obstructive pulmonary disease (COPD; seven reviews) and asthma (five reviews). The median number of AMSTAR checklist items met was five: few reviewers searched for unpublished literature or described the primary studies and interventions in detail. Most reviews covered comprehensive services across the care continuum or standardization of care through inter-professional teams, but organizational culture, governance structure or financial management were rarely assessed. A majority of reviews found beneficial effects of integration, including reduced hospital admissions and re-admissions (in CHF and DM), improved adherence to treatment guidelines (DM, COPD and asthma) or quality of life (DM). Few reviews showed reductions in costs.
Conclusions
Systematic reviews of integrated care programmes were of mixed quality, assessed only some components of integration of care, and showed consistent benefits for some outcomes but not others.
doi:10.1093/intqhc/mzu071
PMCID: PMC4195469  PMID: 25108537
integrated healthcare; health services research; quality improvement; chronic conditions; systematic review
8.  Towards a measurement instrument for determinants of innovations 
Objective
To develop a short instrument to measure determinants of innovations that may affect its implementation.
Design
We pooled the original data from eight empirical studies of the implementation of evidence-based innovations. The studies used a list of 60 potentially relevant determinants based on a systematic review of empirical studies and a Delphi study among implementation experts. Each study used similar methods to measure both the implementation of the innovation and determinants. Missing values in the final data set were replaced by plausible values using multiple imputation. We assessed which determinants predicted completeness of use of the innovation (% of recommendations applied). In addition, 22 implementation experts were consulted about the results and about implications for designing a short instrument.
Setting
Eight innovations introduced in Preventive Child Health Care or schools in the Netherlands.
Participants
Doctors, nurses, doctor's assistants and teachers; 1977 respondents in total.
Results
The initial list of 60 determinants could be reduced to 29. Twenty-one determinants were based on the pooled analysis of the eight studies, seven on the theoretical expectations of the experts consulted and one new determinant was added on the basis of the experts' practical experience.
Conclusions
The instrument is promising and should be further validated. We invite researchers to use and explore the instrument in multiple settings. The instrument describes how each determinant should preferably be measured (questions and response scales). It can be used both before and after the introduction of an innovation to gain an understanding of the critical change objectives.
doi:10.1093/intqhc/mzu060
PMCID: PMC4195468  PMID: 24951511
implementation; preventive child healthcare; school-based health promotion
9.  The eCollaborative: using a quality improvement collaborative to implement the National eHealth Record System in Australian primary care practices 
Quality problem
The new national patient-controlled electronic health record is an important quality improvement, and there was a pressing need to pilot its use in Australian primary care practices. Implementation of electronic health records in other countries has met with mixed success.
Initial assessment
New work was required in general practices participating in the national electronic health record. National implementers needed to engage with small private general practices to test the changes before general introduction.
Choice of solution
The National E-health Transition Authority contracted the Improvement Foundation Australia to conduct a quality improvement collaborative based on 9 years of experience with the Australian Primary Care Collaborative Program.
Implementation
Aims, measures and change ideas were addressed in a collaborative programme of workshops and supported activity periods. Data quality measures and numbers of health summaries uploaded were collected monthly. Challenges such as the delay in implementation of the electronic health summary were met.
Evaluation
Fifty-six practices participated. Nine hundred and twenty-nine patients registered to participate, and 650 shared health summaries were uploaded. Five hundred and nineteen patient views occurred. Four hundred and twenty-one plan/do/study/act cycles were submitted by participating practices.
Lessons learned
The collaborative methodology was adapted for implementing innovation and proved useful for engaging with multiple small practices, facilitating low-risk testing of processes, sharing ideas among participants, development of clinical champions and development of resources to support wider use. Email discussion between participants and system designers facilitated improvements. Data quality was a key challenge for this innovation, and quality measures chosen require development. Patient participants were partners in improvement.
doi:10.1093/intqhc/mzu059
PMCID: PMC4126615  PMID: 24925685
quality improvement; primary care/general practice; health system reform; ehealth
10.  Learning from the design and development of the NHS Safety Thermometer 
Quality issue
Research indicates that 10% of patients are harmed by healthcare but data that can be used in real time to improve safety are not routinely available.
Initial assessment
We identified the need for a prospective safety measurement system that healthcare professionals can use to improve safety locally, regionally and nationally.
Choice of solution
We designed, developed and implemented a national tool, named the NHS Safety Thermometer (NHS ST) with the goal of measuring the prevalence of harm from pressure ulcers, falls, urinary tract infection in patients with catheters and venous thromboembolism on one day each month for all NHS patients.
Implementation
The NHS ST survey instrument was developed in a learning collaborative involving 161 organizations (e.g. hospitals and other delivery organizations) using a Plan, Do, Study, Act method.
Evaluation
Testing of operational definitions, technical capability and use were conducted and feedback systems were established by site coordinators in each participating organization. During the 17-month pilot, site coordinators reported a total of 73 651 patient entries.
Lessons learned
It is feasible to obtain national data through standardized reporting by site coordinators at the point of care. Some caution is required in interpreting data and work is required locally to ensure data collection systems are robust and data collectors were trained. Sampling is an important strategy to optimize efficiency and reduce the burden of measurement.
doi:10.1093/intqhc/mzu043
PMCID: PMC4041095  PMID: 24787136
harm; measurement; testing
11.  Involving patients in detecting quality gaps in a fragmented healthcare system: development of a questionnaire for Patients' Experiences Across Health Care Sectors (PEACS) 
Objective
The purpose of this study was to develop and validate a generic questionnaire to evaluate experiences and reported outcomes in patients who receive treatment across a range of healthcare sectors.
Design
Mixed-methods design including focus groups, pretests and field test.
Setting
The patient questionnaire was developed in the context of a nationwide program in Germany aimed at quality improvements across the healthcare sectors.
Participants
For the field test, 589 questionnaires were distributed to patients via 47 general practices.
Main Measurements
Descriptive item analyzes non-responder analysis and factor analysis (PCA). Retest coefficients (r) calculated by correlation of sum scores of PCA factors. Quality gaps were assessed by the proportion of responders choosing a response category defined as indicating shortcomings in quality of care.
Results
The conceptual phase showed good content validity. Four hundred and seventy-four patients who received a range of treatment across a range of sectors were included (response rate: 80.5%). Data analysis confirmed the construct, oriented to the patient care journey with a focus on transitions between healthcare sectors. Quality gaps were assessed for the topics ‘Indication’, including shared-decision-making (6 items, 24.5–62.9%) and ‘Discharge and Transition’ (10 items; 20.7–48.2%). Retest coefficients ranged from r = 0.671 until r = 0.855 and indicated good reliability. Low ratios of item-non-response (0.8–9.3%) confirmed a high acceptance by patients.
Conclusions
The number of patients with complex healthcare needs is increasing. Initiatives to expand quality assurance across organizational borders and healthcare sectors are therefore urgently needed. A validated questionnaire (called PEACS 1.0) is available to measure patients' experiences across healthcare sectors with a focus on quality improvement.
doi:10.1093/intqhc/mzu044
PMCID: PMC4041096  PMID: 24758750
quality measurement; quality management; patient satisfaction; measurement of quality; patient-centered care; quality improvement
12.  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.
doi:10.1093/intqhc/mzu026
PMCID: PMC4001692  PMID: 24671121
quality management; audit; implementation; on-site visits; hospital
13.  The associations between organizational culture, organizational structure and quality management in European hospitals 
Objective
To better understand associations between organizational culture (OC), organizational management structure (OS) and quality management in hospitals.
Design
A multi-method, multi-level, cross-sectional observational study.
Setting and participants
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.
Main outcome measures
Extent of implementation of quality management systems, extent of compliance with existing management procedures and implementation of clinical quality activities.
Results
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.
Conclusion
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.
doi:10.1093/intqhc/mzu027
PMCID: PMC4001695  PMID: 24671119
organizational culture; organizational structure; hospital; quality management; quality improvement; DUQuE
14.  Deepening our understanding of quality improvement in Europe (DUQuE): overview of a study of hospital quality management in seven countries 
Introduction and Objective
This paper provides an overview of the DUQuE (Deepening our Understanding of Quality Improvement in Europe) project, the first study across multiple countries of the European Union (EU) to assess relationships between quality management and patient outcomes at EU level. The paper describes the conceptual framework and methods applied, highlighting the novel features of this study.
Design
DUQuE was designed as a multi-level cross-sectional study with data collection at hospital, pathway, professional and patient level in eight countries.
Setting and Participants
We aimed to collect data for the assessment of hospital-wide constructs from up to 30 randomly selected hospitals in each country, and additional data at pathway and patient level in 12 of these 30.
Main outcome measures
A comprehensive conceptual framework was developed to account for the multiple levels that influence hospital performance and patient outcomes. We assessed hospital-specific constructs (organizational culture and professional involvement), clinical pathway constructs (the organization of care processes for acute myocardial infarction, stroke, hip fracture and deliveries), patient-specific processes and outcomes (clinical effectiveness, patient safety and patient experience) and external constructs that could modify hospital quality (external assessment and perceived external pressure).
Results
Data was gathered from 188 hospitals in 7 participating countries. The overall participation and response rate were between 75% and 100% for the assessed measures.
Conclusions
This is the first study assessing relation between quality management and patient outcomes at EU level. The study involved a large number of respondents and achieved high response rates. This work will serve to develop guidance in how to assess quality management and makes recommendations on the best ways to improve quality in healthcare for hospital stakeholders, payers, researchers, and policy makers throughout the EU.
doi:10.1093/intqhc/mzu025
PMCID: PMC4001699  PMID: 24671120
quality management systems; clinical indicators; clinical effectiveness; quality of healthcare; hospitals; cross-national research; patient outcomes
16.  Development and validation of an index to assess hospital quality management systems 
Objective
The aim of this study was to develop and validate an index to assess the implementation of quality management systems (QMSs) in European countries.
Design
Questionnaire 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 participants
As 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 Measure
The extent of implementation of QMSs.
Results
Factor 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.
Conclusion
Assessing 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.
doi:10.1093/intqhc/mzu021
PMCID: PMC4001698  PMID: 24618212
quality management; hospital care; surveys; patient safety; health care system
17.  Measuring clinical management by physicians and nurses in European hospitals: development and validation of two scales 
Objective
Clinical management is hypothesized to be critical for hospital management and hospital performance. The aims of this study were to develop and validate professional involvement scales for measuring the level of clinical management by physicians and nurses in European hospitals.
Design
Testing of validity and reliability of scales derived from a questionnaire of 21 items was developed on the basis of a previous study and expert opinion and administered in a cross-sectional seven-country research project ‘Deepening our Understanding of Quality improvement in Europe’ (DUQuE).
Setting and Participants
A sample of 3386 leading physicians and nurses working in 188 hospitals located in Czech Republic, France, Germany, Poland, Portugal, Spain and Turkey.
Main Outcome Measures
Validity and reliability of professional involvement scales and subscales.
Results
Psychometric analysis yielded four subscales for leading physicians: (i) Administration and budgeting, (ii) Managing medical practice, (iii) Strategic management and (iv) Managing nursing practice. Only the first three factors applied well to the nurses. Cronbach's alpha for internal consistency ranged from 0.74 to 0.86 for the physicians, and from 0.61 to 0.81 for the nurses. Except for the 0.74 correlation between ‘Administration and budgeting’ and ‘Managing medical practice’ among physicians, all inter-scale correlations were <0.70 (range 0.43–0.61). Under testing for construct validity, the subscales were positively correlated with ‘formal management roles’ of physicians and nurses.
Conclusions
The professional involvement scales appear to yield reliable and valid data in European hospital settings, but the scale ‘Managing medical practice’ for nurses needs further exploration. The measurement instrument can be used for international research on clinical management.
doi:10.1093/intqhc/mzu014
PMCID: PMC4001689  PMID: 24615595
clinical management; professional involvement; quality systems; hospital management
18.  Involvement of patients or their representatives in quality management functions in EU hospitals: implementation and impact on patient-centred care strategies 
Objective
The objective of this study was to describe the involvement of patients or their representatives in quality management (QM) functions and to assess associations between levels of involvement and the implementation of patient-centred care strategies.
Design
A cross-sectional, multilevel study design that surveyed quality managers and department heads and data from an organizational audit.
Setting
Randomly selected hospitals (n = 74) from seven European countries (The Czech Republic, France, Germany, Poland, Portugal, Spain and Turkey).
Participants
Hospital quality managers (n = 74) and heads of clinical departments (n = 262) in charge of four patient pathways (acute myocardial infarction, stroke, hip fracture and deliveries) participated in the data collection between May 2011 and February 2012.
Main Outcome Measures
Four items reflecting essential patient-centred care strategies based on an on-site hospital visit: (1) formal survey seeking views of patients and carers, (2) written policies on patients' rights, (3) patient information literature including guidelines and (4) fact sheets for post-discharge care. The main predictors were patient involvement in QM at the (i) hospital level and (ii) pathway level.
Results
Current levels of involving patients and their representatives in QM functions in European hospitals are low at hospital level (mean score 1.6 on a scale of 0 to 5, SD 0.7), but even lower at departmental level (mean 0.6, SD 0.7). We did not detect associations between levels of involving patients and their representatives in QM functions and the implementation of patient-centred care strategies; however, the smallest hospitals were more likely to have implemented patient-centred care strategies.
Conclusions
There is insufficient evidence that involving patients and their representatives in QM leads to establishing or implementing strategies and procedures that facilitate patient-centred care; however, lack of evidence should not be interpreted as evidence of no effect.
doi:10.1093/intqhc/mzu022
PMCID: PMC4001693  PMID: 24615596
quality management; quality measurement; patient-centred care; hospital care, hospital, patient involvement
19.  A checklist for patient safety rounds at the care pathway level 
Objective
To define a checklist that can be used to assess the performance of a department and evaluate the implementation of quality management (QM) activities across departments or pathways in acute care hospitals.
Design
We developed and tested a checklist for the assessment of QM activities at department level in a cross-sectional study using on-site visits by trained external auditors.
Setting and participants
A sample of 292 hospital departments of 74 acute care hospitals across seven European countries. In every hospital, four departments for the conditions: acute myocardial infarction (AMI), stroke, hip fracture and deliveries participated.
Main Outcome Measures
Four measures of QM activities were evaluated at care pathway level focusing on specialized expertise and responsibility (SER), evidence-based organization of pathways (EBOP), patient safety strategies and clinical review (CR).
Results
Participating departments attained mean values on the various scales between 1.2 and 3.7. The theoretical range was 0–4. Three of the four QM measures are identical for the four conditions, whereas one scale (EBOP) has condition-specific items. Correlations showed that every factor was related, but also distinct, and added to the overall picture of QM at pathway level.
Conclusion
The newly developed checklist can be used across various types of departments and pathways in acute care hospitals like AMI, deliveries, stroke and hip fracture. The anticipated users of the checklist are internal (e.g. peers within the hospital and hospital executive board) and external auditors (e.g. healthcare inspectorate, professional or patient organizations).
doi:10.1093/intqhc/mzu019
PMCID: PMC4001694  PMID: 24615594
quality improvement; quality management; external quality assessment; measurement of quality; surgery; professions; hospital care
20.  DUQuE quality management measures: associations between quality management at hospital and pathway levels 
Objective
The assessment of integral quality management (QM) in a hospital requires measurement and monitoring from different perspectives and at various levels of care delivery. Within the DUQuE project (Deepening our Understanding of Quality improvement in Europe), seven measures for QM were developed. This study investigates the relationships between the various quality measures.
Design
It is a multi-level, cross-sectional, mixed-method study.
Setting and Participants
As part of the DUQuE project, we invited a random sample of 74 hospitals in 7 countries. The quality managers of these hospitals were the main respondents. Furthermore, data of site visits of external surveyors assessing the participating hospitals were used.
Main Outcome Measures
Three measures of QM at hospitals level focusing on integral systems (QMSI), compliance with the Plan-Do-Study-Act quality improvement cycle (QMCI) and implementation of clinical quality (CQII). Four measures of QM activities at care pathway level focusing on Specialized expertise and responsibility (SER), Evidence-based organization of pathways (EBOP), Patient safety strategies (PSS) and Clinical review (CR).
Results
Positive significant associations were found between the three hospitals level QM measures. Results of the relationships between levels were mixed and showed most associations between QMCI and department-level QM measures for all four types of departments. QMSI was associated with PSS in all types of departments.
Conclusion
By using the seven measures of QM, it is possible to get a more comprehensive picture of the maturity of QM in hospitals, with regard to the different levels and across various types of hospital departments.
doi:10.1093/intqhc/mzu020
PMCID: PMC4001696  PMID: 24615597
quality management; quality improvement; external quality assessment; measurement of quality; organization science, healthcare system; patient safety; hospital care
21.  The effect of certification and accreditation on quality management in 4 clinical services in 73 European hospitals 
Objective
To investigate the relationship between ISO 9001 certification, healthcare accreditation and quality management in European hospitals.
Design
A mixed method multi-level cross-sectional design in seven countries. External teams assessed clinical services on the use of quality management systems, illustrated by four clinical pathways.
Setting and Participants
Seventy-three acute care hospitals with a total of 291 services managing acute myocardial infarction (AMI), hip fracture, stroke and obstetric deliveries, in Czech Republic, France, Germany, Poland, Portugal, Spain and Turkey.
Main Outcome Measure
Four composite measures of quality and safety [specialized expertise and responsibility (SER), evidence-based organization of pathways (EBOP), patient safety strategies (PSS) and clinical review (CR)] applied to four pathways.
Results
Accreditation in isolation showed benefits in AMI and stroke more than in deliveries and hip fracture; the greatest significant association was with CR in stroke. Certification in isolation showed little benefit in AMI but had more positive association with the other conditions; greatest significant association was in PSS with stroke. The combination of accreditation and certification showed least benefit in EBOP, but significant benefits in SER (AMI), in PSS (AMI, hip fracture and stroke) and in CR (AMI and stroke).
Conclusions
Accreditation and certification are positively associated with clinical leadership, systems for patient safety and clinical review, but not with clinical practice. Both systems promote structures and processes, which support patient safety and clinical organization but have limited effect on the delivery of evidence-based patient care. Further analysis of DUQuE data will explore the association of certification and accreditation with clinical outcomes.
doi:10.1093/intqhc/mzu023
PMCID: PMC4001697  PMID: 24257160
accreditation; certification; health care quality assessment; quality management; patient safety
22.  Evidence-based organization and patient safety strategies in European hospitals 
Objective
To explore how European hospitals have implemented patient safety strategies (PSS) and evidence-based organization of care pathway (EBOP) recommendations and examine the extent to which implementation varies between countries and hospitals.
Design
Mixed-method multilevel cross-sectional design in seven countries as part of the European Union-funded project ‘Deepening our Understanding of Quality improvement in Europe’ (DUQuE).
Setting and participants
Seventy-four acute care hospitals with 292 departments managing acute myocardial infarction (AMI), hip fracture, stroke, and obstetric deliveries.
Main outcome measure
Five multi-item composite measures—one generic measure for PSS and four pathway-specific measures for EBOP.
Results
Potassium chloride had only been removed from general medication stocks in 9.4–30.5% of different pathways wards and patients were adequately identified with wristband in 43.0–59.7%. Although 86.3% of areas treating AMI patients had immediate access to a specialist physician, only 56.0% had arrangements for patients to receive thrombolysis within 30 min of arrival at the hospital. A substantial amount of the total variance observed was due to between-hospital differences in the same country for PSS (65.9%). In EBOP, between-country differences play also an important role (10.1% in AMI to 57.1% in hip fracture).
Conclusions
There were substantial gaps between evidence and practice of PSS and EBOP in a sample of European hospitals and variations due to country differences are more important in EBOP than in PSS, but less important than within-country variations. Agencies supporting the implementation of PSS and EBOP should closely re-examine the effectiveness of their current strategies.
doi:10.1093/intqhc/mzu016
PMCID: PMC4001691  PMID: 24578501
patient safety; quality improvement; quality management; practice variations; appropriate healthcare; hospital care; effectiveness
23.  Feasibility of using administrative data to compare hospital performance in the EU 
Objective
To describe hospitals' organizational arrangements relevant to the abstraction of administrative data, to report on the completeness of administrative data collected and to assess associations between organizational arrangements and completeness of data submission.
Design
A cross-sectional study design utilizing administrative data.
Setting and Participants
Randomly selected hospitals from seven European countries (The Czech Republic, France, Germany, Poland, Portugal, Spain, and Turkey).
Main Outcome Measures
Completeness of data submission for four quality indicators: mortality after acute myocardial infarction, stroke and hip fractures and complications after normal delivery.
Results
In general, hospitals were able to produce data on the four indicators required for this research study. A substantial proportion had missing data on one or more data items. The proportion of hospitals that was able to produce more detailed indicators of relevance for quality monitoring and improvement was low and ranged from 40.1% for thrombolysis performed on patients with acute ischemic stroke to 63.8% for hip-fracture operations performed within 48 h after admission for patients aged 65 or older. National factors were strong predictors of data completeness on the studied indicators.
Conclusions
At present, hospital administrative databases do not seem to be an appropriate source of information for comparison of hospital performance across the countries of the EU. However, given that this is a dynamic field, changes to administrative databases may make this possible in the near future. Such changes could be accelerated by an in-depth comparative analysis of the issues of using administrative data for comparisons of hospital performances in EU countries.
doi:10.1093/intqhc/mzu015
PMCID: PMC4001688  PMID: 24554645
audit; external quality assessment; quality management; quality indicators; measurement of quality; benchmarking; measurement of quality; health policy; health care system; safety indicators; patient safety; hospital care; setting of care
24.  Is having quality as an item on the executive board agenda associated with the implementation of quality management systems in European hospitals: a quantitative analysis 
Objective
To assess whether there is a relationship between having quality as an item on the board's agenda, perceived external pressure (PEP) and the implementation of quality management in European hospitals.
Design
A quantitative, mixed method, cross-sectional study in seven European countries in 2011 surveying CEOs and quality managers and data from onsite audits.
Participants
One hundred and fifty-five CEOs and 155 quality managers.
Setting
One hundred and fifty-five randomly selected acute care hospitals in seven European countries (Czech Republic, France, Germany, Poland, Portugal, Spain and Turkey).
Main outcome measure(s)
Three constructs reflecting quality management based on questionnaire and audit data: (i) Quality Management System Index, (ii) Quality Management Compliance Index and (iii) Clinical Quality Implementation Index. The main predictor was whether quality performance was on the executive board's agenda.
Results
Discussing quality performance at executive board meetings more often was associated with a higher quality management system score (regression coefficient b = 2.53; SE = 1.16; P = 0.030). We found a trend in the associations of discussing quality performance with quality compliance and clinical quality implementation. PEP did not modify these relationships.
Conclusions
Having quality as an item on the executive board's agenda allows them to review and discuss quality performance more often in order to improve their hospital's quality management. Generally, and as this study found, having quality on the executive board's agenda matters.
doi:10.1093/intqhc/mzu017
PMCID: PMC4001687  PMID: 24550260
quality management; executive board; quality on the agenda; external pressure; international research; acute care hospitals
25.  Improving mental health outcomes: achieving equity through quality improvement 
Objective
To investigate equity of patient outcomes in a psychological therapy service, following increased access achieved by a quality improvement (QI) initiative.
Design
Retrospective service evaluation of health outcomes; data analysed by ANOVA, chi-squared and Statistical Process Control.
Setting
A psychological therapy service in Westminster, London, UK.
Participants
People living in the Borough of Westminster, London, attending the service (from either healthcare professional or self-referral) between February 2009 and May 2012.
Intervention(s)
Social marketing interventions were used to increase referrals, including the promotion of the service through local media and through existing social networks.
Main Outcome Measure(s)
(i) Severity of depression on entry using Patient Health Questionnaire-9 (PHQ9). (ii) Changes to severity of depression following treatment (ΔPHQ9). (iii) Changes in attainment of a meaningful improvement in condition assessed by a key performance indicator.
Results
Patients from areas of high deprivation entered the service with more severe depression (M = 15.47, SD = 6.75), compared with patients from areas of low (M = 13.20, SD = 6.75) and medium (M = 14.44, SD = 6.64) deprivation. Patients in low, medium and high deprivation areas attained similar changes in depression score (ΔPHQ9: M = −6.60, SD = 6.41). Similar proportions of patients achieved the key performance indicator across initiative phase and deprivation categories.
Conclusions
QI methods improved access to mental health services; this paper finds no evidence for differences in clinical outcomes in patients, regardless of level of deprivation, interpreted as no evidence of inequity in the service with respect to this outcome.
doi:10.1093/intqhc/mzu005
PMCID: PMC3979278  PMID: 24521701
quality improvement; mental health; public health; inequalities; outcome assessment (health care)

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