Ana Escoval

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.

The hospital survey on patient safety culture in Portuguese hospitals: instrument validity and reliability.

PURPOSE Quantitative instruments to assess patient safety culture have been developed recently and a few review articles have been published. Measuring safety culture enables healthcare managers and staff to improve safety behaviours and outcomes for patients and staff. The study aims to determine the AHRQ Hospital Survey on Patient Safety Culture (HSPSC) Portuguese versions validity and reliability. DESIGN/METHODOLOGY/APPROACH A missing-value analysis and item analysis was performed to identify problematic items. Reliability analysis, inter-item correlations and inter-scale correlations were done to check internal consistency, composite scores. Inter-correlations were examined to assess construct validity. A confirmatory factor analysis was performed to investigate the observed datas fit to the dimensional structure proposed in the AHRQ HSPSC Portuguese version. To analyse differences between hospitals concerning composites scores, an ANOVA analysis and multiple comparisons were done. FINDINGS Eight of 12 dimensions had Cronbachs alphas higher than 0.7. The instrument as a whole achieved a high Cronbachs alpha (0.91). Inter-correlations showed that there is no dimension with redundant items, however dimension 10 increased its internal consistency when one item is removed. ORIGINALITY/VALUE This study is the first to evaluate an American patient safety culture survey using Portuguese data. The survey has satisfactory reliability and construct validity.

Improvement of hospital performance through innovation: toward the value of hospital care.

The perspective of innovation as the strategic lever of organizational performance has been widespread in the hospital sector. While public value of innovation can be significant, it is not evident that innovation always ends up in higher levels of performance. Within this context, the purpose of the article was to critically analyze the relationship between innovation and performance, taking into account the specificities of the hospital sector. This article pulls together primary data on organizational flexibility, innovation, and performance from 95 hospitals in Portugal, collected through a survey, data from interviews to hospital administration boards, and a panel of 15 experts. The diversity of data sources allowed for triangulation. The article uses mixed methods to explore the relationship between innovation and performance in the hospital sector in Portugal. The relationship between innovation and performance is analyzed through cluster analysis, supplemented with content analysis of interviews and the technical nominal group. The main findings reveal that the cluster of efficient innovators has twice the level of performance than other clusters. Organizational flexibility and external cooperation are the 2 major factors explaining these differences. The article identifies various organizational strategies to use innovation in order to enhance hospital performance. Overall, it proposes the alignment of perspectives of different stakeholders on the value proposition of hospital services, the embeddedness of information loops, and continuous adjustments toward high-value services.

Evaluation of elderly persons' functionality and care needs

OBJETIVO: avaliar a funcionalidade dos idosos com base na Classificacao Internacional da Funcionalidade. METODOS: estudo transversal, descritivo; amostra aleatoria, estratificada, com 903 idosos; nivel de confianca 95%; margem de erro 2,5%. Questionario desenvolvido com base na Classificacao Internacional da Funcionalidade; dados coletados a partir de entrevista estruturada por profissionais de saude nos centros de saude do Alentejo. RESULTADOS: 30,7% dos idosos declaram-se analfabetos, 22,9% vivem sozinhos. As necessidades de alimentacao (18,7%), habitacao (19,2%) e saude (26,0%) nao estao satisfeitas. Funcoes de orientacao preservadas em 83,4%; 58% dos idosos referem uma intensidade de dor que requer cuidados; 73,3% dos idosos nao apresentam denticao funcional. Niveis de desempenho superior a 80% nas atividades de participacao: lavar-se (82,6%), atividades relacionadas ao processo de excrecao (92,2%), vestir, comer, beber (89%). CONCLUSAO: decrescimo progressivo da funcionalidade a medida que a idade avanca; todavia, esta preservada em grande parte as dimensoes ate cerca dos 75 anos.

Contratualização na Atenção Primária à Saúde: a experiência de Portugal e Brasil

The contractual arrangements adopted in the Family Health Strategy are a topic as yet scantly addressed in studies. It is introduced in Brazil in different models in accordance with the contracting entity and the legal status of the contracted service provider; and in Portugal, it is based on a model of inter-governmental contractual arrangements with the Family Health Units. In this paper, the current status of contractual arrangements in both countries is presented and their attributes of joint planning, accountability with autonomy and performance-based incentive programs are discussed. The main contributions are: better coordination of the health organizations; substitution of the hierarchical command-control logic with greater participation; and accountability of professionals with enhanced performance of their activities. The conclusion reached is that one of the facilitating elements is gradual construction, in an environment of ongoing learning, with health professionals playing the leading role. However, the major challenges include transparency in the implementation of processes, the enforcement of sound auditing mechanisms and information systems, as well as the continuous review of indicators and their suitability for the health needs of the population.A contratualizacao desenvolvida na Estrategia Saude da Familia e um tema ainda pouco estudado. E introduzida no Brasil em diferentes modelos, de acordo com o ente federativo contratante e o estatuto juridico do prestador de servicos contratado; e em Portugal, a partir de modelo unico de contratualizacao publico-publico com as Unidades de Saude Familiar. Apresenta-se neste artigo o panorama atual da contratualizacao nos dois paises, por meio de estudo de casos, e discutem-se seus atributos de planejamento conjunto, responsabilizacao com autonomia e sistema de incentivos ao desempenho. As principais contribuicoes da contratualizacao sao: melhor coordenacao das organizacoes de saude; substituicao da logica hierarquica de comando-controle pela de maior participacao; e responsabilizacao dos profissionais com melhor desempenho das suas atividades. Conclui-se que um dos elementos facilitadores e sua construcao gradual, em um ambiente de aprendizagem permanente, com o protagonismo dos profissionais de saude; e que seus maiores desafios sao a transparencia na conducao dos processos, o fortalecimento dos mecanismos de auditoria e dos sistemas de informacao, bem como a revisao permanente dos indicadores de monitoramento e sua adequacao as necessidades de saude da populacao.

Hospitals as Learning Organizations: Fostering Innovation Through Interactive Learning

The article aims to provide an analytical understanding of hospitals as “learning organizations.” It further analyzes the development of learning organizations as a way to enhance innovation and performance in the hospital sector. The article pulls together primary data on organizational flexibility, innovation, and performance from 95 administrators from hospital boards in Portugal, collected through a survey, interviews with hospitals boards, and a nominal group technique with a panel of experts on health systems. Results show that a combination of several organizational traits of the learning organization enhances its capacity for innovation development. The logistic model presented reveals that hospitals classified as “advanced learning organizations” have 5 times more chance of developing innovation than “basic learning organizations.” Empirical findings further pointed out incentives, standards, and measurement requirements as key elements for integration of service delivery systems and expansion of the current capacity for structured and real-time learning in the hospital sector. The major implication arising from this study is that policy needs to combine instruments that promote innovation opportunities and incentives, with instruments stimulating the further development of the core components of learning organizations. Such a combination of policy instruments has the potential to ensure a wide external cooperation through a learning infrastructure.

Avaliação da funcionalidade e necessidades de cuidados dos idosos

OBJETIVO: avaliar a funcionalidade dos idosos com base na Classificacao Internacional da Funcionalidade. METODOS: estudo transversal, descritivo; amostra aleatoria, estratificada, com 903 idosos; nivel de confianca 95%; margem de erro 2,5%. Questionario desenvolvido com base na Classificacao Internacional da Funcionalidade; dados coletados a partir de entrevista estruturada por profissionais de saude nos centros de saude do Alentejo. RESULTADOS: 30,7% dos idosos declaram-se analfabetos, 22,9% vivem sozinhos. As necessidades de alimentacao (18,7%), habitacao (19,2%) e saude (26,0%) nao estao satisfeitas. Funcoes de orientacao preservadas em 83,4%; 58% dos idosos referem uma intensidade de dor que requer cuidados; 73,3% dos idosos nao apresentam denticao funcional. Niveis de desempenho superior a 80% nas atividades de participacao: lavar-se (82,6%), atividades relacionadas ao processo de excrecao (92,2%), vestir, comer, beber (89%). CONCLUSAO: decrescimo progressivo da funcionalidade a medida que a idade avanca; todavia, esta preservada em grande parte as dimensoes ate cerca dos 75 anos.

Contributo para a classificação da funcionalidade na população com mais de 65 anos, segundo a Classificação Internacional de Funcionalidade

Purpose Identification of categories of the International Classification of Functioning (ICF), disability and health, for the classification of functioning in the population over 65 years of age.

Narrowing the Skills Gap for Innovation: An Empirical Study in the Hospital Sector

Background The current financial crisis and the increasing burden of chronic diseases are challenging hospitals to enhance their innovation capacity to deliver new and more effective health services. However, the shortage of skills has been widely recognized as a key obstacle for innovation. Ensuring the presence of a skilled workforce has become a priority for the health system in Portugal and across Europe. Objective The aim of this study was to examine the demand of new skills and their influence in both investments in innovation and development of skills. Methods We used a mixed-methods approach combining statistical analysis of data survey and content analysis of semistructured interviews with the Administration Boards of hospitals, using a nominal group technique. Results The results illustrate an increasing demand of a broad range of skills for innovation development, including responsibility and quality consciousness (with a significant increase of 55%, 52/95), adaptation skills (with an increase of 44%, 42/95) and cooperation and communication skills (with an increase of 55%, 52/95). Investments in the development of skills for innovation are mainly focused on aligning professional training with an organizational strategy (69%, 66/95) as well as collaboration in taskforces (61%, 58/95) and cross-department teams (60%, 57/95). However, the dynamics between the supply and demand of skills for innovation are better explained through a broader perspective of organizational changes towards enhancing learning opportunities and engagement of health professionals to boost innovation. Conclusions The results of this study illustrate that hospitals are unlikely to enhance their innovation capacity if they pursue strategies failing to match the skills needed. Within this context, hospitals with high investments in innovation tend to invest more in skills development. The demand of skills and investments in training are influenced by many other factors, including the hospital’s strategies, as well as changes in the work organization. Relevant implications for managers and policy makers can be drawn from the empirical findings of this paper, building on the current efforts from leading innovating hospitals that are already defining the future of health care.

Self-perception of oral health in older adults from an urban population in Lisbon, Portugal

ABSTRACT OBJECTIVE To analyze if the self-perception of oral health in the urban context is associated with sociodemographic factors that interfere in the life quality of oral health. METHODS Cross-sectional study with convenience sample of older individuals (65 years old or more) enrolled in the Agrupamento de Centros de Saúde de Lisboa Norte (ACES Lisboa Norte – Health Centers Groupings North Lisbon). The self-perception of oral health and associated life quality was evaluated by the Geriatric Oral Health Assessment Index and the individuals were classified according to sociodemographic characteristics. The internal consistency of the questionnaire was evaluated by Cronbach’s alpha (α). Later, we used binary logistic regression models to characterize the factors associated with the self-perception of oral health, considering the sociodemographic variables and the older adults’ clinical conditions of oral health and establishing the crude and adjusted (to age) odds ratios and their 90% confidence intervals. RESULTS A total of 369 older adults participated in this study, with an average age of 74.2 years (SD = 6.75); 62.9% were female. On average, the index was moderated, with tendency to be high: 32.9 (SD = 3.6; 12-36 interval). The Cronbach’s alpha was high: 0.805. Age, marital status, and the last dental appointment were the factors significantly associated with self-perception of oral health. CONCLUSIONS The study shows that these individuals have a moderate, with tendency to high, self-perception of oral health. The self-perception of oral health assessment allowed us to identify the main associated sociodemographic factors. This instrument can help guiding planning strategies and oral health promotion directed toward a better life quality for this population group.