Solvejg Kristensen

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.

Selection of indicators for continuous monitoring of patient safety: recommendations of the project 'safety improvement for patients in Europe'

BACKGROUND Initiatives to improve patient safety have high priority among health professionals and politicians in most developed countries. Currently, however, assessment of patient safety problems relies mainly on case-based methodologies. The evidence for their efficiency and reproducibility, proving that safety of care has improved with their usage, is questionable. The exact incidence and prevalence of patient safety quality problems are unknown. Therefore, there is a need for firm, evidence-based methods to survey and develop patient safety and derived activities. OBJECTIVE The objective of this paper is to describe a method to select patient safety indicators and present the indicators derived through this process. METHODS The patient safety indicators were derived and recommended for use in a formalized consensus process based on literature review, targeted information gathering, expert consultation and rating procedures. RESULTS A total of 42 indicators, of which 28 originated from existing international indicator programmes, were selected. The processes and outcome indicators that were recommended for institutional-level use in Europe were 24, covering safety of care aspects such as culture, infections, surgical complications, medication errors, obstetrics, falls and specific diagnostic areas. CONCLUSION The patient safety indicators recommended present a set of possible measures of patient safety. One of the future perspectives of implementing patient safety indicators for systematic monitoring is that it will be possible to continuously estimate the prevalence and incidence of patient safety quality problems. The lesson learnt from quality improvement is that it will pay off in terms of improving patient safety.

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.

Quality improvement and accountability in the Danish health care system

Denmark has unique opportunities for quality measurement and benchmarking since Denmark has well-developed health registries and unique patient identifier that allow all registries to include patient-level data and combine data into sophisticated quality performance monitoring. Over decades, Denmark has developed and implemented national quality and patient safety initiatives in the healthcare system in terms of national clinical guidelines, performance and outcome measurement integrated in clinical databases for important diseases and clinical conditions, measurement of patient experiences, reporting of adverse events, national handling of patient complaints, national accreditation and public disclosure of all data on the quality of care. Over the years, Denmark has worked up a progressive and transparent just culture in quality management; the different actors at the different levels of the healthcare system are mutually attentive and responsive in a coordinated effort for quality of the healthcare services. At national, regional, local and hospital level, it is mandatory to participate in the quality initiatives and to use data and results for quality management, quality improvement, transparency in health care and accountability. To further develop the Danish governance model, it is important to expand the model to the primary care sector. Furthermore, a national quality health programme 2015-18 recently launched by the government supports a new development in health care focusing upon delivering high-quality health care-high quality is defined by results of value to the patients.

Quality management and perceptions of teamwork and safety climate in European hospitals

OBJECTIVE This study aimed to investigate the associations of quality management systems with teamwork and safety climate, and to describe and compare differences in perceptions of teamwork climate and safety climate among clinical leaders and frontline clinicians. METHOD We used a multi-method, cross-sectional approach to collect survey data of quality management systems and perceived teamwork and safety climate. Our data analyses included descriptive and multilevel regression methods. SETTING AND PARTICIPANTS Data on implementation of quality management system from seven European countries were evaluated including patient safety culture surveys from 3622 clinical leaders and 4903 frontline clinicians. MAIN OUTCOME MEASURES Perceived teamwork and safety climate. RESULTS Teamwork climate was reported as positive by 67% of clinical leaders and 43% of frontline clinicians. Safety climate was perceived as positive by 54% of clinical leaders and 32% of frontline clinicians. We found positive associations between implementation of quality management systems and teamwork and safety climate. CONCLUSIONS Our findings, which should be placed in a broader clinical quality improvement context, point to the importance of quality management systems as a supportive structural feature for promoting teamwork and safety climate. To gain a deeper understanding of this association, further qualitative and quantitative studies using longitudinally collected data are recommended. The study also confirms that more clinical leaders than frontline clinicians have a positive perception of teamwork and safety climate. Such differences should be accounted for in daily clinical practice and when tailoring initiatives to improve teamwork and safety climate.

Adaption and validation of the Safety Attitudes Questionnaire for the Danish hospital setting.

Purpose Measuring and developing a safe culture in health care is a focus point in creating highly reliable organizations being successful in avoiding patient safety incidents where these could normally be expected. Questionnaires can be used to capture a snapshot of an employee’s perceptions of patient safety culture. A commonly used instrument to measure safety climate is the Safety Attitudes Questionnaire (SAQ). The purpose of this study was to adapt the SAQ for use in Danish hospitals, assess its construct validity and reliability, and present benchmark data. Materials and methods The SAQ was translated and adapted for the Danish setting (SAQ-DK). The SAQ-DK was distributed to 1,263 staff members from 31 in- and outpatient units (clinical areas) across five somatic and one psychiatric hospitals through meeting administration, hand delivery, and mailing. Construct validity and reliability were tested in a cross-sectional study. Goodness-of-fit indices from confirmatory factor analysis were reported along with inter-item correlations, Cronbach’s alpha (α), and item and subscale scores. Results Participation was 73.2% (N=925) of invited health care workers. Goodness-of-fit indices from the confirmatory factor analysis showed: c2=1496.76, P<0.001, CFI 0.901, RMSEA (90% CI) 0.053 (0.050–0056), Probability RMSEA (p close)=0.057. Inter-scale correlations between the factors showed moderate-to-high correlations. The scale stress recognition had significant negative correlations with each of the other scales. Questionnaire reliability was high, (α=0.89), and scale reliability ranged from α=0.70 to α=0.86 for the six scales. Proportions of participants with a positive attitude to each of the six SAQ scales did not differ between the somatic and psychiatric health care staff. Substantial variability at the unit level in all six scale mean scores was found within the somatic and the psychiatric samples. Conclusion SAQ-DK showed good construct validity and internal consistency reliability. SAQ-DK is potentially a useful tool for evaluating perceptions of patient safety culture in Danish hospitals.

Strengthening leadership as a catalyst for enhanced patient safety culture: a repeated cross-sectional experimental study

Objectives Current literature emphasises that clinical leaders are in a position to enable a culture of safety, and that the safety culture is a performance mediator with the potential to influence patient outcomes. This paper aims to investigate staffs perceptions of patient safety culture in a Danish psychiatric department before and after a leadership intervention. Methods A repeated cross-sectional experimental study by design was applied. In 2 surveys, healthcare staff were asked about their perceptions of the patient safety culture using the 7 patient safety culture dimensions in the Safety Attitudes Questionnaire. To broaden knowledge and strengthen leadership skills, a multicomponent programme consisting of academic input, exercises, reflections and discussions, networking, and action learning was implemented among the clinical area level leaders. Results In total, 358 and 325 staff members participated before and after the intervention, respectively. 19 of the staff members were clinical area level leaders. In both surveys, the response rate was >75%. The proportion of frontline staff with positive attitudes improved by ≥5% for 5 of the 7 patient safety culture dimensions over time. 6 patient safety culture dimensions became more positive (increase in mean) (p<0.05). Frontline staff became more positive on all dimensions except stress recognition (p<0.05). For the leaders, the opposite was the case (p<0.05). Staff leaving the department after the first measurement had rated job satisfaction lower than the staff staying on (p<0.05). Conclusions The improvements documented in the patient safety culture are remarkable, and imply that strengthening the leadership can act as a significant catalyst for patient safety culture improvement. Further studies using a longitudinal study design are recommended to investigate the mechanism behind leaderships influence on patient safety culture, sustainability of improvements over time, and the association of change in the patient safety culture measures with change in psychiatric patient safety outcomes.

Patient Experience Shows Little Relationship with Hospital Quality Management Strategies

Objectives Patient-reported experience measures are increasingly being used to routinely monitor the quality of care. With the increasing attention on such measures, hospital managers seek ways to systematically improve patient experience across hospital departments, in particular where outcomes are used for public reporting or reimbursement. However, it is currently unclear whether hospitals with more mature quality management systems or stronger focus on patient involvement and patient-centered care strategies perform better on patient-reported experience. We assessed the effect of such strategies on a range of patient-reported experience measures. Materials and Methods We employed a cross-sectional, multi-level study design randomly recruiting hospitals from the Czech Republic, France, Germany, Poland, Portugal, Spain, and Turkey between May 2011 and January 2012. Each hospital contributed patient level data for four conditions/pathways: acute myocardial infarction, stroke, hip fracture and deliveries. The outcome variables in this study were a set of patient-reported experience measures including a generic 6-item measure of patient experience (NORPEQ), a 3-item measure of patient-perceived discharge preparation (Health Care Transition Measure) and two single item measures of perceived involvement in care and hospital recommendation. Predictor variables included three hospital management strategies: maturity of the hospital quality management system, patient involvement in quality management functions and patient-centered care strategies. We used directed acyclic graphs to detail and guide the modeling of the complex relationships between predictor variables and outcome variables, and fitted multivariable linear mixed models with random intercept by hospital, and adjusted for fixed effects at the country level, hospital level and patient level. Results Overall, 74 hospitals and 276 hospital departments contributed data on 6,536 patients to this study (acute myocardial infarction n = 1,379, hip fracture n = 1,503, deliveries n = 2,088, stroke n = 1,566). Patients admitted for hip fracture and stroke had the lowest scores across the four patient-reported experience measures throughout. Patients admitted after acute myocardial infarction reported highest scores on patient experience and hospital recommendation; women after delivery reported highest scores for patient involvement and health care transition. We found no substantial associations between hospital-wide quality management strategies, patient involvement in quality management, or patient-centered care strategies with any of the patient-reported experience measures. Conclusion This is the largest study so far to assess the complex relationship between quality management strategies and patient experience with care. Our findings suggest absence of and wide variations in the institutionalization of strategies to engage patients in quality management, or implement strategies to improve patient-centeredness of care. Seemingly counterintuitive inverse associations could be capturing a scenario where hospitals with poorer quality management were beginning to improve their patient experience. The former suggests that patient-centered care is not yet sufficiently integrated in quality management, while the latter warrants a nuanced assessment of the motivation and impact of involving patients in the design and assessment of services.

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.

The virgin land of quality management: a first measure of patient safety climate at the National Hospital of the Faroe Islands

Purpose The Faroe Islands are formally part of the Kingdom of Denmark, but the islands enjoy extensive autonomy as home ruled. In Denmark, extensive quality management initiatives have been implemented throughout hospitals, this was not the case in the Faroese Islands in 2013. The purpose of this study is to investigate the patient safety culture in the National Hospital of the Faroe Islands prior to implementation of quality management initiatives. Methods The Danish version of the Safety Attitudes Questionnaire (SAQ-DK) was distributed electronically to 557 staff members from five medical centers of the hospital, and one administrative unit. SAQ-DK has six cultural dimensions. The proportion of respondents with positive attitudes and mean scale scores were described, and comparison between medical specialties, and between clinical leaders and frontline staff was made using analysis of variance and chi-square test, respectively. Results The response rate was 65.8% (N=367). Job satisfaction was rated most favorable, and the perceived culture of the top management least favorable. Safety climate was the dimension with the greatest variability across the 28 units. The diagnostic center had the most favorable culture of all centers. More leaders than frontline staff had positive attitudes toward teamwork and safety climate, and working conditions, respectively. Also, the leaders perceived these dimensions more positive than the frontline staff, P<0.05. Among three management levels, the unit management was perceived most favorable and the top management least favorable. Conclusion The management group is recommended to raise awareness of their role in supporting a safe and caring environment for patients and staff, moreover the leaders should ensure that every day work achieves its objectives; keeping the patients safe. Furthermore, following the development in patient safety culture over time is recommended.