Søren Bie Bogh

Accreditation and improvement in process quality of care: a nationwide study

OBJECTIVE To examine whether performance measures improve more in accredited hospitals than in non-accredited hospital. DESIGN AND SETTING A historical follow-up study was performed using process of care data from all public Danish hospitals in order to examine the development over time in performance measures according to participation in accreditation programs. PARTICIPANTS All patients admitted for acute stroke, heart failure or ulcer at Danish hospitals. INTERVENTION Hospital accreditation by either The Joint Commission International or The Health Quality Service. MEASUREMENTS The primary outcome was a change in opportunity-based composite score and the secondary outcome was a change in all-or-none scores, both measures were based on the individual processes of care. These processes included seven processes related to stroke, six processes to heart failure, four to bleeding ulcer and four to perforated ulcer. RESULTS A total of 27 273 patients were included. The overall opportunity-based composite score improved for both non-accredited and accredited hospitals (13.7% [95% CI 10.6; 16.8] and 9.9% [95% 5.4; 14.4], respectively), but the improvements were significantly higher for non-accredited hospitals (absolute difference: 3.8% [95% 0.8; 8.3]). No significant differences were found at disease level. The overall all-or-none score increased significantly for non-accredited hospitals, but not for accredited hospitals. The absolute difference between improvements in the all-or-none score at non-accredited and accredited hospitals was not significant (3.2% [95% -3.6:9.9]). CONCLUSIONS Participating in accreditation was not associated with larger improvement in performance measures for acute stroke, heart failure or ulcer.

Compliance with accreditation and recommended hospital care—a Danish nationwide population-based study

Objective To examine the association between compliance with accreditation and recommended hospital care. Design A Danish nationwide population-based follow-up study based on data from six national, clinical quality registries between November 2009 and December 2012. Setting Public, non-psychiatric Danish hospitals. Participants Patients with acute stroke, chronic obstructive pulmonary disease, diabetes, heart failure, hip fracture and bleeding/perforated ulcers. Interventions All hospitals were accredited by the first version of The Danish Healthcare Quality Programme. Compliance with accreditation was defined by level of accreditation awarded the hospital after an announced onsite survey; hence, hospitals were either fully (n = 11) or partially accredited (n = 20). Main Outcome Measures Recommended hospital care included 48 process performance measures reflecting recommendations from clinical guidelines. We assessed recommended hospital care as fulfilment of the measures individually and as an all-or-none composite score. Results In total 449 248 processes of care were included corresponding to 68 780 patient pathways. Patients at fully accredited hospitals had a significantly higher probability of receiving care according to clinical guideline recommendations than patients at partially accredited hospitals across conditions (individual measure: adjusted odds ratio (OR) = 1.20, 95% CI: 1.01-1.43, all-or-none: adjusted OR = 1.27, 95% CI: 1.02-1.58). For five of the six included conditions there were an association; the pattern appeared particular strong among patients with acute stroke and hip fracture (all-or-none; acute stroke: adjusted OR = 1.39, 95% CI: 1.05-1.83, hip fracture: adjusted OR = 1.57, 95% CI: 1.00-2.49). Conclusion High compliance with accreditation standards was associated with a higher level of evidence-based hospital care in Danish hospitals.

Proposing leading indicators for blood sampling - application of a method based on the principles of Resilient Healthcare

In recent years, healthcare has put a growing attention to the investigation of successful processes as a supplement to analyzing and investigating unwanted processes, like adverse events and near misses. This new perspective paves the way for developing methods and tools for investigating and understanding how processes function, and how variability can contribute to both success and failure. In the light of this, we have developed a method applicable for identifying leading indicators for successful outcomes of complex healthcare processes. The method, which is termed leading indicator identification method (LIIM) was inspired from similar methods applied in high-risk industries. To demonstrate the usefulness of the method we have conducted a case study with the aim of identifying leading indicators for blood sampling among patients in a Biomedical Department within a Danish hospital. The method builds on and uses steps from the functional resonance analysis method (FRAM). FRAM was developed to analyze how work is performed on a daily basis, in complex systems and can be used prospectively to monitor, manage and control such systems. The contribution of the work is to present the LIIM along with four leading indicators that are important to consider in the planning, management and monitoring of the blood sampling process.

Learn from what goes right: A demonstration of a new systematic method for identification of leading indicators in healthcare

Abstract The work in patient safety is often centred on adverse events and errors. Typical methods to improve patient safety are reactive and focus on understanding past failures. This article presents the development of a proactive method towards improving patient safety and understanding why processes function as intended on a daily basis. The paper presents the steps of how the method was developed and demonstrates it by using a former case study of early detection of sepsis. Emphasis is on understanding complex processes and identify aspects important for things going right and achieving intended outcomes. The study resulted in the development of six overall steps for identifying leading indicators in complex healthcare processes. These were (1) identification of relevant functions, (2) cluster of functions in sets, (3) identification of functions with variability, (4) identification of functions with upstream–downstream functions, (5) identification of leading indicators, and (6) confirmation of leading indicators through experts and adverse events. The study outlined the development a new method on the topic of leading indicators in the context of patient safety.

Consecutive cycles of hospital accreditation: Persistent low compliance associated with higher mortality and longer length of stay

Objective To examine the association between compliance with consecutive cycles of accreditation and patient-related outcomes. Design A Danish nationwide population-based study from 2012 to 2015. Setting In-patients admitted with one of the 80 diagnoses at public, non-psychiatric hospitals. Participants In-patients admitted with one of 80 primary diagnoses which accounted for 80% of all deaths occuring within 30 dyas after admission. Intervention Admission to a hospital with high (n = 125 485 in-patients) or low compliance (n = 152 074 in-patients) in both cycles of accreditation by the Danish Healthcare Quality Programme. Main outcome measures A 30-day mortality, length of stay (LOS) and all-cause acute readmission. We computed adjusted odds ratios (OR) and hazard ratios (HR) using logistic and Cox Proportional Hazard regression including adjustment for six potential patient-related confounders. Results The 30-day mortality risk for in-patients admitted at high compliant hospitals was 3.95% (95% confidence interval (CI): 3.84-4.06) and 4.39% (95% CI: 4.29-4.49) at low compliant hospitals. In-patients admitted at low compliant hospitals had a substantially higher risk of dying within 30-day after admission (adjusted OR: 1.26 (95% CI: 1.11-1.43) and a longer LOS (adjusted HR of discharge: 0.89 (95% CI: 0.82-0.95) than in-patients at high compliant hospitals. No difference was seen for acute readmission (adjusted HR: 0.98 (95% CI: 0.90-1.06)). Focusing on the second cycle alone, in-patients at partially accredited hospitals had a higher 30-day mortality risk and longer LOS than admissions at fully accredited hospitals (30-day: adjusted OR: 1.12 (95% CI: 1.02-1.24) and LOS: adjusted HR: 0.91 (95% CI: 0.84-0.98)). Conclusion Persistent low compliance with the DDKM (in Danish: Den Danske Kvalitetsmodel) accreditation was associated with higher 30-day mortality and longer LOS.

Application of a non-linear model to understand healthcare processes: using the functional resonance analysis method on a case study of the early detection of sepsis

Abstract The use of non-linear models to understand complex processes in healthcare is not a fully adopted concept. Current patient safety research focuses on events by studying adverse events, typically trying to understand the root causes of failures. This article describes an attempt in a Danish hospital to create an understanding of how complex processes produce positive outcomes despite variability and unforeseen factors, using the functional resonance analysis method (FRAM) to describe a frequent activity in healthcare: early detection of sepsis. The model presents 40 activities performed by nurses, doctors, secretaries, health workers and laboratory technicians; and illustrates possible and actual variability in the process. The results reveal that the application of FRAM helped to gain a heightened understanding of a complex healthcare process. The FRAM provided new insights to staff by focusing on aspects that previously had not been central when working with the patient safety during sepsis detection. This included aspects such as becoming aware of the importance of asking the right questions during the referral process from a general practitioner, using experience and clinical judgement during early assessment of patients and the importance of having a good collegial relationship between doctors and nurses. The method helped reveal how the process is often able to succeed despite variability, and how aspects like experience and clinical judgement play a vital role in adapting to everyday conditions. This knowledge can enhance the understanding of how complex processes develop and be useful in supporting their management and improving patient safety.

Hospital accreditation: staff experiences and perceptions

Purpose The purpose of this paper is to understand how staff at various levels perceive and understand hospital accreditation generally and in relation to quality improvement (QI) specifically. Design/methodology/approach In a newly accredited Danish hospital, the authors conducted semi-structured interviews to capture broad ranging experiences. Medical doctors, nurses, a quality coordinator and a quality department employee participated. Interviews were audio recorded and subjected to framework analysis. Findings Staff reported that The Danish Healthcare Quality Programme affected management priorities: office time and working on documentation, which reduced time with patients and on improvement activities. Organisational structures were improved during preparation for accreditation. Staff perceived that the hospital was better prepared for new QI initiatives after accreditation; staff found disease specific requirements unnecessary. Other areas benefited from accreditation. Interviewees expected that organisational changes, owing to accreditation, would be sustained and that the QI focus would continue. Practical implications Accreditation is a critical and complete hospital review, including areas that often are neglected. Accreditation dominates hospital agendas during preparation and surveyor visits, potentially reducing patient care and other QI initiatives. Improvements are less likely to occur in areas that other QI initiatives addressed. Yet, accreditation creates organisational foundations for future QI initiatives. Originality/value The authors study contributes new insights into how hospital staff at different organisational levels perceive and understand accreditation.

Education trajectories and malpractice complaints - A study among Danish general practitioners

Abstract Malpractice litigation is an increasing concern in general practice and other healthcare services but possibly is susceptible to changes in education schemes. In this study using Danish register data, we aimed to investigate the association between general practitioners’ risk of becoming involved in a malpractice complaint in a 1-year time frame and their educational trajectory. Greater age at graduation was associated with increased odds of later complaints, but decreased odds of complaints leading to critique by a disciplinary board. In addition, the time following specialisation, in particular, was associated with increased odds of complaints. Complaint occurrence appeared unrelated to place of education. These findings suggest that, from the point of view of complaints, attention may reasonably be drawn to the significance of medical education and continuing professional development.

ISQUA17-1573CONSECUTIVE CYCLES OF ACCREDITATION: PERSISTENT LOW COMPLIANCE ASSOCIATED WITH HIGHER MORTALITY AND LONGER LENGTH OF STAY

patterns. Results: A three-class model representing unique combination of the 15 non-compulsory standards from the HU Certification Program demonstrated the best fit (Bayesian Information Criterion = 4,617.906; Akaike Information Criterion = 4,407.159; Chi-square goodness of fit = 536.951.3). Class I (18.5% of units) and Class III (36.5% of units) were characterized by having a high rate of specialized units and belong to more recent certification projects. Class II (51.0% of units) presented the highest proportion of primary care units. When comparing standard compliance behavior, Class I had the best general performance on standards relating to the establishment of an individualized health management plan (100%), involvement of professionals on the agreed HU objectives (98%), the implantation of action lines according to comprehensive Health Plans (91%), the issuance a comprehensive activity report (87%), the assessment of the person needs to facilitate access to resources (74%), incorporation of the patients opinion on the organization (71%), promotion of citizen participation as an element of continuous improvement (57%) implementation of a Patient Safe Strategy (45%), or a Quality Plan implementation (41%) amongst others. There was only one quality standard where Class I did not show the best performance when compared with the other classes. The standard related to optimal information dissemination on health promotion activities to the citizen was more likely to be accomplished by class II (79%) that the Class I (70%). Class III showed similar o less compliance than class II, except for the standard related to the issuance a comprehensive activity report (68%), and the standard about the establishment of an individualized health management plan (86%).