Are performance indicators used for hospital quality management: a qualitative interview study amongst health professionals and quality managers in The Netherlands.

BACKGROUND: Hospitals are under increasing pressure to share indicator-based performance information. These indicators can also serve as a means to promote quality improvement and boost hospital performance. Our aim was to explore hospitals' use of performance indicators for internal quality management activities. METHODS: We conducted a qualitative interview study among 72 health professionals and quality managers in 14 acute care hospitals in The Netherlands. Concentrating on orthopaedic and oncology departments, our goal was to gain insight into data collection and use of performance indicators for two conditions: knee and hip replacement surgery and breast cancer surgery. The semi-structured interviews were recorded and summarised. Based on the data, themes were synthesised and the analyses were executed systematically by two analysts independently. The findings were validated through comparison. RESULTS: The hospitals we investigated collect data for performance indicators in different ways. Similarly, these hospitals have different ways of using such data to support their quality management, while some do not seem to use the data for this purpose at all. Factors like 'linking pin champions', pro-active quality managers and engaged medical specialists seem to make a difference. In addition, a comprehensive hospital data infrastructure with electronic patient records and robust data collection software appears to be a prerequisite to produce reliable external performance indicators for internal quality improvement. CONCLUSIONS: Hospitals often fail to use performance indicators as a means to support internal quality management. Such data, then, are not used to its full potential. Hospitals are recommended to focus their human resource policy on 'linking pin champions', the engagement of professionals and a pro-active quality manager, and to invest in a comprehensive data infrastructure. Furthermore, the differences in data collection processes between Dutch hospitals make it difficult to draw comparisons between outcomes of performance indicators.

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.

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.

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.

To what degree is the governance of Dutch hospitals orientated towards quality in care? Does this really affect performance?

INTRODUCTION: Changing health care systems and market competition requires hospital boards to shift their focus towards a systematic governance of the quality of care. The objective of our study was to describe hospital governance and the quality orientation in the Netherlands. Also we wished to investigate the relationship with hospital performance. MATERIALS AND METHODS: The chairs of both the boards of trustees and the management boards from all 97 Dutch hospitals were asked to participate in a cross-sectional study between November 2010 and February 2011. In this period data on their quality orientation were collected using a web-based survey. Data on hospital performance over the year 2010 were obtained in July 2011. RESULTS: A mixture of reforms and national guidelines increased the emphasis on quality governance in Dutch hospitals. Our results show that boards of trustees and management boards had a reasonable quality orientation. Boards were familiar with quality guidelines, received a reasonable amount of information related to quality and used this for monitoring quality and policy-making. However, we found no association between their quality orientation and hospital performance. CONCLUSION: There was a growing awareness of the quality of care among boards of trustees and management boards; yet some boards still lagged behind. Quality orientation is an important asset because receiving, reviewing and responding to the quality of their performance should provide opportunities to improve quality. However, we were not able to find a relationship between quality orientation and hospital performance. Future research should investigate how boards can develop quality management systems which in turn could enable medical professionals to optimise their delivery of care and thus its quality.

A systematic review of instruments that assess the implementation of hospital quality management systems.

PURPOSE: Health-care providers invest substantial resources to establish and implement hospital quality management systems. Nevertheless, few tools are available to assess implementation efforts and their effect on quality and safety outcomes. This review aims to (i) identify instruments to assess the implementation of hospital quality management systems, (ii) describe their measurement properties and (iii) assess the effects of quality management on quality improvement and quality of care outcomes. DATA SOURCES: We performed a systematic literature search from 1990 to 2011 in PubMed, CINAHL, EMBASE, Cochrane Library and Web of Science. In addition, we used snowball strategies, screened the reference lists of eligible papers, reviewed grey literature and contacted experts in the field. STUDY SELECTION: and data extraction Two reviewers screened eligible papers based on pre-defined inclusion and exclusion criteria and all authors extracted data. Eligible papers are described in terms of general characteristics (settings, type and level of respondents, mode of data collection), methodological properties (sampling strategy, item derivation, conceptualization of quality management, assessment of reliability and validity, scoring) and application/implementation (accounting for context, organizational adaptations, sensitivity to change, deployment and effect size). RESULTS: Eighteen papers were deemed eligible for inclusion. While some common domains emerged in measurement conceptualization, substantial differences in scope persist. The instruments' measurement properties were insufficiently described and only few instruments assessed links between the implementation of quality management systems (QMS) and improvement strategies or outcomes. CONCLUSIONS: There is currently no well-established measure to assess the implementation and effectiveness of quality management systems. Future research should address this gap.

On-site observations of physical work demands of train conductors and service electricians in the Netherlands.

The objective of the present study was to assess the exposure to physical work demands of train conductors and service electricians at a railway company in the Netherlands. On-site observations were performed using the Task Recording and Analysis on Computer observation system to identify the mean duration and frequency of tasks, activities and body postures. In total, 36 train conductors and 41 service electricians were observed for a net working day of 7 h. Results showed that train conductors and service electricians climbed a flight of stairs on average 249 and 258 times, respectively, and that service electricians worked above shoulder height for 65 min on average. In both jobs, guidelines were exceeded, e.g. duration of standing, the number of times climbing a flight of stairs, kneeling and squatting or working in awkward postures, which are risk factors for developing musculoskeletal complaints. Suggestions are made concerning how to reduce these risk factors. STATEMENT OF RELEVANCE: Understanding physical work demands is essential for recognising risk factors for musculoskeletal disorders. Since train conductors and service electricians in the Netherlands reported work-related complaints, on-site observations were performed to determine the duration and frequency of physical work demands. Risk factors were identified in both professions, providing insights concerning preventative measures.