Improving patient discharge and reducing hospital readmissions by using Intervention Mapping.

BACKGROUND: There is a growing impetus to reorganize the hospital discharge process to reduce avoidable readmissions and costs. The aim of this study was to provide insight into hospital discharge problems and underlying causes, and to give an overview of solutions that guide providers and policy-makers in improving hospital discharge. METHODS: The Intervention Mapping framework was used. First, a problem analysis studying the scale, causes, and consequences of ineffective hospital discharge was carried out. The analysis was based on primary data from 26 focus group interviews and 321 individual interviews with patients and relatives, and involved hospital and community care providers. Second, improvements in terms of intervention outcomes, performance objectives and change objectives were specified. Third, 220 experts were consulted and a systematic review of effective discharge interventions was carried out to select theory-based methods and practical strategies required to achieve change and better performance. RESULTS: Ineffective discharge is related to factors at the level of the individual care provider, the patient, the relationship between providers, and the organisational and technical support for care providers. Providers can reduce hospital readmission rates and adverse events by focusing on high-quality discharge information, well-coordinated care, and direct and timely communication with their counterpart colleagues. Patients, or their carers, should participate in the discharge process and be well aware of their health status and treatment. Assessment by hospital care providers whether discharge information is accurate and understood by patients and their community counterparts, are important examples of overcoming identified barriers to effective discharge. Discharge templates, medication reconciliation, a liaison nurse or pharmacist, regular site visits and teach-back are identified as effective and promising strategies to achieve the desired behavioural and environmental change. CONCLUSIONS: This study provides a comprehensive guiding framework for providers and policy-makers to improve patient handover from hospital to primary care.

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.

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.

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.

Sustainable healthcare accreditation: messages from Europe in 2009.

BACKGROUND: Healthcare accreditation has grown rapidly since the 1980s but critics question the value of accreditation rather than certification or inspection. Research has focused more on evidence of impact on provider institutions than on health systems; little has been published on the determinants of growth or decline of accreditation organizations and programmes. OBJECTIVE: To describe the development of national accreditation organizations in Europe in relation to incentives, funding and market position in 2009; to identify trends over time using data from previous surveys. METHODS: Contacts in 24 countries, identified by previous surveys, were invited to complete a web-based questionnaire comprising 183 items seeking numerical data or posing multiple choice options. Preliminary results were verified with respondents and agreed for publication. MAIN OUTCOME MEASURES: National healthcare environment, incentives, government policy, legislation, regulation; programme governance, development, funding. RESULTS: The survey identified 18 active national accreditation organizations in Europe. Older ones tend to be independent, profession-dominated and self-financing; they have shown little growth in activity and coverage of the potential market. Newer ones have broad stakeholder governance, support from government policy and growth sustained by legal or financial incentives-giving wide coverage across the healthcare system. The traditional collegial model of accreditation is moving towards a semi-regulatory model of external assessment which could integrate minimal standards of licensing, public safety and accountability with aspirational standards for organizational development and improvement. CONCLUSIONS: The principal challenges to sustainable accreditation appear to be market size, consistency of policy support, programme funding and financial incentives for participation.

Towards hospital standardization in Europe.

QUALITY PROBLEM: There is no simple tool to assess compliance with common national and European directives, guidance and professional advice on the management of healthcare institutions. Despite evidence of unacceptable variations in the protection of patient and staff safety little attention has been given to harmonizing the way services are organized and managed. INITIAL ASSESSMENT: Existing systems which define organizational standards, or assess compliance with them, are not in a position to extend this activity into or across national borders in Europe. Certification, accreditation and licensing programmes are too variable to provide a common basis for consistent assessment. Consensual standards would inevitably be minimal if they were to achieve acceptance by all or a majority of member state governments; they would not be standards for excellence or help the majority of organizations to improve performance. PROPOSED SOLUTION: This paper proposes the development of a framework and measurement tool, initially for hospitals, which could be used for self-assessment or peer review to demonstrate compliance with European legislation, guidance and public expectations without infringing national responsibilities. A common code of management practice could be developed through a process similar to that adopted for clinical practice guidelines by the European commission-funded project on appraisal of guidelines research and evaluation. CONCLUSIONS: In practice, the legal relationships between member states and intergovernmental organizations inhibit the harmonization of management practice across-borders. Faster progress to higher levels of performance would be achieved by voluntary, non-regulatory cooperation of enthusiasts to define, measure and improve the quality of healthcare in European hospitals.