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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., (© The Author 2015. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved.)

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.

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.

Objective: The objective of this study was to describe the involvement of patients or their representatives in quality management (QM) functions and to assess associations between levels of involvement and the implementation of patient-centred care strategies., Design: A cross-sectional, multilevel, Study Design: that surveyed quality managers and department heads and data from an organizational audit., Setting: Randomly selected hospitals (n = 74) from seven European countries (The Czech Republic, France, Germany, Poland, Portugal, Spain and Turkey)., Participants: Hospital quality managers (n = 74) and heads of clinical departments (n = 262) in charge of four patient pathways (acute myocardial infarction, stroke, hip fracture and deliveries) participated in the data collection between May 2011 and February 2012., Main Outcome Measures: Four items reflecting essential patient-centred care strategies based on an on-site hospital visit: (1) formal survey seeking views of patients and carers, (2) written policies on patients' rights, (3) patient information literature including guidelines and (4) fact sheets for post-discharge care. The main predictors were patient involvement in QM at the (i) hospital level and (ii) pathway level., Results: Current levels of involving patients and their representatives in QM functions in European hospitals are low at hospital level (mean score 1.6 on a scale of 0 to 5, SD 0.7), but even lower at departmental level (mean 0.6, SD 0.7). We did not detect associations between levels of involving patients and their representatives in QM functions and the implementation of patient-centred care strategies; however, the smallest hospitals were more likely to have implemented patient-centred care strategies., Conclusions: There is insufficient evidence that involving patients and their representatives in QM leads to establishing or implementing strategies and procedures that facilitate patient-centred care; however, lack of evidence should not be interpreted as evidence of no effect.

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.

Objective: The assessment of integral quality management (QM) in a hospital requires measurement and monitoring from different perspectives and at various levels of care delivery. Within the DUQuE project (Deepening our Understanding of Quality improvement in Europe), seven measures for QM were developed. This study investigates the relationships between the various quality measures., Design: It is a multi-level, cross-sectional, mixed-method study., Setting and Participants: As part of the DUQuE project, we invited a random sample of 74 hospitals in 7 countries. The quality managers of these hospitals were the main respondents. Furthermore, data of site visits of external surveyors assessing the participating hospitals were used., Main Outcome Measures: Three measures of QM at hospitals level focusing on integral systems (QMSI), compliance with the Plan-Do-Study-Act quality improvement cycle (QMCI) and implementation of clinical quality (CQII). Four measures of QM activities at care pathway level focusing on Specialized expertise and responsibility (SER), Evidence-based organization of pathways (EBOP), Patient safety strategies (PSS) and Clinical review (CR)., Results: Positive significant associations were found between the three hospitals level QM measures. Results of the relationships between levels were mixed and showed most associations between QMCI and department-level QM measures for all four types of departments. QMSI was associated with PSS in all types of departments., Conclusion: By using the seven measures of QM, it is possible to get a more comprehensive picture of the maturity of QM in hospitals, with regard to the different levels and across various types of hospital departments.

Objective: To define a checklist that can be used to assess the performance of a department and evaluate the implementation of quality management (QM) activities across departments or pathways in acute care hospitals., Design: We developed and tested a checklist for the assessment of QM activities at department level in a cross-sectional study using on-site visits by trained external auditors., Setting and Participants: A sample of 292 hospital departments of 74 acute care hospitals across seven European countries. In every hospital, four departments for the conditions: acute myocardial infarction (AMI), stroke, hip fracture and deliveries participated., Main Outcome Measures: Four measures of QM activities were evaluated at care pathway level focusing on specialized expertise and responsibility (SER), evidence-based organization of pathways (EBOP), patient safety strategies and clinical review (CR)., Results: Participating departments attained mean values on the various scales between 1.2 and 3.7. The theoretical range was 0-4. Three of the four QM measures are identical for the four conditions, whereas one scale (EBOP) has condition-specific items. Correlations showed that every factor was related, but also distinct, and added to the overall picture of QM at pathway level., Conclusion: The newly developed checklist can be used across various types of departments and pathways in acute care hospitals like AMI, deliveries, stroke and hip fracture. The anticipated users of the checklist are internal (e.g. peers within the hospital and hospital executive board) and external auditors (e.g. healthcare inspectorate, professional or patient organizations).

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.

Quality Problem: Patient-centred care is increasingly being acknowledged as an integral part of evaluating health care. Yet, from a quality improvement perspective the rationale, measurement and implementation of strategies to improve patient-centred care is often subject to debate., Objective: The aim of this paper is to review why quality improvement efforts should embrace patient-centredness, to examine some of the measurement issues and to assess conceptual underpinnings that should inform both measurement and actions to improve patient-centred care., Lessons: The causal pathway through which quality improvement affects and/or is associated with patient centredness is complex and goes beyond patients' rights and assessing patient views. Interventions to improve patient-centred care should reflect on key rationale, measurement strategy and underlying theory.

Background: Hospital accreditation and International Standardisation Organisation (ISO) certification offer alternative mechanisms for improving safety and quality, or as a mark of achievement. There is little published evidence on their relative merits., Objective: To identify systematic differences in quality management between hospitals that were accredited, or certificated, or neither. Research design, Analysis: of compliance with measures of quality in 89 hospitals in six countries, as assessed by external auditors using a standardized tool, as part of the EC-funded, Methods: of Assessing Response to Quality Improvement Strategies project., Main Outcome Measures: Compliance scores in six dimensions of each hospital-grouped according to the achievement of accreditation, certification or neither., Results: Of the 89 hospitals selected for external audit, 34 were accredited (without ISO certification), 10 were certificated under ISO 9001 (without accreditation) and 27 had neither accreditation nor certification. Overall percentage scores for 229 criteria of quality and safety were 66.9, 60.0 and 51.2, respectively. Analysis confirmed statistically significant differences comparing mean scores by the type of external assessment (accreditation, certification or neither); however, it did not substantially differentiate between accreditation and certification only. Some of these associations with external assessments were confounded by the country in which the sample hospitals were located., Conclusions: It appears that quality and safety structures and procedures are more evident in hospitals with either the type of external assessment and suggest that some differences exist between accredited versus certified hospitals. Interpretation of these results, however, is limited by the sample size and confounded by variations in the application of accreditation and certification within and between countries.

Despite a strong tradition in the literature on the patient information, education and involvement, there are few practical tools available to support hospitals in implementing such strategies. Based on the WHO Health Promoting Hospitals and Health Services (HPH) Strategy, we developed a self-assessment tool for health promotion in hospitals. We describe the development process and validity testing of the tool in a convenience sample of 38 hospitals from eight countries. We computed an overall compliance score, assessed internal consistency and tested associations of self-reported compliance with hospital characteristics, such as accreditation status and being member of the HPH network. The mean compliance with the tool, which assigns a possible score from 0 to 136, was 71.8 (SD 25.0). Floor effects were observed for standards 4 and 5 only (10.5 and 15.8%, respectively), but not for the overall score. Cronbach's alpha for the five scales in the tool ranged from 0.77 to 0.88. Being accredited or being a member of the HPH network was significantly associated with higher overall compliance (score 86.9 versus 64.2, p = 0.012 and 79.3 versus 51.9, p = 0.003, respectively). We developed and established preliminary validity of a self-assessment tool for health promotion in hospitals. Based on assessment of basic psychometric properties, analysis of reliability and construct validity, the tool suggests robustness for self-assessment purposes; however, further research on its validity is strongly warranted if the tool is to be used for other purposes than self-assessment.

Context: Strategy development and implementation in acute care settings is often restricted by competing challenges, the pace of policy reform and the existence of parallel hierarchies., Objective: To describe a generic approach to strategy development, illustrate the use of the Balanced Scorecard as a tool to facilitate strategy implementation and demonstrate how to break down strategic goals into measurable elements., Design: Multi-method approach using three different conceptual models: Health Promoting Hospitals Standards and Strategies, the European Foundation for Quality Management (EFQM) Model and the Balanced Scorecard. A bundle of qualitative and quantitative methods were used including in-depth interviews, standardized organization-wide surveys on organizational values, staff satisfaction and patient experience., Setting: Three acute care hospitals in four different locations belonging to a German holding group., Participants: Chief executive officer, senior medical officers, working group leaders and hospital staff., Intervention(s): Development and implementation of the Balanced Scorecard., Main Outcome Measure(s): Twenty strategic objectives with corresponding Balanced Scorecard measures., Results: A stepped approach from strategy development to implementation is presented to identify key themes for strategy development, drafting a strategy map and developing strategic objectives and measures., Conclusions: The Balanced Scorecard, in combination with the EFQM model, is a useful tool to guide strategy development and implementation in health care organizations. As for other quality improvement and management tools not specifically developed for health care organizations, some adaptations are required to improve acceptability among professionals. The step-wise approach of strategy development and implementation presented here may support similar processes in comparable organizations.

Background: Assessing the quality of health care has become increasingly important in health care in response to growing demands from purchasers, providers, clinicians and the public. Given the increase in projects and programs to assess performance in health care in the last 15 years, the purpose of this paper is to review current indicator projects for hospital performance assessment and compare them to the Performance Assessment Tool for Quality Improvement in Hospitals (PATH), an initiative by the WHO Regional Office for Europe., Methodology: We identified current indicator projects through a systematic literature search and through contact with experts. Using an inductive approach based on a review of the literature, we identified 10 criteria for the comparison of indicator projects. We extracted data and contacted the coordinators of each indicator project to validate this information. In addition, we carried out interviews with coordinators to gather additional information on the evaluation of the respective projects., Results: We included 11 projects that appear to have adopted a common methodology for the design and selection of indicators; however, major differences exist with regard to the philosophy, scope and coverage of the projects. This relates in particular to criteria such as participation, disclosure of results and dimensions of hospital performance assessed., Conclusion: Hospital performance assessment projects have become common worldwide, and initiatives such as the WHO PATH project need to be well coordinated with existing projects. Our review raised questions regarding the impact of hospital performance assessment that should be pursued in further research.

Objective: To evaluate the pilot implementation of the World Health Organization Performance Assessment Tool for Quality Improvement in hospitals (PATH)., Design: Semi-structured interviews with regional/country coordinators and Internet-based survey distributed to hospital coordinators., Setting: A total of 37 hospitals in six regions/countries (Belgium, Ontario (Canada), Denmark, France, Slovakia, KwaZulu Natal (South Africa))., Participants: Six PATH regional/country coordinators and 37 PATH hospital coordinators., Intervention: Implementation of a hospital performance assessment pilot project., Outcome Measure: Experience of regional/country coordinators (structured interviews) and experience of hospital coordinators (survey) with the pilot implementation., Results: The main achievement has been the collection and analysis of data on a set of indicators for comprehensive performance assessment in hospitals in regions and countries with different cultures and resource availability. Both regional/country coordinators and hospital coordinators required seed funding and technical support during data collection for implementation. Based on the user evaluation, we identified the following research and development tasks: further standardization and improved validity of indicators, increased use of routine data, more timely feedback with a stronger focus on international benchmarking and further support on interpretation of results., Conclusions: Key to successful implementation was the embedding of PATH in existing performance measurement initiatives while acknowledging the core objective of the project as a self-improvement tool. The pilot test raised a number of organizational and methodological challenges in the design and implementation of international research on hospital performance assessment. Moreover, the process of evaluating PATH resulted in interesting learning points for other existing and newly emerging quality indicator projects.

The health-promoting hospitals (HPH) movement in Estonia was initiated in 1999. This study aimed to compare the implementation of health-promoting and quality-related activities in HPH and those which have not joined the HPH network (non-HPH). In the beginning of 2005, a postal survey was conducted among the top managers of 54 Estonian hospitals. The questionnaire was based on the WHO standards for HPH and on the set of the national quality assurance (QA) requirements for health services. The study demonstrated some significant differences in the uptake of health promotion and QA activities between HPH and non-HPH. For example, regular patient satisfaction studies were conducted in 83% of HPH and 46% of non-HPH (P < 0.03) and 65% of HPH and 46% of non-HPH cooperated with various patient organizations (P < 0.03). Systems for reporting and analysis of complications were implemented in 71% of HPH and 33% of non-HPH (P < 0.03); also, the implementation of various guidelines was more developed in HPH. All HPH have carried out a risk analysis on the workplace and staff job satisfaction studies were conducted in 89% of HPH and 41% non-HPH (P < 0.05). This study indicates that the concepts of HPH and QA are closely related. Making progress in health promotion is accompanied with QA and vice versa. Implementation of health-promoting activities in hospitals will promote the well-being and health of patients and hospital staff, and creates a supportive environment to provide safe and high-quality health services.