Association Between Monetary Deposits and Weight Loss in Online Commitment Contracts

PURPOSE

To examine the characteristics of voluntary online commitment contracts that may be associated with greater weight loss.

DESIGN

Retrospective analysis of weight loss commitment contracts derived from a company that provides web-based support for personal commitment contracts. Using regression, we analyzed whether percentage weight loss differed between participants who incentivized their contract using monetary deposits and those who did not.

SETTING

Online.

PARTICIPANTS

Users (N = 3857) who voluntarily signed up online in 2013 for a weight loss contract.

INTERVENTION

Participants specified their own weight loss goal, time period, and self-reported weekly weight. Deposits were available in the following 3 categories: charity, anticharity (a nonprofit one does not like), or donations made to a friend.

MEASURES

Percentage weight loss per week.

ANALYSIS

Multivariable linear regressions.

RESULTS

Controlling for several participant and contract characteristics, contracts with anticharity, charity, and friend deposits had greater reported weight loss than nonincentivized contracts. Weight change per week relative to those without deposits was -0.33%, -0.28%, and -0.25% for anti-charity, charity, and friend, respectively ( P < 0.001). Contracts without a weight verification method claimed more weight loss than those with verification.

CONCLUSION

Voluntary use of commitment contracts may be an effective tool to assist weight loss. Those who choose to use monetary incentives report more weight loss. It is not clear whether this is due to the incentives or higher motivation.

Use of Gene Expression Profiling and Chemotherapy in Early-Stage Breast Cancer: A Study of Linked Electronic Medical Records, Cancer Registry Data, and Genomic Data Across Two Health Care Systems

PURPOSE

The 21-gene recurrence score (RS) identifies patients with breast cancer who derive little benefit from chemotherapy; it may reduce unwarranted variability in the use of chemotherapy. We tested whether the use of RS seems to guide chemotherapy receipt across different cancer care settings.

METHODS

We developed a retrospective cohort of patients with breast cancer by using electronic medical record data from Stanford University (hereafter University) and Palo Alto Medical Foundation (hereafter Community) linked with demographic and staging data from the California Cancer Registry and RS results from the testing laboratory (Genomic Health Inc., Redwood City, CA). Multivariable analysis was performed to identify predictors of RS and chemotherapy use.

RESULTS

In all, 10,125 patients with breast cancer were diagnosed in the University or Community systems from 2005 to 2011; 2,418 (23.9%) met RS guidelines criteria, of whom 15.6% received RS. RS was less often used for patients with involved lymph nodes, higher tumor grade, and age < 40 or ≥ 65 years. Among RS recipients, chemotherapy receipt was associated with a higher score (intermediate v low: odds ratio, 3.66; 95% CI, 1.94 to 6.91). A total of 293 patients (10.6%) received care in both health care systems (hereafter dual use); although receipt of RS was associated with dual use (v University: odds ratio, 1.73; 95% CI, 1.18 to 2.55), there was no difference in use of chemotherapy after RS by health care setting.

CONCLUSION

Although there was greater use of RS for patients who sought care in more than one health care setting, use of chemotherapy followed RS guidance in University and Community health care systems. These results suggest that precision medicine may help optimize cancer treatment across health care settings.

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.

Robotic versus laparoscopic versus open surgery in morbidly obese endometrial cancer patients - a comparative analysis of total charges and complication rates

OBJECTIVE

To compare the complications and charges of robotic vs. laparoscopic vs. open surgeries in morbidly obese patients treated for endometrial cancer.

METHODS

Data were obtained from the Nationwide Inpatient Sample from 2011. Chi-squared, Wilcoxon rank sum two-sample tests, and multivariate analyses were used for statistical analyses.

RESULTS

Of 1087 morbidly obese (BMI ≥40kg/m(2)) endometrial cancer patients (median age: 59years, range: 22 to 89), 567 (52%) had open surgery (OS), 98 (9%) laparoscopic (LS), and 422 (39%) robotic surgery (RS). 23% of OS, 13% of LS, and 8% of RS patients experienced an intraoperative or postoperative complication including: blood transfusions, mechanical ventilation, urinary tract injury, gastrointestinal injury, wound debridement, infection, venous thromboembolism, and lymphedema (p<0.0001). RS and LS patients were less likely to receive blood transfusions compared to OS (5% and 6% vs. 14%, respectively; p<0.0001). The median lengths of hospitalization for OS, LS, and RS patients were 4, 1, and 1days, respectively (p<0.0001). Median total charges associated with OS, LS, and RS were $39,281, $40,997, and $45,030 (p=0.037), respectively.

CONCLUSIONS

In morbidly obese endometrial cancer patients, minimally invasive robotic or laparoscopic surgeries were associated with fewer complications and less days of hospitalization relative to open surgery. Compared to laparoscopic approach, robotic surgeries had comparable rates of complications but higher charges.

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.

The centralization of robotic surgery in high-volume centers for endometrial cancer patients--a study of 6560 cases in the U.S

OBJECTIVE

To evaluate the hospital and patient factors associated with robotic surgery for endometrial cancer in the United States.

METHODS

Data was obtained from the Nationwide Inpatient Sample from the year 2010. Chi-squared and multivariate analyses were used for statistical analysis.

RESULTS

Of the 6560 endometrial cancer patients who underwent surgery, the median age was 62 (range: 22 to 99). 1647 (25%) underwent robotic surgery, 820 (13%) laparoscopic, and 4093 (62%) had open surgery. The majority was White (65%). Hospitals with 76 or more hysterectomy cases for endometrial cancer patients per year (4% of hospitals in the study) performed 31% of all hysterectomies and 40% of all robotic hysterectomies (p<0.01). 29% of Whites had robotic surgery compared to 15% of Hispanics, 12% of Blacks, and 11% of Asians (p<0.01). Patients with upper-middle and high incomes underwent robotic surgery more than patients with low or middle incomes (p<0.01). 27% of Medicare patients and 26% of patients with private insurance had robotic surgery compared to only 14% of Medicaid patients and 12% of uninsured patients (p<0.01).

CONCLUSIONS

The majority of robotic surgeries for endometrial cancer were performed at a small number of high-volume hospitals in the United States. Socioeconomic status, insurance type, and race were also important predictors for the use of RS. Further studies are warranted to better understand the barriers to receiving minimally invasive surgery.

Leading Causes of Death among Asian American Subgroups (2003-2011)

BACKGROUND

Our current understanding of Asian American mortality patterns has been distorted by the historical aggregation of diverse Asian subgroups on death certificates, masking important differences in the leading causes of death across subgroups. In this analysis, we aim to fill an important knowledge gap in Asian American health by reporting leading causes of mortality by disaggregated Asian American subgroups.

METHODS AND FINDINGS

We examined national mortality records for the six largest Asian subgroups (Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese) and non-Hispanic Whites (NHWs) from 2003-2011, and ranked the leading causes of death. We calculated all-cause and cause-specific age-adjusted rates, temporal trends with annual percent changes, and rate ratios by race/ethnicity and sex. Rankings revealed that as an aggregated group, cancer was the leading cause of death for Asian Americans. When disaggregated, there was notable heterogeneity. Among women, cancer was the leading cause of death for every group except Asian Indians. In men, cancer was the leading cause of death among Chinese, Korean, and Vietnamese men, while heart disease was the leading cause of death among Asian Indians, Filipino and Japanese men. The proportion of death due to heart disease for Asian Indian males was nearly double that of cancer (31% vs. 18%). Temporal trends showed increased mortality of cancer and diabetes in Asian Indians and Vietnamese; increased stroke mortality in Asian Indians; increased suicide mortality in Koreans; and increased mortality from Alzheimer's disease for all racial/ethnic groups from 2003-2011. All-cause rate ratios revealed that overall mortality is lower in Asian Americans compared to NHWs.

CONCLUSIONS

Our findings show heterogeneity in the leading causes of death among Asian American subgroups. Additional research should focus on culturally competent and cost-effective approaches to prevent and treat specific diseases among these growing diverse populations.

Linking electronic health records to better understand breast cancer patient pathways within and between two health systems

INTRODUCTION

In a fragmented health care system, research can be challenging when one seeks to follow cancer patients as they seek care which can continue for months or years and may reflect many physician and patient decisions. Claims data track patients, but lack clinical detail. Linking routine electronic health record (EHR) data with clinical registry data allows one to gain a more complete picture of the patient journey through a cancer care episode. However, valid analytical approaches to examining care trajectories must be longitudinal and account for the dynamic nature of what is "seen" in the EHR.

METHODS

The Oncoshare database combines clinical detail from the California Cancer Registry and EHR data from two large health care organizations in the same catchment area-a multisite community practice and an academic medical center-for all women treated in either organization for breast cancer from 2000 to 2012. We classified EHR encounters data according to typical periods of the cancer care episode (screening, diagnosis, treatment) and posttreatment surveillance, as well as by facility used to better characterize patterns of care for patients seen at both organizations.

FINDINGS

We identified a "treated" cohort consisting of women receiving interventions for their initial cancer diagnosis, and classified their encounters over time across multiple dimensions (type of care, provider of care, and timing of care with respect to their cancer diagnosis). Forty-three percent of the patients were treated at the academic center only, 42 percent at the community center only, and 16 percent of the patients obtained care at both health care organizations. Compared to women seen at only one organization, the last group had similar-length initial care episodes, but more frequently had multiple episodes and longer observation periods.

DISCUSSION

Linking EHR data from neighboring systems can enhance our information on care trajectories, but careful consideration of the complexity of the treatment process and data generating mechanisms is necessary to make valid inferences.

CONCLUSION/NEXT STEPS

If analyzed as a timeline, and with careful characterization of diagnostic tests, surgical interventions, and type and frequency of physician encounters, the pathways taken by women through their breast cancer episode may lead to better understanding of patient decisions.

Patient and provider characteristics associated with colorectal, breast, and cervical cancer screening among Asian Americans

BACKGROUND

Routinely recommended screening for breast, cervical, and colorectal cancers can significantly reduce mortality from these types of cancer, yet screening is underutilized among Asians. Surveys rely on self-report and often are underpowered for analysis by Asian ethnicities. Electronic health records (EHR) include validated (as opposed to recall-based) rates of cancer screening. In this article, we seek to better understand cancer screening patterns in a population of insured Asian Americans.

METHODS

We calculated rates of compliance with cervical, breast, and colorectal cancer screening among Asians from an EHR population and compared them with non-Hispanic whites. We performed multivariable modeling to evaluate potential predictors (at the provider- and patient-level) of screening completion among Asian patients.

RESULTS

Aggregation of Asian subgroups masked heterogeneity in screening rates. Asian Indians and native Hawaiians and Pacific Islanders had the lowest rates of screening in our sample, well below that of non-Hispanic whites. In multivariable analyses, screening completion was negatively associated with patient-physician language discordance for mammography [OR, 0.81; 95% confidence interval (CI), 0.71-0.92] and colorectal cancer screening (OR, 0.79; CI, 0.72-0.87) and positively associated with patient-provider gender concordance for mammography (OR, 1.16; CI, 1.00-1.34) and cervical cancer screening (OR, 1.66; CI, 1.51-1.82). In addition, patient enrollment in online health services increased mammography (OR, 1.32; CI, 1.20-1.46) and cervical cancer screening (OR, 1.31; CI, 1.24-1.37).

CONCLUSIONS

Language- and gender-concordant primary care providers and culturally tailored online health resources may help improve preventive cancer screening in Asian patient populations.

IMPACT

This study demonstrates how the use of EHR data can inform investigations of primary prevention practices within the healthcare delivery setting.

Selection bias modeling using observed data augmented with imputed record-level probabilities

PURPOSE

Selection bias is a form of systematic error that can be severe in compromised study designs such as case-control studies with inappropriate selection mechanisms or follow-up studies that suffer from extensive attrition. External adjustment for selection bias is commonly undertaken when such bias is suspected, but the methods used can be overly simplistic, if not unrealistic, and fail to allow for simultaneous adjustment of associations of the exposure and covariates with the outcome, when of interest. Internal adjustment for selection bias via inverse probability weighting allows bias parameters to vary with the levels of covariates but has only been formalized for longitudinal studies with covariate data on patients up until loss to follow-up.

METHODS

We demonstrate the use of inverse probability weighting and externally obtained bias parameters to perform internal adjustment of selection bias in studies lacking covariate data on unobserved participants.

RESULTS

The "true" or selection-adjusted odds ratio for the association between exposure and outcome was successfully obtained by analyzing only data on those in the selected stratum (i.e., responders) weighted by the inverse probability of their being selected as function of their observed covariate data.

CONCLUSIONS

This internal adjustment technique using user-supplied bias parameters and inverse probability weighting for selection bias can be applied to any type of observational study.

Measuring professionalism in medicine and nursing: results of a European survey

Background

Leveraging professionalism has been put forward as a strategy to drive improvement of patient care. We investigate professionalism as a factor influencing the uptake of quality improvement activities by physicians and nurses working in European hospitals.

Objective

To (i) investigate the reliability and validity of data yielded by using the self-developed professionalism measurement tool for physicians and nurses, (ii) describe their levels of professionalism displayed, and (iii) quantify the extent to which professional attitudes would predict professional behaviors.

Methods and Materials

We designed and deployed survey instruments amongst 5920 physicians and nurses working in European hospitals. This was conducted under the cross-sectional multilevel study “Deepening Our Understanding of Quality Improvement in Europe” (DUQuE). We used psychometric and generalized linear mixed modelling techniques to address the aforementioned objectives.

Results

In all, 2067 (response rate 69.8%) physicians and 2805 nurses (94.8%) representing 74 hospitals in 7 European countries participated. The professionalism instrument revealed five subscales of professional attitude and one scale for professional behaviour with moderate to high internal consistency and reliability. Physicians and nurses display equally high professional attitude sum scores (11.8 and 11.9 respectively out of 16) but seem to have different perceptions towards separate professionalism aspects. Lastly, professionals displaying higher levels of professional attitudes were more involved in quality improvement actions (physicians: b = 0.019, P<0.0001; nurses: b = 0.016, P<0.0001) and more inclined to report colleagues’ underperformance (physicians – odds ratio (OR) 1.12, 95% CI 1.01–1.24; nurses – OR 1.11, 95% CI 1.01–1.23) or medical errors (physicians – OR 1.14, 95% CI 1.01–1.23; nurses – OR 1.43, 95% CI 1.22–1.67). Involvement in QI actions was found to increase the odds of reporting incompetence or medical errors.

Conclusion

A tool that reliably and validly measures European physicians’ and nurses’ commitment to professionalism is now available. Collectively leveraging professionalism as a quality improvement strategy may be beneficial to patient care quality.

A checklist for patient safety rounds at the care pathway level

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).

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.

Involvement of patients or their representatives in quality management functions in EU hospitals: implementation and impact on patient-centred care 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.

The use of on-site visits to assess compliance and implementation of quality management at hospital level

OBJECTIVE

Stakeholders of hospitals often lack standardized tools to assess compliance with quality management strategies and the implementation of clinical quality activities in hospitals. Such assessment tools, if easy to use, could be helpful to hospitals, health-care purchasers and health-care inspectorates. The aim of our study was to determine the psychometric properties of two newly developed tools for measuring compliance with process-oriented quality management strategies and the extent of implementation of clinical quality strategies at the hospital level.

DESIGN

We developed and tested two measurement instruments that could be used during on-site visits by trained external surveyors to calculate a Quality Management Compliance Index (QMCI) and a Clinical Quality Implementation Index (CQII). We used psychometric methods and the cross-sectional data to explore the factor structure, reliability and validity of each of these instruments.

SETTING AND PARTICIPANTS

The sample consisted of 74 acute care hospitals selected at random from each of 7 European countries.

MAIN OUTCOME MEASURES

The psychometric properties of the two indices (QMCI and CQII).

RESULTS

Overall, the indices demonstrated favourable psychometric performance based on factor analysis, item correlations, internal consistency and hypothesis testing. Cronbach's alpha was acceptable for the scales of the QMCI (α: 0.74-0.78) and the CQII (α: 0.82-0.93). Inter-scale correlations revealed that the scales were positively correlated, but distinct. All scales added sufficient new information to each main index to be retained.

CONCLUSION

This study has produced two reliable instruments that can be used during on-site visits to assess compliance with quality management strategies and implementation of quality management activities by hospitals in Europe and perhaps other jurisdictions.

Development and validation of an index to assess hospital quality management systems

Objective

The aim of this study was to develop and validate an index to assess the implementation of quality management systems (QMSs) in European countries.

Design

Questionnaire development was facilitated through expert opinion, literature review and earlier empirical research. A cross-sectional online survey utilizing the questionnaire was undertaken between May 2011 and February 2012. We used psychometric methods to explore the factor structure, reliability and validity of the instrument.

Setting and participants

As part of the Deepening our Understanding of Quality improvement in Europe (DUQuE) project, we invited a random sample of 188 hospitals in 7 countries. The quality managers of these hospitals were the main respondents.

Main Outcome Measure

The extent of implementation of QMSs.

Results

Factor analysis yielded nine scales, which were combined to build the Quality Management Systems Index. Cronbach's reliability coefficients were satisfactory (ranging from 0.72 to 0.82) for eight scales and low for one scale (0.48). Corrected item-total correlations provided adequate evidence of factor homogeneity. Inter-scale correlations showed that every factor was related, but also distinct, and added to the index. Construct validity testing showed that the index was related to recent measures of quality. Participating hospitals attained a mean value of 19.7 (standard deviation of 4.7) on the index that theoretically ranged from 0 to 27.

Conclusion

Assessing QMSs across Europe has the potential to help policy-makers and other stakeholders to compare hospitals and focus on the most important areas for improvement.

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.