Is a hospital quality policy based on a triad of accreditation, public reporting and inspection evidence-based? A narrative review

Effect on hospital incentive payments and quality performance of a hospital pay for performance (P4P) programme in Belgium

BACKGROUND

Belgium initiated a hospital pay for performance (P4P) programme after a decade of fixed bonus budgets for "quality and safety contracts". This study examined the effect of P4P on hospital incentive payments, performance on quality measures, and the association between changes in quality performance and incentive payments over time.

METHODS

The Belgian government provided information on fixed bonus budgets in 2013-2017 and hospital incentive payments as well as hospital performance on quality measures for the P4P programmes in 2018-2020. Descriptive analyses were conducted to map the financial repercussion between the two systems. A difference-in-difference analysis evaluated the association between quality indicator performance and received incentive payments over time.

RESULTS

Data from 87 acute-care hospitals were analyzed. In the transition to a P4P programme, 29% of hospitals received lower incentive payments per bed. During the P4P years, quality performance scores increased yearly for 55% of hospitals and decreased yearly for 5% of hospitals. There was a significant larger drop in incentive payments for hospitals that scored above median with the start of the P4P programme.

CONCLUSIONS

The transition from fixed bonus budgets for quality efforts to a new incentive payment in a P4P programme has led to more hospitals being financially impacted, although the effect is marginal given the small P4P budget. Quality indicators seem to improve over the years, but this does not correlate with an increase in reward per bed for all hospitals due to the closed nature of the budget.

A multiphase, multicentre development and validation of two maturity tools assessing the implementation of the FlaQuM co-creation roadmap

As part of the new Flanders Quality Model (FlaQuM) towards sustainable quality management systems, a co-creation roadmap with 6 primary drivers and 19 building blocks that guides healthcare organizations has been developed. Currently, no assessment tool is available to monitor hospitals' quality management systems implementation according to this co-creation roadmap. Therefore, we aimed to measure the maturity of the implementation of the FlaQuM co-creation roadmap in hospitals. A three-phase approach in co-design with 19 hospitals started with defining the scope, followed by establishing content validity through a literature review, involvement of content experts (n = 47), 20 focus groups with content experts (n = 79), and a Delphi round with healthcare quality managers (n = 19) to test the content validity index. Construct validity was assessed by confirmatory factor analyses and convergent validity by Spearman's ρ correlation coefficients. Based on 17 included existing maturity instruments and subcomponents of content experts, two maturity tools were developed according to the implementation of the FlaQuM co-creation roadmap: (i) a maturity matrix with 52 subcomponents and (ii) a co-creation scan with 19 statements. The overall scale-content validity index varied between 93.3% and 90.0% in terms of relevance and clarity, respectively. In a sample of 119 healthcare professionals, factor analyses revealed a six-factor structure and 16 (84.2%) of the 19 hypothesis for testing convergent validity between both maturity tools were statistically significant. Measuring the implementation of the FlaQuM co-creation roadmap and monitoring its maturity over time should be feasible by using these comprehensive maturity tools in hospitals. Results of both tools should be able to describe the current state of hospitals' implementation of the co-creation roadmap as basis for strategic improvement plans and next steps.

Sustainable quality management in hospitals: The experiences of healthcare quality managers

BACKGROUND

Quality management systems are essential in hospitals, but evidence shows a real literature gap on the sustainable implementation of quality.

PURPOSE

This study aimed to explore and identify enablers towards sustainable quality management in hospitals. Research design and Study Sample: Interviews were conducted with 23 healthcare quality managers from 20 hospitals. Data collection and/or Analysis: Data collection and analysis were conducted simultaneously by using the Qualitative Analysis Guide of Leuven and following the COREQ Guidelines. Thematic analysis from interview transcripts was performed in NVivo 12.

RESULTS

The results reveal two categories: (1) quality in the organisation's DNA and (2) quality in the professional's DNA. The first category consists of: bottom-up and top-down management, the organisation-wide integration of quality and an organisational culture shift. The second one consists of: quality awareness, understanding the added value, the encouragement and engagement, the accountability and ownership for quality. Moving towards sustainable quality management systems in hospitals requires a good interaction between a bottom-up approach and leadership to ensure continuous support from healthcare stakeholders.

CONCLUSIONS

This study contributes to existing conceptual and theoretical foundations with practical insights into sustainable quality management. The findings can guide quality departments and hospital management to regain professionals' commitment to quality and to establish a sustainable quality management system.

Improving patient safety governance and systems through learning from successes and failures: qualitative surveys and interviews with international experts

Patient harm is a leading cause of global disease burden with considerable morbidity, mortality, and economic impacts for individuals, families, and wider society. Large bodies of evidence exist for strategies to improve safety and reduce harm. However, it is not clear which patient safety issues are being addressed globally, and which factors are the most (or least) important contributors to patient safety improvements. We aimed to explore the perspectives of international patient safety experts to identify: (1) the nature and range of patient safety issues being addressed, and (2) aspects of patient safety governance and systems that are perceived to provide value (or not) in improving patient outcomes. English-speaking Fellows and Experts of the International Society for Quality in Healthcare participated in a web-based survey and in-depth semistructured interview, discussing their experience in implementing interventions to improve patient safety. Data collection focused on understanding the elements of patient safety governance that influence outcomes. Demographic survey data were analysed descriptively. Qualitative data were coded, analysed thematically (inductive approach), and mapped deductively to the System-Theoretic Accident Model and Processes framework. Findings are presented as themes and a patient safety governance model. The study was approved by the University of South Australia Human Research Ethics Committee. Twenty-seven experts (59% female) participated. Most hailed from Africa (n = 6, 22%), Australasia, and the Middle East (n = 5, 19% each). The majority were employed in hospital settings (n = 23, 85%), and reported blended experience across healthcare improvement (89%), accreditation (76%), organizational operations (64%), and policy (60%). The number and range of patient safety issues within our sample varied widely with 14 topics being addressed. Thematically, 532 textual segments were grouped into 90 codes (n = 44 barriers, n = 46 facilitators) and used to identify and arrange key patient safety governance actors and factors as a 'system' within the System-Theoretic Accident Model and Processes framework. Four themes for improved patient safety governance were identified: (1) 'safety culture' in healthcare organizations, (2) 'policies and procedures' to investigate, implement, and demonstrate impact from patient safety initiatives, (3) 'supporting staff' to upskill and share learnings, and (4) 'patient engagement, experiences, and expectations'. For sustainable patient safety governance, experts highlighted the importance of safety culture in healthcare organizations, national patient safety policies and regulatory standards, continuing education for staff, and meaningful patient engagement approaches. Our proposed 'patient safety governance model' provides policymakers and researchers with a framework to develop data-driven patient safety policy.

Patient-reported outcomes of the nurse-patient relationship in psychiatric inpatient hospitals: A multicentred descriptive cross-sectional study

WHAT IS KNOWN ON THE SUBJECT?: Psychiatric and/or mental health nurses are struggling to measure the outcomes of the nurse-patient relationship. Collecting nurse-sensitive patient outcomes is a strategy to provide outcomes of a nurse-patient relationship from patients' perspectives. Because there was no validated scale, the Mental Health Nurse-Sensitive Patient Outcome-Scale (six-point Likert-scale) was recently developed and psychometrically evaluated. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This is the first study using the Mental Health Nurse-Sensitive Patient Outcome-scale to measure nurse-sensitive patient outcomes of the nurse-patient relationship in psychiatric hospitals. Moderate to good average scores for the MH-NURSE-POS total (4.42) and domains scores (≥4.09). are observed. Especially outcomes related to 'motivation' to follow and stay committed to the treatment received high average scores (≥4.60). Our results are consistent with the patient-reported effect(s) of relation-based nursing in qualitative research. The scores generate evidence to support the outcomes of the nurse-patient relationship and implicates that further investment in (re)defining and elaborating nurse-patient relationships in mental healthcare is meaningful and justified. More comparative patient-reported data can determine how nurse-sensitive patient outcomes are affected by the patient, nurse, and context. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Demonstrating patient-reported outcomes of the nurse-patient relationship can be important to enhance the therapeutic alliance between nurses and patients, organize responsive nursing care, and create nursing visibility in mental healthcare. Further nursing staff training on interpersonal competencies, such as self-awareness and cultural sensitivity, can be pivotal to achieving the patient-reported outcomes for inpatients with mental health problems.

ABSTRACT

INTRODUCTION: Identifying patient-reported outcomes of the nurse-patient relationship is a priority in inpatient mental healthcare to guide clinical decision-making and quality improvement initiatives. Moreover, demonstrating nurse-sensitive patient outcomes can be a strategy to avoid further erosion of the specialism of psychiatric and/or mental health nursing.

AIM/QUESTION

To measure nurse-sensitive patient outcomes of the nurse-patient relationship.

METHOD

In a multicentred cross-sectional study, 296 inpatients admitted to five psychiatric hospitals completed the recently developed and validated Mental Health Nurse-Sensitive Patient Outcome-Scale (MH-NURSE-POS). The MH-NURSE-POS consists of 21 items (six-point Likert-scale) in four domains: 'growth', 'expression', 'control', and 'motivation'.

RESULTS

Participants displayed moderate to good average scores for the MH-NURSE-POS total (4.42) and domain scores (≥4.09). Especially outcomes related to 'motivation' to follow and stay committed to the treatment received high average scores (≥4.60).

DISCUSSION

The results demonstrate that patients perceive the nurse-patient relationship and the care given by psychiatric and/or mental health nurses as contributing to their treatment.

IMPLICATIONS FOR PRACTICES

Patient-reported outcomes can guide nurses and managers to provide and organize nursing care and to build a nurse-patient relationship that has a positive impact on these outcomes. Additionally, outcomes can create nursing visibility as a profession in- and outside mental healthcare.

Cornerstones of a sustainable national quality policy: A qualitative study based on international expert opinions

BACKGROUND

National initiatives launched to improve the quality of care have grown exponentially over the last decade. Public reporting, accreditation and governmental inspection form the basis for quality in Flemish (Belgian) hospitals. Due to the lack of evidence for these national initiatives and the questions concerning their sustainability, our research aims to identify cornerstones of a sustainable national quality policy for acute-care hospitals based on international expert opinion.

METHODS

A qualitative study was conducted using in-depth semi-structured interviews with 12 renowned international quality and patient safety experts selected by purposive sampling. Interviews focussed on participants' perspectives and their recommendations for a future, sustainable quality policy. Inductive analysis was carried out with themes being generated from the data using the constant comparison method.

RESULTS

Three major and five minor themes were identified and integrated into a framework as a basis for national quality policies. Quality culture, minimum requirements for quality education and quality control as well as continuous learning and improvement act as cornerstones of this framework.

CONCLUSIONS

Complementary to the current national policy, this study demonstrated the need for profound attention to quality cultures in acute-care hospitals. Policymakers need to provide a control system and minimum requirements for quality education for all healthcare workers. A model for continuous learning and improvement with data feedback loops has to be installed in each hospital to obtain a sustainable quality system. This framework can inspire policymakers to further develop bottom-up initiatives in co-governance with all relevant stakeholders adapted to individual hospitals' context.

The Cost of a First and Second Hospital-Wide Accreditation in Flanders, Belgium

BACKGROUND

Hospital accreditation is a popular and widely used quality control and improvement instrument. Despite potential benefits, questions are raised whether it constitutes appropriate use of hospitals' limited financial resources. This study aims to calculate the cost of preparing for and undergoing a first and second accreditation by the Joint Commission International or Qualicor Europe in acute-care hospitals.

METHODS

All (n=53) acute-care hospitals in Flanders (Belgium) were invited to participate and report on the costs in preparing for and undergoing a first and/or second accreditation cycle. To measure costs, a questionnaire with six domains and 90 questions was developed based on literature review, policy documents and a multidisciplinary expert group. All costs were recalculated to 2020 EUR to correct for inflation and reported as medians with interquartile range (IQR).

RESULTS

Twenty-five hospitals (47%) participated in the study. Additional investments and direct operational costs for a first accreditation cycle amounted to 879.45 EUR (IQR:794.81) per bed and 3.8 FTE per hospital additional new staff members were recruited for coordination and implementation of the trajectory. A second accreditation survey costed remarkably less with a total cost of extra investments and direct operational cost of 222.88 EUR (IQR: 244.04) per bed and less investment in additional staff (1.50 FTE). Most of the costs were situated in consulting costs and investments in infrastructure. The median total extra cost (direct operational cost and additional investments) amounted to 0.2% of the hospital's operating income for a first accreditation cycle and 0.05% for a second cycle.

CONCLUSION

A first accreditation cycle requires a strong financial commitment of hospitals, as many costs result from the preparation in the years prior to an accreditation survey. A second survey is less expensive for hospitals, but still requires a considerable effort in terms of budget and staff. Policy makers should be aware of these significant costs as hospitals are operating with public resources and budget is scarce. The identification of these costs is a necessary building block to evaluate cost-effectiveness of accreditation versus other quality improvement systems and the continuation of these accreditation systems and their costs needs further study and a thorough debate.

A decade of commitment to hospital quality of care: overview of and perceptions on multicomponent quality improvement policies involving accreditation, public reporting, inspection and pay-for-performance

Background

Quality improvement (QI) initiatives such as accreditation, public reporting, inspection and pay-for-performance are increasingly being implemented globally. In Flanders, Belgium, a government policy for acute-care hospitals incorporates aforementioned initiatives. Currently, questions are raised on the sustainability of the present policy.

Objective

First, to summarise the various initiatives hospitals have adopted under government encouragement between 2008 and 2019. Second, to study the perspectives of healthcare stakeholders on current government policy.

Methods

In this multi-method study, we collected data on QI initiative implementation from governmental and institutional sources and through an online survey among hospital quality managers. We compiled an overview of QI initiative implementation for all Flemish acute-care hospitals between 2008 (n = 62) and 2019 (n = 53 after hospital mergers). Stakeholder perspectives were assessed via a second survey available to all healthcare employees and a focus group with healthcare policy experts was consulted. Variation between professions was assessed.

Results

QI initiatives have been increasingly implemented, especially from 2016 onwards, with the majority (87%) of hospitals having obtained a first accreditation label and all hospitals publicly reporting performance indicators, receiving regular inspections and having entered the pay-for-performance initiative. On the topic of external international accreditation, overall attitudes within the survey were predominantly neutral (36.2%), while 34.5% expressed positive and 29.3% negative views towards accreditation. In examining specific professional groups in-depth, we learned 58% of doctors regarded accreditation negatively, while doctors were judged to be the largest contributors to quality according to the majority of respondents.

Conclusions

Hospitals have demonstrated increased efforts into QI, especially since 2016, while perceptions on currently implemented QI initiatives among healthcare stakeholders are heterogeneous. To assure quality of care remains a top-priority for acute-care hospitals, we recommend a revision of the current multicomponent quality policy where the adoption of all initiatives is streamlined and co-created bottom-up.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07007-w.