Patient expectations do matter - experimental evidence on antibiotic prescribing decisions

 

Inappropriate prescription of antibiotics remains a major contributor to the global antimicrobial resistance crisis despite clear linkages between antibiotic utilization and resistance spread. This study aims to better understand the simultaneous and independent effect of previous prescription behavior, patient expectation, and clinical uncertainty on antibiotic prescribing. This discrete choice experiment was embedded within a routine organizational climate survey administered to all physicians working in the Tuscany healthcare system administered between Nov 11 and Nov 20, 2019 (Qualtrics). Participants were provided with a patient encounter vignette and subsequently asked to in which of two alternatives they were more likely to prescribe antibiotics. The two alternatives varied in levels of clinical uncertainty, patient expectations, and the physician’s past behavior. We fitted a conditional logistic regression model. Respondents included 1,436 hospital-based physicians, of which 52% were female, 78% practiced in a general hospital setting, and 33% were between the ages of 50 and 59. Results show that the odds of prescribing antibiotics decrease when a patient requests it (OR = 0.80, 95%CI [0.72,0.89]) and increase when the physician has prescribed antibiotics to a patient under similar circumstances previously (OR = 1.15, 95%CI [1.03,1.27]). We found no significant effect of clinical uncertainty on the odds of prescribing antibiotics (OR = 0.96, 95%CI [0.87, 1.07]). We show that patient expectation has a significant negative association with antibiotic prescribing among hospital-based physicians. Our findings inform the design of antibiotic stewardship programs in Tuscany and highlight the importance of cultural context in shaping the physician’s disposition when confronted with patient expectations. We suggest shared decision-making to improve prudent prescribing without compromising on patient satisfaction.

Key messages

• Health administrators should address patient expectations when designing hospital antibiotic stewardship programs.

• Physicians’ past prescribing behaviour influences antibiotic prescribing decisions and should be considered during intervention design.

Tools for assessing implementation of health promotion standards in hospital/health service settings

 

The International Network of Health Promoting Hospitals and Health Services (HPH) was initiated by the World Health Organization as a settings approach toward reorienting health services. Over 600 members from 30 countries promote the integration of health promotion into the hospital/ health service setting. The International HPH Network developed the 2020 Standards for Health Promoting Hospitals and Health Services, representing years of experience and expertise reflected in 5 standards, 18 substandards, and 85 standard statements. Complementary self-assessment tools were developed to operationalize the standards and to identify concrete measurable elements against which each standard can be measured. The aim of the tools is to assist hospitals and health services in transforming the setting into a health promoting one. The standards are comprehensive and address topics to encourage the complete refocusing of an organization’s strategy and to stimulate a process of continuous internal improvement. Standards address management, patient-centered care, occupational health, health literate organizations, environmental sustainability, and target groups such as the elderly and children and adolescents. Excel and pdf tools may be utilized by institutions to measure and track progress in implementing each of the standards. The tools state measurable elements for each standard that were identified by an expert panel of HPH members and external subject experts to be directly observable and applicable across various regional and institutional contexts. As part of internal and external assessment processes, standards can be rated on a scale from 1 (not implemented) to 10 (fully implemented). The tools store data and generate graphs that allow organizations to assess their level of performance, identify areas for improvement, and devise data-driven action plans.

Key messages

• Progress towards transforming the setting must be tracked and included in an organization’s continuous internal improvement processes.

• The transformation of the hospitals/health service setting into a health promoting environment results in better health outcomes for patients, families, the community, and the environment.

Managing COVID-19 within and across health systems: why we need performance intelligence to coordinate a global response

Background

The COVID-19 pandemic is a complex global public health crisis presenting clinical, organisational and system-wide challenges. Different research perspectives on health are needed in order to manage and monitor this crisis. Performance intelligence is an approach that emphasises the need for different research perspectives in supporting health systems’ decision-makers to determine policies based on well-informed choices. In this paper, we present the viewpoint of the Innovative Training Network for Healthcare Performance Intelligence Professionals (HealthPros) on how performance intelligence can be used during and after the COVID-19 pandemic.

Discussion

A lack of standardised information, paired with limited discussion and alignment between countries contribute to uncertainty in decision-making in all countries. Consequently, a plethora of different non-data-driven and uncoordinated approaches to address the outbreak are noted worldwide. Comparative health system research is needed to help countries shape their response models in social care, public health, primary care, hospital care and long-term care through the different phases of the pandemic. There is a need in each phase to compare context-specific bundles of measures where the impact on health outcomes can be modelled using targeted data and advanced statistical methods. Performance intelligence can be pursued to compare data, construct indicators and identify optimal strategies. Embracing a system perspective will allow countries to take coordinated strategic decisions while mitigating the risk of system collapse.A framework for the development and implementation of performance intelligence has been outlined by the HealthPros Network and is of pertinence. Health systems need better and more timely data to govern through a pandemic-induced transition period where tensions between care needs, demand and capacity are exceptionally high worldwide. Health systems are challenged to ensure essential levels of healthcare towards all patients, including those who need routine assistance.

Conclusion

Performance intelligence plays an essential role as part of a broader public health strategy in guiding the decisions of health system actors on the implementation of contextualised measures to tackle COVID-19 or any future epidemic as well as their effect on the health system at large. This should be based on commonly agreed-upon standardised data and fit-for-purpose indicators, making optimal use of existing health information infrastructures. The HealthPros Network can make a meaningful contribution.

Comparing the effectiveness and cost-effectiveness of self-management interventions in four high-priority chronic conditions in Europe (COMPAR-EU): a research protocol

INTRODUCTION

Population ageing and increasing chronic illness burden have sparked interest in innovative care models. While self-management interventions (SMIs) are drawing increasing attention, evidence of their efficacy is mostly based on pairwise meta-analysis, generally derived from randomised controlled trials comparing interventions versus a control or no intervention. As such, relevant efficacy data for comparisons among different SMIs that can be applied to specific chronic conditions are missing. Therefore, the relevance of the available evidence for decision-making at clinical, organisational and policy levels is limited.

AIM

To identify, compare and rank the most effective and cost-effective SMIs for adults with four high-priority chronic conditions: type 2 diabetes, obesity, chronic obstructive pulmonary disease,and heart failure.

METHODS AND ANALYSIS

All activities will be conducted as part of the cost-effectiveness of self-management interventions in four high-priority chronic conditions in Europe(COMPAR-EU, Comparing effectiveness of self-management interventions in 4 high priority chronic diseases inEurope) Project, an European Union (EU)-funded project designed to bridge the gap between current knowledge and practice on SMIs. In the first phase of the project, we will develop and validate a taxonomy, and a Core Outcome Set for each condition. These activities will inform a series of systematic review and network meta-analysis about the effectiveness of SMIs. We will also perform a cost-effectiveness analysis of the most effective SMIs and an evaluation of contextual factors. We will finally develop tailored decision-making tools for the different relevant stakeholders.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the local ethics committee (University Institute for Primary Care Research - IDIAP Jordi Gol). All patients and other stakeholders will provide informed consent prior to participation. This project has been funded by the EU Horizon 2020 research and innovation programme (grant agreement no. 754936). Results will be of interest to relevant stakeholder groups (patients, professionals, managers, policymakers and industry), and will be disseminated in a tailored multi-pronged approach that will include deployment of an interactive platform.

Using routine data to benchmark quality and outcomes of diabetes care in the EU HEALTHPROS project

Background

The EU-funded Marie Curie project HEALTHPROS aims to foster a new generation of “Healthcare Performance Intelligence Professionals” through a cohesive stream of 13 doctoral projects (www.healthpros-h2020.eu). Over 48 months, researchers will investigate key levers of healthcare improvement in 7 different countries, using methods drawn from the diverse fields of biostatistics, medical informatics and health services research.

Objectives

To describe barriers and enablers in the conduction of two doctoral projects aimed at exploring the impact of personal risk factors and organizational arrangements on lower extremity amputations in diabetes, through the use of large-scale databases from England, Scotland, Denmark and Germany.

Results

The research plan included a systematic review, structured comparison of data sources, predictive modelling and software development for automated international comparisons. Barriers encountered by researchers were: knowledge and access to data sources from different countries, dealing with data protection rules and the ability to carry out international comparisons when individual records are not easily allowed to leave national boundaries. Enabling factors included: a targeted educational process for risk modelling in diabetes and a multidisciplinary support team to help doctoral students overcoming the above barriers across different sites. Further clinical insight and contextual knowledge of data systems in place at different locations were needed in addition to the statistical, epidemiological and technical skills initially foreseen by the program.

Conclusions

The success of studies within a general educational program on health systems performance may depend from the continued support of a multidisciplinary team helping students in their educational process as well as with the practicalities of their research. International comparisons using routine data may require prioritisation to meet the tight timelines of doctoral theses.

Key messages

Academic programs for international comparisons in health care may be hampered by different type of barriers including technical aspects, legal regulations and a range of contextual factors. The establishment of multidisciplinary support teams may be essential for training doctoral students aiming to conduct international comparisons using routine data.

External institutional strategies for health care organizations as a quality strategy

Accreditation, certification and supervision are quality strategies that intend to encourage the compliance of health care organizations with published standards through external assessment. The idea is that health care organizations will increase compliance with standards in advance of a planned external inspection. Despite several common characteristics of the three strategies, their origins and initial objectives differ. This presentation aims to disambiguate these concepts, inform on their utilization in European countries and discuss the evidence on their effectiveness, cost-effectiveness and implementation.

External assessment strategies have been widely implemented in Europe. Most countries make use of several strategies, including basic supervision as part of the licensing process for healthcare providers, coupled with certification or accreditation strategies to ensure and improve the quality of care. The scope of these strategies and their regulation differs substantially between countries. Despite this widespread uptake, there is little robust evidence to support their effectiveness and there is a complete absence of evidence on cost-effectiveness. Furthermore, due to the broad purpose range of external assessments and the lack of consensus in the use of terminology, implementation strategies are sparse or missing. However, this presentation highlights several facilitators and barriers that may affect the implementation of external assessment strategies in health care organizations as well as relevant insights for policy-makers.

The involvement of medical doctors in hospital governance and implications for quality management: a quick scan in 19 and an in depth study in 7 OECD countries

Background

Hospital governance is broadening its orientation from cost and production controls towards ‘improving performance on clinical outcomes’. Given this new focus one might assume that doctors are drawn into hospital management across OECD countries. Hospital performance in terms of patient health, quality of care and efficiency outcomes is supposed to benefit from their involvement. However, international comparative evidence supporting this idea is limited. Just a few studies indicate that there may be a positive relationship between medical doctors being part of hospital boards, and overall hospital performance. More importantly, the assumed relationship between these so-called doctor managers and hospital performance has remained a ‘black-box’ thus far. However, there is an increasing literature on the implementation of quality management systems in hospitals and their relation with improved performance. It seems therefore fair to assume that the relation between the involvement of doctors in hospital management and improved hospital performance is partly mediated via quality management systems. The threefold aim of this paper is to 1) perform a quick scan of the current situation with regard to doctor managers in hospital management in 19 OECD countries, 2) explore the phenomenon of doctor managers in depth in 7 OECD countries, and 3) investigate whether doctor involvement in hospital management is associated with more advanced implementation of quality management systems.

Methods

This study draws both on a quick scan amongst country coordinators in OECD’s Health Care Quality Indicator program, and on the DUQuE project which focused on the implementation of quality management systems in European hospitals.

Results

This paper reports two main findings. First, medical doctors fulfil a broad scope of managerial roles at departmental and hospital level but only partly accompanied by formal decision making responsibilities. Second, doctor managers having more formal decision making responsibilities in strategic hospital management areas is positively associated with the level of implementation of quality management systems.

Conclusions

Our findings suggest that doctors are increasingly involved in hospital management in OECD countries, and that this may lead to better implemented quality management systems, when doctors take up managerial roles and are involved in strategic management decision making.

Population-based cohort study of the management and survival of patients with early-stage oesophageal adenocarcinoma in England

BACKGROUND

Until recently, oesophagectomy was the treatment of choice for early oesophageal cancer. Endoscopic treatment has been introduced relatively recently. This observational national database study aimed to describe how endoscopic therapy has been introduced in England and to examine the safety of this approach.

METHODS

A population-based cohort study was undertaken of patients diagnosed with oesophageal adenocarcinoma between October 2007 and June 2009 using three linked national databases. Patients with early-stage disease (T1 tumours with no evidence of spread) were identified, along with the primary treatment modality where treatment intent was curative. Short-term outcomes after treatment and 5-year survival were evaluated.

RESULTS

Of 5192 patients diagnosed with oesophageal adenocarcinoma, 306 (5·9 per cent) were considered to have early-stage disease before any treatment, of whom 239 (79·9 per cent of 299 patients with data on treatment intent) were managed with curative intent. Of 175 patients who had an oesophagectomy, 114 (65·1 (95 per cent c.i. 57·6 to 72·7) per cent) survived for 5 years. Among these, 47 (30·3 per cent of 155 patients with tissue results available) had their disease upstaged after pathological staging; this occurred more often in patients who did not have staging endoscopic ultrasonography before surgery. Of 41 patients who had an endoscopic resection, 27 (66 (95 per cent c.i. 49 to 80) per cent) survived for 5 years. Repeat endoscopic therapy was required by 23 (56 per cent) of these 41 patients.

CONCLUSION

Between 2007 and 2009, oesophagectomy remained the initial treatment of choice (73·2 per cent) among patients with early-stage oesophageal cancer treated with curative intent; one in five patients were managed endoscopically, and this treatment was more common in elderly patients. Although the groups had different patient characteristics, 5-year survival rates were similar.

Risk adjustment models for short-term outcomes after surgical resection for oesophagogastric cancer

BACKGROUND

Outcomes for oesophagogastric cancer surgery are compared with the aim of benchmarking quality of care. Adjusting for patient characteristics is crucial to avoid biased comparisons between providers. The study objective was to develop a case-mix adjustment model for comparing 30- and 90-day mortality and anastomotic leakage rates after oesophagogastric cancer resections.

METHODS

The study reviewed existing models, considered expert opinion and examined audit data in order to select predictors that were consequently used to develop a case-mix adjustment model for the National Oesophago-Gastric Cancer Audit, covering England and Wales. Models were developed on patients undergoing surgical resection between April 2011 and March 2013 using logistic regression. Model calibration and discrimination was quantified using a bootstrap procedure.

RESULTS

Most existing risk models for oesophagogastric resections were methodologically weak, outdated or based on detailed laboratory data that are not generally available. In 4882 patients with oesophagogastric cancer used for model development, 30- and 90-day mortality rates were 2·3 and 4·4 per cent respectively, and 6·2 per cent of patients developed an anastomotic leak. The internally validated models, based on predictors selected from the literature, showed moderate discrimination (area under the receiver operating characteristic (ROC) curve 0·646 for 30-day mortality, 0·664 for 90-day mortality and 0·587 for anastomotic leakage) and good calibration.

CONCLUSION

Based on available data, three case-mix adjustment models for postoperative outcomes in patients undergoing curative surgery for oesophagogastric cancer were developed. These models should be used for risk adjustment when assessing hospital performance in the National Health Service, and tested in other large health systems.

The associations between organizational culture, organizational structure and quality management in European hospitals

Objective

To better understand associations between organizational culture (OC), organizational management structure (OS) and quality management in hospitals.

Design

A multi-method, multi-level, cross-sectional observational study.

Setting and participants

As part of the DUQuE project (Deepening our Understanding of Quality improvement in Europe), a random sample of 188 hospitals in 7 countries (France, Poland, Turkey, Portugal, Spain, Germany and Czech Republic) participated in a comprehensive questionnaire survey and a one-day on-site surveyor audit. Respondents for this study (n = 158) included professional quality managers and hospital trustees.

Main outcome measures

Extent of implementation of quality management systems, extent of compliance with existing management procedures and implementation of clinical quality activities.

Results

Among participating hospitals, 33% had a clan culture as their dominant culture type, 26% an open and developmental culture type, 16% a hierarchical culture type and 25% a rational culture type. The culture type had no statistically significant association with the outcome measures. Some structural characteristics were associated with the development of quality management systems.

Conclusion

The type of OC was not associated with the development of quality management in hospitals. Other factors (not culture type) are associated with the development of quality management. An OS that uses fewer protocols is associated with a less developed quality management system, whereas an OS which supports innovation in care is associated with a more developed quality management system.

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.

Feasibility of using administrative data to compare hospital performance in the EU

OBJECTIVE

To describe hospitals' organizational arrangements relevant to the abstraction of administrative data, to report on the completeness of administrative data collected and to assess associations between organizational arrangements and completeness of data submission.

DESIGN

A cross-sectional

STUDY DESIGN

utilizing administrative data.

SETTING AND PARTICIPANTS

Randomly selected hospitals from seven European countries (The Czech Republic, France, Germany, Poland, Portugal, Spain, and Turkey).

MAIN OUTCOME MEASURES

Completeness of data submission for four quality indicators: mortality after acute myocardial infarction, stroke and hip fractures and complications after normal delivery.

RESULTS

In general, hospitals were able to produce data on the four indicators required for this research study. A substantial proportion had missing data on one or more data items. The proportion of hospitals that was able to produce more detailed indicators of relevance for quality monitoring and improvement was low and ranged from 40.1% for thrombolysis performed on patients with acute ischemic stroke to 63.8% for hip-fracture operations performed within 48 h after admission for patients aged 65 or older. National factors were strong predictors of data completeness on the studied indicators.

CONCLUSIONS

At present, hospital administrative databases do not seem to be an appropriate source of information for comparison of hospital performance across the countries of the EU. However, given that this is a dynamic field, changes to administrative databases may make this possible in the near future. Such changes could be accelerated by an in-depth comparative analysis of the issues of using administrative data for comparisons of hospital performances in EU countries.

Is having quality as an item on the executive board agenda associated with the implementation of quality management systems in European hospitals: a quantitative analysis

Objective

To assess whether there is a relationship between having quality as an item on the board's agenda, perceived external pressure (PEP) and the implementation of quality management in European hospitals.

Design

A quantitative, mixed method, cross-sectional study in seven European countries in 2011 surveying CEOs and quality managers and data from onsite audits.

Participants

One hundred and fifty-five CEOs and 155 quality managers.

Setting

One hundred and fifty-five randomly selected acute care hospitals in seven European countries (Czech Republic, France, Germany, Poland, Portugal, Spain and Turkey).

Main outcome measure(s)

Three constructs reflecting quality management based on questionnaire and audit data: (i) Quality Management System Index, (ii) Quality Management Compliance Index and (iii) Clinical Quality Implementation Index. The main predictor was whether quality performance was on the executive board's agenda.

Results

Discussing quality performance at executive board meetings more often was associated with a higher quality management system score (regression coefficient b = 2.53; SE = 1.16; P = 0.030). We found a trend in the associations of discussing quality performance with quality compliance and clinical quality implementation. PEP did not modify these relationships.

Conclusions

Having quality as an item on the executive board's agenda allows them to review and discuss quality performance more often in order to improve their hospital's quality management. Generally, and as this study found, having quality on the executive board's agenda matters.

Quality requirements for cross-border care in Europe: a qualitative study of patients', professionals' and healthcare financiers' views

BACKGROUND

In the past decade the issue of patient mobility has emerged on the European health policy agenda. Although the volume of patients crossing borders to obtain healthcare is low, it is increasing continuously and, due to its legal, financial and medical implications, has generated considerable interest among health policy and other decision makers. However, there is little information available on the safety and patient-centredness of cross-border care and neither governments nor citizens have an explicit basis for comparing healthcare delivery in Europe.

METHODS

This study investigated the viewpoints of patients, professionals and healthcare financiers on the safety and patient-centredness of cross-border care. Qualitative interviews were carried out during 2005 and early 2006 with 40 patients, 30 professionals (doctors, nurses and managers) and 3 healthcare-financing bodies.

RESULTS

Although cross-border care has become a common issue in many European countries, there remain uncertainties on the side of each of the parties addressed--patients, professionals and financiers--with regard to the provision of cross-border care. One of the most striking results of this project is the current lack of research on systematic knowledge on the quality of cross-border care.

CONCLUSION

Many of the issues identified through this research may have a potential impact on the quality and safety of cross-border care and will support further investigation and help shape the health policy agenda on patients crossing borders in European Union countries.

Implementation of patient safety strategies in European hospitals

CONTEXT

This study is part of the Methods of Assessing Response to Quality Improvement Strategies (MARQuIS) research project on cross-border care, investigating quality improvement strategies in healthcare systems across the European Union (EU).

AIM

To explore to what extent a sample of acute care European hospitals have implemented patient safety strategies and mechanisms and whether the implementation is related to the type of hospital.

METHODS

Data were collected on patient safety structures and mechanisms in 389 acute care hospitals in eight EU countries using a web-based questionnaire. Subsequently, an on-site audit was carried out by independent surveyors in 89 of these hospitals to assess patient safety outputs. This paper presents univariate and bivariate statistics on the implementation and explores the associations between implementation of patient safety strategies and hospital type using the chi(2) test and Fisher exact test.

RESULTS

Structures and plans for safety (including responsibilities regarding patient safety management) are well developed in most of the hospitals that participated in this study. The study found greater variation regarding the implementation of mechanisms or activities to promote patient safety, such as electronic drug prescription systems, guidelines for prevention of wrong patient, wrong site and wrong surgical procedure, and adverse events reporting systems. In the sample of hospitals that underwent audit, a considerable proportion do not comply with basic patient safety strategies--for example, using bracelets for adult patient identification and correct labelling of medication.

Is patient-centredness in European hospitals related to existing quality improvement strategies? Analysis of a cross-sectional survey (MARQuIS study)

BACKGROUND

There is growing recognition of patients' contributions to setting objectives for their own care, improving health outcomes and evaluating care.

OBJECTIVE

To quantify the extent to which European hospitals have implemented strategies to promote a patient-centred approach, and to assess whether these strategies are associated with hospital characteristics and the development of the hospital's quality improvement system.

DESIGN

Cross-sectional survey of 351 European hospital managers and professionals.

MAIN OUTCOME MEASURES

Patients' rights, patient information and empowerment, patient involvement in quality management, learning from patients, and patient hotel services at the hospital and ward level were assessed. The hypothesis that the implementation of strategies to improve patient-centredness is associated with hospital characteristics, including maturity of the hospital's quality management system, was tested using binary logistic regression.

RESULTS

In general, hospitals reported high implementation of policies for patients' rights (85.5%) and informed consent (93%), whereas strategies to involve patients (71%) and learn from their experience (66%) were less frequently implemented. For 13 out of 18 hospital strategies, institutions with a more developed quality improvement system consistently reported better results (percentage differences within maturity classification ranged from 12.4% to 46.6%). The strength of association between implementation of patient-centredness strategies and the quality improvement system, however, seemed lower at the ward than at the hospital level. Some associations (OR 2.1 to 5.1) disappeared or were weaker after adjustment for potential confounding variables (OR 2.2 to 3.7).

CONCLUSIONS

Although quality improvement systems seem to be effective with regard to the implementation of selected patient-centredness strategies, they seem to be insufficient to ensure widespread implementation of patient-centredness throughout the organisation.

Learning from MARQuIS: future direction of quality and safety in hospital care in the European Union

This article summarises the significant lessons to be drawn from, and the policy implications of, the findings of the Methods of Assessing Response to Quality Improvement Strategies (MARQuIS) project--a part of the suite of research projects intended to support policy established by the European Commission through its Sixth Framework Programme. The article first reviews the findings of MARQuIS and their implications for healthcare providers (and particularly for hospitals), and then addresses the broader policy implications for member states of the European Union (EU) and for the commission itself. Against the background of the European Commission's Seventh Framework Programme, it then outlines a number of future areas for research to inform policy and practice in quality and safety in Europe. The article concludes that at this stage, a unique EU-wide quality improvement system for hospitals does not seem to be feasible or effective. Because of possible future community action in this field, attention should focus on the use of existing research on quality and safety strategies in healthcare, with the aim of combining soft measures to accelerate mutual learning. Concrete measures should be considered only in areas for which there is substantial evidence and effective implementation can be ensured.

Standards for health promotion in hospitals: development and pilot test in nine European countries

PURPOSE

To describe the process of development of standards for health promotion in hospitals, including pilot study, method and results.

DESIGN/METHODOLOGY/APPROACH

A set of standards for health promotion in hospitals was developed by a task force of the International Network of Health Promoting Hospitals, following the recommendations of the ALPHA programme. The standards were pilot tested and assessed qualitatively and quantitatively in 36 hospitals in nine European countries. Subsequently, standards were reviewed by representatives from the piloting hospitals. A self-assessment tool was produced to evaluate whether hospital managers and professionals perceive the standards to be relevant and applicable and whether they are currently met. Participants provided comments from their national health system perspective and rated the standards.

FINDINGS

General comments and specific comments were provided for each standard regarding its relevance, applicability and current level of compliance. A total of 35 standards' criteria were assessed and 86 per cent (30/35) were rated > 80 per cent relevant and applicable, while 14 per cent (5/35) were rated > 60 per cent relevant. The degree of current fulfilment of the criteria, however, was low.

RESEARCH LIMITATIONS/IMPLICATIONS

While the standards should be applicable to other regions (South America, Africa, Asia) additional testing may be required to adapt them to prevailing health care challenges.

PRACTICAL IMPLICATIONS

The pilot test revealed that the standards are applicable and were considered relevant, and showed that current compliance is low. It also showed that there is a clear need to facilitate continuous monitoring and improvement of compliance. The standards are regarded as being public domain, are applicable to other organisations and can be incorporated into existing quality systems.

ORIGINALITY/VALUE

Standards are a common tool for quality assurance in health care, but so far have considered health promotion activities only partly, if at all. The standards for health promotion in hospitals developed by WHO fill this important gap.