Similarities and differences in the associations between patient safety culture dimensions and self-reported outcomes in two different cultural settings: a national cross-sectional study in Palestinian and Belgian hospitals

OBJECTIVES

To investigate the relationships between patient safety culture (PSC) dimensions and PSC self-reported outcomes across different cultures and to gain insights in cultural differences regarding PSC.

DESIGN

Observational, cross-sectional study.

SETTING

Ninety Belgian hospitals and 13 Palestinian hospitals.

PARTICIPANTS

A total of 2836 healthcare professionals matched for profession, tenure and working hours.

PRIMARY AND SECONDARY OUTCOME MEASURES

The validated versions of the Belgian and Palestinian Hospital Survey on Patient Safety Culture were used. An exploratory factor analysis was conducted. Reliability was tested using Cronbach's alpha (α). In this study, we examined the specific predictive value of the PSC dimensions and its self-reported outcome measures across different cultures and countries. Hierarchical regression and bivariate analyses were performed.

RESULTS

Eight PSC dimensions and four PSC self-reported outcomes were distinguished in both countries. Cronbach's α was α≥0.60. Significant correlations were found between PSC dimensions and its self-reported outcome (p value range <0.05 to <0.001). Hierarchical regression analyses showed overall perception of safety was highly predicted by hospital management support in Palestine (β=0.16, p<0.001) and staffing in Belgium (β=0.24, p<0.001). The frequency of events was largely predicted by feedback and communication in both countries (Palestine: β=0.24, p<0.001; Belgium: β=0.35, p<0.001). Overall grade for patient safety was predicted by organisational learning in Palestine (β=0.19, p<0.001) and staffing in Belgium (β=0.19, p<0.001). Number of events reported was predicted by staffing in Palestine (β=-0.20, p<0.001) and feedback and communication in Belgium (β=0.11, p<0.01).

CONCLUSION

To promote patient safety in Palestine and Belgium, staffing and communication regarding errors should be improved in both countries. Initiatives to improve hospital management support and establish constructive learning systems would be especially beneficial for patient safety in Palestine. Future research should address the association between safety culture and hard patient safety measures such as patient outcomes.

A multicenter record review of in-hospital adverse drug events requiring a higher level of care

OBJECTIVE

Adverse drug events (ADEs) are a worldwide concern, particularly when leading to a higher level of care. This study defines a higher level of care as an unplanned (re)admission to an intensive care unit or an intervention by a Medical Emergency Team. The objectives are to describe the incidence and preventability of ADEs leading to a higher level of care, to assess the types of drug involved, and to identify the risk factors.

METHODS

A three-stage retrospective review was performed in six Belgian hospitals. Patient records were assessed by a trained clinical team consisting of a nurse, a physician, and a clinical pharmacist. Descriptive statistics, univariate, and multiple logistic regressions were used.

RESULTS

In this study, 830 patients were detected for whom a higher level of care had been needed. In 160 (19.3%) cases, an ADE had occurred; 134 (83.8%) of these were categorized as preventable adverse drug events (pADEs). The overall incidence rate of patients transferred to a higher level of care because of a pADE was 33.9 (95% CI: 28.5-39.3) per 100,000 patient days at risk. Antibiotics and antithrombotic agents accounted both for one-fifth of all pADEs. Multivariate analysis indicated American Society of Anaesthesiologists physical status score as a risk factor for pADEs.

CONCLUSIONS

The high number of pADE with patient harm shows that there is a need for structural improvement of pharmacotherapeutic care. Detection of these pADEs can be the basis for the implementation of these improvements.

The Belgian—Dutch Clinical Pathway Network

In 2000, the Centre for Health Services & Nursing Research, Catholic University Leuven, Belgium, launched the Belgian—Dutch Clinical Pathway Network. This is a joint effort by both Belgian and Dutch hospitals to implement clinical pathways in the organisation of their practice. This article describes why the network was started, the core objectives and the organisation of the network.

Where is the pilot? The changing shapes of governance in the European hospital sector

Hospital governance refers to the complex of checks and balances that determine how decisions are made within the top structures of hospitals. This article explores the essentials of the concept by analysing the root notion of governance and comparing it with applications in other sectors. Recent developments that put pressure on the decision-making system within hospitals are outlined. Examples from the UK, France and the Netherlands are presented.

Based on an evaluation of the current state of affairs, a research framework is developed, focusing on the determinants of governance configurations within the national healthcare systems and the wider legal and socio-economic context, as well as on the impact of governance configurations on the efficiency of the governing bodies and overall hospital performance.

The article concludes with a preview of the European Hospital Governance Project, which follows the outlines of the described research framework. New techniques of data mining that are used in this project are explained by means of a real data example.

Risk factors for unplanned hospital re-admissions: a secondary data analysis of hospital discharge summaries

RATIONALE, AIMS AND OBJECTIVES

To identify patient groups at risk for unplanned hospital re-admissions and risk factors for re-admission.

METHOD

We analysed the Belgian Hospital Discharge Dataset including data from 1 130 491 patients discharged in 2008. Patient and hospital factors contributing to re-admission rate were analysed using a multivariable model for logistic regression.

RESULTS

The overall unplanned re-admission rate was 5.2%. Cardiovascular and pulmonary diagnoses were the most common reasons for re-admission. We found that 10.4% of all re-admissions were due to complications. A high number of previous emergency department (ED) visits proved to be a predictor for re-admission [odds ratio (OR) for patients with at least four ED visits in the past 6 months 4.65; 95% confidence interval (CI) 4.25-5.08]. Patients discharged on Friday (OR 1.05; 95% CI 1.01-1.08) and patients with a long length of stay (OR 1.19; 95% CI 1.15-1.23) also had a higher risk for re-admission. Patients with short lengths of stay were not at risk for re-admission (OR 0.99; 95% CI 0.95-1.02).

CONCLUSIONS

Actions to reduce re-admissions can be targeted to patient groups at risk, and should be aimed at the caring for chronic cardiovascular or pulmonary diseases, preventing complications and multiple ED visits, and ensuring continuity of care after discharge, especially for patients discharged on Friday.

Incidence and outcome of inappropriate in-hospital empiric antibiotics for severe infection: a systematic review and meta-analysis

INTRODUCTION

The aims of this study were to explore the incidence of in-hospital inappropriate empiric antibiotic use in patients with severe infection and to identify its relationship with patient outcomes.

METHODS

Medline (from 2004 to 2014) was systematically searched by using predefined inclusion criteria. Reference lists of retrieved articles were screened for additional relevant studies. The systematic review included original articles reporting a quantitative measure of the association between the use of (in)appropriate empiric antibiotics in patients with severe in-hospital infections and their outcomes. A meta-analysis, using a random-effects model, was conducted to quantify the effect on mortality by using risk ratios.

RESULTS

In total, 27 individual articles fulfilled the inclusion criteria. The percentage of inappropriate empiric antibiotic use ranged from 14.1% to 78.9% (Q1-Q3: 28.1% to 57.8%); 13 of 27 studies (48.1%) described an incidence of 50% or more. A meta-analysis for 30-day mortality and in-hospital mortality showed risk ratios of 0.71 (95% confidence interval 0.62 to 0.82) and 0.67 (95% confidence interval 0.56 to 0.80), respectively. Studies with outcome parameter 28-day and 60-day mortality reported significantly (P ≤0.02) higher mortality rates in patients receiving inappropriate antibiotics. Two studies assessed the total costs, which were significantly higher in both studies (P ≤0.01).

CONCLUSIONS

This systematic review with meta-analysis provides evidence that inappropriate use of empiric antibiotics increases 30-day and in-hospital mortality in patients with a severe infection.

Staffing levels and the use of physical restraints in nursing homes: a multicenter study

There is an unclear relation between staffing levels and the use of physical restraints in nursing homes (NHs). A survey design was used in 570 older adults (median age = 86; 77.2% women), living on 23 wards within seven NHs. Restraint use was high (50% of residents, of which 80% were restrained on a daily basis). Multivariate analysis was conducted at the level of the individual wards. Neither staff intensity nor staff mix was a determinant of restraint use. Bathing dependency, transfer difficulties, risk for falls, frequent restlessness/agitation, and depression were independent predictors of restraint use. Patient characteristics have significant greater impact on physical restraint use than staffing levels. Therefore, improving knowledge and skills of NH staff to better deal with restlessness/agitation, mobility problems, and risk for falls is encouraged to decrease the use of physical restraints in NH residents.

The Global Trigger Tool shows that one out of seven patients suffers harm in Palestinian hospitals: challenges for launching a strategic safety plan

OBJECTIVE

The aim of this study was to evaluate patient safety levels in Palestinian hospitals and to provide guidance for policymakers involved in safety improvement efforts.

DESIGN

Retrospective review of hospitalized patient records using the Global Trigger Tool.

SETTING

Two large hospitals in Palestine: a referral teaching hospital and a nonprofit, non-governmental hospital.

PARTICIPANTS

A total of 640 random records of discharged patients were reviewed by experienced nurses and physicians from the selected hospitals.

INTERVENTION

Assessment of adverse events.

MAIN OUTCOME MEASURES

Prevalence of adverse events, their preventability and harm category. Descriptive statistics and Cohen kappa coefficients were calculated.

RESULTS

One out of seven patients (91 [14.2%]) suffered harm. Fifty-four (59.3%) of these events were preventable; 64 (70.4%) resulted in temporary harm, requiring prolonged hospitalization. Good reliability was achieved among the independent reviewers in identifying adverse events. The Global Trigger Tool showed that adverse events in Palestinian hospitals likely occur at a rate of 20 times higher than previously reported. Although reviewers reported that detecting adverse events was feasible, we identified conditions suggesting that the tool may be challenging to use in daily practice.

CONCLUSION

One out of seven patients suffers harm in Palestinian hospitals. Compromised safety represents serious problems for patients, hospitals and governments and should be a high priority public health issue. We argue that direct interventions should be launched immediately to improve safety. Additional costs associated with combating adverse events should be taken into consideration, especially in regions with limited resources, as in Palestine.

The Arabic version of the hospital survey on patient safety culture: a psychometric evaluation in a Palestinian sample

BACKGROUND

A growing global interest in patient safety culture has increased the development of validated instruments to asses this phenomenon. The aim of this study is to investigate the psychometric properties of the Hospital Survey on Patient Safety Culture (HSOPSC) and its appropriateness for Arab hospitals.

METHODS

The 7-step guideline of the Agency for Healthcare Research and Quality was used to translate and validate the HSOPSC. A panel of experts evaluated the face and content validity indexing of the Arabic version. Data were collected from 13 Palestinian hospitals including 2022 healthcare professionals who had direct or indirect interaction with patients, hospital supervisors, managers and administrators. Descriptive statistics and psychometric evaluation (a split-half validation technique) were then used to test and strengthen the validity and reliability of the instrument.

RESULTS

With respect to face and content validity, the CVI analysis showed excellent results for the Arab context (CVI = 0.96). As to construct validity, the 12 original dimensions could not be applied to the Palestinian data. Furthermore, three of the 12 original dimensions were not reliable (α <0.6). The split-half technique resulted in an optimal 11-factor model.

CONCLUSIONS

Our study is the first study in the Arab world to provide an evaluation of the HSOPSC using Arabic data from Palestine. The Arabic translation of the HSOPSC comprises an 11-factor structure showing good validity and acceptable reliability. Despite the similarity between the Arab factor structure of the HSOPSC and that of the original one, and taking into account that our version may be applied in Arabic hospitals, there is a need for caution in comparing HSOPSC data between countries.

ENT one day surgery: critical analysis with the HFMEA method

OBJECTIVES

Research shows that 51.4% of adverse events in hospitals occur in surgery and that 3-22% of surgical patients experience adverse events. The risk may be even higher when turnover is high and when patients are children, as is often the case in ear, nose and throat surgery. This quality project therefore started in response to requests from physicians in two hospitals in the Flemish part of Belgium. The aim of this study is to use the Healthcare Failure Mode & Effect Analysis method to evaluate the process flow for ear, nose and throat patients, and to redesign the process to enhance patient safety.

METHODOLOGY

In two One Day Clinics, processes were prospectively analysed using the Healthcare Failure Mode & Effect Analysis method.

RESULTS

Similar potential failures were reported in both hospitals. The major failure mode was linked to the absence of an active identity check throughout the process. The process was therefore redesigned by implementing a surgical safety checklist and an active identity check protocol. Although the Healthcare Failure Mode & Effect Analysis is a time-consuming method, this systematic approach by a multidisciplinary team has been found to be useful in detecting failure modes that need immediate safety responses. The involvement of all disciplines and an open safety culture during the procedure were the most important conditions.

CONCLUSIONS

The Healthcare Failure Mode & Effect Analysis is a useful instrument for detecting the failure modes in this care process.

Health care professionals as second victims after adverse events: a systematic review

Adverse events within health care settings can lead to two victims. The first victim is the patient and family and the second victim is the involved health care professional. The latter is the focus of this review. The objectives are to determine definitions of this concept, research the prevalence and the impact of the adverse event on the second victim, and the used coping strategies. Therefore a literature research was performed by using a three-step search procedure. A total of 32 research articles and 9 nonresearch articles were identified. The second victim phenomenon was first described by Wu in 2000. In 2009, Scott et al. introduced a detailed definition of second victims. The prevalence of second victims after an adverse event varied from 10.4% up to 43.3%. Common reactions can be emotional, cognitive, and behavioral. The coping strategies used by second victims have an impact on their patients, colleagues, and themselves. After the adverse event, defensive as well as constructive changes have been reported in practice. The second victim phenomenon has a significant impact on clinicians, colleagues, and subsequent patients. Because of this broad impact it is important to offer support for second victims. When an adverse event occurs, it is critical that support networks are in place to protect both the patient and involved health care providers.

A quality improvement initiative to reduce ventilator-associated pneumonia at a large regional hospital

Ventilator-associated pneumonia (VAP) is the leading cause of death among hospital-acquired infections and prolongs time spent on the ventilator, length of intensive care unit (ICU) stay and length of hospital stay after discharge from the ICU. The ventilator bundle of the Institute of Healthcare Improvement includes five evidence-based guidelines which are proven to be effective in the prevention of VAP. The main purpose of this study is to determine the incidence of VAP at two intensive care units at the Jessa Hospital. In addition, compliance rates with the different elements of the VAP bundle are determined. From 1 January 2011 to 31 March 2011 an explorative study was conducted on a 18-bed surgical intensive care unit (SICU) and a six-bed medical intensive care unit (MICU). VAP was diagnosed using Johanson et al. criteria. Bedside observations and analysis of the electronic patient record were performed in order to determine compliance relative to the VAP bundle. At the SICU 10 VAPs were diagnosed resulting in an incidence of 38.46% and a VAP rate of 22.56. Three VAPs were diagnosed at the MICU. The incidence of VAP at the MICU was 18.75% resulting in a VAP rate of 18.75%. Compliance to all elements of the VAP bundle was observed in 0.52% (SICU) and 19.64% (MICU) of the observations. Compliance at the level of individual elements of the bundle varies between 1.03% and 99.48% (SICU) and 32.14% and 100% (MICU).

Design of a medical record review study on the incidence and preventability of adverse events requiring a higher level of care in Belgian hospitals

BACKGROUND

Adverse events are unintended patient injuries that arise from healthcare management resulting in disability, prolonged hospital stay or death. Adverse events that require intensive care admission imply a considerable financial burden to the healthcare system. The epidemiology of adverse events in Belgian hospitals has never been assessed systematically.

FINDINGS

A multistage retrospective review study of patients requiring a transfer to a higher level of care will be conducted in six hospitals in the province of Limburg. Patient records are reviewed starting from January 2012 by a clinical team consisting of a research nurse, a physician and a clinical pharmacist. Besides the incidence and the level of causation and preventability, also the type of adverse events and their consequences (patient harm, mortality and length of stay) will be assessed. Moreover, the adequacy of the patient records and quality/usefulness of the method of medical record review will be evaluated.

DISCUSSION

This paper describes the rationale for a retrospective review study of adverse events that necessitate a higher level of care. More specifically, we are particularly interested in increasing our understanding in the preventability and root causes of these events in order to implement improvement strategies. Attention is paid to the strengths and limitations of the study design.

Monitoring quality in a federal state with shared powers in healthcare: the case of Belgium

The Belgian healthcare system consists of a complex of more or less autonomous groups of healthcare providers. It is the responsibility of the government to ensure that the fundamental right to qualitative healthcare is secured through the services they provide. In Belgium, the regulatory powers in healthcare are divided between the federal state and the three communities. Both levels, within their area of competence, monitor the quality of healthcare services. Unique to the Belgian healthcare system is that the government that providers are accountable to is not always the same as the government that is competent to set the criteria. The goal of this article is to provide an overview of the main mechanisms that are used by the federal government and the government of the Flemish community to monitor healthcare quality in hospitals. The Flemish community is Belgian's largest community (6.2 million inhabitants). The overview is followed by a critical analysis of the dual system of quality monitoring.

Why pathways cannot be taken from the shelf

Summary

Clinical pathways are our most valuable and performant tool in managing health-care processes. Sloppiness and inaccuracy, in both definition and implementation, threaten to erode the concept and, thus, to undermine its power. Back to basics is not a plea for nostalgia, but for continuing consistently to design care according to a patient's needs, to focus on desired clinical outcomes and to anchor the care processes into the daily life of the health-care organization.

Management challenges in care pathways: Conclusions of a qualitative study within 57 health-care organizations

Summary

The objectives of this paper are to study the aim of care pathways, who has decisional power concerning pathways, the actual follow-up, challenges in cross-boundary development and the support provided by information and communication technology (ICT). The study design included a qualitative study using semi-structured interviews with 88 care pathway coordinators and members of the executive board in 57 health-care organizations enrolled in the Belgian- Dutch Clinical Pathway Network. The study revealed that the most important objectives for introducing care pathways are more standardization and quality of care. In 76% of the interviewed organizations, pathways are discussed in a committee. There is a lack of continuous follow-up when care pathways are implemented. Pathways can facilitate cross-boundary care, but are a challenge because of the fragmentation within primary care. There is a need for more ICT support for care pathways. In conclusion, the executive board members and pathway coordinators state that clearly formulated objectives, a special steering committee, a clear follow-up to keep pathways alive, cross-boundary collaboration and ICT support are among the main challenges for the management of an organization.

Improving patient safety culture

PURPOSE

Improving hospital patient safety means an open and stimulating culture is needed. This article aims to describe a patient safety culture improvement approach in five Belgian hospitals.

DESIGN/METHODOLOGY/APPROACH

Patient safety culture was measured using a validated Belgian adaptation of the Hospital Survey on Patient Safety Culture (HSOPSC) questionnaire. Studies before (autumn 2005) and after (spring 2007) the improvement approach was implemented were completed. Using HSOPSC, safety culture was measured using 12 dimensions. Results are presented as evolving dimension scores.

FINDINGS

Overall, 3,940 and 3,626 individuals responded respectively to the first and second surveys (overall response rate was 77 and 68 percent respectively). After an 18 to 26 month period, significant improvement was observed for the "hospital management support for patient safety" dimension--all main effects were found to be significant. Regression analysis suggests there is a significant difference between professional subgroups. In one hospital the "supervisor expectations and actions promoting safety" improved. The dimension "teamwork within hospital units" received the highest scores in both surveys. There was no improvement and sometimes declining scores in the lowest scoring dimensions: "hospital transfers and transitions", "non-punitive response to error", and "staffing".

RESEARCH LIMITATIONS/IMPLICATIONS

The five participating hospitals were not randomly selected and therefore no representative conclusions can be made for the Belgian hospital sector as a whole. Only a quantitative approach to measuring safety culture was used. Qualitative approaches, focussing on specific safety cultures in specific parts of the participating hospitals, were not used.

PRACTICAL IMPLICATIONS

Although much needs to be done on the road towards better hospital patient safety, the study presents lessons from various perspectives. It illustrates that hospital staff are highly motivated to participate in measuring patient safety culture. Safety domains that urgently need improvement in these hospitals are identified: hospital transfers and transitions; non-punitive response to error; and staffing. It confirms that realising progress in patient safety culture, demonstrating at the same time that it is possible to improve management support, is complex.

ORIGINALITY/VALUE

Safety is an important service quality aspect. By measuring safety culture in hospitals, with a validated questionnaire, dimensions that need improvement were revealed thereby contributing to an enhancement plan.

Nurse staffing and patient outcomes in Belgian acute hospitals: cross-sectional analysis of administrative data

BACKGROUND

Studies have linked nurse staffing levels (number and skill mix) to several nurse-sensitive patient outcomes. However, evidence from European countries has been limited.

OBJECTIVES

This study examines the association between nurse staffing levels (i.e. acuity-adjusted Nursing Hours per Patient Day, the proportion of registered nurses with a Bachelor's degree) and 10 different patient outcomes potentially sensitive to nursing care. DESIGN-SETTING-PARTICIPANTS: Cross-sectional analyses of linked data from the Belgian Nursing Minimum Dataset (general acute care and intensive care nursing units: n=1403) and Belgian Hospital Discharge Dataset (general, orthopedic and vascular surgery patients: n=260,923) of the year 2003 from all acute hospitals (n=115).

METHODS

Logistic regression analyses, estimated by using a Generalized Estimation Equation Model, were used to study the association between nurse staffing and patient outcomes.

RESULTS

The mean acuity-adjusted Nursing Hours per Patient Day in Belgian hospitals was 2.62 (S.D.=0.29). The variability in patient outcome rates between hospitals is considerable. The inter-quartile ranges for the 10 patient outcomes go from 0.35 for Deep Venous Thrombosis to 3.77 for failure-to-rescue. No significant association was found between the acuity-adjusted Nursing Hours per Patient Day, proportion of registered nurses with a Bachelor's degree and the selected patient outcomes.

CONCLUSION

The absence of associations between hospital-level nurse staffing measures and patient outcomes should not be inferred as implying that nurse staffing does not have an impact on patient outcomes in Belgian hospitals. To better understand the dynamics of the nurse staffing and patient outcomes relationship in acute hospitals, further analyses (i.e. nursing unit level analyses) of these and other outcomes are recommended, in addition to inclusion of other study variables, including data about nursing practice environments in hospitals.

International experts' perspectives on the state of the nurse staffing and patient outcomes literature

PURPOSE

To assess the key variables used in research on nurse staffing and patient outcomes from the perspective of an international panel.

DESIGN

A Delphi survey (November 2005-February 2006) of a purposively-selected expert panel from 10 countries consisting of 24 researchers specializing in nurse staffing and quality of health care and 8 nurse administrators.

METHODS

Each participant was sent by e-mail an up-to-date review of all evidence related to 39 patient-outcome, 14 nurse-staffing and 31 background variables and asked to rate the importance/usefulness of each variable for research on nurse staffing and patient outcomes. In two subsequent rounds the group median, mode, frequencies, and earlier responses were sent to each respondent.

FINDINGS

Twenty-nine participants responded to the first round (90.6%), of whom 28 (87.5%) responded to the second round. The Delphi panel generated 7 patient-outcome, 2 nurse-staffing and 12 background variables in the first round, not well-investigated in previous research, to be added to the list. At the end of the second round the predefined level of consensus (85%) was reached for 32 patient outcomes, 10 nurse staffing measures and 29 background variables. The highest consensus levels regarding measure sensitivity to nurse staffing were found for nurse perceived quality of care, patient satisfaction and pain, and the lowest for renal failure, cardiac failure, and central nervous system complications. Nursing Hours per Patient Day received the highest consensus score as a valid measure of the number of nursing staff. As a skill mix variable the proportion of RNs to total nursing staff achieved the highest consensus level. Both age and comorbidities were rated as important background variables by all the respondents.

CONCLUSIONS

These results provide a snapshot of the state of the science on nurse-staffing and patient-outcomes research as of 2005. The results portray an area of nursing science in evolution and an understanding of the connections between human resource issues and healthcare quality based on both empirical findings and opinion.

Challenging patient safety culture: survey results

PURPOSE

The purpose of this paper is to measure patient safety culture in five Belgian general hospitals. Safety culture plays an important role in the approach towards greater patient safety in hospitals.

DESIGN/METHODOLOGY/APPROACH

The Patient Safety Culture Hospital questionnaire was distributed hospital-wide in five general hospitals. It evaluates ten patient safety culture dimensions and two outcomes. The scores were expressed as the percentage of positive answers towards patient safety for each dimension. The survey was conducted from March through November 2005. In total, 3,940 individuals responded (overall response rate = 77 per cent), including 2,813 nurses and assistants, 462 physicians, 397 physiotherapists, laboratory and radiology assistants, social workers and 64 pharmacists and pharmacy assistants.

FINDINGS

The dimensional positive scores were found to be low to average in all the hospitals. The lowest scores were "hospital management support for patient safety" (35 per cent), "non-punitive response to error" (36 per cent), "hospital transfers and transitions" (36 per cent), "staffing" (38 per cent), and "teamwork across hospital units" (40 per cent). The dimension "teamwork within hospital units" generated the highest score (70 per cent). Although the same dimensions were considered problematic in the different hospitals, important variations between the five hospitals were observed.

PRACTICAL IMPLICATIONS

A comprehensive and tailor-made plan to improve patient safety culture in these hospitals can now be developed.

ORIGINALITY/VALUE

Results indicate that important aspects of the patient safety culture in these hospitals need improvement. This is an important challenge to all stakeholders wishing to improve patient safety.

Adverse outcomes in Belgian acute hospitals: retrospective analysis of the national hospital discharge dataset

OBJECTIVE

The prevalence and variability of adverse outcome rates in Belgian acute hospitals is examined by using the national hospital discharge database.

DESIGN

setting, and participants. Retrospective analysis based on administrative data of all Belgian acute hospitals, covering the full medical (n = 1 024 743) and surgical (n = 633 027) in-patients population for the year 2000.

MAIN OUTCOME MEASURES

For 11 adverse outcomes and failure-to-rescue, the rates and variability among hospitals were studied. The all patient refined diagnostic-related groups (APR-DRG) method was used for risk adjustment.

RESULTS

The prevalence of adverse outcomes was 7.12% in the medical and 6.32% in the surgical group. Rates ranged from 6.25 (deep venous thrombosis) to 32.3 (urinary tract infection) outcomes per 1000 discharges in the medical group and from 3.39 (deep venous thrombosis) to 17.6 (urinary tract infection) outcomes per 1000 discharges in the surgical group. The failure-to-rescue rate was 240 and 211 per 1000 discharges, respectively. Except for pressure ulcers and hospital-acquired sepsis, the prevalence of adverse outcomes was significantly higher (P = 0.001) in the medical group. All adverse outcome rates varied substantially among the hospitals surveyed.

CONCLUSIONS

This study identifies the occurrence of adverse outcomes in a national population. It adds information to the growing body of knowledge in predominantly Anglo-Saxon countries about adverse outcomes. Striking variation exists in the risk-adjusted adverse outcome rates across Belgian acute hospitals, revealing a large potential for quality gains that encourage further action.

From Corporate Governance To Hospital Governance

As a result of multiple developments in health care and health care policy, hospital administrators, policy makers and researchers are increasingly challenged to reflect on the meaning of good hospital governance and how they can implement it in the hospital organisations. The question arises whether and to what extent governance models that have been developed within the corporate world can be valuable for these reflections. Due to the unique societal position of hospitals--which involves a large diversity of stakeholders--the claim for autonomy of various highly professional groups and the lack of clear business objectives, principles of corporate governance cannot be translated into the hospital sector without specific adjustments. However, irrespective of these contextual differences, corporate governance can provide for a comprehensive 'frame of reference', to which the hospital sector will have to give its own interpretation. A multidisciplinary research unit of the university of Leuven has taken the initiative to develop a governance model for Belgian hospitals. As part of the preliminary research work a survey has been performed among 82 hospitals of the Flemish Community on their governance structure, the composition of the governance entities, the partition of competencies and the relationship between management and medical staff.

A model for calculating the hospital costs for pediatric endoscopy

BACKGROUND

Hospitals increasingly need, besides effectiveness data, accurate and reliable cost data to allocate their resources as efficiently as possible. In this article, a framework to calculate the hospital costs of setting up a new activity is presented and applied to pediatric endoscopy.

METHODS

The cost calculations were based on a detailed registration of labor time, materials, space, and equipment needed to perform endoscopy in pediatric patients in a tertiary care hospital, the University Hospital in Leuven, Belgium.

RESULTS

The initial investment expenses amount to 70,000 ECU ($91,000 in U.S. money), assuming that the facilities of the adult endoscopy unit can be shared. The additional variable cost for each procedure, including labor time and materials, varies between 100 and about 170 ECU ($130 and $221 U.S.), depending on the type of endoscopy (upper or lower, diagnostic or therapeutic). These basic data can be used to calculate the total costs for pediatric endoscopy under alternative scenarios (e.g., varying total number of procedures).

CONCLUSIONS

The costing exercise has given the hospital better insights into the working procedures (and hence costs) of pediatric endoscopy. Other organizations will be able to apply this framework in their setting, since all included cost components, as well as volumes and unit prices, are reported separately.

Cost-efficient management in surgery. The view of the hospital administrator

The views of hospital administrators, doctors and payers on cost-efficiency in surgery do not necessarily coincide. The difference between charges and cost and the particularities of the financing mechanisms may induce situations in which savings for the society as a whole result in financial loss for the hospital. Examples are in the use of stapling devices, in ambulatory surgery, in endoscopic surgery: they all result in better quality of care and decreasing health care cost for society; they often induce, however, a not compensated increase in hospital costs. Surgeons and administrators can find each other in a common concern for optimizing efficiency. This asks for an agreement regarding the techniques and equipment to be used, and regarding the necessary minimum case load. This paper presents the case of the endoscopic cholecystectomy as an example. The second part of the paper deals with various aspects of quality and cost of the hospital product. It warns against purely technology-inspired investments which entail a risk for overconsumption and inappropriate use. It also asks for attention for the educational cost and for the continuing running cost which may result from capital investment decisions. Finally it underscores the role that surgeons can play in reducing the running cost, by paying attention to a smoother organisation of the OR activities and to the choice of materials, consumables and pharmaceuticals.

The Flemish Centre for the Study of Perinatal Epidemiology and its registry

The Flemish Centre for the Study of Perinatal Epidemiology was formally established in 1986. Its objectives are the promotion of perinatal epidemiology and the study of maternal and perinatal mortality and morbidity. One of the means to accomplish these objectives was the creation of a databank of perinatal medicine. The registry at present covers almost 80% of all deliveries in Flanders. The registry indicates a maternal death rate of 5.8/100,000 living births whereas the Belgian official national statistics indicate a maternal death rate of 2.8/100,000. This means that either the matter is under reported at the national level or there is a real problem in the Flemish part of the country. The perinatal death rate varies among the participating services form 3.9 to 22.4%.

The changing pattern of medical activity in a major Belgian university hospital

To evaluate the changes in the pattern of clinical activity in a 1900-bed Belgian teaching hospital in the period 1979-1987, we extracted data from the historical files of the hospital's central invoicing system. The total charge for a day of hospitalization, care and treatment increased by 83%. In this total per diem charge the share of hospital charges in the strict sense declined from 60 to 53%; the shares of charges for services and for pharmaceuticals rose, respectively, from 29 to 32, and from 10 to 15%. Within charges for services the share for diagnostic services declined by 22%; the share for surgery rose by 16%, and that for miscellaneous other services by 89%. For diagnostic services the decline was particularly clear for laboratory medicine (-32%) and for conventional imaging services (-22%), while cardiac and endoscopic investigations show a prominent expansion (+78 and +83%, respectively). In surgery the growth is quite homogeneous with the charges for urology, ophthalmology and orthopedics as the most important growers. In a group of miscellaneous, not diagnostic nor surgical services, which grows faster than all other groups, there is a marked shift from rather simple to technologically more advanced services. The increase in the pharmacy's bill results from increases in charge for both drugs (+49%) and materials (+95%). We conclude that the observed changes in charges reflect an intensification of care and an impact of technological innovation on clinical practice, including a phenomenon of substitution of old technologies for newer ones.

Use of diagnosis related groups for hospital management

This paper gives an overview on the use of Diagnosis Related Groups (DRGs) for internal hospital management. Some figures derived from a comparative study between 3 university hospitals in Belgium are used to illustrate specific points. Attention is given to cost accounting and cost control on the one hand, and utilization review and quality assurance testing on the other. Costs have been approximated by billed charges. It is concluded that DRGs can effectively be used for hospital management, in addition to hospital financing for which some pressure also exists in Europe.

Ionic currents during hypoxia in voltage-clamped cat ventricular muscle

To explore the mechanisms underlying the shortening of the cardiac action potential in hypoxia, we studied the effect of hypoxia on the ionic currents in cat papillary and trabecular muscles using the single sucrose gap-voltage clamp technique. For potentials positive to -70 mV, hypoxia induces an increase in time-independent outward current. The changes in the tail current suggest that time-dependent outward current is not increased but, rather, reduced. Because the time course of ik remains unchanged, we concluded that the shortening of the action potential is not a result of a change in the time-dependent outward current. In the potential range of the plateau, the amplitude of the slow inward current is not affected by hpoxia. Its time constant of inactivation appears slightly decreased. The prolongation of the action potential by epinephrine during hypoxia is accompanied by an increase in the slow inward current. As a result of these studies, we conclude that the shortening of the cardiac action potential in the early stage of hypoxia results from an increase in K+ outward background current.

Differential effects of hypoxia with age on the chick embryonic heart. Changes in membrane potential, intracellular K and Na, K efflux and glycogen

The effects of hypoxia on different parameters of cell membrane function were studied in 7 and 19 day chick embryonic hearts. The following changes were observed: 1. Transmembrane potential: A depolarization of the cell membrane and a decrease in the duration and in the overshoot of the action potential. 2. Intracellular ion concentrations: A decrease in (K)i and an increase in (Na)i. Cellular Ca-content remained constant. 3. K efflux: An increase in the rate coefficient, which was larger in stimulated preparations. These changes were more pronounced in 19 day than in 7 day hearts. The effects of hypoxia were increased by simultaneous substrate depletion and counteracted by an excess external glucose. We conclude that: 1. The 19 day hearts are more sensitive to oxygen lack than the 7 day hearts. The difference can be correlated with the observation that the younger hearts are able to consume more glycogen during hypoxia. 2. The changes of the resting membrane potential and the overshoot of the action potential correlate with changes in respectively (K)i and (Na)i. 3. An increase in the background K current may be an important factor in explaining the shortening of the action potential during hypoxia.

Hypoxia increases potassium efflux from mammalian myocardium

Hypoxia with or without simultaneous depletion of extracellular glucose increases 42K-efflux in cat and guinea-pig papillary muscles and bovine Purkinje fibres. The change observed in K efflux may be the result of an increase in K conductance at rest.

Choline permeability in cardiac muscle cells of the cat

Permeability of the cardiac cell membrane to choline ions was estimated by measuring radioactive choline influx and efflux in cat ventricular muscle. Maximum values for choline influx in 3.5 and 137 mM choline were respectively 0.56 and 9 pmoles/cm(2).sec. In 3.5 mM choline the intracellular choline concentration was raised more than five times above the extracellular concentration after 2 hr of incubation. In 137 mM choline, choline influx corresponded to the combined loss of intracellular Na and K ions. Paper chromatography of muscle extracts indicated that choline was not metabolized to any important degree. The accumulation of intracellular choline rules out the existence of an efficient active pumping mechanism. By measuring simultaneously choline and sucrose exchange, choline efflux was analyzed in an extracellular phase, followed by two intracellular phases: a rapid and a slow one. Efflux corresponding to the rapid phase was estimated at 16-45 pmoles/cm(2).sec in 137 mM choline and at 1.3-3.5 pmoles/cm(2).sec in 3.5 mM choline; efflux in 3.5 mM choline was proportional to the intracellular choline concentration. The absolute figures for unidirectional efflux were much larger than the net influx values. The data are compared to Na and Li exchange in heart cells. Possible mechanisms for explaining the choline behavior in heart muscle are discussed.