Studying Quality and Safety in European Hospitals - QUASER

9th June, 2010

Prof Naomi Fulop

Dr. Janet Anderson

NIHR King’s Patient Safety and Service Quality Research Centre

Background: EU Policy

Right of patients to seek healthcare in another Member State

Directive on safe, high quality and efficient cross-border healthcare (2008) – one of main goals:

“Patients should be confident that the quality and safety standards of the treatment they will receive in another Member State are regularly monitored and based on good medical practices”

"Study the relationship of organisational quality management and culture, professionals' involvement, and patient empowerment with the quality of hospital care, including clinical effectiveness, patient safety and patient involvement.

Identify organisational and cultural characteristics of hospitals and professional- and patient-related tools that are associated with better quality of care.

This research should serve to guide hospitals to develop their own effective safety and quality improvement programmes and provide the basis for assessing hospital quality of care by purchasers and national and local governments.

Funding scheme: Collaborative Project (Small or medium-scale focused research project)."

Background: EU 7th Framework Programme Call on Quality and Safety

Two proposals funded

QUASER DuQue – builds on MARQuIS study (QSHC,

2009) further develop ‘maturity classification model’ focus on associations between this model &

measures of org culture, prof involvement and pt empowerment

measures of clinical effectiveness, patient safety and patient involvement

QUASER – Overall Aim

To explore relationships between organisational and cultural characteristics of hospitals and how these impact on clinical effectiveness, patient safety and patient experience in European countries

QUASER - Objectives

1. To design and disseminate the Quality and Safety Guide for Hospitals – assist hospitals to implement quality and safety programmes

2. To design and disseminate the Framework for Assessing Hospital Quality – assist purchasers of hospital services and governments to assess quality of hospital care

QUASER - Partners

1. Patient Safety and Service Quality Research Centre, King’s College London, England

2. Erasmus University, Netherlands

3. Jönköping County Council, Sweden

4. Centre for Patient Safety and Service Quality, Imperial College London, England

5. ISCTE, Portugal

6. University of Stavanger, Norway

QUASER - Stakeholders

Stakeholder group – hospitals and payers from:• Spain• Romania• Turkey• Denmark• Poland• Estonia• Norway• Netherlands• Sweden

QUASER – key features of study

Quality as a human and social accomplishment, not just technical

Multi level, longitudinal study – focus on the interactions between the macro, meso and micro levels and their effect on quality

Translational research – translate research into outputs with relevance, utility and value.

QUASER – conceptual approach

Start with the practice What are people doing, or not doing in terms of

quality improvement at the hospital level and at the bedside?

What are the rationales that are driving their day-to-day practice?

QUASER – conceptual approach

Lean Six Sigma Plan do study act Clinical governance Risk management

Specific tools and strategies CRM Surgery checklist Standardised care

pathways

Good understanding of types of quality improvement strategies - examples

QUASER – conceptual approach

Less understanding of the factors that increase effectiveness of these

Less understanding of longitudinal factors – the quality journey and building capacity

Quality is not just technical, it has human and social components Leadership Organisational culture Team based structures Organisational structures and processes

QUASER – Key questions

What cultural factors influence the success of quality improvement efforts at different levels of the system?

How do these factors relate to one another? How do hospitals influence these factors? How is quality improvement carried out day to day? How are challenges in implementing quality improvement overcome? How do high and low performing hospitals differ in terms of culture,

leadership, management structures?

QUASER Work Packages

Work Package Work Package Leader and Board members

WP1 Management and co-ordination

Prof. Naomi Fulop, Dr. Glenn Robert KCL, Dr. Janet Anderson KCL, Susan Burnett IC

WP2 Selection of hospitals, indicators, data collection tools and protocol development

Prof. Charles Vincent, Prof. Boel Andersson-Gare HJ, Dr. Paul Aylin IC, Susan Burnett IC, Prof N Fulop KCL, Dr Janet Anderson KCL, Dr Glenn Robert KCL, Dr. Anneliese Dodds

WP3 Determine the best methods and mechanisms for developing, designing and disseminating the practical guide and framework

Prof. Roland Bal, Dr. Glenn Robert KCL, Susan Burnett IC, Dr. Anneliese Dodds KCL

WP4a Netherlands Hospital case study

Anne Marie Weggelaar, Prof. Roland Bal Eras, Prof. Jorge Correia Jesuíno ISCTE, Dr. Johan Thor HJ

WP4b Sweden hospital case study

Prof. Boel Andersson-Gare, Johan Calltorp HJ, Gerd Ahlström HJ, Bengt Fridlund HJ, Göran Henriks HJ, Anne Marie Weggelaar Eras, Susan Burnett IC

WP4c UK Hospital case study Susan Burnett, Dr. Glenn Robert KCL, Prof. Karina Aase UiS, Prof. Roland Bal Eras

QUASER Work Packages cont….

WP4d Portugal Hospital case study

Prof. Jorge Correia Jesuíno, Prof. Karina Aase UiS, Prof. Boel Andersson-Gare HJ

WP4e Norway Hospital case study

Prof. Karina Aase, Prof. Ron Westrum UiS, Dr. Glenn Robert KCL, Siri Wiig UiS, AnneMarie Weggelaar Eras

WP5. Analysis and Synthesis Dr. Glenn Robert, Dr. Janet Anderson KCL, Susan Burnett IC, Prof. Karina Aase UiS, Prof. Roland Bal Eras, Prof. Boel Andersson-Gare HJ, Prof. Jorge Correia Jesuíno ISCTE

WP6. Design the Quality and Safety Guide for Hospitals and the Framework for Assessing Hospital Quality

Prof. Johan Calltorp, Dr. Glenn Robert KCL, Susan Burnett IC, Prof. Karina Aase UiS, Prof. Roland Bal Eras, Prof. Boel Andersson-Gare HJ, Prof. Jorge Correia Jesuíno ISCTE

WP7 Translation and dissemination

Dr Janet Anderson, Prof. Naomi Fulop KCL, Dr. Glenn Robert KCL, Dr. Anneliese Dodds KCL, Susan Burnett IC, Prof. Karina Ase Uis, Prof. Roland Bal Eras

Overview of QUASER research design and activities

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WP 2 ICScoping review of the literature to identify- quantitative and qualitative indicators of hospital quality- organisational and cultural characteristics of hospitals associated with high quality careReview of indicators available in each country

1. Selection framework for case study sites2. Analytical tools for data collection3. Protocols for data collection

WP 7 KCLTranslational workshop 1 with stakeholders in EU countries to 1. Review data collection tools and protocols for feasibility and

2. Review design requirements

WP 3 ErasReview current guides for implementing hospital quality and safety improvement programmesReview current mechanisms for disseminating quality and safety information eg. management and practice networksReview how managers and clinicians are trained in quality

1. Understanding of context 2. Design requirements for the Guide for Hospitals and Framework for Payers3. Dissemination strategies

Determine methods for designing and disseminating Guide and Framework

Selection of hospitals, indicators, data collection tools and protocol development

Hospital case studies WPs 4a-e

Overview of QUASER research design and activities

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Macro LevelReview macro level context in each country – five EU partnersInfluence of broad socio political context on quality – financial structures, accreditation, policies, regulation, legislation

Meso LevelMeso level case study – two hospitals in each country – ten studiesRelationship between quality and safety improvement programmes, how quality and safety are organised and managed, cultural characteristics of hospitals and indicators of qualityDifficulties faced – how were they overcome?

Micro LevelMicro level case study – two clinical micro systems in one hospital – ten studies in five hospitals How are quality and safety organised in two micro systems – maternity and one other?How are meso level initiatives implemented?Practitioners’ perceptionsLocal initiatives, local leaders and champions

Comprehensive report of case studies in each country

WPs 4a-e, 7Dissemination workshop in each country

Overview of QUASER research design and activitiesR

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WP 6 HJDesign Guide and Framework

WP 5 KCLCross case analysis and synthesis

WP 7 KCLDissemination

Produce dissemination planCo-ordinate translational activitiesCo-ordinate national workshops

WP 7 KCLTranslational workshop 2 with

stakeholdersGain feedback on emerging

results

Review case study results from each EU country

Identify similarities and differences between countries, hospitals and micro systems

Synthesise results

WP 7 KCLTranslational workshop 3 with

stakeholdersGain feedback on Guide and

Framework

Final Guide and Framework

Disseminate the Guide and Framework

Design Guide for Hospitals and Framework for Payers

1. Identify elements of the Guide2. Identify elements of Framework

Final project report

Del. no.

Deliverable name WP no.

Lead bene-ficiary

Delivery date

(proj.

month)

1 Suite of data collection tools and protocols

2 IC 6

2 Report on current quality and safety guides, current dissemination strategies, design requirements and dissemination strategies for the project outputs

3 Eras 6

3 Report of hospital case studies 4a-e KCL and all

24

4 Report of cross case analysis and synthesis

5 KCL 30

5 Quality and Safety Guide for Hospitals

6 HJ 36

6 Framework for Assessing Hospital quality for Providers/Payers

6 HJ 36

QUASER Management Structure

Project Management Executive

DirectorProject Manager

Others as necessary

Work Package BoardsAssist and advise WP leaders

Work Package LeadersResponsible for management

and delivery of work

Expert Advisory BoardMeets three times during

project

Project Management Board

Chaired by DirectorMembers – WP leadersPrimary decision making

responsibility

QUASER Management Structure

Consortium meetings – include all researchers. Meet annually to review progress

Project Management Board meetings – via phone. Need to determine how often to meet

Expert advisory board – timing of first meeting Work package leaders – need to arrange

communication with work package boards

QUASER team responsibilities

Active participation in work package boards Timely completion of work Responsive to communication and requests from

others Attendance at meetings

QUASER – links with DUQUE project

Prof. Fulop is a member of the advisory board Intend to invite DUQUE participation in QUASER

advisory board Potential for further collaboration - eg:

Joint outputs Hospital selection in Portugal and England Use of their maturity framework for selection Joint dissemination activities

Links with other research groups

Taiwan Medical University and WanFang Hospital Taipei Invited to present QUASER project at International

Patient Safety Workshop, Taipei, December, 2009 Interested in participating as stakeholder organisations Interested in replicating study in Taiwan (self funded) Meeting June 28th to discuss further

QUASER next steps

Official start date – 1st April 2010 Will need to request extension Progress on recruitment in London

Interviews for Project Manager, Research Fellow (KCL) and Research Associate (IC) on June 17th