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

Does public health policy quality foster state innovation capacity? Evidence from a global panel data

The design and implementation of public health policy may shape state innovation capacity with governance effectiveness, political stability, and government integrity. Previous studies, however, failed to incorporate these relationships simultaneously. This study aims to combine two distinct scholarships to examine whether the quality of policies in the public health sector contributes to state innovation capacity. We extracted data from the WHO international health regulatory dataset covering the WHO Member States between 2010 and 2017 to investigate the relationship (N = 145). Our fixed-effects models and regression discontinuity design (RDD) suggest a positive impact of public health policy quality on state innovation capacity. There are several contributions to the study of the relationship between public health and innovation in this study. Firstly, it fills a theoretical void concerning the relationship between policy development and implementation in the public health sector and country-specific innovations. Second, it provides an empirical quantitative analysis of policy quality in the public health sector. Third, this study contributes evidence that public health plays an important role in fostering state innovation beyond urbanization, investment in science and technology, and foreign trade. Furthermore, our quasi-experimental evidence found that this mechanism may be significant only between the more politically stable countries and the most politically stable countries. These contributions have empirical implications for governments across the world that seek to balance public health and innovation capacity in the context of the post-pandemic era.

Contribution of Healthcare Professionals in Issues that Relate to Quality Management

Background:

The health sector should adopt integrated quality systems because of the need to survive and develop in a highly competitive environment. Inefficiency of mechanistic procedures, along with inadequate administrative infrastructure, impose innovative appoaches to improve operations and increase revenues by reducing quality feilures.

Objective:

A health system that relies on quality healthcare services can directly benefit the entire society, may reduce mortality, disease severity, and increase life expectancy. The following literature review constitutes an attempt to assess the contribution of healthcare professionals in issues that relate to quality management over the course of recent years.

Methods:

This systematic review took place between May 2019 and June 2020 in the databases PubMed, Cochrane Library, Wiley Online Library, Web of Science, Google Scholar and Scopus search engine databases. Study Selection and Data Extraction: This review includes articles written in English language, which contain quantitative and qualitative analysis of healthcare professionals’ involvement in quality activities. Correspondingly, the exclusion criteria were: languages other than English, secondary surveys (general and systematic reviews or post-analyses), letters to the publisher, and editorials or articles that did not illuminate the subject under study. After an extensive literature review, a standardised Excel spreadsheet was developed for data extraction from the included studies. The main characteristics of the studies were recorded (author’s name, place and time of work, the article under study and the methodology) so that all research articles corresponding to the review could be included. 31 articles were included.

Results:

Healthcare professionals are engaged in quality improvement activities and there is high association between quality management strategies and clinical processes. A systematic approach on healthcare activities based on the input of healthcare professionals can help increase business performance, reduce errors, improve patient safety, and contribute to a more proactive care.

Conclusion:

Health professionals’ contribution in the strategic planning of healthcare organisations that address quality activities can lead to better output, both in patient satisfaction and safety.

Publication of inspection frameworks: a qualitative study exploring the impact on quality improvement and regulation in three healthcare settings

Background

The Dutch healthcare inspectorate publishes its inspection frameworks to inform both the public and healthcare providers about regulatory procedures and in the hope that publication will motivate healthcare providers to improve quality and comply with standards. This study explores the consequences of publishing these frameworks for the regulation of quality and safety in healthcare.

Methods

We selected recently published inspection frameworks used in three healthcare settings: nursing home care, dental care and hospital care. We conducted 37 interviews with 39 respondents (healthcare professionals, managers, quality officers, policy advisers and inspectors) and explored their awareness of and experiences with these frameworks. We held a group interview with three inspectors to reflect on our findings. All data underwent thematic content analysis.

Results

We found that the institutional infrastructure of a sector plays an important role in how an inspection framework is used after publication; particularly the presence and maturity of quality improvement work in the sector and the inspectorate’s grip on a sector matter. Respondents mentioned differences in framework use in organisational contexts, particularly relating to scale. In some organisations, the framework served as an accountability mechanism to check if quality meets basic standards, while in other organisations professionals adopted it to stimulate discussion and learning across teams.

Conclusion

Publication of inspection frameworks might result in quality improvement work, and in particular contexts could be used as a regulatory strategy to target quality improvement in a healthcare sector. For this, it is important that regulators consider the capabilities and possibilities for learning and improving within a sector.

Facilitators and barriers in implementing medication safety practices across hospitals within 11 European Union countries

Background:

The study was carried out as part of the European Network for Patient Safety (EUNetPas) project in 2008-2010.

Objective:

To investigate facilitators and barriers in implementation process of selected medication safety practices across hospitals within European Union countries.

Methods:

This was an implementation study of seven selected medication safety practices in 55 volunteering hospitals of 11 European Union (EU) member states. The selected practices were two different versions of medicine bed dispensation; safety vest; discharge medication list for patients; medication reconciliation at patient discharge; medication reconciliation at patient admission and patient discharge, and sleep card. The participating hospitals submitted an evaluation report describing the implementation process of a chosen practice in their organisation. The reports were analysed with inductive content analysis to identify general and practice-specific facilitators and barriers to the practice implementation.

Results:

Altogether 75 evaluation reports were submitted from 55 hospitals in 11 EU member states. Implementation of the medication safety practices was challenging and more time consuming than expected. The major reported challenge was to change the work process because of the new practice. General facilitators for successful implementation were existence of safety culture, national guidelines and projects, expert support, sufficient resources, electronic patient records, interdisciplinary cooperation and clinical pharmacy services supporting the practice implementation.

Conclusions:

The key for the successful implementation of a medication safety practice is to select the right practice for the right problem, in the right setting and with sufficient resources in an organization with a safety culture.

Domains associated with successful quality improvement in healthcare - a nationwide case study

Background

There is a distinct difference between what we know and what we do in healthcare: a gap that is impairing the quality of the care and increasing the costs. Quality improvement efforts have been made worldwide by learning collaboratives, based on recognized continual improvement theory with limited scientific evidence. The present study of 132 quality improvement projects in Norway explores the conditions for improvement from the perspectives of the frontline healthcare professionals, and evaluates the effectiveness of the continual improvement method.

Methods

An instrument with 25 questions was developed on prior focus group interviews with improvement project members who identified features that may promote or inhibit improvement. The questionnaire was sent to 189 improvement projects initiated by the Norwegian Medical Association, and responded by 70% (132) of the improvement teams. A sub study of their final reports by a validated instrument, made us able to identify the successful projects and compare their assessments with the assessments of the other projects. A factor analysis with Varimax rotation of the 25 questions identified five domains. A multivariate regression analysis was used to evaluate the association with successful quality improvements.

Results

Two of the five domains were associated with success: Measurement and Guidance (p = 0.011), and Professional environment (p = 0.015). The organizational leadership domain was not associated with successful quality improvements (p = 0.26).

Conclusion

Our findings suggest that quality improvement projects with good guidance and focus on measurement for improvement have increased likelihood of success. The variables in these two domains are aligned with improvement theory and confirm the effectiveness of the continual improvement method provided by the learning collaborative. High performing professional environments successfully engaged in patient-centered quality improvement if they had access to: (a) knowledge of best practice provided by professional subject matter experts, (b) knowledge of current practice provided by simple measurement methods, assisted by (c) improvement knowledge experts who provided useful guidance on measurement, and made the team able to organize the improvement efforts well in spite of the difficult resource situation (time and personnel). Our findings may be used by healthcare organizations to develop effective infrastructure to support improvement and to create the conditions for making quality and safety improvement a part of everyone’s job.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2454-2) contains supplementary material, which is available to authorized users.

A review of national policies and strategies to improve quality of health care and patient safety: a case study from Lebanon and Jordan

Background

Improving quality of care and patient safety practices can strengthen health care delivery systems, improve health sector performance, and accelerate attainment of health-related Sustainability Development Goals. Although quality improvement is now prominent on the health policy agendas of governments in low- and middle-income countries (LMICs), including countries of the Eastern Mediterranean Region (EMR), progress to date has not been optimal. The objective of this study is to comprehensively review existing quality improvement and patient safety policies and strategies in two selected countries of the EMR (Lebanon and Jordan) to determine the extent to which these have been institutionalized within existing health systems.

Methods

We used a mixed methods approach that combined documentation review, stakeholder surveys and key informant interviews. Existing quality improvement and patient safety initiatives were assessed across five components of an analytical framework for assessing health care quality and patient safety: health systems context; national policies and legislation; organizations and institutions; methods, techniques and tools; and health care infrastructure and resources.

Results

Both Lebanon and Jordan have made important progress in terms of increased attention to quality and accreditation in national health plans and strategies, licensing requirements for health care professionals and organizations (albeit to varying extents), and investments in health information systems. A key deficiency in both countries is the absence of an explicit national policy for quality improvement and patient safety across the health system. Instead, there is a spread of several (disjointed) pieces of legal measures and national plans leading to fragmentation and lack of clear articulation of responsibilities across the entire continuum of care. Moreover, both countries lack national sets of standardized and applicable quality indicators for performance measurement and benchmarking. Importantly, incentive systems that link contractual agreement, regulations, accreditation, and performance indicators are underutilized in Lebanon and absent in Jordan. At the healthcare organizational level, there is a need to instill a culture of continuous quality improvement and promote professional training in quality improvement and patient safety.

Conclusion

Study findings highlight the importance of aligning policies, organizations, methods, capacities and resources in order to institutionalize quality improvement and patient safety practices in health systems. Gaps and dysfunctions identified can help inform national deliberations and dialogues among key stakeholders in each study country. Findings can also inform future quality improvement efforts in the EMR and beyond, with a particular emphasis on LMICs.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2528-1) contains supplementary material, which is available to authorized users.

Mandatory national quality improvement systems using indicators: An initial assessment in Europe and Israel

INTRODUCTION

Quality improvement systems (QIS) that are based on empirical performance assessment have increasingly been implemented as a mandatory part of health systems across countries. This study aims to describe national mandatory QIS in Europe in 2014.

MATERIALS AND METHODS

Relevant national agencies for national mandatory QIS in Europe were identified through online searches and key informants. A questionnaire was compiled during a workshop with these agencies and filled out by representatives from these particular agencies.

RESULTS

Agencies in charge of national mandatory QIS in seven countries (Denmark, France, Germany, Israel, Scotland, Sweden and Switzerland) were included in the study. An analysis of QIS revealed similarities, such as the use of routine data for performance assessment and the aim to hold healthcare providers accountable. Differences relate to the different forms of feedback systems and improvement mechanisms used. Trends include the development towards greater implementation of QIS within health systems, the inclusion of the patient's perspective in performance assessment, and experiments with pay for performance-related measures.

CONCLUSION

On a country level, for health systems striving for newly implementing QIS it is recommended to start where routine data is available, add qualitative methodologies once the QIS is getting more complex, report performance data back to service providers and be patient centred. On the inter-country level exchange of information between agencies commissioned with implementing national QIS is very much needed for.

Deepening our Understanding of Quality in Australia (DUQuA): a study protocol for a nationwide, multilevel analysis of relationships between hospital quality management systems and patient factors

INTRODUCTION

Despite the growing body of research on quality and safety in healthcare, there is little evidence of the association between the way hospitals are organised for quality and patient factors, limiting our understanding of how to effect large-scale change. The 'Deepening our Understanding of Quality in Australia' (DUQuA) study aims to measure and examine relationships between (1) organisation and department-level quality management systems (QMS), clinician leadership and culture, and (2) clinical treatment processes, clinical outcomes and patient-reported perceptions of care within Australian hospitals.

METHODS AND ANALYSIS

The DUQuA project is a national, multilevel, cross-sectional study with data collection at organisation (hospital), department, professional and patient levels. Sample size calculations indicate a minimum of 43 hospitals are required to adequately power the study. To allow for rejection and attrition, 70 hospitals across all Australian jurisdictions that meet the inclusion criteria will be invited to participate. Participants will consist of hospital quality management professionals; clinicians; and patients with stroke, acute myocardial infarction and hip fracture. Organisation and department-level QMS, clinician leadership and culture, patient perceptions of safety, clinical treatment processes, and patient outcomes will be assessed using validated, evidence-based or consensus-based measurement tools. Data analysis will consist of simple correlations, linear and logistic regression and multilevel modelling. Multilevel modelling methods will enable identification of the amount of variation in outcomes attributed to the hospital and department levels, and the factors contributing to this variation.

ETHICS AND DISSEMINATION

Ethical approval has been obtained. Results will be disseminated to individual hospitals in de-identified national and international benchmarking reports with data-driven recommendations. This ground-breaking national study has the potential to influence decision-making on the implementation of quality and safety systems and processes in Australian and international hospitals.

Development and Validation of the CPO Scale, a New Instrument for Evaluation of Health Care Improvement Efforts

OBJECTIVE

To develop and validate an instrument for guidance and evaluation of quality and safety improvement efforts in health care.

CONTEXT

The instrument is based on the Plan-Do-Study-Act cycle and the 3 fundamental improvement questions regarding aims, measurement, and change-making.

METHODS

An interdisciplinary team of improvement experts developed the Change Process and Outcome (CPO) scale. After studying the improvement literature, the scale was tested and refined on a sample of 5 projects. The CPO evaluation process and classification system was developed when evaluating 189 of the quality improvement projects of the Norwegian Medical Association by their final reports. The scale was validated by applying statistical testing to the evaluation results.

RESULTS

The final CPO scale consists of 13 process items and 7 outcome items. Interrater reliability ranged from 0.53 to 0.79, and test-retest reliability was 0.82. Factor analyses with Varimax rotation identified 2 significant process domains: Aims/change-making and Measurement/reporting, with Cronbach α values 0.88 and 0.95, respectively. The classification system produced 3 performance levels: successful, promising, and uncertain.

CONCLUSION

The CPO scale shows good internal consistency, reliability, and validity for evaluating the success of quality improvement initiatives.

Implementing hospital quality assurance policies in Iran

Purpose

– The purpose of this paper is to provide an overview of applied hospital quality assurance (QA) policies in Iran.

Design/methodology/approach

– A mixed method (quantitative data and qualitative document analysis) study was carried out between 1996 and 2010.

Findings

– The QA policy cycle forms a tight monitoring system to assure hospital quality by combining mandatory and voluntary methods in Iran. The licensing, annual evaluation and grading, and regulatory inspections statutorily implemented by the government as a national package to assure and improve hospital care quality, while implementing quality management systems (QMS) was voluntary for hospitals. The government’s strong QA policy legislation role and support has been an important factor for successful QA implementation in Iran, though it may affected QA assessment independency and validity. Increased hospital evaluation independency and repositioning, updating standards, professional involvement and effectiveness studies could increase QA policy impact and maturity.

Practical implications

– The study highlights the current QA policy implementation cycle in Iranian hospitals. It provides a basis for further quality strategy development in Iranian hospitals and elsewhere. It also raises attention about finding the optimal balance between different QA policies, which is topical for many countries.

Originality/value

– This paper describes experiences when implementing a unique approach, combining mandatory and voluntary QA policies simultaneously in a developing country, which has invested considerably over time to improve hospital quality. The experiences with a mixed obligatory/voluntary approach and comprehensive policies in Iran may contain lessons for policy makers in developing and developed countries.

Continuity of care in the cross-border context: insights from a survey of German patients treated abroad

BACKGROUND

Continuity of care is important for outcomes and patient satisfaction and includes additional considerations in the context of cross-border health care. Although this has been discussed in research and was picked up in the recently transposed Directive on patients' rights (2011/24/EU), there is limited evidence about related issues actually encountered by patients crossing borders.

METHODS

An anonymous postal survey was carried out by the Techniker Krankenkasse, one of the largest sickness funds in Germany. The questionnaire was sent to 45 189 individuals who had received treatment in EU/EEA countries and included items on relational, management and informational continuity.

RESULTS

The survey had a response rate of 41% (n = 17 543). Of those respondents who had travelled for care (n = 3307), ∼19% (n = 570) did so due to a relationship of trust with a given provider. Only 8% of all respondents required emergency follow-up services due to complications, the majority of which was obtained back in Germany. Twelve percentage of those who were prescribed medication abroad (n = 4208) reported problems, spanning unknown products, dispensation and reimbursement. Information exchange between providers across borders was rare and largely carried out by the patients themselves.

CONCLUSIONS

Although relational continuity may be important to specific groups of patients travelling for care, it is primarily informational continuity and its interrelation with management continuity that need to be addressed in the cross-border context. Information exchange should be endorsed at European level. Additional focus is required on informing patients about documentation rights and requirements and providing health records that are comprehensive and comprehensible.

Influence of shared medical appointments on patient satisfaction: a retrospective 3-year study

PURPOSE

Shared medical appointments (SMAs) are becoming popular, but little is known about their association with patient experience in primary care. We performed an exploratory analysis examining overall satisfaction and patient-centered care experiences across key domains of the patient-centered medical home among patients attending SMAs vs usual care appointments.

METHODS

We undertook a cross-sectional study using a mailed questionnaire measuring levels of patient satisfaction and other indicators of patient-centered care among 921 SMA and 921 usual care patients between 2008 and 2010. Propensity scores adjusted for potential case mix differences between the groups. Multivariate logistic regression assessed propensity-matched patients' ratings of care. Generalized estimating equations accounted for physician-level clustering.

RESULTS

A total of 40% of SMA patients and 31% of usual care patients responded. In adjusted analyses, SMA patients were more likely to rate their overall satisfaction with care as "very good" when compared with usual care counterparts (odds ratio=1.26; 95% CI, 1.05-1.52). In the analysis of patient-centered medical home elements, SMA patients rated their care as more accessible and more sensitive to their needs, whereas usual care patients reported greater satisfaction with physician communication and time spent during their appointment.

CONCLUSIONS

Overall, SMA patients appear more satisfied with their care relative to patients receiving usual care. SMAs may also improve access to care and deliver care that patients find to be sensitive to their needs. Further research should focus on enhancing patient-clinician communication within an SMA as this model of care becomes more widely adopted.

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

Background

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

Objective

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

Methods and Materials

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

Results

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

Conclusion

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

Deepening our understanding of quality improvement in Europe (DUQuE): overview of a study of hospital quality management in seven countries

Introduction and Objective

This paper provides an overview of the DUQuE (Deepening our Understanding of Quality Improvement in Europe) project, the first study across multiple countries of the European Union (EU) to assess relationships between quality management and patient outcomes at EU level. The paper describes the conceptual framework and methods applied, highlighting the novel features of this study.

Design

DUQuE was designed as a multi-level cross-sectional study with data collection at hospital, pathway, professional and patient level in eight countries.

Setting and Participants

We aimed to collect data for the assessment of hospital-wide constructs from up to 30 randomly selected hospitals in each country, and additional data at pathway and patient level in 12 of these 30.

Main outcome measures

A comprehensive conceptual framework was developed to account for the multiple levels that influence hospital performance and patient outcomes. We assessed hospital-specific constructs (organizational culture and professional involvement), clinical pathway constructs (the organization of care processes for acute myocardial infarction, stroke, hip fracture and deliveries), patient-specific processes and outcomes (clinical effectiveness, patient safety and patient experience) and external constructs that could modify hospital quality (external assessment and perceived external pressure).

Results

Data was gathered from 188 hospitals in 7 participating countries. The overall participation and response rate were between 75% and 100% for the assessed measures.

Conclusions

This is the first study assessing relation between quality management and patient outcomes at EU level. The study involved a large number of respondents and achieved high response rates. This work will serve to develop guidance in how to assess quality management and makes recommendations on the best ways to improve quality in healthcare for hospital stakeholders, payers, researchers, and policy makers throughout the EU.

Effects of auditing patient safety in hospital care: design of a mixed-method evaluation

BACKGROUND

Auditing of patient safety aims at early detection of risks of adverse events and is intended to encourage the continuous improvement of patient safety. The auditing should be an independent, objective assurance and consulting system. Auditing helps an organisation accomplish its objectives by bringing a systematic, disciplined approach to evaluating and improving the effectiveness of risk management, control, and governance. Audits are broadly conducted in hospitals, but little is known about their effects on the behaviour of healthcare professionals and patient safety outcomes. This study was initiated to evaluate the effects of patient safety auditing in hospital care and to explore the processes and mechanisms underlying these effects.

METHODS AND DESIGN

Our study aims to evaluate an audit system to monitor and improve patient safety in a hospital setting. We are using a mixed-method evaluation with a before-and-after study design in eight departments of one university hospital in the period October 2011-July 2014. We measure several outcomes 3 months before the audit and 15 months after the audit. The primary outcomes are adverse events and complications. The secondary outcomes are experiences of patients, the standardised mortality ratio, prolonged hospital stay, patient safety culture, and team climate. We use medical record reviews, questionnaires, hospital administrative data, and observations to assess the outcomes. A process evaluation will be used to find out which components of internal auditing determine the effects.

DISCUSSION

We report a study protocol of an effect and process evaluation to determine whether auditing improves patient safety in hospital care. Because auditing is a complex intervention targeted on several levels, we are using a combination of methods to collect qualitative and quantitative data about patient safety at the patient, professional, and department levels. This study is relevant for hospitals that want to early detect unsafe care and improve patient safety continuously.

TRIAL REGISTRATION

Netherlands Trial Register (NTR): NTR3343.

Clinical risk management in hospitals: strategy, central coordination and dialogue as key enablers

OBJECTIVE

The study aims to identify key enablers fostering clinical risk management (CRM) in hospitals to guide health care in this vital area of patient safety.

METHOD

A cross-sectional survey was conducted at the national level in 324 Swiss hospitals in 2007-2008 to assess the relationship between key elements and systematic CRM. Therefore, a comprehensive monitoring instrument for CRM was used for the first time. Organizational factors (e.g. strategy, coordination, resources) and structural conditions (e.g. hospital size) were tested as key elements. CRM was assessed by evaluating its maturity (i.e. the level of CRM development) by 12 theoretically derived indices joining together essential aspects of CRM at the hospital level and the service level. Chi-square measures were used to analyse the relationships between organizational factors or structural conditions and maturity of CRM.

RESULTS

Participation in this voluntary survey was good, with CRM experts of 138 out of 324 hospitals responding (response rate 43%). Three key enablers for CRM were identified: implementing a function for central CRM coordination, assuring dialogue with and between the different hospital services, and developing strategic CRM objectives.

CONCLUSIONS

This study offers, for the first time, an assessment of the maturity of hospitals' CRM and identifies key enablers related to CRM. This is a feasible first step in guiding hospitals to shape their CRM and presents a basis for future studies, for example, linking CRM to outcome data.

Use of cross-border healthcare services among ethnic Danes, Turkish immigrants and Turkish descendants in Denmark: a combined survey and registry study

BACKGROUND

Healthcare obtained abroad may conflict with care received in the country of residence. A special concern for immigrants has been raised as they may have stronger links to healthcare services abroad. Our objective was to investigate use of healthcare in a foreign country in Turkish immigrants, their descendants, and ethnic Danes.

METHODS

The study was based on a nationwide survey in 2007 with 372 Turkish immigrants, 496 descendants, and 1,131 ethnic Danes aged 18-66. Data were linked to registry data on socioeconomic factors. Using logistic regression models, use of doctor, specialist doctor, hospital, dentist in a foreign country as well as medicine from abroad were estimated. Analyses were adjusted for socioeconomic factors and health symptoms.

RESULTS

Overall, 26.6% among Turkish immigrants made use of cross-border healthcare, followed by 19.4% among their descendants to 6.7% among ethnic Danes. Using logistic regression models with ethnic Danes as the reference group, Turkish immigrants were seen to have made increased use of general practitioners, specialist doctors, hospitals, and dentists in a foreign country (odds ratio (OR), 5.20-6.74), while Turkish descendants had made increased use of specialist doctors (OR, 4.97) and borderline statistically significant increased use of hospital (OR, 2.48) and dentist (OR, 2.17) but not general practitioners. For medicine, we found no differences among the men, but women with an immigrant background made considerably greater use, compared with ethnic Danish women. Socioeconomic position and health symptoms had a fairly explanatory effect on the use in the different groups.

CONCLUSIONS

Use of cross-border healthcare may have consequences for the continuity of care, including conflicts in the medical treatment, for the patient. Nonetheless, it may be aligned with the patient's preferences and thereby beneficial for the patient. We need more information about reasons for obtaining cross-border healthcare among immigrants residing in European countries, and the consequences for the patient and the healthcare systems, including the quality of care. The Danish healthcare system needs to be aware of the significant healthcare consumption by immigrants, especially medicine among women, outside Denmark's borders.

Factors associated with the implementation of quality and safety requirements for cross-border care in acute myocardial infarction: Results from 315 hospitals in four countries

OBJECTIVE

Cross-border patients have specific quality and safety requirements for hospital care. Little is known to what extent hospitals meet these requirements. We aim to assess their current level, and the factors associated with their implementation.

METHODS

A cross-sectional survey of 315 hospitals and cardiology departments in the Czech Republic, France, Poland and Spain. Employing bi-variate statistics and logistic regression analysis, we assess quality and safety requirements for cross-border patients and their association with hospital characteristics, cross-border care arrangements, proximity to EU borders, the hospital's quality improvement system, and country.

RESULTS

Certain quality and safety requirements are frequently met (administrative support or informed consent using forms in various EU languages) while others are widely absent (case-managers, contacts to patients' general practitioners). Due to communication problems, it is often not possible to inform patients about their condition and treatment. Discharge summaries are rarely available in other than the vernacular languages, and medication upon discharge and arranging back-transfer occur occasionally only. Logistic regression analysis suggests a strong effect of country-level covariates (followed by type of hospital, hospital size and hospital's quality improvement system), but covariates are not consistently associated with higher rates of implementation. Hospitals with existing cross-border care collaboration do not differ substantially from hospitals without such arrangements.

CONCLUSION

Cross-border patients have specific quality and safety requirements that are not always met. Various factors are associated with these requirements; however, the trend is not systematic and the underlying mechanisms need to be studied further to inform policy decisions.

Investigating organizational quality improvement systems, patient empowerment, organizational culture, professional involvement and the quality of care in European hospitals: the 'Deepening our Understanding of Quality Improvement in Europe (DUQuE)' project

Background

Hospitals in European countries apply a wide range of quality improvement strategies. Knowledge of the effectiveness of these strategies, implemented as part of an overall hospital quality improvement system, is limited.

Methods/Design

We propose to study the relationships among organisational quality improvement systems, patient empowerment, organisational culture, professionals' involvement with the quality of hospital care, including clinical effectiveness, patient safety and patient involvement. We will employ a cross-sectional, multi-level study design in which patient-level measurements are nested in hospital departments, which are in turn nested in hospitals in different EU countries. Mixed methods will be used for data collection, measurement and analysis. Hospital/care pathway level constructs that will be assessed include external pressure, hospital governance, quality improvement system, patient empowerment in quality improvement, organisational culture and professional involvement. These constructs will be assessed using questionnaires. Patient-level constructs include clinical effectiveness, patient safety and patient involvement, and will be assessed using audit of patient records, routine data and patient surveys. For the assessment of hospital and pathway level constructs we will collect data from randomly selected hospitals in eight countries. For a sample of hospitals in each country we will carry out additional data collection at patient-level related to four conditions (stroke, acute myocardial infarction, hip fracture and delivery). In addition, structural components of quality improvement systems will be assessed using visits by experienced external assessors. Data analysis will include descriptive statistics and graphical representations and methods for data reduction, classification techniques and psychometric analysis, before moving to bi-variate and multivariate analysis. The latter will be conducted at hospital and multilevel. In addition, we will apply sophisticated methodological elements such as the use of causal diagrams, outcome modelling, double robust estimation and detailed sensitivity analysis or multiple bias analyses to assess the impact of the various sources of bias.

Discussion

Products of the project will include a catalogue of instruments and tools that can be used to build departmental or hospital quality and safety programme and an appraisal scheme to assess the maturity of the quality improvement system for use by hospitals and by purchasers to contract hospitals.

Cross-border care and healthcare quality improvement in Europe: the MARQuIS research project

Citizens are increasingly crossing borders within the European Union (EU). Europeans have always been free to travel to receive care abroad, but if they wished to benefit from their statutory social protection scheme, they were subject to their local or national legislation on social protection. This changed in 1991 with the European Court of Justice defining healthcare as a service, starting a debate on the right balance between different principles in European treaties: movement of persons, goods and services, versus the responsibility of member states to organise their healthcare systems. Simultaneously, cross-border cooperation has developed between member states.

In this context, patient mobility has become a relevant issue on the EU’s agenda. The EU funded a number of Scientific Support to Policies (SSP) activities within the Sixth Framework Programme, to provide the evidence needed by EU policy makers to deal with issues that European citizens face due to enhanced mobility in Europe. One SSP project “Methods of Assessing Response to Quality Improvement Strategies” (MARQuIS), focused on cross-border care. It aimed to assess the value of different quality strategies, and to provide information needed when: (1) countries contract care for patients moving across borders; and (2) individual hospitals review the design of their quality strategies. This article describes the European context related to healthcare, and its implications for cross-border healthcare in Europe. The background information demonstrates a need for further research and development in this area.