PLoS One. 2015 Nov 20;10(11):e0141157. doi: 10.1371/journal.pone.0141157.

Implementation of Departmental Quality Strategies Is Positively Associated with Clinical Practice: Results of a Multicenter Study in 73 Hospitals in 7 European Countries.

Sunol R1,2, Wagner C3,4, Arah OA5, Kristensen S6,7, Pfaff H8,9, Klazinga N10, Thompson CA11, Wang A5, DerSarkissian M5, Bartels P6,7, Michel P12, Groene O13;DUQuE Project Consortium.

Author information

• 1Avedis Donabedian Research Institute (FAD), Universitat Autonoma de Barcelona, Barcelona, Spain.
• 2Red de investigación en servicios de salud en enfermedades crónicas REDISSEC, Barcelona, Spain.
• 3NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands.
• 4Department of Public and Occupational Health,EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
• 5Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles (UCLA), Los Angeles, California, United States of America.
• 6Danish Clinical Registries, Aarhus, Denmark.
• 7Department of Health Science and Technology, Aalborg University, Aalborg, Denmark.
• 8Institute for Medical Sociology, Health Services Research and Rehabilitation Science, University of Cologne, Cologne, Germany.
• 9Center for Health Services Research Cologne, University of Cologne, Cologne, Germany.
• 10Department of Public Health, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
• 11Palo Alto Medical Foundation Research Institute (PAMFRI), Palo Alto, California, United States of America.
• 12Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France.
• 13Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom.

Abstract

BACKGROUND:

Given the amount of time and resources invested in implementing quality programs in hospitals, few studies have investigated their clinical impact and what strategies could be recommended to enhance its effectiveness.

OBJECTIVE:

To assess variations in clinical practice and explore associations with hospital- and department-level quality management systems.

DESIGN:

Multicenter, multilevel cross-sectional study.

SETTING AND PARTICIPANTS:

Seventy-three acute care hospitals with 276 departments managing acute myocardial infarction, deliveries, hip fracture, and stroke in seven countries.

INTERVENTION:

None.

MEASURES:

Predictor variables included 3 hospital- and 4 department-level quality measures. Six measures were collected through direct observation by an external surveyor and one was assessed through a questionnaire completed by hospital quality managers. Dependent variables included 24 clinical practice indicators based on case note reviews covering the 4 conditions (acute myocardial infarction, deliveries, hip fracture and stroke). A directed acyclic graph was used to encode relationships between predictors, outcomes, and covariates and to guide the choice of covariates to control for confounding.

RESULTS AND LIMITATIONS:

Data were provided on 9021 clinical records by 276 departments in 73 hospitals. There were substantial variations in compliance with the 24 clinical practice indicators. Weak associations were observed between hospital quality systems and 4 of the 24 indicators, but on analyzing department-level quality systems, strong associations were observed for 8 of the 11 indicators for acute myocardial infarction and stroke. Clinical indicators supported by higher levels of evidence were more frequently associated with quality systems and activities.

CONCLUSIONS:

There are significant gaps between recommended standards of care and clinical practice in a large sample of hospitals. Implementation of department-level quality strategies was significantly associated with good clinical practice. Further research should aim to develop clinically relevant quality standards for hospital departments, which appear to be more effective than generic hospital-wide quality systems.