Variation in care and outcome for fragile hip fracture patients: a European multicentre study benchmarking fulfilment of established quality indicators.

PURPOSE: Despite the availability of clinical guidelines for hip fracture patients, adherence to these guidelines is challenging, potentially resulting in suboptimal patient care. The goal of this study was (1) to evaluate and benchmark the adherence to recently established quality indicators (QIs), and (2) to study clinical outcomes, in fragile hip fracture patients from different European countries. METHODS: This observational, cross-sectional multicenter study was performed in 10 hospitals from 9 European countries including data of 298 consecutive patients. RESULTS: A large variation both within and between hospitals were seen regarding adherence to the individual QIs. QIs with the lowest overall adherence rates were the administration of systemic steroids (5.4%) and tranexamic acid (20.1%). Indicators with the highest adherence rates (above 95%) were pre-operative (99.3%) and post-operative haemoglobin level assessment (100%). The overall median time to surgery was 22.6 h (range 15.7-42.5 h). The median LOS was 9.0 days (range 5.0-19.0 days). The most common complications were delirium (23.2%) and postsurgical constipation (25.2%). CONCLUSION: The present study shows large variation in the care for fragile patients with hip fractures indicating room for improvement. Therefore, hospitals should invest in benchmarking and knowledge-sharing. Large quality improvement initiatives with longitudinal follow up of both process and outcome indicators should be initiated.

Effect on hospital incentive payments and quality performance of a hospital pay for performance (P4P) programme in Belgium.

BACKGROUND: Belgium initiated a hospital pay for performance (P4P) programme after a decade of fixed bonus budgets for "quality and safety contracts". This study examined the effect of P4P on hospital incentive payments, performance on quality measures, and the association between changes in quality performance and incentive payments over time. METHODS: The Belgian government provided information on fixed bonus budgets in 2013-2017 and hospital incentive payments as well as hospital performance on quality measures for the P4P programmes in 2018-2020. Descriptive analyses were conducted to map the financial repercussion between the two systems. A difference-in-difference analysis evaluated the association between quality indicator performance and received incentive payments over time. RESULTS: Data from 87 acute-care hospitals were analyzed. In the transition to a P4P programme, 29% of hospitals received lower incentive payments per bed. During the P4P years, quality performance scores increased yearly for 55% of hospitals and decreased yearly for 5% of hospitals. There was a significant larger drop in incentive payments for hospitals that scored above median with the start of the P4P programme. CONCLUSIONS: The transition from fixed bonus budgets for quality efforts to a new incentive payment in a P4P programme has led to more hospitals being financially impacted, although the effect is marginal given the small P4P budget. Quality indicators seem to improve over the years, but this does not correlate with an increase in reward per bed for all hospitals due to the closed nature of the budget.

The FlaQuM-Quickscan: A starting point to include primary care professionals' perspectives in the evaluation of hospital quality priorities.

INTRODUCTION: Today, primary care professionals' (PCPs) perspectives on hospital quality are unknown when evaluating hospital quality priorities. The aims of the present study were to identify key healthcare quality attributes from PCPs' perspective, to validate an instrument that measures PCPs' experiences of healthcare quality multidimensionally and to define hospital quality priorities based on PCPs' experiences. MATERIAL AND METHODS: Focus groups with PCPs were conducted to identify quality attributes through a qualitative in-depth analysis. A multicentre study of 18 hospitals was used to quantitatively assess construct, discriminant and criterion validity of the FlaQuM-Quickscan, an instrument that measures 'Healthcare quality for patients and kin' (part 1) and 'Healthcare quality for professionals' (part 2). To set quality priorities, scores on quality domains were analyzed descriptively and between-hospital variation was examined by evaluating differences in hospitals' mean scores on the quality domains using one-way Analysis of Variance (ANOVA). RESULTS: Identified key attributes largely corresponded with Lachman's multidimensional quality model. Including 'Communication' as a new quality domain was recommended. The FlaQuM-Quickscan was completed by 550 PCPs. Confirmatory factor analyses showed reasonable to good fit, except for the Root Mean Square Error of Approximation (RMSEA) in part 2. The 'Equity' domain scored the highest in parts 1 and 2. Domains 'Kin-centred care' and 'Accessibility and timeliness' scored the lowest in part 1 and 'Resilience' and 'Partnership and co-production' in part 2. Significant variation in hospitals' mean scores was observed for eleven domains in part 1 and sixteen domains in part 2. CONCLUSIONS: The results gained a better understanding of PCPs' perspective on quality. The FlaQuM-Quickscan is a valid instrument to measure PCPs' experiences of hospital quality. Identified priorities indicate that hospital management should focus on multifaceted quality strategies, including technical domains, person-and kin-centredness, core values and catalysts.

A quasi-experimental study on the effect of electrical aversion treatment on imposed mechanical restraint for severe self-injurious behavior.

Eight individuals with mental retardation and imposed mechanical restraints due to severe, life-threatening self-injurious behavior received electrical aversive treatment. Eight other individuals, who had been matched with the treatment group in terms of the degree of imposed mechanical restraint due to the above problem behavior, had not received electrical aversion treatment. A comparison of imposed mechanical restraint scores, as a measure of severity of self-injurious behavior, between both groups over a period of three years, revealed that electrical aversion treatment significantly reduces the degree of imposed mechanical restraint.

Resident behaviors and characteristics as determinants of quality of residential care: an observational study.

The effects of resident behaviors and resident characteristics on the quantity and quality of care they receive from direct-care staff was examined. Four hundred and fifty-two residents with severe and profound mental retardation and 416 direct care staff members were involved. Naturalistic observations were conducted on direct-care staff behavior, that is, staff-resident initiatives, staff affection, staff communicative behavior, on resident behaviors (i.e., maladaptive, stereotypic, and adaptive behavior, position, attending, and communicative behavior), and on resident characteristics (i.e., gender, age, ambulancy, sensory handicaps, and seizure disorder). By importance, residents' ambulancy/motoric skills, their communicative behavior, and attending behavior accounted for the greatest differences in the quality and quantity of the care they receive from direct-care staff. Given that certain resident characteristics can be ameliorated through training, residents themselves may control, to a certain extent, the care they receive from direct-care staff in residential facilities.

An inventory method for assessing the degree of restraint imposed by others.

An inventory for assessing the degree of mechanical restraint imposed by others to prevent individuals from inflicting physical injuries to themselves or to others, the Imposed Mechanical Restraint Inventory (IMRI), was developed. The inventory was administered to pairs of residential direct-care staff members to assess 113 individuals with mental retardation who showed self-injurious behavior while various sorts of mechanical restraint were imposed on them. The results indicate that the inventory showed acceptable levels of interobserver reliability, intraobserver reliability, and accuracy.

Long-term use of electrical aversion treatment with self-injurious behavior.

Twelve severely and profoundly mentally retarded individuals with life-threatening self-injurious behaviors were exposed to electrical aversion treatment using a remotely controlled device. Long-term effectiveness was assessed for periods ranging from 2 to 47 months for the 12 individuals, respectively. The degree of imposed physical restraint was used as the major dependent variable. With two individuals, the treatment failed to suppress self-injurious behavior. With seven individuals, however, suppression was nearly complete in that physical restraints were no longer necessary. With three individuals moderate effects were obtained, in that, although a substantial decrease of imposed physical restraint had been achieved, they still needed daily administrations of electrical aversive stimuli. The results are discussed in terms of the practical application of this procedure.

Occupational conditions of ward staff and quality of residential care for individuals with mental retardation.

Effects of occupational conditions of ward staff on the quality of residential care for individuals with mental retardation was assessed. Three questions were asked: (a) Does type of contract under which staff members are employed differentially affect their distribution of activities? (b) Does length of duty have an effect on their distribution of activities? (c) Does the number of staff members present on the living group influence quality of care? Over a 40-week period, data were collected on 30 ward staff members who were responsible for 39 residents with severe and profound mental retardation. Results show that staff differentially distributed their activities, especially with respect to organizational activities and the amount of custodial care, depending on the type of contract they were employed under and the number of consecutive days they worked. Number of staff present on the living group appeared to be a major factor in terms of distribution of activities. Implications for staff managers and administrators of residential facilities were discussed.

Analysis of ward staff initiatives towards mentally retarded residents: clues for intervention.

Traditionally, efforts to improve the quality of residential care for the mentally retarded are focused on modifying particular ward staff behaviours. Several studies suggest, however, that ward staff behaviours are, at least partly, controlled by certain resident behaviours. This study investigated the relationship between resident behaviour and resident directed initiatives by ward staff. Recording occurred on four living groups with 39 residents during 32 weeks on the average for each group. Pearson product-moment correlations revealed that residents' level of ambulation, waking state, looking behaviours, adaptive-, maladaptive- and stereotype behaviours were related to the amount and quality of resident directed initiatives. The results suggest that modifying certain resident behaviours might offer a fruitful strategy for improving residential care for mentally retarded individuals.

Effects of staff management on the quality of residential care for mentally retarded individuals.

Effects of two interventions on the quality of residential care for severely and profoundly mentally retarded individuals were assessed. Four living groups (N = 39 residents) were involved. Effects of assigning one extra staff member on staff's distribution of activities were evaluated as were effects of assigning extra tasks (including organizing daily staff meetings, providing feedback, and prompting self-recording) to the extra staff member on staff's distribution of activities, on staff's initiatives towards residents, and on residents' behavior. Results showed that assigning one extra staff member to living groups did not produce any change in staff's distribution of activities. Assigning extra tasks to the extra staff member, however, produced significant changes in the direction of more time spent on training residents. Also, several changes in staff's initiatives towards residents were recorded, whereas few changes in resident behavior were found.

Effects of a supervisory treatment package on staff-mentally retarded resident interactions.

Effects of scheduled activities vs. scheduled activities and supervision on staff-mentally retarded resident interactions were investigated. After baseline, scheduled activities that provided fixed times for resident training, custodial care, recreational activities, and organizational and house-keeping activities was instituted. Further, a supervision package was in effect consisting of (a) self-recording and public posting, (b) daily staff meetings, and (c) feedback and prompting. After a return to scheduled activities alone, the treatment was reinstated. Results showed that a supervision package (added to scheduled activities) produced a statistically significant decrease in the time that ward staff spent on custodial care as well as off-task and an increase in time engaged in training of residents. Follow-up measures taken while the treatment was still in effect affirmed the stability of the results.

[Use of aversive stimuli in serious behavior disorders of mentally disturbed patients]. / Anwendung von aversiven Reizen bei ernsten Verhaltensstörungen Geistigbehinderter.

This study refers to the effects of aversive stimuli in the treatment of very serious problem behaviours of severely and profoundly mentally retardates. The treatments were implemented in the natural environment of the ward. Methodological control of the effects of the treatment was applied. The practical aspects of long-term treatments with aversive stimuli in the natural environment are discussed.