The effect of certification and accreditation on quality management in 4 clinical services in 73 European hospitals.

OBJECTIVE: To investigate the relationship between ISO 9001 certification, healthcare accreditation and quality management in European hospitals. DESIGN: A mixed method multi-level cross-sectional design in seven countries. External teams assessed clinical services on the use of quality management systems, illustrated by four clinical pathways. SETTING AND PARTICIPANTS: Seventy-three acute care hospitals with a total of 291 services managing acute myocardial infarction (AMI), hip fracture, stroke and obstetric deliveries, in Czech Republic, France, Germany, Poland, Portugal, Spain and Turkey. MAIN OUTCOME MEASURE: Four composite measures of quality and safety [specialized expertise and responsibility (SER), evidence-based organization of pathways (EBOP), patient safety strategies (PSS) and clinical review (CR)] applied to four pathways. RESULTS: Accreditation in isolation showed benefits in AMI and stroke more than in deliveries and hip fracture; the greatest significant association was with CR in stroke. Certification in isolation showed little benefit in AMI but had more positive association with the other conditions; greatest significant association was in PSS with stroke. The combination of accreditation and certification showed least benefit in EBOP, but significant benefits in SER (AMI), in PSS (AMI, hip fracture and stroke) and in CR (AMI and stroke). CONCLUSIONS: Accreditation and certification are positively associated with clinical leadership, systems for patient safety and clinical review, but not with clinical practice. Both systems promote structures and processes, which support patient safety and clinical organization but have limited effect on the delivery of evidence-based patient care. Further analysis of DUQuE data will explore the association of certification and accreditation with clinical outcomes.

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.

Standardization in patient safety: the WHO High 5s project.

QUALITY PROBLEM: Despite its success in other industries, process standardization in health care has been slow to gain traction or to demonstrate a positive impact on the safety of care. INTERVENTION: The High 5s project is a global patient safety initiative of the World Health Organization (WHO) to facilitate the development, implementation and evaluation of Standard Operating Protocols (SOPs) within a global learning community to achieve measurable, significant and sustainable reductions in challenging patient safety problems. GOALS: The project seeks to answer two questions: (i) Is it feasible to implement standardized health care processes in individual hospitals, among multiple hospitals within individual countries and across country boundaries? (ii) If so, what is the impact of standardization on the safety problems that the project is targeting? METHOD: The two key areas in which the High 5s project is innovative are its use of process standardization both in hospitals within a country and in multiple participating countries, and its carefully designed multi-pronged approach to evaluation. STATUS: Three SOPs-correct surgery, medication reconciliation, concentrated injectable medicines-have been developed and are being implemented and evaluated in multiple hospitals in seven participating countries. Nearly 5 years into the implementation, it is clear that this is just the beginning of what can be seen as an exercise in behavior management, asking whether health care workers can adapt their behaviors and environments to standardize care processes in widely varying hospital settings.

Asymptotic turbulent friction in 2D rough-walled flows.

The friction f is the property of wall-bounded flows that sets the pumping cost of a pipeline, the draining capacity of a river, and other variables of practical relevance. For highly turbulent rough-walled pipe flows, f depends solely on the roughness length scale r, and the f - r relation may be expressed by the Strickler empirical scaling f ∝ r 1/3 Here, we show experimentally that for soap film flows that are the two-dimensional (2D) equivalent of highly turbulent rough-walled pipe flows, f ∝ r and the f - r relation is not the same in 2D as in 3D. Our findings are beyond the purview of the standard theory of friction but consistent with a competing theory in which f is linked to the turbulent spectrum via the spectral exponent α: In 3D, α = 5/3 and the theory yields f ∝ r 1/3; in 2D, α = 3 and the theory yields f ∝ r.

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.

Towards hospital standardization in Europe.

QUALITY PROBLEM: There is no simple tool to assess compliance with common national and European directives, guidance and professional advice on the management of healthcare institutions. Despite evidence of unacceptable variations in the protection of patient and staff safety little attention has been given to harmonizing the way services are organized and managed. INITIAL ASSESSMENT: Existing systems which define organizational standards, or assess compliance with them, are not in a position to extend this activity into or across national borders in Europe. Certification, accreditation and licensing programmes are too variable to provide a common basis for consistent assessment. Consensual standards would inevitably be minimal if they were to achieve acceptance by all or a majority of member state governments; they would not be standards for excellence or help the majority of organizations to improve performance. PROPOSED SOLUTION: This paper proposes the development of a framework and measurement tool, initially for hospitals, which could be used for self-assessment or peer review to demonstrate compliance with European legislation, guidance and public expectations without infringing national responsibilities. A common code of management practice could be developed through a process similar to that adopted for clinical practice guidelines by the European commission-funded project on appraisal of guidelines research and evaluation. CONCLUSIONS: In practice, the legal relationships between member states and intergovernmental organizations inhibit the harmonization of management practice across-borders. Faster progress to higher levels of performance would be achieved by voluntary, non-regulatory cooperation of enthusiasts to define, measure and improve the quality of healthcare in European hospitals.

Viscosimeter on a microfluidic chip.

In this work, a viscosimeter implemented on a microfluidic chip is presented. The physical principle of this system is to use laminar parallel flows in a microfluidic channel. The fluid to be studied flows side by side with a reference fluid of known viscosity. By using optical microscopy, the shape of the interface between both fluids can be determined. Knowing the flow rates of the two liquids and the geometrical features of the channel, the mean shear rate sustained by the fluid and its viscosity can thus be computed. Accurate and precise measurements of the viscosity as a function of the shear rate can be made using less than 300 microL of fluid. Several complex fluids are tested with viscosities ranging from 10(-)(3) to 70 Pa.s.