Measuring in-hospital quality multidimensionally by integrating patients', kin's and healthcare professionals' perspectives: development and validation of the FlaQuM-Quickscan.

BACKGROUND: Measuring quality is essential to drive improvement initiatives in hospitals. An instrument that measures healthcare quality multidimensionally and integrates patients', kin's and professionals' perspectives is lacking. We aimed to develop and validate an instrument to measure healthcare quality multidimensionally from a multistakeholder perspective. METHODS: A multi-method approach started by establishing content and face validity, followed by a multi-centre study in 17 Flemish (Belgian) hospitals to assess construct validity through confirmatory factor analysis, criterion validity through determining Pearson's correlations and reliability through Cronbach's alpha measurement. The instrument FlaQuM-Quickscan measures 'Healthcare quality for patients and kin' (part 1) and 'Healthcare quality for professionals' (part 2). This bipartite instrument mirrors 15 quality items and 3 general items (the overall quality score, recommendation score and intention-to-stay score). A process evaluation was organised to identify effective strategies in instrument distribution by conducting semi-structured interviews with quality managers. RESULTS: By involving experts in the development of quality items and through pilot testing by a multi-stakeholder group, the content and face validity of instrument items was ensured. In total, 13,615 respondents (5,891 Patients/kin and 7,724 Professionals) completed the FlaQuM-Quickscan. Confirmatory factor analyses showed good to very good fit and correlations supported the associations between the quality items and general items for both instrument parts. Cronbach's alphas supported the internal consistency. The process evaluation revealed that supportive technical structures and approaching respondents individually were effective strategies to distribute the instrument. CONCLUSIONS: The FlaQuM-Quickscan is a valid instrument to measure healthcare quality experiences multidimensionally from an integrated multistakeholder perspective. This new instrument offers unique and detailed data to design sustainable quality management systems in hospitals. Based on these data, hospital management and policymakers can set quality priorities for patients', kin's and professionals' care. Future research should investigate the transferability to other healthcare systems and examine between-stakeholders and between-hospitals variation.

Sustainable quality management in hospitals: The experiences of healthcare quality managers.

BACKGROUND: Quality management systems are essential in hospitals, but evidence shows a real literature gap on the sustainable implementation of quality. PURPOSE: This study aimed to explore and identify enablers towards sustainable quality management in hospitals. Research design and Study Sample: Interviews were conducted with 23 healthcare quality managers from 20 hospitals. Data collection and/or Analysis: Data collection and analysis were conducted simultaneously by using the Qualitative Analysis Guide of Leuven and following the COREQ Guidelines. Thematic analysis from interview transcripts was performed in NVivo 12. RESULTS: The results reveal two categories: (1) quality in the organisation's DNA and (2) quality in the professional's DNA. The first category consists of: bottom-up and top-down management, the organisation-wide integration of quality and an organisational culture shift. The second one consists of: quality awareness, understanding the added value, the encouragement and engagement, the accountability and ownership for quality. Moving towards sustainable quality management systems in hospitals requires a good interaction between a bottom-up approach and leadership to ensure continuous support from healthcare stakeholders. CONCLUSIONS: This study contributes to existing conceptual and theoretical foundations with practical insights into sustainable quality management. The findings can guide quality departments and hospital management to regain professionals' commitment to quality and to establish a sustainable quality management system.

Patients' and kin's perspective on healthcare quality compared to Lachman's multidimensional quality model: Focus group interviews.

OBJECTIVES: To identify key attributes of healthcare quality relevant to patients and kin and to compare them to Lachman's multidimensional quality model. METHODS: Four focus groups with patients and kin were conducted using a semi-structured interview guide and a purposive sampling method. Classical content analysis and constant comparison method were used to focus data analysis on individual and group level. RESULTS: Communication with patients, kin and professionals emerged as a new dimension from interview transcripts. Other identified key attributes largely corresponded with Lachman's multidimensional quality model. They were mainly classified in dimensions: 'Partnership and Co-Production', 'Dignity and Respect' and 'Effectiveness'. Technical quality dimensions were linked to organisational aspects of care in terms of staffing levels and time. The dimension 'Eco-friendly' was not addressed by patients or kin. CONCLUSIONS: The results enhance the comprehension of healthcare quality and contribute to its academic understanding by validating Lachman's multidimensional quality model from patients' and kin's perspective. The model robustness is increased by including communication as a quality dimension surrounding technical domains and core values. PRACTICE IMPLICATIONS: The key attributes can serve as a holistic framework for healthcare organisations to design their quality management system. An instrument can be developed to measure key attributes.

A co-creation roadmap towards sustainable quality of care: A multi-method study.

OBJECTIVE: Hospitals demonstrated increased efforts into quality improvement over the past years. Their growing commitment to quality combined with a heterogeneity in perceptions among healthcare stakeholders cause concerns on the sustainable incorporation of quality into the daily workflow. Questions are raised on the drivers for a sustainable hospital quality policy. We aimed to identify drivers and incorporate them into a new, unique roadmap towards sustainable quality of care in hospitals. DESIGN: A multi-method design guided by an eight-phase approach to develop a conceptual framework consists of multiple, iterative phases of data collection, synthesis and validation. Starting with a narrative review followed by a qualitative in-depth analysis and including feedback of national and international healthcare stakeholders. SETTING: Hospitals. RESULTS: The narrative review included 59 relevant papers focusing on quality improvement and the sustainability of these improved quality results. By integrating, synthesising and resynthesizing concepts during thematic and content analysis, the narrative review evolved to an integrated, co-creation roadmap. The Flanders Quality Model (FlaQuM) is presented as a driver diagram that features six primary drivers for a sustainable quality policy: (1) Quality Design and Planning, (2) Quality Control, (3) Quality Improvement, (4) Quality Leadership, (5) Quality Culture and (6) Quality Context. Six primary drivers are described in 19 building blocks (secondary drivers) and 104 evidence-based action fields. CONCLUSIONS: The framework suggests that a manageable number of drivers, building blocks and action fields may support the sustainable incorporation of quality into the daily workflow. Therefore, FlaQuM can serve as a useful roadmap for future sustainable quality policies in hospitals and for future empirical and theoretical work in sustainable quality management.

Altered Skeletal Muscle Fatty Acid Handling in Subjects with Impaired Glucose Tolerance as Compared to Impaired Fasting Glucose.

Altered skeletal muscle fatty acid (FA) metabolism contributes to insulin resistance. Here, we compared skeletal muscle FA handling between subjects with impaired fasting glucose (IFG; n = 12 (7 males)) and impaired glucose tolerance (IGT; n = 14 (7 males)) by measuring arterio-venous concentration differences across forearm muscle. [²H2]-palmitate was infused intravenously, labeling circulating endogenous triacylglycerol (TAG) and free fatty acids (FFA), whereas [U-(13)C]-palmitate was incorporated in a high-fat mixed-meal, labeling chylomicron-TAG. Skeletal muscle biopsies were taken to determine muscle TAG, diacylglycerol (DAG), FFA, and phospholipid content, their fractional synthetic rate (FSR) and degree of saturation, and gene expression. Insulin sensitivity was assessed using a hyperinsulinemic-euglycemic clamp. Net skeletal muscle glucose uptake was lower (p = 0.018) and peripheral insulin sensitivity tended to be reduced (p = 0.064) in IGT as compared to IFG subjects. Furthermore, IGT showed higher skeletal muscle extraction of VLDL-TAG (p = 0.043), higher muscle TAG content (p = 0.025), higher saturation of FFA (p = 0.004), lower saturation of TAG (p = 0.017) and a tendency towards a lower TAG FSR (p = 0.073) and a lower saturation of DAG (p = 0.059) versus IFG individuals. Muscle oxidative gene expression was lower in IGT subjects. In conclusion, increased liver-derived TAG extraction and reduced lipid turnover of saturated FA, rather than DAG content, in skeletal muscle accompany the more pronounced insulin resistance in IGT versus IFG subjects.

Impact of dietary fat quantity and quality on skeletal muscle fatty acid metabolism in subjects with the metabolic syndrome.

Insulin resistance is characterized by disturbances in lipid metabolism in skeletal muscle. Our aim was to investigate whether gene expression and fatty acid (FA) profile of skeletal muscle lipids are affected by diets differing in fat quantity and quality in subjects with the metabolic syndrome (MetS) and varying degrees of insulin sensitivity. 84 subjects (age 57.3±0.9 y, BMI 30.9±0.4 kg/m(2), 42 M/42 F) were randomly assigned to one of four iso-energetic diets: high-SFA (HSFA); high-MUFA (HMUFA) or two low-fat, high-complex carbohydrate diets, supplemented with 1.24 g/day of long-chain n-3 PUFA (LFHCCn-3) or control oil (LFHCC) for 12 weeks. In a subgroup of men (n=26), muscle TAG, DAG, FFA and phospholipid contents were determined including their fractional synthetic rate (FSR) and FA composition at fasting and 4h after consumption of a high-fat mixed-meal, both pre- and post-intervention. Genes involved in lipogenesis were downregulated after HMUFA (mean fold change -1.3) and after LFHCCn-3 (fold change -1.7) in insulin resistant subjects (< median of (S(I))), whereas in insulin sensitive subjects (>median of insulin sensitivity) the opposite effect was shown (fold change +1.6 for both diets). HMUFA diet tended to decrease FSR in TAG (P=.055) and DAG (P=.066), whereas the LFHCCn-3 diet reduced TAG content (P=.032). In conclusion, HMUFA and LFHCCn-3 diets reduced the expression of the lipogenic genes in skeletal muscle of insulin resistant subjects, whilst HMUFA reduced the fractional synthesis rate of DAG and TAG and LFHCC n-3 the TAG content. Our data indicate that these diets may reduce muscle fat accumulation by affecting the balance between FA synthesis, storage and oxidation.

PUFAs acutely affect triacylglycerol-derived skeletal muscle fatty acid uptake and increase postprandial insulin sensitivity.

BACKGROUND: Dietary fat quality may influence skeletal muscle lipid processing and fat accumulation, thereby modulating insulin sensitivity. OBJECTIVE: The objective was to examine the acute effects of meals with various fatty acid (FA) compositions on skeletal muscle FA processing and postprandial insulin sensitivity in obese, insulin-resistant men. DESIGN: In a single-blind, randomized, crossover study, 10 insulin-resistant men consumed 3 high-fat mixed meals (2.6 MJ), which were high in SFAs, MUFAs, or PUFAs. Fasting and postprandial skeletal muscle FA processing was examined by measuring differences in arteriovenous concentrations across the forearm muscle. [²H2]Palmitate was infused intravenously to label endogenous triacylglycerol and FFAs in the circulation, and [U-¹³C]palmitate was added to the meal to label chylomicron-triacylglycerol. Skeletal muscle biopsy samples were taken to assess intramuscular lipid metabolism and gene expression. RESULTS: Insulin and glucose responses (AUC) after the SFA meal were significantly higher than those after the PUFA meal (P = 0.006 and 0.033, respectively). Uptake of triacylglycerol-derived FAs was lower in the postprandial phase after the PUFA meal than after the other meals (AUC60₋240; P = 0.02). The fractional synthetic rate of the triacylglycerol, diacylglycerol, and phospholipid pool was higher after the MUFA meal than after the SFA meal. PUFA induced less transcriptional downregulation of oxidative pathways than did the other meals. CONCLUSION: PUFAs reduced triacylglycerol-derived skeletal muscle FA uptake, which was accompanied by higher postprandial insulin sensitivity, a more transcriptional oxidative phenotype, and altered intramyocellular lipid partitioning and may therefore be protective against the development of insulin resistance.

Transcriptional metabolic inflexibility in skeletal muscle among individuals with increasing insulin resistance.

Disturbances in skeletal muscle lipid metabolism may play an important role in development of insulin resistance (IR). The aim was to investigate transcriptional control of skeletal muscle fatty acid (FA) metabolism in individuals with the metabolic syndrome (MetS) with varying degrees of insulin sensitivity (S(I)). 122 individuals with MetS (NCEP-ATP III criteria) at age 35-70 years, BMI 27-38 kg/m(2) were studied (subgroup EU-LIPGENE study). Individuals were divided into quartiles of S(I) measured during a frequently sampled insulin modified intravenous glucose tolerance test. Skeletal muscle normalized mRNA expression levels of genes important in skeletal muscle FA handling were analyzed with quantitative real-time PCR. The expression of sterol regulatory element binding protein 1c (SREBP1c), acetyl-CoA carboxylase 2 (ACC2), diacylglycerol acyltransferase (DGAT1), and nuclear respiration factor (NRF) was higher in the lowest two quartiles of S(I) (<50th) compared with the highest two quartiles of S(I) (>50th). Interestingly, peroxisome proliferator-activated receptor coactivator 1α (PGC1α), peroxisome proliferator-activated receptor α (PPARα), and muscle carnitine palmitoyl transferase 1b (mCPT1), important for oxidative metabolism, showed a complex mRNA expression profile; levels were lower in both the most "insulin sensitive" (IS) as well as the most "IR" individuals. Lipoprotein lipase (LPL) mRNA was reduced in the lowest quartile of S(I). Enhanced gene expression of SREBP1c and ACC2 in the IR state suggests a tendency towards FA storage rather than oxidation. From the lower expression of PGC1α, PPARα, and mCPT1 in both the most "IS" as well as the most "IR" individuals, it may be speculated that "IS" subjects do not need to upregulate these genes to have a normal FA oxidation, whereas the most "IR" individuals are inflexible in upregulating these genes.

Skeletal muscle fatty acid handling in insulin resistant men.

Disturbances in skeletal muscle lipid metabolism may precede or contribute to the development of whole body insulin resistance. In this study, we examined fasting and postprandial skeletal muscle fatty acid (FA) handling in insulin resistant (IR) men. Thirty men with the metabolic syndrome (MetS) (National Cholesterol Education Program-Adult Treatment Panel III) were included in this sub-study to the LIPGENE study, and divided in two groups (IR and control) based on the median of insulin sensitivity (S(I) = 2.06 (mU/l(-1))·min(-1)·10(-4)). Fasting and postprandial skeletal muscle FA handling were examined by combining the forearm balance technique with stable isotopes of palmitate. [(2)H(2)]-palmitate was infused intravenously to label endogenous triacylglycerol (TAG) and free FAs (FFAs) in the circulation and [U-(13)C]-palmitate was incorporated in a high-fat mixed meal (2.6 MJ, 61 E% fat) to label chylomicron-TAG. Muscle biopsies were taken to determine muscle TAG, diacylglycerol (DAG), FFA, and phospholipid (PL) content, their fractional synthetic rates (FSRs) and degree of saturation, as well as messenger RNA (mRNA) expression of genes involved in lipid metabolism. In the first 2 h after meal consumption, forearm muscle [(2)H(2)]-labeled TAG extraction was higher in IR vs. control (P = 0.05). Fasting percentage saturation of muscle DAG was higher in IR vs. control (P = 0.016). No differences were observed for intramuscular TAG, DAG, FFA, and PL content, FSR, and muscle mRNA expression. In conclusion, increased muscle (hepatically derived) TAG extraction during postprandial conditions and increased saturation of intramuscular DAG are associated with insulin resistance, suggesting that disturbances in skeletal muscle FA handling could play a role in the development of whole body insulin resistance and type 2 diabetes.

Increased hepatic myeloperoxidase activity in obese subjects with nonalcoholic steatohepatitis.

Inflammation and oxidative stress are considered critical factors in the progression of nonalcoholic fatty liver disease. Myeloperoxidase (MPO) is an important neutrophil enzyme that can generate aggressive oxidants; therefore, we studied the association between MPO and nonalcoholic fatty liver disease. The distribution of inflammatory cells containing MPO in liver biopsies of 40 severely obese subjects with either nonalcoholic steatohepatitis (NASH) (n = 22) or simple steatosis (n = 18) was investigated by immunohistochemistry. MPO-derived oxidative protein modifications were identified by immunohistochemistry and correlated to hepatic gene expression of CXC chemokines and M1/M2 macrophage markers as determined by quantitative PCR. MPO plasma levels were determined by ELISA. The number of hepatic neutrophils and MPO-positive Kupffer cells was increased in NASH and was accompanied by accumulation of hypochlorite-modified and nitrated proteins, which can be generated by the MPO-H2O2 system. Liver CXC chemokine expression was higher in patients with accumulation of MPO-mediated oxidation products and correlated with hepatic neutrophil sequestration. Plasma MPO levels were elevated in NASH patients. Interestingly, neutrophils frequently surrounded steatotic hepatocytes, resembling the crown-like structures found in obese adipose tissue. Furthermore, hepatic M2 macrophage marker gene expression was increased in NASH. Our data indicate that accumulation of MPO-mediated oxidation products, partly derived from Kupffer cell MPO, is associated with induction of CXC chemokines and hepatic neutrophil infiltration and may contribute to the development of NASH.