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Relationships between the implementation of quality management strategies and clinical outcomes in European hospitals.

Suñol, R., Arah, O.A., Wagner, C., Groene, O. Relationships between the implementation of quality management strategies and clinical outcomes in European hospitals.: , 2013. 1954 p. Abstract. In: Abstractbook 15 Minute Oral Presentations. International Society for Quality in Health Care (ISQUA) 30th International Conference 'Quality and safety in population health and healthcare'. Edinburgh: ISQUA, 2013.
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Objectives: Considerable resources are spent on implementing hospital and departmental quality management strategies. Yet, the evidence on the factors associated with the uptake of hospitals of quality management and the impact of quality management systems on clinical outcomes is limited. We investigated associations between hospital level quality management systems and the implementation of quality strategies at department level and the effect of both on clinical outcomes. Methods: We employed a cross-sectional, multi-level study design that randomly recruited hospitals and their patients from the Czech Republic, France, Germany, Poland, Portugal, Spain, and Turkey between May 2011 and January 2012. We developed a set of algorithms to measure clinical indicators for the four conditions (acute myocardial infarction, Stroke, hip fracture and deliveries) based on their level of evidence, and extracted data from patient charts using standardised methods. Subsequently, we designed composite indicators to measure clinical effectiveness in the four conditions. As explanatory variables we used measures of the maturity of quality management systems at hospital and departmental level. We used directed acyclic graphs to represent and guide the modelling of the complex relationships between explanatory and outcome variables and fitted multivariate linear and logistic mixed models with random intercept by hospital, and adjusted for fixed effects at the country and hospital level. Results: Overall, 9021 patients admitted to 74 hospitals contributed data to the study (acute myocardial infarction n=2019, hip fracture n=2288, deliveries n=2337, stroke n=2377). The associational analysis found weak positive but mostly uncertain relationships between hospital-wide quality management strategies and measures of clinical
effectiveness in the four departments. However, at departmental level we found strong associations between maturity of quality management and measures of clinical effectiveness for acute myocardial infarction (odds ratios from 1.4-2.1), stroke (1.4-16.8) and hip fracture (1.3 – 3.5), and deliveries (avoidance of complications: 0.7). Specialised expertise and responsibility, evidence-based organisation of the pathway and implementation of patient safety strategies were strong predictors for clinical effectiveness. Conclusion: The weak effect of hospital level quality management on clinical outcomes can be expected given that hospital level quality management is more distal to clinical care delivery. As expected, given the proximity to care delivery, implementation of quality management strategies at the departmental level is strongly associated with better clinical outcomes.