social capital and quality management systems in european hospitals 1 holger pfaff 1, onyebuchi a....

Social capital and quality management systems in European hospitals

1

Holger Pfaff 1, Onyebuchi A. Arah2, Oliver Ommen1, Caroline A. Thompson2, Maral DerSarkissian2, Russell Mannion3, Cordula Wagner4, Rosa Sunol5, and Antje Hammer1 on

behalf of the DUQuE Project Consortium*

1 Institute for Medical Sociology, Health Services Research and Rehabilitation Science, Faculty of Human Science and Faculty of Medicine; University of Cologne; Germany; 2 Department of Epidemiology; UCLA Fielding School of Public

Health; Los Angeles; USA; 3 Health Services Management Centre, University of Birmingham; United Kingdom; 4 NIVEL, Nederlands instituut voor onderzoek van de gezondheidszorg; Utrecht; The Netherlands; 5 Avedis Donabedian Research

Institute Universitat Autònoma de Barcelona; Spain

4th annual International Improvement Science and Research Symposium, Paris 2014

April 8th 2014

University of CologneFaculty of Human ScienceFaculty of Medicine

Institute forMedical Sociology, Health Services Research and Rehabilitation Science

Overall objective of the DUQuE-study

• To test whether organisational quality improvement and culture, professionals' involvement, and patient empowerment are associated with the quality of care in European hospitals (as measured in terms of clinical effectiveness, patient safety and patient involvement)

April 8th 2014Paris 2014 | Prof. Dr. Holger Pfaff 2



Background

• Strategic leadership:• Important organizational capability • Essential for quality improvement in hospital settings

• Quality of leadership • Depends crucially on common set of shared values and• Relationships of mutual trust among hospital management board members

According to the concept of social capital, these are essential requirements for successful cooperation and coordination within groups




Hypothesis

• Assumption:• Social capital within hospital management boards is an important generic

factor in the development of effective organizational systems for overseeing health care quality

• Hypothesis:

• The degree of social capital within the hospital management boards is associated with the effectiveness and maturity of quality management system in European hospitals




Methods - Setting, study design and population

• EU-project “Deepening our understanding of quality improvement in Europe (DUQuE)” funded by the EU 7th Research Framework Program: www.duque.eu

• Purpose: To test whether organisational quality improvement and culture, professionals' involvement, and patient empowerment are associated with the quality of care in European hospitals (as measured in terms of clinical effectiveness, patient safety and patient involvement)

Cross-sectional study Multi-method approach to data collection and measurements Approached 210 randomly selected hospitals in 7 European countries Data collected at hospital, departmental, professional and patient levels


http://www.duque.eu/



Countries participating in the field test

Partner (blue)

Participating countries (orange)

Criteria for Countries:

• They cover different European health

systems and social variation

• They are big enough to have sufficient

number of hospitals for the sampling

strategy

Criteria for Hospitals:

• Min 130 beds

• Covers at least 3 out of 4 conditions

(AMI, STR, DEL, HIP)




Outcome measure - Quality Management System (QMSIH)

• Newly developed multi-item and multi-dimensional instrument (Wagner et.al 2014)

• Consists of 46 items and 9 sub scales measuring the degree of implementation of quality management systems in hospitals

• Items were incorporated into the QM’s questionnaires • Answers were given on 4-point Likert scales

• ‘not available’ (1), to ‘fully implemented in (nearly) all relevant inpatient units’ (4)

• ‘strongly disagree’ (1) to ‘strongly agree’ (4) • ‘not available’ (1), to ‘published annually over the past years’ (4)

• QMSIH-score ranges from 0 to 27 points (Composite score over the 9 subscales)




QMSIH-Sub-dimensions and example items

Subscales Example ItemsQuality Policy Documents To what extent do the following documents exist in your hospital?

•Written description of a formally agreed quality policy in your hospital?Quality Monitoring by the board

To what extent do you agree with the statements for your hospital?•The hospital (management) board has established formal roles for quality leadership (visible in organizational chart).

Training of professionals To what extent do you agree with the statements for your hospital?•Care professionals are trained by the organization to do their job.

Formal protocols for infection control

Has your hospital implemented the following formal protocols?• Up-to-date hospital protocol for prevention of central line infection

Formal protocols for medication and patient handling

Has your hospital implemented the following formal protocols?•Up-to-date hospital protocol for medication reconciliation

Analysing performance of care processes

To what extent do the following activities take place systematically in your hospital?•Risk management (a systematic process of identifying, assessing and taking action to prevent or manage clinical events in the care process)

Analysing performance of professionals

To what extent do the following activities take place systematically in your hospital?•Monitoring individual nurses’ performance (nurses undergo systematic and documented performance assessments)

Analysing feedback patient experiences

To what extent do the following activities take place systematically in your hospital?•Complaints analysis (periodical evaluation of complaints is used to implement improvements)

Evaluate results What data are used in your hospital by (general) managers to evaluate and adjust care processes?•Data used from incident reporting system to evaluate and adjust care processes




Outcome measure – QMSIH Properties

• Psychometric analyses found satisfactory Cronbach’s alpha (ranging from 0.72 to 0.82) for eight of the nine scales

• A low Cronbach’s alpha (0.48) for the scale ‘analysing feedback & patient experiences’

(Wagner et.al 2014)




Exposure: Social Capital (SCB)

• Measure two key features of social capital: • 1) common values and• 2) perceived mutual trust in groups

• Variable consisted of six items • Validated scaled (Cronbach’s alpha of 0.83) (Pfaff et al. 2005)

• Items were incorporated into the CEO’s questionnaires • Answers were given on a 4-point Likert scale ranging from ‘strongly disagree’ (1)

to ‘strongly agree’ (4)


Social capital – example items Within our Hospital (management) Board there is unity and agreement. Within our Hospital (management) Board we trust one another. Within our Hospital (management) Board the work climate is good.



Covariates

• Dominant organizational culture type• Competing values framework (CVF) (Shortell 1995)

• Answers from CEO, CMO and HRN• 5 dimensions, each consisting of 4 statements reflecting four different types of

organizational culture (clan or group culture; open or developmental culture; hierarchical culture; rational or market culture)

• Number of hospital board members

• Hospital characteristics• Ownership• Teaching status• Nr. of beds




Analyses

• Descriptive statistics• Multilevel linear regression

• 1: multivariate linear mixed model with random intercept by country, adjusted for fixed effects at the hospital (number of beds, teaching status, and ownership)

• 2. further adjustment for number of hospital board members and organizational culture types




Descriptive results

• 188 (= 89.5%) hospitals participated in the DUQuE-study. • The final dataset used for this analysis contains only hospitals with complete

records on all variables used in the regression model


Characteristic N %Hospitals used in analysis 138 (100)Teaching Hospitals 57 (41.3)Public Hospitals 114 (82.6)

Approximate number of beds in hospital

<200 14 (10.1)

200-500 61 (44.2)

501-1000 42 (30.4)

>1000 21 (15.2)



Descriptive statistics (N=138)

Mean (SD)Exposure Variable (Scale)

Social Capital Board (1-4) 3.3 (0.6)Outcome Variable (Scale)

QMS-Index (0-27) 19.2 (4.5)Covariates

Number of Board Members (continuous) 7.7 (4.2)Organizational Culture, N (%)1

Clan 46 (33.3)Open 35 (25.3)Hierarchy 21 (15.2)Rational 36 (26.0)


1These are the number of hospitals assigned to each organizational type (based on dominant culture type). Of the hospitals used in this analysis, 4 are missing the categorized organizational culture variable as there was a tie in the mean scores for each of the culture types (i.e., no clear dominant type).



Multivariate linear mixed model on (Dependent: QMSIH)

Model 1 (N=142)1 Model 2 (N=142)2

b (SE) P-value b (SE) P-valueSocial Capital (Board) 1.42 (0.62) 0.0235 1.41 (0.64) 0.0294

Number of Board Members

-- -- -0.08 (0.12) 0.5214

Organizational Culture Type

Clan -- -- -0.45 (1.04) 0.6671

Open -- -- 0.25 (1.13) 0.8248

Hierarchy -- -- 0.05 (1.28) 0.9683

Rational -- (ref)

ICC 0.191 0.203


Regression coefficient estimates (standard errors) from random-intercept linear mixed models for the effect of hospital-level social capital on quality management systems index (QMSI); 1Multivariate linear mixed model adjusted for fixed effects at the hospital level (number of beds, teaching status, and ownership). 2 Additionally adjusted for number of board members (continuous), and organizational culture (categorical variable).



Strengths and limitations

Strengths• Cross national, multi-method approach to data collection and measurements• Use of validated scales as much as possible• Different sources of data for exposure and outcome variable to decrease the risk

of common method variance bias• High response rates in the professional questionnaires (about 90% from

expected)

Limitations• Cross-sectional design • Use of key informants• Missing values in the set of variables used in the regression model• Uncontrolled confounding and reverse causation cannot be completely ruled out• Hospital participation with countries




Conclusions and practical implications

• Results suggest a positive influence of social capital in the hospital (management) board on quality management systems in European hospitals

• Social capital of board matters for quality improvement!

Strengthening the existing social capital in hospital management boards• personal development • further education teamwork within the hospital management board

Further research • Longitudinal studies that may reveal causal relationships • Stratified, qualitative follow-up studies to analyze the influence of social

capital in hospital management and to develop strategies for an effective quality management system




The DUQuE Project consortium comprises• Klazinga N, Kringos DS, MJMH Lombarts and Plochg T (Academic Medical Centre-AMC,

University of Amsterdam, THE NETHERLANDS); Lopez MA, Secanell M, Sunol R and Vallejo P (Avedis Donabedian University Institute-Universitat Autónoma de Barcelona FAD. Red de investigación en servicios de salud en enfermedades crónicas REDISSEC, SPAIN); Bartels P and Kristensen S (Central Denmark Region & Center for Healthcare Improvements, Aalborg University, DENMARK); Michel P and Saillour-Glenisson F (Comité de la Coordination de l'Evaluation Clinique et de la Qualité en Aquitaine, FRANCE) ; Vlcek F (Czech Accreditation Committee, CZECH REPUBLIC); Car M, Jones S and Klaus E (Dr Foster Intelligence-DFI, UK); Bottaro S and Garel P (European Hospital and Healthcare Federation-HOPE, BELGIUM); Saluvan M (Hacettepe University, TURKEY); Bruneau C and Depaigne-Loth A (Haute Autorité de la Santé-HAS, FRANCE); Shaw C (University of New South Wales, Australia); Hammer A, Ommen O and Pfaff H (Institute of Medical Sociology, Health Services Research and Rehabilitation Science, University of Cologne-IMVR, GERMANY); Groene O (London School of Hygiene and Tropical Medicine, UK); Botje D and Wagner C (The Netherlands Institute for Health Services Research-NIVEL, the NETHERLANDS); Kutaj-Wasikowska H and Kutryba B (Polish Society for Quality Promotion in Health Care-TPJ, POLAND); Escoval A and Lívio A (Portuguese Association for Hospital Development-APDH, PORTUGAL) and Eiras M, Franca M and Leite I (Portuguese Society for Quality in Health Care-SPQS, PORTUGAL); Almeman F, Kus H and Ozturk K (Turkish Society for Quality Improvement in Healthcare-SKID, TURKEY); Mannion R (University of Birmingham, UK); Arah OA, , DerSarkissian M, Thompson CA and Wang A (University of California, Los Angeles-UCLA, USA); Thompson A (University of Edinburgh, UK).




Acknowledgements• The DUQuE indicators were critically reviewed by independent parties before their implementation. The

following individual experts critically assessed the proposed indicators: Dr J. Loeb, The Joint Commission (All four areas), Dr S. Weinbrenner, Germany Agency for Quality in Medicine (All four areas), Dr V. Mohr, Medical Scapes GmbH & Co. KG, Germany (All four areas), Dr V. Kazandjian, Centre for Performance Sciences (All four areas), Dr A. Bourek, University Center for Healthcare Quality, Czech Republic (Delivery). In addition, in France a team reviewed the indicators on myocardial infarction and stroke. This review combined the Haute Autorité de la Santé (HAS) methodological expertise on health assessment and the HAS neuro cardiovascular platform scientific and clinical practice expertise. We would like to thank the following reviewers from the HAS team: L. Banaei-Bouchareb, Pilot Programme-Clinical Impact department, HAS , N. Danchin, SFC, French cardiology scientific society, Past President, J.M. Davy, SFC, French cardiology scientific society, A.Dellinger, SFC, French cardiology scientific society, A. Desplanques-Leperre, Head of Pilot Programme-Clinical Impact department, HAS, J.L.Ducassé, CFMU, French Emergency Medicine-learned and scientific society, practices assessment, President, M. Erbault, Pilot Programme-Clinical Impact department, HAS, Y. L’Hermitte, Emergency doctor, HAS technical advisor , B. Nemitz, SFMU, French Emergency Medicine scientific societyB. Nemitz, SFMU, French Emergency Medicine scientific society, F. Schiele, SFC, French cardiology scientific society, C. Ziccarelli, CNPC French cardiology learned society, M. Zuber, SFNV, Neurovascular Medicine scientific and learned society, President. We also invited the following five specialist organization to review the indicators: European Midwifes Association, European Board and College of Obstetrics and Gynaecology, European Stroke Organisation, European Orthopaedic Research Society, European Society of Cardiology.




References• Pfaff H, Badura B, Pühlhofer F, Siewerts D (2005) Das Sozialkapital der Krankenhäuser - wie es

gemessen und gestärkt werden kann. In: Badura B, Schellschmidt H, Vetter C, editors. Fehlzeiten-Report 2004 : Gesundheitsmanagement in Krankenhäusern und Pflegeeinrichtungen; Zahlen, Daten, Analysen aus allen Branchen der Wirtschaft. Berlin: Springer. pp. 81-109.

• Shortell SM, O'Brien JL, Carman JM, Foster RW, Hughes EFX, Boerstler H, O'Connor EJ (1995) Assessing the impact of continuous quality improvement / total quality management: concept versus implementation. Health Serv Res 30: 377-401.

• Wagner C, Groene O, Thompson CA, Klazinga N, DerSarkissian M, Arah OA, Sunol R (2014) Development and validation of an index to assess hospital quality management systems. Int J Qual Health Care (suppl).

• Results are published in:

Hammer, Antje; Arah, Onyebuchi A.; DerSarkissian, Maral; Thompson, Caroline A.; Mannion, Russell; Wagner, Cordula et al. (2013): The relationship between social capital and quality management systems in European hospitals: A quantitative study. In PLoS One 8 (12), pp. e85662. DOI: 10.1371/journal.pone.0085662.


Thank you very much

In case of any question, please contact

Antje Hammer: [email protected]: www.ímvr.de

DUQuE-website: www.duque.eu

April 8th 2014 22Paris 2014 | Prof. Dr. Holger Pfaff

mailto:[email protected]

http://www.xn--mvr-qma.de/

http://www.duque.eu/

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