Does hospital quality management make a difference to patients?

MILLIONS of dollars are spent annually implementing quality management strategies in Australian public hospitals — ranging from hospital accreditation to teamwork training to quality improvement initiatives. Many of the individual programs are based on some forms of evidence (although often not RCT, level 1 evidence). Evaluation of their effectiveness is typically restricted to single hospitals, wards or teams, with little consideration of the system-wide effects of multiple interventions.

What impact do these policies and procedures in combination have on the care patients receive in hospital? The fact is, we have very little understanding of this.

Over 5 years, we worked intensively with 32 public hospitals and 119 departments nationwide to answer this question. We went inside the black box of quality improvement to uncover how things were working, in-depth.

The Deepening our Understanding of Quality in Australia (DUQuA) study is an Australia-wide research project funded by the National Health and Medical Research Council that focuses on the standards, consistency and outcomes of care in Australian public hospitals. It involved 2387 participants, including clinicians (doctors, nurses, and allied health professionals), hospital managers, 2401 medical record reviews and 151 external assessments of the quality of care; 14 031 patients were involved.

DUQuA provides a national profile of acute care, and efforts to improve the quality of that care – a detailed snapshot of performance plus a unique Australian perspective, adding to the international body of knowledge established by earlier European work, the Deepening our Understanding of Quality Improvement in Europe (DUQuE) study. This research, half a decade ago, sought to understand the relationship between quality management systems and patient outcomes in 188 hospitals across seven European countries.

As a guiding principle, DUQuA sought to answer two main questions: what is the relationship between strategies to manage quality of care at the organisation and department levels within the hospital, and do these strategies make a significant difference to the quality of patient care?

Can hospitals be made safer for patients?

Our work in DUQuA is tied very closely to our longstanding interest in making care safer for patients. It is generally accepted that one in 10 patients will experience some form of harm while in the health system. Unfortunately, and despite countless attempts to reduce harm over many years, this figure has remained persistent in Australia and overseas.

With DUQuA, we recognised the need to dive deeper. We wanted to understand how quality and safety measures are implemented both on the wards and by hospital management. How do these strategies work in practice, and do they demonstrably improve care for patients?

To execute the study, we focused on three major health conditions that typically result in a person presenting to hospital: acute myocardial infarction, stroke, and hip fracture. We followed patients with these conditions on their journey from admission to the ward, and on to discharge.

Are organisational level quality management strategies effective?

While DUQuA is the largest and most ambitious study on quality management to date in Australian public hospitals, and one of the largest conducted internationally, we found no compelling evidence that quality management strategies driven at the organisational level result in better quality healthcare. These hospital-wide strategies include directives and policies emanating from governance boards, CEOs and executives, and performance monitoring initiatives, such as mandating systems for incident reporting and auditing. We found that while a hospital may have these structures in place, it is the degree to which they are enacted on the frontline that is most likely to influence patient care.

Put simply, DUQuA not only assessed whether a hospital had a policy to reduce hospital-acquired infections, it also examined the extent of practical application such as whether hand hygiene gel was available on the wards, standards were being met, and patient safety posters were omnipresent. Likewise, protocols may be written around medication reconciliation, but DUQuA also looked on the ward at how medication safety was handled, including observation of patients and their experiences of safety-related activities during their time in hospital.

Our results suggest that frontline interventions might be more effective in improving care than hospital level strategies. In the emergency department, for example, we were able to establish that while implementing evidence-based safety strategies resulted in slightly longer waiting and treatment times for patients, the care delivered was more in line with best practice, clinically and procedurally.

How can hospitals make gains in patient safety? 

Nobody doubts that providing care to patients in hospital takes place within an extremely complex system with an array of stakeholders with differing levels of responsibility. This includes clinical teams and individuals, governing bodies, administrators, funders and consumers – all operating at distinctive yet interconnected levels within the system. Any attempt at change and improvement at a hospital therefore needs to be a concerted effort by multiple parties. Almost all meaningful change needs to be multi-pronged, and should be adapted to the circumstances, with progress measured over time. To attempt to change one thing in isolation—say a clinical technique or a nursing routine or an allied health practice—without factoring in adjustments required elsewhere, by others in the system, is quite simply to invite failure.

Importantly, with DUQuA, we have developed tools to measure quality management systems in hospitals, both at the organisational level and also at the department level, for the conditions for heart attack, stroke, and hip fracture. The organisational level tools align with accreditation measures and may therefore be useful for hospitals in creating more effective change. They can be adapted for other conditions, too.

We have also developed tools to assess clinician leadership and safety culture across care pathways. And we have purpose designed or modified existing tools including those to enable patients to report on safety-related aspects of their care.  Add this all up, and there’s something for everyone who wants to be in the improvement business and make a difference.

The way ahead

The results of DUQuA will inform the future direction of quality and safety interventions in Australia and internationally. We remain optimistic that as our ways to measure the quality of patient care mature, we will also make headway in tackling the thorny problem of improving quality of patient care in our hospitals and health systems.

In line with our Institute’s commitment to ensuring research is translated into real actionable terms for the health system, each hospital in the study received a confidential benchmarking report comparing their performance against others in the study. Feedback from the hospitals receiving their reports already provides evidence that hospitals will use the information to not only understand their current performance, but also to measure the effectiveness of ongoing and future quality and safety initiatives. As much as it is satisfying for us as researchers to publish articles from our studies in high-quality international journals, this may be the best of all markers of success.

Overarching, summary results from DUQuA are available on our website. The full collection of articles appears in the International Journal for Quality in Health Care.

Dr Robyn Clay-Williams is a senior research fellow with the Australian Institute of Health Innovation at Macquarie University, and leads a research stream in the field of human factors and resilient health care in the Centre for Healthcare Resilience and Implementation Science.

Professor Jeffrey Braithwaite is Founding Director of the Australian Institute of Health Innovation, Director of the Centre for Healthcare Resilience and Implementation Science, and Professor of Health Systems Research at Macquarie University. Professor Braithwaite is President-Elect of the International Society for Quality in Health Care.

 

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.