Hospital Quality Systems - working mechanisms unraveled.

Context: Quality systems were implemented in healthcare institutions to assure and improve the quality of care. Despite the fact that all Dutch hospitals have implemented a quality system, incidents persist to surface. How could this be explained? The current research was set out to gain thorough insights in the working mechanisms underlying the structure-process-outcome relationships of quality improvement within hospital quality systems and to understand the conditions under which a quality system lead to higher quality of care. The main research question of this research was: ‘What are working mechanisms of hospital quality systems that lead to high quality of care?' Methods: This research was based on a combination of several research methods. Quantitative as well as qualitative data were used to address the research question. We have used triangulation of data sources such as longitudinal survey data on quality systems in hospitals between 1995 and 2011, data of the evaluation of a national Patient Safety Program, two measurements with a questionnaire that maps elements of organizational process control, observations of compliance with a surgical checklist and interview data on the attitudes of healthcare professionals towards quality protocols. Data were measured at the structure, process and outcome level in order to get insight in all the levels that are involved in quality improvement. Advanced multilevel statistical techniques were used to analyze the results. Results: Results of this research showed that 45% of Dutch hospitals reached a stage of development of their quality system in which all the elements of a quality system are in place and this is used for continuous improvement. Results showed that a higher stage of development of a quality system is related to higher perceived organizational outcomes and that the outcomes are used to improve the quality system. A higher stage of development of a quality system was not associated with higher scores on process indicators measured at the hospital department level. Analysis of risk assesment at department level showed large differences between hospital departments on the perceived risks in several organizational domains. Especially in the domain ‘procedures', and a further investigation of attitudes of healthcare professionals towards procedures showed low compliance, general acceptance of deviations and a wide variety of strategies to communicate about deviations. Discussion: The results of this research show the complexity of the relation between hospital quality systems and high quality of care. In order to obtain the desired high quality of care and a cycle of continuous improvement, hospitals will need to use the data and results from the system to improve their quality system as well as their processes. It is not only important to focus on the effect of the quality system on the organizational outcomes but also to focus on the effect of the system on the processes. When processes are being neglected in quality improvement, it is unlikely that the effects of the quality system will reach its intended effects: improvement of the quality of patient care. A key aspect is to keep healthcare professionals involved in quality improvement, only with their committment to quality and valuable input to quality improvement can the quality system function optimally