1. Studying Quality and Safety in European Hospitals - QUASER Work Package 4a-4e Case studies by country Dr. Glenn Robert NIHR King’s Patient Safety and Service Quality Research Centre

2. WP4 – national case studies  begins month 6 (Jan’11), ends month 24 (July’12)  nominated lead from each partner:  The Netherlands – Anne Marie Weggelaar  Sweden – Boel Andersson-Gare  UK – Susan Burnett  Portugal – Jorge Correia Jesuíno  Norway – Karina Aase  multi-level case studies to investigate in-depth how hospitals implement, spread and sustain quality improvement, including the difficulties they face and how they can be overcome  including national seminar at end of WP in each country to verify findings

3. A multi-level perspective MESO LEVEL How a hospital ‘organises’ for clinical effectiveness, safety and patient experience Regulatory system Accreditation National prioritie s and policies Structures MACRO LEVEL How a national healthcare system ‘organises’ for clinical effectiveness, safety and patient experience European Union policies and regulations Strategies Cultures Systems MICRO LEVEL Clinical effectiveness, safety and patient experience of hospital care Practices Process es Finance

4. Objectives macro-level: describe national context and how influences organisational management of quality in hospitals  meso-level: describe structures and processes for managing quality in 2 hospitals in each country  micro-level: examine in one of the two hospitals how quality is organised in two clinical services (probably maternity services plus one other)  study the interactions between the 3 levels

5. Macro-level  supplement existing EU-funded Simpatie and Marquis projects  data will be collected only where necessary to supplement existing data about the macro level influences, such as financial structures, insurance, accreditation systems, policies, regulation and legislation in each country  informed in part by WP2 findings

6. Meso-level conducted longitudinally in 2 hospitals in each country using agreed tools and protocols from WP2 focus on processes of managing quality in practice across a hospital: semi-structured interviews non-participant observation of key meetings/events documentary analysis quantitative data collected where available

7. Micro level  one of the two hospitals selected: one micro-system likely to be maternity service with the other to be decided* with both to be studied longitudinally  explore what influences the relative effectiveness, safety and patient experience of care, including the interaction between the meso and micro levels and how processes at either level can either facilitate or hinder quality improvement  semi-structured interviews non-participant observation of key meetings/events documentary analysis quantitative data collected where available * aim is to select a micro system that will contrast with maternity and allow us to study the differing influence of meso level influences at the micro level.

9. Outputs  data collated, analysed using agreed framework and written reports - prepared by each partner (month 24)  including reflections from national seminar  leads to WP5: cross-case analysis & synthesis (begins month 25)

10. Conceptualising quality  defining the ‘organisational and cultural characteristics associated with better quality of care’:  all the features of a hospital that might be hypothesised to impact upon clinical effectiveness, patient safety and/or patient experience (e.g. leadership styles and systems, management structures & roles, sophistication and use of available information systems, the levels and nature of staff engagement etc*)  did not specify in the proposal precisely which of these - or other - characteristics will be integral to our study  intend to undertake a very broad-ranging study of structures, processes, strategies, systems, cultures, and practices. The key variables will emerge during the course of our scoping review (WP2) and fieldwork (WP4) * in each of the case studies we will specifically analyse if and how hospitals are engaging patients in quality and safety improvement

11. The art and the science

12. A starter for ten …

13. Selected case studies differently purposive sample nominations from international experts prizes and awards sustained trajectory over 15- 20 years

14. Case study methods  in-depth case studies in the US and Europe over 18 months  mainly qualitative but also microsystem survey questionnaire  observation and semi-structured interviews  narrative/storytelling methodologies: journey metaphor  from the practitioners’ perspective  multi-level: ‘meso-’ and ‘micro-systems’

15. ‘Organising for Quality’ Despite huge variety similar sets of challenges: Structural Political Cultural Educational Emotional Physical and technical

16. Solutions to challenges Organisational strategy for quality Task-centred leadership Whole-systems design Decentralised authority Quality leadership positions Multi-level leadership Quality change team QI training programs Supportive central functions Boundary spanner roles Communities of practice Results-oriented planning Governance structure Organisational ‘slack’ Data & monitoring systems Structural

17. What QUASER adds …  the current proposal seeks to extend and apply this research in several important ways:  we will study a range of hospitals at different stages on the quality journey (as opposed to just high performing hospitals)  we will explicitly include clinical effectiveness, patient safety and patient experience as key components of what we mean by ‘quality’ (as opposed to focusing just on service improvement)  we will incorporate available qualitative and quantitative measures of quality into our cross-case analysis (as opposed to a purely qualitative analysis)  we will include a much broader range of EU countries  we will provide context-specific guidance to hospitals depending on where they are on their quality journey and macro-system in which they operate

18. Looking ahead to work package 5 … !!

20. Next steps – preparing for WP4  June-Dec’10 in each partner country:  begin process of securing ethics and local R&D approval in each country  recruit research staff  assisting with WP2 and help identify ‘long list’ of hospitals to study in each country  scheduling national seminars (month 24, July 2012)  PM Board meeting (all WP leads) in Jan’11 for 1.5 days to:  develop framework/template for describing macro-level in each country  agree research tools and protocol (informed by WP2)  confirm micro-system selection: ?maternity and one other (informed by WP2)  apply selection framework from WP2 and decide on hospital sites in each partner country  post-Dec’10 in each partner country:  begin macro-system description  approach hospitals to participate  secure ethics and local R&D approval  begin fieldwork …