Talking about quality: exploring how ‘quality’ is conceptualized in European hospitals and healthcare systems

BACKGROUND: Conceptualization of quality of care - in terms of what individuals, groups and organizations include in their meaning of quality, is an unexplored research area. It is important to understand how quality is conceptualised as a means to successfully implement improvement efforts and bridge potential disconnect in language about quality between system levels, professions, and clinical services. The aim is therefore to explore and compare conceptualization of quality among national bodies (macro level), senior hospital managers (meso level), and professional groups within clinical micro systems (micro level) in a cross-national study. METHODS: This cross-national multi-level case study combines analysis of national policy documents and regulations at the macro level with semi-structured interviews (383) and non-participant observation (803 hours) of key meetings and shadowing of staff at the meso and micro levels in ten purposively sampled European hospitals (England, the Netherlands, Portugal, Sweden, and Norway). Fieldwork at the meso and micro levels was undertaken over a 12-month period (2011-2012) and different types of micro systems were included (maternity, oncology, orthopaedics, elderly care, intensive care, and geriatrics). RESULTS: The three quality dimensions clinical effectiveness, patient safety, and patient experience were incorporated in macro level policies in all countries. Senior hospital managers adopted a similar conceptualization, but also included efficiency and costs in their conceptualization of quality. 'Quality' in the forms of measuring indicators and performance management were dominant among senior hospital managers (with clinical and non-clinical background). The differential emphasis on the three quality dimensions was strongly linked to professional roles, personal ideas, and beliefs at the micro level. Clinical effectiveness was dominant among physicians (evidence-based approach), while patient experience was dominant among nurses (patient-centered care, enough time to talk with patients). Conceptualization varied between micro systems depending on the type of services provided. CONCLUSION: The quality conceptualization differed across system levels (macro-meso-micro), among professional groups (nurses, doctors, managers), and between the studied micro systems in our ten sampled European hospitals. This entails a managerial alignment challenge translating macro level quality definitions into different local contexts.

The effect of a Computerised Decision Support System (CDSS) on compliance with the prehospital assessment process: results of an interrupted time-series study

BACKGROUND: Errors in the decision-making process are probably the main threat to patient safety in the prehospital setting. The reason can be the change of focus in prehospital care from the traditional "scoop and run" practice to a more complex assessment and this new focus imposes real demands on clinical judgment. The use of Clinical Guidelines (CG) is a common strategy for cognitively supporting the prehospital providers. However, there are studies that suggest that the compliance with CG in some cases is low in the prehospital setting. One possible way to increase compliance with guidelines could be to introduce guidelines in a Computerized Decision Support System (CDSS). There is limited evidence relating to the effect of CDSS in a prehospital setting. The present study aimed to evaluate the effect of CDSS on compliance with the basic assessment process described in the prehospital CG and the effect of On Scene Time (OST). METHODS: In this time-series study, data from prehospital medical records were collected on a weekly basis during the study period. Medical records were rated with the guidance of a rating protocol and data on OST were collected. The difference between baseline and the intervention period was assessed by a segmented regression. RESULTS: In this study, 371 patients were included. Compliance with the assessment process described in the prehospital CG was stable during the baseline period. Following the introduction of the CDSS, compliance rose significantly. The post-intervention slope was stable. The CDSS had no significant effect on OST. CONCLUSIONS: The use of CDSS in prehospital care has the ability to increase compliance with the assessment process of patients with a medical emergency. This study was unable to demonstrate any effects of OST.

The impact of personal background and school contextual factors on academic competence and mental health functioning across the primary-secondary school transition

Students negotiate the transition to secondary school in different ways. While some thrive on the opportunity, others are challenged. A prospective longitudinal design was used to determine the contribution of personal background and school contextual factors on academic competence (AC) and mental health functioning (MHF) of 266 students, 6-months before and after the transition to secondary school. Data from 197 typically developing students and 69 students with a disability were analysed using hierarchical linear regression modelling. Both in primary and secondary school, students with a disability and from socially disadvantaged backgrounds gained poorer scores for AC and MHF than their typically developing and more affluent counterparts. Students who attended independent and mid-range sized primary schools had the highest concurrent AC. Those from independent primary schools had the lowest MHF. The primary school organisational model significantly influenced post-transition AC scores; with students from Kindergarten--Year 7 schools reporting the lowest scores, while those from the Kindergarten--Year 12 structure without middle school having the highest scores. Attending a school which used the Kindergarten--Year 12 with middle school structure was associated with a reduction in AC scores across the transition. Personal background factors accounted for the majority of the variability in post-transition AC and MHF. The contribution of school contextual factors was relatively minor. There is a potential opportunity for schools to provide support to disadvantaged students before the transition to secondary school, as they continue to be at a disadvantage after the transition.

Characterisation and investigation of local variations in mechanical behaviour in cast aluminium using gradient solidification, Digital Image Correlation and finite element simulation

Due to design and process-related factors, there are local variations in the microstructure and mechanical behaviour of cast components. This work establishes a Digital Image Correlation (DIC) based method for characterisation and investigation of the effects of such local variations on the behaviour of a high pressure, die cast (HPDC) aluminium alloy. Plastic behaviour is studied using gradient solidified samples and characterisation models for the parameters of the Hollomon equation are developed, based on microstructural refinement. Samples with controlled microstructural variations are produced and the observed DIC strain field is compared with Finite Element Method (FEM) simulation results. The results show that the DIC based method can be applied to characterise local mechanical behaviour with high accuracy. The microstructural variations are observed to cause a redistribution of strain during tensile loading. This redistribution of strain can be predicted in the FEM simulation by incorporating local mechanical behaviour using the developed characterization model. A homogeneous FEM simulation is unable to predict the observed behaviour. The results motivate the application of a previously proposed simulation strategy, which is able to predict and incorporate local variations in mechanical behaviour into FEM simulations already in the design process for cast components.

Determination of the columnar to equiaxed transition in hypoeutectic lamellar cast iron

Shrinkage porosity as a volume change related casting defect in lamellar cast iron was reported in theliterature to form during solidification in connection to the dendrite coherency. The present work includesan experimental study on dendrite coherency – also called columnar-to-equiaxed transition in lamellar castiron using thermal analysis and expansion force measurements. Investigation was carried out in order tostudy the mechanism of dendrite coherency formation. Cylindrical test bars were cast from the same alloywith different pouring temperature, amount of inoculant and time between the addition of inoculant andstart of pouring the samples. Cooling rate and expansion force was recorded as a function of time. Anumerical algorithm based on temperature differences measured under solidification was used to inter-pret the solidification process. Three different methods have been compared to determine the columnarto equiaxed transition. The compared methods were based on registered temperature differences, basedon registered expansion forces during the volume change of the solidifying samples and based on the cal-culated released latent heat of crystallization. The obtained results indicate a considerable influence on theformation and progress of coherency due to variation of casting parameters. It has been shown that thecoherency is not a single event at a defined time moment rather a process progressing during a timeinterval.

The impact of spatial externalities : Skills, education and plant productivity

This paper analyses the role of a broad range of spatial externalities in explaining average labour productivity of Swedish manufacturing plants. The main findings show positive effects from general urbanization economies and labour market matching, as well as a negative effect from within-industry diversity. These results confirm previous research despite methodological differences,which implies wider generalizability. Additionally, the empirical findings support Marshall–Arrow–Romer (MAR) and Porter externalities, i.e. positive effects from specialization and competition. No evidence is found of Jacobs externalities, neither when measured as between-industry diversity nor as within-industry diversity. Finally, plant-specific characteristics play a key role in explaining plant-level productivity.

Behavioural outcomes of next-generation family members’ commitment to their firm

Are there variations in behaviours and leadership styles of next-generation family members or descendants who join their family business due to different forms of commitment? Evidence from a dual respondent study of 109 Canadian and Swiss family firms suggests that descendants with affective commitment to their family firms are more likely to engage in discretionary activities going beyond the job description, thereby contributing to organizational performance. Next-generation members with normative commitment are more likely to engage in transformational leadership behaviours. Both affectively and normatively motivated next-generation members use contingent reward forms of leadership. A surprising finding of this study is the binding force of normative commitment on positive leadership behaviours of next-generation members. This study empirically tests the generalizability of the three-component model of commitment to family businesses, a context in which different forms of commitment may play a unique role.

Physical Activity, Blood Glucose and C-Peptide in Healthy School-Children, a Longitudinal Study

Aim To further elucidate the relationship between physical activity and several risk factors for development of diabetes (glucose, C-peptide and obesity) over time. Methods A prospective longitudinal study where physical activity was measured on 199 children from Kalmar and Linköping at age 8, and the same 107 children from Linköping again at age 12. Anthropometric data was collected and blood was analyzed for C-peptide and f-glucose. The children in the study were representative for the general Swedish child population, and on an average lean. Results High physical activity was related to lower C-peptide at age 8 and 12. This correlation was especially pronounced in boys, who also were more physically active than girls at both time points. The association seen at 8 years of age was similar at age 12 in most children. Children with higher BMI Z-Score had a higher fasting C-peptide (age 12) but linear regression showed that children with more steps per day were less likely to have a higher fasting C-peptide irrespective of BMI. Longitudinal follow-up showed that a decrease in physical activity increased insulin resistance and β-cell load. Conclusions Already in young children, physical activity improves insulin sensitivity and decreases the need of C-peptide over time. This seems to become even more pronounced with increasing age when children are followed longitudinally. Low physical activity increases the load on insulin producing β-cells, might increase the risk for both type 1- and 2 diabetes.

Comparing children's self-report instruments for health-related quality of life using the International Classification of Functioning, Disability and Health for Children and Youth (ICF-CY)

Children with chronic conditions often experience a long treatment which can be complex and negatively impacts the child's well-being. In planning treatment and interventions for children with chronic conditions, it is important to measure health-related quality of life (HrQoL). HrQoL instruments are considered to be a patient-reported outcome measure (PROM) and should be used in routine practice. Purpose: The aim of this study was to compare the content dimensions of HrQoL instruments for children's self-reports using the framework of ICF-CY. Method: The sample consist of six instruments for health-related quality of life for children 5 to 18 years of age, which was used in the Swedish national quality registries for children and adolescents with chronic conditions. The following instruments were included: CHQ-CF, DCGM-37, EQ-5D-Y, KIDSCREEN-52, Kid-KINDL and PedsQL 4.0. The framework of the ICF-CY was used as the basis for the comparison. Results: There were 290 meaningful concepts identified and linked to 88 categories in the classification ICF-CY with 29 categories of the component body functions, 48 categories of the component activities and participation and 11 categories of the component environmental factors. No concept were linked to the component body structures. The comparison revealed that the items in the HrQoL instruments corresponded primarily with the domains of activities and less with environmental factors. Conclusions: In conclusion, the results confirm that ICF-CY provide a good framework for content comparisons that evaluate similarities and differences to ICF-CY categories. The results of this study revealed the need for greater consensus of content across different HrQoL instruments. To obtain a detailed description of children's HrQoL, DCGM-37 and KIDSCREEN-52 may be appropriate instruments to use that can increase the understanding of young patients' needs.

Feeling existentially touched - A phenomenological notion of the well-being of elderly living in special housing accommodation from the perspective of care professionals

This article presents a phenomenological analysis of interview material, in which 12 care professionals in elderly care reflect on the elderly's well-being within the frame of special housing accommodation. The perspective of the care professionals is of special interest. The findings show that the well-being is characterized as the elderly's feelings of being existentially touched. The well-being is an existential experience of being acknowledged as a human being and is an approach that classifies the elderly's needs as those of having, loving, and being. The meaning of the phenomenon is elucidated by the constituents: (1) to feel the freedom of choice, (2) to feel pleasure, and (3) to feel closeness to someone or something. The findings contribute new understanding of well-being in the elderly care by its existential dimension of the well-being as "just being'' and of doing things in order to experience meaningfulness. Accordingly, the well-being of the elderly as it is seen from the perspective of the care professionals involves both carers' subjectivity and intersubjectivity between the care professional and the elderly. An implication for promoting elderly's well-being is to develop awareness of these existential dimensions.

Through Eurocentric logics : The construction of difference in foreign news discourse on Venezuela

This study aims to explore the construction of difference in foreign news discourse on culturally similar but politically different non-Western subjects. Applying critical discourse analysis (CDA) together with a critique of Eurocentrism, the study examines difference in newspaper constructions of government supporters and oppositional groups in Venezuela. Discursive differences are evident in the strategies used for constructing the two groups with regard to political rationality and violence. Government supporters are associated with social justice, Venezuela’s poor, dogmatic behavior, and the use of political violence. The opposition, in contrast, is constructed as following a Western democratic rationale that stresses anti-authoritarianism. This group is primarily associated with victims of violence. While the opposition is conveyed as being compatible with Eurocentric values and practices, government supporters to great extent deviate from these norms. Such constructions serve to legitimize politico-ideological undercurrents of Eurocentrism, as the defense of liberalism.

Finite element modeling of tube deformation during cold pilgering

A three-dimensional finite element model of cold pilgering of stainless steel tubes is developed in this paper. The objective is to use the model to increase the understanding of forces and deformations in the process. The focus is on the influence of vertical displacements of the roll stand and axial displacements of the mandrel and tube. Therefore, the rigid tools and the tube are supported with elastic springs. Additionally, the influences of friction coefficients in the tube/mandrel and tube/roll interfaces are examined. A sensitivity study is performed to investigate the influences of these parameters on the strain path and the roll separation force. The results show the importance of accounting for the displacements of the tube and rigid tools on the roll separation force and the accumulative plastic strain.

Factors facilitating a national quality registry to aid clinical quality improvement : findings of a national survey

Objectives: While national quality registries (NQRs) are suggested to provide opportunities for systematic follow-up and learning opportunities, and thus clinical improvements, features in registries and contexts triggering such processes are not fully known. This study focuses on one of the world's largest stroke registries, the Swedish NQR Riksstroke, investigating what aspects of the registry and healthcare organisations facilitate or hinder the use of registry data in clinical quality improvement. Methods: Following particular qualitative studies, we performed a quantitative survey in an exploratory sequential design. The survey, including 50 items on context, processes and the registry, was sent to managers, physicians and nurses engaged in Riksstroke in all 72 Swedish stroke units. Altogether, 242 individuals were presented with the survey; 163 responded, representing all but two units. Data were analysed descriptively and through multiple linear regression. Results: A majority (88%) considered Riksstroke data to facilitate detection of stroke care improvement needs and acknowledged that their data motivated quality improvements (78%). The use of Riksstroke for quality improvement initiatives was associated (R2=0.76) with ‘Colleagues’ call for local results’ (p=<0.001), ‘Management Request of Registry data’ (p=<0.001), and it was said to be ‘Simple to explain the results to colleagues’ (p=0.02). Using stepwise regression, ‘Colleagues’ call for local results’ was identified as the most influential factor. Yet, while 73% reported that managers request registry data, only 39% reported that their colleagues call for the unit's Riksstroke results. Conclusions: While an NQR like Riksstroke demonstrates improvement needs and motivates stakeholders to make progress, local stroke care staff and managers need to engage to keep the momentum going in terms of applying registry data when planning, performing and evaluating quality initiatives.

Energy performance comparison of three innovative HVAC systems for renovation through dynamic simulation

In this paper, dynamic simulation was used to compare the energy performance of three innovativeHVAC systems: (A) mechanical ventilation with heat recovery (MVHR) and micro heat pump, (B) exhaustventilation with exhaust air-to-water heat pump and ventilation radiators, and (C) exhaust ventilationwith air-to-water heat pump and ventilation radiators, to a reference system: (D) exhaust ventilation withair-to-water heat pump and panel radiators. System A was modelled in MATLAB Simulink and systems Band C in TRNSYS 17. The reference system was modelled in both tools, for comparison between the two.All systems were tested with a model of a renovated single family house for varying U-values, climates,infiltration and ventilation rates.It was found that A was the best system for lower heating demand, while for higher heating demandsystem B would be preferable. System C was better than the reference system, but not as good as A or B.The difference in energy consumption of the reference system was less than 2 kWh/(m2a) betweenSimulink and TRNSYS. This could be explained by the different ways of handling solar gains, but also bythe fact that the TRNSYS systems supplied slightly more than the ideal heating demand.

Changes in the prevalence of breast feeding in preterm infants discharged from neonatal units : a register study over 10 years

Objective: There are indications that the prevalence of exclusively breastfed preterm infants is decreasing in Sweden. The objective was to investigate trends in exclusive breast feeding at discharge from Swedish neonatal units and associated factors in preterm infants. Design, setting and participants: This is a register study with data from the Swedish Neonatal Quality Register. Data from 29 445 preterm infants (gestational age (GA) <37 weeks) who were born during the period 2004–2013 were retrieved. Data included maternal, perinatal and neonatal characteristics. Data were analysed for the whole population as well as for 3 GA groups. Results: From 2004 to 2013, the prevalence of exclusive breast feeding decreased, in extremely preterm (GA 22–27 weeks) from 55% to 16%, in very preterm (GA 28–31 weeks) from 41% to 34% and in moderately preterm infants (GA 32–36 weeks) from 64% to 49%. The decline was statistically significant (p<0.001) in all 3 GA groups. This decline remained significant when adjustments were made for factors negatively associated with exclusive breast feeding and which became more prevalent during the study period, that is, small for GA (all groups) and maternal mental illness (very preterm and moderately preterm infants). Conclusions: In the past 10 years, Sweden has experienced a lower rate of exclusive breast feeding in preterm infants, especially in extremely preterm infants. The factors analysed in this study explain only a small proportion of this decline. The decline in exclusive breast feeding at discharge from neonatal units raises concern and present challenges to the units to support and promote breast feeding.