title: Deepening our understanding of quality improvement in Europe (DUQuE): overview of a study of hospital quality management in seven countries.
abstract: OBJECTIVE
  This paper provides an overview of the DUQuE (Deepening our Understanding of Quality Improvement in Europe) project, the first study across multiple countries of the European Union (EU) to assess relationships between quality management and patient outcomes at EU level. The paper describes the conceptual framework and methods applied, highlighting the novel features of this study.
  
  
  METHODS
  DUQuE was designed as a multi-level cross-sectional study with data collection at hospital, pathway, professional and patient level in eight countries.
  
  
  METHODS
  We aimed to collect data for the assessment of hospital-wide constructs from up to 30 randomly selected hospitals in each country, and additional data at pathway and patient level in 12 of these 30.
  
  
  METHODS
  A comprehensive conceptual framework was developed to account for the multiple levels that influence hospital performance and patient outcomes. We assessed hospital-specific constructs (organizational culture and professional involvement), clinical pathway constructs (the organization of care processes for acute myocardial infarction, stroke, hip fracture and deliveries), patient-specific processes and outcomes (clinical effectiveness, patient safety and patient experience) and external constructs that could modify hospital quality (external assessment and perceived external pressure).
  
  
  RESULTS
  Data was gathered from 188 hospitals in 7 participating countries. The overall participation and response rate were between 75% and 100% for the assessed measures.
  
  
  CONCLUSIONS
  This is the first study assessing relation between quality management and patient outcomes at EU level. The study involved a large number of respondents and achieved high response rates. This work will serve to develop guidance in how to assess quality management and makes recommendations on the best ways to improve quality in healthcare for hospital stakeholders, payers, researchers, and policy makers throughout the EU.
authors.affiliation: Avedis Donabedian Reseach Institute, University Autonomous of Barcelona, C/Provenza 293, Pral. 08037 Barcelona, Spain. marionasecanell@gmail.com.
authors.forename: Mariona
authors.initials: M
authors.lastname: Secanell
authors.forename: Oliver
authors.initials: O
authors.lastname: Groene
authors.forename: Onyebuchi A
authors.initials: OA
authors.lastname: Arah
authors.forename: Maria Andrée
authors.initials: MA
authors.lastname: Lopez
authors.forename: Basia
authors.initials: B
authors.lastname: Kutryba
authors.forename: Holger
authors.initials: H
authors.lastname: Pfaff
authors.forename: Niek
authors.initials: N
authors.lastname: Klazinga
authors.forename: Cordula
authors.initials: C
authors.lastname: Wagner
authors.forename: Solvejg
authors.initials: S
authors.lastname: Kristensen
authors.forename: Paul Daniel
authors.initials: PD
authors.lastname: Bartels
authors.forename: Pascal
authors.initials: P
authors.lastname: Garel
authors.forename: Charles
authors.initials: C
authors.lastname: Bruneau
authors.forename: Ana
authors.initials: A
authors.lastname: Escoval
authors.forename: Margarida
authors.initials: M
authors.lastname: França
authors.forename: Nuria
authors.initials: N
authors.lastname: Mora
authors.forename: Rosa
authors.initials: R
authors.lastname: Suñol
mesh_terms: D003430:Cross-Sectional Studies; D005060:Europe; D006761:Hospitals / Q000592:standards*; D017063:Outcome Assessment, Health Care; D011785:Quality Assurance, Health Care; D058996:Quality Improvement; D012107:Research Design; D011795:Surveys and Questionnaires
keywords: clinical effectiveness; clinical indicators; cross-national research; hospitals; patient outcomes; quality management systems; quality of healthcare