Background

Clinicians, nurses, and managers in hospitals are continuously confronted by new technologies and methods that require changes to working practice. Quality systems can help to manage change while maintaining a high quality of care. A new model of quality systems inspired by the works of Donabedian has three factors: structure (resources and administration), process (culture and professional co-operation), and outcome (competence development and goal achievement). The objectives of this study were to analyse whether structure, process, and outcome can be used to describe quality systems, to analyse whether these components are related, and to discuss implications.

Methods

A questionnaire was developed and sent to a random sample of 600 hospital departments in Sweden. The adjusted response rate was 75%. The data were analysed with confirmatory factor analysis and structural equation modeling in LISREL. This is to our knowledge the first large quantitative study that applies Donabedian's model to quality systems.

Results

The model with relationships between structure, process, and outcome was found to be a reasonable representation of quality systems at hospital departments (p = 0.095, indicating no significant differences between the model and the data set). Structure correlated strongly with process (0.72) and outcome (0.60). Given structure, process also correlated with outcome (0.20).

Conclusion

The model could be used to describe and evaluate single quality systems or to compare different quality systems. It could also be an aid to implement a systematic and evidence-based system for working with quality improvements in hospital departments.

Quality systems can help departments do the right things and do things right, but organisation and design need to be considered. The aim was to analyse whether quality systems that include certain quality improvement designs differ with regard to organisational factors and degrees of organisation. A questionnaire was developed and sent to a random sample of 600 hospital departments in Sweden (response rate=75%). A k-means cluster analysis was used to group departments into three degrees of organisation. Analyses of variance were done to study differences in organisational factors and quality improvement designs among the clusters. LISREL analyses were done to study the relationships between organisational factors and quality improvement designs. The results showed that quality systems that included certain quality improvement designs differed with regard to the organisational factors available resources, administration, culture, cooperation, and goal achievement. The results also showed that departments with quality systems of different organisational degrees used different quality improvement designs. Some quality improvement designs may require a quality system with a high degree of organisation to support a successful implementation. The appended questionnaire could be used to plan implementations and evaluate their results.

Objective: To analyse whether the organisation of quality systems (structure, process, and outcome) is related to how these systems were implemented (implementation prerequisites, cooperation between managers and staff, and source of initiative).

Methods: A questionnaire was developed, piloted and distributed to 600 hospital departments. Questions were included to reflect implementation prerequisites (adequate resources, competence, problem-solving capacity and high expectations), cooperative implementation, source of initiative (manager, staff and purchaser), structure (resources and administration), process (culture and cooperation) and outcome (goal evaluation and competence development). The adjusted response rate was 75%. Construct validity and reliability was assessed by confirmatory factor analysis, and Cronbach alpha scores were calculated. The relationships among the variables were analysed with structural equation modelling with LISREL.

Results: Implementation prerequisites were highly related to structure (0.51) and process (0.33). Cooperative implementation was associated with process (0.26) and outcome (0.34). High manager initiative was related to structure (0.19) and process (0.17). The numbers in parentheses can be interpreted as correlations. Construct validity was good, and reliability was excellent for all factors (Cronbach alpha>0.78). The model was a good representation of reality (model fit p value = 0.082).

Conclusions: The implementation of organisationally demanding quality systems may require managers to direct and lead the process while assuring that their staff get opportunities to contribute to the planning and designing of the new system. This would correspond to a cooperative implementation strategy rather than to top-down or bottom-up strategies. The results of this study could be used to adjust implementation processes.