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Investigating organizational quality improvement systems, patient empowerment, organizational culture, professional involvement and the quality of care in European hospitals: the 'Deepening our Understanding of Quality Improvement in Europe (DUQuE)' project

Oliver Groene1*, Niek Klazinga2, Cordula Wagner3, Onyebuchi A Arah4, Andrew Thompson5, Charles Bruneau6, Rosa Suñol1 and DUQuE Research Project

Author Affiliations

1 Avedis Donabedian University Institute, Autonomous University of Barcelona, CIBER Epidemiology and Public Health, Barcelona, Spain

2 Department of Social Medicine, Academic Medical Centre, Amsterdam, the Netherlands

3 Netherlands Institute of Health Services Research (NIVEL), Utrecht, the Netherlands

4 Department of Epidemiology, School of Public Health, University of California, Los Angeles (UCLA); and the Center for Health Policy Research, UCLA, Los Angeles, USA

5 School of Social and Political Science, University of Edinburgh, Edinburgh, UK

6 Haute Autorité de la Sante, Paris, France

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BMC Health Services Research 2010, 10:281  doi:10.1186/1472-6963-10-281

Published: 24 September 2010



Hospitals in European countries apply a wide range of quality improvement strategies. Knowledge of the effectiveness of these strategies, implemented as part of an overall hospital quality improvement system, is limited.


We propose to study the relationships among organisational quality improvement systems, patient empowerment, organisational culture, professionals' involvement with the quality of hospital care, including clinical effectiveness, patient safety and patient involvement. We will employ a cross-sectional, multi-level study design in which patient-level measurements are nested in hospital departments, which are in turn nested in hospitals in different EU countries. Mixed methods will be used for data collection, measurement and analysis. Hospital/care pathway level constructs that will be assessed include external pressure, hospital governance, quality improvement system, patient empowerment in quality improvement, organisational culture and professional involvement. These constructs will be assessed using questionnaires. Patient-level constructs include clinical effectiveness, patient safety and patient involvement, and will be assessed using audit of patient records, routine data and patient surveys. For the assessment of hospital and pathway level constructs we will collect data from randomly selected hospitals in eight countries. For a sample of hospitals in each country we will carry out additional data collection at patient-level related to four conditions (stroke, acute myocardial infarction, hip fracture and delivery). In addition, structural components of quality improvement systems will be assessed using visits by experienced external assessors. Data analysis will include descriptive statistics and graphical representations and methods for data reduction, classification techniques and psychometric analysis, before moving to bi-variate and multivariate analysis. The latter will be conducted at hospital and multilevel. In addition, we will apply sophisticated methodological elements such as the use of causal diagrams, outcome modelling, double robust estimation and detailed sensitivity analysis or multiple bias analyses to assess the impact of the various sources of bias.


Products of the project will include a catalogue of instruments and tools that can be used to build departmental or hospital quality and safety programme and an appraisal scheme to assess the maturity of the quality improvement system for use by hospitals and by purchasers to contract hospitals.