Response
A total of 366 questionnaires was sent to hospitals in the Netherlands (N = 149), Hungary (N = 134) and Finland (N = 83). All hospitals were approached, including university hospitals, county hospitals and regional hospitals. 278 Questionnaires were returned. The overall response was 76%. The response rate in the Netherlands was 68% (N = 101), in Hungary 94% (N = 116) and in Finland 71% (N = 59).
QM-activities
Table 1 gives an overview of the 38 QM-activities investigated and shows the percentage of hospitals in The Netherlands, Hungary and Finland performing these activities. The QM-activities are clustered into the focal areas: quality policy documents, human resources management, guidelines, QI-activities and patient participation.
Quality policy documents
Compared to Finland and Hungary, more hospitals in The Netherlands report that they have drawn up quality policy documents such as a mission statement (91%) and an annual quality report (97%). Nearly every hospital in the Netherlands publish an annual quality report, which is required by law. In Hungary and Finland 10% publishes such a report. In Hungary, more hospitals have written a quality manual (47%), but few have developed a written quality policy (37%). In general, less Finnish hospitals are concentrating on quality policy documents.
Human resources management
Overall, most attention has been spent on QM-training for professional staff and managers, and less to the training of new staff. The latter is important for the continuity of QM-activities. In Finland, more than 85% of the professionals and managers are trained in quality management. Compared to the Netherlands, fewer managers in Finland explain quality requirements to their staff (51% vs. 65%). In Hungary, more managers, i.e. 52% compared to 30% and 34%, control the compliance of staff with existing quality procedures. In the Netherlands, less attention is paid to new staff, i.e. 12% vs 24% and 29%. Minor differences exist with regard to training based on the quality policy.
Guidelines
More guidelines are reported in the Netherlands and in Finland compared with Hungary, e.g. patient information, critical incidents, diagnostic related groups and the cooperation with other health care providers. In Finland, most hospitals have guidelines for patient information and medical aids. In the three countries, most hospitals have guidelines for medical treatment. Less common are guidelines for the routing of the patient trough the hospital and for critical incidents.
Quality improvement(QI)- activities
It must be noted that the figures in the table represent the hospitals that apply the QI-activities, as well as the hospitals that use the results of the QI-activities for improvements of the care process.
In the Netherlands, more hospitals use mono-disciplinary peer review and fewer hospitals use need surveys among users and referrers. In Hungary, hospitals use more often internal audits, a management information system and need surveys among users. Finnish hospitals use more often satisfaction surveys among users and staff, and less often the complaint registration. Minor differences exist in the use of incident and infection committees, job assessment interviews, and user satisfaction surveys.
Patient participation
Minor differences exist with regard to patient participation between the three countries, except for the development of quality criteria. Nearly 40% of the hospitals in the Netherlands and Hungary invite patients for the development of quality criteria, whilst in Finnish hospitals this is only 14%. In general, the table shows that few hospitals invite patients to evaluate quality goals, participate in committees and improvement projects, or in the development of guidelines. Only in the Netherlands hospitals are obliged to have a client council and to discuss important topics with regard to the quality of care. In practice 63% of the Dutch hospitals have a client council (not in table 1).
The average number of QM-activities that have been developed in the three countries is 22 in the Netherlands and Finland, and 20 in Hungary.
Country profile
Figure 3 gives an overview of the QM-activities that 75% of the hospitals of a country have developed. This figure, therefore, shows the strong points in the QMS of the hospitals. In the Netherlands, 75% of the hospitals have developed at least one QM-activity in the focal areas Quality policy, human resources management, guidelines, and cyclic QI-activities. In Hungary, the hospitals are concentrating more on the focal area QI-activities. Finnish hospitals are concentrating on training (HRM), guidelines for professionals and QI-activities. None of the three countries is concentrating on patient participation.
The weak points (<25%) in the Netherlands are the quality manual, feedback about results, training new staff and patient participation. Weak points for Hungary are the training of new staff, multidisciplinary peer review and patient participation. For Finland the weak points are the quality manual and patient participation.
Developmental stage of the quality management systems
To determine the developmental stage of the QMS, the QM-activities within each focal area have been divided by national quality experts into four developmental stages, e.g. orientation and awareness (stage 0), preparation (stage 1), experimentation and implementation (stage 2), and integration into normal business operations (stage 3) (Figure 2). At stage zero, there are no systematic activities for quality assurance and improvement of health care processes. Some disciplines monitor their own quality through peer review and the use of standards for specific treatments. The management has started describing the mission, vision and products of the hospital. In this stage, the professionals are mainly responsible for quality assurance. At stage 1, hospitals create the conditions necessary for systematic quality assurance and improvement. At stage 2, hospitals develop different kinds of QM-activities and improvement projects. The purpose is to cross the boundaries of separate disciplines using the quality improvement cycle. At stage 3, the hospital reaches the stage of integration and establishment. Quality management is no longer an experimental activity, but is integrated into normal business operations. The results of QM-activities in one focal area will be used for changes and improvements in other focal areas. Therefore, it is necessary that hospitals develop activities simultaneously on more than one focal area.
Table 2 shows the developmental stage of the QMS for each focal area. Dutch hospitals are further with the participation of patients and one third of the hospitals has reached stage 3 for the focal area "Guidelines". Nearly one third of the Hungarian hospitals is in stage 3 for the focal area "Quality policy documents" and "QI-activities". Like the Dutch hospitals, more than one third of the Finnish hospitals has reached stage 3 for the focal area "Guidelines". A hospital can only reach a specific stage if it has developed the QM-activities of that stage. For example: a hospital can reach stage 3 of focal area "Quality policy documents" if it has developed a quality action plan and a quality manual (see Figure 2). Stage 3 hospitals have developed most of the QM-activities of the earlier stages.
Based on table 3, a small majority of Dutch hospitals (57%) has reached stage 2, 62% of the Hungarian hospitals have reached stage 1, and in Finland, half of the hospitals has reached stage 1 and half has reached stage 2.
Table 3 shows that there is no Hungarian hospital that has reached stage 3 for the overall QMS, despite the larger number of hospitals that has reached stage 3 of a specific focal area. These results seam to contradict each other. The explanation based on table 2 and table 3 is that a small group of Hungarian hospitals focuses on specific focal areas. They fulfil the requirements of a QMS within that area, but neglect the other areas. For the QMS as a whole, the five focal areas are equally important.