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Background Quality improvement (QI) initiatives such as accreditation, public reporting, inspection and pay-for-performance are increasingly being implemented globally. In Flanders, Belgium, a government policy for acute-care hospitals incorporates aforementioned initiatives. Currently, questions are raised on the sustainability of the present policy. Objective First, to summarise the various initiatives hospitals have adopted under government encouragement between 2008 and 2019. Second, to study the perspectives of healthcare stakeholders on current government policy. Methods In this multi-method study, we collected data on QI initiative implementation from governmental and institutional sources and through an online survey among hospital quality managers. We compiled an overview of QI initiative implementation for all Flemish acute-care hospitals between 2008 (n = 62) and 2019 (n = 53 after hospital mergers). Stakeholder perspectives were assessed via a second survey available to all healthcare employees and a focus group with healthcare policy experts was consulted. Variation between professions was assessed. Results QI initiatives have been increasingly implemented, especially from 2016 onwards, with the majority (87%) of hospitals having obtained a first accreditation label and all hospitals publicly reporting performance indicators, receiving regular inspections and having entered the pay-for-performance initiative. On the topic of external international accreditation, overall attitudes within the survey were predominantly neutral (36.2%), while 34.5% expressed positive and 29.3% negative views towards accreditation. In examining specific professional groups in-depth, we learned 58% of doctors regarded accreditation negatively, while doctors were judged to be the largest contributors to quality according to the majority of respondents. Conclusions Hospitals have demonstrated increased efforts into QI, especially since 2016, while perceptions on currently implemented QI initiatives among healthcare stakeholders are heterogeneous. To assure quality of care remains a top-priority for acute-care hospitals, we recommend a revision of the current multicomponent quality policy where the adoption of all initiatives is streamlined and co-created bottom-up.

Background Since 2009, hospital quality policy in Flanders, Belgium, is built around a Quality-of-Care Triad, which encompasses accreditation, public reporting and inspection. Policy makers are currently reflecting on the added value of this Triad. Methods We performed a narrative review of the literature published between 2009 and 2020 to examine the evidence-base of the impact accreditation, public reporting and inspection, both individually and combined, has on patient processes and outcomes. The following patient outcomes were examined: mortality, length-of-stay, readmissions, patient satisfaction, adverse outcomes, failure-to-rescue, adherence to process measures and risk aversion. The impact of accreditation, public reporting and inspection on these outcomes was evaluated as either positive, neutral (i.e. no impact observed or mixed results reported) or negative. Results We identified 69 studies, of which 40 on accreditation, 24 on public reporting, three on inspection and two on accreditation and public reporting concomitantly. Identified studies reported primarily low-level evidence (level-IV, n=53) and were heterogenous in terms of implemented programs and patient populations (often narrow in public reporting research). Overall, a neutral categorization was determined in 30 papers for accreditation, 23 for public reporting and 4 for inspection. Ten of these recounted mixed results. For accreditation, a high number (n=12) of positive research on adherence to process measures was discovered. Conclusion The individual impact of accreditation, public reporting and inspection, the core of Flemish hospital quality, was found to be limited on patient outcomes. Future studies should investigate the combined effect of multiple quality improvement strategies.

Objective Hospitals demonstrated increased efforts into quality improvement over the past years. Their growing commitment to quality combined with a heterogeneity in perceptions among healthcare stakeholders cause concerns on the sustainable incorporation of quality into the daily workflow. Questions are raised on the drivers for a sustainable hospital quality policy. We aimed to identify drivers and incorporate them into a new, unique roadmap towards sustainable quality of care in hospitals. Design A multi-method design guided by an eight-phase approach to develop a conceptual framework consists of multiple, iterative phases of data collection, synthesis and validation. Starting with a narrative review followed by a qualitative in-depth analysis and including feedback of national and international healthcare stakeholders. Setting Hospitals. Results The narrative review included 59 relevant papers focusing on quality improvement and the sustainability of these improved quality results. By integrating, synthesising and resynthesizing concepts during thematic and content analysis, the narrative review evolved to an integrated, co-creation roadmap. The Flanders Quality Model (FlaQuM) is presented as a driver diagram that features six primary drivers for a sustainable quality policy: (1) Quality Design and Planning, (2) Quality Control, (3) Quality Improvement, (4) Quality Leadership, (5) Quality Culture and (6) Quality Context. Six primary drivers are described in 19 building blocks (secondary drivers) and 104 evidence-based action fields. Conclusions The framework suggests that a manageable number of drivers, building blocks and action fields may support the sustainable incorporation of quality into the daily workflow. Therefore, FlaQuM can serve as a useful roadmap for future sustainable quality policies in hospitals and for future empirical and theoretical work in sustainable quality management.