External inspections of healthcare organizations : A study of organizational and clinical effects of inspections on the management of sepsis in Norwegian hospitals

Abstract

External inspections of healthcare organizations serve different purposes, one of which is to bring about quality improvements in the care offered to patients. Research has offered many different perspectives on how well inspections and other external assessment approaches fare in this endeavor. There is, however, no general agreement about the effects of inspections or the mechanisms by which inspections influence quality improvement work.

This thesis is part of a research project, headed by the Norwegian Board of Health Supervision, into the effects of inspections. The thesis examines the effects of inspections of care for patients with sepsis in the emergency departments of 24 hospitals in Norway during the period 2016 to 2018. The research aim has been to find out if inspections of healthcare organizations can lead to improved work processes and health outcomes for patients, and to explore the mechanisms that link external inspections and internal improvement efforts. The results have been reported in three published studies.

The two first studies relied on data from electronic health records and the Norwegian Patient Registry. Study 1 is an observational study of the care processes and patient outcomes for patients with sepsis presenting to emergency departments. We included data from 1559 patients presenting to hospital emergency departments with sepsis. Assessing the timeliness of diagnostic procedures for recognizing sepsis, we found that 72.9% (95% confidence interval [CI]: 70.7-75.1) had documented triage within 15 minutes of presentation to the emergency departments, 44.9% (95% CI: 42.4 47.4) were examined by a physician in accordance with the triage priority, 44.4% (95% CI: 41.4-46.9) were adequately observed through continual monitoring of signs while in the emergency department, and 25.4% (95% CI: 23.2-27.7) received antibiotics within 1 hour. Next, we estimated associations between diagnostic procedures and time to antibiotic treatment, and between time to antibiotic treatment and mortality. We found that delay or non-completion of key diagnostic procedures predicted a delay of more than 2.5 hours to antibiotic treatment. Patients who received antibiotics within 1 hour had an observed 30-day all-cause mortality of 13.6% (95% CI: 10.1-17.1), in the timespan 2 to 3 hours after admission 5.9% (95% CI: 2.8 9.1), and 4 hours or later after admission 10.5% (5.7-15.3).

Study 2 is a stepped wedge study of the effects of the inspection on care processes and patient outcomes. The study included 7407 patients presenting to hospital emergency departments with sepsis. We first studied the effects of the inspection on process measures for sepsis diagnostics and treatment. We found significant improvements in the proportions of patients examined by a physician within the time frame set in triage (odds ratio [OR] = 1.28, 95% CI: 1.07-1.53), undergoing a complete set of vital measurements within 1 hour (OR = 1.78, 95% CI: 1.10 2.87), having lactate measured within 1 hour (OR = 2.75, 95% CI: 1.83 4.15), having an adequate observation regimen (OR = 2.20, 95% CI: 1.51-3.20), and receiving antibiotics within 1 hour (OR = 2.16, 95% CI: 1.83-2.55). We then studied the effects of the inspection on length of hospital stay and 30-day all-cause mortality. We found a significant reduction in mortality and length of stay, but these findings were no longer significant when adjusting the analyses for year of admission.

Study 3 used focus group interviews with inspection teams, hospital management, and hospital staff to explore how the inspections affected quality improvement work in inspected hospitals. The data of this study were twelve focus groups interviews, with a total of 47 participants. We identified three themes that were central for understanding how the inspection could contribute to clinical improvement in the emergency departments: 1) increasing awareness about the need to improve the quality of care by providing data on clinical performance, 2) building acceptance for improvement through professional credibility and focus on clinical practice, and 3) fostering leader¬ship commitment.

In conclusion, the three studies suggest that the inspections brought to light deficiencies in the emergency departments’ work with recognizing sepsis and treating patients presenting with sepsis. After the inspections, the process measures of diagnosis and treatment had improved, and our analyses showed that these changes were associated with the inspections. This indicates that the inspection had a positive effect on the emergency departments’ efforts to improve the management of patients with sepsis. The focus group interviews offer some insight into how the inspection may have contributed to improving care: The inspection could help hospitals to identify and understand weaknesses in the clinical care processes and bolster the organizational commitment to systemic quality improvement. This shows the potential for the inspection to become an instrument of improvement. It is, however, also important to recognize that such change processes are context-dependent, and that regulatory agencies should reflect on how to design inspections in a way that contributes to the goal of improved care for patients.