The investigators reflect: what we have learned from the Deepening our Understanding of Quality Improvement in Europe (DUQuE) study

In 2009, we launched Deepening our Understanding of Quality Improvement in Europe (DUQuE), an ambitious study on the effectiveness of quality improvement systems of hospitals in eight European countries. We believe this to be the most comprehensive and detailed study of quality improvement systems to date in terms of the a priori development of a coherent theory to guide the measurement and analytical strategy , the diverse countries involved and the range of standardized data collected (including surveys, chart reviews, administrative data and organizational audit). The papers published in this supplement describe the key findings of the project so far [1]. Here we discuss the overarching lessons emerging from the study. Without the relentless efforts of healthcare professionals and patients to gather data, research on quality improvement would not be possible. Despite the demanding workload of the study, response rates and completion of data collection have been exceptional, reflecting the efforts of country and hospital coordinators. However, there were some lessons about feasibility as the field test was complex and challenging for two reasons. First, in some countries an increasing 'quality burn-out' (where professionals are overwhelmed by existing requirements to document and monitor aspects of quality and safety) made it difficult to motivate staff to take on yet another project. Secondly, restrictive research ethics criteria (appropriate for interventional studies, but questionable for observational research) led to substantial delays in advancing the study. These are serious issues of relevance for any future primary data collection in European healthcare settings, in particular when providers are approached by multiple EU projects. The EU itself may be able to take a role by establishing governing mechanisms that increase coordination between research projects addressing similar topics. Measuring what is important in quality and safety Quality and safety evaluations in health care are frequently dominated by what can be easily measured, rather than by what is important. The DUQuE Consortium took a deliberate decision to build a conceptual model and populate it with existing instruments where possible, while developing new ones where needed [2]. These new instruments are crucial outputs of the project and we hope they will undergo further validation. However, quality and safety research needs to go beyond descriptive or prevalence studies. Associational analyses that attempt to quantify the complex relationships between quality systems and healthcare processes and outcomes have the potential to contribute much to our understanding of how quality improvement systems work. …