The role of government in improving quality in health care

1. The role of government in improving quality in health care towards innovation in healthcare improvement “choosing for quality” Peter Wognum Stupava 25112005

2. Basic line of presentation: • Basic problems in healthcare • Combining 3 models for performance and accountability • Improvement oriented healthcare system • Sneller Beter

3. Basic Problems in Health Carefrom the patient point of view • "The way we deliver care“: profession • overuse, underuse, misuse (patient safety) • "The way we organize care“: organisation • health care is an archipelago • access-problems, waiting times, delays • coordination problems • communication gap • "The way we take care“ : relationship • Information • co-decision making - patient view • empathy

4. Or in other words • implementation of quality systems goes too slow (rate of change) • Management of health care institutions don’t steer on quality • No insight (transparancy) in type and quality of care • Chain quality underdeveloped • Innovations develop, but implementation and diffusion are too slow (rate of change) • Patient perspective underdeveloped – patient is not aware of what can be done and is not able to really influence this • Too much attention to instruments and procedural aspects of care; too few attention to results • Relation ICT and quality policy underdeveloped • Relation on primary registration and internal or external accountability underdeveloped • Role of insurance companies growing but not enough • Need of more active role of health care inspectorate

5. Or in other words • … Gap exists between what we have done and what we could do for the future • rate of change • Linking improvement and performance management • at national level, not always focussed on areas or organisations that are priorities at local level • connecting strongly at the level of specific local teams, but not always significantly with Chief Executives and leaders • challenged to sustain the improvement gains we have made • good at generating but not always so good at generalising • working in ways that are not always coherent when examined at local level

6. 3 models for performance and accountability • Professional • Economic – market • Government • Combining (instruments of) these models proves to be effective

7. Creating systemic capacity for improvement • By combining • Professional methods = internal motivation • standards, peer review, learning collaboratives, etc. • Economic methods = external motivation • pay for performance, regulated competition, etc. • Traditional governmental methods • licensing, inspectorate, obligatory public performance measurement, etc.

8. (inter)national strategy on improving health care • Improving quality of care = patient safety (*), effectiveness and patient centeredness • Improving information and position of patients (*) • Prevention: active strategy on diabetes, smoking and overweight (*) • Health system reform • regulated competitive market: deregulating strategies and transparent price-systems (DBC) • New insurance system for maintaining affordability and accessibility • Reorganizing knowledge infrastructure – quality institutions (*) • More and more differentiated health care workers (*) • Improving use of ICT (*) • More effective enforcement on health care institutions and market behavior • * = EU-priorities • Others are – cross boarder healthcare purchasing and providing – health impact assessment - health systems impact assessment

9. The Improvement-Oriented Healthcare System Project – and Programme – based Improvement

10. Projects and programs • Momentum for improvement • Many clinical teams engaged • Local adoption of improvement principles • National pilots – what and how • Local initiatives – regional spread? • Need to accelerate rate and spread of change

11. Project – and Programme – based Improvement Strategically Focused Large-System Change The Improvement-Oriented Healthcare System

12. Policy formulation • Identify priorities • Safety • Patient logistics • Set transformational goals • IHI – no avoidable deaths, no unnecessary pain, no waste, no delays, no feelings of helplessness • “our clinicians practice in an interdependent system not an institution” • Defect free services • Move a big dot – HSMR – 100K lives

13. Project – and Programme – based Improvement Strategically Focused Large-System Change Building Improvement Into Daily Work The Improvement-Oriented Healthcare System

14. Making modernisation mainstream • Patient, carer, user and payer involvement • a strategic approach to improvement • contribution of clear leadership to modernisation • systems and processes to support staff in modernisation • “space” or time for staff to think about change • approach to implementing the improvement agenda • approach to measuring progress with modernisation • communicating progress • community-wide approach to improvement

15. Receptive Organisational Context for Improvement bringing healthcare improvement to the next stage Project – and Programme – based Improvement Strategically Focused Large-System Change Building Improvement Into Daily Work Leadership for Improvement

16. “Sneller Beter” Accelerating improvement Faster Healthier Improvement program for hospital care on 2 priority areas

17. Sneller Beter: initiated by the ministry of health • Sneller Beter: announced to 2nd chamber • nov03 • Benchmark hospitals on efficiency • inspectorate indicators on quality • spread of “best practices”, Breakthrough Other sectors!!

18. SnellerBeter 3 • Why? • Chasm between knowledge and practice • Effectivity: inter-dokter/hospitalvariation • use of guidelines • Safety: harm done to patient • Efficiency: loss of money wast on professional and organisational aspects • On time: access, flow, waiting time • Patiëntcenteredness: information, co-decision, empathy

19. Sneller Beter 3: Mission statement Ambition • Is it possible • In the next four years • In 20% of hospitals (3 waves of 8 hospitals) • To show ambitious improvement • On 2 priority areas (patiëntlogistics and patiëntsafety) • Which, as a consequence, is obligatory for the other 80% of hospitals?

20. 3. Vliegwiel Sneller Beter 3: goals • Goals on patientlogistics: • Access time for policlinic (less than 1 week) • Reducing flowtime on diagnostics and treatment by 40-90% • OK-productivity 30% higher • Stay in hospital 30% shorter • Goals on patientsafety: • Reduce medicationerrors with 50% • Postoperative woundinfections 50% lower • Decubitus-prevalence under 7% • Introducing blame-free reporting

21. Advanced Access : accesstime MCL Accesstime to outpatient clinic in days Medisch Contact 2004;9:328-331

22. Decubitus: (Univ.Maastricht, 2002)Acad.Hospitals: 16,5% Gen.Hospitals: 22,3% Nursinghomes: 33,0% athome-care: 18,5% <5% Patiëntsafety: examples: • P.O.Woundinfections(PREZIES, CBO/RIVM, 2002) Breastsurgery: 25%: <3%, 25%: >9% Hipsurgery: 25%: <2%, 25%: >4% Kneesurgery: 25%: <1%, 25%: >4%

23. Reduction of incidence and severity of decubitus 15% 7% Doorbraak-project-IC

24. Reduction postoperative pain VAS: 6 VAS: 2,5 DOORBRAAK-project Medicatieveiligheid

25. Medicationsafety:

26. Sneller Beter 3 • Methods: integrated application! • Breakthrough • Integral processredesign • Networks CEO’s, CFO’s, medical staff, etc. • Underlying functions: finance, ICT, HRM, MD • Matrix: horizontal and vertical -on all participants • Breakthroughprojects: 7 subjects, 2 teams per hospital • Projectleaders per subject for 8 hospitals -per hospital Account-managers for each hospital: via CEO • Integration of all projects, traininginfrastructure support by finance, ICT, HRM, MD Internal spread: results, new subject, infrastructure • Spread, assurance, internal and external

27. Matrix: integratingthemes and procesredesign

28. Integralprocessredesign Professionalqualitysystem Adjustment of tasks standardised pathways integrated planning Process- Supporting ICT

29. Sneller Beter 3: goals (2) • “blamefree reporting” • internal spreadresults knowledge gained new subject and other priorities • medical staff • supporting processes: FA, ICT, HRM, MD • integrating: DBC, IGZ-indicators, budget Responsiblity of management and CEO: Result: internal acceleration

30. Peter Wognum, pharmacist, policy advisor on quality and innovation in healthcare Ministry of Health, Welfare and Sports P.O. Box 20350 2500 EJ The Hague The Netherlands Tel: 070-3407241 E-mail: pj.wognum@minvws.nl www.snellerbeter.nl