MARQuIS : Methods of Assessing Response to Quality Improvement Strategies Rosa Suñol, MD, Ph.D.

1. MARQuIS:Methods of Assessing Response to Quality Improvement Strategies • Rosa Suñol, MD, Ph.D. • Director, Avedis Donabedian Foundation • Director AD Quality Chair. Fac. of Medicine. Autonomous University of Barcelona • 8th European Forum • Gastein, October 2005

2. Overview • MARQuIS team • EU Context • Project description: • Objectives • Design • Expected outcomes • Results so far: • Quality strategies • Type of care provided • Patient requirement • Recommendations

3. PARTNERS HOPE Standing Committee of the Hospitals of the European Union, Belgium ESQH European Society for Quality in Healthcare, Ireland; CEREF Centre for Research and Advanced Training,) Italy FAD Avedis Donabedian Foundation, Spain AMC Department of Social Medicine, Academic Medical Centre / University of Amsterdam,) The Netherlands CBO Dutch Institute for Healthcare Improvement,) The Netherlands MCHM University of Manchester / Manchester Centre for Healthcare Management, United Kingdom NCQA, National Centre for Quality Assessment in Health Care Poland COUNTRY COORDINATORS École de Santé Publique,Université Libre de Bruxelles, Belgium Belgium; Katholieke Universiteit Leuven, Belgium SAK CR Spojena akreditacni komise Ceske republiky, Czech Republic HAS Haute Autorité de Santé, France NCQA National Centre for Quality Assessment in Health Care, Poland FADA Foundation for Accreditation and Health Care Development, Spain NIAZ Nederlands Instituut voor Accreditatie van Ziekenhuizen, The Netherlands HQS The Health Quality Service,United Kingdom INVOLVED ORGANIZATIONS Coordination: Prof. Rosa Suñol (FAD)

4. EU CONTEXT: Movement of citizens within the European Union is increasing. Many of the citizens move for reasons unrelated to healthcare, but, whatever the reason, all these movements have a potential impact on health services, creating new needs and demands. Freedom of movement of goods, services, capital and people is also affecting health services. Countries use this principles to address professional shortage, to support drug policy etc,but some concern arise when they’re also responsible of the care provided in another country(type of service,qualityand cost)

5. EU CONTEXT: Examples of health policydivergence in Europe • Health system funding level and sources • Health system design/structure • Insurance coverage and benefits • Co-payment, fees and expenses • Treatment thresholds and choices • Patient and public expectations • Strategies for improving care (accreditation, indicators..) • Quality requirements (criteria, standards, etc) • Patients’ rights

6. PROJECT DESCRIPTION:Objectives • Toassess andcompare different quality strategies(accreditation of health care institutions, implementation of clinical guidelines, performance indicators, patient satisfaction surveys…),and their potential use in health services when patients move across borders to obtain care; this would provide a first basis to assess the need and the development of formal, quality procedures at EU level for secondary care institutions.

7. PROJECT DESCRIPTION: Objectives • WP-2To identify and analyze quality strategies(including accreditation, certification, indicators,patient surveys, etc.) used at national level (25 countries) based in a specific framework developed by research team • WP-3 To identify quality requirements for hospitals (safety and pat. empowerment) • Review legislation and jurisprudence (mainly in patient rights) • Identify volume and type of care provided to cross border care • Identify patients’ requirements • Identify providers requirements’ (doctors, nurses and managers)

8. PROJECT DESCRIPTION: Objectives • WP-4 /5To describein a sample of stateshow hospitals have applied national quality strategies, how far they meet the defined requirements of cross-border patients and what variables of organisation and methodology are associated with meeting these requirements(questionnaire to 500 hospitals, audit to 100 hospitals) • WP-6/7To use these data to draw general conclusions aboutthe association of various national quality strategies and compliance with defined requirements andthe need for developing formal quality procedures at EU level.

9. Development and applying measures Audit • Development and applying questionnaires (indicators, standards) • Developing and testing questionnaires • Distribution and analyses • Field test • Preliminary conclusions • Consultation with governments Generating hypothesis Quality strategies National and international level WP-2 Quality requirements for cross-border patients WP-3 HOSPITALS Literature review Framework Info retrieval + validity Report • Regulation and jurisprudence • Health financing authorities • Statistics on type of care provided • Patients requirements • Other stake holders requirements • Literature review Structural Characteristics • Organization • Quality culture • Etc. Priorities for patients with cross-border care Design

10. Questions to answer to EU officers • Is it convenient to develop a unique quality strategy/ instrument for Europe? • Is a convergence process possible and acceptable for the governments and involved organizations? • What are the key quality requirements to promote ? • Can they be used as a guidance for quality development in hospitals? • Are there special requirements when patients moving across borders? • What is the relationship of Quality requirements with purchasing services between countries? • What are the next steps to cover?

11. EU CONTEXT: Patientmobility in Europe • Tourism and short time stay (transport) and “false tourists” • Residents: People living and working in another EU state (elderly, ..etc) • Capacity transfer initiatives (waiting lists) • Private patients (in vitro-fertilization, aesthetic surgery, others..) • Border regions • Highly specialised care

12. QUALITY STRATEGIES IN EUROPE: Conceptual framework: Policy development Policy implementation Policy outcomes/ impact Quality strategies Literature review Information retrieval and validation in 25 countries Accreditation ISO EFQM Indicators Contracts

13. QUALITY REQUIREMENTS: Patient requirements Regulation & jurisprudence Quality requirements Other stakeholders requirements (doctors,nurses,managers.. Volume and type of care provided Literature review

14. TYPE OF CARE PROVIDED • A. Border regions projects • B. Case study. Catalonia • C. Purpose sample: 18 hospitals • D. Insurance companies

15. A. COOPERATION IN BORDER REGIONS Border region areas: 35 Hospital cooperation programs: 170 Treatment cooperation programs: 123 AREAS OF COOPERATION: Emergency Management Conferences, seminars, meetings Funding / social security agreements Common structure Language course Care/ medical treatment Exchange of professionals Research Telemedicine Education / training Equipment shared HOPE: Hospital co-operation in border regions in Europe, June 2003

16. B. CASE STUDYCataluña • Field of study: • Admissions to the Public Catalan System Hospitals during 2003 • Source of data: • CMBD de Cataluña, Servei Català de la Salut • Main results: • Total patients admitted: 714.404 • Total EU patients admitted: 1502 • % EU patients out of all admissions: 0.21%

17. PROPOSED diagnosisLIST TO STUDY • Acute myocardial infarction • Deliveries • Appendicitis • Several kinds of fractures • Ophthalmology • Cancer • Diagnostic procedures

18. PATIENT REQUIREMENTS: Methodology • Qualitative research using semi-structured interviews • Patients from an EU country admitted to a hospital abroad • Expected number of interviews: 60 • Countries of study: • Italy, Spain, Netherlands, Belgium • Goal: to identify relevant issues and priorities of individual patients using care across national borders

19. ENVIROMENTAL / ORGANIZATIONAL ISSUES Cleanliness Food Noise / visitors Environment of care Organization of the environment of care Daily routine ATTENTION TO PATIENTS Help / attention to patients Timeliness Professional attitude - ATTENTION TO RELATIVES COMMUNICATION / INFORMATION Translation/communication in other languages Information about illness and treatment Involvement of care / informed consent Information about hospital procedures Information to family doctor at home - PROFESIONAL CAPABILITIES - GENERAL COMMENTS PATIENT REQUIREMENTS: Preliminary findings

20. LESSONS LEARNEDSO FAR: • 1- Cross-border hospitalization in Europe varies widely, it seems to be a low occurrence phenomena, but underestimation could be important • 2- The volume of care provided to EU patients at the emergency unit seems to be higher than the events of hospitalization for this population • 3- Even when DRG codification system is only used in some European countries, all countries involved on this study use ICD either version 9 or 10, so data could be compared

21. LESSONS LEARNEDSO FAR: • 4- EU patients hospitalized abroad seem to have a more homogeneous pathology than the regular population admitted to the same hospital • 5- Most frequent diagnosis for hospitalized EU patients, are acute myocardial infarction, deliveries, appendicitis, disrhytmias and several kinds of fractures (this accounts for 25% of all cases) • 6- Preliminary analysis of patients requirements seems to show differences between EU patients and local patients needs (different diagnosis, specific groups, extra patients needs due to information and language problems and lack of family environmental support)

22. Recommendations: • 1- In order to be able to perform valid studies about the cross-border care, it would be necessary to include some common equivalent fields on hospitals and national healthcare databases. So it’s recommended to: Include country of origin as a mandatory field in hospitals and country databases. (data available in hospitals but not at country levels) both in inpatients and emergency areas • 2- It would be interesting to agree among different research groups on the typology of cross border care (also from patients point of view) • 3- The information currently available does not include the data that would be needed to independently study different categories of cross-border care (residents,,turists etc) Once country is identified, health information databases of EU countries should progressively start incorporating the information on types of cross border care as mandatory fields. • 4- Specific discharge information seems necessary for cross border care. It will be useful to consider a common content of the discharge letter in EU hospitals

23. Contact details: • Rosa Sunol MD PhD • marquis@fadq.org • www.fadq.org • www.marquis.be