Quality in The Netherlands an integrated approach

Transcription

1 Quality in The Netherlands an integrated approach Objectives Build a team of stakeholders to work on system-wide improvement Summarize the experience of teams in the Netherlands working on large-scale quality improvement 1

2 Faculty & Disclosures Eric Hans Eddes, PhD, Gastrointestinal Surgeon, Deventer Ziekenhuis Wim Schellekens, MD, Chief Inspector of Curative Health Care, Dutch Healthcare Inspectorate Anemone Bogels, MSc, MBA, Dutch Federation of Cancer Patient Organization Marjolein I. Verstappen, Drs. M.I. Verstappen, Achmea, Divisie Zorg & Gezondheid, Vicevoorzitter, Directeur Zorginkoop Michel WJM Wouters, MD, Surgical Oncologist, Dutch Institute for Clinical Auditing These presenters have nothing to disclose. Quality in The Netherlands: timeline 1970 now: professional quality (doctors) guidelines, peer review, internal indicators 1995 now: + organisational quality (hospitals) TQM, flow, lean management, integrated care 1996: new quality law: quality, quality system, accountability 2004 now: + patient safety safety management system, national program (-50%) : + external indicators national program (ZiZo) with all parties involved 2005: new hc-law: marketdriven healthcare: patient-provider-purchaser 2010 now: new initiatives government: Quality Inst.: standards of care, transparancy professionals: this presentation purchasers and patients: this presentation 2

3 Quality in The Netherlands: lessons learned Doctors first and then doctors/hospital together: process-focus Final responsibility of the board of directors: vision, ambition Paradigm good-bad, versus good-better Implementation and spread: ? External drivers: supervision (IGZ), purchasers (hc-insurers) From outside in or: from inside out Measurement for learning and improvement measurement for accountability, supervision, making choices Difference between internal and external indicators New initiatives from government, professionals, purchasers Paradigms of Quality f P50 f 80% 5% 20% - + Q - + Q 3

4 Indicators for internal and external use Internal indicators: Focus on improvement Valid, reliable Specific Measurement over time Registration: simple No external use Fast, instructive, fun Stimulating Paradigm good-better External indicators: Focus: comparing, ranking, choices Valid, reliable + comparable Aspecific Measures here and now Registration, gathering, correction, publishing: very complex No relevance internal Difficult, threatening, resistance Demotivating Paradigm good-bad from Dutch Surgical Colorectal Audit to Dutch Institute for Clinical Auditing Dr EH Eddes, MD PhD colorectal surgeon Deventer Ziekenhuis Managing Director DICA 4

5 Dutch Healthcare, the costs 64 billion 7% annual growth 9% of National Product in 2008 towards15% Bron CBS Dutch Healthcare, reality Aging population Cancer incidence increases with 40% towards 2020 Decreasing National Product because of disappointing economic growth Healthcare becomes prohibitive 5

6 Dutch Healthcare, necessity Quality must go up Costs have to go down Increasing medical results often go with significant cost reduction Understanding of Quality 6

7 Quality of Healthcare homo informaticus Does auditing effect quality of care review of literature 28 articles in Pub Med 26 articles positive effect 4 combined with improvement course Only 2 articles show no effect 7

8 Dutch Surgical Colorectal Audit preconditions Presence of evidence based guideline Online benchmark, strongest driver Fast yearly reporting Consistent, thematic reporting, EBG Commitment professional organisations Property Privacy, TTP Online feedback/report Improvement of care Evidence Based Guideline Data collection/dictionary Registration Dutch Surgical Colorectal Audit preconditions Correction casemix Correction coincidence Open, verifiable; welcome to stakeholders Validity Completeness Online feedback/report Improvement of care Evidence Based Guideline Data collection/dictionary Registration 8

9 Dutch Surgical Colorectal Audit preconditions Helpdesk FAQ module Website open/closed Newsletter Dutch Surgical Colorectal Audit 9

10 Dutch Surgical Colorectal Audit Dutch Surgical Colorectal Audit 10

11 Dutch Surgical Colorectal Audit Dutch Surgical Colorectal Audit

12 Dutch Surgical Colorectal Audit Dutch Surgical Colorectal Audit 12

13 Dutch Surgical Colorectal Audit hospital variation CTx Stage III colon carcinoma < 75 yr Good performance Less comorbidity Monitoren essentieel Simunovic, Annals of Surgical Oncology,

14 Savings by auditing Savings healthcare until ,3 billion by auditing 2,0 billion by concentration Colorectale savings 32 milj/yr Lymphnodes 5 milj Complications 10 milj Hospital stay 17 milj Dutch Institute of Clinical Auditing plug and play Executive Council Management Scientific Office Advisory Board Privacy Council DBCA DUCA DCCA DSCA DSLCA DGEA 14

15 Dutch Institute of Clinical Auditing central docking station General applicable quality system Facilitating central organisation Seperate registrations in the lead Stakeholders welcome Plug and play in 6 months NON PROFIT One-stop shopping 15

16 Integrated qualityssystem by auditing Customer intimacy PROM, CQ index Operational Excellence kosteneffectiviteit Product Leadership kwaliteit Choices in Healthcare? 16

17 Improving quality of care: Initiatives of the Dutch College of Surgeons Characteristics Dutch Health Care System 16.6 million inhabitants (Florida 17.4 million) 41,526 km2 (Florida 170,451 km2) 94 full-service hospitals on 140 locations Mean travel distance 3.2 miles 99.8% in hospital within 30 minutes 1,020 surgeons (8 academic hospitals) 17

18 Challenges of the Dutch Health Care System Hospital variation in Quality of Care 18

19 Report of the Quality of Care Taskforce Dutch Cancer Society Hospital variation in optimal treatment rates Resection of stage I & II Lungcancer 19

20 Hospital variation in optimal treatment rates Chemo & radiation stage III Lungcancer Improving Quality of Care Concentration of complex (surgical) treatments Implementing minimal quality standards Infrastructure Procedural volume Specialisation & organisation Outcomes registration (transparency) 20

21 Dutch College of Surgeons Quality standards (oncology) Quality standards 1.0 January 2011 Breast cancer Colorectal cancer Lungcancer Melanoma Sarcoma Quality standards 2.0 Septembre 2011 Breastcancer Colorectal cancer Lungcancer Melanoma Sarcoma Esophageal cancer Pancreatic cancer Livermetastases Thyroid cancer Adrenal tumors Quality standards 3.0 January 2012 Breastcancer Colorectal cancer Lungcancer Melanoma Sarcoma Esophageal cancer Pancreatic cancer Livermetastases Thyroid cancer Adrenal tumors Stomach cancer Peritoneal mets Clinical audit To reliably collect risk-adjusted outcomes information, that can be analyzed and fed back.. to empower surgeons to improve quality of care! 21

22 Clinical audit The Dutch Surgical Colorectal Audit Casemix of hospitals 22

23 Bad Apples? Bad Apple Program Verification of hospital-specific data and analyses Consultation by Quality Improvement Committee Identification of Quality Issues Development of Quality Improvement Program ( best practices ) Implementation of Quality Improvement Program Monitoring outcomes 23

24 No Shaming & Blaming Quality Assurance an integrated approach Training Surgeon Board Certification Surgeon Quality standards Institute Audit Institute Consultation & Accreditatio n Institute Evidence-based guideline = common thread 24

25 Effective?

26 The Merits of Clinical Audit. Monitoring performance and guideline adherence Benchmarking Identification of Best Practices d Knowledge transfer Quality assurance Outcome-based referral / concentration of care as an integrated part of Dutch QI program! Integrated transparancy Anemone Bögels, NFK 26

27 NFK Dutch Federation of Cancer Patient Organizations An umbrella organization Federation of 25 cancer patient organizations (CPOs) Patient Guides Cancer. Cancer. What do you do? Choose the best hospital yourself What do you do? 27

28 Opting for the best hospital? General information on the quality of hospitals has limited relevance Considerable differences in quality between hospitals Patients opt for specific treatment Patient Guides Quality criteria from a patient s perspective Minimum conditions with specialist associations Question: Response: 92%- 96%! Analysis Transparency ( ) 28

29 Patient Guides Cancer. What do you do? Support in selecting a hospital and the treatment options Blood Cancers Colon Cancer Breast Cancer 2012: Prostate Cancer 2012: Lung Cancer 29

30 ? This hospital does not offer a fixed contactperson (throughout the entire treatment process or in each treatment phase) for the patient. As a result, it does not meet this criterion However, it does satisfy the other conditions. 30

31 Patient guides 1 Strengthening individual Stimulating healthcare improvements: 40% 80% within one year Supporting referrers Patient guides 2 Facilitate partnership of patient organizations and professional associations and hospitals in defining and improving quality of care 31

32 Vision for the future Integrated transparancy Integrated: The perspective of healthcare providers and patients in relation to The organization and outcomes of healthcare And transparent for healthcare providers and referreres/users! 32

33 Quality Improvement Marjolein Verstappen IHI conference 2011, USA Achmea is the largest private health insurer in The Netherlands The Dutch health insurance market [market shares, 2011] Achmea Health Care, key figures [2011] Menzis Other Achmea 29% 4.8 million people have an Achmea health insurance policy Total health care cost of EUR ca 10 billion 4500 employees CZ UVIT 5 labels 33

34 Achmea identifies three levels of quality Licence to operate Doing the right things Offer insight in volumes (create transparency) Apply restricted contracting, based on volume. Only applicable if there is consensus on the minimum volume necessary to provide safe care Offer insight in volumes per provider, corrected for population differences Develop decision trees for treatment options, together with leading professionals Doing things right Develop outcome measures Activate professionals and patients to base decisions on outcomes Working on Quality of Health Care 4 longterm initiatives LEAN Achmea Practice Status & Region Monitor Program Quality of Health Care Health Care Infrastructure & Regionally Focused Operation 34

35 Achmea Practice Status en Region Monitor Improved care by discussing (advanced) feedback on integral use of health care Example Region Monitor Example Practice Status Program Quality of Health Care Achmea invests in creating transparency and development of outcome measures At present 6% quality information available in NL (in e.g. Sweden 30%) Achmea aims to make 40-50% of Dutch health care transparant in the coming 5 years Actions: Invest in knowledge Invest in registration Invest in partnership 35

36 Achmea believes that creating transparency helps professionals to improve Achmea wants to shift the curve right Under achieving professionals Average achieving professionals Best achieving professionals Quality of care c Do you have questions? c 36

37 Summary Roles and responsibilities Professionals and professional collages Hospitals, hospitalboards Purchasers (HC-insurers) Patients Paradigm Good-Better 37