the role of government in improving quality in health care
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The role of government in improving quality in health care. towards innovation in healthcare improvement “choosing for quality” Peter Wognum Stupava 25112005. Basic line of presentation:. Basic problems in healthcare Combining 3 models for performance and accountability - PowerPoint PPT PresentationTRANSCRIPT
Ministerie van Volksgezondheid, Welzijn en Sport
The role of government in improving quality in health
care
towards innovation in healthcare improvement
“choosing for quality”
Peter WognumStupava
25112005
Ministerie van Volksgezondheid, Welzijn en Sport
Basic line of presentation:
• Basic problems in healthcare• Combining 3 models for
performance and accountability • Improvement oriented
healthcare system• Sneller Beter
Ministerie van Volksgezondheid, Welzijn en Sport
Basic Problems in Health Care
from 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
Ministerie van Volksgezondheid, Welzijn en Sport
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
Ministerie van Volksgezondheid, Welzijn en Sport
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
Ministerie van Volksgezondheid, Welzijn en Sport
3 models for performance and
accountability• Professional• Economic – market• Government• Combining (instruments of)
these models proves to be effective
Ministerie van Volksgezondheid, Welzijn en Sport
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.
Ministerie van Volksgezondheid, Welzijn en Sport
(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
Ministerie van Volksgezondheid, Welzijn en Sport
The Improvement-Oriented Healthcare
SystemProject – and
Programme – basedImprovement
Ministerie van Volksgezondheid, Welzijn en Sport
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
Ministerie van Volksgezondheid, Welzijn en Sport
The Improvement-Oriented Healthcare
SystemProject – and
Programme – basedImprovement
StrategicallyFocused
Large-SystemChange
Ministerie van Volksgezondheid, Welzijn en Sport
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
Ministerie van Volksgezondheid, Welzijn en Sport
The Improvement-Oriented Healthcare
SystemProject – and
Programme – basedImprovement
StrategicallyFocused
Large-SystemChange
BuildingImprovement
Into Daily Work
Ministerie van Volksgezondheid, Welzijn en Sport
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
Ministerie van Volksgezondheid, Welzijn en Sport
bringing healthcare improvement to the next
stageProject – and
Programme – basedImprovement
StrategicallyFocused
Large-SystemChange
BuildingImprovement
Into Daily Work
Leadership for Improvement
Receptive OrganisationalContext for Improvement
Ministerie van Volksgezondheid, Welzijn en Sport
“Sneller Beter”Accelerating improvement
Faster HealthierImprovement program for hospital care
on 2 priority areas
Ministerie van Volksgezondheid, Welzijn en Sport
Sneller Beter: initiated by the ministry of health
Sneller Beter: announced to 2nd chambernov03
1. Benchmark hospitals on efficiency
2. inspectorate indicators on quality
3. spread of “best practices”, Breakthrough
Other sectors!!
Ministerie van Volksgezondheid, Welzijn en Sport
Sneller Beter 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
Ministerie van Volksgezondheid, Welzijn en Sport
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?
Ministerie van Volksgezondheid, Welzijn en Sport
Sneller Beter 3: goals
1. 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
2. Goals on patientsafety:– Reduce medicationerrors with 50%
– Postoperative woundinfections 50% lower
– Decubitus-prevalence under 7%
– Introducing blame-free reporting
3. Vliegwiel
Ministerie van Volksgezondheid, Welzijn en Sport
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Advanced Access : accesstime MCL
Medisch Contact 2004;9:328-331
Accesstime to outpatient clinic in days
Ministerie van Volksgezondheid, Welzijn en Sport
•P.O.Woundinfections (PREZIES, CBO/RIVM, 2002)
Breastsurgery: 25%: <3%, 25%: >9%Hipsurgery: 25%: <2%, 25%: >4%Kneesurgery:25%: <1%, 25%: >4%
Patiëntsafety: examples:
<5%
•Decubitus: (Univ.Maastricht, 2002)
Acad.Hospitals: 16,5%Gen.Hospitals: 22,3%Nursinghomes: 33,0%athome-care: 18,5%
Ministerie van Volksgezondheid, Welzijn en Sport
Reduction of incidence and severity of decubitus
8,2
11,7
6,5
23,8
2,0
16,7
13,6 13,0 13,0
6,1
7,7 7,5 7,1
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%
1 4 6 8 9
Doorbraak-project-IC
15%
7%
Ministerie van Volksgezondheid, Welzijn en Sport
Hoogste VAS score per patient in de eerste 24 uur postoperatief
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1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71 73 75 77 79 81 83 85 87
Patienten
VAS-score
mediaan
VASscore
VAS-score meetperiode:
Nov ember t/m mei 2002
Reduction postoperative pain
DOORBRAAK-project Medicatieveiligheid
VAS: 6
VAS: 2,5
Ministerie van Volksgezondheid, Welzijn en Sport
Medication-errors on admission
0
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48
Patients
mediaan
start interventie
Medicationsafety:
Ministerie van Volksgezondheid, Welzijn en Sport
Sneller Beter 3Methods: 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 CEOIntegration of all projects, traininginfrastructuresupport by finance, ICT, HRM, MDInternal spread: results, new subject, infrastructure
Spread, assurance, internal and external
Ministerie van Volksgezondheid, Welzijn en Sport
Out-patient clinic
Diagn. ward.
Surg. theatre
Hospitalward
Advanced access
flow OK-projectPOWI
Decubitus Medicationsafety
Tumors Mamma-ca
Lung-ca
Electivesurgery
Hip
Inguinal hernia
Matrix: integratingthemes and procesredesign
Ministerie van Volksgezondheid, Welzijn en Sport
Adjustment of tasks
integrated planning
Professionalqualitysystem
Integral processredesign
Process-Supporting
ICT
standardisedpathways
Ministerie van Volksgezondheid, Welzijn en Sport
Sneller Beter 3: goals (2)Responsiblity of management and CEO:
• “blamefree reporting”• internal spread results
knowledge gainednew subject and other priorities
• medical staff• supporting processes: FA, ICT, HRM, MD• integrating: DBC, IGZ-indicators, budget
Result: internal acceleration
Ministerie van Volksgezondheid, Welzijn en Sport
Peter Wognum, pharmacist, policy advisor on quality and innovation in healthcare
Ministry of Health, Welfare and Sports
P.O. Box 203502500 EJ The HagueThe NetherlandsTel: 070-3407241E-mail: [email protected]