Ministerie van Volksgezondheid, Welzijn en Sport The role of government in improving quality in...

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


Basic line of presentation:

• Basic problems in healthcare• Combining 3 models for

performance and accountability • Improvement oriented

healthcare system• Sneller Beter


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


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


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


3 models for performance and

accountability• Professional• Economic – market• Government• Combining (instruments of)

these models proves to be effective


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.


(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


The Improvement-Oriented Healthcare

SystemProject – and

Programme – basedImprovement


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





StrategicallyFocused

Large-SystemChange


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






Large-SystemChange

BuildingImprovement

Into Daily Work


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


bringing healthcare improvement to the next

stageProject – and



Large-SystemChange

BuildingImprovement

Into Daily Work

Leadership for Improvement

Receptive OrganisationalContext for Improvement


“Sneller Beter”Accelerating improvement

Faster HealthierImprovement program for hospital care

on 2 priority areas


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!!


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


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?


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


-5

0

5

10

15

20

25

30

35

40

45

Okt

ob

er

3-fe

b

7-m

rt

31-m

rt

12-5

-03

13-6

-03

9-7-

03

5-8-

03

1-10

-03

data

Advanced Access : accesstime MCL

Medisch Contact 2004;9:328-331

Accesstime to outpatient clinic in days


•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%


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

5,4 6,0

9,3

6,5

0

5

10

15

20

25

SEPTEMBER

OKTOBER

NOVEM

BER

DECEMBER

JANUARI '0

0

FEBRUARI

MAART

APRILM

EIJU

NIJU

LI

AUGUSTUS

SEPTEMBER

OKTOBER

NOVEM

BER

DECEMBER

JANUARI '0

1

FEBRUARI

MAART

APRILM

EI

%

1 4 6 8 9

Doorbraak-project-IC

15%

7%


Hoogste VAS score per patient in de eerste 24 uur postoperatief

0

2

4

6

8

10

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


Medication-errors on admission

0

1

2

3

4

5

6

7

8

9

10

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:


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


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


Adjustment of tasks

integrated planning

Professionalqualitysystem

Integral processredesign

Process-Supporting

ICT

standardisedpathways


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


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]

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