Quality and Innovation in Dutch Health Care

1
Quality and Innovation in Dutch Health Care

• policies on improving quality in Dutch Health
  Care
• Peter Wognum
• Innsbruck
• 17062004

2
Basic line of presentation

• Patients, health care providers and insurance
  companies are more responsible for the use of
  health care
• Regulated markets ask for a balance between price
  and supply, reliable information on results and
  prices and must result in efficient use and fair
  prices.
• Use of specific temporary programs on priority
  areas and specific themes

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 communicatio
  n gap
• "The way we take care relationship information
  co-decision making empathy

4
Basic Problems in Health Care

• implementation of quality systems goes too slow
• Management of health care institutions dont
  steer on quality
• No insight (transparancy) in type and quality of
  care
• Chain quality underdeveloped
• Innovations develop, but implementation and
  diffusion are too slow
• 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
National strategy on improving health care

• Improving quality of care and patient safety
• Improving information and position of patients
• Prevention active strategy on diabetes, smoking
  and overweight
• 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 inspectorate on health care
  institutions and market behavior.

6
Intensified approach (1)

• clearer responsibilities - less polderen - more
  consequences
• providers responsible for delivering care of
  adequate quality and safety
• clearly described products attainable results
  registration external accountability all come
  with that
• modern care-products - adequate all-in prices -
  including ICT, registrations, innovation.
• local markets for change - via insurance
  companies - contracts - production, price,
  quality, reporting, etc.

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Intensified approach (2)

• Insurance companies will be judged on their
  activities (buyer of care)
• knowledge of results is essential for this new
  situation
• indicators - transparancy - benchmarking
• independent inspection (for providers and
  insurers)
• empowered consumers/patiënt-organisations (on
  what points do they really experience change)
• parties have possibility of choice, eg. to move
  (do they?)

8
Patients

• Old
• Laws on patients rights (WGBO, WKCZ, WMCZ)
• organisations - NP/CF - categoral
• activities merely on patient satisfaction
• better developed in care for chronically ill,
  scarcely developed in hospital care
• New
• explicit preferences - priorities - best
  practices
• they ask their ins.comp to contract care that
  delivers according to their preferences
• transparancy many different initiatives on
  publishing results
• but also good patiënt practice

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Providers

• Old
• Adequate care care of good quality, which is
  effective, efficient and patientcentered, based
  on the expressed and real needs of the patiënt.
• New
• PDSA is integrated in normal business
• organisations invest more in healthcare workers
• assurance via certification/accreditation - part
  of contract and payment
• structured external accountability - benchmarking
  - etc.
• Structured quality report forms part of
  accountability to society
• certification obligatory part of membership?

10
Insurance companies

• Old
• Administrative role
• New
• buyer/contractor of care - sufficient - adequate
  quality and safety
• more and greater financial risks
• good insurance practice - certification?
• Inspectorate on insurance-companies CTZ - yearly
  report
• parallel report and health-charts of IGZ
• parallel reports of NP/CF etc.

11
Government

• Old
• Procuring the system to work and provide care
  that is safe, effective, patientcentered,
  efficient, timely and equa for all.
• Procure that parties are in balance and perform
  well, transparant, etc.
• Too many quality institutions funded and
  maintained by government
• new
• deregulating old rules, price-systems, etc.
  (modernisation)
• enhancing patiënt empowerment - Personal budget
• enhancing diffusion of best practices via
  programs
• introducing indicators. Performance framework

12
Inspectorate

• Old
• only when things went wrong
• can not depend on certification (only 5 of
  institutions)
• new
• More freedom, less rules and more competition
  asks for more and different ways of inspection -
  phased inspection - focus on patiënt and product
  safety
• have right to ask providers for insight in
  risk-management-systems
• active role in asking detailed information from
  providers
• own data collection Provider report charts
• Promoting best practices?
• Good inspectorate practice? - operating
  transparant
• Marketauthority and health authority working
  together

13
The near future

• Consumerism (patientrights, information
  explosion, etc) and clinical governance
  (internal, external) are driving forces for
  improvement on all the aspects of quality- no way
  back
• the goals in healthcare are indisputable
• step by step improvement
• dont expect immediate results - long term
  investment
• parties play their specific role - accept that
  role, but urge parties to play that role
  professionally.

14
Sneller Beter

• Faster Healthier
• Improvement program for hospital care
• on 2 priority areas

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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!!
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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

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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?

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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

19
Advanced Access accesstime MCL
Accesstime to outpatient clinic in days
Medisch Contact 20049328-331
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Patiëntsafety examples

• P.O.Woundinfections (PREZIES, CBO/RIVM,
  2002) Breastsurgery 25 lt3, 25
  gt9 Hipsurgery 25 lt2, 25
  gt4 Kneesurgery 25 lt1, 25 gt4

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Reduction of incidence and severity of decubitus
15
7
Doorbraak-project-IC
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Reduction postoperative pain
VAS 6
VAS 2,5
DOORBRAAK-project Medicatieveiligheid
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Medicationsafety
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Incomplete registration on medicationtransfer
From ICU to ward
DOORBRAAK-project Medicatieveiligheid
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Sneller Beter 3

• Methods integrated application!
• Breakthrough
• Integral processredesign
• Networks CEOs, CFOs, 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, traininginfrastructu
  re support by finance, ICT, HRM, MD Internal
  spread results, new subject, infrastructure
• Spread, assurance, internal and external

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Matrix integratingthemes and procesredesign

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Integral processredesign
Adjustment of tasks
Professionalqualitysystem
standardised pathways
integrated planning
Process- Supporting ICT
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Sneller Beter 3 goals (2)

• Responsiblity of management and CEO

• blamefree reporting
• internal spread results knowledge gained new
  subject and other priorities
• medical staff
• supporting processes FA, ICT, HRM, MD
• integrating DBC, IGZ-indicators, budget

Result internal acceleration
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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_at_minvws.nl www.snelle
rbeter.nl