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 Wognum Stupava

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 System Project – and Programme – based Improvement

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 System Project – and Programme – based Improvement Strategically Focused Large-System Change

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 System Project – and Programme – based Improvement Strategically Focused Large-System Change Building Improvement 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 stage Project – and Programme – based Improvement Strategically Focused Large-System Change Building Improvement Into Daily Work Leadership for Improvement Receptive Organisational Context for Improvement

Ministerie van Volksgezondheid, Welzijn en Sport “Sneller Beter” Accelerating improvement Faster Healthier Improvement 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 2 nd chamber nov03 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 Advanced Access : accesstime MCL Medisch Contact 2004;9: Accesstime to outpatient clinic in days

Ministerie van Volksgezondheid, Welzijn en Sport P.O.Woundinfections (PREZIES, CBO/RIVM, 2002) Breastsurgery:25%: 9% Hipsurgery:25%: 4% Kneesurgery: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 Doorbraak-project-IC 15% 7%

Ministerie van Volksgezondheid, Welzijn en Sport Reduction postoperative pain DOORBRAAK-project Medicatieveiligheid VAS: 6 VAS: 2,5

Ministerie van Volksgezondheid, Welzijn en Sport Medicationsafety:

Ministerie van Volksgezondheid, Welzijn en Sport Incomplete registration on medicationtransfer From ICU to ward DOORBRAAK-project Medicatieveiligheid

Ministerie van Volksgezondheid, Welzijn en Sport Sneller Beter 3 Methods: i ntegrated 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 CEO Integration of all projects, traininginfrastructure support by finance, ICT, HRM, MD Internal spread: results, new subject, infrastructure Spread, assurance, internal and external

Ministerie van Volksgezondheid, Welzijn en Sport Out- patient clinic Diagn. ward. Surg. theatre Hospital ward Advanced access flow OK- project POWI Decubitus Medicationsafety Tumors Mamma- ca Lung- ca Elective surgery Hip Inguinal hernia Matrix: integrating themes and procesredesign

Ministerie van Volksgezondheid, Welzijn en Sport Adjustment of tasks integrated planning Professional qualitysystem Integral processredesign Process- Supporting ICT standardised pathways

Ministerie van Volksgezondheid, Welzijn en Sport 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

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 EJ The Hague The Netherlands Tel: