Quality in Health care
Lessons learnt from quality programmes in health
in European countries
Jaap Koot MD, MBA
In many European countries, especially in the United Kingdom, since the 1980s,a number of quality projects in health care have been initiated. Many of these projects have not resulted in improvement of quality, but gradually a body of knowledge has developed on what are important factors in quality programmes in health care. In recent years, international programmes have been developed in Europe, often supported by the European Union. Although health care per se is left to the member states to regulate and organise, through the perspective of consumer protection and public health, the EU got more and more involved in issues of quality of health care.
Here we present some of the lessons learnt.
The definition of quality
Quality of health care appears difficult to define. Stakeholders look at it each from another perspective. Patients perceive quality in their own way; emotions play a big role. Their views on quality may be determined by the way professionals treat them, pay attention to their complaints, show compassion. Patients consider waiting times, nursing care, and other factors of care as important as cure.Health Insurance Companies may look more from a value for money perspective. They want the best health care at the lowest possible costs. They are less inclined to accept innovations which increase costs. Governments and Parliaments may take in intermediate position between insurance companies and consumers. On the one hand they are interested in the lowest possible costs, and on the other hand in satisfaction of the patients, who in the end are also voters. Professionals on the other end may only be interested in scientific state-of-the-art health care, disregarding costs completely.
Mostly quality programmes come to definitions, which take some of all view points: scientific standards, costs, and patient satisfaction.
Critical Mass
It is widely acknowledged that evidence based medicine provides the necessary clinical guidelines, which should be applied to improve quality of care. Evidence-based medicine can only lead to improvement of the health status of the population, if the majority of health care practitioners follow these guidelines. This has proven to be a though job to achieve. Medical professionals do not change easily their habits in diagnosis and treatment of patients.
The introduction of evidence-based medicine requires leadership. The professional organisations (medical societies or chambers), universities, and senior scientists have to support the introduction of clinical guidelines. Also leading clinicians in hospitals and clinics should support evidence-based medicine in their institution. Only with the support of national and local leaders to clinical guidelines, evidence-based medicine can be introduced on a scale large enough to make impact. When at least 25% of the professionals accepts a new standard, the change becomes unstoppable.
Professionals are sensitive to appeals on their professional and ethical standards (the oath of Hippocrates). They derive job satisfaction from diagnosis and treatment of patients according to scientific standards. Peer pressure based on professionalism is a strong tool in bringing more professionals on board. Clinical meetings, peer reviews, etc. in health institutions or local organisations of professionals can be ways to spread evidence-based medicine.
Continuous quality programmes
The introduction of quality in health care cannot be done through one-off activities (e.g. developing clinical guidelines or producing protocols). Most of the quality programmes are too short to make a difference, and attention is shifted to newer issues, before an impact can be made. Quality programmes should be long-term, even decades, and build on experience to constantly improve health care.
Countries, which successfully implement quality programmes, have permanent quality systems in place. The quality system includes government organisations, scientific organisations, professional organisations, health facilities, and patient organisations. The system has elements of development of guidelines, introduction of these guidelines in health facilities, education (of professionals and students), monitoring and evaluation. New scientific insights and new pharmacological and technical developments, should lead to updates of guidelines and a redefinition of quality. This indeed calls for a continuous quality programme, rather than isolated projects.
Enabling environment
Effective health care requires a combination of inputs. Facilities should bedesigned to be safe, be a pleasant environment in which to visit or work andbe sufficiently adaptable to respond to changing needs and expectations. Theworkforce must be trained, highly motivated and participate in programmesof life-long learning. In addition, evidence is growing that a supportive environmentnot only makes a hospital a better place to work but improves patientoutcomes. Concepts such as the WHO International Network of Health PromotingHospitals offer many examples of good practice.
These inputs must be combined effectively. This requires new ways ofworking for both managers and health professionals. Management and qualityassurance activities have often proceeded along two parallel but separatetrajectories. The concept of clinical governance requires that these activitiesconverge. This calls for involvement by all those working in the hospital inimproving the quality of care, within a wider framework for optimizing theachievements of the health care system.
Measuring and reporting quality
Improvement of the health status of the population is the final goal of quality programmes. However, it is difficult to see the linkage between interventions in health care and health status in general, as the health status of the population is determined by so many different factors. Therefore, a series of indicators should measure quality at an intermediate level. The intermediate level indicators can be over a longer period of time, e.g. 5-years’s survival after chemotherapy for certain types of cancer, or over short periods, e.g. post-operative wound infections. Internationally, thousands of indicators have been developed in specific health areas, which have been accepted in measuring quality. For measuring indicators health facilities have to develop reliable information systems, which can provide the basic data. Nowadays computer technology has made it possible to develop automated systems, which link patient files to monitoring of indicators.
Standardised reporting is necessary. This allows for data aggregation. Thus, data from individual providers and health facilities can become national or even international information. Standardisation of reporting allows for comparing the performanceof professionals and health facilities. Government, insurance companies and last but not least patients and consumer organisations have shown much interest in comparing information on quality. This enables choice for individuals, who can go to the facility of health care provider where the best care is given; choice for insurance companies, which can contract the best providers; choice for governments, which can exclude mal-performing providers.
Comparison also allows for benchmarking, whereby professionals can compare their own performance with others, who are working in similar circumstances. This appears to be strong impetus for quality improvement: nobody wants to end last in the comparison.
Financial compensation for quality
Everything mentioned above, like professional ethics, peer pressure, comparison of performance, benchmarking, etc. does not suffice to achieve better quality of health care. Improving quality, and maintaining quality at a high level requires investments: time of professionals and managers, equipment, information technology and so on. Individuals and institutions are not willing to invest in quality, if that results in a lower net income. The financial incentives are therefore important, at least to compensate for the invested time and money. Quality improvement at no cost has proven to be an illusion of many policy makers.
Some more lessons:
Market mechanism in health
Many countries in Europe put the market mechanism in health as an important instrument in quality development. This is working in other industrial areas: the best car at the lowest price sells best. So it can work in health as well, is the assumption. However, the health care “market” has proven to be an imperfect market. Quality of health care is not easily defined like fuel consumption in “kilometres per litre”. Quality has a multi-faceted definition. Health care providers are not distributed like car dealers: distances to health care providers play a role. This skews competition. Many patients are short-term users, for the short period that they are sick. Therefore, they don’t behave like regular consumers. Governments cannot rely on market mechanisms to achieve quality in health care.
Interestingly, chronic conditions like diabetes, hypertension, chronic obstructive pulmonary diseases and disabilities provide options for competition, whereby providers can offer a comparative advantage to (experienced) clients, at an attractive price for insurance companies. In the Netherlands, for example chronic patients receive their own budget to buy services from wherever they want.
Government responsibilities
Privatisation, decentralisation and de-regulation are international trends in Europe. However, governments continue to have a regulatory function in health care, even if they do not longer aspire to have an implementing function. One of the main tasks for governments is to regulate access to health care: equity, allowing the poorest in society to get at least basic health services. The other regulatory function concerns quality. Governments must look at all aspects, which contribute to quality, ranging from sanitary regulations to introduction of new medical techniques. Education and registration of professionals are also areas where governments should provide regulations.
As argued above, quality in health care is something which takes time, costs energy and requires investments. Politicians – per definition – have a time horizon to the next elections and may go for short term effects. More often than once quality programmes have suffered from political interference, when governments are driven by political motives rather than long-term perspectives. Nowadays, in most European countries, transparent information to the general public and international benchmarking expose such behaviour quickly.
Pushing and pulling
Development of quality programmes in health is not a gradual process, which starts and continues smoothly. There are too many interests: professional, economical, political, personal, which influence the process. This is unavoidable. Some safeguards for continuity are necessary. First of all, there should be a quality system in place, not a series of isolated initiatives to improve health care here or there. Secondly, continuous monitoring of quality programmes, with regular reporting, provides insight in how the process develops. It shows which elements do work, and which are failures. Learning lessons from experience has to become an inbuilt element of every quality programme in health.
Concluding remark
The experiences in quality programmes in health care in Europe were important for the health quality systems project in the SlovakRepublic. They showed which elements were to be included in the project. Other articles in this booklet discuss the different aspects of quality, like definition of clinical practice guidelines, monitoring of quality, external or internal quality assurance, and the framework for a quality system.