What an Outcome! Four Years of Learning About the Quality of Healthcare

What an Outcome! Four Years of Learning About the Quality of Healthcare Robbert Huijsman Robbert.Huijsman@achmea.nl Samuel Smits Samuel.Smits@gupta.nl Pre-reading material for Master class (I9) Improve the success of your Quality Improvement Program For private use only. Nothing from this could be spread, cited or produced without prior approval from the authors. Introduction Under the current Dutch healthcare system, health insurers are responsible for procuring healthcare services on behalf of their customers based on volume, price and quality. The objective is to generate maximum health gains at the lowest possible price, a concept we refer to as value-based healthcare. Quality of care is defined in this context in terms of added value or outcome, with examples including health and recovery, quality of life, performance, and regaining control and self-reliance. This focus on positive outcome indicators was the main defining principle of the Kwaliteit van Zorg (Quality of Care) programme organised by Dutch health insurer Zilveren Kruis. On completion of the programme on 31st December 2016, we achieved our goal of making approximately 40 per cent of healthcare versus just 7 to 8 per cent in 2011 transparent in terms of outcomes in just four years time, a process in which we worked together with various stakeholders. We also marked the completion of the programme with the publication of the book Wat een uitkomst! Vier jaar leren over kwaliteit van Zorg ( What an Outcome! Four Years of Learning About the Quality of Healthcare ). In this book, we relate our experiences shared with various other health industry leaders with issues such as registration, the process of mirroring the experiences of clients and employees, improving, benchmarking, and providing patients with access to information about quality and the options available to them. We share some of the following experiences in this summary: Outcomes are needed in order to assess the value of healthcare. Learning and systematically improving quality requires transparency and a safe environment in which professionals can share knowledge and experiences with each other; Insurers customers need information on outcomes in order to make informed decisions regarding healthcare services; Zilveren Kruis intends to actively contribute to providing the highest-quality healthcare to its customers, including by developing new procurement models which reward and promote quality; We are collectively responsible for creating an ecosystem for quality. Quality improvement: higher average and less variety In order to promote our goal of measurement and improvement, we use the motto Shifting the curve up and to the right. The curve, in this case, represents the statistical breakdown of the lowest to the highest scores for an outcome indicator. Our aim is not just to improve the average ( to the right ), but also to reduce the gap between the lowest and the highest scores ( up ). While we are aware that we cannot all achieve a perfect score of 10, we are sure to generate real gains if the many thousands of professionals and institutions that currently hover around the average can all take that single step toward improvement (this is addressed in Chapter 4 of the book). Professionals are, by their very nature, driven by a strong desire to innovate and improve the quality of the care they provide. Health insurance providers, for their part, aim to contract the highest-quality -1-

care at competitive rates, in order to procure the highest possible added value on behalf of their customers. So how do we deal with these differences in quality between insurance carriers? Underperforming healthcare providers tend to feel frustrated if they are instantly penalised during the procurement process instead of being challenged to improve their performance. By the same token, providers that have demonstrated the quality of their services also deal with feelings of frustration when conducting the same conversation as the providers that find themselves on the left side of the curve. This means that health insurers are faced with the challenge of linking the intrinsic motivation for improvement to extrinsic motivation in the form of financial rewards. Core of the Quality Programme The primary mission of the programme was to develop and/or measure sets of outcome indicators (this is covered in chapters 1 and 3). Chapter 6 describes the methodologies used for this purpose in long-term projects. The project focused on a total of more than 20 medical conditions. We worked closely with the healthcare sector, which was also involved in validating indicators and the corresponding case-mix models (see the table next page). One of the other key objectives of the programme was to promote periodic quality measurement as part of the primary professional process, in a way that was as clear and simple as possible. This calls for effective quality registrations, since there is no outcome without registration (see Chapter 7). Various registrations have received funding to support the establishment and organisation, the incorporation of outcome indicators and the generation or mirroring data. Quality registrations which showed improvement over the course of the project later turned out to be better equipped to generate reliable information on outcomes, while at the same time convincing healthcare providers that mirroring and improvement both add value. There is a need for a national infrastructure for standardising quality registrations at the source, while at the same time professionalising and especially simplifying them in terms of organisation and funding. It was for this reason that we initiated the establishment in late 2014 of the Task Force for Quality Registrations at the Dutch Associated Health Insurance Companies (Zorgverzekeraars Nederland/ZN), so that insurers will have the opportunity to cooperate in the future. Initiatives currently being developed include a National Service Platform for Quality Registrations, which is dedicated to standardised data exchange and processing. -2-

Indicators developed as part of Achmea s Quality of Care programme (2011-2015) Condition Sets of outcome indicators developed and/or measured Case-mix model developed Registration organised or improved with the support of the programme Arthrosis Registration funded or partially funded by the programme Breast Cancer Cerebrovascular Disease (Stroke), also for informal carers Coronary Atherosclerosis Cystic Fibrosis Colon Cancer Diagnostics Dementia Depression, also for informal carers Diabetes Natal Care In Vitro Fertilisation (IVF) Lower Back Pain Lung Cancer Expected January 2016 Oral Care Elderly Care Palliative Care Ongoing Discussion stage Peripheral Arterial Disease Prostate Cancer Rheumatoid Arthritis Convalescence Services Care for People with Intellectual Disabilities Parkinson s Disease, also for informal carers Ongoing -3-

Need for new forms of co-creation Ongoing improvement is a search process involving collective action initiated by patients, professionals and health insurers. The process of implementing improvements together requires transparency and security, along with focus, perseverance and a focus on results. However, as Chapter 5 of the book demonstrates, what it requires above all is trust, and experience has shown that this trust is fostered through a focus on substance, as removed from financial and other interests as possible. The objective of the exercise is to support policyholders in making a choice and to share best practices in order to ensure ongoing improvement of the healthcare sector as a whole (this is covered in chapters 2 and 10). Zilveren Kruis pursues a policy of patient empowerment, which involves prioritising the patient journey of policyholders over healthcare procurement instead of the other way around. We reward healthcare providers that align with this policy and show results that improve patient care by purchasing services from them in larger volumes, entering into long-term contracts with them and explaining to policyholders the added value of choosing a particular healthcare provider (see the figure and Chapter 9 of the book). All this requires new procurement models we would like to test in conjunction with the healthcare sector. Zilveren Kruis has detailed its ideas about healthcare procurement in a white paper titled Van Goed naar Beter: inkopen op kwaliteit ( From Good to Better: Quality-Based Procurement ) and is developing value potential models for a variety of medical conditions. Zilveren Kruis has overhauled its procurement system for this and other reasons: instead of procuring services from hospitals and general practitioners in two separate processes, it provides the integrated care required during a patient journey by focusing on specific medical conditions. Healthcare modules have been developed for renal failure, natal care, oncology and community health services. In addition, we are also focusing on improvement throughout the entire healthcare supply chain, across the barriers which exist between the various healthcare providers (this process is described in Chapter 8). Based on this philosophy, we will be procuring and funding on a more differentiated basis, partly based on quality differences. This calls for a different division of duties, one that is focused more on connectedness, relationships, customer needs and coherence in the local community. In the procurement process, we have witnessed a shift in focus from the lowest price to a substantive discussion about the content and quality of the care (i.e. the healthcare supply chain). The healthcare procurement process will therefore focus increasingly on the added value for insured persons: improving the quality of care and quality of life, and reducing costs. Towards an ecosystem for quality We are in the process of creating an ecosystem for quality (addressed in Chapter 11), with each party assuming its own responsibility: health insurance providers will embrace the practice of comparing themselves to each other and improving their performance by managing outcomes; customers will make more informed choices and will achieve their healthcare goals through self-management during the patient journey; while health insurance providers will adopt more differentiated procurement policies in order to achieve better outcomes with less variety at lower rates. The book details our initial experiences, but we still have some way to go in terms of quality improvement. This is possible only if the various parties involved join forces, each based on their own area of responsibility, but based on the awareness that quality calls for close cooperation. We note here that improvement and innovation come with their own set of obligations and appeal to a sense of social entrepreneurship and cooperation based on commitments. Health insurance providers and health insurers are jointly responsible for effectively and efficiently achieving the proposed objectives. There is also a clear need for input from the government and their regulators, as we are faced with numerous complex issues in our efforts to establish a transparent healthcare system. We would be interested in receiving feedback from you on our book and in learning more about your experiences in our common quest for higherquality healthcare at more effectively managed rates, resulting in a higher quality of life for our customers. -4-

Management summary book chapters Chapter 1 Quality, in our definition, refers to achieving outcomes that meet and, in some cases, exceed customers expectations. While investing in quality pays off in the long term, it does require collective action on the part of patients, professionals and health insurers. While the healthcare system developed in the Netherlands in recent years has proved effective, it has also become highly complex, involving numerous intricate processes and myriad guidelines and procedures. The question to ask is: what are the outcomes for customers? What added value does the healthcare system deliver? This book provides an account of the four-year journey leading up to the establishment of the Kwaliteit van Zorg (Quality of Care) programme, which involved a number of chain processes and searching for outcomes for various medical conditions. It is all part of the process of developing a new ecosystem for quality. Chapter 2 The central idea is to put customers and their needs first. Although customers have always relied on the expertise of their doctors and other medical professionals, they are presented with a growing amount of information and are required to make choices and assess the pros and cons of specific treatments. The journey from the initial symptoms to diagnosis, followed by treatment and aftercare, is a lengthy one. Zilveren Kruis worked with customer panels and patient associations to develop a patient journey which included the provision of all sorts of information, used as a tool in asking the most effective questions. We firmly believe that correct, reliable information facilitates the decisionmaking process during the patient journey. We have noted that the need for information goes beyond clinical outcomes and also extends to patients quality of life and day-to-day functioning. Chapter 3 On the launch of the Kwaliteit in Zorg (Quality of Care) programme in 2011, there were already a large number of process indicators in place. The bulk of the Zichtbare Zorg (Visible Care) programme consists of such indicators. Some of the volume standards are set by healthcare professionals, but process indicators and volume standards focus mainly on how the healthcare system is organised and do not reveal anything about the quality provided at the end of the healthcare process. The missing link here are outcome indicators: if we can compare these with the processes and related expenses, we will understand the value of the care provided. Outcomes will become the main criterion for process improvement and innovation. This process of investing in added value is sometimes referred to as value-based healthcare. Chapter 4 At the outset of the programme, there was little information or data available about healthcare outcomes, and whatever data was available showed substantial differences between health institutions or healthcare providers. This proved to be a genuine eye-opener, both for the professionals themselves and for patients. These differences provided opportunities for improvement: not by focusing on the underperformers, but rather by highlighting and sharing best practices, which is a complex and time-consuming process. At the same time, they did result in dramatically improved average scores and a less pronounced distribution of these scores. We refer to this process as Shifting the curve up and to the right. Chapter 5 Professionals, healthcare providers and health insurers work together to provide the highest-quality care to their customers. This requires mutual trust trust that is created based on a shared focus on the actual content of the task at hand, aside from financial and other interests. It is also important to negotiate the interests and power positions of the various stakeholders involved. It can be challenging to transcend your own or your organisation s interests and to be committed to adding real value for your customers. The professionals involved need to take a leading role in determining quality levels, and developing and establishing quality indicators comes with its own share of responsibilities. This -5-

process needs to be safe, the division of duties should be clear, and health insurers must facilitate whenever they can. Chapter 6 Working together on improving healthcare and the quality of life for all customers: isn t that what we all want? However, this does call for measurable outcomes, and the process of developing, measuring and implementing such outcomes requires very specific skills and is as yet underdeveloped in the Netherlands. Outcome indicators link the professional s perspective ( Does the treatment achieve the expected effect? ) to the perspective of the customer ( How can I get rid of my symptoms? ; Will I ever have the same quality of life again ; Will I be able to function normally again? ). Are you sure you are measuring what needs to be measured? A careful process includes steps such as selecting and testing the correct indicators, adjusting for differences in patient categories, and making comparisons between various institutions. Professionals are then faced with the challenge of using these outcome indicators to improve their healthcare processes as systematically as possible. We have learned from these measuring issues that one needs to be alert to how carefully the process is conducted, along with the validity of the data and correct analysis. This should occur in the context of a trusted and secure collaborative environment, thereby encouraging professionals and institutions to be transparent about their outcomes. Chapter 7 You cannot have outcomes without an established quality registry. Quality registries are needed in order to measure, collect and compare outcomes for the quality of healthcare, make them visible through reports, and improving them. The Netherlands has many different quality registries which are of significant value when it comes to improving the quality of healthcare. However, this is a highly fragmented landscape, with substantial differences in structure, content and strategy. At the same time, pressure on quality registries intensifies caused by the growing administrative burden and higher expenses. This calls for a higher level of professionalism, so that the national quality systems can really deliver on the added value promised. For this reason, it is important the quality registries become part of the core professional process. Professionals should preferably take a leading role when it comes to the medical-substantive aspects of quality systems. There is also a need for additional expertise to create a supporting national infrastructure that contributes to achieving better outcomes at a lower cost. Chapter 8 Determining outcome indicators is one thing, but it will really only become valuable when professionals achieve ongoing quality improvement. While professionals nearly always possess the intrinsic motivation to do this, there is still a great deal of progress to be made, as the culture of improvement and the related methodologies are not yet at the level they should be. In addition to time and a safe environment, improvement also requires knowledge and skills. There is a fear that health insurance providers are too quick in drawing conclusions and lack nuance in doing so. The objective is to appeal to the learning capacity of professionals; only then will they have the scope they need to improve and innovate. Chapter 9 And that s when the moment of truth arrives: are best practices actually rewarded? Professionals are driven by a strong desire to innovate and improve the quality of the care they provide. Health insurance providers, for their part, aim to contract the highest-quality care at competitive rates, in order to procure the highest possible added value on behalf of their customers. So how do we deal with these differences in quality between insurance carriers? Underperforming healthcare providers tend to feel frustrated if they are instantly penalised during the procurement process instead of being challenged to improve their performance. By the same token, providers that have demonstrated the quality of their services also deal with feelings of frustration when conducting the same conversation as the providers that find themselves on the left side of the curve. This means that health insurers are faced with the challenge of linking the intrinsic motivation for improvement to extrinsic motivation in the form of financial rewards. -6-

Section 10 With a growing amount of data available on outcomes, it is important to interpret this data for policyholders, so they can start using this information. Our healthcare system is based on the principle of well-informed customers: policyholders must, as patients, be able to make an informed choice from the health insurance policies available. What is even more important, however, is that customers, in making these choices, receive maximum support through good information and insight throughout the entire patient journey. This is required that information is presented in a comprehensible way, in text and images. And the next question is: will policyholders actually use this information? Section 11 We have nearly come to the end of this book, but the transition towards a system of outcome management is set to continue. Continuous improvement and innovation of the healthcare system using outcome indicators creates an all-new dynamic between customers, professionals and insurers. We are moving away from bureaucracy, responsibility and fear and towards a new ecosystem of ongoing quality improvement. The system of value-based healthcare is really beginning to take shape, but we continue to retain all kinds of influences and experiences from the past. What steps are required in order to create a new ecosystem for quality? -7-