Improving Hospital Performance creating synergy between quality, efficiency and payment models Niek Klazinga, Zagreb Januari 28 2013
Average OECD health expenditure Growth rates in real terms, 2000 to 2010, public and total 2
Average annual growth in health spending Real terms, 2000-2010 3
.menu The life cycle of hospitals Strategies to improve quality of care Measuring hospital performance Synergy between quality and efficiency Synergy between quality, efficiency and payment models
The life cycle of hospitals 19 th century roots 20 th century: golden age of the hospital as a modern high tech industry with specialized work-force focused on clinical medicine 21th century: decline and transformation of hospitals
The life cycle of hospitals Less need to concentrate the technology associated with clinical care in one location (smaller and portable equipment for diagnoses and treatment). Less need to concentrate all clinical functions in one location (ICT) Gradual shift towards dealing with the acute phases of chronic diseases
The life cycle of hospitals Emergency care in local health posts and ambulances Shift from in-patient care towards day-care and out-patient care Shift towards long-term care (nursing homes, home care) Shift from specialization towards generalization in the professional workforce
Types of Hospitals Ownership public or private Not-for profit hospitals For-profit hospitals Nature and level of specialization of clinical functions Teaching Research
Croatia 5.6 in 2010 (small decline in 10 years) EU average 5.3
Hospitals Croatia/EU 27 Hospital beds per 1000 population in 2010 5.6 (EU 5.3) and small decline in past 10 years (- 0.7) Average length of stay in hospital for all causes 2010 9.8 (EU 6.9) Average length of stay AMI 10.2 (EU 7.1)
European Projects on Hospital Performance PATH (WHO/Euro) Marquis Duque Mortality based indicators (HSMR) (re)admission based indicators Patient safety indicators Patient experiences
Quality Strategies Results of the EU funded Marquis project Theme issue Quality and Safety in Health Care. February 2009, Vol.18 Supplement 1
Strategies studied Hospital Level Q.I. Strategies Ward Level AIM Deliveries Appendicitis QI Strategies QI Strategies QI Strategies Outputs Outputs Outputs 1- External pressure 2- Organizational quality management programs (TQM) 3- Audit, internal assessment of clinical standards 4- Patient safety systems 5- Clinical practice guidelines 6- Performance indicators 7- Systems for getting patient views
Participation in the study Questionnaire Audit UK 14 5 Ireland 25 6 The Netherlands 10 0 Belgium 25 1 France 78 18 Spain 113 29 Poland 80 15 Czech Rep 44 15 Total hospitals 389 89
Analysis of strategies inter-connection Exploratory Factor Analysis: Hospital Level Q.I. Strategies Ward Level AIM Deliveries Appendici tis QI Strategies QI Strategies QI Strategies Outputs Outputs Outputs Strategy Indexes Loading weights - Performance indicators or measures.717 - Organizational quality management programs (TQM).706 - Patient safety systems.695 - Clinical guidelines.692 - Audit, internal assessment of clinical standards.656 - Systems for getting patients views.652 Total variation explained Clinical guidelines 47% Patients views Cronbach s alpha=0.724 N=389
Summary of preliminary recommendations: (EU level supporting hospitals) - It is recommended that hospitals work on combining quality strategies instead of focusing all the efforts on one of them, since we found that the quality strategies studied are part of one single construct. - We did not find any evidence of effect of ownership or teaching status in any output measure. There is no reason for differentiating QI strategies to be promoted based on teaching / ownership hospital status. - - We recommend to promote external assessment of hospitals, and consider that the type of external pressure should be accommodated with the goals and context of health care delivery - Support further research to further develop and validate the maturity index on the hospital s quality management system and to promote its use by healthcare organizations.
Synergy quality and efficiency Differences between efficiencies on department, hospital and whole system level Value creation perspective (Porter et al) Waste perspective (RAND) Quite often existing payment systems do not allow a business case for quality
Synergy between quality, efficiency and payment models Assess hospital performance from a whole system perspective Focus on process as well as short and long term outcome indicators Align the hospital infrastructure with the changes in the hospital life cycle Align the interests of management and professionals Adapt incentive structures including payfor-performance models