scope, aims and results -...
TRANSCRIPT
AQUA-Tagung 2014, 14. Mai 2014 - Qualität kennt keine Grenzen
The Danish national quality improvement programme; scope, aims and results
Medical Director Paul D. Bartels
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Background
Paul D. Bartels, M.D. Chem.Path.
Medical Director, CEO: Danish Clinical Registries
Ass. Professor, University of Aalborg
Vice President, European Society for Quality in Healthcare
(ESQH)
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Governance of healthcare in DK
Regions - responsible for: Provision of hospital and
outpatient care for citizens
Municipalities – responsible for: Long-term care,
rehabilitation, prevention
National Government: Mandates framework for health care
via yearly economy agreements and a relatively limited legislation
Strong tendency towards centralisation
6
Governance of Quality Management in DK
National and regional governments +
professionals
Mainly regional governments – but
increasing governmental influence
Play-/battleground for centralisation and
party policies
Who mandates quality assurance?
Who finances and govern quality
systems?
How do politics and quality assurance
interact?
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Regional quality management
Founded on national initiatives
Part of political rationale – active political interference,
especially in areas of registries, waiting lists – delays,
patient safety and patient satisfaction
Part of management efforts on all levels – priority of
accountability, support of ”big plans” and - QI
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DK Clinical Registries - Mission
Improving prevention, diagnostics, treatment and
rehabilitation………………………………… Improvement
Documentation for clinical governance and organisational
priority setting …………………………….. Management/
Accountability
Information for citizens and patients……... Transparency
Research infrastructure…………………......... Innovation
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DK Clinical Registries
Originally founded (from 1978) by medical associations
Financed by regional governments
Mandated by law (2003)– Owned and financed by regional governments -
regulated by national government
Pass appraisal in the National Health Authority every 3 years
Contain information about individual patients – exempt from patient
consent to data collection
Information can be used for surveillance and improvement of quality (and
research)
Each registry has a professional board appointed by professional
societies/associations
Supported by National Organisation (RKKP)
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Legal definition
Registries which contain information about individual patients – exempt
from patient consent to data collection
Information can be used for surveillance and improvement of quality
National coverage
Fulfilment of national criteria for functionality, data safety and
methodology
Pass appraisal in the National Health Board every 3 years
Yearly publication of all results
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DK registries: Organisation
Each registry has a professional board – representing main stakeholders, now including patients
Registries supported by national organisation; RKKP/ Danish Clinical Registries
• 3 epidemiological units
• 2 units providing IT and QI support
Governed by a secretariat referring to the ’Political Board’ representing the Regions, Health authorities, professional and patient organisations
Financed by the regions: Total budget around 6.5 mio. Euro
DK Registries; Status
Total number 60-70
24 cancer registries, including quality of palliative care and national
screening programmes
12 non-neoplastic elective surgery/orthopaedic surgery, gynaecology
6 major chronic disease
5 cardiovascular disease
3 psychiatry
3 obstetrics
10 misc.
1 primary care (expanding – presently 5 chronic diseases)
Parallel to S, GB
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Strategic and operational issues
Usability – how, by whom, for what:
Selection of appropriate topics for registries
Clinical ownership versus standardisation of methods and outputs (plus structure)
Data collection burden – smart use of available data sources
Timing of feed-back and reporting from registries
QI activities at regional/hospital/clinical level
Coordination Health Authorities – local governments
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Good start; clarity of purpose and scope of indicators – scientific foundations
Clinical QI
Clinical Management
System Management/
Governance
Contracting – P4P
Inspection
Citizen Info
Medical/ Health Service
Research
Effectiveness
Safety
Access
Patient orientation
Equity
Efficiency
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The objective with data collection for quality is not…..
The data collection itself – but the use of data by appropriate action:
Closing the knowing-doing gap!
What do we know?
What do we do?
How to change clinical behaviour and organisation – with data
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How to select appropriate topics for registries (and close those who are not)
Disease severity, incidence/prevalence, quality problems….
Improvement possibility?
Resources – and appropriateness?
Coupling to implementation of national clinical guidelines/
cancer plan/cardiovascular plan/chronic care model?
Political and patient preferences
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Clinical QI – Framework; Clinical ownership – essential for effectiveness and data reliability
Clinical control of content (areas for indicators – framework of
interpretation = clinical targets)
Coupling to evidence based clinical guidelines
Audit and peer review
Priority of research applications
Minimal burden of documentation – reuse of accessible
data (Health IT solutions required)
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Clinical QI – Management; Predictable outputs to clinicians and organisation
Online feed-back to clinical level
Supporting data formats (SPC)
Standard yearly report with analysis and improvement plan
Capture of relevant
data or direct
reporting by
responsible
clinicians
Clinical Registry
Real or virtual
Data analyses by
clinical
epidemiologists
Data transmission
via Internet
Clinical activities and
data registration Monthly/quarterly feedback to all
clinical departments and MIS
Feedback of risk adjusted data
once a year
National clinical audit -
or Regional clinical audit
– or…
Quality
improvement
Important phases in the Danish Clinical Registries
Public release
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Clinical registries – effectiveness in improvement - variation
High volume cancers +++
Stroke +++
PCI/CB +++
Schizophrenia+++
Diabetes, COLD, Heart Failure ++
Hernia +++
Vascular surgery +
Childhood diabetes +++
Perforated gastric ulcer +++
Obstetrics +
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Postoperativ monitorering - gastrointestinal perforation
0
10
20
30
40
50
60
70
80
90
100
jan
-09
ma
r-0
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ma
j-0
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jul-
09
se
p-0
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no
v-0
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jan
-10
ma
r-1
0
ma
j-1
0
jul-
10
se
p-1
0
no
v-1
0
jan
-11
ma
r-1
1
ma
j-1
1
jul-
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se
p-1
1
no
v-1
1
jan
-12
ma
r-1
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ma
j-1
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jul-
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se
p-1
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no
v-1
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jan
-13
ma
r-1
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ma
j-1
3
jul-
13
Tid
Pro
ce
nt
Danmark
Region Hovedstaden
Region Midtjylland
Region Nordjylland
Region Sjælland
Region Syddanmark
Emergency surgery: Perforated gastroduodenal ulcer
Mortalitet - gastrointestinal perforation
0
10
20
30
40
50
60
70
80
90
100
jan-
09
mar
-09
maj-0
9
jul-0
9
sep-
09
nov-09
jan-
10
mar
-10
maj-1
0
jul-1
0
sep-
10
nov-10
jan-
11
mar
-11
maj-1
1
jul-1
1
sep-
11
nov-11
jan-
12
mar
-12
maj-1
2
jul-1
2
sep-
12
nov-12
jan-
13
mar
-13
maj-1
3
Tid
Pro
cen
t
Danmark
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System management; lung cancer in DK
1. Access to (surgical) treatment:
Delay - and organisation of diagnosis – creation of bundles
2. Quality of surgery:
Short term mortality rates – changes of patient selection,
techniques
3. Diagnostic quality: New imaging techniques
4. Life prolongation by chemo/radiotherapy
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On Site Visit from Korea 25 April 2014
Tallinn, 28-29 August 2013
Diagnostic accuracy
Source: annual report 2012, the Danish Lung Cancer Registry/Group (www.lungecancer.dk)
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On Site Visit from Korea 25 April 2014
Tallinn, 28-29 August 2013
Lung Cancer - 30 days postoperative survival
Source: annual report 2012, the Danish Lung Cancer Registry/Group (www.lungecancer.dk)
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On Site Visit from Korea 25 April 2014
Tallinn, 28-29 August 2013
Trend - 1 year survival
Source: annual report 2012, the Danish Lung Cancer Registry/Group (www.lungecancer.dk)
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On Site Visit from Korea 25 April 2014
Trend - 5 year survival
Source: annual report 2012, the Danish Lung Cancer Registry/Group (www.lungecancer.dk)
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Governance - leadership – effectiveness in promoting clinical QI?
Management attention Jha A., Epstein A: Hospital governance and the quality of care Health Affairs 29(1), 182-7; 2010
Quality contracts with professionals and hospital Danish experience 2011-13
Pay for performance/ value-based purchasing Constant increase in litterature volume – recent evidence of effect on both process and outcome!
Making results publicly available constant increase in litterature volume – effects variable!
Grade C evidence
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Current mechanisms in management and
governance via DK-registries
Name-and-shame (mandatory unit-level publication)
Coercion by line-management: From Political Council, via CEOs to clinical directors
By contractual conditions in yearly budget
No governmental interference – yet…
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Registries as a part of a coherent (?) national framework for
QI and accountability (e.g., accreditation, peer-review, patient surveys, …)
Activity Institution Remarks
Accreditation Independent institution (IKAS) Financed by Ministry of Health and
Regions.
Chairman of the Board from health
authorities, Vice Chairman from Regions.
Active cooperation with national registries
National reporting system for
adverse events
Dedicated health authority Owned and financed by Ministry of Health s
National Patient Satisfaction
Survey
Cooperation between two regional
organisations
Owned and financed by Regions –
cooperation with Ministry of Health
Patient safety activities apart
from reporting systems
Independent organisation (national
patient safety organisation)
Owned and financed by professional
associations (e.g. medical/nursing societies,
pharmacies), contribution from region,
political chairman appointed by regions
National clinical guidelines Health authority (National Health
Board)
Financed by Ministry of Health,
Active and close cooperation with N.Q.R.
Quality monitoring on generic
level (e.g. follow up on cancer
and heart plan, waiting time
standards, OECD indicators)
Health authority owning national
epidemiological/public health
registries (SSI)
Financed by Ministry of Health, close
cooperation with National Quality Registries
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Registries as a part of a coherent (?) National framework for
QI and accountability (e.g., accreditation, peer-review, patient surveys, …)?
Activity institution Remarks
Inspection/regulation Natíonal Health Board Financed by ministry
No connection to registry data yet
Campaigns National patient safety Regional governance
Role for registries
Cancer Surgeon Certification Professional societies National/regional government reluctant
Cooperation with NQR
National Speciality plan National Health Board Mandatory concentration of advanced
services.
Registries form documentation
National Nursing guidelines Professional societies
+ university
Financed (indirectly) by regions
Institutes for improvement University + region Like IHI
Initiatives for cooperation with NQR