scope, aims and results -...

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

2

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)

3

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

5 regions in Denmark

Central Denmark

Region

5

Quality is central to policy and management

in all levels of government

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?

7

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

8

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

9

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)

10

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

11

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

13

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

14

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

15

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

16

You can’t fatten the pig by weighing it; But…

17

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

18

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)

19

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

http://www.clipartconnection.com/clipartconnection.com/showphoto.php?photo=15301&papass=&sort=1&thecat=500

21

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 +

22

Postoperativ monitorering - gastrointestinal perforation

0

10

20

30

40

50

60

70

80

90

100

jan

-09

ma

r-0

9

ma

j-0

9

jul-

09

se

p-0

9

no

v-0

9

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-

11

se

p-1

1

no

v-1

1

jan

-12

ma

r-1

2

ma

j-1

2

jul-

12

se

p-1

2

no

v-1

2

jan

-13

ma

r-1

3

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

23

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

24

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)

25



Lung Cancer - 30 days postoperative survival


26



Trend - 1 year survival


27


Trend - 5 year survival


28

Governance – leadership: Performance management (been there since 1800 B.C.)

29

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

30

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…

31

P4P Danish style

32

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

33

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

34

Thank you for your attention

Questions?

35

Danish Lung Cancer Registry system

scope, aims and results -...

Documents