Driving quality in healthcare in Europe: an exchange to accelerate improvements

Executive summary

In December 2006 The Health Foundation and ZonMw, the Netherlands Organisation for Health Research and Development, co-hosted an exchange between healthcare leaders from eight European countries and invited  speakers. This was the second exchange between countries actively driving quality improvements. The purpose of the meeting was to provide an informal opportunity for healthcare leaders to hear about and discuss developments in quality improvement policy and practice and to share experience, with the aim of accelerating improvements.

The countries participating in the exchange were Denmark, England, France, Germany, Norway, Scotland, Sweden and The Netherlands. The challenges in healthcare are similar in each country and all eight countries have in common universal healthcare coverage.

The meeting, facilitated by Professor Tom van der Grinten, discussed three themes:

• How can reforms to national health systems such as the introduction of stronger market forces be used to improve quality?
  
• How can quality improvement become one of the drivers of cost containment and reduction?
  
• How can we use evidence about the performance of health services to achieve improvements in quality?

The first theme was introduced by presentations from Marc Berg, Partner, Plexus Medical Group, The Netherlands, and François de Brantes, National Coordinator, Bridges to Excellence, United States. Professor Sheila Leatherman, University of North Carolina, Rick Norling, CEO of Premier Inc   and Professor Richard Grol, University of Nijmegen/Maastricht, gave presentations to introduce the second theme.  Christof Veit, Manager of the National Quality Benchmarking Project, Germany, and François Romaneix, Director of the Haute Autorité de Santé (HAS), France, gave presentations on the third theme.

For the final session, Professor Tom van der Grinten facilitated a panel discussion between Professor Dr Gerrit van der Wal, Inspector General for Healthcare, The Netherlands, Professor Martin Marshall, Deputy Chief Medical Officer, England, and John-Arne Røttingen, Director General of the Norwegian Knowledge Centre for Health Services. 

Participants agreed on a number of points:

• healthcare provider organisations should systematically measure quality for accountability and for internal quality improvement
• measures should be chosen by clinical consensus based on evidence
• there should be patient involvement in defining quality measures as patients have a legitimate voice and their views are not always the same as those of clinicians
• standards for accountability should be independently determined and data independently validated

There were some issues on which participants were divided. On public reporting, some participants argued that full disclosure is necessary to enable stakeholders to make rational decisions and that it is unethical for information to be withheld from patients and the public. Against this, some were concerned about the consequences of revealing poor quality for trust between patients, clinicians and provider organisations, especially where action was being taken to tackle poor quality. Others argued that full disclosure should be timely but allow clinicians to interpret the data prior to disclosure because of the risk that data will be misused by the media or politicians. Communications need to be balanced and focus on improvement. 

Some participants felt pay for performance is a legitimate incentive, albeit not the only one, to reward high quality and, potentially, not pay for error. Some were concerned that the intrinsic motivation of clinicians might be eroded. Some felt it is wrong to offer economic incentives to clinicians.

During the exchange there were lively discussions about the standard of evidence required for quality improvement. Some participants pointed out that the evidence base for many quality improvement tools is weak and it is rarely possible to determine whether any measured change is a consequence of a particular quality improvement tool. Other participants drew attention to the validity of evidence from the social sciences and process engineering which can be applied to healthcare. Many argued that the best available evidence is enough to act to improve quality and that it would be wrong to wait for research results. 

Participants identified three areas where there are major barriers to achieving improvement in quality:

1. It is necessary to define integrated care products and quality measures for them so that payers can commission high quality healthcare for patients with long term conditions whose care crosses organisational boundaries but a way to do this has not yet been found. This is in contrast to the tools now available to define products and measure desirable outcomes for elective surgery procedures such as hip replacement and acute emergency episodes such as community acquired pneumonia.
2. Clinicians are not taught about how to improve quality. Provider organisations need help to re-engineer. The exchange heard examples of support that focused on improving reliability in specific clinical priority areas and facilitating collaborative work to support change.
3. Clinicians are not equipped to handle the demands of quality, transparency and accountability. These issues need to be included in clinical education and training

In summary, participants felt there is a lot to learn from experiences in different countries and they are willing to explore together how common problems might be solved.

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