Report of the International Quality Improvement Exchange 2005

Between 24-26 November 2005, senior leaders from seven European countries participated in an exchange about their experiences in improving the quality of health services. Hosted by The Health Foundation, the purpose of the meeting was to explore whether national leaders in healthcare policy and practice could learn from each other about how to drive effective quality and performance improvements.
Participants identified many key challenges in common across the seven countries. These include increasing patient and population expectations, demographic changes and the rising prevalence of chronic conditions. Concerns about value for money and quality clearly resonate with all.

Participants drew from their discussions and the examples of system reform presented by speakers five key lessons:

• The importance of a vision that encapsulates the values of the organisation and the commitment to these required of staff
  
• Systematic and pervasive means to engage staff in the vision
  
• Integration of quality and performance measurement into the business
  
• Electronic information systems as a key infrastructure of the healthcare business
  
• The need to engage patients and the public
  

Participants at the meeting came from Denmark, England, France, the Netherlands, Norway, Scotland and Sweden. The participants’ positions ranged from senior Ministry and Government officials, clinical and service leaders, patients’ advocates, academics, quality improvement practitioners and independent European bodies.
The meeting, facilitated by Professor Chris Ham, focused on two major themes. The first was how complex systems achieve demonstrable improvements in outcomes. The second was the use of information on clinical outcomes to improve quality and performance. The style of the meeting was to hear experiences, question and discuss, reflect, summarise and conclude.
Presentations by Dr Jonathan Perlin from the Veterans Health Administration in the USA and Mr Göran Henriks from Jönköping County Council in Sweden stimulated discussion in small working groups on the first theme. Discussion on the second theme was encouraged by presentations by Professor Brian Jarman from Imperial College, London, Dr Paul Bartels and Dr Jan Mainz from the Danish National Indicator Project and Dr Tim Doran from the University of Manchester.
The final session included a presentation by Mme Eliane Apert from the Ministry of Health and Social Affairs about reforms in healthcare in France. Professor Geert Blijham from Utrecht spoke about reforms in the Netherlands. Professor Sir Liam Donaldson then provided reflections about progress in England, and there was a final dialogue about underlying approaches to reform.
Arising from the discussions on the use of quality measures, there was a considerable consensus about the need for quality measures both to drive improvement and to ensure accountability to stakeholders. On national reform, many different efforts were being made to improve quality, each involving risks and benefits. Views were mixed on the use of competition and pay-for-performance for improving quality.
Participants were interested in exploring how self-management might be promoted by a radical re-design of the delivery of healthcare. Comparisons were made to the way that re-design in the recorded music and banking sectors has changed customer behaviour. All stressed the importance of creating a culture within healthcare organisations that focused on achieving the highest possible quality among healthcare professionals, and the need for leaders who can achieve this.
Participants provided very positive feedback about the meeting. In responses to an evaluation several weeks after the exchange, nearly all had followed up contacts made at the event and 80 percent reported that they had done, or intended to do, something differently as a result of their attendance.

The Health Foundation is an independent charity that aims to improve health and the quality of healthcare in the UK. One of its strategic aims is to build knowledge about the performance of healthcare systems in delivering high-quality healthcare and the most effective strategies to drive performance improvement.
A number of European countries with universal health cover are actively driving quality improvements at a national level. These include Denmark, England, France, the Netherlands, Norway, Scotland and Sweden. The activities being conducted in each country and their shared social values present a natural experiment that could be used to accelerate improvements.
The intention of The Health Foundation was to provide an informal opportunity for high-level policy advisors, such as Chief Medical Officers and other healthcare leaders with a prime interest in, and responsibility for, quality and performance improvements, to meet with others with similar interests and perspectives and reflect on what works well and why.
The purpose of the meeting was to determine whether an opportunity for exchange between these countries – through a private and informal meeting hosted by a neutral organisation – would provide the right environment to enable national leaders in healthcare policy and practice to learn from each other about how to drive effective quality and performance improvements.
For the purposes of the meeting, the term ‘quality’ was used in the sense defined by the US Institute of Medicine: the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
Quality is seen as inextricably linked with the performance of healthcare systems overall.

The Health Foundation invited people from Denmark, England, France, the Netherlands, Norway, Scotland and Sweden who were known for their work on quality issues to meet informally to discuss whether there was merit in an exchange between countries. The group strongly supported the idea. Members then met in a planning group to provide advice at several points throughout the year about who might
be involved and what would be the most useful focus for discussion.
Through these informal discussions, two significant policy questions common to all of
the countries emerged. These were:

• What is needed at a national level to improve quality across systems of care?
  
• Can we drive quality improvement by making healthcare more transparent to patients and the public, and, if so, how?

With advice from the planning group, The Health Foundation arranged a meeting to be held late in 2005. It invited up to five senior people from each of the seven countries. People were chosen who would bring different perspectives, such as policy, service management, regulation, technical quality improvement, professional leadership and patient involvement.
Background papers were circulated in advance of the meeting. These included current issues in healthcare, experience of quality improvement in each country and data comparing performance.
Leading practitioners and experts were invited to provide presentations to stimulate discussion on the identified themes. The programme was planned so that more than 75 percent of the time at the meeting would be available for discussion between participants.

Session one held on Thursday 24 November

Setting the scene
Sir David Carter, Chairman of The Health Foundation, and Dr Vin McLoughlin, Director of Programmes and Policy, opened the meeting by welcoming all of the guests, providing a brief introduction to The Health Foundation and outlining the background to the meeting. This was the first exchange of this type that The Health Foundation had supported, and its value would rest on the participants. The intention was to produce a report that would be available publicly, but none of the material would be attributable and participants would be asked to approve the draft before its release.
The exchange opened with a discussion, facilitated by Professor Chris Ham, exploring the challenges for quality improvement in healthcare in each participant country and some of the changes to policy and practice that are being made.

Challenges
Participants identified several challenges. These included the need to manage cost pressures and achieve greater value for money; to prioritise in the context of rising numbers of elderly people in total – and as a proportion of the population; workforce shortages; better detection and treatment, and longer survival; and the threat of new diseases.
In some countries management of these issues is more difficult because of divisions between clinicians and managers, and the difficulty in involving doctors in discussions about priorities and costs. In all countries, health and healthcare are the subject of intense media interest.

Reform at national level
In response to these challenges participants are engaged in national reforms. Examples include requirements for healthcare providers to guarantee levels of service to patients to drive improved access (Sweden), a requirement for hospitals to have a safety-management system by 2008 (Denmark) and a strategy to provide a robust basis for decisions on the reconfiguration of specialist healthcare services (Scotland). In England and the Netherlands, competition is being introduced to drive patient-centred care and efficiency.
In all countries, investments in information systems are being made to create electronic patient records, which should improve safety and quality. Some countries are also pursuing strategies to encourage individuals to improve their own health.
Participants agreed that one consequence of national reforms is that there are further constraints on clinician decision-making.

Using quality and performance data to drive improvement
All countries are using quality and performance data to drive improvement. Participants want to use external comparators, including international ones, as well as internal ones. In some countries there is difficulty in getting agreement between stakeholders on which measures of quality are valid and should be used for internal management and external reporting. There are also tensions resulting from the reporting of quality and performance data. These tensions arise from disputes about the validity and accuracy of data, and about ownership and control.

Session 2 held on Friday 25 November

Systems approaches to quality and performance improvement

The presentations
The first formal session of the exchange concentrated on whole-system approaches to quality and performance improvement. The discussion was started by presentations from Dr Jonathan Perlin, Chief Executive of the Veterans Health Administration, Washington DC, USA, and Göran Henriks, Chief Executive of Learning and Innovation, from Jönköping County Council in Sweden.
Dr Perlin explained that the context for the improvement strategy adopted by the Veterans Health Administration in the late 1980s was a system that was believed to be performing poorly and had a poor reputation but, in common with all health systems, lacked measures. The transforming principles were:

• A need to change because of a poor reputation and declining political capital
  
• A shift from safety-net hospitals to a system fostering health promotion and disease prevention

Looking ahead, Dr Perlin said that, with quality measurement now embedded in Veterans Health Administration systems supported by electronic health records, the next strategy for improvement would be collaborative education and training for all healthcare professions. Lapses in communication are responsible for 60 percent of errors in healthcare and a major contributing factor is the different cultural education of doctors and nurses. Collaborative education and training needs to include opportunities for doctors and nurses to socialise together to tackle their different cultural education.
In his presentation, Göran Henriks explained that Jönköping County Council delivers the highest-quality and best-value care of all the counties in Sweden. The county council has benefited from a strong and continuous relationship between the Chairman and Chief Executive. This has been important in delivering a consistent vision over several years.
The challenges in healthcare for Jönköping County, in common with other counties in Sweden, include:

• The oldest population in Europe, driving up demand for healthcare
  
• New technologies and treatments and longer survival rates driving up costs
  
• The recruitment and retention of sufficient healthcare professionals

The strategy for improvement at Jönköping County includes:

• Investment in staff – this includes enabling them to do their current job well and
  to change their own jobs to meet future expectations
  
• Applying knowledge from elsewhere, for example, quality improvement methods from the Institute of Healthcare Improvement in the US, healthcare clinical standards from the UK and modern industrial process methods from Toyota
  
• Building information systems to support improved processes, rather than building information systems on unreformed processes
  
• Considering how all the available funds are used, not just the marginal amount that changes each year

The workshops
Participants divided into four workshops to discuss the issues raised from the presentations. The key points identified during the discussions were:

• The importance of a vision that encapsulates the values of the organisation and the commitment to these needed from staff
  
• Systematic and pervasive means to engage staff in the vision
  
• Integration of quality and performance measurement into the business
  
• Electronic information systems as a key infrastructure of the healthcare business
  
• Engaging patients and the public

Vision
A feature of the Veterans Health Administration and Jönköping County is that both organisations have benefited from a consistent vision over time. The presenters stressed that everyone in the system must be committed to the vision year after year – this means leaders and all staff.
Participants in the exchange recognised the difficulty of achieving consistency of vision where continuity of leadership is not possible. In some places, what appears to be a single system may in fact be separate tribes that struggle to work together. Others may perceive strategies for improvement adopted by one group in the system as tools in a power struggle.
In a large system such as the Veterans Health Administration, with over five million enrolees and facilities across the USA, the balance between clarity of vision and direction from the centre and local autonomy is also critical. The nature of central/local relationships is likely to differ in each country.

Staff engagement
Participants discussed the considerable difficulties in achieving staff engagement in quality improvement in healthcare delivery.
Some felt that it was unclear what type of relationships work best to improve quality and in what contexts, for example, the balance between support and challenge; relationships between individuals and levels in the same organisation and between organisations.
The experience of participants and the material from the presentations suggested that three factors are essential. First, line managers must be responsible for quality improvement, starting with the Chief Executive and their team. Secondly, there must be clinicians in senior managerial positions. Finally, a no-blame culture is essential to improve quality and safety.
Participants were interested in the internal communications used by the Veterans Health Administration to reinforce messages to all staff, including constant reporting of performance on key quality indicators. Participants felt systematic internal communications are necessary, especially in large organisations.
The need for doctors and other healthcare professionals to have improvement knowledge as well as professional knowledge was also discussed. A common difficulty is getting medical schools to recognise the importance of improvement knowledge, but some medical schools are now taking this on.
Better alignment of continuing medical education with pre-and post-registration training is also needed, otherwise when students try to put new methods into practice they get no support from existing staff. There are examples of success in teaching quality improvement methods to clinicians in their own context. Research also shows that the momentum of quality improvement is easily lost once those trained to lead projects leave.

Quality and performance measurement
Participants were clear that the selection of measures should follow agreed priorities
identified from the vision of the organisation and that patients have a role in defining quality.
In some of the participant countries there is no agreement at national level on key indicators
or open disclosure, and attempts to achieve this have failed.

Electronic information systems
Participants from all countries reported substantial investment in information systems including electronic health records. In some countries there is, as yet, no national co-ordination and this will limit the benefits.
There are still issues of confidentiality to be resolved and user adoption remains a critical issue. Participants noted that research on public attitudes to electronic patient records shows patients want their record to be available to appropriate healthcare professionals. They also want the right to have some ‘locked areas’ that can be shared only with explicit consent.

Engaging patients and the public
Participants identified several issues of common concern across the seven countries. These included the challenge to equity from patient empowerment, which is bound to be established differentially; doubt about whether the public will give as high a priority to prevention as to the provision of healthcare; how to educate the public about risk in healthcare and how to support healthcare leaders to engage with the media. Some participants were positive about the possibilities of engaging patients in self-care by re-thinking delivery methods so that they incorporate co-production, as do retailers such as IKEA. Successful self-care requires changes by healthcare professionals for example, they must accept that the patient owns their record.

Session 3 held on Friday 25 November

Quality measurement as a tool to achieve quality improvement

The presentations
The second session of the exchange focused on three examples of the use of quality measures to improve quality. First, Professor Brian Jarman, Emeritus Professor in the Faculty of Medicine, Imperial College, London, England, presented his work on the use of Hospital Standardised Mortality Ratios (HSMRs) as an indicator of quality. Professor Jarman explained the political background to and practical use of HSMRs:

• The data has been available in many developed countries since the 1960s but has not been used because of professional and provider interests; in England, the data demonstrating quality problems in children’s cardiac surgery at Bristol Royal Infirmary, which was the subject of a major inquiry that reported in 2001, was available for a long time before it was used
• There is now much greater interest in analysing the data and, in the UK, growing professional support for publication; for example, a healthcare provider with consistently poor outcomes from cardiac surgery, the Oxford Radcliffe NHS Trust, unsuccessfully challenged the right of Dr Foster, a healthcare information provider, to publish its data
  
• The Walsall Hospitals NHS Trust used relative poor performance on HSMRs to establish a major programme of quality improvements which achieved good results in a remarkably short period of time; the trust has reduced its hospital mortality rate from the highest mortality of comparable hospitals to lower than the average; the turn around was achieved using a wide range of techniques led by seven quality improvement facilitators and a complete overhaul of the trust’s clinical governance structure

On the technical issues, Professor Jarman explained that his model adjusts the data for case mix because this is a proxy for social deprivation. Canadian data includes pre-admission diagnosis. This explains 37 percent of the variation in hospital mortality and is useful in interpreting results because it is independent of what happens in hospital.
Analysis of HSMRs shows a clear relationship between hospital mortality and length of stay, although the reason for this is not clear. It is only for some procedures that there is a relationship between the volume of procedures carried out in a hospital and mortality rates. Evidence relating to the size of hospital and mortality ratios is also mixed.
Dr Paul Bartels, Medical Director, and Professor Jan Mainz, Project Manager, of the Danish National Indicator Project, presented their project to the participants.
The key points are:

• Sponsors include Government and professional bodies, and participation by hospitals is compulsory
  
• Professionals treat the results from the project very seriously and are willing to examine their own practice
  
• There is lively debate about which clinical indicators are valid and the standards that are set; for example, there is a dispute about the indicator for post-operative mortality after 30 days for patients with gastric bleeding; the standard for this is 10 percent or less but the actual average is 28 percent
  
• As elsewhere, there is no evidence that patient decisions are altered by the information; the team wants to develop a reporting system for consumers that is as easy to understand as those used in hotels and campsites

Dr Tim Doran, Senior Research Fellow in Public Health, National Primary Care Research and Development Centre, University of Manchester, England, presented the results from the first year of the new UK general medical practitioners’ contract. This contract offers significant payments to practices for the achievement of specific quality markers.
The key points are:

• Achievement, and therefore cost, is higher than planned
  
• The evidence shows wide variation between practices in the exclusion of specific patients from reporting, with some practices excluding over 50 percent of apparently eligible patients; this suggests that ‘gaming’ is significant
  
• Such high levels of exclusion mean that the contract has failed to achieve fairness between practices – one of its major purposes – with those practices good at ‘gaming’ receiving financial reward and those serious about quality potentially receiving less
  

The workshops
Participants re-joined their four workshops to discuss the issues raised from the presentations. The key points identified during the discussions were:

• Data-collection analysis and reporting
  
• Publication
  
• Pay for performance

Data collection analysis and reporting
There was general agreement that organisations should select a few key measures for quality improvement, focusing on what matters most to achieve the organisation’s mission. Financial indicators should be included and patients should be involved in defining what ought to
be measured.
Measures selected should also depend on the purpose. Clinicians, healthcare providers, commissioners, insurers, payers and patients have different but legitimate requirements for reports. Four separate purposes were identified: internal quality improvement, accountability, informing patients and external judgement.
At the level of a clinical service, measures selected should include process as well as outcome, perhaps particularly for people with long-term conditions. The general concern that ‘what gets measured gets done’ can distort the organisation’s mission is a risk but it can be managed.
A number of suggestions were made to enable organisations to avoid becoming submerged in data and to promote accuracy and reliability. Solutions included data collection as part of the clinical process and as far as possible by clinicians, and collaboration between those who collect the data and those who analyse
and report on it.
Several participants stressed the importance of all staff understanding the significance of the data that is collected and the resulting reports on quality and performance. Although it is still difficult to measure quality in some areas, such as integrated care and mental health, all processes can yield data.
There was general agreement that data needs to be understood in context, for example, epidemiology and local social circumstances. Performance should be compared internally and externally, over time and with the best, as well as the average. This encourages everyone to work towards continuously improving quality rather than focusing on outliers, which encourages ‘bad-apple’ thinking.
All agreed that quality and performance measurement systems to support continuous improvement require infrastructure at a national and international level as well as within the healthcare organisation.

Publication
There was consensus that internal and external disclosure of results is necessary for accountability and to promote willingness to change. Many felt that it is inevitable, given the public and media interest in health and healthcare, that reports on quality measures will be published. There was recognition that publication carries risks, including unintended incentives to clinicians and healthcare providers to prioritise some activities over others.
Several participants had experience of initiatives to improve quality in healthcare organisations
as a direct consequence of the publication of patient outcome data. These initiatives were set up because staff like to be considered as good as their peers. In addition, publication of league tables in a number of countries has stimulated clinicians to co-operate with data collection to ensure accuracy. In one country a professional body has started to take responsibility for those of its members whose performance is less than adequate, as a result of the publication of clinician-specific data.
Participants felt that the impact of publication needs to be better understood and a public debate about risks in healthcare would be useful. Some participants felt that independent organisations rather than governments should publish results.
Evidence that few patients use published measures of quality to choose a provider is well known to participants. Nevertheless, some patients are using website discussion boards to share information about healthcare options and experiences. Some insurance companies are including patient satisfaction in their payment structures.
Participants suggested two essential areas where healthcare organisations could improve their ability to manage the publication of quality and performance measures. First, organisations should seek constructive relationships with patient groups. Secondly, they should seek to integrate the way errors and complaints are handled into their quality improvement processes. Immediate admission of error, apology, rectification and improved systems can restore customer confidence, encourage staff to admit mistakes and prevent media exploitation of cases.
Some participants stressed that a professional culture that is open to learning from measurement is more important than publication. An active process is needed to turn projects like the Danish Indicator Project and the clinical registers in Sweden into tools for quality improvement.

Payment for performance
Some participants felt that the financial incentives in the UK general practitioners’ contract pays doctors for what they should be doing anyway. Others felt that there is value in establishing scrutiny of GP quality and performance for the first time, and there is an opportunity to achieve greater sophistication over time. The contract may be a useful tool to drive improvements, together with other tools such as disclosure. Unintended consequences can also be addressed.

Session 4 held on Saturday 26 November

National systems reform and quality

Reform in France and the Netherlands
Mme Eliane Apert, Deputy Director for Quality and Performance, Ministry of Health and Social Affairs, France, and Professor Geert Blijham, Chairman of the Executive Board, University Medical Centre, Utrecht, the Netherlands, gave presentations about system reform in France and the Netherlands respectively.
In France the Government is trying to exert control over the healthcare system. This is a struggle rather like the Lilliputians tying down Gulliver. In theory quality is at the centre of the reforms. But there is an elephant in the room that is never spoken about – the cost of healthcare.
In the Netherlands the Government is trying to create markets between the citizen and the insurance companies and insurance companies and hospitals. It is taking responsibility only for whether these markets work. Before the reforms, employers paid health insurance premiums for their employees; now individuals must pay directly and claim back through the tax system. Insurers must cover all those who apply and must offer a minimum level of cover. For care above this level they compete for enrolees.
Hospitals used to be paid for just being; now the insurance companies negotiate on price and volume using Diagnostic Related Groups (DRGs).
The key points identified during the discussions were:

• Patient involvement in quality improvement
  
• The impact on quality of different payments systems

Patient involvement in quality
Participants agreed that patient involvement needs to go beyond just asking about satisfaction to enabling informed choice; but there is no single, easy way to achieve this. In the USA, where there is an abundance of choice and information, on average a person will spend 14.5 minutes choosing their health plan, compared with four hours choosing a car.

This is partly the fault of healthcare professionals who mystify their business and dispute reported measures of quality. It is difficult to enable patients and the public to gain a reliable understanding of the truth given many sources of information and extensive media coverage.
Solutions suggested by participants included teaching how to be effective patients in school and re-thinking the design of healthcare to incorporate co-production on the lines of that achieved in banking.
Another strategy might include encouraging GPs to be better advisors about choices. Evidence from England shows patients want to turn to their GP for advice. Dr Foster, the healthcare information service, organises discussions with 250 GPs quarterly to seek their views on what patients are interested in. The information is used to shape quality indicators, for example, those on maternity.

Impact on quality of different payments systems
Several of the participant countries have experience of using DRGs as a currency for healthcare transactions. Some with such experience felt that although it appears desirable to build quality into DRGs, the sole communication between commissioners, healthcare providers and doctors should not be about income. This is dangerous and undermines ethics. The aim of a DRG system is to enhance productivity, and this should remain its focus. There are risks and there will be consequences. Other tools should be used to improve quality and deal with the unintended consequences.
Participants who were knowledgeable about Jönköping County commented that the county has the highest productivity in the Swedish healthcare system and does not pay for performance. Rather than attempting to drive quality through DRGs, staff motivation is the key.
Some participants also advised caution about the role of markets in quality improvement. The dministrative costs of US healthcare amount to $2,000 per capita: the average amount spent
on healthcare in Europe. All agreed there is no perfect method for financing healthcare.

Session 5 held on Saturday 26 November

Reflections on progress in England
In the final session of the exchange, in discussion with Professor Chris Ham, Professor Sir Liam Donaldson, Chief Medical Officer, Department of Health, England, reflected on the recent experience in seeking quality improvement in the healthcare system in England.
A quality framework was established in 1998 with three strands:

• National clinical standards, in National Service Frameworks and National Institute for Clinical Excellence guidelines
  
• Clinical governance in all NHS bodies
  
• Robust feedback on performance via the Commission for Healthcare Improvement
  until 2003 and The Healthcare Commission from 2004

It is the right framework and there is strong commitment from the top. Quality and safety feature in policy documents. In five years the electronic health record will improve co-ordination and some aspects of safety. It will support clinician decision-making and there should be less need to rely on trying to influence clinical behaviour by education.
But there is insufficient alignment of quality in the mainstream structure of the NHS.

• In practice the NHS gives the highest priority to access targets – access has improved,
  but this is a very narrow view of quality
  
• There is a continuing rising-costs crisis and this weighs more than quality
  
• Chief executives lose sleep over financial targets not quality
  
• The system allows provider-driven attitudes to dominate; the attitude of a minority of staff is unacceptable and would not be accepted by customers or managers in commercial service industries such as banks or hotels

Sir Liam described a recent case of a young woman with meningitis whose treatment was delayed by five hours after her arrival at the A&E Department for a variety of reasons. She died.
Professor Ham identified two main issues arising from these reflections:

• How can customer-focused health services be achieved? Can a publicly-funded and provided system be customer focused?Can competition drive improvement?
  
• Is there useful learning from other service industries? Is healthcare really different from other service industries? Can healthcare learn from the private sector?

Customer focus in public-funded and provided systems and competitive systems
Several participants pointed out that systems in a healthcare organisation are important but the culture and what is taught about what matters is more important. Any healthcare organisation must have very strong values about the centrality of patient care. Some financing systems have stronger imperatives for cost management than others, for example, capitated systems like the UK NHS. It is all the more important in these systems to have strong values.
In addition to the importance of valuing patient care above all other purposes, leadership education needs to teach how to manage risks and motivate people, rather than reacting to events. Participants felt strongly that if individual employees do not adopt organisational values that put the patient at the centre, they should not be in healthcare and that there must be means to expel people from healthcare if they ignore the needs of the patient.
There was a range of views about the role of competition in quality improvement. Some felt that competition between healthcare commissioners and healthcare providers does not need to result in differential access to healthcare nor lower quality. In some European countries there is universal access to healthcare and a long tradition of independent not-for-profit hospitals that compete against each other and against state-owned and controlled hospitals.
In the Netherlands insurance companies compete for customers on quality and, especially in cities, can and do move their contracts from hospital to hospital on quality grounds.

Healthcare and other service industries
A number of participants felt that there are lessons from the private sector that are relevant to healthcare. One is the importance of leaders challenging their staff to deliver better value – the same or better quality for less. For example, the Chief Executive of IKEA saw a vase two euros cheaper than one in his stores. He asked his design team to find a way to produce a better-designed vase that could sell for two euros less again, and the team achieved this.
There is pressure in all countries to show that quality improvement in healthcare can save money. In England, access is better at the expense of a financial crisis, trust leaders have taken their eye off the financial ball. In the UK Tesco has shown that it is possible for an organisation to lead its way out of a financial crisis through quality improvement and the NHS needs to do the same. Quality and cost must be two sides of the same coin.
Other sources of learning might be to examine how to exploit new technology to support a re-framing of the system that enables the customer to adopt self-management. There may be parallels with how Apple has changed the way that people access music with the iPod, and how personal banking has now become automated. There should be a common interest between commissioners and customers of healthcare in adopting self-management, as both want to minimise hospitalisation.

Participants’ views about the exchange were invited before they left and a few weeks later. All those who responded (there was a 50 percent response rate) were very positive. From the initial evaluation, respondents particularly welcomed the discussions on quality and system reform in the plenary sessions and workshops. They also appreciated being able to discuss comparisons between countries and several reported making new contacts.
In the second evaluation, all respondents reported that the information presented was
of practical use to them in their work. They highlighted a wide range of aspects of the exchange as being useful. Those most frequently mentioned included:

• The approach to the quality agenda in different countries
  
• System-wide approaches that have been adopted by the Veterans Health Administration and Jönköping
  
• Understanding how European countries think about and develop quality
  
• The differences in healthcare systems and how these differences relate to the way performance indicators are effective in improving quality
  
• The role of culture and leadership in quality improvement
  
• The importance of the electronic medical record
  
• Discussions with colleagues around the issues

As a result of the event, almost 90 percent of respondents have either contacted or intend
to contact other participants as part of their work. Where networks had been forged
before the event, these have since been ‘reactivated’. Some respondents are following
up specific contacts; others are in touch with all participants.
Almost 80 percent of the respondents had either done something differently in their work, or plan to do something differently, as a consequence of the exchange. Proposed activities include:

• Considering the use of hospital mortality as an indicator for patient safety
  
• Making their quality improvement plan their business plan
  
• Giving electronic medical records higher priority within organisations
  
• Presenting the case for a ‘quality agenda’ to the Board
  
• Changing the way quality issues are organised
  
• Sourcing international examples of best practice to influence local service development
  
• Collaborating on whole-system measures with one of the other countries in the exchange
  

Almost 90 percent of respondents said they would attend another exchange and, of these, most said they would be willing to undertake preparatory work.

From The Health Foundation’s point of view the exchange demonstrated that sharing experience between healthcare leaders from different positions, backgrounds and countries can generate knowledge.
A number of participants have encouraged a further meeting and this is being seriously considered.