Universidad de Murcia INTERNAL INITIATIVES OR EXTERNAL FEEDBACK: WHAT WILL WORK? Pedro J. Saturno,...

Universidad de Universidad de MurciaMurcia

INTERNAL INITIATIVES OR INTERNAL INITIATIVES OR EXTERNAL FEEDBACK: WHAT EXTERNAL FEEDBACK: WHAT

WILL WORK?WILL WORK?

Pedro J. Saturno, MD, Dr PHPedro J. Saturno, MD, Dr PH

Profesor de Salud Pública, Universidad de MurciaProfesor de Salud Pública, Universidad de Murcia

Visiting Lecturer in Quality Management,Visiting Lecturer in Quality Management,

Harvard School of Public HealthHarvard School of Public Health

EQuiP Conference, Brussels November 2004EQuiP Conference, Brussels November 2004

© PJ Saturno© PJ Saturno

““Quality can be measured externally. Internally it can be Quality can be measured externally. Internally it can be

measured measured and and improved”improved”

R.H. PalmerR.H. Palmer


measured measured and and improved”improved”


““Every program or initiative to improve quality Every program or initiative to improve quality

has some effect. Everything seems to work”has some effect. Everything seems to work”

A. DonabedianA. Donabedian





I.I. INTERNAL AND EXTERNAL DEFINEDINTERNAL AND EXTERNAL DEFINED

II.II. IMPLEMENTATION RESEARCH: WHAT DO WE KNOW?IMPLEMENTATION RESEARCH: WHAT DO WE KNOW?

III.III. STRATEGIES TO IMPROVE QUALITYSTRATEGIES TO IMPROVE QUALITY• A TAXONOMYA TAXONOMY• MODELS AND THEORIES EXPLAINING THE STRATEGIESMODELS AND THEORIES EXPLAINING THE STRATEGIES• THE ELEMENTS OF MANAGING CHANGETHE ELEMENTS OF MANAGING CHANGE

IV.IV. THE TYPE AND ROLE OF INCENTIVESTHE TYPE AND ROLE OF INCENTIVES

V.V. ADDITIONAL FOOD FOR THOUGHT: SOME QUESTIONS ARISING FROM ADDITIONAL FOOD FOR THOUGHT: SOME QUESTIONS ARISING FROM HEALTH-SYSTEM-WIDE EMPIRICAL DATA.HEALTH-SYSTEM-WIDE EMPIRICAL DATA.

VI.VI. CONCLUSIONSCONCLUSIONS








I.I. INTERNAL AND EXTERNAL DEFINEDINTERNAL AND EXTERNAL DEFINEDI.I. INTERNAL AND EXTERNAL DEFINEDINTERNAL AND EXTERNAL DEFINED

THE INITIATIVE TO IMPROVE IS INTERNAL, THE INITIATIVE TO IMPROVE IS INTERNAL, AND THE DOMAINS, TOPICS, INDICATORS AND THE DOMAINS, TOPICS, INDICATORS AND METHODS FOR QI ARE DECIDED BY THE AND METHODS FOR QI ARE DECIDED BY THE CENTER, TEAM, GROUP OR INDIVIDUAL CENTER, TEAM, GROUP OR INDIVIDUAL PRACTITIONERSPRACTITIONERS

THE INITIATIVE TO IMPROVE IS INTERNAL, THE INITIATIVE TO IMPROVE IS INTERNAL, AND THE DOMAINS, TOPICS, INDICATORS AND THE DOMAINS, TOPICS, INDICATORS AND METHODS FOR QI ARE DECIDED BY THE AND METHODS FOR QI ARE DECIDED BY THE CENTER, TEAM, GROUP OR INDIVIDUAL CENTER, TEAM, GROUP OR INDIVIDUAL PRACTITIONERSPRACTITIONERS

EXTERNAL FOCUS

THE INITIATIVE TO IMPROVE IS EXTERNAL, AND THE DOMAINS, TOPICS, INDICATORS AND (AT LEAST PARTIALLY) METHODS FOR QI ARE DECIDED BY THE ADMINISTRATIVE UNITS OR INSTITUTIONS OUTSIDE THE CENTER, TEAM OR GROUP.

THE INITIATIVE TO IMPROVE IS EXTERNAL, AND THE DOMAINS, TOPICS, INDICATORS AND (AT LEAST PARTIALLY) METHODS FOR QI ARE DECIDED BY THE ADMINISTRATIVE UNITS OR INSTITUTIONS OUTSIDE THE CENTER, TEAM OR GROUP.

INTERNAL FOCUS


II. IMPLEMENTATION RESEARCH. WHAT DO II. IMPLEMENTATION RESEARCH. WHAT DO WE KNOW?WE KNOW?

II. IMPLEMENTATION RESEARCH. WHAT DO II. IMPLEMENTATION RESEARCH. WHAT DO WE KNOW?WE KNOW?

LITTLE !! ….

• LITTLE COMPARATIVE INFORMATION ABOUT HE MOST EFFECTIVE WAYS TO IMPLEMENT QI.

• MOST EMPIRICAL DATA ARE DESCRIPTIVE

• MOST STUDIES ARE CASE STUDIES


…. BUT VARIED !! …

• EXAMPLES, MODELS AND THEORIES ABOUND


Two main tracks for researchTwo main tracks for research• DIFUSSION OF KNOWLEDGEDIFUSSION OF KNOWLEDGE• BEHAVIOURAL CHANGEBEHAVIOURAL CHANGE

Two main tracks for researchTwo main tracks for research• DIFUSSION OF KNOWLEDGEDIFUSSION OF KNOWLEDGE• BEHAVIOURAL CHANGEBEHAVIOURAL CHANGE

… AND RELATIVELY FOCUSED:

Three main and distinct levels for interventions:Three main and distinct levels for interventions:• FRONT LINE HEALTH PRACTITIONERS FRONT LINE HEALTH PRACTITIONERS (Individuals, groups or teams)(Individuals, groups or teams)

• ORGANIZATIONSORGANIZATIONS• HEALTH CARE SYSTEMHEALTH CARE SYSTEM

Three main and distinct levels for interventions:Three main and distinct levels for interventions:• FRONT LINE HEALTH PRACTITIONERS FRONT LINE HEALTH PRACTITIONERS (Individuals, groups or teams)(Individuals, groups or teams)

• ORGANIZATIONSORGANIZATIONS• HEALTH CARE SYSTEMHEALTH CARE SYSTEM

Three main targets for strategies:Three main targets for strategies:• PROVIDERESPROVIDERES

• PATIENTSPATIENTS

• SYSTEM SYSTEM (practice environment)(practice environment)

Three main targets for strategies:Three main targets for strategies:• PROVIDERESPROVIDERES

• PATIENTSPATIENTS

• SYSTEM SYSTEM (practice environment)(practice environment)

INTERVENTIONS, STRATEGIES AND EXPECTED RESULTS MAY BE INTERVENTIONS, STRATEGIES AND EXPECTED RESULTS MAY BE DIFFERENT FOR DIFFERENT LEVELS AND TARGETSDIFFERENT FOR DIFFERENT LEVELS AND TARGETS

INTERVENTIONS, STRATEGIES AND EXPECTED RESULTS MAY BE INTERVENTIONS, STRATEGIES AND EXPECTED RESULTS MAY BE DIFFERENT FOR DIFFERENT LEVELS AND TARGETSDIFFERENT FOR DIFFERENT LEVELS AND TARGETS


III. STRATEGIES TO IMPROVE QUALITYIII. STRATEGIES TO IMPROVE QUALITY

• A TAXONOMYA TAXONOMY

• MODELS AND THEORIES EXPLAINING THE STRATEGIESMODELS AND THEORIES EXPLAINING THE STRATEGIES

• THE ELEMENTS OF MANAGING CHANGETHE ELEMENTS OF MANAGING CHANGE

III. STRATEGIES TO IMPROVE QUALITYIII. STRATEGIES TO IMPROVE QUALITY

• A TAXONOMYA TAXONOMY

• MODELS AND THEORIES EXPLAINING THE STRATEGIESMODELS AND THEORIES EXPLAINING THE STRATEGIES

• THE ELEMENTS OF MANAGING CHANGETHE ELEMENTS OF MANAGING CHANGE


I. TARGETED TO THE ORGANIZATIONI. TARGETED TO THE ORGANIZATIONI. TARGETED TO THE ORGANIZATIONI. TARGETED TO THE ORGANIZATION

A TAXONOMY OF QI STRATEGIESA TAXONOMY OF QI STRATEGIES

Adapted from: Shojania KG, McDonald KM, Wachter RM, Owens OK: Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies. Vol. 1. AHRQ, 2004.Adapted from: Shojania KG, McDonald KM, Wachter RM, Owens OK: Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies. Vol. 1. AHRQ, 2004.

1.ORGANIZATIONAL CHANGE 1.ORGANIZATIONAL CHANGE (e.g. QM programmes, EFQM model)2. PROVIDER REMINDER SYSTEMS AND ALIKE2. PROVIDER REMINDER SYSTEMS AND ALIKE1.ORGANIZATIONAL CHANGE 1.ORGANIZATIONAL CHANGE (e.g. QM programmes, EFQM model)2. PROVIDER REMINDER SYSTEMS AND ALIKE2. PROVIDER REMINDER SYSTEMS AND ALIKE

II. TARGETED TO PROVIDERSII. TARGETED TO PROVIDERSII. TARGETED TO PROVIDERSII. TARGETED TO PROVIDERS

3. AUDIT AND FEEDBACK3. AUDIT AND FEEDBACK4. PROVIDER EDUCATION4. PROVIDER EDUCATION5. FACILITATED RELAY OF CLINICAL DATA5. FACILITATED RELAY OF CLINICAL DATA6. INCENTIVES 6. INCENTIVES (financial, regulatory or legislative(financial, regulatory or legislative))

3. AUDIT AND FEEDBACK3. AUDIT AND FEEDBACK4. PROVIDER EDUCATION4. PROVIDER EDUCATION5. FACILITATED RELAY OF CLINICAL DATA5. FACILITATED RELAY OF CLINICAL DATA6. INCENTIVES 6. INCENTIVES (financial, regulatory or legislative(financial, regulatory or legislative))

III. TARGETED TO PATIENTSIII. TARGETED TO PATIENTSIII. TARGETED TO PATIENTSIII. TARGETED TO PATIENTS

7. PATIENT REMINDERS7. PATIENT REMINDERS8. PATIENT EDUCATION/EMPOWERMENT8. PATIENT EDUCATION/EMPOWERMENT9. PROMOTION OF SELF-MANAGEMENT9. PROMOTION OF SELF-MANAGEMENT

7. PATIENT REMINDERS7. PATIENT REMINDERS8. PATIENT EDUCATION/EMPOWERMENT8. PATIENT EDUCATION/EMPOWERMENT9. PROMOTION OF SELF-MANAGEMENT9. PROMOTION OF SELF-MANAGEMENT


I.I. CONCEPTUAL MODELS OR GRAND THEORIESCONCEPTUAL MODELS OR GRAND THEORIESI.I. CONCEPTUAL MODELS OR GRAND THEORIESCONCEPTUAL MODELS OR GRAND THEORIES

MODELS AND THEORIES FOR QI INTERVENTIONSMODELS AND THEORIES FOR QI INTERVENTIONS

I.1.I.1. CLASSICAL THEORIES OF CHANGE CLASSICAL THEORIES OF CHANGEDIFFUSION OF INNOVATION THEORYDIFFUSION OF INNOVATION THEORY

I.1.I.1. CLASSICAL THEORIES OF CHANGE CLASSICAL THEORIES OF CHANGEDIFFUSION OF INNOVATION THEORYDIFFUSION OF INNOVATION THEORY

I.2.I.2. PLANNED MODELS OF CHANGE PLANNED MODELS OF CHANGEPRECEDE-PROCEEDPRECEDE-PROCEEDSOCIAL MARKETINGSOCIAL MARKETINGBERWICK´S SEVEN RULES FOR DISSEMINATIONBERWICK´S SEVEN RULES FOR DISSEMINATIONOTAWA MODEL FOR HCR USEOTAWA MODEL FOR HCR USE

I.2.I.2. PLANNED MODELS OF CHANGE PLANNED MODELS OF CHANGEPRECEDE-PROCEEDPRECEDE-PROCEEDSOCIAL MARKETINGSOCIAL MARKETINGBERWICK´S SEVEN RULES FOR DISSEMINATIONBERWICK´S SEVEN RULES FOR DISSEMINATIONOTAWA MODEL FOR HCR USEOTAWA MODEL FOR HCR USE

II.II. MID-RANGE THEORIES (DISCIPLINE-SPECIFIC)MID-RANGE THEORIES (DISCIPLINE-SPECIFIC)II.II. MID-RANGE THEORIES (DISCIPLINE-SPECIFIC)MID-RANGE THEORIES (DISCIPLINE-SPECIFIC)


EXPLORERSEXPLORERSEXPLORERSEXPLORERS

CHANGE IS CHANGE IS NEVER GOODNEVER GOODCHANGE IS CHANGE IS

NEVER GOODNEVER GOOD

STONESSTONESSTONESSTONES

PIONEERSPIONEERSPIONEERSPIONEERSLAGGARDSLAGGARDSLAGGARDSLAGGARDS

SETTLERSSETTLERSSETTLERSSETTLERS

CHANGE CHANGE BECAUSE BECAUSE

EVERYBODY EVERYBODY DOESDOES

CHANGE CHANGE BECAUSE BECAUSE

EVERYBODY EVERYBODY DOESDOES

CHANGE BY CHANGE BY EVIDENCE EVIDENCE

(OBSERVED (OBSERVED RESULTS)RESULTS)

CHANGE BY CHANGE BY EVIDENCE EVIDENCE

(OBSERVED (OBSERVED RESULTS)RESULTS)

RATIONAL AND RATIONAL AND INTELECTUALLY INTELECTUALLY

CONVINCEDCONVINCED

RATIONAL AND RATIONAL AND INTELECTUALLY INTELECTUALLY

CONVINCEDCONVINCED

CHANGE CHANGE NEVER NEVER

QUESTIONEDQUESTIONED

CHANGE CHANGE NEVER NEVER

QUESTIONEDQUESTIONED

THE DEMOGRAPHY OF CHANGETHE DEMOGRAPHY OF CHANGE

Based on: E. Rogers´ Diffusion of Innovations TheoryBased on: E. Rogers´ Diffusion of Innovations Theory


MODELS AND THEORIES FOR QI INTERVENTIONSMODELS AND THEORIES FOR QI INTERVENTIONS

II.1.II.1. SOCIAL PSYCHOLOGICAL THEORIES SOCIAL PSYCHOLOGICAL THEORIESSOCIAL INFLUENCE THEORIESSOCIAL INFLUENCE THEORIESMOTIVATIONAL THEORIESMOTIVATIONAL THEORIES

• Social cognitive theorySocial cognitive theory• Theory of planned behaviourTheory of planned behaviour

ACTION THEORIESACTION THEORIESSTAGE THEORIESSTAGE THEORIES

II.1.II.1. SOCIAL PSYCHOLOGICAL THEORIES SOCIAL PSYCHOLOGICAL THEORIESSOCIAL INFLUENCE THEORIESSOCIAL INFLUENCE THEORIESMOTIVATIONAL THEORIESMOTIVATIONAL THEORIES

• Social cognitive theorySocial cognitive theory• Theory of planned behaviourTheory of planned behaviour

ACTION THEORIESACTION THEORIESSTAGE THEORIESSTAGE THEORIES

I.I. CONCEPTUAL MODELS OR GRAND THEORIES CONCEPTUAL MODELS OR GRAND THEORIESI.I. CONCEPTUAL MODELS OR GRAND THEORIES CONCEPTUAL MODELS OR GRAND THEORIES

II.II. MID-RANGE THEORIES (DISCIPLINE-SPECIFIC) MID-RANGE THEORIES (DISCIPLINE-SPECIFIC)II.II. MID-RANGE THEORIES (DISCIPLINE-SPECIFIC) MID-RANGE THEORIES (DISCIPLINE-SPECIFIC)

II.2. II.2. ORGANIZATIONAL THEORIES ORGANIZATIONAL THEORIES RATIONAL MODELSRATIONAL MODELSINSTITUTIONAL MODELSINSTITUTIONAL MODELS

II.2. II.2. ORGANIZATIONAL THEORIES ORGANIZATIONAL THEORIES RATIONAL MODELSRATIONAL MODELSINSTITUTIONAL MODELSINSTITUTIONAL MODELS

II.3. II.3. OTHER DISCIPLINE-BASED THEORIES OTHER DISCIPLINE-BASED THEORIESADULT LEARNING THEORYADULT LEARNING THEORYMARKETING APPROACHESMARKETING APPROACHESECONOMIC THEORIES ECONOMIC THEORIES (e.g. Quality based purchasing)(e.g. Quality based purchasing)

II.3. II.3. OTHER DISCIPLINE-BASED THEORIES OTHER DISCIPLINE-BASED THEORIESADULT LEARNING THEORYADULT LEARNING THEORYMARKETING APPROACHESMARKETING APPROACHESECONOMIC THEORIES ECONOMIC THEORIES (e.g. Quality based purchasing)(e.g. Quality based purchasing)


11StSt EVALUATIÓNEVALUATIÓN

2nd 2nd EVALUATIÓNEVALUATIÓN

72,072,0

p=0.02p=0.02

PhysicalPhysical examexam

RESULTS: INTERNAL QI ACTIVITIES GROUPRESULTS: INTERNAL QI ACTIVITIES GROUP

7070

% Relative% Relativeimprovementimprovement

86.086.0

72.572.5

4949Recording ofRecording ofprescribedprescribedtreatmenttreatment

52.952.9

p=0.05p=0.05

67.667.6

90.290.2 7070

0%

100%

No prescription No prescription of Ab/Ah/Ctof Ab/Ah/Ct

p=0.04p=0.04


39.739.7

RESULTS: FEEDBACK GROUP + TRAINING IN QIRESULTS: FEEDBACK GROUP + TRAINING IN QI

50.450.4p=0.04p=0.04



22ndnd EVALUATIÓNEVALUATIÓN


1818

Recording ofRecording ofprescribedprescribedtreatmenttreatment

97.997.9p=0.03p=0.03 6969


22.022.0

43.143.1

0%

100%

93.393.3

2727P<0.001P<0.001


42.242.236.636.6n.s.n.s.



22ndnd EVALUATIÓNEVALUATIÓN

RESULTS: FEEDBACK S-GROUP WITHOUT TRAININGRESULTS: FEEDBACK S-GROUP WITHOUT TRAINING


89.989.993.093.0

n.s.n.s.

n.s.n.s.


0%

100%

PhysicalPhysical examexam 17.017.0

n.s.n.s.

n.s.n.s.

n.s.n.s.

26.026.0



2nd 2nd EVALUATIÓNEVALUATIÓN

56,056,0p=0.01p=0.01

RESULTS IN THE CONTROL GROUPRESULTS IN THE CONTROL GROUP


94.094.0

74.474.4n.s.n.s.

40.040.0

0%

100%

70.570.5

95.095.0




n.s.n.s.

1212


AVERAGE TREATMENT COST AVERAGE TREATMENT COST ( ( € € ))

6.07 €6.07 €3.44 €3.44 €

7.45 €7.45 €7.09 €7.09 €

7.49 €7.49 €10.11 €10.11 €

6.21 €6.21 €5.54 €5.54 €

p<0.01

n.s.

n.s.

n.s.


Intentionally planed and performedIntentionally planed and performed

Defined strategyDefined strategy

Defined structure for QMDefined structure for QM

Comprehensive vision for QM activitiesComprehensive vision for QM activities

ResourcesResources

IncentivesIncentives

THE ELEMENTS OF MANAGING THE ELEMENTS OF MANAGING CHANGE FOR QICHANGE FOR QI


SYSTEM LEVELS FOR SYSTEM LEVELS FOR QUALITYQUALITY

SYSTEM LEVELS FOR SYSTEM LEVELS FOR QUALITYQUALITY

Population-based indicators, including all dimensions of quality and all Population-based indicators, including all dimensions of quality and all institutions.institutions.

Focus on overall system strategies.Focus on overall system strategies.

Responsibility of high level managers and political authorities.Responsibility of high level managers and political authorities.

Indicators on the quality of the specific services for the specific population Indicators on the quality of the specific services for the specific population served by the institution. served by the institution.

Focus on optimizing resources and regulating processes Indicators on the Focus on optimizing resources and regulating processes Indicators on the quality of the organization.quality of the organization.

Responsibility of the managers of the institution Responsibility of the managers of the institution

Indicators on satisfaction, technical quality and effectiveness for specific Indicators on satisfaction, technical quality and effectiveness for specific conditions and type of patients.conditions and type of patients.

Focus on clinical quality on a broad sense.Focus on clinical quality on a broad sense.

Responsibility mostly of clinical personnel.Responsibility mostly of clinical personnel.

CHARACTERISTICS AND RESPONSABILITIESCHARACTERISTICS AND RESPONSABILITIESCHARACTERISTICS AND RESPONSABILITIESCHARACTERISTICS AND RESPONSABILITIES

Quality management through the health care Quality management through the health care systemsystem

HEALTH SYSTEM HEALTH SYSTEM QUALITYQUALITY

QUALITY OFQUALITY OF INDIVIDUALINDIVIDUAL

HEALTH CAREHEALTH CARE

INFORMATION

INFORMATION

SUPERVISION/INFORMATION

SUPERVISION/INFORMATION

QUALITY OF AQUALITY OF A HEALTH CAREHEALTH CARE

INSTITUTION/CENTREINSTITUTION/CENTRE






ResourcesResources




MONITORINGMONITORING

QUALITY QUALITY PLANNING PLANNING

ORORDESIGNDESIGN

QUALITY QUALITY IMPROVEMENT IMPROVEMENT

CYCLESCYCLES

GROUPS OF ACTIVITIES FOR GROUPS OF ACTIVITIES FOR QUALITY IMPROVEMENTQUALITY IMPROVEMENT






ResourcesResources







Comprehensive Comprehensive vision for QM activitiesvision for QM activities

ResourcesResources




IntrinsicIntrinsic

IV. THE TYPE AND ROLE OF IV. THE TYPE AND ROLE OF INCENTIVESINCENTIVES

Extrinsic Extrinsic

unlimited and with permanent effectunlimited and with permanent effect

limited and with short time effectlimited and with short time effect

FinancialFinancial

Reputational Reputational mostly extrinsicmostly extrinsic

mostly intrinsicmostly intrinsic


FACTORS THAT MAY INFLUENCE THE EFFECTIVENES OF FACTORS THAT MAY INFLUENCE THE EFFECTIVENES OF FINANCIAL INCENTIVESFINANCIAL INCENTIVES

1.1.1.1. FINANCIAL FINANCIALADEQUACY OF RECIPIENTADEQUACY OF RECIPIENTPOTENTIAL IMPACT ON REVENUEPOTENTIAL IMPACT ON REVENUECOST OF COMPLIANCECOST OF COMPLIANCE

1.1.1.1. FINANCIAL FINANCIALADEQUACY OF RECIPIENTADEQUACY OF RECIPIENTPOTENTIAL IMPACT ON REVENUEPOTENTIAL IMPACT ON REVENUECOST OF COMPLIANCECOST OF COMPLIANCE

1.1. CHARACTERISTCS OF THE INCENTIVE CHARACTERISTCS OF THE INCENTIVE1.1. CHARACTERISTCS OF THE INCENTIVE CHARACTERISTCS OF THE INCENTIVE

2.2. CONTEXTUAL FACTORS CONTEXTUAL FACTORS2.2. CONTEXTUAL FACTORS CONTEXTUAL FACTORS

1.2.1.2. NON FINANCIAL NON FINANCIALACCEPTABILITY OF GOALSACCEPTABILITY OF GOALSATTAINABILITY OF GOALSATTAINABILITY OF GOALSINTRINSIC MOTIVATIONINTRINSIC MOTIVATIONPROVIDER PREFERENCES FOR DOMAIN OF GOALSPROVIDER PREFERENCES FOR DOMAIN OF GOALSAPPROACH TO REINFORCEMENT APPROACH TO REINFORCEMENT (POSITIVE OR NEGATIVE)(POSITIVE OR NEGATIVE)

1.2.1.2. NON FINANCIAL NON FINANCIALACCEPTABILITY OF GOALSACCEPTABILITY OF GOALSATTAINABILITY OF GOALSATTAINABILITY OF GOALSINTRINSIC MOTIVATIONINTRINSIC MOTIVATIONPROVIDER PREFERENCES FOR DOMAIN OF GOALSPROVIDER PREFERENCES FOR DOMAIN OF GOALSAPPROACH TO REINFORCEMENT APPROACH TO REINFORCEMENT (POSITIVE OR NEGATIVE)(POSITIVE OR NEGATIVE)

2.1.2.1. PREDISPOSING PREDISPOSING MIX OF OTHER INCENTIVESMIX OF OTHER INCENTIVES INDIVIDUAL PROVIDER CHARACTERISTICSINDIVIDUAL PROVIDER CHARACTERISTICS


2.2.2.2. ENABLING ENABLING ORGANIZATIONAL/STRUCTURE LEVELORGANIZATIONAL/STRUCTURE LEVEL PATIENT LEVELPATIENT LEVEL


Adapted from: Dudley RA, Frolich A, Robinow itz DL et al: Strategies to support quality-based Purchasing: A review of the Evidence. AHRQ. Technical Review N.10. 2004Adapted from: Dudley RA, Frolich A, Robinow itz DL et al: Strategies to support quality-based Purchasing: A review of the Evidence. AHRQ. Technical Review N.10. 2004


FACTORS THAT MAY INFLUENCE THE EFFECTIVENES OF FACTORS THAT MAY INFLUENCE THE EFFECTIVENES OF FINANCIAL INCENTIVESFINANCIAL INCENTIVES

1.1.1.1. FINANCIAL FINANCIALADEQUALS OF RECIPIENTADEQUALS OF RECIPIENTPOTENTIAL IMPACT OF REVENUEPOTENTIAL IMPACT OF REVENUECOST OF COMPLIANCECOST OF COMPLIANCE

1.1.1.1. FINANCIAL FINANCIALADEQUALS OF RECIPIENTADEQUALS OF RECIPIENTPOTENTIAL IMPACT OF REVENUEPOTENTIAL IMPACT OF REVENUECOST OF COMPLIANCECOST OF COMPLIANCE

1.1. CHARACTERISTCS OF THE INCENTIVE CHARACTERISTCS OF THE INCENTIVE1.1. CHARACTERISTCS OF THE INCENTIVE CHARACTERISTCS OF THE INCENTIVE

2.2. CONTEXTUAL FACTORS CONTEXTUAL FACTORS2.2. CONTEXTUAL FACTORS CONTEXTUAL FACTORS

1.2.1.2. NON FINANCIAL NON FINANCIALACCEPTABILITY OF GOALSACCEPTABILITY OF GOALSATTINABILITY OF COALSATTINABILITY OF COALSINTRINSIC MOTIVATIONINTRINSIC MOTIVATIONPROVIDER PREFERENCES FOR DOMAIN OF GOALSPROVIDER PREFERENCES FOR DOMAIN OF GOALSAPPROACH TO REINFORCEMENT APPROACH TO REINFORCEMENT (POSITIVE OR NEGATIVE)(POSITIVE OR NEGATIVE)

1.2.1.2. NON FINANCIAL NON FINANCIALACCEPTABILITY OF GOALSACCEPTABILITY OF GOALSATTINABILITY OF COALSATTINABILITY OF COALSINTRINSIC MOTIVATIONINTRINSIC MOTIVATIONPROVIDER PREFERENCES FOR DOMAIN OF GOALSPROVIDER PREFERENCES FOR DOMAIN OF GOALSAPPROACH TO REINFORCEMENT APPROACH TO REINFORCEMENT (POSITIVE OR NEGATIVE)(POSITIVE OR NEGATIVE)





Adapted from: Dudley RA, Frolich A, Robinow itz DL et al: Strategies to support quality-based Purchasing: A review of the Evidence. AHRQ. Technical Review N.10. 2004Adapted from: Dudley RA, Frolich A, Robinow itz DL et al: Strategies to support quality-based Purchasing: A review of the Evidence. AHRQ. Technical Review N.10. 2004


USA: Accreditation and quality. USA: Accreditation and quality. Is there a Is there a relationship?relationship?

UK: The new GP contract. UK: The new GP contract. Why it will or it will not Why it will or it will not work?work?

Commonwealth: Commonwealth: Comparing data, comparing systems?Comparing data, comparing systems?

IV. ADDITIONAL FOOD FOR THOUGHT: SOME QUESTIONS IV. ADDITIONAL FOOD FOR THOUGHT: SOME QUESTIONS ARISING FROM HEALTH-SYSTEM-WIDE PROJECTS AND ARISING FROM HEALTH-SYSTEM-WIDE PROJECTS AND

EMPIRICAL DATAEMPIRICAL DATA


USA: Accreditation and quality. Is there a USA: Accreditation and quality. Is there a relationship?relationship?

96% of hospital beds are accredited by the JCAHO96% of hospital beds are accredited by the JCAHO(J. Loew, President of JCAHO, ISQua Meeting, Oct. 2004)(J. Loew, President of JCAHO, ISQua Meeting, Oct. 2004)

96% of hospital beds are accredited by the JCAHO96% of hospital beds are accredited by the JCAHO(J. Loew, President of JCAHO, ISQua Meeting, Oct. 2004)(J. Loew, President of JCAHO, ISQua Meeting, Oct. 2004)

ACCREDITATION: ACCREDITATION: external initiative, reputational/financial incentiveexternal initiative, reputational/financial incentive ACCREDITATION: ACCREDITATION: external initiative, reputational/financial incentiveexternal initiative, reputational/financial incentive

(MCGlynn et al: The Quality of Health Care Delivered to Adults in the United States. NEJM, 2003)(MCGlynn et al: The Quality of Health Care Delivered to Adults in the United States. NEJM, 2003)

50% of compliance with quality indicators50% of compliance with quality indicatorsAssessment of 439 indicators related to 30 health problems, in a population sample of 6700 adults.Assessment of 439 indicators related to 30 health problems, in a population sample of 6700 adults.

Worse scores: Worse scores: • Indicators on patient education a counselling (18%)Indicators on patient education a counselling (18%)

• Alcoholism (10%)Alcoholism (10%)

• Hip fracture (23%)Hip fracture (23%)

Best score: senile cataract (78.7%)Best score: senile cataract (78.7%)

50% of compliance with quality indicators50% of compliance with quality indicatorsAssessment of 439 indicators related to 30 health problems, in a population sample of 6700 adults.Assessment of 439 indicators related to 30 health problems, in a population sample of 6700 adults.

Worse scores: Worse scores: • Indicators on patient education a counselling (18%)Indicators on patient education a counselling (18%)

• Alcoholism (10%)Alcoholism (10%)

• Hip fracture (23%)Hip fracture (23%)

Best score: senile cataract (78.7%)Best score: senile cataract (78.7%)


UK: The new GP contract: Why it will or it will UK: The new GP contract: Why it will or it will not work?not work?

External initiative, financial incentive to groups.External initiative, financial incentive to groups.

Aggregate score (points) based on compliance with 146 indicators grouped in 7 groups.Aggregate score (points) based on compliance with 146 indicators grouped in 7 groups.

1 point = 1 point = £75 (to be increased to £120 by 2005/2006)£75 (to be increased to £120 by 2005/2006)

External initiative, financial incentive to groups.External initiative, financial incentive to groups.

Aggregate score (points) based on compliance with 146 indicators grouped in 7 groups.Aggregate score (points) based on compliance with 146 indicators grouped in 7 groups.

1 point = 1 point = £75 (to be increased to £120 by 2005/2006)£75 (to be increased to £120 by 2005/2006)


GROUP OF INDICATORS NUMBER POINTS AVAILABLE (MAX)

1. Clinical (10 subgroups) 75 550

2. Organizational 56 184

3. Patient experience 4 100

4. Additional services 10 36

5. Holistic care Av.%Group 1 100

6. Quality Practice Low.% Groups

2,3,4 30

7. Access Above targets 50

INDICATORS FOR THE NEW GP CONTRACT (UK)INDICATORS FOR THE NEW GP CONTRACT (UK)

Adapted from: UK Department of Health : Investing in General Practice. The New GPS Contract. London, 2003Adapted from: UK Department of Health : Investing in General Practice. The New GPS Contract. London, 2003


CVA

Hypothyroidism

CHD

EpilepsyCOPD

Cáncer

DiabetesHypertension

Mental Health

Asthma

THE SUBGROUP OF CLINICAL INDICATORSTHE SUBGROUP OF CLINICAL INDICATORS

CHD- Coronary Heart DiseaseCOPD- Chronic Obstructuve Pulmonary DiseaseCVA – Cerebrovascular Accident (stroke)


INDICATORS POINTS AVAILABLE

1. Length of consultation (min.8, 10 minutes)

30

2. Annual Patient survey 40

3. The practice have reflected on survey results

15

4. The practice have discussed survey results, proposed and (at least partially) implemented changes

15

NEW GP CONTRACT: INDICATORS ON PATIENT EXPERIENCENEW GP CONTRACT: INDICATORS ON PATIENT EXPERIENCE


THE NEW GP CONTRACTTHE NEW GP CONTRACT

Domains and areas non covered?Domains and areas non covered?

Indicators non included?Indicators non included?

Weightings?Weightings?

Gaming?Gaming?

Disadvantaged areas?Disadvantaged areas?

Domains and areas non covered?Domains and areas non covered?

Indicators non included?Indicators non included?

Weightings?Weightings?

Gaming?Gaming?

Disadvantaged areas?Disadvantaged areas?


Commonwealth Fund: Commonwealth Fund: 2004 International Health Policy Survey2004 International Health Policy Survey

TopicsTopics: System Views, Access, Doctor-Patient Communication, : System Views, Access, Doctor-Patient Communication, Coordination, Emergency Room Care, Prescription Drugs, Coordination, Emergency Room Care, Prescription Drugs, Preventive Care, and Chronic Illness ManagementPreventive Care, and Chronic Illness Management

Telephone surveyTelephone survey of 1,400 adults ages 18 and older in Australia, of 1,400 adults ages 18 and older in Australia, Canada, New Zealand, the United States, with an expanded sample Canada, New Zealand, the United States, with an expanded sample of 3,061 in the United Kingdom (funded by The Health Foundation)of 3,061 in the United Kingdom (funded by The Health Foundation)


29

35

17

26

34

44

912

40

57

0

25

50

75

All Adults Adults with BelowAverage Incomes

AUS CAN NZ UK US AUS CAN NZ UK US

GOING WITHOUT NEEDED CARE DUE TO COSTS, GOING WITHOUT NEEDED CARE DUE TO COSTS, TOTAL AND LOW INCOMETOTAL AND LOW INCOME

Percent went without care due to cost


1014

22

127 5

57

411

26

0

25

50

75

No out-of-pocket cost More than US $1,000

Out-of-Pocket Medical Costs Out-of-Pocket Medical Costs in the Past Yearin the Past Year

Percent

AUS CAN NZ UK US AUS CAN NZ UK US



measured and improved”measured and improved”



measured and improved”measured and improved”









VI. CONCLUSIONSVI. CONCLUSIONS

1.1. Most research and evidence points out the importance of internal Most research and evidence points out the importance of internal programsprograms

2.2. External programs may External programs may facilitatefacilitate internal initiatives, though internal initiatives, though support, supervision, provision of comparative data, and support, supervision, provision of comparative data, and appropriate incentives.appropriate incentives.

3.3. Interventions to QI for specific conditions have to be implemented Interventions to QI for specific conditions have to be implemented and probably also designed, internally, Health System and practice and probably also designed, internally, Health System and practice environment changes may provide an appropriate environment changes may provide an appropriate contextcontext for QI. for QI.

4.4. To succeed, an important attention must be given to the factors To succeed, an important attention must be given to the factors that promote desired that promote desired behavioral changes among front-line behavioral changes among front-line clinicians.clinicians.

1.1. Most research and evidence points out the importance of internal Most research and evidence points out the importance of internal programsprograms

2.2. External programs may External programs may facilitatefacilitate internal initiatives, though internal initiatives, though support, supervision, provision of comparative data, and support, supervision, provision of comparative data, and appropriate incentives.appropriate incentives.

3.3. Interventions to QI for specific conditions have to be implemented Interventions to QI for specific conditions have to be implemented and probably also designed, internally, Health System and practice and probably also designed, internally, Health System and practice environment changes may provide an appropriate environment changes may provide an appropriate contextcontext for QI. for QI.

4.4. To succeed, an important attention must be given to the factors To succeed, an important attention must be given to the factors that promote desired that promote desired behavioral changes among front-line behavioral changes among front-line clinicians.clinicians.


DEAR AUDIENCE,DEAR AUDIENCE,

IF YOU OR ANYONEIF YOU OR ANYONE

YOU LOVE UNDERSTANDS YOU LOVE UNDERSTANDS

THE PRECEDINGTHE PRECEDING

CONVERSATION CONVERSATION

YOU HAVE MYYOU HAVE MY

DEEPEST SYMPATHYDEEPEST SYMPATHY

Universidad de Universidad de MurciaMurcia [email protected]@um.es

http://www.calidadsalud.comhttp://www.calidadsalud.com

Pedro J. SaturnoPedro J. Saturno

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