|Implemented in this survey?|
Initiated by the Dutch MoH and based on reports of four captains of industry, effort has been undertaken to improve quality of hospital care. Five priority areas were defined; hospitals were given expertise and support. A robust evaluation scheme has been set up. First results show meaningful improvements. However, many projects don't achieve pre-stated objectives and there are no indications yet that results will be better than those of earlier, less expensive, so-called breakthrough projects.
Program "Sneller Beter" (Sooner Better) to improve quality of care
There are serious doubts on the effectiveness, efficiency and safety of all health care systems. The government, health insurers, health care providers and other stakeholders deal with the question of how to improve the quality - including the effectiveness, efficiency, safety and client orientation - of health services. Improving the quality of care must become an integral part of everyday practice, both for professionals and for health care organizations. Experience demonstrates that successful innovations in health care usually take much longer than reorganization processes in the world of trade and business. To fasten the implementation of innovations in health care, policymakers promote the use of methods and principles which are commonly used in the business world.
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
The Dutch government is determined to introduce more business and market principles in health care. For that purpose, it transformed the system from a public service into a private service under public control. At the same time, the government will retain its accountability for the quality and cost of health care. In this respect, the Minister of Health decided to stimulate meaningful innovations by contributing financially to experiments organized by its organization for health services research (ZonMw) under the program Sneller Beter that was implemented in November 2003 (see report "Benchmarking: stimulating efficiency and innovation"). The innovative experiments also include a systematic evaluation.
|Implemented in this survey?|
Encouraged by experiences in the USA various governments are considering which business methods and principles may contribute to an efficient health care system. From 2002 till 2007 the Netherlands was governed by a Liberal/Christian government that was strongly in favor of market principles in public affairs. The (liberal) Minister of Health consulted captains of industry and asked them to report to him on possibilities to improve the quality and the implementation of innovations in health care. He used their advices for his further strategy.
The program Sneller Beter was developed in three stages (called pillars)
Pillar 1. Awareness
To create awareness four Dutch top captains of industry were invited to report to the Minister on their ideas on how to best set up innovations.
Pillar 2: Development of performance indicators
The main idea is to use the quality circle as a model for quality improvement. Comparing performance figures is considered as the vehicle for quality improvement. To put this in operation, the main areas for improvement and the aspects they cover must be translated into measurable indicators. These indicators are used to measure the situation at the beginning of the process ('diagnosis') and as a benchmark to measure the progress of the implementation.
A basic set of performance indicators was developed by the Health Care Inspectorate in cooperation with the Dutch Hospital Association (NVZ), the Association of University Hospitals (NFU) and the Dutch Society of Medical Specialists (OMS). They include for example the percentage of pain-scores above 7 during the first 72 hours after an operation; the percentage of cancellations 24 hours before a planned elective operation; fulltime equivalents of intensivists working on a standardized intensive care unit; the percentage of patients with diabetes who consult a opthalmogist during one year etc.
Pillar 3: Breakthrough projects Sneller Beter
The main idea of the breakthrough projects of the program Better Faster is to use front-runners (hospitals and identified groups or departments within hospitals) as a driving wheel for innovations. Furthermore, the focus is on those aspects where success can be demonstrated within a short time period. Demonstration of successes is considered to be a driving wheel that stimulates others to adopt innovations. The program has been divided in blocks, each consisting of 8 hospitals. It was the intention to start each year with 8 hospitals, forming a new block. For the first block innovative hospitals and innovative departments of these hospitals were selected. In the second and third block other hospitals and departments were selected.
The following aspects were defined in five priority areas:
For each aspect explicit, measurable targets were defined. For instance:
At the program level the target is that 20 percent of the Dutch hospitals implement considerable and meaningful improvements in the areas of logistics and patient safety.
From all Dutch hospitals (98) 24 have been elected to participate in Sneller Beter. These 24 are assigned to the three blocks of 8 hospitals.
A central program organization has been created, located at the Dutch Organization for Health Services Research (ZonMw). The Dutch Organization for Quality Improvement in Health Care (CBO), ZonMw and the Erasmus University form a consortium that supports the hospitals to implement their improvement projects. They organize meetings for the project teams in the hospitals and communicate and exchange knowledge. The program is evaluated by a different group, composed of researchers of the Dutch Institute for Primary Care Research (Nivel), the Free University Amsterdam and Maastricht University.
The former Dutch Minister of Health was dedicated to improve the quality of care. The reports of the captains of industry strongly stimulated him to involve quality in the daily working process of the caregivers and care institutions. Their advices were in accordance with the experience of the former Managing Director of CBO in breakthrough projects. CBO defines its role as demonstrating that improvements are really possible in many areas of health care by means of breakthrough projects, implementation of guidelines, and best practices. He had the opinion that hospitals themselves must disseminate their results as widely as possible. The changing market position is an important driver for organizations of hospitals and medical specialists to be intrinsically interested in upgrading the quality of hospitals.
The four leaders in industry reported their findings to the Minister. The performance indicators are summarized in a publication of the Health Inspectorate and Nivel has published a report on the results of the first block of hospitals.
|Minister of Health||very supportive||strongly opposed|
|Hospitals||very supportive||strongly opposed|
|Organization for Quality Improvement in Health Care (CBO)||very supportive||strongly opposed|
There was no need for a formal legislative process other than financing the program in the budget of the Ministry and ZonMw. The reports of the advisors were discussed in the Parliament.
|Minister of Health||very strong||none|
|Organization for Quality Improvement in Health Care (CBO)||very strong||none|
The "Sooner Better" program has attracted a lot of attention of hospitals, medical specialists, policymakers and the press. The encouraging results of the frontrunner-group had a stimulating impact.
Implementation must be considered at different levels: at the level of the participating hospitals, at the level of other hospitals and at the level of other domains in health care. Other departments and hospitals asked for the same support as the departments and hospitals received from the consortium. A comparable program has been set up for nursing homes and homes for the elderly (Care for Better, Zorg voor Beter).
The evaluation of the "Sooner Better" program is the responsibility of the Dutch Organization for Health Services Research (ZonMw) and consists of a process evaluation by ZonMw and a scientific evaluation of the third pillar by a group composed of Nivel, Free University Amsterdam and Maastricht University, supervised by an independent review committee. Till now the Nivel group has produced one report about the first block - the frontrunners - dealing with striking results, influencing factors and sustainability. The evaluation of the second and third block is still under way (see References for the title of this report).
The evaluation study of the first block showed that the eight hospitals have set up 113 improvement projects by 77 project teams. It demonstrates that the projects success strongly depends on the extent to which employees involved see results and are appreciated for their efforts, for example by allowing them to invest in new improvements. The aim of the program was achieved by 20% of the projects within one year. In one third of the projects the aims had not been achieved at the moment of evaluation. For the remaining projects the results were not clear. It was concluded that these large-scale and heavily supported projects did not have a more positive result than the previous separate breakthrough projects. However, positive elements were the systematic approach, the involvement of the top management of the participating hospitals and the enthusiasm in these hospitals by creating a win-win situation.
No single hospital scored positively or negatively on all aspects, but some hospitals achieved better results than other hospitals.
Concerning the balance between cost and benefit the logistic projects had a more positive result than the projects to improve patient safety.
Further evaluations are not available yet. However, there are indications that the results of the hospitals participating in the blocks 2 and 3 are less than in block 1. Keeping top management involved appears to be a fundamental problem.
The expectation of the initiators was that the systematic approach, the support given by the consortium and the use of clear performance indicators would bring about a substantial improvement of the quality of care. Looking at the first evaluation and estimates of the results of the later included hospitals, there are indications that improvements have indeed been made, but there is no reason to expect that these results will reach the level that the initiators had in mind. According to the latest information available, the present minister of Health plans to terminate the program at the end of the year 2008.
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
Wagner C, Dückers M and M de Bruijn. Doing the right things right; results and diffusion of large-scale improvement actions. Utrecht: Nivel, 2006.
Cor Spreeuwenberg is Professor for Integrated Chronic Care, Department of Social Medicine, Maastricht University, The Netherlands