|Implemented in this survey?|
Reflecting international developments in the area of patient safety a critical reporting system came into effect. CIRSmedical aims at creating a platform for knowledge exchange between providers and is run by doctors. The government ensured some oversight and will conduct evaluations. Whether care will become safer for patients will depend on the credibility of the process of knowlege generation and on the degree providers are being held accountable for adverse events in care provision.
A Critical Incident Reporting System (CIRSmedical.at) was launched in November 2009 in response to increasing claims for promoting patient safety in Austria. Designed as a one year pilot, CIRSmedical.at is a nationwide electronic learning tool for knowledge exchange which medical and non-medical providers may use to fill in adverse events anonymously in a web-based reporting system. It mainly aims at providing for mutual learning about medical errors and other adverse events within and across organisations and care settings.
The development of this policy is anchored in the current government programme and in the general agreement about hospital financing between the federal government and federal states, "Länder" (15a B-VG Vereinbarung 2008-2013). In this context, CIRSmedical.at forms a starting point in the development of an Austrian quality strategy.
Neither are specific incentives to raise awareness of health care providers about the reporting system CIRSmedical.at obvious nor are financial incentives foreseen. The technical implementation and the administration of CIRSmedical.at is currently financed by the chamber of physicians.
Health care personal, Ministry of Health and Chamber of Physicians, Patients
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
This policy is surely innovative in the Austrian context and has potential to create a quality oriented and a more patient-centred "code of conduct" of health care professionals. However, the effectiveness of this policy depends on whether CIRSmedical.at will gain credibility by making providers truly accountable for their actions. As this is not yet fully ensured, the degree of controversy will probably increase as many other actors and patients advocates remain suspicious about the adequacy of "self-audits" of doctors even after the government took some oversight role in this process. While visibility may increase in the future when reports and assessments are being discussed in the public, the structural and systemic impact will probably remain unchanged. This may change if for example reporting at CIRSmedical.at leads to closures of health care facilities etc, a situation which is not very likely.
While in the early 90s quality-related work in Austria mostly aimed at ensuring structural quality, process quality and patient safety issues have been increasingly addressed in the late 90s and the beginning of 2000. In particular, with the phasing-in of a Diagnosis-Related-Reimbursement scheme in hospitals in 1997, quality standards were also enforced. For example, the current scheme penalizes premature discharges by lowering reimbursement levels. Also, most hospital providers established wider quality management programmes encompassing issues of process quality. Ambulatory care providers may receive certificates when they participate in quality workshops organized by the chamber of physicians. But all initiatatives remained scattered across jurisdictions in federal states ("Länder") and across providers. In additon there was hardly systematic documentation of indicators and/or outcomes collected in the process of these initiatives.
Austria´s quality performance is poorly understood
Austria´s performance on a set of quality indicators seems inferior when compared with other countries, but not consistently so across diseases. For example, case fatality rates for acute myocardiac infarction after 30 days of admission to hospitals is very high and exceeds the OECD average. At the same time the likelihood to die in hospitals in Austria is manifold probably indicating that emergency service is effective. This in concert with a high level of bed capacity available increases the odds to die in hospitals. Further, the chance for women to survive breast cancer at least 5 years appears better in Austria than in other OECD countries. However, the likelihood to die in Austria following an adverse event is reported to be double when compared to other OECD countries like Germany or France (OECD Health at a Glance 2007).
Who "owns" health care quality?
Legislation as put forward by the 2005 health reform (see survey 04(2004)) set milestones for the development of a structured and encompassing approach to improve the quality of health care provision and patient safety in Austria. In this context the annexed 2005 health quality law stipulates the framework for development work in this area and specifies institutional requirements (see also survey 04(2004)) which led to the foundation of the Federal Institute of Quality (BIQG) in July 2007 as a branch within the newly structured Austrian Health Institute (GOEG). While the 2005 law aims at promoting more accountability by external surveillance of all health care providers, practising doctors in ambulatory care via their represenatives resisted successfully the establishment of such an external audit. As a consequence an organisation was formed in 2006 on the level of the chamber of doctors to monitor quality and patient safety in ambulatory care. In fall 2008 a network for patient safety ("Plattform Patientensicherheit"-ANetPAS) was established. It aims at improving patient-centred care through the provision of safe care. Thus, currently there are three institutional layers in operation for promoting quality of care provision. In addition, a syndicate of patient counsellors exists and offices are established in all nine federal states. Patient counselors are not bound to instructions and make sure that patients receive proper information if requested. They are also in charge of enforcing patients´ claims in case of adverse events in hospitals and nursing homes.
Austrian Health Institute - GOEG and Federal Institute of Quality-BIQG
In the context of the 2005 legislation the "Federal Institute of Quality" (Bundesinstiut für Qualität im Gesundheitswesen - BIQG) was founded in 2007 as a branch within the newly structured "Austrian Health Institute" (Gesundheit Österreich GmbH-GOEG) It aims at developing a cross-cutting approach in quality work and in evaluation on the basis of patient-orientation, transparency, effectiveness and efficiency. The main tasks of the Institute of Quality are:
Austrian Association of Quality Assurance and Management-OEQMED
This organisation was formed in 2006 also in response to increasing claims for better quality assurance in ambulatory care. As a subsidiary company of the chamber of physicians it is run on the basis of current laws applicable to the medical profession ("Ärztegesetz") supported by advisory boards. While the scientific advisory board consists also of external experts mainly coming from the Ministry of Health, the "evaluation advisory board" is solely in the hands of representatives of the chamber. The organisation aims at ensuring quality standards in doctors officies by employing surveys for self-evaluation. In June 2009 the first report was released. Participation was voluntary but could be enforced by "quality managers" who - on a random basis - may visit doctors officies. Results are presented as simple counts of the number of deficiencies. Reported deficencies must be corrected within a certain period. A certificate to the office is granted on the basis of corrections made which is monitored by administrators of the organisation.
Platform patient saftey-ANetPAS
In fall 2008 a network for patient safety ("Plattform Patientensicherheit"-ANetPAS) was established. It aims at improving patient-centred care through the provision of safe care. The independent network is located at the University of Viennas Institute of Ethics and Medical Law. Supported by the Ministry of Health, it consists of national and international experts and is a collaborating partner of the European network for patient saftey (EUNetPaS).
The network claims are:
In March 2009 the platform published a summary report where in Austria reporting systems for adverse events have been so far established. This report is purely descriptive and also presents information on currently active reporting systems in other EU-countries and in the US.
The current government programme contains the claim ?to ensure quality of health care provision through improving patient safety?.
|Implemented in this survey?|
In April 2009 the chamber of physicians announced the establishment of a nation-wide comprehensive clinical incidence reporting system. Reflecting much international developments in this area, this initiative was largely in response to increasing public claims to promote patient safety and quality of care in Austria. Moreover, the 2005 quality law (see survey 04(2004)) stipulates the establishment of quality reporting across health care settings. Thus, the chamber anticipated that sooner or later regulations will come into effect where providers - in particular doctors - are being requested to participate in systemwide reporting. In recent years some health care organisations created clinical reporting systems but no standardised procedure was applied. Further no systematic evaluations of these systems are in place.
In concert with the Ministry of Health the Federal Institute of Quality (BIQG) became active in shaping this policy. In particular, in the course of the development of the framework of CIRSmedical.at, BIQG ensured the establishment of standards for data and and a framework for evaluation accompanying the pilot phase of the policy. In addition, it is envisioned that reporting is analysed and summary accounts are being published through this Institute.
The chamber of physicians pushed for the establishment of this policy and it took financial, technical and administrative ownership. As with quality assurance in ambulatory care through a own subsidiary of the chamber (OEQMED), the initiative has been widely critized by other actors including the syndicate of patient counsellors and the platform for patient safety. To ensure independent surveillance and oversight in the development of the reporting system, the Ministry of Health commissioned the Federal Institute of Quality (BIQG) to become active in designing the framework. Currently BIQG sits in the centre, representing the government and acting as a mediator balancing public interests and professional (self-) interests.
|Ministry of Health||very supportive||strongly opposed|
|Federal Institute of Quality||very supportive||strongly opposed|
|Ministry of Justice||very supportive||strongly opposed|
|Chamber of Physicians||very supportive||strongly opposed|
|Association of Nurses||very supportive||strongly opposed|
|Syndicate of Patient counsellors||very supportive||strongly opposed|
|Platform Patient Safety||very supportive||strongly opposed|
|Ministry of Health||very strong||none|
|Federal Institute of Quality||very strong||none|
|Ministry of Justice||very strong||none|
|Chamber of Physicians||very strong||none|
|Association of Nurses||very strong||none|
|Syndicate of Patient counsellors||very strong||none|
|Platform Patient Safety||very strong||none|
The Austrian Association of Quality Assurance (OEQMED), a subsidiary organisation of the chamber of physicians, runs CIRSmedical.at. Providers including nurses and other allied personal may use the tool anonymously via access to internet in their respective organisation or institution. While currently CIRSmedical.at targets health care personal it is envisioned that other persons outside care organisations including patients also may use the reporting system in the future. Once an event is reported it will be send to a server in Basel (CH) where anonymity is created. The reports are then sent to OEQMED where they are being reviewed for inclusion. Once approved by administrators of the OEQMED reports are being filed and sent to defined "CIRS-experts" in respective bodies, i.e. associations of cardiologists etc. A nominated expert is requested to write a commentary and to make suggestions for improvements. This commentary is also anonymous. Both the reports and commentaries are entrusted to the Federal Institute of Quality (BIQG) where administrators review them according to a defined set of rules before they are published on CIRSmedical.at. All readers of released reports have the possibility to comment web-based. Legally requested notifications and complaints about medical errors are not excluded through reporting at CIRSmedical.at. However, as OEQMED is no sovereign body an obligation to notify complaints does not exist.
The one-year pilot will be accompanied by an evaluation which is commissioned by the Ministry of Health and by the chamber of physicians. It will be conducted by the Federal Institute of Quality (BIQG) and aims at:
The framework for evaluation is currently in development and is generally bound to those data and reports the chambers´ subsidiary OEQMED will release.
Results of the evaluations are expected to be available within three months after the one-year pilot expires. So far the evaluation does not foresee the generation of patient-specific data to assess whether or not care has become safer through knowledge exchange, i.e. changes in morbidity or mortality.
In light of world-wide booming intitiatives to improve patient care through more emphasis on qualiy of care and patient safety, CIRSmedical.at is overdue and innovative in the Austrian context. In particular as it extends to all health care personnel and finally also other persons including patients. While the institutional set-up in which reporting of adverse events will take place appears functional, it remains uncertain whether this policy sufficiently promotes safe care for patients:
First, the propensity of providers to report about adverse events appears low even though local initiatives have in some cases proved to be successful. The current framework for setting-up reporting does not contain appropriate incentives for providers to report and seems to be highly dependent on "word-by-mouth" promotion. For example, the press relase of the chamber of physicians does not make any reference to the webpage CIRSmedical.at. Also, no campaign appears to be envisioned to promote the use of the reporting system. Thus, value judgements about the usefulness of the tool will probably prevail over a more patient-centred and quality oriented code of conduct. Further, currently it appears that there is no framework how training courses or instructions for providers who report an adverse event will be conducted or organized.
Second, representatives of medical doctors may probably even welcome a slow up-take in the use of the tool by their clientel as the reputation of the whole profession is at stake once the frequency of the reporting of adverse events will increase. In addition, the nomination process of anonymously acting "CIRS-experts" to review anonymous reports is unclear which will probably create mistrust regarding the validity of the procedure.
Finally, reports and their reviews will be pre-screened by administrators of CIRSmedial before they are released to the "public domain", notably to the Federal Institute of Quality where evaluations will be conducted. Even though "self-audits" as the only source of reporting are prevented through the active role the government has taken in the development phase, doctors and their representatives have once again successfully resisted fully disclosed external audits of their performance. This does not seem to reflect the basic intentions of the 2005 health quality law nor does it comply with provisions used in some other countries (OECD 2007).
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
The level of quality of health care services may gradually increase once knowledge exchanges really transcend into improved medical practice. This will take some time however. No impact on the level of cost-efficiency is expected in the short-term. On the contrary, in the short-term cost may even increase after investments prove necessary to improve the performance of providers. No impact on the level of equity is expected. But a general increase in the level of quality of care provision has likely a more pronounced impact on care provision for disadvantaged groups when compared with affluent groups.
Bundesgesetz zur Qualität von Gesundheitsleistungen
(Gesundheitsqualitätsgesetz - GQG)
Bundesgesetz über die Gesundheit Österreich GmbH (GÖGG)
Erläuterungen zum Gesundheitsqualitätsgesetz, Vorblatt zum Gesundheitsqualitätsgesetz: http://www.bmg.gv.at/cms/site/attachments/3/4/1/CH0703/CMS1043931577060/pdf_erlaeuterungen_gesundheitsqualitaetsgesetz.pdf
Hofmarcher, M.M., Monika Riedel. "Health Quality Law". Health Policy Monitor, October 2004. Available at http://www.hpm.org/survey/at/a4/3
OECD (2007) Health Care Quality Indicator Project, Patient Safety Data Systems in the OECD: A report of a joint Irish Department of Health - OECD Conference, Paris http://www.oecd.org/dataoecd/12/4/38705981.pdf
OECD (2008): Health at a Glance 2007, Paris
Plattform Patientensicherheit (2009): Learning and Reporting Systems, Meldesysteme für "kritische Ereignisse" in Österreich, Wien,http://www.plattformpatientensicherheit.at/
Various press releases
Maria M. Hofmarcher
The author is grateful for many helpful comments received by: