Quality Improvement – a Policy Strategy

Britt Wendelboe, Acting CEO, The Danish Society

for Patient Safety

Jens Winther Jensen, Senior Fellow IHI

Britt

Jurans Triangle

Quality

improvement

Quality control

Quality planning

Britt

• Clinical registries – reseach and development

• Hospital accreditation

• Central planning of specialized treatments

• Patient safety agenda

Central elements in DK hospital qualityjourney in recent years

Jens

DK Clinical Registries

Total number 70

• 28 cancer registries including quality of palliative care and national screening programmes

• 12 intervention – related (e.g. intensive care, emergency medicine)

• 8 non-neoplastic elective surgery/orthopaedic surgery, gynaecology

• 8 major chronic disease

• 6 cardiovascular disease

• 3 psychiatry

• 3 obstetrics

• 3 pediatrics

• 2 emergency surgery

Jens

• ‘National Strategy for Quality Improvement in Health - Common

goals and action plan 2002-2006‘

• The Danish Health Care Quality Assessment Program (DDKM)

was a common model for assessing the quality of health service

• In 2005 The Danish Institute for Quality and Accreditation i

Healthcare (IKAS) was established

IKAS, The Danish Institute for Quality and Accreditation in Health Care

Jens

Canada (2004) 8%

Colorado/Utah (1999)

3%New York

(1991) 4%

Denmark (2001)

9%

UK (2000) 11%

Sweden (2008)

9%

France (2004) 9%

The Netherlands (2007) 6%New Zealand (2001) 13%

Australia (1994) 13%

The Journey: Patient Safety – Incidents with harm

Britt

Stakeholders took leadership

Danish Regions

Local Government Denmark

Danish Medical Association

Danish Nurses Organization

Trade union for social- and health care workers/assistants (FOA)

Association of Danish Pharmacies

Danish Patients

Disabled Peoples Organisations Denmark

Medical Device Industry The Danish Association of the

Pharmaceutical Industry (LiF)

The Danish Journey

Risk

Manage

ment

Effective

and timely

treatment

Dignity and

respect

The patient

as partner

1999 – 2001 – 2003 – 2005 – 2007 – 2009 – 2011 – 2013 – 2015 – 2016

The Patient’s book

10 good advice

Operation Life

All-or-none

Patient ambassadorsIn the patient’s footsteps

Dressed to be relative

Shared Decision

Making

The Safer Hospital

Program

New improvemnt

projects

Hallo Health Care

Triple Aim

‘Acceleration’ and a

national quality

program

Revision of

national reporting

system

Medication labels

- SADDanish AE Study - Physical

environment Learning sets

Safe Mental Care

The boards vision

International Milestones

Risk

Manage

ment

Effective

and timely

treatment

Dignity and

respect

The patient

as partner

1999 – 2001 – 2003 – 2005 – 2007 – 2009 – 2011 – 2013 – 2015 – 2016

The Patient’s book

10 good advice

Operation Life

All-or-none

Patient ambassadorsIn the patient’s footsteps

Dressed to be relative

Shared Decision

Making

The Safer Hospital

Program

New improvemnt

projects

Hallo Health Care

Triple Aim

‘Acceleration’ and a

national quality

program

Revision of

national reporting

system

Medication labels

- SADDanish AE Study - Physical

environment Learning sets

Safe Mental Care

The boards vision

IOM: To err

is human

IOM:

Quality

Chasm

IHI

100.000

Lives

Campaign

USA

Health

Foundation

Safer Patients

Initiative UK

Health

Foundation

Co-creating

Health

Kings Fund:

Silent

misdiagnosis

NEJM:

What

matters

to you?

IOM:

Improving

Diagnosis

NPSF:

Free

from

Harm

• Quality chasm – bundle concept – all-or-none

• Local engagement – celebrations – prof. pride

• Local real-time data

Operation Life 2007-2009Sepsis trolley with all

equipment for sepsis

treatment

Local real-time data

Ambitious overall goal – saving 3000 lives

Engagement

• “Close-to-the-clinic leadership”

• Improvement across the entire organization

• Transparency – ‘going naked’

Safer Hospital Programme 2010-2013

Close to the clinic leadership Hospital-level data presented at public boards

Joy from getting good results

“Social movements emerge as a result of the efforts of purposeful

actors (individuals, organizations) to assert new public values, form

new relationships rooted in those values, and mobilize the political,

economic, and cultural power to translate these values into action. They

differ from fashions, styles, or fads (viral or otherwise) in that they are

collective, strategic, and organized. The differ from interest groups in that

they focus less on allocating good than on redefining them – not only on

winning the but also changing the rules.” (Marshall Ganz*)

A movement of Quality Improvement

Ref: Ganz, Marshall: Leading Change – Leadership, organization, and social movements (2010), Harvard

Business Press

14

Jens

Grand, J. Le. (2010). Knights and Knaves Return: Public Service Motivation and the Delivery of Public Services.

International Public Management Journal, 13(1), 56–71.

Acc

red

itat

ion

Ben

chm

ark

ing

Tru

str

efro

m

Per

form

ance

man

agem

ent

Pay

by

DR

G

Pla

nn

ing

of

spec

ialt

y

fun

ctio

n

Cli

nic

ald

atab

ases

Nat

ion

alc

lin

ical

guid

elin

es

Pat

ien

tsa

tisf

acti

on

Competition xx xx xx xx

PatientCo-

production x

Command

andcontrolxx xx xx xx x x

Collaboration xx x x

Nature of national regulation of healthcare in Denmark

Mental Models of GovernancePUBLIC SERVICE MOTIVATION AND THE DELIVERY OF PUBLIC SERVICES

LeGrand’s

Categories

Choice

Voice

Mistrust

Trust

Derek’s Translation

Competition

Patient co-production

Command and

control

Collaboration

Grand, J. Le. (2010). Knights and Knaves Return: Public Service Motivation and the Delivery of Public Services.

International Public Management Journal, 13(1), 56–71.

System for improvements

Quality improvement

Innovation Control

Supervision

Excellent

quality

Quality

Unacceptable

quality

Health Care system

units

Control and command Cooperation and trust CompetetionUsers voice

Steering paradigms

Governance review of hospitals -Suggestions for procedures and rules simplification, May 2015

• An excess of generalised and standardised procedure-

and monitoring demands

• Employees use a lot of time on tasks which are

questioned by employees and their leaders

• Implementation overload – not the specific standard or

monitoring but the overall burden and trend

• Fear of not being accredited has produced a large

number of local quality standards

• Reduced local room for leadership

• Quality problems and standards are defined externally

• Leadership role reduced to implementation

Bent Hansen, President of Danish Regions

'Quality work must be simplified and focused.

The time has come to strengthen it by putting

the patient at the centre, rather than focusing

on compliance with a variety of standards.

Accreditation has been justified and useful,

but we move on. We need a few national

targets to be met locally with strong

commitment from the staff and with room for

local solutions.'

April 2015: Denmark to stop hospital accreditation

New Danish Quality Program

• National targets

• Systematic involvements of patients

• Leadership developmemt

• Systematic use of real-time data and data-driven

improvement work

• Transperancy of results

• Learning- and quality teams

Indicators

Local

goal

Local

goal

Local

goal

Local

goal

Local

goal

Local

goal

Local

goal

Local

goal

Local

goal

Local

goal

Hospital

Hospital

MunicipalityHospital

Municipality Municipality

Local

goal

Local

goal

Local

goal

Local

goal

Local

goal

Local

goal

The national goals – Hierarchy of goals

Nat

ion

al L

evel

Loca

l lev

eL

The patient as the center

Improved efforts for

the chronically ill

and elderly patients

More coherent

continuity of care

Improved survival

and patient safety

Treatment of high

qualityRap

Rapid diagnosis and

treatmentRapIncreased patient

involvementRapMore healthy live

yearsRapMore effevtive

health care

Indicators Indicators Indicators Indicators Indicators Indicators Indicators

Hospital

GP

GP

Jurans Triangle

Quality

planning

Quality

improvement

Quality control

Quality

control

Quality planning

Quality

improvement

Drivers for policy change

• A Coalition for change: a new paradigm

• Building Will: Leaders, civil servants and public opinion,

exemplar sites

• Execution: Window of opportunity, policy suggestions

Britt