1. Dutch case for the Risk Working Group
Ine Borghans
The Netherlands

2. Risk Working Group 1
Select Case 2
Look at data 3
Could this have been prevented?

3. Selected case: a Dutch Hospital
For a long time the medical staff was not focused on structural improvement of quality and safety of care.
The board of directors was unable to change this and the supervisory board was not able to intervene in this.
Middle staff and support staff were not able to achieve the substantial improvements that were needed.
All this led to an ‘island-culture’ in the hospital
Safe care and good quality of care was not obvious.
The inspectorate found problems at the department of cardiology
Novembre-2012 till May-2013: tightened supervision

4. Inspectorate when visiting the hospital: Comparing outcomes of care (benchmarking) is important. December 2011: a significant high HSMR was found in data 2010 This led to the awakening of the inward-looking organisation. Board of directors asked independent researchers to study the HSMR/SMR by record reviewing. Results of this study led to a VT in the period November 2012 till May June 2013: the hospital was declared bankrupt

5. Data: Dutch HSMR’s 2010 HSMR = 149
Titel van presentatie | datum van presentatie

6. Important
A high HSMR is no evidence that care is unsafe: Record reviewing is needed to find out the causes of the high HSMR The researchers found serious problems with quality of care at the department of cardiology. Medical Staff and cardiologists minimised the problems just to registration issues and did not improve care. The hospital choose not to recognize fundamental problems in health care and no structural improvements were done.

7. Could the inspectorate have detected the quality problems in this hospital in an earlier stage?

8. 2009: no participation in HSMR

9. 2009: record reviewing: yes

10. Could this have been prevented?
The hospital did not participate in the HSMR: this could have been an important signal
But:
The hospital said they did do record reviewing. At that time we thought this was of more importance than participating the HSMR
What is the value of such a process indicator?
Quality of record reviewing often is poor, especially the conclusions
Maybe the inspectorate should have asked to show the report of the record reviewing and judged the quality of the research.

11. Care-related indicators Company information
Incident reports
Inspection findings
Patient experiences
Care-related indicators
Company information
Titel van presentatie | datum van presentatie