1. MARQuIS - Methods of Assessing Response to Quality Improvement Strategies MARQuIS: Methods of Assessing Response to Quality Improvement Strategies Rosa Suñol, MD, Ph.D. Director, Avedis Donabedian Foundation Director AD Quality Chair. Fac. of Medicine. Autonomous University of Barcelona 8th European Forum Gastein, October 2005

2. MARQuIS - Methods of Assessing Response to Quality Improvement Strategies Overview MARQuIS team EU Context Project description: Objectives Design Expected outcomes Results so far: Quality strategies Type of care provided Patient requirement Recommendations

3. MARQuIS - Methods of Assessing Response to Quality Improvement Strategies INVOLVED ORGANIZATIONS PARTNERS HOPE Standing Committee of the Hospitals of the European Union, Belgium ESQH European Society for Quality in Healthcare, Ireland; CEREF Centre for Research and Advanced Training,) Italy FAD Avedis Donabedian Foundation, Spain AMC Department of Social Medicine, Academic Medical Centre / University of Amsterdam,) The Netherlands CBO Dutch Institute for Healthcare Improvement,) The Netherlands MCHM University of Manchester / Manchester Centre for Healthcare Management, United Kingdom NCQA, National Centre for Quality Assessment in Health Care Poland COUNTRY COORDINATORS École de Santé Publique,Université Libre de Bruxelles, Belgium Belgium; Katholieke Universiteit Leuven, Belgium SAK CR Spojena akreditacni komise Ceske republiky, Czech Republic HAS Haute Autorité de Santé, France NCQA National Centre for Quality Assessment in Health Care, Poland FADA Foundation for Accreditation and Health Care Development, Spain NIAZ Nederlands Instituut voor Accreditatie van Ziekenhuizen, The Netherlands HQS The Health Quality Service, United Kingdom Coordination: Prof. Rosa Suñol (FAD)

4. MARQuIS - Methods of Assessing Response to Quality Improvement Strategies EU CONTEXT: Movement of citizens within the European Union is increasing. Many of the citizens move for reasons unrelated to healthcare, but, whatever the reason, all these movements have a potential impact on health services, creating new needs and demands. Freedom of movement of goods, services, capital and people is also affecting health services. Countries use this principles to address professional shortage, to support drug policy etc, but some concern arise when they’re also responsible of the care provided in another country (type of service, quality and cost)

5. MARQuIS - Methods of Assessing Response to Quality Improvement Strategies EU CONTEXT: Examples of health policy divergence in Europe Health system funding level and sources Health system design/structure Insurance coverage and benefits Co-payment, fees and expenses Treatment thresholds and choices Patient and public expectations Strategies for improving care (accreditation, indicators..) Quality requirements (criteria, standards, etc) Patients’ rights

6. MARQuIS - Methods of Assessing Response to Quality Improvement Strategies PROJECT DESCRIPTION: Objectives To assess and compare different quality strategies (accreditation of health care institutions, implementation of clinical guidelines, performance indicators, patient satisfaction surveys…), and their potential use in health services when patients move across borders to obtain care; this would provide a first basis to assess the need and the development of formal, quality procedures at EU level for secondary care institutions.

7. MARQuIS - Methods of Assessing Response to Quality Improvement Strategies PROJECT DESCRIPTION: Objectives WP-2 To identify and analyze quality strategies (including accreditation, certification, indicators, patient surveys, etc.) used at national level (25 countries) based in a specific framework developed by research team WP-3 To identify quality requirements for hospitals (safety and pat. empowerment) Review legislation and jurisprudence (mainly in patient rights) Identify volume and type of care provided to cross border care Identify patients’ requirements Identify providers requirements’ (doctors, nurses and managers)

8. MARQuIS - Methods of Assessing Response to Quality Improvement Strategies PROJECT DESCRIPTION: Objectives WP-4 /5 To describe in a sample of states how hospitals have applied national quality strategies, how far they meet the defined requirements of cross- border patients and what variables of organisation and methodology are associated with meeting these requirements (questionnaire to 500 hospitals, audit to 100 hospitals) WP-6/7 To use these data to draw general conclusions about the association of various national quality strategies and compliance with defined requirements and the need for developing formal quality procedures at EU level.

9. MARQuIS - Methods of Assessing Response to Quality Improvement Strategies Design HOSPITALS Quality strategies National and international level WP-2 Quality strategies National and international level WP-2 Quality requirements for cross-border patients WP-3 Quality requirements for cross-border patients WP-3 Development and applying measures Development and applying measures Audit Development and applying questionnaires (indicators, standards) Developing and testing questionnaires Distribution and analyses Generating hypothesis Organization Quality culture Etc. Structural Characteristics Regulation and jurisprudence Health financing authorities Statistics on type of care provided Patients requirements Other stake holders requirements Literature review Priorities for patients with cross-border care Literature review Framework Info retrieval + validity Report Field test Preliminary conclusions Consultation with governments

10. MARQuIS - Methods of Assessing Response to Quality Improvement Strategies Questions to answer to EU officers Is it convenient to develop a unique quality strategy/ instrument for Europe? Is a convergence process possible and acceptable for the governments and involved organizations? What are the key quality requirements to promote ? Can they be used as a guidance for quality development in hospitals? Are there special requirements when patients moving across borders? What is the relationship of Quality requirements with purchasing services between countries? What are the next steps to cover?

11. MARQuIS - Methods of Assessing Response to Quality Improvement Strategies EU CONTEXT: Patient mobility in Europe Tourism and short time stay (transport) and “false tourists” Residents: People living and working in another EU state (elderly,..etc) Capacity transfer initiatives (waiting lists) Private patients (in vitro-fertilization, aesthetic surgery, others..) Border regions Highly specialised care

12. MARQuIS - Methods of Assessing Response to Quality Improvement Strategies Information retrieval and validation in 25 countries Conceptual framework: Policy development Policy implementation Policy outcomes/ impact Literature review Quality strategies QUALITY STRATEGIES IN EUROPE : Accreditation ISO EFQM Indicators Contracts

13. MARQuIS - Methods of Assessing Response to Quality Improvement Strategies Regulation & jurisprudence Volume and type of care provided Patient requirements Other stakeholders requirements (doctors,nurses,managers.. Literature review Quality requirements QUALITY REQUIREMENTS:

14. MARQuIS - Methods of Assessing Response to Quality Improvement Strategies TYPE OF CARE PROVIDED A. Border regions projects B. Case study. Catalonia C. Purpose sample: 18 hospitals D. Insurance companies

15. MARQuIS - Methods of Assessing Response to Quality Improvement Strategies A. COOPERATION IN BORDER REGIONS HOPE: Hospital co-operation in border regions in Europe, June 2003

16. MARQuIS - Methods of Assessing Response to Quality Improvement Strategies A. COOPERATION IN BORDER REGIONS HOPE: Hospital co-operation in border regions in Europe, June 2003 Border region areas: 35 Hospital cooperation programs: 170 Treatment cooperation programs: 123 Care/ medical treatment Exchange of professionals Research Telemedicine Education / training Equipment shared AREAS OF COOPERATION: Emergency Management Conferences, seminars, meetings Funding / social security agreements Common structure Language course

17. MARQuIS - Methods of Assessing Response to Quality Improvement Strategies B. CASE STUDY Cataluña Field of study: Admissions to the Public Catalan System Hospitals during 2003 Source of data: CMBD de Cataluña, Servei Català de la Salut Main results: Total patients admitted: 714.404 Total EU patients admitted: 1502 % EU patients out of all admissions: 0.21%

18. MARQuIS - Methods of Assessing Response to Quality Improvement Strategies PROPOSED diagnosis LIST TO STUDY – Acute myocardial infarction – Deliveries – Appendicitis – Several kinds of fractures – Ophthalmology – Cancer – Diagnostic procedures

19. MARQuIS - Methods of Assessing Response to Quality Improvement Strategies PROJECT DESCRIPTION: Dimensions of quality Production efficiency Clinical effectiveness Staff Responsive governance Patient centeredness Safety WHO EURO, Barcelona. Measuring hospital performance: defining the sub dimensions and a framework for selecting evidence-based indicators Barcelona, WHO 2003. int EUR/03/5038066 www.euro.whowww.euro.who

20. MARQuIS - Methods of Assessing Response to Quality Improvement Strategies Qualitative research using semi-structured interviews Patients from an EU country admitted to a hospital abroad Expected number of interviews: 60 Countries of study: Italy, Spain, Netherlands, Belgium Goal: to identify relevant issues and priorities of individual patients using care across national borders PATIENT REQUIREMENTS: Methodology

21. MARQuIS - Methods of Assessing Response to Quality Improvement Strategies PATIENT REQUIREMENTS: Preliminary findings ENVIROMENTAL / ORGANIZATIONAL ISSUES Cleanliness Food Noise / visitors Environment of care Organization of the environment of care Daily routine ATTENTION TO PATIENTS Help / attention to patients Timeliness Professional attitude - ATTENTION TO RELATIVES COMMUNICATION / INFORMATION Translation/communication in other languages Information about illness and treatment Involvement of care / informed consent Information about hospital procedures Information to family doctor at home - PROFESIONAL CAPABILITIES - GENERAL COMMENTS

22. MARQuIS - Methods of Assessing Response to Quality Improvement Strategies LESSONS LEARNED SO FAR: 1- Cross-border hospitalization in Europe varies widely, it seems to be a low occurrence phenomena, but underestimation could be important 2- The volume of care provided to EU patients at the emergency unit seems to be higher than the events of hospitalization for this population 3- Even when DRG codification system is only used in some European countries, all countries involved on this study use ICD either version 9 or 10, so data could be compared

23. MARQuIS - Methods of Assessing Response to Quality Improvement Strategies LESSONS LEARNED SO FAR: 4- EU patients hospitalized abroad seem to have a more homogeneous pathology than the regular population admitted to the same hospital 5- Most frequent diagnosis for hospitalized EU patients, are acute myocardial infarction, deliveries, appendicitis, disrhytmias and several kinds of fractures (this accounts for 25% of all cases) 6- Preliminary analysis of patients requirements seems to show differences between EU patients and local patients needs (different diagnosis, specific groups, extra patients needs due to information and language problems and lack of family environmental support)

24. MARQuIS - Methods of Assessing Response to Quality Improvement Strategies Recommendations: 1- In order to be able to perform valid studies about the cross-border care, it would be necessary to include some common equivalent fields on hospitals and national healthcare databases. So it’s recommended to: Include country of origin as a mandatory field in hospitals and country databases. (data available in hospitals but not at country levels) both in inpatients and emergency areas 2- It would be interesting to agree among different research groups on the typology of cross border care (also from patients point of view) 3- The information currently available does not include the data that would be needed to independently study different categories of cross- border care (residents,,turists etc) Once country is identified, health information databases of EU countries should progressively start incorporating the information on types of cross border care as mandatory fields. 4- Specific discharge information seems necessary for cross border care. It will be useful to consider a common content of the discharge letter in EU hospitals

25. MARQuIS - Methods of Assessing Response to Quality Improvement Strategies Contact details: Rosa Sunol MD PhD marquis@fadq.org www.fadq.org www.marquis.be