- Abstract The Field Of Health Care Is Changing Due To A Variety Of Factors Such As Rising Costs Demographic Changes Te 1 (266.72 KiB) Viewed 35 times
Abstract The field of health care is changing due to a variety of factors, such as rising costs, demographic changes, technological innovation, the introduction of more business-like and market-based principles, and an increased involvement of the media and the general public. Within this context, quality control and quality reporting have become increasingly important to health care providers, governmental institutions and insurance companies, as well as patients. Although there is a general consensus that measuring and monitoring quality is important in health care, there are many different notions about the required characteristics of management control systems for quality and how and for what purposes they should be used. What is quality? How do you measure quality, and how can it be measured in a reliable and valid way? How do you build a system that satisfies the needs of all the stakeholders involved? Who should you involve in building such a system? What impact will the system have on other organizational elements? These are important questions that need to be answered before and during the course of building and implementing a management control system focused on quality. This case presents the challenges faced by the founders of Xpert Clinic in relation to - among other things - the questions posed above. The clinic was founded in 2008, when Reinier Feitz and Thybout Moojen left the hospital at which they had set up a separate business unit for hand and wrist surgery (HWS). The issue of quality control was very important to them, not only because of their vision about how to organize health care, but also because of the (unfavorable) reputation of Zelfstandige Behandelcentra (ZBC's: independent treatment centers) and the need for attracting insurers, patients and good surgeons. Case For part A of this case, click here. The first Xpert Clinic opened in October 2008. After eight months of hard work, the first positive cash flows were realized. During the second year, the clinics generated a revenue stream of 1.4 million euros. In subsequent years, revenues increased from €3 million in 2010 to €5.5 million in 2011, and an estimated €7.5–8 million for 2012 was anticipated. The first stage - building Xpert Clinic - had been deemed a success. Growing Xpert Clinic, however, was another story. Feitz and Moojen needed a way to coordinate all the different care providers, standardize and optimize patient care, and demonstrate a track record of providing quality patient care to their stakeholders: patients, insurance companies, the government, doctors, and therapists. In order to do that, they needed a quality measurement system that could both assess and drive quality in their daily practice. The barriers facing them were significant. They would have to build an entirely new system from the ground up. Even once they managed to build it, doubt remained whether they would achieve buy-in from their stakeholders or meet resistance. For the system to be successful and the partners to realize their goals, they would have to find a way to get everyone on board with a radical change. PULSE - Towards a New Direction in Quality Care Xpert Clinic developed its new quality measurement system - PULSE - in cooperation with the Erasmus Medical Centre in Rotterdam. While Erasmus used the system for academic research, Feitz and Moojen wanted to use it to monitor surgeons and as an interactive patient communication tool. Harm Slijper was appointed Quality Innovation Manager and researcher in May 2011. With a background in developing innovative measurement systems in healthcare, he was the right person for getting this new system up and
running. The PULSE development team expanded by bringing in experts, system engineers, surgeons and managers to help deliver a comprehensive tool to coordinate patient care, measure treatment outcomes, motivate staff improvement and give the founders a greater degree of control over the clinic. PULSE was not only managerially viable, but it was driven by a medical professional desire to provide top-quality health care. By 2012, the system was up and running. But to use the system to continuously improve treatment and service quality, Feitz and Moojen knew they had to make surgeons, therapists, and patients feel like they "owned" the new system and eager to work with it. They also needed to convince insurance companies and the government inspectorate to trust this "unusual" system so that these organizations could become a positive force that helped drive quality improvement within Xpert Clinic, as well as the entire Dutch healthcare sector. The Erasmus Medical Centre was PULSE's main investor. The system was designed as a web-based platform for collecting and analyzing data. With the PULSE software, doctors and therapists could assign a specific measurement trajectory (i.e., a number of questionnaires to be filled out and measurements by hand therapists) to each patient, so that the patient's health and progress could be evaluated throughout the entire course of treatment. The system registered and measured the quality of different medical treatments, enabled interactive communication with patients, and facilitated academic research. The overarching goal of the PULSE system was to create transparency in the healthcare sector by providing insight into the quality of healthcare. The founders believed it would give Xpert Clinic the opportunity to demonstrate its high-quality care - a competitive edge in the industry that would be completely unique. This was also important to healthcare insurers, patients, doctors, and the entire Xpert management team. As Dekker explained, "PULSE helps us to show to what extent we make people better. The term health gain is in fashion nowadays, but nobody really seems to give substance to this term." From an organizational perspective, Feitz and Moojen found that PULSE increased the ability to learn and assess which treatments worked best. It also enabled them to identify which doctors could perform a particular surgery best, and what other doctors could learn from them. One of the most important features of PULSE was the ability to ultimately predict treatment outcomes and recovery processes for different types of patients, conditions and treatment courses. Characteristics of PULSE Though PULSE offered ample opportunities for measurement, Xpert Clinic focused on two central themes: medical quality, and service and communication. Medical quality referred to objective quality and the results of treatments performed. PULSE enabled medical staff to quantify treatment effectiveness. Hand therapists, for example, measured to what extent mobility and strength increased after surgery or treatment in comparison to before surgery or treatment. They also measured the effects of the treatment on ADLs (Activities of Daily Living) and on participation levels (for example, returning to work). Surgeon quality was thus objectified and quantified by details about the recovery of the patient. The hand therapist registered the results in PULSE as therapist reported outcomes (TRO) - a relatively unique feature of management quality control systems at the time. Service and communication measurements were based on inputs from the patients about their perceptions on a variety of topics, from the surgeon's listening skills to the quality of the coffee served at the clinic. This data was translated into a Net Promoter Score (NPS). Results covered many aspects of the organization and different groups of employees, with the input coming only from reports made by hand therapists and patients. Developing & Implementing PULSE There were a number of hurdles to overcome in designing and implementing an effective measurement system. Slijper, the quality innovation manager at Equipe, recalled some of these hurdles: "The difficulty is knowing what you should and should not measure, and how the system can be built most effectively. It has
been an incredible challenge to see how the healthcare process works and how to make the system fit." Moojen agreed that decision making and being selective was important. Though he agreed obtaining specific measurements of all patients was critical, the measurement itself and getting that data into the system should not be a lengthy process. When PULSE was built, the designers set up an online Wiki, and a large group of hand therapists was asked for input about what should and should not be measured as quality indicators. Slijper reflected on the process, stating, "There was a lot of chitchatting, and we never seemed to come to a decision. Then we decided to get together with three or four real specialists in the field of hand surgery, and we just made the decisions." Implementing the system was generally accomplished in a top-down manner, as Feitz and Moojen wanted to get the system up and running as soon as possible. "Sometimes, somebody just has to make the decisions - people can talk forever," Moojen explained. According to Slijper, the Equipe culture contributed to the system's rapid development and implementation. "We listen, but we are not afraid to decide," he stated. Dekker said the actual implementation process went surprisingly well: "Everything seemed to go according to plan, and we did not meet major challenges," despite the fact they had to address complex issues, such as compatibility with the existing software systems and guaranteeing patient privacy. Though significant financial investments were necessary, the development team believed the system would eventually result in overall cost savings. PULSE would decrease employee workload on non-core processes and make it easier and more efficient for them to fulfill their tasks. Significant time savings could be achieved as patients filled out questionnaires online instead of during their visit to the clinic. PULSE also automated quality reports, and all relevant data was readily available for analysis any time a surgeon or staff member needed it. The team was also convinced they could reap additional financial benefits through increased patient satisfaction, referrer satisfaction (e.g., GPs), and insurer satisfaction. Using PULSE By 2012, the basic functionalities of PULSE had been implemented. Hand therapists recorded the data, patients filled out questionnaires online, and surgeons communicated with patients about using the system. Patient compliance rates were approximately 50-70%, and the PULSE team wanted to increase this to 60-80% Surgeons received quarterly feedback on their performance. This feedback was presented as a benchmark and was based on the Net Promoter Score (NPS), which was included in the measurement track. Four performance indicators were utilized: listening skills, treatment results, expertise, and personal interaction. Surgeons also received an overview of the PULSE medical outcome measurements, which had not been translated yet into individual performance indicators. Every six months, surgeons received a performance evaluation interview. Based on the objective outcomes measured by the PULSE system, adjustments were made to the surgeon's educational program. Major deviations could impact the future of a surgeon at Xpert Clinic, though there were no pre-defined decision criteria. For example, if service and communication performance measurements were below the desired level, it was possible the surgeon could be fired. Baseline scores were also used for recruitment criteria. PULSE performance outcomes were not linked to financial incentives for surgeons, although as stated, surgeons could find themselves without a job. Instead, salaries were based primarily on their treatments, as was the industry practice. This was true for therapists as well. Nevertheless, both surgeons and therapists perceived important non-financial rewards, such as workload reduction, the opportunity to design tailored measurement tracks, and the ability to perform studies with the data provided by the system. There was also a personal sense of pride and satisfaction in seeing positive results, and a professional satisfaction as quality results showing successful patient outcomes were quantified and easily interpreted. Using the database, surgeons also were able to see the average performance of their colleagues. The development team considered making results instantly available to surgeons on a personalized dashboard. While the system was still mainly used to allow surgeons access to the results of their own work, in the future,
the development team wanted surgeons to be able to use the system for individual performance diagnosis, internal and external benchmarking, and developing ways to improve. Stakeholders - Resistance Meets Acceptance One of the biggest issues to face the Xpert Clinic founders was getting buy-in from their stakeholders. The best system in the world would only deliver the results they wanted if people used it and used it comprehensively. Initially, the pair expected at least a fair amount of skepticism and resistance, but hoped they could convince the stakeholders that PULSE would be a benefit. Health Insurance Companies and the Inspectorate Health care insurers were probably the most important stakeholder group for Xpert Clinic, as they were in control of patient coverage decisions. They could make or break Xpert Clinic. One of its main objectives for insurers was in providing patients with the best care for the lowest price. As insurers traditionally had limited trust in ZBCs, it was not an easy task for Xpert Clinic to convince them of the reliability and high quality of their care or the PULSE system. The founders actively sought to inform insurers and the inspectorate about PULSE, for example, through presentations and conferences. They assured that PULSE enabled the quantification of "best care" and thereby made it easier for insurers to judge quality. They also published an annual quality report that described the progress and results achieved in the previous year. Insurance companies actually paid a lot of attention to the quality of treatment. They were well informed about quality issues and innovation in healthcare. Xpert's demonstration of a new measurement system that could improve quality and eventually lower overall costs won over quite a few insurers. Feitz and Moojen reasoned that this would eventually improve their organization's position in areas such as contract negotiation. This was important for the viability of the clinic, as normally, insurers expected a 5 to 10% discount on rates determined by the Dutch Healthcare Authorities. Xpert Clinics sought to circumvent this discount system by proving the high quality of their medical care, which would lead to lower overall costs for insurance companies. The IGZ was also concerned about the issue of quality in healthcare. Xpert used the same message with the Inspectorate as they did with health insurers. The essence of the argument was that PULSE helped make healthcare more transparent, and therefore, beneficial for quality improvement. Surgeons Surgeons were one of the main subjects of the PULSE measurements. Their involvement and acceptance, therefore, was of highest importance to the system's success. As medical professionals, surgeons have their own particular needs; they value their autonomy and professional freedom and are not used to having to transfer their knowledge and expertise into a digital system. However, this is exactly what PULSE aimed to achieve. "With PULSE, we try to get the knowledge in the system and not in the doctor," said Moojen. Some surgeons were initially anxious about the system. One explained his initial doubts: "I had to get used to the transparency within our clinics. For a surgeon, this can be very confronting." Feitz and Moojen, however, pointed out another often overlooked, but important, intrinsic characteristic of surgeons - people who choose medical science as a profession did not work for money alone. They truly loved what they did and were internally motivated to perform better. "[To motivate a surgeon) you don't even need to say it. Just show him the data and he will know – he has the drive to improve," said Feitz. Though there were no predefined financial rewards or incentives for surgeons to perform, it turned out motivation was never an issue, nor was convincing surgeons to accept PULSE as a performance measurement tool. The opportunity to use PULSE for research also played a role in surgeons' acceptance of the system. Prior to PULSE, a lot of data for academic research was collected in the old system, but often the data was incomplete, making it difficult to conduct proper and valid research. Through PULSE, all relevant data
was collected in a standardized way and on fixed time points. Conducting and analyzing scientific studies regarding surgical outcomes became more efficient and less time consuming. Scientific publications and presentations at international hand surgery meetings attracted new and more science-orientated surgeons to Xpert Clinic. It was exactly what Feitz and Moojen hoped to achieve. To make PULSE an objective measurement tool, it was important that the measurements used were complete and representative. According to Dekker, "The question is not whether or not you should measure performance and benchmark doctors, but how this should be done. We want surgeons to see their own potential for growth, and we want them to help each other." Slijper predicted that it would take another three to five years to gather enough data to empirically and reliably show how surgeons performed in different types of surgery. Hand therapists Hand therapists performed much of the work with respect to measuring and adding results to the system. However, there were limited direct benefits for them. This created a challenge in motivating therapists to comply with the clinic's requirements. In general, therapists showed high response rates in filling in the questionnaires, as the system provided them with feedback about their own work, and it significantly reduced their workload compared to the old system. The PULSE team was interested and involved in achieving high compliance rates for filling in the questionnaires, especially during the early stages of the implementation process. They needed to show therapists how important measuring quality was for their own practices and for health care in general, as well as demonstrating the benefits of correctly and fully utilizing the system. The team used multiple training sessions to get this message across. Furthermore, making the system visually appealing and easy to work with was also another major tactic to increase compliance among therapists. Patients Much about the success of the PULSE system was dependent upon voluntary patient compliance. PULSE required patients to fill in several questionnaires at different times throughout their treatment trajectory. One question that confronted the development team with respect to patient buy-in and compliance was what benefits patients would receive. The team identified several ways to provide value for the patient. First, PULSE served as an interactive communication tool between the patient and the clinic in general. Every patient was given a personal patient page (PPP). The PPP provided patients with a personalized selection of relevant information and access to the questionnaires. When building the PPP, particular attention was given to user-friendliness, including the length of the questionnaires. The interface was made clear and simple so that every patient could work with and navigate through it easily. Some additional features, such as a graphical display of the treatment and recovery process, were designed to motivate patients to put effort into filling out the questionnaires in order to get a full and complete view of their progress. The PPP also enabled the clinic to react instantly to outliers in measurements and to communicate directly with the patient about questions, wishes, and complaints. One example of this feature in practice is the "extreme value detection" tool, which detects outliers - values in patient data that are above or below a previously determined threshold. For example, if a patient is experiencing unexpected pain levels, the system is capable of detecting the situation. Immediately after detection, an email is sent to a nurse, and the patient is contacted by phone. Some surgeons also used the system to discuss the results of the PULSE questionnaires with patients directly and offered them a printout of the results to track their developments over time. In addition, staff expounded the importance of measuring results and quality control to patients at the very beginning of their treatment course, and this was a consistent message throughout the entire course of treatment Six months after implementation, the PULSE team began to consider another application of PULSE for palienis: benchmarking with other palients. By gathering and comparing dala, palients could see (anonymously) how they recovered compared to other patients. In this way, the team hoped to create a feeling of patient responsibility for their own health and treatment. One potentially problematic consequence of this
application was that those patients whose recovery was slower than that of their peers might begin to worry about their recovery Future of PULSE Feitz and Moojen have big plans for the future of PULSE. They want PULSE to become the number one quality measurement system in healthcare throughout the Netherlands. Their goal is to make healthcare more transparent and enable organizations to demonstrate health gains in their patient pool. The founders are involved in expanding the use of the system to other Equipe brands. They want to make the basic functionality open source outside Equipe, so that different parties can extend the source code. However, there seemed to be a collective distrust towards PULSE among the different players in the health care industry. According to Dekker, "If we provide a system, nobody will trust it. Hospitals won't trust it because it was developed by a ZBC. Other ZBC's won't trust it because it comes from a competitor, and they expect us to have some hidden advantage." Despite years of fighting, and even though Xpert Clinic had begun to build a positive image as a ZBC, trust remained a sore spot. Despite increasing pressure for transparency and quality in Dutch healthcare, there was still a debate about whether insurers were entitled to information about quality measurement, in fear they would stop paying for treatments that were not up to standard. "Pay for performance," which Xpert Clinic strongly promoted, was not something ready to be put into practice in the Netherlands. Feitz and Moojen's ambitions did not stop at building PULSE. They hoped to use PULSE to augment the reform of the entire Dutch healthcare industry. But it seemed they still had a long way to go.