The implementation of quality management systems in hospitals: a comparison between three countries

Background

Is the implementation of Quality Management (QM) in health care proceeding satisfactorily and can national health care policies influence the implementation process? Policymakers and researchers in a country need to know the answer to this question. Cross country comparisons can reveal whether sufficient progress is being made and how this can be stimulated.

The objective of the study was to investigate agreement and disparities in the implementation of QMS between The Netherlands, Hungary and Finland with respect to the evaluation model used and the national policy strategy of the three countries.

Methods

The study has a cross sectional design, based on measurements in 2000. Empirical data about QM-activities in hospitals were gathered by a self-administered questionnaire. The questionnaires were answered by the directors of the hospitals or the quality coordinators. The analyses are based on data from 101 hospitals in the Netherlands, 116 hospitals in Hungary and 59 hospitals in Finland.

Outcome measures are the developmental stage of the Quality Management System (QMS), the development within five focal areas, and distinct QM-activities which were listed in the questionnaire.

Results

A mean of 22 QM-activities per hospital was found in the Netherlands and Finland versus 20 QM-activities in Hungarian hospitals. Only a small number of hospitals has already implemented a QMS (4% in The Netherlands,0% in Hungary and 3% in Finland). More hospitals in the Netherlands are concentrating on quality documents, whereas Finnish hospitals are concentrating on training in QM and guidelines. Cyclic quality improvement activities have been developed in the three countries, but in most hospitals the results were not used for improvements. All three countries pay hardly any attention to patient participation.

Conclusion

The study demonstrates that the implementation of QM-activities can be measured at national level and that differences between countries can be assessed. The hypothesis that governmental legislation or financial reimbursement can stimulate the implementation of QM-activities, more than voluntary recommendations, could not be confirmed. However, the results show that specific obligations can stimulate the implementation of QM-activities more than general, framework legislation.

[Priorisation in health-care; drug-reimbursement priorities in Hungary in 2004]

In our research we assessed the drug reimbursement of the National Health Insurance Fund Administration (NHIFA) in different ATC groups. We used the aggregated data of retail pharmacies in 2004, analysing separately the accentuated and elevated categories associated with medical indications. According to the 2004 data it was the drugs for cardiovascular; endocrine and metabolic disorders affecting the largest population and making the highest proportion of the total reimbursement. In addition, the turnover of some drugs for mental disorders was also significant. As for the number of patients in the cancer group it is much smaller, but as a result of the huge costs of their therapies these belong to the highest reimbursed categories as well. Without the special, separately financed category the annual drug subsidy was 257 bill. HUF, which totalled 423 bill. HUF on consumer price. The reimbursement of the NHIFA in the top 25 categories exceeded 177 bill. HUF. In the accentuated category the contribution of the NHIFA approximated 49 bill. HUF spent on the treatment of cancer, diabetic and some psychiatric disorders. In the elevated category based on health status the products of mental, digestive, bone and respiratory systems disorders were responsible for the highest turnover with more than 55 bill. HUF subsidy. Besides knowing the amount of reimbursement it is also important to be familiar with the size of affected, treated population. However in many cases we do not have any detailed, up-to-date Hungarian data, so the under-, or the possible overtreatment can hardly be analysed accurately.

[Critical evaluation of clinical trials]

The primary source of scientific evidence are well designed and well executed randomised controlled clinical trials. However, the sources of scientific evidence are multifaceted. The concept of evidence based medicine is wider, encompassing the best available scientific data, the preference of patients and the professional experience of physicians. Decisions on therapies or other types of interventions are based on these three components. The authors give an overview of the evaluation of the results of randomised controlled clinical trials and present an easily applicable assessment list for practising physicians.

[Risk and prevention in cardiovascular diseases]

The RCTs are the most important sources of drug therapy related scientific evidence (RCT--Randomised Controlled clinical Trials). In most cases RCTs studying identical or similar clinical issues are slightly or considerably varied. However, for such cases we have the appropriate methodology to compare the more or less different RCT results. This publication was written to provide a general overview of this methodology such as relative and absolute risk reduction (RRR, ARR), odd ratio (OR), number needed to treat and number needed to harm (NNT, NNH).

Issues for countries considering introducing the "fourth hurdle": the case of Hungary

OBJECTIVES

This study outlines the needs and current development of the "fourth hurdle" (i.e., requirement of effectiveness and cost-effectiveness data for drug coverage policy decisions) in Hungary, describes the legal background and seeks to address some of the most important questions in this field.

METHODS

The study draws on international experiences and discusses five issues that a given jurisdiction needs to consider before introducing the "fourth hurdle" for pharmaceuticals.

RESULTS

The "fourth hurdle" is very relevant in Hungary because many existing drugs are unevaluated and many new, expensive drugs are becoming available. On the other hand, the existing resources for health technology assessment, including economic evaluation, are quite limited. All the five issues are relevant in the Hungarian setting and were helpful in determining exactly how the "fourth hurdle" should be applied.

CONCLUSIONS

The most important issue seems to be that the implementation of the "fourth hurdle" needs to be achieved in a way consistent with the limited resources for HTA in Hungary. Specifically this means that, in setting priorities for drugs to evaluate, additional criteria need to be applied. In particular, priority should be given to assessing drugs that have been evaluated in other countries, because this affords the opportunity to adapt existing studies or models to the Hungarian situation.

[Market share of the for-profit and not-for-profit sector from health insurance expenditures]

AIM

The aim of the study is to analyze the market share of for-profit private and not-for-profit sector from the expenditures on medical services of the Hungarian National Health Insurance Fund (NHIF), to show its changes in the last years and to show on which field they can be found.

DATA AND METHODS

The data derives from the financial database of the National Health Insurance Fund (NHIF) covering the period 1995-2002. The analysis includes the medical provisions (primary care, health visitors, dental care, out- and inpatient care, home care, kidney dialysis, CT-MRI).

RESULTS

In 1995 only 6.91% (12.5 billions Ft) of total expenditure for medical services went to for-profit private providers. By 2002 the market share of private providers increased to 15.95% (78.5 billions Ft). During the same period we realized a dynamic increase in the market share of non-profit sector: from 1.04% in 1995 to 2.58% in 2002. The role of private providers is dominant in the case of general practitioners, dental care, transportation, kidney dialysis, CT/MRI and home care (home nursing).

CONCLUSIONS

The financial data of the NHIF showed the dynamic increase of market share of for-profit private providers and non-profit sector in many field of health care, although they role in the two most important fields (out- and inpatient care) is still negligible.

[Health economics analysis of breast cancer screening]

INTRODUCTION

The organized breast cancer screening programme has started in Hungary at the end of 2001.

AIM

To assess the screening rate, the cost of screening and treatment and to calculate the expected epidemiological and economic gain and cost-effectiveness of mass-screening programme.

METHODS

The data derive from the financial database of the National Health Insurance Fund of Hungary from 2001. To assess the screening rate the authors used the code "No. 42400 mammography screening" of outpatient care. The cost of treatment includes the cost of outpatient care, the acute and chronic inpatient care, the subsidies of the prices of medicines and the expenditure on disability to work (including sickness-pay). The expected benefits of the screening programme were modeled with changing mortality decrease for a 10 years interval.

RESULTS

The screening rates of women aged 45-65 for 2001 and 2002 were 7% and 21.7%, respectively. The cost of treatment of breast cancer was around 8.6 billion Hungarian forints (29,939,868 USD, 33,426,321 EUR) in 2001. In the age-group 45-65 with 10% mortality decline 509 lives (net present value, NPV: 365), with 20% mortality decline 1.074 (NPV: 772) lives and with 30% mortality decline 1.582 (NPV: 1.139) lives can be saved during a 10 years screening programme. The cost of one life saved varies between 5.7 million forints (19,876 USD, 22,190 EUR)/life saved and 17.8 million forints (62,047 USD, 69,273 EUR)/life saved according to the mortality decline. The cost of one life year saved varies between 271,000 forints (946 USD, 1057 EUR)/life year saved and 847,000 forints (2955 USD, 3299 EUR)/life years saved.

CONCLUSION

The implementation of organized breast cancer screening can lead to cost savings in Hungary. The cost-effectiveness of breast cancer screening seems to be acceptable for purchaser.

[New models in the model (Managerial challenges in the Hungarian managed care model)]

The Hungarian managed care model integrates the different levels of health care services. Its goal is a more efficient resource allocation within the health care system, quality improvement of services, developing incentives and financing methods. The basic concept of the model is to introduce the benefits of the American managed care and the British fundholding system. The managed care model brought a new approach in the Hungarian health care system and meets a lot of expectation in both professional and political context. The model has certain problems, but these are handled at macro level. Without an integrated approach of macro, meso and micro levels is hardly believable the efficient and effective functioning of the model. Such macro level problems are the cost-efficiency versus high quality health services, financing incentives, and risk taking. At meso and micro level we are facing with questionable efficiency and effectiveness of the MCOs other health care organisations, which are based on strong bureaucratic paradigms and are convicted to a long lasting crisis in their changing environment. The integrated use of Mintzberg's management models (machine model, network model, performance-control model, virtual government model and normative-control model) adapted by us for the Hungarian managed care model could resolve certain problems or make them at least more solvable. In the changing environment of the health cares organisations the top management has to frame the change-scenario, to initiate, realise and sustain organisational changes. Achieving this, the proposed management models are a useful support. Their practical application could contribute to the efficient and effective functioning of the Hungarian managed care model at macro, meso and micro levels, as well.

[Scientific evidence in clinical practice: cost-effective and guaranteed quality of care]

According to the literature quality improvement methods were implemented successfully under various circumstances in many countries, through almost countless ways in order to achieve diverse quality improvement goals. Evidence suggests that quality improvement can be achieved through appropriate implementation of various methods. Literature on the effects of quality assurance on cost is relatively limited in number, however, the relation between the cost and quality is an issue of universal interest. Without any public consensus about what is meant by either quality or cost containment, it is difficult to evaluate their relation to each other fairly. However, there is sufficient support for the hypothesis that it is not too much quality, but rather too low quality that creates costs.

[Requirements of clinical excellence]

The history of the evidence based medicine, health technology assessment, health economics and quality improvement proved to be a success story in developed countries. It is partly due to that change in the attitude towards health care occurred in the past ten or fifteen years. Two major factors played important roles in this process. On the one hand, the booming health care costs in developed countries, and on the other, the health benefit was not proportional to costs. First, governments around the world applied the tool of cutting costs, which proved to be uneffective even in mid-term. It was soon revealed that people prefer good-quality health care rather than the cheap one. These disciplines are having a more and more considerable influence on medical care and nursing. However, impacts on health care are not automatic and can be most different regarding both their quantity and nature. They may result in a significant improvement in prevention, diagnostics, cure and care, and may yield a more appropriate use of ever-limited resources.

Pricing and reimbursement of drugs and medical devices in Hungary

Similarly to other countries of Central and Eastern Europe, Hungary has witnessed massive diffusion of healthcare technology such as drugs and medical devices since 1990. While substantial new pharmaceuticals, medical devices, and procedures have been liberalized, there has been no proper evaluation or training in their use. Healthcare providers have come to find themselves as entrepreneurs in private practice, while patients are acquiring an increasing awareness as customers of healthcare,demanding services in return for their taxes and contributions. This has led to extremely irrational patterns of investment in technology, with most an obvious waste of resources, while leaving basic needs unmet. Both the National Health Insurance Fund and the Ministry of Finance believe that the current pharmaceutical and medical device bill is too high. However, introducing a more transparent and flexible pricing and reimbursement framework may enable a more efficient allocation of the limited resources to be achieved.

Risk-adjusted infection rates in surgery: a model for outcome measurement in hospitals developing new quality improvement programmes

Assessment of healthcare quality is a major challenge in countries such as Hungary where there is limited experience with measurement of patient outcomes. We sought to develop the capacity for valid outcome measurement in Hungarian hospitals using surgical site infection (SSI) surveillance as a model and to identify areas for improvement by comparing SSI rates in Hungarian hospitals to benchmarks published by the United States Centers for Disease Control and Prevention's National Nosocomial Infection Surveillance (NNIS) System. We surveyed the incidence of SSI among 5126 patients undergoing 6006 procedures in 20 public hospitals in Hungary during 1996 using the Hospitals in Europe Link for Infection Control through Surveillance (HELICS) protocol, a protocol consistent with the methods used by the NNIS System. Cholecystectomy, herniorrhaphy, appendectomy, and open reduction of fracture--four of the five most commonly performed procedures in Hungary in 1996--comprised 85% of the procedures analysed. Cumulative SSI rates for herniorrhaphy and appendectomy were comparable to NNIS System benchmarks. Cumulative SSI rates for cholecystectomy were significantly higher in Hungarian hospitals among risk categories that included open procedures. Nearly half of the hospitals had SSI rates for cholecystectomy that were high outliers (>90% percentile) compared to NNIS System benchmarks. Cumulative SSI rates for open reduction of fracture and mastectomy were significantly higher in Hungarian hospitals due to high rates in a few hospitals. The duration of surgery for all procedure types was substantially shorter in Hungarian hospitals compared with NNIS System hospitals. Future work should focus on optimizing prevention strategies for patients undergoing cholecystectomy, open reduction of fracture, and mastectomy. The effect of the utilization of open vs. laparoscopic cholecystectomy, short procedure duration, and procedure volume on SSI rates should be evaluated further. This programme expanded the capacity of Hungarian hospitals to perform surgical site infection surveillance and can serve as a model for hospitals in other countries with limited experience with outcome measurement.

Hospital infection prevention and control: a model for improving the quality of hospital care in low- and middle-income countries

Continuous quality improvement (CQI) is a powerful methodology for improving clinical outcomes and patient satisfaction while reducing inefficiency and costs. However, most hospitals in low- and middle-income countries have little experience with CQI methods. Hospital infection prevention is an ideal model for nascent efforts to improve the quality of hospital care because of its proven efficacy in reducing the occurrence of infections that compromise patient outcomes and increase costs. This article describes the design and implementation of a demonstration project to reduce the incidence of surgical-site infections (SSIs) for hospitals with little experience with quality-improvement methods. The project has a high likelihood of producing measurable reductions in SSI rates and hospital costs related to inefficient use of perioperative antimicrobial prophylaxis. Moreover, participating staff will gain experience that can be applied to efforts to improve the quality of other aspects of hospital care.