Can you really define procedures and measure quality across a national healthcare system? The Dutch are now doing just this. Jan Maarten van den Berg, an inspector with the Inspectie voor de Gezondheidszorg says a recent pilot of 12 Dutch hospitals found that a combination of process restructuring, defining essential information points and quality measurements halved mortality rates for surgery. The new transparency is now transforming the hospital system, allowing insurers to create a competitive marketplace across eventually 90% of all procedures.

HCE: Some Dutch academics are sceptical as to whether you can really measure quality on healthcare services. They say it merely leads to bureaucratic waste.

JV: Well, quality is harder to measure than costs, but if you get the timing and the situation right, then the results are startling. In practice over 50% of patients admissions are surgery and they are largely definable and the percentage which is definable is growing.

HCE: How did the system get built?

JV: Before the Dutch system was very fragmented. Every operation was different and so when you asked ‘why did it go wrong?’ you couldn’t really come up with an answer. Was it because something was done wrongly or was it ‘just one of those days’? As we hadn’t properly defined best practice, and had no national measurements, it was always ‘one of those days’.

So the current system has come out of a lot of concern within the profession about how to improve.

We were lucky really, there was a lot of consensus. It came out of three big projects in the early noughties. One looked at what actually happened in the operating theatre, one at how to maximize safety by drawing up lists of what needs to be done and the other at broader measurement generally.

But it wasn’t really built. It is an iterative process. You start measuring things and that leads to better clinical pathways, which are themselves more measurable. So you measure them and that then leads to further improvements in procedures.

HCE: How does the system work?

JV: We used to measure results in three groups. Firstly, hospital-wide issues such as bed sores, pain management, nutrition and how they care for the elderly, secondly, high risk departments such as intensive care and, thirdly, for specific diseases, such as heart infarction and breast cancer.

Now we have a much more integrated system, in which the indicators form a matrix so you can see the results for a specific process or department or within a specific hospital. The 15 societies of specialist doctors are closely involved in defining these parameters. This combined set is called the Basisset.

Every year we come up with a new Basisset. We have just completed the set for 2012, allowing the hospitals six months to think things through carefully.

All this is backed up by inspection teams, by patient surveys and by a drive by specialist doctors towards best practice. Insurers are also getting involved, for instance, by only contracting hospitals that comply to the minimum standards. They check this by systematic surveys of patients through Stichting Miletus.

HCE: How do the doctors and hospitals respond to all this. Do they like it?

JV: I think we were lucky when we started in 2003 as the inspector general had been the head of the specialist doctors and there was a general consensus that this was the way forward. That does not mean that every individual specialist loves us!

At first, some hospitals refused to give us the data. Then the press used the general conditions, such as bed sores etc, to define a hospital hit parade. Those who had not given us data quickly joined the scheme at that point.

Hospital management quickly learnt that if they took action and dealt with problems then they would go up the ranking. Hospital managers tell us they like and use the data. I think they find it empowering especially when they are on top of the list. The hospitals at the bottom like to pretend that it means nothing. .

HCE: What about the doctors?

JV: Here the response was more mixed. But the 15 specialist societies who interact with patients directly agreed that measuring results in this way would lead to the identification of best practice and quicker implementation of these and so to better outcomes. So they have gone along with it.
At first we went in hard and just asked the data. We quickly found out that collaboration leads to much better results.

HCE: So what are the results of all this?

JV: As I have already said, it is an iterative process. You start measuring and then you can design better and more defined clinical pathways. These pathways can then be measured better and we can then spot ways of improving them further.

For most operations clinical pathways are now set almost in stone. If a surgeon wants to deviate from a pathway he doesn’t just have to give his signature, he more or less has to convince everyone in the operating theatre that moving away from the pathway is essential to the patient’s safety! The only society which hasn’t gone along with this is the thoracic surgeons and they have to explain why to the other 14!

HCE: And does this whole system lead to better results?

JV: Yes much better. In a large scale pilot project we found that a comparison between 12 hospitals, six of whom followed the new approach and six of whom didn’t, saw mortality rates of patients during their hospital stay fall by 50%. And bear in mind that, because they were under observation, the rates in the other six were still better than the average. This has been a real game changer and the programme has been rolled out nationwide since March 2011.

HCE: There is a saying that what gets measured gets delivered and what gets rewarded gets delivered again. In other words, organisations and individuals are good at gaming. They can change their behaviour to hit targets and they can also under report bad data. How do you deal with this?

JV: The data matrix is so complex that we can quickly spot discrepancies and we will then investigate. We had a case, for instance, where a hospital claimed a very high level of control of pain for its patients. We carried out a short patient survey and this threw back very different results!

The system is also self-governing. Hospitals will report their neighbours to us if they believe they are under reporting!

HCE: And what do you do in those circumstances?

JV: We carry out unannounced inspections, arriving at 7.45 in the morning. If we find something wrong they have two months to fix it or they go on a national watchlist which is published. The first hospital which missed this target went bust and was taken over by a neighbouring hospital.

We also regularly observe surgeons at work. We find that just watching a surgeon operating allows you to draw rapid conclusions about the quality of his or her work. Within half an hour you can tell if someone is just cutting and following procedures. In 70% of all operations something used to go wrong because of poor procedure. So you don’t need a lot of time to see the difference

HCE: How do you interpret all this data?

JV: You are right to ask! In 2008 we found that you really have to know the questions you want to ask before collecting data. Often too much data is a problem, rather than a blessing.

We looked at pancreatic sections, where mortality rates were 25%. What we found was that the operation was spread out across the Netherlands with most hospitals doing just five procedures a year. Techniques and surgeons change annually and different patients have different levels of complications so we couldn’t meaningfully compare the results. But it was already well known that there was a strong correlation between the number of procedures a surgeon carried out and success. We also found that reputations were correct - in other words there was a strong correlation between the degree of trust the referring doctor had in the surgeon or the department and the result.

In five years mortality has dropped from 25% to 4% and the operation has been concentrated in a few centres of excellence.

HCE: What impact will the new system have on the hospital sector in the Netherlands?

JV: As you know, for many elective procedures there is a competitive market with the insurers getting hospitals to tender. This is expected to rise from 34% of procedures today to 90% within five years. Having a proper quality system means that the insurers can move forward with more certainty. They can analyse the results and know who are the best on the criteria set by the medical society and make their decisions accordingly.

All this means that hospitals are undergoing a revolution in which they chose to specialise in the things they are best at. Some hospitals may go for many relatively simple elective procedures, others chose to concentrate on a few complex operations.

And the university hospitals are not exempt from this process. They are facing growing competition from general hospitals. They are having to fight on quality grounds to retain their patients. They can no longer take them for granted.

HCE: How do patients fit into this. How much access to the data do they have?

JV: Compete access at www.ziekenhuizentransparant.nl. They are not the primary readership, but data are freely available. We have a hotline number they can call if they have any questions.