status quo of quo vadis? - KCE

KCE Reports 76 Quality development in general practice in Belgium: status quo or quo vadis ? 27
INTERNAL QUALITY MANAGEMENT AT THE PRACTICE LEVEL
In 2004, the government designed a law that makes the introduction of internal quality
management for all practices in primary care mandatory by 2009. This law creates a free
market for companies to promote their initiatives for Quality Management.
The outline of the format and a timetable are hosted at a national committee:
Gemeinsamer Bundesausschuss. 101 In October 2005 they proposed minimum standards
for the quality systems that should be introduced in all general practices (goals and
instruments). There is also an indication on the time frame and re evaluation of the
implementation of this quality management system. In every practice, the introduction
should be completed over a period of 4 years. 102
There are no financial incentives for GPs: the providers promote their activities by
stating that a quality label will attract patients and give more respect to the image of the
practice (culture of enterprise). The certificate validity lasts three years. The costs of
the quality management depend heavily on the system used with DIN-ISO (5.600 EUR)
and EFQM (2.800 EUR) being the more expensive, while EPA (1.800 EUR) and QEP
(850 EUR) are much less costly. 103
• The DIN-ISO management system. This is the best known system, based on
the ISO 9001 guidelines for the introduction of a QM system. The
introduction of a plan and a quality manual are central.
• The EFQM system. This system is based on the European model for
Excellence as described by the criteria of the EFQM award. It is not clear
how EFQM is used and we found no reports on the effects of the
implementation of this program.
• The European Practice Assessment. This procedure managed by the AQUA
(Institut für angewandte Qualitätsförderung und Forschung im
Gesundheitswesen) 104
• ‘Qualität und Entwicklung in Praxen’ (QEP) 105, 106 has been developed by a
multiprofessional team fostered by a professional body, the Kassenärztliche
Bundesvereinigung.
2.4.2.3 Evidence for effectiveness
The evidence about the effectiveness is scarce. Germany developed substantially the
Quality circle method: GPs in the quality circles seem to accept the use of quality
indicators and the feedback reports. 94
2.4.2.4 Future Developments
Two thirds of all doctors have not yet decided which quality management system to
use: recommendations from colleagues are important when selecting a system. The
level of satisfaction with QM service providers is generally high. 103 There is a group of
enthusiastic ‘early adopters’, but also a substantial number of physicians (about 25%)
who are highly sceptical towards implementing quality management. 103
The use of clinical indicators on a large scale is yet not clear. Nowadays, the
accreditation of practices follows the culture of private enterprise i.e., "show your
values". Sickness funds are interested in accreditation schemes or similar forms of
transparency about quality. However, there is no evaluation of the impact of the quality
management systems on the market.
2.4.2.5 Learning points and suggestions for Belgium
The legislation on the mandatory introduction of a quality management system in
ambulatory care is of great importance. GPs are forced by law to adhere to a program
offered by for-profit organizations that operate as third parties.
The guidelines for implementation and the content of a framework are negotiated in
close cooperation with the professional organizations and the government. Practices get
a four-year period to start up.