Pay for Quality
Pay for Quality
Pay for Quality
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86 <strong>Pay</strong> <strong>for</strong> <strong>Quality</strong> KCE Reports 118<br />
There are some important points to consider when interpreting the results. These have<br />
to do with the purpose of P4Q (i.e. the basic philosophy supporting the concept), how<br />
to use it as a quality supportive tool and the expectations in terms of effect size.<br />
It seems that there are two ways of looking at P4Q.<br />
One philosophy sees P4Q as a broad target based rule set, mainly focusing on minimally<br />
required quality standards which are the same <strong>for</strong> all providers, and which remain<br />
relatively stable in terms of target selection. The target selection in this philosophy is<br />
mainly driven by the level of evidence supporting the target, being able to measure the<br />
target and providers having sufficient control over the targets. In this philosophy no<br />
adaptations are made according to local needs. National or regional needs guide the<br />
process. From this point of view, are the results above adequate to support widespread<br />
P4Q dissemination? The answer will be no if one expects P4Q to cause a ‘leapfrog’ jump<br />
in quality improvement on the whole set of targets, while keeping the programme fixed<br />
and static as it is. However, because in this philosophy local needs are not accounted<br />
<strong>for</strong> in terms of the potential room <strong>for</strong> improvement <strong>for</strong> specific targets, is such a<br />
‘leapfrog’ expectation in fact not unrealistic? In many of the programmes on a number of<br />
the included targets an already pre existing high baseline level of target achievement was<br />
reached be<strong>for</strong>e P4Q programme implementation. For example one Australian study<br />
showed already a 100% per<strong>for</strong>mance on its most important target included. One cannot<br />
do better than 100% and <strong>for</strong> many targets it can be questioned how much improvement<br />
is still possible once thresholds of above 80 and 90% have been reached. If these targets<br />
are to be included in P4Q programmes, as a kind of long term control measure, then<br />
their result of showing no significant effect or a modest sized effect is likely the best that<br />
can be expected. This sheds already a completely different light over the wide range of<br />
results reported above. The above philosophy will lead to more and more of such no<br />
significant and small sized P4Q effects, as everybody will reach the thresholds during<br />
multiple feedback cycles. Then afterwards the programme may be refocused at other<br />
national or regional priorities. The results indicate that P4Q can fit such a purpose,<br />
however without getting the maximal P4Q effects possible out of the system. In the<br />
long run this leads to providers receiving a bonus <strong>for</strong> things they are already doing<br />
without changing behaviour. One can question whether this is the best option <strong>for</strong><br />
society, both in terms of health gain as in terms of cost effectiveness as will be discussed<br />
in section 5.2.2 (page 87).<br />
There is however a second P4Q philosophy conceivable to amend the shortcomings<br />
mentioned above. As the results show, high effects can also be reached by implementing<br />
P4Q, but different ones according to local programmes and targets. This corresponds<br />
to the fact that the highest gains are found <strong>for</strong> providers per<strong>for</strong>ming the least on a<br />
specific target, as shown in several studies. So the purpose of a P4Q programme,<br />
instead of or combined with reaching top per<strong>for</strong>mance on all minimal measures, may<br />
also be to correct locally existing quality gaps. And the results indicate that P4Q may<br />
also fit this purpose when aligned with the targets with the highest local room <strong>for</strong><br />
improvement. It is remarkable to note that almost no study really focused on local<br />
target relevance and timeliness as additional selection criteria. With relevance we mean<br />
that local baseline data are used to further prioritize final target selection, based on the<br />
identification of quality of care gaps.<br />
Timeliness points to the fact that P4Q can be used in a much more dynamical way than<br />
currently used by seeing it as part of the basic concept of quality improvement<br />
management: cycles of continuous improvement, also referred to as PDCA (plan do<br />
check act) cycles. These two criteria, which are fundamental to quality of healthcare<br />
theories and practice, are underused in current P4Q practice, as presented in evaluation<br />
studies. By simply making it possible <strong>for</strong> local providers and organizations to prioritize<br />
targets based on their biggest quality gaps a P4Q programme would become focused on<br />
those targets where the highest quality gains can be expected and the chance to reach<br />
high gains as compared to absent or small gains will increase. This modification will also<br />
raise local responsibility, involvement and awareness, which is sometimes lacking in<br />
current P4Q programmes. Finally, by such prioritizing the whole P4Q system<br />
automatically becomes much more dynamical, beyond a periodic review of target<br />
selection, towards a more continuous process.