Pay for Quality
Pay for Quality
Pay for Quality
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KCE Reports 118 <strong>Pay</strong> <strong>for</strong> <strong>Quality</strong> 137<br />
7.3 DISCUSSION AND CONCLUSIONS<br />
This chapter addresses the question of feasibility of P4Q within the context of Belgian<br />
healthcare. The components of the conceptual framework were used to study feasibility<br />
starting from existing quality improvement initiatives and/or starting from scratch.<br />
The option to start from scratch has the advantage of lacking any historically<br />
determined restraints which result from an already ongoing quality initiative. Each<br />
existing initiative has its own quality definition, goals, targets and quality measurement<br />
system in place. Some combine this already with financial incentives, others don’t.<br />
There<strong>for</strong>e, when adding P4Q to these initiatives this might threaten the original<br />
programme purpose when done inadequately. In addition, the existing common practice<br />
might in itself become an obstacle to state-of-the-art P4Q implementation. This risk of<br />
combining both and coming out with none of both adequately accomplished should be<br />
carefully considered. A disruption of an ongoing initiative might undo years of ef<strong>for</strong>t and<br />
evolution. However, these risks neither imply that an existing quality initiative never<br />
might evolve towards P4Q integration. As initiatives are regularly evaluated and<br />
modified, each initiative might add P4Q characteristics, based on the internally based<br />
consensus of long term involved stakeholders. This process describes a kind of natural<br />
evolution of existing initiatives towards P4Q.<br />
As described in the results section, it is feasible to adapt existing quality initiatives to<br />
include a P4Q component. Although there are some weaknesses (e.g. lack of monitoring<br />
of unintended consequences), there are also many strengths (e.g. high experience in<br />
implementing and communicating a programme) to support P4Q implementation. The<br />
identified weaknesses and threats can be addressed specifically, based on national and<br />
international theory, evidence and stakeholder consensus. The analysis of existing<br />
initiatives has shown that there is a substantial body of knowledge and experience that<br />
can be leveraged to assist in P4Q implementation. It is not about ‘reinventing the<br />
wheel’. The option to start from scratch there<strong>for</strong>e shouldn’t result in ignoring all<br />
lessons learned, on the contrary. Furthermore, the existing quality initiatives can also be<br />
used as a target, because most of them are examples of care management processes.<br />
P4Q can be aimed at the use of benchmarking, the use of clinical pathways, the use of<br />
safety management tools, etc.<br />
Practical feasibility has been confirmed in this chapter. Many of the so called weaknesses<br />
are more related to the will to address them as to the ability to address them. The level<br />
of data validity is one example often cited as a potential threat to P4Q implementation,<br />
due to other purposes of existing data collection and due to the risk of gaming. This<br />
argument serves as a primary example of what P4Q in fact stands <strong>for</strong>: taking quality of<br />
care seriously and acting accordingly, based on verifiable quality demanding standards.<br />
Just as financial data are strictly monitored using an elaborate accounting system, quality<br />
data deserve a similar ardour. There is no room to apply double standards when<br />
addressing quality of care as compared to financing of care. P4Q relates both and<br />
re<strong>for</strong>mulates priorities. The idea of ‘<strong>for</strong> financing purposes’ becomes equal to ‘<strong>for</strong><br />
quality purposes’. Instead of a permissive approach towards gaming, and using this as an<br />
argument against P4Q feasibility, P4Q en<strong>for</strong>ces high standard requirements, and the<br />
reallocation of resources and ef<strong>for</strong>t to ensure those standards. Currently it is<br />
considered common sense in every sector that gaming with financial data equals fraud<br />
and that a control system is institutionalized. The same kind of high intensity attention,<br />
ef<strong>for</strong>t and resources are consumed daily to ensure that one’s PC receives regular<br />
updates to maintain adequate functioning. This same kind of logic (en<strong>for</strong>cing minimal<br />
standards of how to address quality, monitoring those standards, and updating those<br />
standards on a very short time span) is not applied on quality of care, the core value and<br />
mission of healthcare. As such these are questions of ‘willingness’ and not of ‘ability’.