Pay for Quality

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152 Pay for Quality KCE Reports 118 Widening gaps in performance among providers Some stakeholders expect two basic attitudes in practitioners: those who want to develop their value and impact by subscribing to pay for quality programmes, and others who don’t want to involve in it. Various factors will play a role in this, like e.g. part-time working. 8.2.6.6 Organisational system change and extra cost / time required Many stakeholders mentioned that the programmes should not be too complicated either at the process level or at the assessment level. Otherwise, additional costs, workload and time required to fulfil the programme would be excessive for both general practitioners and small size hospitals. Doubts were raised in GP stakeholders on the ability of the government to keep quality programmes simple. To deal with complexity of programmes several suggestions were made: coordination at the local level within group practice in primary care or coordination of the programmes at the national level to support the providers when performing extra tasks related to the implementation of the programme. 8.2.7 Implementing and communicating the programme 8.2.7.1 Involvement of providers in setting goals For most stakeholders, the involvement of the professionals in the definition of goals seems to be essential. The rationale behind this idea is that providers directly face problems ‘in the field’, have access to local data and perfectly know the work that has to be performed. They also represent the most direct link to the patient who is the first target unit. Stakeholders also mentioned that the involvement of providers is in itself a way of promoting quality, motivating providers, and preparing them for self-assessment and external evaluation. Some stakeholders mentioned the need for an institution to help providers in defining goals and to make the link between the different actors of a programme. Some of the existing institutions have, to their point of view, the competencies and the required organisational framework. Organizations/institutions that were mentioned were NIHDI and the Forum des Associations des Généralistes (FAG). 8.2.7.2 Involvement of patients in setting goals Some stakeholders think patient’s representatives should be part of the board which sets the goals of the P4Q programmes as patients are primarily concerned by the quality of healthcare. Moreover patients’ representatives are members of many committees at the Ministry of Health, consumers’ associations or the Health Promotion Council, giving them a wide, transversally and realistic overview of health care. It is noted that this opinion wasn’t supported by any of the providers’ representatives (except one) but only by patients themselves, insurers and regional government. 8.2.7.3 Communication to patients Stakeholders think that the authorities should clarify the definition, concepts and the aim of quality as a first important step towards the development of pay for quality. Then, a clear communication to the patients is required to maximize their commitment to the programme. Stakeholders agree there is a need for increased public accountability towards the patient, as this indicated in related legislation. Stakeholders however strongly differ in their opinions to what extent information about prices and/or quality should be made available to the public. Many stakeholders state that at least every citizen should be able to consult up-to-date information whether or not a particular hospital or service applies quality improvement approaches and follows up on its performance. Some stakeholders take a step ahead and suggest that the disclosure of a list of indicators that are related to quality in so called ‘reference centres’, is a mandatory minimum.
KCE Reports 118 Pay for Quality 153 The idea of ‘ranking’ such as hospitals is not supported by the majority of stakeholders. It is said that there is no evidence that this kind of information would be of additional benefit to the patient. In some cases it can have a pervert effect, giving them dissymmetric and biased information. Overall it is assumed that quality should be defined in agreement with patient representatives. 8.2.7.4 Mandatory or voluntary participation Many stakeholders subscribe to the principle of voluntary participation to pay for quality programmes, at least as a first step towards the implementation of such programmes. They evoked various reasons for it including e.g. increased chances for success (strongly related to changes in attitudes), improved awareness on the importance of quality in providers and a greater chance for the acceptance of the programme. In contrast to stakeholders that favour voluntary participation other stakeholders defend the idea of mandatory participation mainly because of methodological requirements. However, the latter stakeholders also admitted it would be very difficult to gain widespread acceptance for mandatory participation. Some softened their opinion in proposing the mandatory participation as a final step of implementation or with a self definition of own goals. 8.2.7.5 Staged approach of implementation It was commonly declared that a progressive and staged approach should be followed to implement P4Q programmes. The main reason is the time required to change attitudes, develop buy-in and to increase motivation. Some stakeholders proposed to start on a local basis in those domains were success is not too difficult to achieve which would potentially result into high participation rates in providers and patients. Critical success factors for the implementation of pay for quality programmes are defined as: clear role definition, responsibilities and tasks of the parties involved, the development of a common methodology for the design, evaluation and validation of those programmes. In this context, some stakeholders referred to the methodology of clinical trials and action research. Baseline evaluations and periodic assessments were also mentioned. In this way, Belgian stakeholders comply with the international requirements for a staged implementation of pay for quality programmes. 8.2.7.6 Communication to the providers Clear communication using professional tools is considered necessary to reach the professionals involved. It is recommended that any confusion with programmes that are badly perceived (e.g. accreditation, feedback) is to be avoided. Some stakeholders stressed the importance of a clear definition of objectives and standards and of the use of evidence based data. 8.2.7.7 Stand alone or embedded in a broader quality project It is considered important that pay for quality programmes become part of a global vision and plan on quality improvement of the Belgian health care system. Stakeholders stressed that coordination is required to ensure a common approach of the programmes.
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