Pay for Quality

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154 Pay for Quality KCE Reports 118 8.3 PART III: CONCRETE PLANNING IN THE BELGIAN SITUATION 8.3.1 The need for an “evidence collecting institute” All stakeholders agree that pay for quality, if implemented, should be based on sound scientific evidence on standards, indicators, and internationally proven ways to achieve them to provide the best guarantees for success. Stakeholders highlight the need for independent and academic scientific advice to help decision makers on the subject. This could be an extended KCE- or WIV/IP type, or an academic consortium type, acting as Independent Scientific Advisory Institute. Others defend the idea of one single national institute that will finally become responsible for the development and implementation of pay for quality programmes in Belgium. Reference is made by some to existing examples in our neighbouring countries: NIVEL or Dutch Institute for Health and Welfare. Only when concepts and instruments are scientifically validated, decision makers can come to action. 8.3.2 A new role for a revised National Council on Quality Promotion (NCQP) All stakeholders agree that Pay for Quality should be a governmental-led initiative, responsible for the coordination, implementation and follow up. For some of them, it should be initiated and guided by a multidisciplinary initiative, joining academic and public health scientists, providers’ representatives (GPs, specialists), trade unions, scientific societies, the National Council of Hospitals, insurers and patients’ representatives. This group should define the goals, the content and the implementation strategy for pay for quality programmes. There is no unanimity which governmental body should lead it. Some mentioned an extended NIHDI group, bringing in nurses and patient representatives. Many stakeholders refer to the National Council for Quality Promotion, established 8 years ago for this purpose. Many propose that, if that choice is made, adaptations are necessary to make the present council more performant, as there is a under representation of the hospital organisations and its directors, the main focus is currently on medical aspects in primary and ambulatory care. There is also a need for a new management style and new impact possibilities. Some even argue a complete make-over of the present body. Or do we need a new specific agency on Quality Implementation issues? Patient representation is felt important in the organisation of pay for quality, but it is not clear amongst the stakeholders who should represent them: insurers, government, mutualities or specific patient organisations. There is debate on the role of the mutualities in this: some see this as a new function for their future, some state that a conflict of interest will arise. 8.3.3 Think global, act local: the crucial need for organizing at the local level, and paying for local support initiatives Centrally-led pay for quality initiatives are felt needed, but not to be sufficient by many stakeholders. The idea of decentralisation in pay for quality programmes was supported by multiple stakeholders. Ownership is an important aspect whilst therapeutic freedom is a sensitive issue in Belgian healthcare. Initiatives that are locally developed in individual practices, hospitals or regional networks are considered to provide the best guarantees for success. Best practice examples have to relate to the local situation, opportunities and context. A decentralised pool of interest is necessary in the real local environment. Support, knowledge and qualification should be available at the local level. Quality managers in hospital as well as in primary care are judged by many stakeholders to play a crucial role in the management of the intermediate level. If this level is important, there should also be foreseen an important budget that includes training, implementation, data-collection, feedback and reflection.
KCE Reports 118 Pay for Quality 155 Some stakeholders suggest a sort of intermediate level, between centrally-led and local bodies, to be responsible for the design and implementation of pay for quality programmes, and suggest on giving this task to their scientific societies. In Belgium, although a legal framework exists for a national quality coordinator this is not yet made operational. 8.3.4 How and where to start in Belgium A stepwise approach for the development of a global pay for quality programme is suggested by most stakeholders. As a first step, a broad range of potential quality improving initiatives and projects (that have proven their success in the past) should be listed by the institute that coordinates pay for quality in Belgium. It is suggested that domains for which the needs are urgently displayed, the benefits clearly documented and the targets widely accepted should be considered first. These are often domains where international experience and results is available too. Hospital care and primary care, and in this a target population of medical doctors is considered a priority choice. There is however no consensus on the type of initiatives that should be launched first. Many propose to start with initiatives that have a traditional disease-related scope, but some advocate a practice or service-related scope. Chronic diseases seem to be the most obvious choice, as the domain of prevention is expected to present important measurement difficulties. Some stakeholders clearly state that mental health is not yet ready for pay for quality systems since the measurement of outcomes is hardly developed. 8.3.5 Schematic view The figure below visualizes the point of views of stakeholders with regard to the organization of pay for quality in Belgium. Figure 14: Structure for implementation of P4Q in Belgium Urgent need, clear benefit, acceptable target Disease‐ related scope Scientific evidence Multipartite central‐led institute NCQP ? Practice or service‐ related scope Local initiatives and management Staged approach Voluntary/mandatory participation? Strong involvement of professionals and patients representatives
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Pay for Quality

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