Pay for Quality

162 Pay for Quality KCE Reports 118
A number of studies relate absence of P4Q effects to an absent or insufficient
awareness and poor communication. Studies that used more extensive and direct
transparent communication about P4Q to the involved providers found more positive
effects. Involvement of all stakeholders, in the first place the providers themselves,
when developing the P4Q programme proved important, but findings remain mixed
(sometimes positive, sometimes no effect). Experts and Belgian stakeholders clearly
confirm this need for communication, creating awareness and obtaining involvement.
For successful implementation, stakeholders insist that centrally conceived programmes
should be supported by decentralised availability of knowledge, qualified support and
local organised input like quality management skills in hospital and primary care, and
performing IT systems at all levels.
The role of medical leadership in supporting the P4Q programme is potentially
influencing motivation and therefore effectiveness of a P4Q programme, but is rarely
reported upon in the studies. Belgian stakeholders considered the role of leadership
crucial.
9.8 TOWARDS P4Q IN BELGIUM?
Although many P4Q studies show design problems, leading to mixed evidence on
several aspects, elements that ideally should be taken into account when undertaking
P4Q initiatives in Belgium can be listed.
P4Q should not be started simply as a nice new idea. It should be made clear why to
start, what the current quality issue is, and how it could be addressed with a P4Q
programme. Already in this process, all stakeholders should be involved and consulted.
A first key aspect is the definition of quality. The following aspects appear to be of
importance, either based on theoretical grounds, or supported by evidence, experts or
stakeholders:
• Quality is more than just clinical effectiveness; the different dimensions of
quality should be kept in mind. The quality definition and conceptualisation
should be in line with both the health system and the provider values.
• When translating quality into indicators, structure, process, and intermediate
outcome indicators should all be considered, since they all have their own
value (e.g. IT adoption enhancement as a structural goal). But they should all
be supported by evidence, and by evidence on room for improvement.
• Consider both increasing appropriate care (reducing clinical inertia) and
reducing inappropriate care. In some circumstances, maintaining quality can
also be an option.
• Plan already next targets when current targets have been largely achieved (i.e.
following a plan do check act approach).
The way that quality achievement will be measured, must also be planned. The following
could be taken into account:
• Make use of accurate and validated data, for instance by investing in IT
development, and making data collection automatic
• Make use of data already available as much as possible
• Monitor potential unintended consequences (especially in care equity, patient
experience and provider experience)
• Apply case mix adjustment on intermediate outcome measures.
• Apply exception reporting to guard individualized care.
• Provide an audit system to prevent and detect gaming. This, together with
most of the above elements, requires a well established health information
system.
• Include both baseline and comparison group measurements (in the initial
phase)