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