Improving Performance in Complex Surroundings: A Mixed Methods Evaluation of Two Hospital Strategies in the Netherlands.

BACKGROUND: Hospital strategies aimed at increasing quality of care and simultaneously reducing costs show potential to improve healthcare, but knowledge on real-world effectiveness is limited. In 2014, two Dutch hospitals introduced such quality-driven strategies. Our aim was to evaluate contexts, mechanisms, and outcomes of both strategies using multiple perspectives. METHODS: We conducted a mixed methods evaluation. Four streams of data were collected and analysed: (1) semi-structured interviewing of 62 stakeholders, such as medical doctors, nurses, managers, general practitioners (GPs), and consultants; (2) financial statements of both organisations and other hospitals in the Netherlands (counterfactual); (3) national database of quality indicators, and patient-reported experiences; and (4) existing material on strategy development and effects. RESULTS: Both strategies resulted in a relative decrease in volume of care within the hospital, while quality of care has not been affected negatively. One hospital failed to cut operating costs sufficiently, resulting in declining profit margins. We identified six main mechanisms that impacted these outcomes: (1) Quality-improvement projects spur change and commitment; (2) increased coordination between hospital and primary care leads to substitution of care; (3) insufficient use of data and support hinder quality improvement; (4) scaling down hospital facilities is required to convert volume reductions to cost savings; (5) shared savings through global budgets lead to shared efforts between payer and hospital; and (6) financial security for physicians facilitates shift towards quality-driven care. CONCLUSION: This integrated analysis of mixed data sources demonstrated that the institution-wide nature of the strategies has induced a shift from a focus on production towards quality of care. Longer-term (financial) sustainability of hospital strategies aimed at decelerating production growth requires significant efforts in reducing fixed costs. This strategy poses financial risks for the hospital if operating costs are insufficiently reduced or if payer alignment is compromised.

Development of a decision analytical framework to prioritise operating room capacity: lessons learnt from an empirical example on delayed elective surgeries during the COVID-19 pandemic in a hospital in the Netherlands.

OBJECTIVE: To develop a prioritisation framework to support priority setting for elective surgeries after COVID-19 based on the impact on patient well-being and cost. DESIGN: We developed decision analytical models to estimate the consequences of delayed elective surgical procedures (eg, total hip replacement, bariatric surgery or septoplasty). SETTING: The framework was applied to a large hospital in the Netherlands. OUTCOME MEASURES: Quality measures impacts on quality of life and costs were taken into account and combined to calculate net monetary losses per week delay, which quantifies the total loss for society expressed in monetary terms. Net monetary losses were weighted by operating times. RESULTS: We studied 13 common elective procedures from four specialties. Highest loss in quality of life due to delayed surgery was found for total hip replacement (utility loss of 0.27, ie, 99 days lost in perfect health); the lowest for arthroscopic partial meniscectomy (utility loss of 0.05, ie, 18 days lost in perfect health). Costs of surgical delay per patient were highest for bariatric surgery (€31/pp per week) and lowest for arthroscopic partial meniscectomy (-€2/pp per week). Weighted by operating room (OR) time bariatric surgery provides most value (€1.19/pp per OR minute) and arthroscopic partial meniscectomy provides the least value (€0.34/pp per OR minute). In a large hospital the net monetary loss due to prolonged waiting times was €700 840 after the first COVID-19 wave, an increase of 506% compared with the year before. CONCLUSIONS: This surgical prioritisation framework can be tailored to specific centres and countries to support priority setting for delayed elective operations during and after the COVID-19 pandemic, both in and between surgical disciplines. In the long-term, the framework can contribute to the efficient distribution of OR time and will therefore add to the discussion on appropriate use of healthcare budgets. The online framework can be accessed via: https://stanwijn.shinyapps.io/priORitize/.

Exploring Dutch surgeons' views on volume-based policies: a qualitative interview study.

Objective In many countries, the evidence for volume-outcome associations in surgery has been transferred into policy. Despite the large body of research that exists on the topic, qualitative studies aimed at surgeons' views on, and experiences with, these volume-based policies are lacking. We interviewed Dutch surgeons to gain more insight into the implications of volume-outcome policies for daily clinical practice, as input for effective surgical quality improvement. Methods Semi-structured interviews were conducted with 20 purposively selected surgeons from a stratified sample for hospital type and speciality. The interviews were recorded, transcribed verbatim and underwent inductive content analysis. Results Two overarching themes were inductively derived from the data: (1) minimum volume standards and (2) implications of volume-based policies. Although surgeons acknowledged the premise 'more is better', they were critical about the validity and underlying evidence for minimum volume standards. Patients often inquire about caseload, which is met with both understanding and discomfort. Surgeons offered many examples of controversies surrounding the process of determining thresholds as well as the ways in which health insurers use volume as a purchasing criterion. Furthermore, being held accountable for caseload may trigger undesired strategic behaviour, such as unwarranted operations. Volume-based policies also have implications for the survival of low-volume providers and affect patient travel times, although the latter is not necessarily problematic in the Dutch context. Conclusions Surgeons in this study acknowledged that more volume leads to better quality. However, validity issues, undesired strategic behaviour and the ways in which minimum volume standards are established and applied have made surgeons critical of current policy practice. These findings suggest that volume remains a controversial quality measure and causes polarization that is not conducive to a collective effort for quality improvement. We recommend enforcing thresholds that are based on the best achievable level of consensus and assessing additional criteria when passing judgement on quality of care.

Evaluation of minimum volume standards for surgery in the Netherlands (2003-2017): A successful policy?

PURPOSE: To evaluate the introduction and implications of minimum volume standards for surgery in Dutch health care from 2003 to 2017 and formulate policy lessons for other countries. SETTING: Dutch health care. PRINCIPAL FINDINGS: Three eras were identified, representing a trust-and-control cycle in keeping with changing roles of different stakeholders in Dutch context. In the first era 'regulated trust' (2003-2009), the Dutch Inspectorate introduced national volume criteria and relied on yearly hospital reported data for information on compliance. In the second era 'contract and control' (2009-2017), the effects of market-oriented reform became more evident. The Dutch government intervened in the market and health insurers introduced selective contracting. Medical professionals were prompted to reclaim the initiative. In the current era (2017-), a return of trust in self-regulation seems visible. The number of low-volume hospitals performing complex surgeries in the Netherlands has decreased and research has shown improved outcomes as a result. CONCLUSIONS: Based on the Dutch experience, the following lessons can be useful for other health care systems: 1. professionals should be in the lead in the development of national quality standards, 2. external pressure can be helpful for professionals to take the initiative and 3. volume remains a controversial quality measure. Future research and policies should focus on the underlying mechanism of volume-outcome relationships and overall effects of volume-based policies.

Why do high-volume hospitals achieve better outcomes? A systematic review about intermediate factors in volume-outcome relationships.

OBJECTIVE: To assess the role of process and structural factors in volume-outcome relationships. DATA SOURCES: Pubmed electronic database, until March 2014. STUDY DESIGN: Systematic review. Based on a conceptual framework, peer-reviewed publications were included that presented evidence about explanatory factors in volume-outcome associations. DATA COLLECTION: Two reviewers extracted information about study design, study population, volume and outcome measures, as well as explanatory factors. Included publications were appraised for methodological quality. PRINCIPAL FINDINGS: After screening 1756 titles, 27 met our inclusion criteria. Three main categories of explanatory factors could be identified: 1. Compliance to evidence based processes of care (n = 7). 2. Level of specialization (n = 11). 3. Hospital level factors (n = 10). In ten studies, process and/or structural characteristics partly explained the established volume-outcome association. The median quality score of the 27 studies was 8 out of a possible 18 points. CONCLUSIONS: The vast majority of volume-outcome studies do not focus on the underlying mechanism by including process and structural characteristics as explanatory factors in their analysis. The methodological quality of studies is also modest, which makes us question the available evidence for current policies to concentrate care on the basis of volume.

Sustainability of improvements in access to outpatient specialist care in the Netherlands.

OBJECTIVES: To improve access to specialist outpatient clinics without adding capacity, Dutch hospitals applied the concept of 'Advanced Access'. Our aim was to determine whether initial improvements are sustained for three years and to identify the factors that influence sustainability. METHODS: Qualitative case studies in 14 outpatient specialist clinics. Access measurements at the start, finish and three years after the project were compared. Analysis of sustained and new interventions. Interviews with 52 practitioners, analysed with the constant comparative method to identify general factors that influence sustainability. RESULTS: Eleven out of 14 clinics were able to sustain or improve their reduced delays; two did not and for one it is uncertain. The clinics maintained the majority of the interventions and all introduced new interventions. Three generic factors emerged that influenced their ability to sustain the results: increased responsiveness to better match supply and demand; clinical leadership and incentives; and a shared belief that they can and should control access together. CONCLUSIONS: Reduction of delays in access can be sustained if the way of thinking and the planning system becomes demand driven and flexible and if care providers experience benefits. Unlike previous studies, senior management support and formal training was not relevant though clinical leadership and informal socialization was. Making multidisciplinary teams responsible for improvement appears to be vital.

[Quality of care: intensification, not new policy]. / Kwaliteit van zorg: intensiveren, geen nieuw beleid.

In the nineteen-eighties the introduction, use and maintenance of protocols improved the quality of care. Since then, it has become clear that this does not provide a guarantee: various studies have shown disappointing compliance with validated protocols. Therefore implementation is considered a vital aspect of quality assurance. A recent study in the USA focused on acute myocardial infarction care and compared 11 low- and top-performing hospitals in order to learn more about relevant constraints, interactions and mechanisms. Five factors, the selection of which was based on earlier research, proved to be relevant. Although the Dutch health care system is different from the American system, the outcome of this study is of some value. The homogeneity in the Dutch health care, stimulated by government policy, results in less difference between hospitals. The outcome of the analysis of the 11 hospitals confirms the value of our uniformity. Therefore this study advocates current Dutch policy.

Making sense of delays in outpatient specialty care: a system perspective.

OBJECTIVES: To assess whether delays to outpatient specialty care can be solved by improving the way supply and demand are matched, without adding capacity. METHODS: A systematic review of the interventions applied by 18 clinics using the model of 'advanced access' and a statistical analysis of the effects of the interventions on their delays. RESULTS: The clinics applied different combinations of interventions aimed at improving the way they match supply and demand, improving the efficiency of the way supply is organised and at reducing unnecessary demand. Fourteen clinics show statistically significant improvements. Two probably significantly improved and two clinics did not. Their access reduced on average 55%, from 47 to 21 days. CONCLUSIONS: It seems that delays in outpatient specialty care can be solved to a large extend by improving the way supply and demand are matched. Policy makers should analyse whether delays are caused by capacity problems or matching problems. For the latter, it appears more effective to invest in the ability to react then the ability to plan. Policy makers should create incentives for clinics to keep access short and remove incentives that stimulate delays.