Over the past two decades quality issues in health care has come to the fore. The background was a negative one, namely that is was realized that many patients died or had their hospitalization prolonged because of low treatment quality (wrong, insufficient or not state of the art treatment). To witness: In Denmark it was estimated that 1,500 – 2,000 persons died due to adverse events, that medication errors not only causes untimely deaths but also prolonged hospital stay with up to 7 days on the average, and that 8-10% of hospitalized patients acquire an infection.58 Today Denmark is in the forefront regarding quality assurance and monitoring – but not necessarily in terms of actually measurable quality of treatment.
A national program has been established. The Danish Healthcare Quality Program, DDKM, is a method to generate persistent quality development across the entire health care sector in Denmark. The Danish Healthcare Quality Program, DDKM, provides for standards of good quality – and of methods to measure and control this quality. As such, DDKM does not guarantee a high level of quality, but enables providers of health care to monitor and (partially) control their quality level.
The objectives of the Danish Healthcare Quality Program are59:
To avoid errors causing loss of lives, quality of life and resources
To ensure that knowledge achieved via research and experience is utilized in all branches of the health care sector
To document work performed
To achieve the same high quality across geographical boundaries and sectors
To generate coherence in citizens‘ pathways across sectors – e.g. in the transition from hospital to local health care
To render quality within the health care sector more visible
To avoid that all institutions must invent their own quality assurance system To strive towards excellence – all the time
The Danish Healthcare Quality Program is based on the quality method known as accreditation. The basic principle of accreditation is to determine a minimum level of good quality within a number of areas, which are followed up for their level of compliance. The faults and omissions discovered in the process are used as an empirical basis to improve quality. All private and public Danish hospitals must be accredited – and the first ones have successfully passed the accreditation process.
There has been debate about the value of accreditation, in part because the (economic and clinical) benefits are hard to document, in part because it involves quite a bit of paper work (―bureaucracy‖)60, 61. A rough estimate of the costs of implementing the DDKM is between 0.7 – 1 billion DKr. - equal to less than 1.5%
of total hospital expenditures62. The benefits – to be documented systematically – will come from the savings due to better quality of care.
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The Danish National Indicator Project, NIP, will be integrated into DDKM, as will the annual surveys of patient experienced quality3 so that much of significant ongoing quality initiatives will gradually become an integrated part of DDKM.
The Danish National Indicator Project, NIP,63, 64 was established in 2000 as a nationwide multidisciplinary quality improvement project. From 2000 to 2002, disease-specific clinical indicators and standards were developed for six diseases (stroke, hip fracture, schizophrenia, acute gastrointestinal surgery, heart failure, and lung cancer). Today diabetes, depression, birth and chronic obstructive pulmonary disease (COPD) have been added. The NIP model will become an integrated part of the Danish Healthcare Quality Program, DDKM.
Indicators and standards, see figure below, have been developed and implemented in all clinical units and departments in Denmark treating patients with these diseases, and participation is mandatory. All clinical units and departments receive their results every month. National and regional audit processes are organized to explain the results and to prepare implementation of improvements. All results are published via
www.sundhed.dk in order to inform the public, and to give patients and relatives the opportunity to make informed choices.
A noteworthy feature of the system is seen in the right hand column of the figure. All the indicators (of good care/treatment) are based on graded scientific evidence. The picture for stroke is not unusual, i.e. not
everything that is done – and ought to be done – is firmly based on scientific evidence. It is not an argument against doing it but cautions us toward the lack of solid evidence and where more research is needed.
Figure 17A: The framework for the national indicator project, NIP
Source: Mainz et al.63
Reporting from NIP takes place in a framework like the one shown in figure 17A with information from the previous reporting periods to be able to track changes. Table 2 has been pulled together from the 2009 report on stroke65, 66, including new indicators compared to figure 17A. The system is continually being refined and
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improved. Table 2 has included as an illustration only. The original sources should be consulted for full explanation of the indicators. ‗Standard‘ is the professional judgment of how many patients ideally should receive the service in question (in some areas it is a subset of stroke patients).
Table 2: Quality reporting for stroke, 2009 and 200765, 66.
Indicator Standard
Fulfilled
(2009) 2009 2007
Stroke unit (within 48 hours) 95% yes 91 85
Antiplatelet therapy within 48 hours 95% no 88 87
Oral anticoagulant therapy 95% no 73 77
CT/MRI scan at day of hospitalization 80% no 71 62
Assessment by Physiotherapist within 48 hours 90% no 75 70
Assessment by occupational therapist whitin 48 hours 90% no 72 66
Nutritional risk evaluation 90% no 69 66
Water swallowing test at day of hospitalization 90% no 61 55
Ultrasound/CT-angiography, neck artery, within four
days 90% no 52 35
Mortality within 30 days 15% yes 11 11
All-or-none 25
21 (in 2008) Note: the number of patients included varies by indicator. A total of 11,421 was available, i.e. a substantial number of patients. - 11,281 was used for the first indicator while the subset of relevant patients of indicator number 2 was 7,441 etc. All-or-none‘ refers to patients who received the first 9 services.
The good news is that overall there are improvements from 2007 to 2009. At a more negative level only two standards out of 10 are fulfilled. Now, in sensational journalism, this would be presented as ‗scandalous‘.
But before too hasty conclusions one should for instance consider the evidence level, the circumstances that occasionally makes it difficult if not impossible to carry out the procedures etc. Not in order to ‗apologize‘
but in order to understand.
The next question is: What is the effect of compliance (full or partial) with the standards? At a general level the answer is better patient treatment and care. At a more detailed and relevant level one would want to know: Does it save/increase use of resources? It is often claimed that good/ better quality costs more – but is it so simple? Secondly, does mortality decrease, and if not mortality does the physical and mental
functioning increase if all 9 points in table 2 are fulfilled. At present all of this it is not well explored, but for stroke there are at least two articles address it. Svendsen et al67 looked at the relationship between degree of fulfillment of standards and length of stay, LOS.. They concluded that the median LOS was 13 days.
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Meeting each quality of care criteria was associated with shorter LOS. The size of the reduction was between 13-33 %. The association between meeting more quality of care criteria and LOS followed a dose-response effect, that is, patients who fulfilled between 75% and 100% of the quality of care criteria were hospitalized about one-half as long as patients who fulfilled between 0% and 24% of the criteria. Palnum et al68 looked at quality of care and short-term mortality for stroke patients. Their findings can be summarized so that : elderly stroke patients in Denmark receive a lower quality of care than do younger stroke patients, however, the age-related differences are modest for most examined quality-of-care criteria and do not appear to explain the higher mortality among older patients
With this extended stroke example we have attempted to show how quality is monitored, results and improvement, and consequences in terms of length of stay and mortality. There is no doubt that Denmark is in front. There has been some criticism about ‗bureaucracy‘ surrounding quality monitoring. It is true that collecting the data does consume resources. However, in view of the benefits to patients and the hospitals there is no doubt that in cost-benefit terms it is money well invested. However, it is important with more research of the type mentioned in the preceding paragraph.