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Methods of assessing response to quality improvement strategies

Final Report Summary - MARQUIS (Methods of Assessing Response to Quality Improvement Strategies)

European policy makers had been faced, for a lot of years, with a challenging contradiction. On the one hand, healthcare remained fundamentally a national responsibility of European Union (EU) Member States, outside the competences and powers of the EU as set out in successive treaties. This position was strongly defended by national governments, which were understandably protective of their healthcare systems. Yet on the other hand, the rising tide of economic and social integration, driven both by EU policies such as the single market and by long-term societal trends in the family, employment, education, language and culture, had created increasing pressures for convergence, coherence and coordination in health system funding and provision.

Since the European Commission (EC) first established its high-level reflection process on patient mobility and healthcare developments in 2003, and started the chain of events that culminated in the recent publication of a proposal for a directive on the application of patients' rights in cross-border care, it had been increasingly clear that assuring the quality and safety of healthcare is a central concern for all stakeholders - the EC itself, Member States, health system funding agencies, healthcare providers, health professionals and patients. In commissioning a number of research projects to map, describe and analyse the quality of healthcare, and the policies and systems in place to assure quality, the EC provided an essential evidence base for these policy developments, which had undoubtedly been influential in shaping the content of the current draft directive.

The MARQUIS project was designed to assess the value of different quality strategies, and to provide information on quality requirements for cross-border patients. In addition, it aimed to provide individual hospitals with information on the development of their quality strategies.

Although the phenomena of cross-border care (which can be broadly grouped into five categories: temporary visitors abroad, people retiring as long-term residents to other countries, people living in border areas, people referred abroad for treatment, and people who seek treatment abroad themselves) had received considerable policy attention, the research confirmed that the overall phenomenon reflects only a small percentage of healthcare service delivery. In some regions and for some hospitals, however, the volume of cross-border care can be considerable, not only in terms of hospitalisations but also for emergency visits. For individual hospitals the issue of cross-border care may therefore be highly relevant. Moreover, the term cross-border patient itself can be confusing because a person working for a local company, but who is a citizen of another country, will not be considered a cross-border patient, although the expectations and needs of these patients may differ from those of local patients.

The research provided insight into the profile of cross-border patients, most of whom seek care for acute conditions or for emergency care. For hospitalised cross border patients, the most frequent diagnoses involve the circulatory system or fractures. In addition, deliveries and other diagnoses related to pregnancy, pneumonia, appendicitis and other diseases of the digestive system are common diagnoses for this population.

Cross-border patients' needs are similar to those of other patients, but they have particular requirements that need to be fulfilled to ensure quality healthcare and safety for these patients. Information requirements with regard to the use of different languages are more pronounced among cross-border patients. Although hospitals use interpreters to improve communication with these patients, the study showed that in some cases it might be difficult for cross-border patients and professionals to communicate at the same level and share understanding during history taking, explanation of medications, and during discharge preparation. Moreover, informed consent procedures differ considerably between countries in terms of content and scope, which has practical implications (relating, for example, to participation in clinical trials) and raises potential legal issues related to the diversity of procedures.

Differences can also be identified in medical procedures (such as the use of organs from non-heart patients, the scope of rehabilitation services and caesarean section on demand), and clinical practice guidelines may place emphasis on different aspects across countries. Cross-border patients may also be exposed to additional safety risks in view of prescription procedures for drugs that differ in name and dosage between countries, or in view of the difficulties of arranging medical transport between countries.

With regard to the quality strategies employed by the member states of the EU, the rate of progress varies considerably. Although all countries implement the main quality strategies to some extent (such as accreditation systems, organisational quality management programmes, audit and internal assessment of clinical standards, patient safety systems, clinical practice guidelines, performance indicators and systems for getting patient views), three groups of countries can be identified. Countries where implementation is 'well established' have been active in the implementation of a wide range of quality improvement strategies for years, and have well established systems in place. 'Recent adaptors' have recently established policies and strategies, and are in the process of consolidating their regulatory systems. 'Slow starters' have begun initiatives in the field of quality improvement, but lack a coherent programme of government policy in this area. Member States belonging to the group of 'recent adaptors' or 'slow starters' are thus advised to study the existing experience of other member states with legislation in place, notably the impact of statutory legal requirements, on the implementation of quality improvement strategies in healthcare organisations.

Member States with well-developed systems, on the other hand, could strengthen existing quality improvement legislation and other regulatory instruments to enhance and spread effective approaches to quality improvement.

Although research indicated some benefit of the regulatory approaches to quality improvement, this classification should not be confused with the implementation of quality improvement strategies in hospitals belonging to a given country. Analysis of the implementation of quality improvement strategies in European hospitals reveals that hospitals with a well-developed (and not so well-developed) quality improvement system can be identified in all countries.

The strategies studied in MARQUIS are effective at the hospital level, although the effect is nuanced depending on the level of analysis and the outputs under consideration. External pressure appears to be consistently associated with the implementation of quality improvement strategies at the hospital level. The quality improvement strategies under evaluation influence the implementation of different policies and procedures, and are, to varying extents, associated with the attainment of hospital output goals. Some of these associations, in particular with regard to patient safety and patient-centredness, however, may be confounded by hospital and country effects.

While most of the results of the project were relevant for EU Member States, some were also relevant for countries in other continents, for example in North America, Asia, and Australia. With regard to evaluating the effectiveness of quality improvement strategies, similar research projects in the United States and Australia deserve note, and the exchange of methodologies and findings may accelerate research and quality improvement implementation in the different settings.

It should also be noted that other regions provide cross-border care, for example between the United States and Canadian border, and that some healthcare providers in Asia market specialised healthcare services globally. In this context, the results of the MARQUIS project on cross-border care may also inform developments and quality improvement beyond the EU.