Designing a national health care performance system in the Netherlands: ZORGBALANS

prof dr Gert Westert

Basics

• Ministry of HealthCarefully assess the performance of

the Dutch health care system

• Why performance /why now? - Lissabon 2000 agenda

- EU market in 2010: strong and attractive

- ‘healthy’ public sector

- Less input more output!

• Performance in terms of what? - Performance in terms of health OR in terms of health care

- Health = f (…, Care)

- Care = f (Quality, Access, Costs)

Performance framework for the Dutch healthcare, phase 1

• Health performance of the system versus health care performance of the system

• ‘Steering the oil tanker’

• Balanced score card: health system management (2003-2004)

- Consumer

- Financial

- Internal processes

- Innovation

• Cockpit signals: - 26 baskets with indicators:

- 2 year interactive process

Health

Lifestyle

Environmentalfactors

Health Care†

Financialperspective

ConsumerPerspective

InternalProcesses

perspective

Innovationperspective

Geneticlayout

Balanced scorecardLalonde model

Performance:

Population Health Information Management Information

†Health care includes all sectors: prevention, cure, care and welfare

• Performance framework for healthcare, phase 2

• Health needs: 4x

• Change from BSC perspectives to system goals: quality, accesibility and costs

• OECD HCQI framework

• Baskets with indicators ‘adopted’ from phase 1

- Health impact

- Susceptibility to being influenced by health care system

- Policy importance

• Rearranged merging of baskets:

- Q A €

HEALTH How healthy are the Dutch?

NON-HEALTHCARE DETERMINANTS OF HEALTHAre the non-healthcare factors that also determine health as well as if/how healthcare is

used changing favorably?

HEALTH SYSTEM DESIGN AND CONTEXTWhat are the important design and contextual information that may be specific to the Dutch health system and which are

necessary for interpreting the quality of healthcare?

E

Q

U

I

T

Y

End-of-life care

Living with illness or disability

XXGetting better

Staying healthy

AccessibilityPatient-centeredness

SafetyEffectiveness

Healthcare Needs

Cost AccessQuality

Dimensions of Healthcare Performance

HEALTHCARE SYSTEM PERFORMANCEHow does the healthcare system perform? What is the level of care across the range of patient care needs? What does this

performance cost?

Efficiency(Value for money)

Quality• Effectiveness• Patient-Centeredness (satis-faction, trust)• Safety• Innovativeness

Access• Choice• Concentration• Waiting• Personell• Cost for citizens

Costs• System costs• Productivity• Financial position suppliers• Health care market• Contracting

State of Dutch health care 2006/ ZORGBALANS 2006

• Reference year 2004, published in April 2006

• MACRO-level report 100 pages

• 15 chapters with 125 indicators and results

• Max. 5 key messages per chapter

• Executive summary describing the overall state, including trade-off issues for quality, access and costs

• Chapter on information needs for 2008

• Zorgbalans team: 12 researchers

• Two examples:

- Effectiveness cure

- Waiting list in health care

Effectiveness of curative healthcare in the Netherlands is at best ‘average’

• GP’s are not prescribing medications that should not be prescribed as recommended.

• GP’s refer less to hospitals that 15 year ago.• Hospital-related mortality rates for pneumonia have been fluctuating around 10-

12% over the last several years.• Hospital-related mortality rates for heart failure have also been stable with only

slight improvements from 14% to 12% in the last 2 years.• In-hospital AMI and stroke mortalities within 30 days of hospital admission

are within the OECD average.• Breast cancer mortality, which is improving slowly, is still high in the Netherlands

compared to many other European countries.• Five-year survival rates for cervical and colorectal cancers compare well to

OECD averages.• Asthma mortality is improving and is better than the OECD average.• About 80% of all hip fractures are operated within 48 hours.

Number of people on a waiting list still considerable

• In 2003 218.000 were waiting on waiting list for health care

• Waiting list for hospital inpatient care simular as the year before (64,000 naar 62,500)

• Waiting list for mental health care increased slightly in the periode 2001-2003 (14,100 naar 15,600)

• Waiting list in care much shorter (nursing homes from 11,400 to 6.900);

home care from 39,600 to 19,500.

To conclude…

JIGSAW PUZZLE of 1000 pieces, but we have only 100 pieces

It is all about:

• Selection of indicators

• Representativeness

• Interpretation of results: norms and points of reference

- Time and space comparisons

- Within the Netherlands (benchmarking; small area variations; best practices)

- International indicator sets: OECD (HCQI)