Incorporating Budget Impact Analysis in the Implementation of Complex Interventions: A Case of an Integrated Intervention for Multimorbid Patients within the CareWell Study.

OBJECTIVES: To develop a framework for the management of complex health care interventions within the Deming continuous improvement cycle and to test the framework in the case of an integrated intervention for multimorbid patients in the Basque Country within the CareWell project. METHODS: Statistical analysis alone, although necessary, may not always represent the practical significance of the intervention. Thus, to ascertain the true economic impact of the intervention, the statistical results can be integrated into the budget impact analysis. The intervention of the case study consisted of a comprehensive approach that integrated new provider roles and new technological infrastructure for multimorbid patients, with the aim of reducing patient decompensations by 10% over 5 years. The study period was 2012 to 2020. RESULTS: Given the aging of the general population, the conventional scenario predicts an increase of 21% in the health care budget for care of multimorbid patients during the study period. With a successful intervention, this figure should drop to 18%. The statistical analysis, however, showed no significant differences in costs either in primary care or in hospital care between 2012 and 2014. The real costs in 2014 were by far closer to those in the conventional scenario than to the reductions expected in the objective scenario. The present implementation should be reappraised, because the present expenditure did not move closer to the objective budget. CONCLUSIONS: This work demonstrates the capacity of budget impact analysis to enhance the implementation of complex interventions. Its integration in the context of the continuous improvement cycle is transferable to other contexts in which implementation depth and time are important.

The future of monitoring in clinical research - a holistic approach: linking risk-based monitoring with quality management principles.

Since several years risk-based monitoring is the new "magic bullet" for improvement in clinical research. Lots of authors in clinical research ranging from industry and academia to authorities are keen on demonstrating better monitoring-efficiency by reducing monitoring visits, monitoring time on site, monitoring costs and so on, always arguing with the use of risk-based monitoring principles. Mostly forgotten is the fact, that the use of risk-based monitoring is only adequate if all mandatory prerequisites at site and for the monitor and the sponsor are fulfilled.Based on the relevant chapter in ICH GCP (International Conference on Harmonisation of technical requirements for registration of pharmaceuticals for human use - Good Clinical Practice) this publication takes a holistic approach by identifying and describing the requirements for future monitoring and the use of risk-based monitoring. As the authors are operational managers as well as QA (Quality Assurance) experts, both aspects are represented to come up with efficient and qualitative ways of future monitoring according to ICH GCP.

[Quality management in implementing specialist pediatric palliative home care in Lower Saxony, Germany]. / Qualitätsmanagement bei der Einführung der Spezialisierten Ambulanten Pädiatrischen Palliativversorgung in Niedersachsen.

BACKGROUND: To provide comprehensive high-quality health care is a great challenge in the context of high specialisation and intensive costs. This problem becomes further aggravated in service areas with low patient numbers and low numbers of specialists. Therefore, a multidimensional approach to quality development was chosen in order to optimise the care of children and adolescents with life-limiting conditions in Lower Saxony, a German federal state with a predominantly rural infrastructure. METHODS: Different service structures were implemented and a classification of service provider's specialisation was defined on the basis of existing references of professional associations. Measures to optimise care were implemented in a process-oriented manner. RESULTS: High-quality health care can be facilitated by carefully worded requirements concerning the quality of structures combined with optimally designed processes. Parts of the newly implemented paediatric palliative care structures are funded by the statutory health insurance.

[Surgery and management: natural partners]. / Chirurgie und Management: natürliche Partner.

The term management is a description of the functions: planning, organization, leadership and control in institutions and the corresponding persons holding these powers. In order to efficiently lead a department of surgery, surgeons need to possess management qualities and have to be able to act as team leaders. Good management of a surgical department leads to avoidance of complications and increased profits as well as more efficient use of operating room capacities and a better organization within the department.

Quality management in complementary and integrative medicine.

Quality management (QM) is an important tool for an effective and safe healthcare which also includes complementary and integrative medicine. Improving the three areas of quality (quality of structure, quality of process, and quality of results) is beneficial for patients and providers. Improvements of process, product and QM systems have a direct impact on time, quality, human resources, and costs. As a result, patient care improves and physicians and statutory sickness funds will benefit from increased efficiency. Several QM systems with different main focus exist. First publications about QM in complementary and alternative medicine (CAM) hospitals are from the 1990s. In order to increase the benefit and to avoid pitfalls, the implementation of a QM system should be planned systematically.

[Dynamic evaluation of the effects of quality management]. / Dynamische Evaluierung der Effekte von Qualitätsmanagement.

PURPOSE: Evaluation of the effects of quality management over time at a radiology department. MATERIALS AND METHODS: Data concerning the performance of the department, entered on a monthly basis, will be compared with entries in the error report system on the basis of time series analysis (regression models taking seasons and auto-correlation effects into account). The observation period consists of 46 homogeneous monthly time pulses. RESULTS: Effects of the suggestions and the total number of reports in the quality assurance system on the performance of the department can be observed with a two-month delay. This association is statistically highly significant (p < 0.01) and, because of the procedures used, not attributable to general developmental trends, seasonal fluctuations or autoregressive processes. CONCLUSION: Evaluation of quality assurance measures is a well justified demand and should be based on the analysis of data collected from quality assurance systems operating on a continuous basis over a long period of time. The analysis of data from a radiology department shows that quality assurance is reflected in the performance of the department.

[Implementation of the multi-center basis documentation CL-BaDo for conciliar and liaison services: generating data for internal quality management and cost calculation]. / Implementierung der multizentrischen Basisdokumentation CL-BaDo für den Konsiliarund Liaisondienst: Generierung von Daten für internes Qualitätsmanagement und Kostenkalkulation.

In the German DRG system the funding of CL services is not ensured. The documentation of psychiatric comorbidity and CL care delivery is a pre-condition to the development of funding models for CL-services. A task force of several German psychosomatic associations (German College of Psychosomatic Medicine, German Society of Psychosomatic Medicine and Psychotherapy, General Medical Society for Psychotherapy) developed a new documentation form for CL-services (CL-BaDo). The pilot study explored the multicenter implementation of CL-BaDo and the use of the documentation form for quality management and cost calculation. Over a period of at least three months, participating CL-services documented all CL cases consecutively with the CL-BaDo. One site applied full electronic data processing. 2116 CL cases from eight psychosomatic CL-services were analysed. The CL-BaDo is a time-efficient, feasible and acceptable documentation form for CL-service delivery. The full electronic data processing enables networking with a hospital information system to produce higher data quality. The data of CL-BaDo can be used locally for quality management, development of management strategies and communication with consultants, as well as nationwide for health policy questions and research.

Six Sigma pricing.

Many companies are now good at managing costs and wringing out manufacturing efficiencies. The TQM movement and the disciplines of Six Sigma have seen to that. But the discipline so often brought to the cost side of the business equation is found far less commonly on the revenue side. The authors describe how a global manufacturer of industrial equipment, which they call Acme Incorporated, recently applied Six Sigma to one major revenue related activity--the price-setting process. It seemed to Acme's executives that pricing closely resembled many manufacturing processes. So, with the help of a Six Sigma black belt from manufacturing, a manager from Acme's pricing division recruited a team to carry out the five Six Sigma steps: Define what constitutes a defect. At Acme, a defect was an item sold at an unauthorized price. Gather data and prepare it for analysis. That involved mapping out the existing pricing-agreement process. Analyze the data. The team identified the ways in which people failed to carry out or assert effective control at each stage. Recommend modifications to the existing process. The team sought to decrease the number of unapproved prices without creating an onerous approval apparatus. Create controls. This step enabled Acme to sustain and extend the improvements in its pricing procedures. As a result of the changes, Acme earned dollar 6 million in additional revenue on one product line alone in the six months following implementation--money that went straight to the bottom line. At the same time, the company removed much of the organizational friction that had long bedeviled its pricing process. Other companies can benefit from Acme's experience as they look for ways to exercise price control without alienating customers.

[The role of the critical path in a new hospital payment system according to a diagnosis procedure combination in Japan].

Implementation of the critical path in the healthcare system facilitates standardization of medical practices, which improves both quality and safety management, shortens the length of hospital stays, and economizes on medical resources. In a new payment system introduced to university hospitals in Japan, hospital fees are charged by the day according to the diagnosis-procedure combination (DPC). To prepare for DPC, standardization of medical care, shortening the average length of stay within all hospitals, cost reduction, establishment of hospital networks, and an increase in new patients are critical issues. Cost management can be achived effectively by using the critical path.

[Indications for blood transfusion during orthopedic surgery]. / Indikation zur Bluttransfusion bei orthopädischen Eingriffen.

Ageing of the population increases the number of large orthopedic surgical interventions in elder people. High perioperative blood loss together with a reduced tolerance to anemia increase the transfusion probability in this patient subgroup. The expected cost explosion in the transfusion system (cost intensive quality management, imbalance between the number of donors and recipients) as well as the remaining transfusion related risk of hemolysis, infection and immunosuppression reflect the high socio-economic significance of the development of institutional transfusion programs. The present article summarizes: (1) the (patho-) physiology of anemia compensation, (2) the decision making for transfusion in healthy patients and patients with cardiovascular disease, and (3) the currently applied pre- and intraoperative techniques to reduce allogeneic transfusion in orthopedic patients.

"Virtual" health care organizations and the challenges of improving quality.

This article examines the challenges of improving health care quality continuously within and across "virtual" provider organizations such as independent practice associations and physician-hospital organizations. It draws on recent research and theory about interorganizational networks in other fields to develop recommendations for securing physicians' commitment to quality improvement strategies in today's health care environment.

[Practical usage of a quality management system according to ISO 9001 : 2000 focusing on the double contrast (barium) enema]. / Praktische Anwendung eines Qualitätsmanagementsystems nach ISO 9001:2000 am Beispiel von Qualitätsverbesserungsmassnahmen beim Kolon-Kontrastmitteleinlauf, Germany.

PURPOSE: We describe the implementation of quality improvement measures in a quality management system. METHODS: With questionnaires for radiologists and patients, we investigated the relations between patient preparation and diagnostic quality serving the main purpose, to improve diagnostic quality with the help of more detailed patient information (e.g., changing preparation sheets and handling out "peri-med" information sheets to the patients). Furthermore, a comparative data ascertainment at other institutes was integrated. RESULTS: For the group of outpatients, increasing process quality (patient information) and outcome (diagnostic quality) could be achieved. Taking aspects of quality costs into consideration, a decrease in costs due to failures was achieved. CONCLUSION: More detailed patient information has positive effects on diagnostic quality of the double contrast (barium) enema.

Process-centered revenue-cycle management optimizes payment process.

By implementing a process-centered revenue cycle, healthcare organizations and group practices can achieve a seamless payment process with clear lines of accountability to achieve target outcomes. The integrated, end-to-end, revenue-cycle process involves four key components: jobs, skills, staffing, and structure; information and information systems; organizational alignment and accountability; and performance measures and evaluation measures. The Henry Ford Health System (HFHS), based in Detroit, Michigan, exemplifies the type of results that are achievable with this model. HFHS includes a group practice with more than 1,000 physicians in 40 specialties. After implementing a process-centered revenue cycle, HFHS dramatically improved registration and verification transactions and optimized revenues.

[Electronic data processing assisted quality management in general practice networks]. / EDV-gestütztes Qualitätsmanagement in Praxisnetzen.

Possibilities of an EDP-based quality management for medical networks are presented and some organizational requirements are derived. To show the relevance of the approach, three networks are sketched.

A national disease registry moves beyond clinical impact, fostering measurable cost savings at the community hospital level.

National disease registries have existed for many years, and give hospitals and medical professionals centralized, disease-specific databases that can be used to study both treatment protocols and quality outcomes. To date, most efforts have focused on the quality management and clinical aspects of disease registries. However, Sierra Nevada Memorial Hospital, using the National Registry for Myocardial Infarction, recently concluded a study that identified and then attempted to quantify several positive financial effects on the hospital in terms of improved cost outcomes and resource management. The study concluded that activities that improve clinical outcomes (reduce mortality, morbidity, and complications) for acute myocardial infarction (AMI) patients can have a wide range of effects not only for the patients themselves, but also on the cost of care and the utilization of resources. The study discovered that these effects can be measured and expressed quantitatively or qualitatively. Consequently, improving the clinical quality of AMI patient care or reducing the costs of that care can be expected to produce enhanced value for health care consumers, providers, and the health care economy. Furthermore, it is highly likely that this principle would apply to many other kinds of disease registry programs when used to support quality improvement activities.

System's internal grant program leads to clinical innovations.

Internal grant program inspires caregivers to dream up terrific clinical studies that improve care and post savings to the bottom line. BJC Health System in St. Louis has a long list of success stories from its novel quality improvement program. The one featured in this issue resulted in more than $100,000 in annual savings systemwide after a small change was made in the way suction catheters are used on ventilator machines in the ICU.