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

Document Type : Original Article

Authors

Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands

Abstract

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) semistructured 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.

Keywords

References

  1. Jeurissen P, Duran A, Saltman RB. Uncomfortable realities: the challenge of creating real change in Europe's consolidating hospital sector. BMC Health Serv Res. 2016;16(Suppl 2):168. doi:1186/s12913-016-1389-3
  2. Christensen CM, Grossman JH, Hwang J. The Innovator's Prescription. New York: McGraw-Hill; 2010.
  3. Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA. 2012;307(14):1513-1516. doi:1001/jama.2012.362
  4. Marshall M, Øvretveit J. Can we save money by improving quality? BMJ Qual Saf. 2011;20(4):293-296. doi:1136/bmjqs.2010.050237
  5. Øvretveit J. Does Improving Quality Save Money? A Review of Evidence of Which Improvements to Quality Reduce Costs to Health Service Providers. London: The Health Foundation; 2009. p. 95.
  6. Schouten LM, Hulscher ME, van Everdingen JJ, Huijsman R, Grol RP. Evidence for the impact of quality improvement collaboratives: systematic review. BMJ. 2008;336(7659):1491-1494. doi:1136/bmj.39570.749884.BE
  7. Chatfield SC, Volpicelli FM, Adler NM, et al. Bending the cost curve: time series analysis of a value transformation programme at an academic medical centre. BMJ Qual Saf. 2019;28(6):449-458. doi:1136/bmjqs-2018-009068
  8. Nilsson K, Bååthe F, Erichsen Andersson A, Sandoff M. Value-based healthcare as a trigger for improvement initiatives. Leadersh Health Serv (Bradf Engl). 2017;30(4):364-377. doi:1108/lhs-09-2016-0045
  9. Jabbal J, Lewis M. Approaches to Better Value in the NHS: Improving Quality and Cost. King's Fund; 2018.
  10. Wackers E, Stadhouders N, Heil A, Westert G, van Dulmen S, Jeurissen P. Hospitals bending the cost curve with increased quality: a scoping review into integrated hospital strategies. Int J Health Policy Manag. 2021;11(11):2381-2391. doi:34172/ijhpm.2021.168
  11. Li SA, Jeffs L, Barwick M, Stevens B. Organizational contextual features that influence the implementation of evidence-based practices across healthcare settings: a systematic integrative review. Syst Rev. 2018;7(1):72. doi:1186/s13643-018-0734-5
  12. Øvretveit J. Understanding the conditions for improvement: research to discover which context influences affect improvement success. BMJ Qual Saf. 2011;20(Suppl_1):i18-23. doi:1136/bmjqs.2010.045955
  13. Greenhalgh T, Humphrey C, Hughes J, Macfarlane F, Butler C, Pawson R. How do you modernize a health service? A realist evaluation of whole-scale transformation in London. Milbank Q. 2009;87(2):391-416. doi:1111/j.1468-0009.2009.00562.x
  14. Nurjono M, Shrestha P, Lee A, et al. Realist evaluation of a complex integrated care programme: protocol for a mixed methods study. BMJ Open. 2018;8(3):e017111. doi:1136/bmjopen-2017-017111
  15. Moore GF, Audrey S, Barker M, et al. Process evaluation of complex interventions: Medical Research Council guidance. BMJ. 2015;350:h1258. doi:1136/bmj.h1258
  16. van Leersum N, Bennemeer P, Otten M, Visser S, Klink A, Kremer JAM. Cure for increasing health care costs: the Bernhoven case as driver of new standards of appropriate care. Health Policy. 2019;123(3):306-311. doi:1016/j.healthpol.2019.01.002
  17. Visser S, Westendorp R, Cools K, Kremer J, Klink A. Kwaliteit als medicijn Aanpak voor betere zorg en lagere kosten. Booz & Company; 2012.
  18. Venhuizen G. Can patient centred care plus shared decision making equal lower costs? BMJ. 2019;367:l5900. doi:1136/bmj.l5900
  19. Polak L. Bernhoven approach is more than just patient centred care and shared decision making. BMJ. 2019;367:l6560. doi:1136/bmj.l6560
  20. Campbell M, Fitzpatrick R, Haines A, et al. Framework for design and evaluation of complex interventions to improve health. BMJ. 2000;321(7262):694-696. doi:1136/bmj.321.7262.694
  21. Skivington K, Matthews L, Simpson SA, et al. A new framework for developing and evaluating complex interventions: update of Medical Research Council guidance. BMJ. 2021;374:n2061. doi:1136/bmj.n2061
  22. Curry LA, Krumholz HM, O'Cathain A, Plano Clark VL, Cherlin E, Bradley EH. Mixed methods in biomedical and health services research. Circ Cardiovasc Qual Outcomes. 2013;6(1):119-123. doi:1161/circoutcomes.112.967885
  23. Damschroder LJ, Lowery JC. Evaluation of a large-scale weight management program using the consolidated framework for implementation research (CFIR). Implement Sci. 2013;8:51. doi:1186/1748-5908-8-51
  24. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4:50. doi:1186/1748-5908-4-50
  25. Croes RR, Krabbe-Alkemade Y, Mikkers MC. Competition and quality indicators in the health care sector: empirical evidence from the Dutch hospital sector. Eur J Health Econ. 2018;19(1):5-19. doi:1007/s10198-016-0862-6
  26. Zorginstituut Nederland. Transparantiekalender. https://www.zorginzicht.nl/transparantiekalender. Accessed November 2020.
  27. Donabedian A. The quality of care. How can it be assessed? JAMA. 1988;260(12):1743-1748. doi:1001/jama.260.12.1743
  28. https://www.zorgkaartnederland.nl/. Accessed November 2021.
  29. Jaarverantwoording in de Zorg. https://digimv8.desan.nl/archive/search.
  30. Diepstraten M, Douven R, Kopányi-Peuker A, Wijnker G. Casestudie Beatrixziekenhuis en Bernhoven. Den Haag: CPB; 2020.
  31. Tsai TC, Orav EJ, Jha AK. Patient satisfaction and quality of surgical care in US hospitals. Ann Surg. 2015;261(1):2-8. doi:1097/sla.0000000000000765
  32. Austin JM, D'Andrea G, Birkmeyer JD, et al. Safety in numbers: the development of Leapfrog's composite patient safety score for US hospitals. J Patient Saf. 2014;10(1):64-71. doi:1097/PTS.0b013e3182952644
  33. Dimick JB, Ryan AM. Methods for evaluating changes in health care policy: the difference-in-differences approach. JAMA. 2014;312(22):2401-2402. doi:1001/jama.2014.16153
  34. Ryan AM, Burgess JF Jr, Pesko MF, Borden WB, Dimick JB. The early effects of Medicare's mandatory hospital pay-for-performance program. Health Serv Res. 2015;50(1):81-97. doi:1111/1475-6773.12206
  35. Mishra A, DeLia D, Zeymo A, et al. ACA Medicaid expansion reduced disparities in use of high-volume hospitals for pancreatic surgery. Surgery. 2021;170(6):1785-1793. doi:1016/j.surg.2021.05.033
  36. Farrar S, Yi D, Sutton M, Chalkley M, Sussex J, Scott A. Has payment by results affected the way that English hospitals provide care? Difference-in-differences analysis. BMJ. 2009;339:b3047. doi:1136/bmj.b3047
  37. Krabbe-Alkemade YJ, Groot TL, Lindeboom M. Competition in the Dutch hospital sector: an analysis of health care volume and cost. Eur J Health Econ. 2017;18(2):139-153. doi:1007/s10198-016-0762-9
  38. van Hoof SJM, Quanjel TCC, Kroese M, Spreeuwenberg MD, Ruwaard D. Substitution of outpatient hospital care with specialist care in the primary care setting: a systematic review on quality of care, health and costs. PLoS One. 2019;14(8):e0219957. doi:1371/journal.pone.0219957
  39. Netherlands Bureau for Economic Policy Analysis (CPB), Dutch Healthcare Authority (NZa), IQ healthcare. Evaluation Programmes Beatrix Hospital and Bernhoven. CPB; 2020.
  40. Van Dulmen S, Stadhouders N, Westert G, Wackers E, Jeurissen P. Op weg naar hoge kwaliteit en lage kosten in de medisch specialistische zorg. Evaluatie veranderprogramma’s Rivas Zorggroep en Bernhoven. Nijmegen: IQ healthcare; 2020.
  41. Wammes J, Stadhouders N, Westert G. International Health Care System Profiles: Netherlands. https://www.commonwealthfund.org/international-health-policy-center/countries/netherlands. Accessed March 12, 2021. Published June 5, 2020.
  42. Quinn AE, Trachtenberg AJ, McBrien KA, et al. Impact of payment model on the behaviour of specialist physicians: a systematic review. Health Policy. 2020;124(4):345-358. doi:1016/j.healthpol.2020.02.007
  43. Douven R, Burger M, Schut F. Does managed competition constrain hospitals' contract prices? Evidence from the Netherlands. Health Econ Policy Law. 2020;15(3):341-354. doi:1017/s1744133119000215
  44. Lee VS, Kawamoto K, Hess R, et al. Implementation of a value-driven outcomes program to identify high variability in clinical costs and outcomes and association with reduced cost and improved quality. JAMA. 2016;316(10):1061-1072. doi:1001/jama.2016.12226
  45. van den Heuvel J, Does RJ, Bogers AJ, Berg M. Implementing six sigma in the Netherlands. Jt Comm J Qual Patient Saf. 2006;32(7):393-399. doi:1016/s1553-7250(06)32051-x
  46. Niemeijer GC, Trip A, de Jong LJ, Wendt KW, Does RJ. Impact of 5 years of lean six sigma in a University Medical Center. Qual Manag Health Care. 2012;21(4):262-268. doi:1097/QMH.0b013e31826e74b7
  47. Barnabè F, Guercini J, Perna MD. Assessing performance and value-creation capabilities in Lean healthcare: insights from a case study. Public Money Manag. 2019;39(7):503-511. doi:1080/09540962.2019.1598197
  48. Strongwater SL. The change process and a clinical evaluation unit at University of Massachusetts Medical Center. Qual Manag Health Care. 1996;4(4):30-39. doi:1097/00019514-199604040-00005
  49. Rees C. How Hospitals Can Save 18 Percent in Direct Costs. Children’s Hospitals Today. July 13, 2014.
  50. Birk S. Quality, cost efficiency, the new quality-cost imperative: systemwide improvements can yield financial gains. World Hosp Health Serv. 2010;46(2):16-19.
  51. van Hoof SJM, Quanjel TCC, Kroese M, Spreeuwenberg MD, Ruwaard D. Substitution of outpatient hospital care with specialist care in the primary care setting: a systematic review on quality of care, health and costs. PLoS One. 2019;14(8):e0219957. doi:1371/journal.pone.0219957
  52. van Hoof SJ, Kroese ME, Spreeuwenberg MD, et al. Substitution of hospital care with primary care: defining the conditions of Primary Care Plus. Int J Integr Care. 2016;16(1):12. doi:5334/ijic.2446
  53. Remers TEP, Wackers EME, van Dulmen SA, Jeurissen PPT. Towards population-based payment models in a multiple-payer system: the case of the Netherlands. Health Policy. 2022;126(11):1151-1156. doi:1016/j.healthpol.2022.09.008
  54. Gaspar K, Portrait F, van der Hijden E, Koolman X. Global budget versus cost ceiling: a natural experiment in hospital payment reform in the Netherlands. Eur J Health Econ. 2020;21(1):105-114. doi:1007/s10198-019-01114-6
  55. Brekke KR, Siciliani L, Straume OR. Hospital competition with soft budgets. Scand J Econ. 2015;117(3):1019-1048. doi:1111/sjoe.12111

Files

History

  • Receive Date: 14 March 2022
  • Revise Date: 12 March 2023
  • Accept Date: 26 March 2023
  • First Publish Date: 28 March 2023

Share

How to cite

Statistics