Austrian Inpatient Quality Indicators (A-IQI)
Bundesministerium für Gesundheit (Federal Ministry of Health)

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
"Austria has the best health care system in the world!" This statement is very prevalent in Austria, however, can only partially be substantiated. There are many quality assurance and quality improvement initiatives. The use of quality management systems in the hospital sector is widespread and the diversity of systems large and the costs of implementing and operating these systems in some cases are considerable. The systems are highly diverse and the main focus usually is not on detailed medical issues. The generation of data on quality, especially on the quality of the results, in Austria so far is still stuck in its infancy and has been reserved for clinical registers or studies only. These are frequently isolated initiatives and an Austria-wide quality data system collecting, measuring and comparing quality data does not exist to date. Quality activities concerning detailed medical topics have been associated with both intense reporting efforts for the doctors and high cost burdens. Nor have we seen any structured processing of the results of these surveys. The A-IQI Initiative (Austrian Inpatient Quality Indicators) basically benefits the entire population since the project covers all hospitals in Austria. The purpose of the system is to provide transparency on quality data, international comparability, and increased patient safety. Statement by the Lower Austrian Patients’ Ombudsman Dr. Gerald Bachinger (nominating organisation for the project): "The innovative A-IQI model (nationwide uniform quality performance measurement from routine data / Austrian Inpatient Quality Indicators) is a milestone and landmark project in the quality activities of Austrian hospitals. The quality of the hospitals can for the first time be measured and evaluated throughout Austria so that subsequently the necessary measures for quality improvements can be initiated and implemented. The fact that we can for the first time not only capture the structures and processes, but also record the results must be emphasized as a special innovation, i.e. a perspective focusing particularly on the actual quality of the service, which is especially important for patients. A-IQI also is particular in that the meaningful quality information can be obtained from routine data such as the performance-orientated hospital financing (LKF) data sets. This means that the doctors have no additional documentation burden. The heart of the A-IQI project is the peer-review process that ensures on the one hand that at the hospital departments the processes are evaluated by experienced experts, whereas on the other hand it also guarantees the specialist view from the "outside". All in all, this is a very positive development which particularly from the patients’ perspective meets the expectations for the best possible quality."

B. Strategic Approach

 2. What was the solution?
A-IQI is a project implemented by the Bundesgesundheitsagentur aimed at establishing a nationwide uniform system for measuring the quality of results within the hospitals. A-IQI is based on a quality measurement system from Germany that had been implemented more than ten years ago and continuously improved ever since. The province of Lower Austria has taken over the pioneering role in the field of measuring and analysing the quality of results. The data instrument from Germany was adopted, then "translated" into the Austrian context and implemented step-by-step together including the peer review process. The Austria-wide roll-out of the project began in mid-2011. Utilizing the experience already gained by this federal province, the project benefitted by taking over an already established system and exploiting the synergy effects. Meanwhile, A-IQI is enshrined in law and is now mandatory for all hospitals. A-IQI is a system of quality indicators and an analytical tool (peer-review). The indicators are calculated on the basis of routine hospital data which in Austria is the only nationally comparable and complete set of such data. The measurements are made in all hospitals using the exact same method based on a nationally standardized evaluation tool. The quality indicators are defined based on particular medical disorders (e.g. heart attacks) or surgery (e.g. removal of the gallbladder) etc. These include a wide range of common standard treatments, right up to highly complex treatments / medical disorders. A total of 191 individual indicators have been established within the A-IQI initiative, including mortality frequencies, intensive treatment frequencies, occurrence of complications, quantity information, surgical techniques used, as well as prophylactic and process indicators. The heart of the system is the peer-review. If the indicator results point out statistical deviations, the respective hospital performs a self-analysis which is then followed by an independent analysis performed by "external" trained senior physicians from various special fields, so called “peers”. Finally the medical records are studied on-site at the hospital and analysed according to standardized criteria. Based on this analysis, the external peers and the management of the involved hospital jointly develop quality improvement measures on a collegiate basis. The peer review process is a medical instrument for quality enhancement. It enables a systematic and critical reflection on one’s own performance as well as that of one’s colleagues. This process is carried out by several members of a profession (peers) using a structured process and with the aim of continuously improving the quality of patient care. Strategic cornerstones (implementation): information, control, training, scientific further development Main objectives: • Involvement of all stakeholders (incl. “service providers”) • Mandatory participation • centralized control • Definition of responsibilities • No additional reporting burden for hospitals • Establishment as a medical tool • international comparability • Optimization of the entire treatment process and sustainability of the improvement process • Establish an open culture of awareness concerning medical errors • Stepwise transparency • The patient should "feel" some of the effects of the initiative“ The project started off by providing extensive information to all stakeholders (Medical directorates, hospital operators, and provincial health funds). To control the project an A-IQI office was set up within the Ministry and a steering group with participants from all provincial health funds was convened for taking the essential project decisions. This was followed by the first peer-training sessions aimed at building a pool of peers from different disciplines. A Scientific Advisory Board was also set up in order to further develop the indicator system. Meanwhile, the indicator system is in use as part of a voluntary association of hospital owners within the quality medicine initiative both in Germany and Switzerland. The countries cooperate concerning the further development of the system so that it is possible to compare the indicators internationally. The A-IQI project addresses several issues: no additional reporting burden for doctors, a measurement system that allows for national and international comparisons, structured processing of the measurement results, and efficient use of resources.

 3. How did the initiative solve the problem and improve people’s lives?
The intense and transparent cooperation of all stakeholders in particular represents a new approach in the Austrian health sector. At the annual follow-up meetings where all stakeholders convene the results of the peer-reviews (i.e. weaknesses found in the system) are openly discussed and nationwide quality improvement initiatives are jointly proposed. The 16 peer review processes concerning preoperative length of stay for hip fractures showed uncertainties in the use of anticoagulant drugs in the day-to-day treatment. The greatest need for action was identified in the establishment of a standard for blood coagulation management and thrombosis prophylaxis in multi-morbid patients. The relevant scientific expert groups took this issue up in the first follow-up meeting in autumn 2013 and jointly developed a decision aid for this complex subject. This resulted in a Clinical being written in August 2014. The provision of this Guideline via an "App" for smartphones makes the desired information quickly and easily retrievable. Innovative approaches: • Pragmatic resource-efficient system • Based on routine data • Internationally comparable • Enshrined in law • Direct involvement of stakeholders and decision-makers • Peer approach: discussion with colleagues and "learning from each other“ • Transparency of quality data: annual reports to politicians and in public concerning quality indicators and peer reviews

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
Following the decision to roll out the A-IQI project nationwide, the first step was to inform all parties concerned. The Ministry of Health organized information sessions in all of the federal provinces to answer questions about the quality indicators and the peer-review process. In developing the A-IQI project strategy, the following three fundamental cornerstones were addressed: • Control, • Operational management, and • Scientific support of the project. First of all, an office was established within the Ministry of Health with competence for the operational management of the project. One of the first tasks was to develop a technical evaluation tool for use throughout Austria. The A-IQI steering group was established for controlling the project, taking basic decisions, and driving further developments. During the design phase it was further decided to involve the ten funds (9 at the provincial level, and 1 for private hospitals) responsible for the interdisciplinary tasks of planning, management and financing of the health care system, including quality agendas. The A-IQI steering group represents the central body having the following terms of reference: • The selection of annual priorities concerning which themes should be addressed by the peer-review process • The selection of the individual peer-review processes (hospitals) • The further development and adaptation of the quality indicators as well as the peer review process • Forwarding of recommendations derived from the analyses to the public health authorities concerned • Monitoring the implementation of the measures agreed in the peer-review process • Monitoring of the quality indicator results following the peer-review processes in relation to their development, and • Preparation of an annual project report As a further step, the Main Association of Austrian Social Security Institutions (Hauptverband der österreichischen Sozialversicherungsträger) was nominated to join the steering group. The decision was also made to bring scientific societies on board to promote the quality of the performance measurement system as well as to increase acceptance of the entire A-IQI system. Thus, a Scientific Advisory Board was formed for the development and adaptation of the indicators. In addition to the key decision makers - namely the Ministry of Health, the Provincial Health Funds, and the Main Association of Austrian Social Security Institutions - members were also included from the hospital owners and the hospitals, as well as the scientific accredited organizations of the Austrian Medical Association. The Ministry of Health’s project office directs the Steering Group and the Scientific Advisory Board and also assumes many operational tasks in the system. In order to define the rights and obligations of each player, an organization manual was created which defines the legal basis, the organization and the responsibilities of each party. Due to the fact that these activities involve highly sensitive data, a document was created which regulates the flow of data and the handling of the data. A further step was the establishment of the peer review process. For this purpose, and with support from Germany (quality medicine initiative) and Lower Austria, the organization and the procedures were established, and the first peer-training session was organised in order to start building a peer-pool. Thereafter, further pilot peer-review processes were held to review the specified procedures and, if necessary, to amend them appropriately.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
In addition to the Ministry of Health, the following stakeholders involved included senior physicians, peers, medical directorates, hospital owners, provincial health funds, private hospital financing funds, accredited scientific organizations of the Austrian Medical Association, and the Main Association of Austrian Social Security Institutions.
 6. How was the strategy implemented and what resources were mobilized?
Funding for the A-IQI project has been provided by the Federal Health Agency (Bundesgesundheitsagentur). In 2011 when the project was commenced the required budget totalled some EURO 17,000. The subsequent annual costs can be given as follows: 2012: EURO 44,000 2013: EURO 20,000 2014: EURO 19,000 The travel expenses of the peers involved in the peer-review process of an approximate annual total of EURO 9,000 must be added on top of these costs and are paid for by the Federal Health Agency. A-IQI is a complex, far-reaching and innovative project, but one of the most cost-effective of all. The Ministry of Health provides the equivalent of 1 full-time person for this project.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
Publication of Austria-wide quality data: the first A-IQI report was published in autumn 2013. This report published the nationwide results concerning the set of indicators. The aim is to provide step-by-step transparency of quality data for the Austrian population. Improvement of indicator results: another very important output that shows that A-IQI is reaching the patients is the improvement of the performance results following conduction of the peer-review process. For example, the indicator "preoperative length of stay for hip fractures ", shows a clearly positive trend following the peer-review process meaning that patients are operated more quickly. For the indicators of heart attack, heart failure, stroke and pneumonia improvements could also already be confirmed in Germany. A performance-based quality measurement based on indicators together with a weak-point analysis based on the peer-review process together manage to achieve significant improvements in the results. As a prerequisite, of course, the identified system weaknesses need to be improved. Clinical Guideline: The 16 peer review processes concerning preoperative length of stay for hip fractures showed uncertainties in the use of anticoagulant drugs in the day-to-day treatment. The relevant scientific expert groups took this issue up in the first follow-up meeting in autumn 2013 and jointly developed a decision aid for this complex subject. This resulted in a Clinical Guideline "treatment of near the hip fractures in patients previously orally treated with anticoagulant medications" being written in August 2014 which provides support for the treatment process and the associated recurrent complex medical issues. The provision of this Clinical Guideline via an "App" for smartphones makes the desired information quickly and easily retrievable at any time. Adaptation of the routine hospital data according to the requirements of the quality measurement: on the basis of proposals from the Scientific Advisory Board some adaptations in the Austrian hospital billing system (Austrian DRG) have already been made. For example, from January 2015 each time a hip operation requires rework the respective reason for the rework (e.g. infection, loosening etc.) must be diagnosed and stated. For example the diagnosis “I64 - stroke unspecified" (i.e. not specified whether ischemia or haemorrhage) can no longer be billed in Austria in order to generate more meaningful indicators concerning strokes. That means that A-IQI also leads to the continuous further development of the routine hospital data in accordance with the requirements of the quality performance measurements.

 8. What were the most successful outputs and why was the initiative effective?
To track the results and activities in the project, two different monitoring systems have been implemented: namely the quality indicators results monitoring and the monitoring of the resulting measures. Are the quality indicator results improving? The monitoring of performance measurement results is concerned with the quality indicators results. If a hospital is selected for a peer-review process based on conspicuities being noticed in the annual priorities, it will at the same time be selected for performance monitoring. In the process the development of the result of the respective quality indicator is then monitored in accordance with A-IQI office procedures. What are the hospitals / hospital owners / federal provinces doing with the improvement suggestions coming from the peer-review process? The monitoring of the resulting measures deals exactly with this topic. The procedure defines the improvement measures and related deadlines for implementation which are then documented in writing in a report. After this deadline period has passed, the involved hospital is prompted by its Provincial Health Fund to provide feed-back information concerning the degree of implementation of the improvement measure via the use of a standardized monitoring form. The monitoring form contains the general information about the peer-review process, such as the Tracer (indicator, theme) or the peer-review team, as well as all agreed improvement measures. Feed-back is required for each improvement measure concerning both the details of the measure and the degree of its implementation, such as: • Open (reasons why still open, the way forward, the time horizon) • Work in Process (status of Implementation, the way forward, the time horizon) • Only partially implemented (for what reasons has the decision not been implemented in full, which parts have been implemented and which are not) • Implemented (how was the practical implementation done) • Not implemented (what were the reasons for the decision to not implement the measure) If no improvement of the quality indicators occurs following a peer-review process (results-monitoring), the first step will be to check the degree of implementation within the resulting measures monitoring system, and as a second step a re-peer-review process can be initiated. The results of the resulting monitoring of measures are to be found in the annual A-IQI report.

 9. What were the main obstacles encountered and how were they overcome?
The data utilized within the A-IQI project are very sensitive. At the beginning a great deal of concern was expressed concerning possible data misuse. Due to this situation, each province only received its own results. When Austria-wide results were discussed in order to determine the peer-review process no actual data were delivered. Furthermore, the publication of data outside of the A-IQI project, for example for promotional purposes, was strictly prohibited. Overall there were small but essential measures that established trust between the players. As in many large-scale projects the information flow is the greatest challenge. A major problem was to ensure that the essential information about the project was made available to the project basis, the senior physicians. This was attempted in the early stages of the project with information sessions. Since especially in the peer-review process, a lack of information regarding the preparation existed, checklists were created and all documents made freely accessible. It was not unusual to find that a senior physician did not know the quality indicator results of "his" department" until he was informed that a peer-review process would take place. The responsible bodies had simply not forwarded this information. It is however only possible to work locally to improve the quality if you know your own results. This situation was not very good for the acceptance of the system. Subsequently, several provincial health funds declared themselves ready to pass the evaluation tool to hospitals so that they themselves could calculate the quality indicators at regular intervals. Two provincial health funds have decided to have the results relayed directly from the Federal Ministry of Health to the medical directorates and senior physicians. The situation led to the fact that the data flow and the responsibilities for disclosure are defined in the A-IQI organization manual.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
Patients: The main benefit of the project is that patients will demonstrably profit from it. For example, near hip fracture patients will be operated more quickly. For example, a hospital received a peer-review process result that 20.36% of patients had an elevated preoperative length of stay. The measures monitoring showed that 100% of the agreed improvement measures from the peer-review process had been implemented at the hospital. As a result, monitoring of the quality indicators results concerning this parameter now give a value of only 9.52% (previously 20.36%) and are thus within the target range. Total health care system: from a systemic perspective the health system also benefits as a whole. The German Medical Association accompanied the peer-review process in Germany and noted that there was a contribution to the promotion of interdisciplinary cooperation and communication, the growing together of the organization, and self-determined quality development by the medical profession. Furthermore it contributed to individual learning readiness and competence development, the development of an open culture concerning errors, to effective transfer of knowledge and applicability in everyday life, shared responsibility in the organization (professional and across the hierarchy), and to establishing a learning organization. Pragmatic system: A further benefit is that a system now exists that is capable in a non-bureaucratic and cost efficient way to identify weaknesses. However, it manages more than this and also highlights the necessary improvements. Physicians: For the doctors the main benefit is that for the first time they can directly compare their own quality data with nationwide quality data. Management levels: The management levels also receive nearly real-time nationally compared quality data for the first time. (Cases from 2013 and 2014 were already processed). The fact that all decision makers were involved enables that the topics can be quickly processed together. Example: In September 2013, a nationwide requirement was identified concerning how to deal with clotting drugs for patients with near hip fractures. Also in September the relevant scientific expert group were commissioned by the Federal Ministry to prepare a Clinical Guideline on this topic. In October, the scientific expert group met for the first time. In February 2014, the first draft was presented, which was forwarded to the Health Funds with a request for comments. All of these responses were received back in March from the professional associations, checked by the latter and, where appropriate, incorporated. In May, the "final" Clinical Guideline was presented and then published on the website of the Ministry of Health. So it took less than a year from the result to the nationwide implementation.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
The international nature of the system IQI (Inpatient Quality Indicators) already shows that the system is transferable. The prerequisite is a performance and diagnostics based billing system in the hospitals. The practical implementation can function in different ways: In Austria the system utilizing quality indicators and a peer-review process is mandatory for all hospitals. In Germany it is based on a voluntary basis and is organized via a non-profit organization consisting of an association of various hospital owners. In Switzerland, the system only utilizes the indicators which are measured and published, and the peer-review method is not part of the application. The peer-review process can also be applied to other institutions and countries. The analysis criteria used in the process are internationally recognized. In Austria a performance measurement-based peer-review process is to be established analogously to A-IQI for the outpatient area. This project is currently in the design phase, but shows that a system such as A-IQI can be used in different ways - stationary, outpatient, and across sectors. A-IQI is surely a promising and sustainable project. In health care - as in other industries - communication and cooperation are among the most important issues for the future development and exactly that is so in A-IQI. Ones own work is scrutinized by colleagues and weaknesses discussed among equals. Hence jointly determined improvement measures were established which will benefit future patients. In this process all learn from each other and everyone is a winner!

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
The information of all stakeholders and the direct involvement of the medical profession in the early stages is essential. The system should be completely transparent. The acceptance of the performance measurement system benefited greatly from direct cooperation with scientific societies. It is also recommended to make the technical evaluation tool directly availability to the hospitals, so as to prevent the problem that individual managers do not know their "own" data and results. The advantage of central control and the nationwide roll-out is to be able to implement nationwide improvement measures. The peer review process is a tool for quality assurance and quality development, which finds wide acceptance in the medical profession. The most important requirement for the use of the peer-review process is the attitude that improvements are possible. There are already evaluated understandings of how it can be successfully established in a company, and experience of how it does not work (No-Gos). The creation of an atmosphere of trust and the competence of the peer review teams are of central importance. The peer-review process has the potential to identify errors and possible improvements in non-bureaucratic and collegially ways. It also shows that optimization potentials can be found on a large scale in more than 60% of the cases. Central themes are: • Interdisciplinary, group-wide cooperation • Medical documentation • Rigorous tracking of work diagnoses • Organization of the treatment process • Compliance with existing guidelines and standards There is still much to do! Only when the collegial leadership knows and interprets quality results with the same motivation as financial results, and can together with the physicians develop improvements; only then has quality management really arrived in the hospitals.

Contact Information

Institution Name:   Bundesministerium für Gesundheit (Federal Ministry of Health)
Institution Type:   Government Department  
Contact Person:   Silvia Türk
Title:   Dr.  
Telephone/ Fax:   +431711004106
Institution's / Project's Website:  
Address:   Radetzkystraße 2
Postal Code:   1030
City:   Vienna

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