| 4. In which ways is the initiative creative and innovative?
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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.
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| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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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.
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| 6. How was the strategy implemented and what resources were mobilized?
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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.
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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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.
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| 8. What were the most successful outputs and why was the initiative effective?
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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.
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| 9. What were the main obstacles encountered and how were they overcome?
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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.
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