Performance Measurement Denmark National Board of Health Niels Hermann

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Vincent Hodges
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1 Performance Measurement Denmark 2011 National Board of Health Niels Hermann Seminar Québec City March

2 What I will not talk about / and will talk about I will not talk about: How measuring leads to improvement through Steady professionally driven improvement Structural change Top-down intervention I will talk about the Danish perspectives on: Current data / register situation Challenges of bringing data into use and how we seek to combine it with organisational development Thoughts on how to move on

capita Funded by taxes Private GPs: Gatekeepers Service for fee (tax

3 Denmark and Danish Health Care Population 5.4 million HC expenditures: 9 % of GNP 3,000 US $ pr. capita Funded by taxes Private GPs: Gatekeepers Service for fee (tax paid) Hospitals: 80 hospitals Almost all public (97 %) Owned & run by 5 regions Long term & home care: Run by 98 municipalities

4 Governance structure National Regional Local Constitutional monarchy Parliament (1 chamber) Minority government (always!) Minister of Health and Interior: 5 Regions - elected regional councils (no taxation rights): Run Hospitals Contracts with GPs Contracts with specialty serv. Contracts with private hospitals 98 Municipalities Elected Municipality Councils: Home Care/Nursing Homes Long term care/rehabilitation Preventive medicine

5 National Health Care - Government level Ministry of Health and Interior Finance Legislation a) National Board of Health Advisory central and local government Regulatory health care professionals Supervisory monitoring health and system performance b) National Health IT [Established January 2011] Setting standards for IT c) Danish Medicines Agency Approval and supervising pharmaceutical products d) State Serum Institute Infectious disease surveillance -

6 National Health Care Information - players National Board of Health Classification, terminology, coding standards National Patient Register Death -, Cancer -, Maternity -, etc. registers DRG (based on NPR and Activity Registers) GP payment registers (no clinical information) Authorization of Clinical Quality Database National Health IT Settings IT standards Danish Medicines Agency Prescription Register State Serum Institute Registers on infectious disease surveillance

7 National Health Care Information - players 5 Regions Patient Administrative Systems (feeding NPR) Activity Registers (Pathology, Laboratory, X-Ray etc.) National disease specific Clinical Quality Databases (ca. 46) National Indicator Project (10 Clinical Quality Databases ) GP Clinical Q Databases (diabetes, COLD common capture module) National Patient Satisfaction Surveys (yearly) Leading Clinicians and Medical Scientific Societies National disease specific Clinical Quality Databases (ca. 56) Danish Institute on Quality and Accreditation Under development

8 Information backbone - Personal ID# Central Person Register ties registers together All citizens and residents have a unique personal identifying number (CPR number) Use for (almost all) relations between individuals and government/public services/banks etc. Key to all individual based documentation Use of and access to data registers is regulated by law Valid cross-references from different data sources Control digit + Sex (even # = female) Day Month Year 3 digit running #

9 National Patient Registry Data reported from hospitals Patient Administrative Systems since 1977 Patient contacts (episodes) in all hospitals (public & private) Discharges from hospitals (somatic and mental health) Updated continuously (daily), but fixed every 10 th Data model Surgical, diagnostic and care procedures (Nordic code) Referral and discharge diagnosis (ICD-10 code) Administrative codes (admission, referral, discharge, etc) Each contact is in principal an isolated incidence (No Pathways) Personal ID#: Contact 1 Contact 2 Contact 3 Contact 4

10 NPR - Treatment Specific Basic Indicators Activities (operations, discharges, ambulatory care fraction) Length of Stay (pre and post operatively) Wait time (till pre examination, treatment) Reoperation (30 days, 90 days) Infection (post operative) Readmission (30 days after discharge, after operation) Mortality (30 days after admission, operation, discharge)

11 Use of Patient Registry patient volume Ovarian cancer stage III operations Operations per year different departments 312 operations per year 48 % in departments < 20/y Ottesen B, 2005

12 National Patient Register - Limitations Data quality - validity - Coding is doctors responsibility BUT put it in the hands of their secretary => not sufficient precision for research and quality work Strict following of coding terminology varies between specialities e.g. Gynaecology is high level Each contact is in principal an isolated incidence No Pathways can be followed by means of the register No detailed clinical information unless new codes are established and broadly brought into use

13 Clinical Quality Databases Danish Breast Cancer Cooperative Group (Scientific Society of Surgeons) established in 1976 in cooperation with radiologists, oncologists and pathologists ( developed and implemented national clinical guidelines clinical database the concept - methods reporting and implementing change excellent biostatics and epidemiology clinical research Funded by the 15 counties (now 5 regions) by a fee per diagnosed patient Clinical Quality Databases followed in many other disease areas Driven alone by dedicated clinicians in their free time CQD Now seen as a goldmine thats needs to be reorganised

14 Danish Clinical Quality Databases p1/3 Toofewortoomany? Acute GI Surgery Database Anaesthesiology Database Benign Prostatic Hyperplasia Treatment Database Bladder Cancer Registry Breast Cancer Cooperative Group Breast Cancer Screening Database Cervical Cancer Screening Database Child and Adolescence Diabetes Database Child and Adolescence Psychiatry Database Child Cancer Registry COLD Database Colorectal Cancer Database Contact Allergy Database Dermatology Biological Treatment Database Diabetes Database Diabetic Retino Maculopathy Screening Database Early Pregnancy and Abortion Database Gall Database Geriatrics Database

15 Danish Clinical Quality Databases p2/3 Toofewortoomany? GP Diabetes Database Gynaecology Cancer Database Haematology Database Head and Neck Cancer Database Head Trauma Database Heart Insufficiency Database Heart Registry Hepatitis B - C Database Hernia Database Hip Fracture Database Hysterectomy Database Hysteroscopy Database Integrated Cancer Pathways Database Intensive Care Database Intrauterine Malformation Screening Database Lung Cancer Registry Multiple Sclerosis Treatment Registry Nephrology Database

16 Danish Clinical Quality Databases p3/3 Toofewortoomany? Neuro Oncology Registry Obesity Surgery Registry Oesophagus - Cardia - Gastro Cancer Database Organ Donation Database Orthopaedic Surgery Database Palliative Treatment Database Pancreatic Cancer Database Rear Diseases Database Rheumatology Database Sarcoma Database Schizophrenia Database Sleep Apnoea Database Stroke Database Tooth Malformation Database Transfusions Database Uro Gynaecology Database Uro Oncology Database Varicose Vein Surgery Database

17 Clinical Quality Databases Too Few or Too Many? History / Prioritising Clinical ownership and dedication Steering Groups running each database Databases at different stages of development Funding if Basic Demands are met Reporting and Acting Obligations annual quarter Supportive functions 3 Competence Centers

18 Clinical Quality Databases Health Act - Regulation - authorization 2006 Government Notice introduced obligation to apply for approval at National Board of Health Approval for 3 years is based on relevance of indicators for the disease issuing of annual and quarter reports mandatory to report data for all departments and practising clinicians dealing with the disease meeting organisational demands Approved databases are free of obtaining informed consent allowed to apply for funding and support from a Competence Center

19 3 Competence Centres for Clinical Quality Databases + National Indicator Project Centers are Supporting Building and Running the CQD They have Competencies iin Biostatistics Epidemiology Data management Support with Selecting variables Defining indicators Analysis Reporting annually quarterly Recommending improvement actions Supporting different kind of auditing Development of common Analysis Portal for the databases

epidemiologists Clinical activities and data registration Weekly / Monthly / Quarterly Annually feedback to all clinical departments Action

20 Important Phases in Improvement from Clinical Quality Databases - Computerized data reporting by responsible clinicians at clinical departments Data transmission via Internet Clinical Q Database / NIP-Registry/ National Patient Registry Data analyses by clinical epidemiologists Clinical activities and data registration Weekly / Monthly / Quarterly Annually feedback to all clinical departments Action Plan: Quality improvement Feedback of risk adjusted data once a year Public release Regional clinical National clinical audit From Danish National Indicator Project

21 Disease areas monitored and evaluated in The Danish National Indicator Project From 2000: Acute stroke Hip fracture Acute GI surgery: - Acute Upper Gastrointestinal Bleeding & - Acute Upper Gastrointestinal Perforation Lung Cancer Heart failure Schizophrenia Diabetes COPD From 2010: Depression Delivery

22 From Danish National Indicator Project The total picture 2009/ Mean patient age Proportion of recommended care provided to patients Proportion of patients dying within 30 days Mean patient age Proportion of recommended care provided to patients Proportion of patients dying within 30 days Stroke 72, (0.63; 0.64) 0.12 (0.11;0.12) 71, (0.77; 0.78) 0.11 (0.11; 0.12) Bleeding ulcer 72, (0.78; 0.80) 0.11 (0.09; 0.14) 72, (0.83; 0.85) 0.11 (0.09; 0.12) Hip fracture 82, (0.55;0.57) 0.10 (0.10; 0.11) 82, (0.88; 0.88) 0.10 (0.10; 0.11) Heart failure 72, (0.52; 0.55) 0.21 (0.19; 0.23)* 70, (0.68; 0.69) 0.17 (0.16; 0.18)* Schizophrenia 42, (0.80; 0.81) - 42, (0.83; 0.84) - *Proportion dying within 365 days.

23 Clinical Quality Databases for Management Information Region Midt (Region of Middle Jutland) Quarterly Generates data on: NIP quality, patient satisfaction service, economy, activity Patient Administrative System Platform of presentation:inform Region Nord (Region of North) Region Sjælland (Region of Zealand) Region Hovedstaden Region of the Capital Region Syd (Region of Southern Denmark) Example of presentation for Top Management and Politicians

25 Clinical Quality Databases in 2012 Initiatives(based on no new money!) Preparing for the May - June budget 2012 negotiations between Government and Regions Demands on: Sharpening of organizational set up Common IT standards for exchange of data Common standards for data, handling and presentation Combining and integrating use of registers and no double registration Use of results

26 National Board of Health Thank you

Cancer Outcomes and Services Dataset. What is COSD? Skin Cancers Workshop October 2012

Cancer Outcomes and Services Dataset What is COSD? Skin Cancers Workshop October 2012 17 years ago......cancer registration and careful monitoring of treatment and outcomes are essential... Calman-Hine