Health and Hospital Care Forward Within Europe
On the occasion of the French Presidency of the European Union, EAHM calls for moving health and hospital care forward in Europe:
Towards evaluation of quality and safety Hospitals in Europe face challenges like increasing patient mobility and the free movement of trained staff, crossborder purchasing of healthcare services triggering increased competition, the protection of public safety and patients’ rights....
Despite the current efforts, services offered around Europe vary widely in terms of quality and safety, which leaves a lot of room for further improvement. Further libe ralisation of the healthcare market may increase the variability in quality of offered services.
There exist many ways of promoting high quality and safety practices targeting the many actors active and responsible in healthcare.
In order to follow up on the state of quality care in Europe, it is important to be able to measure it in a reliable way. This demands a consistent set of standards leaving a small variation of interpretation.
Many standards exist around Europe, making it more difficult to compare results between the different initiatives. Furthermore, most sets of standards pay little attention to outcomes or the broader context of healthcare delivery (e.g. primary care).
Existing information sources on quality and safety should be reviewed and compared. They should be tested by its application in the field. This exercise should include local, national and international programs like ISQua. It should bring the actual systems from living apart to a state of mutual understanding or even comparability, which may eventually lead to a growing together of existing systems.
The existing richness of standards becoming comparable will also help to avoid the use of minimum standards leaving little motivation for improvement.
Special attention need also be given to the use of the standards in the assessment of health services. Although external assessments are more likely to satisfy the improvement of quality and safety, internal assessment should be promoted as a first step towards external assessment.
Comparable to the quality and safety standards, there exist a variety of external evaluation mechanisms. A coherence of evaluation mechanisms may not be feasible in the short term, it is nevertheless important to make them more transparent.
The current status leaves a lot of potential for European action in this field. In order to support patient and professional mobility within the European Union in terms of quality and safety, it is crucial to monitor the evolutions in the different member states in a consistent way.
Ensuring common core standards as well as coherent evaluation mechanisms will also motivate hospitals to focus more on quality and safety as it will lower the administrat ive, financial and practical barriers to introduce them in their daily care and mana gement process.
Towards a Governed and Managed Healthcare
Since patient empowerment, budgetary constraints and increased competition set the tone at the European hospital scene, the issue of hospital governance is subject to increasing public interest.
In many European countries, local public and private hospital boards and managers have been urged to be more effective and efficient in governing the hospital’s performance. Therefore they are currently challenged to find the right “fit” between the changing context of healthcare and the key configurations of the governing structures and processes within their hospitals.
Hospital governance deserves special attention as it differs from corporate governance in several aspects. A majority of
hospitals are public or non-profit private institutions and have no shareholders as in private companies. A large diversity of stakeholders (tax payers, patients, G.P.’s, government authorities, health insurers,..) can be identified as de facto owners, although not always represented in a body of the hospital.
As a consequence of this, the principle of profit maximisation (as a clear-cut touchstone for evaluating decisions in private companies) is missing. Also the outcome of hospitals being complex organizations is less transparent and more difficult to assess.
Hospital governance refers to the combination of checks and balances that determine how decisions are made within the top structures of hospitals. It deals with the configuration (bodies and its composition...) and functioning of the governing bodies of hospitals (control function, strategic development, quality assurance…).
Several evolutions are taking place in the European countries that influence the go - vernance of hospitals (clinical pathways, health service integration, DRG financing, patient empowerment…).
Although the European Union has limited competence in the field of healthcare, it has already had an indirect impact on organisation of the hospital care, for example the EU working time directory pushed France to review the organisation and (internal) functioning of French healthcare and especially hospitals.
Reviewing hospital governance around Europe indicates that it is important to find the right “fit” between the changing context of healthcare and the key configurations of the governing structures and processes within hospitals.
On the one hand, hospitals should remain more or less autonomous business entities and therefore require a well-adjusted, efficient and effective internal framework.
But at the same time, they need to be deeply embedded in, and influenced by, the healthcare system of which they form part. The resulting duality of ‘object of entrepreneurial autonomy’ and ‘instrument of public health policy’ is crucial for hospitals in the delivery of care to the citizens.
It is important for the European Union to create a framework (e.g. through its healthcare service directive) which embeds this duality. Becoming an integrated and accountable actor in the healthcare system is a major challenge for the hospital in the future and the governance of the hospital has a huge impact on this.
It does not depend only on the actors within the governance configurations, the structure and the composition of the governing bodies and the competencies required (the who-question) or the roles and the tasks of the different actors and their mutual adjustment (the what-question).
It depends also on the non-structural checks and balances as well as the techniques used: internal control procedures,
reporting systems, risk management… (the how-question). The European Union can stimulate its member states to share experiences or can help finding the appropriate techniques given the different governance configurations.
Restricted budgets are pushing governments and health authorities to identify new re sources by attracting private providers or insurances. While this potential is generally welcome, some reflection is needed. Mr. Heuschen, our Secretary Ge neral, is expanding on the issue on p.16. The European Affairs subcommittee is following up on this evolution and will report its findings in the near future.
The full text of the paper presented to the French Presidency can be consulted on EAHM’s website: www.eahm.eu.org