HealthManagement, Volume 14, Issue 5, 2012

Putting the Cross-Border Healthcare Directive in Hospital Practice: How to Manage Quality

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Mr. Heinz Kölking, President of EAHM welcomed and thanked the speakers from across Europe and introduced the topic of the seminar: The European Directive on Cross-Border Healthcare. The deadline for implementation is less than a year away

(25 October 2013) and it has been a key focus for the EAHM over the past year. He cast delegates’ minds back to last year’s seminar when the Directive was also the main topic for discussion. We discussed the possible consequences of the Directive and our expectations and it was clear that there would be a direct impact on hospitals. It is for this reason that this second seminar was organised and the aim of the day is to set out concrete goals for hospital managers. Before handing over to the first presentation of the day Mr. Kölking stressed that the buzz words of the seminar will be quality management, setting standards and comparability.


The Results of the Questionnaire on Quality and Patient Information in Hospitals

First to present was Marc Hastert, President of the EAHM European Affairs Subcommittee and Secretary General of the Luxembourg Hospital Federation. He presented the results of our national survey on quality and patient information in hospitals.

EAHM formulated the survey for its members to complete during the transposition process of the Directive. Believing that actors involved at the hospital  management level should express their vision on the quality and patient information topics and should comment on the actions to be taken. Particular emphasis should be given to areas of action on which hospital managers have a decisive influence. The quality management and quality indicators and associated standards are undeniably part of this.

The questionnaire is a good way of clarifying the role of hospital managers and illustrating the importance of pursuing a common strategy.


Hastert presented the main results of the questionnaire and also stressed that it is still open and urged members to complete the survey and pass it on to relevant colleagues. This is just a first step and will help indicate what our next step as an association should be.


Responses from the national association tell us that most countries have national legislation to deal with information. Actions and decisions are taken on national/ regional and in some countries municipal level. In general, hospitals in Europe have a legal obligation to provide information to patients with the government or other bodies playing a relevant role in organising this information (standards, guidelines, accessibility, patient rights, complaints procedures etc). However, this information is often not accessible to the public.


Moving on to answers provided by hospital managers, Hastert explained that we discovered some very interesting information regarding quality. Most hospitals include quality in their mission statement and for many, quality is defined on an internal level. The survey confirms the role of hospital managers in delivering quality: 93,22% of hospital managers say they are involved in organisational quality and 77,97% of hospital managers say they are involved in clinical quality. When asked if quality is part of the evaluation of their work 50.85% of the hospital managers agreed, with quality control as part of audits on patient satisfaction, clinical quality, good practices and risk management. However, the survey also showed that 32.20% of the hospital managers believe quality of care is not part of the evaluation of their work.


Most of the organisations (90.70%) got an external evaluation and are accredited or certified. The accreditation or certification has generally been done on a voluntary basis, otherwise due to legal obligationsMoving on to quality reporting, the survey shows that 61.90% of hospital managers answered that reporting of quality of care given by hospitals is a legal obligation and the reporting is done by the hospital. 57.69% of reporting is benchmarked, mostly by the hospital federation (40%) or by third parties (33.33) or the authorities (20%). Although 57.62% of the hospital managers answered that the annual report of the hospital includes a section on quality in a structured way but 10.17% answered that it doesn’t and 32.20% didn’t answer.


On a more positive note many countries have success stories to share. Belgium have been shortening waiting lists, Germany report better procedures and good results (awards) as do Luxembourg and Portugal has seen claim reduction and increased satisfaction.

Concluding the results from the questionnaire, Hastert explained that the main barriers in enabling quality improvements can be determined as funding, time and obtained comparability.

Implementing the Cross-Border Healthcare Directive in a NHS Country

Alexandre Lourenço, Executive Board Member at Central Administration of the Health System introduced delegates to the National Health Service (NHS) in Portugal and how they are progressing with the implementation of the Directive. Like many countries in the EU, the economic outlook is difficult with an ageing population forcing increased spending teamed with increased unemployment, uncertainty and financial shortfall.


Lourenço explained that Portugal spends less than other countries and the healthcare system has recently been restructured resulting in dramatic changes. Hospital reform must be sharp to reduce spending while ensuring the provision of quality care. Portugal uses several accreditation programmes including Joint Commission International and CHKS. Hospitals have quality and performance indicators to adhere to. Since September 2011, monthly information is published online on hospital performance for each NHS hospital. Indicators include economic and financial, capacity utilisation, human resources / productivity, inpatient care, surgery, outpatient care and emergency department.

Lourenço concluded that Portugal sees opportunities in the Directive for economic growth and also a health internationalisation programme.

Using Quality to Drive Transformation

Richard Dooley, President of the Health Management Institute in Ireland gave an interesting presentation on quality improvement in Ireland in line with the reform of the Health care system. There are several bodies and systems for quality assurance.

Ireland has a Health Information and Quality Authority (NIQA), which was established as a statutory authority in 2008. The main responsibilities of HIQA include driving improvements in the quality and safety of healthcare on behalf of patients, developing standards across services, monitoring and reporting on compliance with standards and health technology assessments. At hospital level this equates to accreditation inspections for services e.g. breast cancer services against prescribed performance criteria, announced/unannounced visits to confirm appropriate governance (including clinical) over service areas e.g. infection control, emergency departments.


The government launched the National Standards for Safer Better Healthcare in June 2012 and HIQA has the authority to monitor compliance. These national standards are for health service users to understand what high quality and safe healthcare should be; what users should expect from a well-run service and for service users to clearly voice their expectations. Compliance with these standards will lead to all hospitals being licensed on a statutory basis by 2015. There is also a Quality and Clinical Care Directorate which oversees the implementation of national standards, clinical governance, system audits and clinical audits.


The Quality of Hospital Services in Luxembourg

Sylvain Vitali from the Hospital Federation of Luxembourg believes that hospital managers are key stakeholders in defining national targets and actors for the local deployment. Preparations for the transposition of the Directive in Luxembourg include the formulation of a new law for the rights and obligations of patients and the development of esanté a national agency to share electronic health records throughout the country. Quality is defined and assessed by a national committee for the quality of hospital care (CoNaQual-PH) and an evaluation committee. Hospital managers are active and responsible for the quality of services within their hospitals. There is a system of quality and performance indicators and benchmarking on a national level.

To conclude Vitali explained that the implementation of the Directive has forced Luxembourg to increase transparency, include transparency of costs and has promoted inter-hospital collaboration for both patient care and logistics. An informed patient will receive high quality and efficient healthcare.


Hospital Performance Indicators in Europe and in Belgium

Dr. Catherine Lucet, an independent consultant in public health in Belgium gave an informative overview of hospital performance indicators in Europe and Belgium.

Putting the Belgian system in context, Lucet explained that the Ministry of Health has put in place quality contracts but these must evolve and show results. Multi-dimensional feedback is not widely used and there is a need for the standardisation of performance indicators. She also stressed that Belgium could better use the wide base of data already available.

Lucet cited numerous international projects on quality and performance indicators including the European PATH Programme with Great Britain, France, The Netherlands, Germany, Luxembourg, Denmark, Sweden and Italy. Her critique of the current Belgian situation centred around the lack of multidimensional projects. There are many different initiatives but these are fragmented. Interviews with representatives in hospitals have shown that there is lack of ties between vision, objectives and the performance indicators. Moreover, hospitals are not prepared enough to use indicators outside of financial activity. So before implementing a series of indicators clear priorities must be set and indicators developed in line with these priorities and goals. Goals should include increased accountability as well as efficiency. Lucet also believes these indicators should be based on actual experiences and healthcare professionals should be involved in their development. They should be tested before widespread implementation and regularly monitored.


Quality Management with the Involvement of the Medical Service Provision

The last presentation came from our German colleague Dr. Matthias Schrappe. Schrappe gave the physician perspective on quality management. He questioned the data we currently have access to: Are we asking the right questions? Are we collecting the right data? He also stressed the importance of using the data to control and improve our healthcare services, especially as increasing life expectancy is putting increasing pressure on quality and safety.


There is currently a lot of data available in Germany, much of which is available to view online but Schrappe stresses that this data is only useful to those who understand the questions. Data is available for issues such as infection and patient safety.

DRGs also include a quality incentive as does the use of checklists (e.g. WHO safe surgery checklist).


Schrappe believes patients also have a role to play. They should be more active, asking questions. He believes this is a problem for the leadership and is something that needs to be addressed.


Roundtable Discussion

After the series of engaging presentations Jacques Scheres, Maastricht University Medical Centre, chaired a vibrant roundtable discussion of the issues raised during the presentations and the Directive in general. Before the discussion got underway Scheres introduced another panel member, Nicolas Decker from the European Empowerment for Customised Solutions (EPECS) to focus on the patient perspective.

Decker highlighted the importance of quality assurance, reminding the audience that the Lisbon Treaty explicitly states that a high level of healthcare should be guaranteed. The Directive on cross border healthcare is a consequence of this treaty. Decker believes it is very important that patients can cross borders. They should know where they will be treated and have indicators to decide by. These indicators need to be the same or comparable and this information must be transparent. For Decker, this is the crucial point; this is not happening in several countries. Results and figures must be published or more and more legal action will be taken.

The roundtable was a lively discussion between panel members and delegates. The key points made included the belief that indicators should show sustainability of health systems; that patients must be treated with kindness, consideration and respect and should have access to all relevant information; that politicians should lead the drive for quality and that the patient is paramount.



Secretary General, Willy Heuschen brought the seminar to a close summarising the main ideas of the day. He highlighted that the first results of the questionnaire surprisingly show that quality is not always a priority and is sometimes missing from hospital mission statements.

The Directive is an opportunity to increase transparency. We call on all Member States, governments and the European Commission to ensure it does not become even more complex. Heuschen continued that although it was not the purpose of the Directive, what is missing is a common language and minimal standards for quality. The EAHM should take on this responsibility. We need a common framework for quality in Europe. EAHM should work together with other professional associations, with patients, governments and the European Commission to develop this European framework for quality. In order to do this, information must come from the field- from hospitals. It should be a bottom-up process so that we can be assured it will work.


The Secretary General also highlighted that our work must continue after the implementation of the Directive. It is written in the Directive that it should be evaluated every three years and we must play a role in this too. He concluded by thanking presenters, sponsors and attendees and reminding everyone that the questionnaire is still open. The information gathered is of vital importance to the work of the EAHM.

Mr. Heinz Kölking, President of EAHM welcomed and thanked the speakers from across Europe and introduced the topic of the seminar: The European Directi

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