‘I’d devote more energy to having genuine conservations with our patients,’ replied cardiologist Gert-Jan Milhous* of Rivas Zorggroep when asked, in the autumn of 2013, what he would do differently for patients if the healthcare system didn’t force him to do things as he did them now. In Milhous’s view, the current system is inconvenient because it rewards volume. It was based on this observation that the ‘Quality as Remedy’ programme, in which the Beatrix Hospital (part of Rivas Rivas Zorggroep), which provides long-term care, rehabilitation, and in-home care, General Practioners (HenZ), and health insurer VGZ are working together to ensure the quality and affordability of health care, both now and in the future, was kicked off in 2014. The premise for this programme is ‘the right care in the right place at the right time’. That means that the patient not only receives care more quickly and closer to home, but that care is often less expensive. The core value in this sense is: hospital care if that is what’s best for the patient, but in-home care or care from a general practitioner if possible. ‘Supported by Strategy&, we at Rivas Zorggroep and HenZ have worked out substantive plans to make more time for the patient without losing income within the current care system. The strength of this approach is that change will be driven by the content of the care and the quality of that care for the patient, facilitated by a financially safe environment. ‘It’s quite special to see that this work process, which we started on a small scale at our hospital, can be applied more broadly in the region, since the issue of care is ultimately larger than a single institution’, says Martijn Canoy, Internist at Rivas Zorggroep.
Martijn Canoy, Internist at Rivas Zorggroep:
‘It’s quite special to see that this work process, which we started on a small scale at our hospital, can be applied more broadly in the region, since the issue of care is ultimately larger than a single institution’.
Initiatives as drivers of change
Many healthcare institutions that embark on a change process have already identified appropriate care as an aim. To turn the impalpable into something tangible and real, that aim needs to be bolstered by content-specific quality initiatives. The transition to another way of providing care starts, as it were, by thinking big and acting small. Initiatives are the drivers of change in that context. A lone initiative will not get very far, but multiple ‘smaller’ ones can be mutually reinforcing and together drive a transition that leads to a structural change in culture. What’s important is that these initiatives must not only improve care for patients but also make care more affordable for society. It’s vital that they do both, and thus offer a double-barrelled advantage.
In this first phase of the transition, organisations find themselves wrestling with many different questions: ‘How do we generate ideas in our organisation?’, ‘How do we prioritise initiatives?’, ‘What do we need to embed initiatives into the organisation?’, ‘How do we inspire our organisation to keep proposing new initiatives?’ and last but not least: ‘How do we measure how well the new procedures and processes are being applied and what impact they’re having?’
Care professionals in the lead
‘Initially, we worked with Strategy& to collect all the ideas floating around the organisation,’ Milhous explains. ‘Initiatives can range from relatively simple process optimisations to complex specialist improvements. Milhous continues: ‘Their passion for their profession often finds care professionals coming up with dozens of good idea, and the same is true within Rivas Zorggroep and HenZ, but they don’t get off the ground for one reason or another. With the right conditions, dedication of the professionals, and experience from Strategy&, we finally had the right ingredients to enable us to take those ideas and successfully implement them. One example of a process optimisation is “Diagnostics at the Doctor’s Surgery (DS)”. It’s made it possible to perform extra diagnostics at the DS to prevent unnecessary flows of patients to Accident & Emergency (A&E). That cuts down on patient waiting times and consequently lowers costs at A&E. An example of a complex specialist initiative is “Fast Track Orthopaedics”. An improved pain protocol, local anaesthetics and earlier joint mobility have led to a sharp drop in the average length of hospitalisation for both knee and hip arthritis.’ ‘The fact that we were asked for our opinion and input as care professionals certainly contributed to the success of our transition. Physicians often have lots of ideas about what can and should change. But before, we had no leeway to make changes because we were mainly preoccupied with production. That is not only better for our patients, it makes our practice more enjoyable and we feel more like owners of the change’, says Milhous.
From initial ideas to detailed initiatives
The initial survey may well produce one hundred to two hundred new initiatives. Inspiration can be drawn from Strategy&’s rapidly growing database, which contains hundreds of quality initiatives drawn from the literature, experiences abroad and best practices at other care institutions. Prioritisation is a must to avoid confusion and a loss of control in the organisation. Important parameters are feasibility and potential impact, both on the quality of care (content-specific) and on the costs to society (financial). In the latter instance, a business case is required. In terms of implementation, it’s essential to draw up a sound monitoring and evaluation plan that allows for adjustments to the innovation where necessary. Rivas Zorggroep and HenZ got off to a roaring start and collected more than 100 ideas during the first phase. ‘Our challenge lay in working out the details,’ says Els van der Stelt, programme manager at Rivas Zorggroep. ‘Strategy& challenged our initiatives and supported us by asking the right questions, for example “What are we actually going to do differently?” and “What obstacles will we encounter?” Together, we came up with a list of concrete ideas that we could tackle immediately.’
Els van der Stelt, programme manager at Rivas Zorggroep:
‘Strategy& challenged our initiatives and supported us by asking the right questions, for example “What are we actually going to do differently?” and “What obstacles will we encounter?” Together, we came up with a list of concrete ideas that we could tackle immediately.’
Roll out and scale up where possible
After prioritisation, Strategy& worked closely with care professionals on drafting an implementation plan. The plan described precisely which organisational changes are needed, who owned the initiative, who the stakeholders were, and who will monitor progress. Once they were implemented successfully, some initiatives could be extended to other parts of the care institution. One example is the Rivas initiative PoliReview, an initiative developed in close cooperation with the physicians group, which involved a systematic review of whether outpatients would be better off under their GP’s care. This initiative began in the Cardiology unit, because they were often seeing patients at their surgery that they believed had no need whatsoever for hospital care. Because of the extremely positive results, the initiative was gradually extended to other divisions, including Gynaecology and Internal Medicine.
Martijn Canoy, an Internist at Rivas Zorggroep, was also involved from the beginning of the transition. He describes how separate initiatives implemented at one hospital have become a regional movement. ‘Where, at the start, the focus of the initiatives was on the hospital, we are now looking to apply them more broadly in the chain. With these initiatives, we are seeking out that exact same cooperation with general practitioners and other institutions. We have thus seen that our bond with, for example, HenZ general practitioners has become even stronger during this period, and that the lines are very short. We are also seeing through this relationship that we can help patients better through the entire chain, and in so doing really get a sustainable movement going. Our ambition is for ‘Quality as remedy’ to be the new standard for our entire region. One example of a very effective initiative at general practitioners is ‘more time for the patient – because general practitioners can now spend additional time with patients with more complex conditions, the number of referrals to the Beatrix Hospital has fallen sharply.
A successful transformation is only possible if a number of conditions are met. These include creating a financially secure environment to avoid being punished for sticking your neck out, a long-range transformation agenda, an organisational culture that supports the transition and, later, an appropriate organisational model and future-proof funding of care. All these topics and more will be covered in future blogs. In our next blog, we’ll discuss how care institutions can create a financially secure environment in which we remove production incentives by making the right financial arrangements with healthcare insurers.
* Gert-Jan Milhous has since left Rivas Zorggroep. He has gone to spread the ‘Quality as remedy’ philosophy elsewhere. Rivas has since begun implementing the fifth wave of initiatives.