By Tina Eriksson
Status of quality development in the framework of the cooperative agreement between PLO and SFU
Contract negotiations in 1995 between the Danish GP’s labour organisation (PLO) and the national health services bargaining committee (SFU) quality projects for GPs received funding administered at county level. The decentralized focus has resulted in considerable local activity. At the same time, the parties set up a central committee for quality development in primary care (CKI). The task of the committee was to coordinate and provide information but not to administrate quality projects. At the renewal of the contract in 2003, a strengthening of the national coordination and initiatives was agreed on. The CKI was given extra means in a period of two years and a central quality development initiative was launched, focusing on the following four priority areas: IT development, shared care, quality indicators and the patients’ perspective. Both centrally and locally the resources are managed by committees comprising researchers, politically appointed administrators and GPs. The purpose of the initiative is to coordinate and generate quality development in collaboration with the secondary health care system through a common quality program; the Danish National Quality Programme.
It was a precondition that quality development should secure coherent care pathway across sectors, develop a Danish set of generic and clinic standards and indicators, make use of existing knowledge and establish an evaluating system. Moreover it was a premise that developments should be based on learning and continuous quality improvement.
Results of the DAK project
The parties agreed that the DAK-project fulfilled the aims set and summarise the results the following way:
· An analyse and test of quality tools in the four areas of priority
· A method of developing quality indicators was tested
· Indicator sets for the care of patients suffering from diabetes and COLD are ready for implementation
· IT-tools have been developed in order to support the implementation of quality development
The parties agreed that the next step will be to disseminate and implement the tools.
Elements of an implementation strategy
The parties picture the implementation as a ’process circle’, comprising the elements in figure 1
Future organisation of the Danish quality improvement work
During the last collective agreement term functioned well in spite of the loose projekt organisation. In the coming period a regular organisation is to be set up in order to meet the goals set.
The following structure has been agreed on:
- Establishment of a “Quality and Informatics Fund”
- A successor of the DAK- project, a national quality unit, called DAK-E is established in the setting of the Quality and Informatics Fund
- The DAK-E is attached closely to the five Danish regions
- Coordinating of quality improvement will be undertaken by a board of directors, outlining the overall strategy and by a professional committee on quality development, involving the regional quality development units.
- Cooperation with the quality organisation of the secondary health sector is increased and that a continuous coordination of activities takes place between the sectors, aiming at organising a coherent quality improvement scheme for the health care system at large.
The Parties agree to further promote quality improvement in primary care and that the activity should be centrally coordinated and led, but regionally organised, and performed in cooperation with the rest of the health care sector.
The following initiatives will be a priority in the coming four year period:
Promotion of consistent ICPC – coding
Secure Internet access and digital signature will be established in all practices and secure data transmission must be established. Standards and indicators for referrals and discharge letters have been developed and will be implemented.
Secure electronic transmission of laboratory data and other test results with the secondary health care system, prescription data with pharmacies and payment data with central authorities must be supported by the data systems used.
The DAK-projekt has build up a national ICPC-code network,
Future aims are:
- Technical solutions to the use of ICPC in the different EPJ systems.
- Promote the interest among GPs of consistent ICPC coding
- Development of the ICPC classification in order to secure that ICPC2 is integrated into EPJs alongside the use of data capture
Indicators
The DAK-project developed a method for selecting and editing indicator sets. Clinical indicator sets for DM 2 and COLD has been developed.
Future aims:
- Implementation of the indicator set for DM2 through the “patient care pathway fee”
- Development and testing of new indicator sets of major chronic diseases
- Development and testing of general indicator sets
- Coordination with indicators of care in the secondary health care sector
- Development of indicators of patients perspective on general practice
Data capture module and data bases
The data capture module has been developed through the DAK-project in a basic version, but technical questions and questions concerning the limits of data captured still remains. So do a solution of the legal and practical problems of data housing.
Publishing of data
Publishing of quality data may take place, but in a form that do not make single GPs recognisable.
From data to learning
The aim is that the data captured in the clinics EPJs must be communicated to the GPs in order to make benchmarking possible and secure change. Ways of communicating data, and settings in which change can be implemented must be developed.
A new model of chronic care
An increasing proportion of the tasks in the health care systems in Europe are dealing with chronic diseases. Acknowledging that fact, the new deal is introducing a model of chronic care, including use of indicators, data capture and by launching a “patient care fee” and risk stratification of chronic care patients in three risk groups, each assigning patients to specific care and self care schemes.
Chronic care fee
The fee introduces a new type of annual fee for diabetes care, and the GP is of course free to charge for care of other health problems, unrelated to diabetes. GPs are free to assign or refuse the system that will be introduced in January 2007.
The annual fee covers the following elements of diabetes care:
- The GP and the patient are obliged to schedule necessary controls and the GP must call the patient if she fails to show up. This outreaching role is new in the Danish GP contract.
- The patient care fee focuses on shared care - with hospitals, municipal health centres (rehab and home nursing) and patients’ self care. The labour division between parties will be organised regionally
- Assigning is conditioned by indicator measurement of the GPs’ quality of care.
The preventive consultation fee
A preventive consultation fee along with two supplementary fees for 1) risk assessment and 2) follow-up visits, according to guidelines was introduced.
Risk stratification
The new agreement imply, that all diabetes patients are risk stratified into the following three risk groups, each assigning patients to specific care and self care schemes:
Level 1: Primary care: Uncomplicated diabetes
Level 2: Shared care: Between the GP and e.g. a hospital ambulatory
Level 3: Specialised care (e.g. in a hospital ambulatory): High-risk patients and patients suffering diabetes that is complicated or difficult to control
Support of patient self care
To each level of care, self care programmes are developed and they are implementated.
GPs as case managers and coordinators
The National Bord of Health in Denmark (Sundhedsstyrelsen) as well as the County Concil recognises that GP should take the responsibility of the role as case manager for chronic patients. The GP may delegate that responsibility to staff members.
