Quality Management Implementation & Verification

• These notes cover the verification of implementation, QM guidelines, implementation status in 2023, evaluation of the results and support services, QM instruments, team meetings, patient surveys, complaints management, error management and reporting systems, critical incidents, negative therapy outcomes, psychotherapy, error management, reporting and learning for enhanced patient safety, risk management, patient information and education and right to information

Who verifies practical QM?

• Regular surveys and presentations on the current status of internal QM implementation and development are conducted for service providers participating in contractual medical and dental care

QM Guideline: Part A §6 Para. 1

• Participating service providers in contractual medical and dental care must use questionnaires
• Hospitals admitted under § 108 SGB V must participate in necessary surveys for presentation

Survey Execution

• Physician associations (KVen) in contractual medical care
• State Hospital Associations (LKGen) in hospitals admitted under § 108 SGB V

Reporting Results

• The results of the survey are reported to the G-BA
• The G-BA receives a bi-annual report, first for 2021, by July 31 of the following year from the National Association of Statutory Health Insurance Physicians (KBV) for the contractual medical and dental sector

Sample Composition (2023)

• Random sample: 4,519 practices
• Included participants: 4,345 (96.1%)
• Submitted questionnaires: 4,169 (N = population)

Implementation Status (Overall in Facilities - 2023)

• Definition of quality goals: 3,871 (93%)
• Collection and evaluation of goal achievement: 3,588 (86%)
• Documentation of self-assessment: 2,654 (64%)
• Regulation of responsibilities: 2,630 (88%)
• Determination of processes and procedures: 3,815 (92%)
• Interface management: 3,609 (87%)
• Use of checklists: 3,780 (91%)
• Use of OP checklists: 319 (91%)
• Team meetings: 2,962 (99%)
• Training and educational measures: 2,763 (93%)
• Collection of training and educational needs: 2,926 (98%)
• Implementation of patient surveys: 2,409 (59%)
• Complaint management: 3,045 (74%)
• Patient information and education: 3,961 (96%)
• Comprehensibility of patient information: 4,004 (97%)
• Risk management: 3,426 (82%)
• Error management: 4,048 (97%)
• Use of an error reporting and learning system: 814 (20%)

Characteristics of the practice facilities

• Performing surgical procedures: 350 (8.4%)
• Employment of staff: 2,981 (71.5%)
• Personal patient contact: 4,109 (98.6%)
• Prescription of medications: 2,640 (63.3%)

Professional Group

• Physicians: 2,940 (70.5%)
• Psychotherapists: 1,229 (29.5%)

Evaluation of Results & Support Services

• KVen conduct professional assessments on the sample results regarding potential improvements and required actions (QM commissions)
• Sample participants receive collegial advice and various support services as needed
• Online service "Mein PraxisCheck" (My Practice Check) in the KBV training portal

Support Services of Health Insurance Associations (From general to individual)

• On-site consultations (practice visits)
• Individual consultations via phone/video conference
• Training on methods, instruments and applications and services (e.g. Notfallmanagement)
• Topic-related information and training materials (e.g., Hygiene-Leitfaden and hygiene plan)
• Feedback letter with general information on quality management (e.g., QEP - Quality and Development in Practices)

QM Instruments

• §4 of the QM guideline list the following established and practical components of quality management that are mandatory
• Measuring and evaluating quality goals
• Assessing the current status and self-assessment
• Regulations of responsibilities and jurisdictions
• Process and procedure descriptions
• Interface Management
• Checklists
• Team meetings
• Further training and educational measures
• Employee surveys
• Patient surveys
• Complaint management
• Patient information and advice
• Risk Management
• Error management and error reporting systems
• Emergency management
• Hygiene management
• Drug therapy safety
• Pain management
• Measures for avoidance of falls
• Prevention of and help for abuse and violence

Team Meetings

• Regular, structured meetings with employees or teams
• Opportunity for all employees to address current issues and problems
• Can be considered a specific form of quality circles for problem solving
• Purpose is information exchange and communication among members
• Scheduling: frequency, dates, agenda, minutes, and possibly rules of discussion

Patient Surveys

• Systematic (not sporadic) with quantifiable statements
• Survey results communicated back to participants
• Consider the objectives of the survey and how to design the questionnaires

Question Types

• Traditional satisfaction surveys questioned for their meaningfulness and tend to yield high values; depends on gratitude, social desirability, etc
• Most patients can't judge the professional qualification of treatment

Suitable Questions

• Ruprecht (2000) suggests survey methods with report questions (how often, how long) capturing aspects relevant to patients such as treatment success, quality of life, avoidance of harm, secondary quality parameters (access, values, emotional support, continuity, and coordination)
• Key considerations for patient surveys in a clinic versus individual practice
• Requirement for validated instruments (e.g., ZAP, 2002)
• ZAP available in multiple languages.

ZAP (Satisfcation in outpatient medical care)

• Structure: 32 items on practice organization, information, doctor-patient interaction, professional competence, and involvement
• Also ask about overall satisfaction
• Includes socio-demographic questions

Complaints Management

• Patient-oriented with regulated handling of complaints
• Information for patients about local complaint possibilities
• Feedback analyzed for potential changes
• Feedback to complainants about measures taken where possible
• Goal is to identify improvements

Complaint Relevance in Individual Practice

• Openness to, or active searching for complaints increases feedback
• Reacting: on a QM level (e.g., improving information about billing) and on a therapeutic level

What A Complaint Actually Is

• Not: Feedback on an expected side effect; complaints about the need of abstinence for alcohol addiction
• Instead: Complaint that potential side effects weren't sufficiently clarified
• Balance: a compromise between openness for criticism and limited criticism

Error Management and Reporting Systems

• Systematic management of errors (error management) is part of risk management; includes recognizing and utilizing errors for improving processes
• Error reporting systems are an instrument for error management, accessible to all occupational groups and easy to use
• The goal is prevention of errors, learning from critical events, and anonymous reporting
• Systematic processing, creating recommendations for prevention, and evaluation in risk management

Goal of Error Management

• Patient safety
• Starting improvement processes

Discussion Points

• What are errors in psychotherapeutic practice? What is the meaning?

Error Types in Psychotherapeutic Practice

• Based on a failure to meet professional and legal guidelines and agreements
• Possible classification of errors in relation to the psychotherapeutic service itself, and how the QM-system influences

Defining Errors

• DIN EN ISO 9000 defines an error as Not-Erfüllung einer Anforderung (Non-fulfilment of a requirement)

Events that Require Action

• Treatment error
• Critical events
• Undesired events?

Managing Treatment Errors

• Includes diagnostic/medical interventions that are not required or if standard of medical science/practice is not met

Unwanted Events

• All negative events that occur as a result of therapy without known connection

Critical Incident

• An event that increases the risk for damage

Negative treatment outcomes

• Iatrogenic harm due to therapy

Psychoterapy

• Events caused by adequate treatment

Information phases to observe

• Before, during, after

What is there to provide, when

1. Theoretical diagnostic model
2. What is next in case of therapy, side effects
3. Clarification of monetary issues
4. type of therapy monitoring in the future
5. inform on future rights and laws

Error Management

• Activities which aim to handle mistakes
• Detect and fix errors Developing attention for Near-Failure ,systematic faults

Analysing

• Correcting and documenting errors

Critical Incident Reporting Systems (CIRS)

• Reporting systems

Analyses and Disussions

• Analysis of caused factors

Reporting Learning

• What is there to improve, how and when

Action on incident

• Action list of improvement

Fehlerkultur

Everyone can contribute to improving the faults. Basis of the system is creating an environment of trust

Führungskräfte

Do not punish for telling you the truth Analyze the faults with professional standards

Risikomanagement

• Prevent the faults from occurring
• Always be active to find new faults and risks

Instruments

• Failure-Management
• Risikoaudits
• Morbiditäts- and Mortalitätskonferenzen
• Fallanalysen

Patient Information Aufklärung

• Always inform about process
• Provide information and recommendations

§ 630c Mitwirkung der Vertragsparteien

Show the diagnostic and therapeutic process in understandable form

§ 630e Aufklärungspflichten

explain every important aspect of the procces, results and side effects

Aktionsbündnis Patientes Sicherheit

A non organization which seeks improvement

Gesetz zur Verbessung der Rechte Patientinnen

Contains patient rights, doctors actions etc.

Definition Qualitätsmanagementsystem (QMS) nach DIN EN ISO 9000:

• „Management system zum Leiten und Lenken einer Organisation bezüglich der Qualität." (im Gegensatz zu anderen Bereichen des Unternehmens wie Wachstum, Finanzen o.ä.)

Grundlegende QM-Modelle

• „Konstruktionspläne" für QM-Systeme, geben eine Struktur und Systematik vor
• Praxen: z.B. QEP - Qualität und Entwicklung in Praxen
• Krankenhäuser: z.B. KTQ - Kooperation für Transparenz und -Qualität im Gesundheitswesen

Grundlegendes

Bei allen QM-Modellen ist der Grundgedanke: QM soll nicht nur Leistungsqualität sicherstellen

Notes covering the verification of implementation, QM guidelines, implementation status in 2023, evaluation of the results and support services, QM instruments. Also covers team meetings, patient surveys, complaints management, error management and reporting systems, critical incidents, negative therapy outcomes, psychotherapy, error management, and risk management.