Background
-
what developers of standards and guidelines for hospital care can do to reduce the number of guidelines/norms and improve clarity and consistency;
-
what norm-enforcing institutions can do to focus and align priorities and reduce uncertainties for hospitals for which they are expected to comply;
-
what hospital boards, managers, and staff can do to integrate norms and guidelines into hospital systems successfully.
Methods
Participants
Number of participants and no-shows | Norm developers | Norm enforcers | Norm users | Researcher/consultant/ policymaker | |
---|---|---|---|---|---|
Focus group 1 | 10 participants (12 invited, 2 could not attend) | 3 | 2 | 1 | 4 |
Focus group 2 | 12 participants (12 invited) | 4 | 1 | 7 | 0 |
Focus group 3 | 6 participants (10 invited, 2 could not attend, 2 no-shows) | 2 | 1 | 2 | 1 |
Procedure
Function/focus | Key questions |
---|---|
Questions on invitation | • What can developers of norms and guidelines for hospital care do to reduce the number of guidelines/norms and improve clarity and consistency? • What can norm-enforcing institutions do to focus and align priorities and reduce uncertainty for hospitals about what they are expected to comply with? • What can hospital boards, managers, and staff do to integrate norms into hospital systems successfully? |
Hospital as part of the system | • What are possible solutions on a system level? |
Norm developers | • What solutions can guideline developers put forward? |
Norm enforcers | • What can norm enforcers contribute to a possible solution? |
Stakeholders view | • Input from parties outside the hospital concerning experience problem by hospitals |
Different perspective | • Possible solutions from a different perspective? |
Results
Acknowledging perceived difficulties
Participants emphasized the burden that perspectives are neither harmonized nor aligned. On the one hand, developers perceived that they support practitioners by developing guidelines and indicators, resulting in requirements owned by the sector. On the other hand, hospitals and professionals perceived those as a burden instead of support.What you or they [pointing to guideline developers] release into the world is not a lot, but all of them together create a jungle (Norm user 8).
I, as a professional, am assisted if I can easily find and access things easily, as soon as I have a question (Norm user 4).
Participants stated that hospitals want to provide excellent care, but norms can have an unintended (and maybe unwanted) impact. They felt that their resistance appeared from the plurality of musts/guidelines and as a result, the onerous process of having to implement the guidelines. All participants emphasized that the system of guidelines and norms did not assist professionals adequately and that it needed to be organized more effectively and efficiently. The Dutch Surgical Colorectal Audit makes information publicly available, leading to the following example of impaired effectiveness for quality improvement:We develop the guidelines to assist professionals and patients, of course. If we disturb others with it, it is sad. We have to investigate together how we can find a good solution so that everyone is assisted (Norm developer 4).
Participants discussed that it is unclear which guidelines need to be followed and claimed that clear definitions are needed. Some referred to guidelines as quality improvement tools; however, others used them as enforcement tools.Anastomotic leakage in colorectal surgery is the indicator to assess whether you deliver good care or not. I am 100% sure that after we score poorly the first time, the surgeon does instruct the specialized nurse to look at it (the indicator and therefore, the registration) somewhat differently. Herewith, you completely miss your target. The indicator is used, in fact, to get a green checkmark. Based on this, healthcare contracts can be purchased! (Norm user 1).
All participants acknowledged the perceived difficulties presented in the previous research, accentuating what their point of view is. Further citations are displayed in Table 3.We think that everyone must adhere properly to the rules and guidelines; the guidelines do not exist without a reason. But I can conceptualize that there is some need for more focus (Norm enforcer 2).
Citation | |
---|---|
‘People are not acquainted with it, they do not know it, they do not know what recommendations they have to know. It really depends on the interest of an individual professional whether it is used or not. I think that you need to look on system-level whether protocols are generally in line with guidelines. Quite often they are not even translated into practice. I think that it depends too much on the individual professional, and I think you should do much more on system level to implement it. And at the same time, I think, there is a problem with the system at organisational level.’ | Norm developer 6 |
‘I did notice that there was a certain reluctance to reformulate an indicator, because the insurers may call them on account, and that was sensed immediately.’ | Norm developer 9 |
‘Yes, if you look at the register, for example. We are asked to provide a tripartite now, including insurers. Thus, it is agreed that insurers play an even more important role. That was not the original question for guideline developers, by definition. Not because one is against it, but one looked at the content and how to deliver the best quality of care.’ | Norm developer 2 |
‘I think it is a very difficult discussion, because I also realize what hospitals encounter. All parties awaken me to that. On the other hand, it is also true, that we have chosen a system in the Netherlands, where patients have an understanding of the quality in order to make the right choices. And yes, you will need information to do so.’ | Norm developer 3 |
‘When I think of a quality label, I see it as a reward. I also notice that it happens in hospitals. Professionals say: we should keep this quality label.’ & ‘In psychology, not getting a reward is a punishment.’ | Norm developer 3 & Norm user 6 |
‘It is questionable whether the field is really waiting for guidelines the way they are presented now.’ | Norm user 8 |
‘And then you have the perverse incentives on all sides, and the control of the board of directors is fundamentally absent. Absolutely absent. There is no testing, nothing. For me, DICA is an example how it should not be done.’ | Norm user 2 |
‘In the final phase, where you could start an improvement project, you cannot achieve it in practice, because you are hampered by so many factors. This is influenced by insurance companies, a patient, by available money or by management choices that must be made. So you have … What I am trying to say is that there is little room to establish improvement.’ | Norm user 9 |
‘As a matter of fact, I would like to say that hospitals do want to provide good care. The resistance comes from the multitude and impossibility.’ | Norm user 1 |
‘The challenge, therefore, is to provide the right information to the professional at the right time during the search. That is the big issue.’ | Norm user 2 |
‘But a guideline, if I may call it that way, is a tool. It is an invitation. We, as a group, have determined that this is the best approach, and we can deviate from guidelines if we argue well. An indicator, on the other hand, encourages reflection, which stimulates the consideration: what is good for one specific patient, but not for the other?’ | Norm user 1 |
‘… the whole exercise in the care sector was to deliver everything at one point in time for multiple purposes. But then you experience problems during realisation, as the insurers first said yes, but then they want to receive it at the first of October [which is a different date than earlier agreed on], because they need it for contracting. And then you have to work with the results from the previous year, so that is very difficult.’ | Norm enforcer 1 |
‘The minute that all enforcing institutions, the patient, the insurers, and inspection, look over your shoulder in the doctor’s office, you might be more careful, perhaps you are going to make strategic choices instead of basing it purely on your professional expertise.’ | Researcher/consultant/policymaker 5 |
Concrete solutions
Be clear about the target (group) and the imposed obligation
After the publication of a guideline, a hospital does not immediately undertake implementation action. They first decide which (part of the) guideline has priority. Participants suggested that certain criteria, such as risk reduction, quality benefits, and health benefits, should be mentioned in the guideline to contribute to a decision.We try to indicate in the guideline whether the registration relates to the organization or the individual specialist, to achieve that the one in charge feels the responsibility for the registration. (Norm developer 2).
Overall, participants underlined that distinction is needed between obligations and options as well as to whom they are relevant. One of the stakeholders from a norm- developing organization put forward a suggestion that his organization (and others) could follow.Can’t we do much more to highlight which things really make a big difference for the patient? (Norm developer 6).
According to participants, this would make the process of implementation and sharing of tasks during execution much easier for users.Actually, you can say without difficulty: these are the guidelines having an organizational impact, and we will create an executive summary, and we sent the executive summary to every board of directors. That is only a small effort. We do not do it now, but it is one of the things we consider if that is what you are waiting for … You can also divide it into three categories: you can say this is purely professional, this is strictly organizational, and this is something in between. Then you are already on the right track. And if you do want to link this to a timeline, you can also highlight what is most important (Norm developer 5).
Be clear about the purpose of a norm/guideline/indicator
Several participants stated that norm developers could indicate that some indicators are used primarily for patient choice and are not explicitly intended to improve quality.We can still improve a lot. The separation of the aim/purpose (Norm developer 6).
Participants stated that clear labelling of the purpose is desirable: which indicators are used to facilitate the choice for the future patients, which indicators are used for internal improvement, which indicators are used for contracts with insurers, etc. However, norm developers cannot control how their produced norms would be used or whether the norms are used for other purposes.Not all indicators are intended to improve quality (Norm developer 3).
Measuring is important, as stated by several participants. One participant illustrated this with an example from 15 years ago, where the Netherlands and Belgium had different approaches for measuring MRSA:Guidelines are used by the inspectorate to enforce or by insurance companies for purchase, while the main objective is still reducing practice variation and knowledge transfer. However, the use by others is possible. Whether the use of the guideline turns out as intended or not, that is the question (Norm developer 1).
Participants stated that norm developers should indicate within a guideline the value and necessity for the guideline. Otherwise, users might not recognize the impact.Belgium had a long time no MRSA problem because they simply did not measure MRSA. Then you also ‘have no problem’ (Norm enforcer 1).
The usefulness and necessity of guidelines need to be explained so that people understand the underlying rationale of why they are doing something. ‘Yes, we need to do it for the board, or yes we need to do it for the inspectorate.’ That does not work. They need to understand what is useful and necessary (Norm enforcer 1).
Work with a maximum frame for indicators
Participants specified that if different indicators are combined, the indicators should then only be used for the purpose for which they were created. Otherwise, the media and other parties could hijack the data. Participants reported that some attempts at synergy were already being made.Two years ago, we thought maybe we should use ONE indicator for multiple purposes. Then you limit the use of indicators, and then you can use the same outcome for several things. (Norm developer 3).
As explained by one participant, the first efforts are being made in the Netherlands: On a national level, 30 conditions were selected to improve the available information for patients with all parties, involving, among others, understandable guidelines for patients and the registration and publication of information. At the same time, insurers agreed that they would establish a limited number of quality indicators for 30 conditions.Insurers compiled a top 30, which is slightly different from the national top 30 which was worked with (Norm enforcer 4).
Ensure proper IT infrastructure
They proposed that norm developers could provide guidelines in such a way that all of them could be found at the same spot. Meta-information and summaries, as well as implementation advisers, should be included. Hospitals should join forces to find an IT solution to connect guidelines to work sequences, to achieve that guidelines can be easily accessed at the point needed. Therefore, electronic patient devices should be linked to guidelines.You should be facilitated. We now have the new electronic health record, and even though it was promised before we purchased it, the registrations [referring to the registration of quality indicators] are not included. Well, I think that we need to take big steps to facilitate the professional in this (Norm user 7).
The hospitals’ experienced dependence on the solutions electronic health record vendors provide. Participants proposed that hospitals should join forces negotiating with the electronic health record vendors, as implementation requires beneficial support at the particular time needed.I think that the whole support by IT to our professionals is a challenge where we are in our infancy. And that these systems are simply not customised for our professionals yet. And I think that the people firing their systems at us, had too much to say so far, without us communicating clearly what we really need to make it work properly (Norm user 2).
Participants suggested that norm-developing institutions could deliver guidelines and indicators in such a way that they are easy to integrate into the institutional IT support systems of users.Well, the gap between IT in hospitals and the possibilities I have with this [points at his mobile phone], surprises me for years. (Norm user 4).
Improvement of the system
Participants stated that norm developers could increase transparency about how they publish and how they distribute guidelines.I think, that there is an international best practice of the Fins, again from the GPs, who did build the guidelines into their medical IT system. This initiative is from Finnish professional organizations. It is indeed an example of how they do it over there (Norm developer 6).
Participants suggested involving managers and professionals: discover what they think is important and create more insight for them about the importance of implementation. After implementation, they proposed that managers and professionals should give feedback to norm developers about usability in practice.We fool ourselves a little bit, as we are actually in a situation, I think, which is caused by us. By sharing little of what we do. I speak from a medical specialist’s perspective. Thus, you end up in a situation of increased mistrust (Norm developer 5).
Participants recommended that the enthusiasm of doctors must be facilitated, to create bottom-up appetite/willingness and to address the relevance of the core of the guideline from the eye of the professional.And I think it is very sensitive to evaluate, as soon as it is fully developed and implemented, how it will be used in practice (Norm developer 8).
The solutions put forward by the participants aimed mainly at a change in culture, where it remained unclear who is responsible for what and when. They suggested finding alternative ways for hospital boards and managers to be in control. Additionally, they suggested strengthening the professionals.I would say that there needs to be willingness by the professionals to share information. You cannot enforce that externally. Make it a habit and necessity (Researcher/consultant/policymaker 5).
You must create much more freedom in your system, to be able to work with local guidelines that are not enforced, but which are used to deliver the best care for the total patient population. That is the freedom that you need (Norm user 1).
What I do believe is in strengthening the professional, both the physician and the nurse (Norm user 1).