Quality management in psychosomatic rehabilitation

1. Uwe KochStephan KawskiUniversity Hospital Hamburg-Eppendorf, Dept. for Medical Psychology koch@uke.uni-hamburg.de Quality management in psychosomatic rehabilitation

2. Characteristics of the rehabilitation system historically: strongly based on traditional “Kur-medicine” today: clear separation between “Kur-medicine” and medical rehabilitation • differentiated system: • approx. 1300 institutions • approx. 1 million treatment measures per year • cost of approx. 4 billion € per year

3. Strengths of the rehabilitation system in Germany • Large tradition of rehabilitation-specific knowledge • Large and differentiated network of treatment institutions • Qualified treatment offers • Interdisciplinary treatment teams • Secondary preventative intervention options

4. Criticism of the German rehabilitation system • Problems resulting from differences in cost carriers • Transitional problems between acute care, rehab and after care • Higher degree of institutionalization with disadvantageous consequences • No adequate system of outpatient rehabilitation with efficient proximity to place of residence • Lack of quality assurance measures • Unresolved usage efficiency • Lack of scientific foundation

5. Parties involved in the GRV’s quality assurance program • approx. 900 clinics and departments • 27 pension insurance carriers (+ Union against Cancer in North Rhein-Westfalia) • 4 scientific institutes • 80 experts from various fields of indication • Coordination committee: moderators from the VDR, BfA and LVA • Evaluation centers of the VDR and BfA

6. Aims of the project • Realization of legal requirements • Strengthening of result quality • Establishment of quality standards • Development of an information system

7. Main tasks of the scientific institutes • Improvement, assimilation and development of survey instruments • Data analysis (development of analysis concepts) • Development of procedural techniques • Recommendations for an integration of regular feedback to the hospitals

8. Structure of the 5-point program PP 1 PP 2 PP 3 PP 4 patient questionnaires quality screening structures and concepts patient therapy plans analyses quality circle

9. PP1: Structure qualityGoals • Stock taking / description • Development of minimum equipment standards • Definition of structurally comparable hospitals • Information about assignment coordination • Common instruments for the assessment of structure quality

10. Documentation questionnaires “Structure” and “Concepts”: • Documentation questionnaire “Structure” • General data • Personnel (incl. qualification and additional training) • Diagnostic services • Therapeutic services • Treatment spectrum • Documentation questionnaire “Concepts” • Internal network • External network • Aspects of staff member qualification • Focus of therapy

11. Guidelines for the definition of “structurally comparable hospitals” • Mere use of criteria excluded from quality judgement • Consideration of a sufficient number of further classification aspects to ensure a fair clinical comparison • Institutions • Main indication • Hospital size • Therapeutic orientation • Patients • Care intensity • Multimorbidity

12. 1996 Structure assessmentStaff density (Beds per full position)

13. Access to process qualityPeer Review Procedure Task: • Assessment and evaluation of the process quality in the participating institutions Information base: • Standardized discharge report of the pension insurance companies • individual therapy plans Evaluation basis: • Multi-dimensional checklist with manual (definition and explanation of “QRPMs” Evaluators: • Trained colleagues from the field of indication (directing function, practical experience)

14. Sections of the checklist • Anamnesis • Findings • Therapeutic goals • Therapy plans • Process and epicrisis • Socio-medical statement • Further therapeutic measurements

15. General and clinical anamnesis Current complaints and restrictions of function Present therapy, responsible physicians General social anamnesis Occupational and professional anamnesis Admittance findings, previous findings, supplementary diagnostics Rehabilitation diagnoses and rehabilitation goals Course of rehabilitation Result of rehabilitation Socio-medical epicrisis Physician’s report in free formPrescribed structure

16. PP3 “Peer Review”:Feedback to the clinics • Graphical representation of the summarizing evaluation of the entire rehabilitation process and the individual areas of the checklist • Table form for the overview of the summarizing evaluations of the entire rehabilitation process and the individual areas of the checklist (incl. Significances) • Table for the evaluations of the individual characteristics of the checklist (incl. Significances) • Polarity profile of particular strengths and weaknesses

17. Risks: Good process does not mean good result – good report does not mean good process Reports become longer Benign (“collegial”) evaluations Lack of socio-medical competence in the evaluators Strengths: Good, handy instrumentarium Transparent evaluation criteria – evaluation by colleagues of the same field Input for quality improvements – clinic comparisons become possible Basis of data for the development of guidelines / standards PP3 “Peer Review”:Risks and strengths

18. Peer Review 2000Summarizing evaluations

19. Peer Review 2000Evaluations of individual aspects Area of indication: Psychosomatics(% “severe insufficiencies“)

20. PP3 “Peer Review”Summary of results • Procedure: Suitable for differentiation • Test-theoretical security • Usefulness for internal quality management

21. Program point 4Patient survey • Goals • Improvement of the process and result quality • Consideration of the assessment of the rehabilitation • Access and procedure • Development of a routine instrument: • Measurement of treatment satisfaction and • perceived treatment success • Survey of randomized samples approx. 6 weeks following discharge • Present state • Scientifically proofed assessment questionnaires • Assessment and evaluation routines • Development of a feedback system

22. Program point 4 Patient questionnaire • General questions on the rehabilitation (6 Items) • Questions concerning the clinic stay (37) • Health complaints (31) • Limitations in occupation and daily life (9) • Lifestyle (4) • Socio-medical status (19)

23. Patient survey 1999Measures / Satsifaction

24. Patient survey 1999Satisfaction: Personal care

25. Patient survey 1999Personal care planning / Organization

26. Quality circle Characteristics of quality circles (Bänfer, 1994) • No hierarchy • Regular • Voluntary • Five to nine members of a field of specialty • Involvement with self chosen problems • Under the direction of a moderator • Includes the assistance of special problem-solving techniques • Development of improvement recommendations • Initiation and monitoring of the realization