Benchmarking and quality
improvement in Emergency
Departments in Belgium.
On behalf of the Belgian Board for
Quality Improvement,
J.B. Gillet.
Eusem, Portoroz 2002.
Federal Ministry of Public Health,
Ministerial Decree , june10, 1999
Buylaert Walter,
Colson Paul,
De Soir Ria (vice-présidente),
D'Orio Vincent (exp.),
Gillet Jean Bernard (Président),
Hachimi Idrissi Said,
Lheureux Philippe (secrétaire),
Marion Eric (exp.),
Meulemans Agnes (exp.),
Stroobants Jan (exp.),
Vergnion Michel,
Vroonen Marie Christine (secrétaire-adjointe).
Partners in Belgium
• Belgian College of
Emergency Physician
(BeCEP)
• Belgian Society for
Emergency and Disaster
Medicine (BeSEDiM)
• Federal Ministry of
Public Health
Belgian Board of
Emergency Physicians
for Quality Improvement
Mission statement
• To define indicators of quality
• To propose a national registry on specific
topics selected by the peers.
• To promote continuous quality
improvement by continuous feed back
• To edit a yearly national report
Quality of care ?
Potential components of quality.
•
•
•
•
•
•
•
•
•
Accessibility
Appropriateness
Continuity
Effectiveness
Efficacy
Efficiency
Patient perception issues
Safety of the care environment
Timeliness of care
By the Joint Commission on
Accreditation of Health Care
Organizations, 1990.
Quality Assurance vs Quality
Improvement
Quality
assurance focus
Bad outcome
Quality
improvement :
shift curve to
the right.
Okay
outcome
Good outcome
Continuous Quality
Improvement
• Error free can not be guaranteed, but quality
of care can always be improved
• CQI focuses on system first and individuals
second.
• CQI requires leadership commitment and
performance measurement.
• CQI is organised around patient care
DS & MR O ’Leary,
Emerg Med Clinics of North America, 1992.
Benchmarking
« The continuous process of measuring
products, services, and practices against
the compagny’s toughest competitors or
those companies renowned as industry
leaders. »
Camp RC : Milwaukee, Wis, 1989,
American Society for Quality Control,
Quality Press.
Benchmarking model
•
•
•
•
Phase 1 : Planning
Phase 2 : Analysis
Phase 3 : Integration
Phase 4 : Action
Aim of the study :
• Evaluate
activity,
architecture,
organization
finances
• Benchmarking
Indirect indicators of quality ?
•Do you have regular staff meetings ?
•Do you have access « round the clock » to the medical
records of the patients ?
•Is the chief of the ED an emergency physician ?
•Do you use guideliness ?
•Do you have a annual disaster plan review, and exercice ?
Benchmarking ?
• A written rapport of the survey (1997)
• An oral presentation to the general assembly of the BeCEP
• Publication in the medical and non medical press (1998)
Aim of the study :
• Evaluate
• activity,
• architecture,
• organization
•Compare with 1996
•Benchmarking
Comparison 1996-2000
• Number of
participating ED :
52/143
• Average size of
participating
hospitals : 416 beds
• Average passages /
ED : 19.000
• Number of
participating ED :
89/143
• Average size of
participating
hospitals : 252 beds
• Average passages /
ED : 19.808
BeCEP 96 vs College 2000 :
Hospital size of the participating ED.
2500
2000
1500
1000
500
0
1996
2000
Do you organize regular ED
staff meetings ?
• In 1996 :
• In 2000 :
– No : 12/52 (23%)
– No : 21/89 (23 %)
– Yes, monthly : 21/52 (40%)
– Yes, monthly: 78/89 (87 %)
ED staff meetings ?
Analysis restricted to the participants at both studies
No (1996) Yes (1996) Total
No (2000)
0
5
5
Yes (2000) 4
21
25
Total
26
30
4
1996 :87% vs 2000 : 83%, Binomial, NS.
Do you have an ED committee
with reprentative of other
services of the hospital ?
• In 1996 :
• In 2000 :
– No : 39/52 (75%)
– No : 64/89 (72%)
– Yes: 13/52 ( 25%)
– Yes: 25/89 ( 28%)
ED committee :
Analysis restricted to the participants at both
studies
No (1996) Yes (1996)
Total
21
2
23
Yes (2000) 9
6
15
Total
8
38
No (2000)
30
Mac Neuman, p=0.035
Are medical records available
« round the clock »?
• In 1996 :
Yes : 36 ( 69% )
No : 16 ( 31%)
• In 2000 :
– Yes: 64/89 (72%)
– No : 25/89 (28%)
Medical record available ?
Analysis restricted to the participants at both studies
No (1996) Yes (1996) Total
No (2000)
1
6
7
Yes (2000) 9
22
31
Total
28
38
11
1996 :74% vs 2000 : 82%,
Binomial, NS.
Do you use guidelines ?
• In 1996 :
– No : 16/52 (31%)
– Yes : 36/52 (69%)
• Medical : 31/52
• Ethical : 18/52
• In 2000 :
– No : 19/89 (23 %)
– Yes, : 70/89 (87 %)
• Medical : 70/89
• Ethical : 39/89
Guidelines ?
Analysis restricted to the participants at both studies
No (1996) Yes (1996) Total
No (2000)
2
4
6
Yes (2000) 9
23
32
Total
27
38
11
1996 :71% vs 2000 : 84%, Binomial, NS.
Do you send systematicaly a
medical letter to the GP ?
• In 1996 :
– No : 11/52 (21%)
– Yes : 41/52 (78%)
– Yes, typed : 8/41
(19%)
• In 2000 :
– No : 20/89 (22 %)
– Yes: 69/89 (78 %)
– yes, typed : 28/69
(40%)
Letter to the GP ?
Analysis restricted to the participants at both studies
No (1996) Yes (1996) Total
No (2000)
7
4
11
Yes (2000) 3
24
27
Total
28
38
10
Binomial, NS.
Letter typed to the GP ?
Analysis restricted to the participants at both studies
No (1996) Yes (1996) Total
No (2000)
18
0
18
Yes (2000) 7
7
14
Total
7
32
25
Binomial, p = 0.016.
Disaster prepardness ?
• In 1996 :
• In 2000 :
– EP involvement in disaster
– EP involvement in disaster
planning :
planning :
• Yes : 42/52 (80%)
– Annual exercice :
• Yes : 22/52 (42%)
– Annual review :
• Yes : 31/52 (60%)
• Yes : 69/89 (77%)
– Annual exercice :
• Yes : 36/89 (40%)
– Annual review :
• Yes : 60/89 (67%)
Disaster planning review ?
Analysis restricted to the participants at both studies
No (1996) Yes (1996) Total
No (2000)
2
1
3
Yes (2000) 8
21
29
Total
22
32
10
1996 :69% vs 2000 : 91%, Binomial p=0.0039
Is the ED under the
responsability of an EP ?
• In 1996 :
– No : /52 (31%)
– Yes : /52 (69%)
• In 2000 :
– No : 20/89 (22 %)
– Yes, : 69/89 (78 %)
Is the ED under the
responsability of an EP?
Analysis restricted to the participants at both studies
No (1996) Yes (1996) Total
No (2000)
0
0
3
Yes (2000) 6
29
35
Total
29
38
6
1996 :83% vs 2000 : 100%, Binomial p=0.0031
Conclusions (1)
• We observed that the participation at such
surveys is increasing with smaller hospitals
participating
• Between 1996 and 2000, some improvements in
quality indicators are observed.
Conclusions (2)
• Benchmarking is one of the possible
explanation.
• Other factors of influence are non excluded :
– Federal decree with dedicated regulation on EM in
1998
– inclusion bias due to participation on voluntary
base.
Conclusions (3)
• Since our results discloses that some ED do not
satisfy to the legal requirements, we conclude
that the answers given by the participating ED
are very honest and reflects the reality of the
emergency medicine in Belgium.
• This seems to be due to the strict independence
and the guaranty of anonymity given by the
Belgian Board.