Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands.
Int J Health Policy Manag. 2023;12:7243. doi: 10.34172/ijhpm.2023.7243. Epub 2023 May 6.
Hospital strategies aimed at increasing quality of care and simultaneously reducing costs show potential to improve healthcare, but knowledge on real-world effectiveness is limited. In 2014, two Dutch hospitals introduced such quality-driven strategies. Our aim was to evaluate contexts, mechanisms, and outcomes of both strategies using multiple perspectives.
We conducted a mixed methods evaluation. Four streams of data were collected and analysed: (1) semi-structured interviewing of 62 stakeholders, such as medical doctors, nurses, managers, general practitioners (GPs), and consultants; (2) financial statements of both organisations and other hospitals in the Netherlands (counterfactual); (3) national database of quality indicators, and patient-reported experiences; and (4) existing material on strategy development and effects.
Both strategies resulted in a relative decrease in volume of care within the hospital, while quality of care has not been affected negatively. One hospital failed to cut operating costs sufficiently, resulting in declining profit margins. We identified six main mechanisms that impacted these outcomes: (1) Quality-improvement projects spur change and commitment; (2) increased coordination between hospital and primary care leads to substitution of care; (3) insufficient use of data and support hinder quality improvement; (4) scaling down hospital facilities is required to convert volume reductions to cost savings; (5) shared savings through global budgets lead to shared efforts between payer and hospital; and (6) financial security for physicians facilitates shift towards quality-driven care.
This integrated analysis of mixed data sources demonstrated that the institution-wide nature of the strategies has induced a shift from a focus on production towards quality of care. Longer-term (financial) sustainability of hospital strategies aimed at decelerating production growth requires significant efforts in reducing fixed costs. This strategy poses financial risks for the hospital if operating costs are insufficiently reduced or if payer alignment is compromised.
旨在提高医疗质量同时降低成本的医院策略具有改善医疗保健的潜力，但实际效果的相关知识有限。2014 年，两家荷兰医院引入了此类以质量为导向的策略。我们的目的是从多个角度评估这两种策略的背景、机制和结果。
我们进行了一项混合方法评估。收集和分析了四个数据流：（1）对 62 位利益相关者（如医生、护士、管理人员、全科医生和顾问）进行半结构化访谈；（2）对两家医院及其荷兰其他医院的财务报表（对照组）；（3）国家质量指标数据库和患者报告的体验；（4）关于策略制定和效果的现有资料。
两种策略都导致医院内护理量相对减少，而护理质量并未受到负面影响。一家医院未能充分降低运营成本，导致利润率下降。我们确定了影响这些结果的六个主要机制：（1）质量改进项目激发了变革和承诺；（2）医院和初级保健之间的协调增加导致护理替代；（3）数据和支持的使用不足阻碍了质量改进；（4）需要缩小医院设施规模才能将减少的工作量转化为成本节约；（5）通过全球预算实现的共享节约促使付款人和医院共同努力；（6）为医生提供财务保障有助于向以质量为导向的护理转变。
对混合数据源的综合分析表明，策略的全院性质促使从注重生产转向注重护理质量。旨在减缓生产增长的医院策略的长期（财务）可持续性需要在降低固定成本方面付出巨大努力。如果运营成本降低不足或付款人一致性受到影响，该策略会给医院带来财务风险。
