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					         Quality management
   in psychosomatic rehabilitation


                             Uwe Koch
                          Stephan Kawski




University Hospital Hamburg-Eppendorf, Dept. for Medical Psychology
                      koch@uke.uni-hamburg.de
                        Universitätsklinikum Hamburg-Eppendorf, Abteilung für Medizinische Psychologie
    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



                         Universitätsklinikum Hamburg-Eppendorf, Abteilung für Medizinische Psychologie
     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




                          Universitätsklinikum Hamburg-Eppendorf, Abteilung für Medizinische Psychologie
    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




                              Universitätsklinikum Hamburg-Eppendorf, Abteilung für Medizinische Psychologie
 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


                       Universitätsklinikum Hamburg-Eppendorf, Abteilung für Medizinische Psychologie
              Aims of the project

• Realization of legal requirements
• Strengthening of result quality
• Establishment of quality standards
• Development of an information system



                   Universitätsklinikum Hamburg-Eppendorf, Abteilung für Medizinische Psychologie
        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




                         Universitätsklinikum Hamburg-Eppendorf, Abteilung für Medizinische Psychologie
            Structure of the 5-point program
PP 1                PP 2                            PP 3                       PP 4

       structures     patient therapy                       quality                        patient
  and concepts             plans                           screening                  questionnaires




                                         analyses




                                        quality circle




                              Universitätsklinikum Hamburg-Eppendorf, Abteilung für Medizinische Psychologie
   PP1: Structure quality
                     Goals
• 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

               Universitätsklinikum Hamburg-Eppendorf, Abteilung für Medizinische Psychologie
          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

                           Universitätsklinikum Hamburg-Eppendorf, Abteilung für Medizinische Psychologie
    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

                              Universitätsklinikum Hamburg-Eppendorf, Abteilung für Medizinische Psychologie
                     1996 Structure assessment
  Staff density (Beds per full position)
                                     No focus               Focus                Focus
                   All clinics                                                                   PA and BT
                                    (BT or PA)               PA                   BT
Professional   Mea
                      min    Max        Mean                 Mean                Mean                Mean
group           n


Physicans      13      7     25          13                   12                  14                  13
(PT)

Psychologist   38      9     184         55                   46                  20                  35
s (PT)

Physicians
and            9       5     26          12                    8                   8                   9
psychologist
s (PT)
                     N=69               n=8                  n=22                 n=13               n=26
                                   Universitätsklinikum Hamburg-Eppendorf, Abteilung für Medizinische Psychologie
            Access to process quality
                   Peer 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)

                            Universitätsklinikum Hamburg-Eppendorf, Abteilung für Medizinische Psychologie
       Sections of the checklist



A) Anamnesis
B) Findings
C) Therapeutic goals
D) Therapy plans
E) Process and epicrisis
F) Socio-medical statement
G) Further therapeutic measurements


              Universitätsklinikum Hamburg-Eppendorf, Abteilung für Medizinische Psychologie
      Physician’s report in free form
                 Prescribed structure
• General and clinical               • Admittance findings,
  anamnesis                            previous findings,
• Current complaints and               supplementary diagnostics
  restrictions of function           • Rehabilitation diagnoses and
• Present therapy,                     rehabilitation goals
  responsible physicians             • Course of rehabilitation
• General social anamnesis           • Result of rehabilitation
• Occupational and                   • Socio-medical epicrisis
  professional anamnesis



                       Universitätsklinikum Hamburg-Eppendorf, Abteilung für Medizinische Psychologie
                      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




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


                            Universitätsklinikum Hamburg-Eppendorf, Abteilung für Medizinische Psychologie
                               Peer Review 2000
                Summarizing evaluations
                                             No            Some        Considerable       Severe
                Area                   insufficiencies insufficiences insufficiencies insufficiencies
                                                                                                      Number

(A) Anamnesis                               30.6           46.7            19.2             3.5          1440

(B) Findings                                24.5           44.4            25.6             5.5          1432

(C) Therapy goals and plans                 33.7           40.1            18.9             7.2          1426

(D) Process and epicrisis                   30.3           43.3            20.3             6.1          1434

(E) Socio-medical statement                 40.0           36.8            16.3             6.9          1432

(F) Further therapeutic measurements        37.9           43.1            14.4             4.6          1442

Total rehabilitation process                21.4           45.8            27.2             5.7          1433



                                        Universitätsklinikum Hamburg-Eppendorf, Abteilung für Medizinische Psychologie
                          Peer Review 2000
   Evaluations of individual aspects
Area of indication: Psychosomatics                                                       (% “severe
                                                                                       insufficiencies“)

       (A) Anamnesis                      Admittance diagnosis stated (A.1.8)                 28.3
                                          Rehabilitation preparationand access (A.9.2)        22.2
       (B) Findings                       Psychodynamic findings (B.2.2)                      24.0
                                          Test psychological findings (B.2.4)                 17.8
                                          Behavior recources (B.2.6)                          23.8
                                          Aggregation of the diagnostics (B.4)                17.9
       (C) Therapy goals and planning Goals discussed with patients (C.3)                     22.8
                                          Health information/adequate training (C.6)          15.7
       (D) Process and epicrise           Result: Patient self-evaluation (D.6.2)             17.2
       (E) Socio-medical statement        Qualitative eval. of capacity assessment (E.2.1)    15.8
                                          Patient self-evaluation (E.4)                       29.7
       (F) Further measures               Patient's own plans (F.3)                           24.4



                                     Universitätsklinikum Hamburg-Eppendorf, Abteilung für Medizinische Psychologie
               PP3 “Peer Review”
            Summary of results

• Procedure: Suitable for differentiation

• Test-theoretical security

• Usefulness for internal quality management




                    Universitätsklinikum Hamburg-Eppendorf, Abteilung für Medizinische Psychologie
                          Program point 4
                         Patient 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

                              Universitätsklinikum Hamburg-Eppendorf, Abteilung für Medizinische Psychologie
                    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)


                      Universitätsklinikum Hamburg-Eppendorf, Abteilung für Medizinische Psychologie
                              Patient survey 1999
              Measures / Satsifaction
                                          Participation                          Satsifaction
Measure                         Pychosomatics      Addiction        Psychosomatics        Addiction

Group therapy                       89.1              99.6                50.5                  62.4

Individual conversation             88.5              93.5                68.0                  79.3

Family / Couple therapy              3.5              35.2                                      70.1

Partner / Relatives seminar          .2               28.1                                      76.3

Occupational therapy                14.7              66.5                59.1                  57.1
Social and professional
                                    20.4              27.8                44.8                  57.1
counseling
Relaxation therapies                91.0              73.8                67.6                  76.1

Creative therapies                  46.9              45.3                73.4                  64.3

ergotherapy                         41.6              84.9                75.2                  60.3

Sport and movement therapy          91.6              93.9                81.0                  70.8

Physical therapy                    53.7              26.5                80.8                  68.9

Training                            49.1              39.1                72.8                  68.8




                                    Universitätsklinikum Hamburg-Eppendorf, Abteilung für Medizinische Psychologie
                           Patient survey 1999
    Satisfaction: Personal care
                                                         Psychosomatics              Addiction

General questions on the rehabilitation              Satisfied   Dissatisfied Satisfied   Dissatisfied

Correct clinic                                          63.3         12.1        77.2         11.0

Physician care during the rehabilitation

Sufficient personal care                                53.9         23.2        60.7         18.9

Sensitive and understanding                             66.7         12.6        62.4         15.7

Intelligible explanations                               55.7         21.1        60.9         18.1

Personal care by nursing care staff

Well cared for and counseled                            69.9         11.0        67.1         10.1

Psychotherapeutic care

Opportunity to address problem areas                    57.4         17.3        72.4         14.0



                                      Universitätsklinikum Hamburg-Eppendorf, Abteilung für Medizinische Psychologie
                             Patient survey 1999
Personal care planning / Organization
                                                       Psychosomatics               Addiction


    Rehabilitation plan and goals                   Satisfied   Dissatisfied   Satisfied Dissatisfied


    Coordination of rehabilitation goals and
                                                      53.9         21.1          56.9        20.6
    treatments


    Patients learn to cope with their limitations     48.7         25.7          62.5        16.1


    Organization

    Organization of the procedures in the clinic      62.4         13.3          59.2        16.7

    Alternating therapists                            74.7         11.6          77.7         9.6




                                       Universitätsklinikum Hamburg-Eppendorf, Abteilung für Medizinische Psychologie
                        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


                         Universitätsklinikum Hamburg-Eppendorf, Abteilung für Medizinische Psychologie

				
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