Intelligent Monitoring?:Assessing the ability of the Care Quality Commission's statistical surveillance tool to predict quality and prioritise NHS hospital inspections

Background The Care Quality Commission (CQC) is responsible for ensuring the quality of the health and social care delivered by more than 30000 registered providers in England. With only limited resources for conducting on-site inspections, the CQC has used statistical surveillance tools to help it identify which providers it should prioritise for inspection. In the face of planned funding cuts, the CQC plans to put more reliance on statistical surveillance tools to assess risks to quality and prioritise inspections accordingly. Objective To evaluate the ability of the CQC's latest surveillance tool, Intelligent Monitoring (IM), to predict the quality of care provided by National Health Service (NHS) hospital trusts so that those at greatest risk of providing poor-quality care can be identified and targeted for inspection. Methods The predictive ability of the IM tool is evaluated through regression analyses and Ï ‡ 2 testing of the relationship between the quantitative risk score generated by the IM tool and the subsequent quality rating awarded following detailed on-site inspection by large expert teams of inspectors. Results First, the continuous risk scores generated by the CQC's IM statistical surveillance tool cannot predict inspection-based quality ratings of NHS hospital trusts (OR 0.38 (0.14 to 1.05) for Outstanding/Good, OR 0.94 (0.80 to -1.10) for Good/Requires improvement, and OR 0.90 (0.76 to 1.07) for Requires improvement/Inadequate). Second, the risk scores cannot be used more simply to distinguish the trusts performing poorly - those subsequently rated either 'Requires improvement' or 'Inadequate' - from the trusts performing well - those subsequently rated either 'Good' or 'Outstanding' (OR 1.07 (0.91 to 1.26)). Classifying CQC's risk bandings 1-3 as high risk and 4-6 as low risk, 11 of the high risk trusts were performing well and 43 of the low risk trusts were performing poorly, resulting in an overall accuracy rate of 47.6%. Third, the risk scores cannot be used even more simply to distinguish the worst performing trusts - those subsequently rated 'Inadequate' - from the remaining, better performing trusts (OR 1.11 (0.94 to 1.32)). Classifying CQC's risk banding 1 as high risk and 2-6 as low risk, the highest overall accuracy rate of 72.8% was achieved, but still only 6 of the 13 Inadequate trusts were correctly classified as being high risk. Conclusions Since the IM statistical surveillance tool cannot predict the outcome of NHS hospital trust inspections, it cannot be used for prioritisation. A new approach to inspection planning is therefore required.</p

Steering by their own lights:Why regulators across Europe use different indicators to measure healthcare quality

Despite widespread faith that quality indicators are key to healthcare improvement and regulation, surprisingly little is known about what is actually measured in different countries, nor how, nor why. To address that gap, this article compares the official indicator sets--comprising some 1100 quality measures-- used by statutory hospital regulators in England, Germany, France, and the Netherlands. The findings demonstrate that those countries’ regulators strike very different balances in: the dimensions of quality they assess (e.g. between safety, effectiveness, and patient-centredness); the hospital activities they target (e.g. between clinical and non-clinical activities and management); and the ‘Donabedian’ measurement style of their indicators (between structure, process and outcome indicators). We argue that these contrasts reflect: i) how the distinctive problems facing each country's healthcare system create different ‘demand-side’ pressures on what national indicator sets measure; and ii) how the configuration of national healthcare systems and governance traditions create ‘supply-side’ constraints on the kinds of data that regulators can use for indicator construction. Our analysis suggests fundamental differences in the meaning of quality and its measurement across countries that are likely to impede international efforts to benchmark quality and identify best practice.</p

When ‘Must’ Means ‘Maybe’:Varieties of Risk Regulation and the Problem of Trade-offs in Europe. HowSAFE Working Paper, No. 1

This paper explains how the inevitable trade-offs between risk and cost in occupational health and safety (OHS) regulation are managed across EU member states. While trade-offs are explicitlysanctioned in UK law, many continental countries mandate ambitious goals of safety. This contrast in statutory goals appears to reflect cleavages identified in the risk regulation literature between European precaution and Anglo-Saxon neoliberal risk-taking, as well as in the Varieties of literature which suggests workers are better protected in co-ordinated than in liberal market economies. However, we challenge those claims through adetailed analysis of OHS regimes in the UK, Netherlands, Germany and France, which shows that a narrow focus on headline regulatory goals misses how each country makes cost-benefit trade-offs on safety. In particular, we show how the nature and outcome of those trade-offs substantially vary according to the degree of coupling between regulation and welfare regimes, and to national traditions of common and civil law. As such, we offer a novel explanation for risk regulation and governance variety that emphasises deep institutional differences among welfare states in the organization of the political economy and their philosophies of regulation

The American Congress and health care policies

Jusqu'au passage du Patient Protection and Affordable Care Act de 2010, loi réformant structurellement le système de santé américain, les politiques d'assurance santé aux Etats-Unis sont apparues comme particulièrement difficiles à réformer. Parmi les facteurs expliquant la résistance de ce secteur aux changements, des éléments institutionnels, tenant dans la configuration du système politique américain et dans un régime fédéral de séparation des pouvoirs, apparurent accentuer ces blocages. Cette thèse aborde cette question en réfléchissant à l'impact du Congrès américain dans la construction et dans les réformes du système de santé américain. Elle propose d'analyser l'implication des scènes législatives américaines dans ce secteur à partir d'une approche historique et qualitative mettant en relation les évolutions internes de la branche législative et la trajectoire des politiques d'assurance santé. L'objectif de cette recherche est d'aborder cette question en reliant deux sous-disciplines de la science politique : les études sur le Congrès d'une part, les analyses des politiques sociales d'autre part. Plus généralement, cette thèse aborde la question des rapports entre la politique (politics) et les politiques (policies) qui se donnent à voir au sein des scènes législatives. Constatant une accélération des réformes à partir des années 1990, elle soutient que les inflexions récentes qu'ont connues les politiques de santé trouvent leur explication dans l'évolution de l'organisation du Congrès et dans un certain renforcement de ses composantes partisanes.Until the vote of the Patient Protection and Affordable Care Act of 2010, a law that structurally reformed the American health care system, important obstacles to change characterized health care policies in the United States. Among the explanations of the gridlock inherent to this policy sector, institutional features of the American political system - a federal regime of separation of power - appeared increasing these gridlocks. This dissertation tackles this question in focusing on the impact of the Congress on the development of the American health car system. Using an historical institutionalist and a qualitative approach, it offers an analysis of the legislative branch's involvement in this issue. For that purpose, this research links internal evolutions of the Congress and the development of health care policies. This research binds two subfields of political science : Congressional studies on one hand, health care analysis on the other hand. More generally, this dissertation approaches the question of the relationships between legislative politics ans health care policy. Noticing icreased reforms from the 1990s on, it supports the idea that recent inflexions are explained by an evolution of the internal organization of the Congress and by e recent strenghening of its parties

Le temps d’une assurance maladie universelle est-il venu ?: [contribution au numéro spécial: États-Unis, quel renouveau à gauche?]

Dix ans après l’Obamacare, le système de santé étasunien reste l’un des plus chers et des plus inégalitaires de l’OCDE. La réforme de 2010 a néanmoins ouvert la voie à l’idée d’une assurance maladie universelle. Cette solution peut-elle prévaloir sur l’option publique, un approfondissement de l’Obamacare défendu par les modérés du parti démocrate

Kingdon en Afrique ? Théories de la mise sur agenda et le développement d’un programme d’assistance santé au Burkina Faso: Commentaire

L'article de Kadio et al., relatif à l’émergence et à la formulation d’une politique d’assistance santé au Burkina Faso, analyse le processus de mise sur agenda d’un programme de subventions pour aider les populations démunies à s’assurer auprès de mutuelles volontaires de santé. Sa particularité est de s’intéresser aux dynamiques politiques nationales ayant conduit à la mise en œuvre de cette politique, un angle qui est assez peu développé dans les recherches actuelles. Centré sur les acteurs et sur les processus de construction des problèmes publics, il mobilise la théorie de la mise sur agenda de John Kingdon (2003), une notion construite aux États-Unis et qui a depuis été très largement adoptée dans l’analyse des politiques publiques d’autres pays. (Premier paragraphe de l'article

The Patient Protection and Affordable Care Act: The Victory of Unorthodox Lawmaking

The 2010 Patient Protection and Affordable Care Act was a major legislative achievement of the 111th Congress. This law structurally reforms the US health care system by encouraging universal health care coverage through regulated competition among private insurance companies. When looking at the process for reform, what strikes an observer of US health care policy in the first place is that the Democratic majority was able to enact something in a political field characterized by strong resistance to change. This article builds on that observation. Arguments concentrate on the legislative process of the reform and support the idea that it may be partly explained by considering an evolution of US legislative institutions, mostly in the sense of a more centralized legislative process. Based on approximately one hundred semidirected interviews, I argue that the Democratic majority, building on lessons from both President Bill Clinton's health care reform attempt and the Republicans' strategy of using strong congressional leadership to pass social reforms, was able to overcome institutional constraints that have long prevented comprehensive change. A more centralized legislative process, which has been described as “unorthodox lawmaking,” enabled the Democratic leadership to overcome multiple institutional and political veto players.</jats:p