Healthcare quality assessment in Austria

In this project we study a prominent aspect of recent healthcare reforms initiatives to measure the quality of healthcare and related attempts to make healthcare services transparent and comparable for different stakeholders through calculative practices. The measurement of quality becomes increas- ingly important against the background of cuts in public funding and the fostering of performance- based competition between providers of healthcare. At the same time, operationalizing and measuring the quality of healthcare can be seen as highly problematic, where many possible indicators exist as proxies for the notion of quality. We study the practice of quality assessment in the specific context of the recent healthcare reform in Austria, investigating how calculative practices construct quality of healthcare; the challenges, opportunities and limitations of quality assessment in healthcare; and the intended and unintended ways in which these quality assessments come to impact healthcare practice. Our project is based on the insight that concepts and methods of quality assessment are not simply straightforward functional, purely technical solutions to existing problems, because the for- mulation of such problems is framed in terms of fashionable management techniques and prevailing political ideas about healthcare, the welfare state and public management more generally. Such dis- courses may contain ideas about the significance and meaning of quality, how quality is related to efficiency of healthcare systems, or whether healthcare systems should be organized as public or pri- vate services. We therefore pursue two interrelated research questions. First, we study how the focus on quality and quality assessment has emerged in the Austrian healthcare system and how it is related to more encompassing discourses, such as value-based healthcare, evidence-based medicine and quality management. This analysis allows us to identify and critically discuss taken-for-granted ideas and institutions that influence and are promoted by the recent initiatives to make healthcare quality measurable. For this purpose we will perform a critical discourse analysis of the healthcare discourse. Secondly, we will investigate how the general ideas, concepts, and regulations of quality measurement are translated into quality-related practices in hospitals, which challenges occur, and what solutions the different actors find to cope with these challenges. For this purpose we will conduct three ethnographic case studies in Austrian hospitals. On the one hand, this project will analyze the quality assessment in healthcare in terms of their context dependency, and precisely how global discourses about good healthcare management are translated into local practices. On the other hand, the project will provide new insights into problems, limitations and strategies for improvement of quality assessment in healthcare in practice. The results of the project are relevant for policy makers; institutions involved in quality assessment in healthcare; healthcare professionals; and patients and patient organizations.

In this project we studied the emergence and practice of a major initiative to measure the quality of healthcare and related attempts to make healthcare services transparent and comparable for different interest groups in Austria. This system - the "Austrian Inpatient Quality Indicators" (A-IQI) - measures the quality of hospital services by systematically recording adverse outcomes of hospital treatments, such as complications, re-admissions, or even deaths. The values for each hospital are compared to the national average results, and hospitals must plausibly explain below-average results ("comply-and-explain" approach). In severe cases, a team of external physicians comes to visit the hospital - a so-called "peer review" - and makes suggestions for quality improvement. The first study part investigated how A-IQI emerged and became institutionalised as a national compulsory quality assessment system using a re-search approach termed "discourse analysis". We find that a precursor was developed in Lower Austria in the wake of major quality scandals in hospitals against initial resistance of medical professionals as well as local politics. We trace how this quality assessment system then became accepted because it was focusing on learning and improvement, and how it then became taken over by the Austrian Ministry for Health. In this process, the system lost its supporting character and became more and more a mere ritual. We connect these findings specifically to peculiarities of the Austrian political system. The second study part investigated how A-IQI is dealt with in hospitals. For this purpose, we studied several hospitals using so-called "ethnographic research". This means that researchers observed what is going on, in part participate in activities, and formally interview people. We find that A-IQI has only very limited impact on quality assurance practices in the hospitals we studied. The quality data are usually only known to and handled by some quality specialists and the top management of the hospitals, i.e., the directorate of the hospital and chief physicians. In general, the A-IQI system is not well-known by other people in the hospitals' administration and medical personnel. Moreover, A-IQI data only are accorded significance in case of extremely negative results which may trigger a peer review - which has become more and more rare over the years. We find that the A-IQI system has become more and more insignificant due to lack of consequences but also due to the political interest to keep up the image of "the world's best healthcare system". Also, the idea of creating transparency on healthcare quality for prospective patients has not been realised specifically as significant parts of the quality data are not publicly available. This lack of access to health data has also been criticised by many researchers in the course of the recent COVID-19 pandemic.