Through the Looking Glass

Through the looking glass

A practical path to improving healthcare through transparency Country report card: Scandinavia (Denmark, Finland, Norway and Sweden)

KPMG International kpmg.com © 2017 KPMG International Cooperative (“KPMG International”). KPMG International provides no client services and is a Swiss entity with which the independent member firms of the KPMG network are affiliated. Foreword

Each of the four Scandinavian countries has a distinct word for transparency: ‘åpenhet’ (Norway), ‘gennemsigtighed’ (Denmark), ’genomskinlighet’ (Sweden) and ’läpinäkyvyys’ (Finland). In the four scandinavian countries these are themes that have been and still are high on the agenda of health care policymakers and institutes. And not without results: Scandinavia dominates the top of KPMG’s first global transparency ranking. The global health systems transparency index show a high level of variation across 32 participating countries and the average score of 55 percent is low. But this is not the case for Denmark, Finland, Sweden and Norway, who achieved the top overall scores ranging from 69 percent to 74 percent. Those familiar with Scandinavian healthcare systems may not be surprised by these findings, which come, however, with a note of caution as transparency has two sides. On the one hand, there is good evidence that data publication drives quality improvement, better data collection and even improved health outcomes. On the other hand, transparency can undermine trust, create too much focus on particular measures, and lead to erroneous conclusions and policies.

Strategic transparency, a positive way forward

It is easy to imagine health systems awash with data that distracts from the real business of healthcare improvement and supports punitive cultures of ‘naming and shaming’, ultimately resulting in less transparent performance and decision-making. In this report we signal better practices that can bring a far more positive way forward. Our Scandinavian examples show that if transparency is applied strategically, it can make a substantial contribution to the quality and value of care.

In this report, we highlight the outcomes of each Scandinavian country and how each experience the value of transparency. We highlight good practices in order to give better insights into why the Scandinavian performance is so good — and what we can learn from each other. Through four case studies, we discuss the importance of a consistent strategy for personal healthcare data in Denmark; how Finland is creating meaningful data; quality of healthcare and measuring what matters from a Swedish perspective; and finally, how Norwegian players are taking the lead from innovative providers.

Allan Juhl Pasi Tyvvi Stefan Lundström Wencke van der Head of Health Head of Health Head of Health Meijden KPMG in Denmark KPMG in Finland KPMG in Sweden Head of Health KPMG in Norway

© 2017 KPMG International Cooperative (“KPMG International”). KPMG International provides no client services and is a Swiss entity with which the independent member firms of the KPMG network are affiliated. 4 | Through the looking glass What is a transparent health system? Transparency of health systems matters, but progress to date has been more symbolic than substantive. KPMG International’s recent report ‘Through the Looking Glass’ showed the wide variation that exists in how far different countries have pursued transparency in healthcare, with the central message that every system needs to improve how strategically it uses this powerful but potentially damaging tool.

What constitutes ‘transparency’ in Using these six dimensions we healthcare is hotly contested around the constructed a scorecard to measure Methodology world, but following a global literature each of the world’s major health This study involved several research search and interviews with experts around systems. Twenty-seven indicators were stages: the world, the following six dimensions measured for each country tracking the surfaced as the most important: extent to which different transparency — Summary literature review of practices were in effect on a systemic the evidence on health systems 1. Quality of healthcare: transparency level. Selection of the indicators was transparency of provider-level performance on the basis of published evidence measures, especially the quality of — 25 interviews with experts and interviews with experts, under the outcomes and processes. guidance of a twelve-member global — Development of the transparency 2. Patient experience: patient health system transparency steering framework and sense-testing perceptions of their healthcare group. We considered indicators that with KPMG heads of health and experience and outcomes. were: employed by other organizations interviewees to measure transparency; likely to 3. Finance: price and payments — Completion of the transparency highlight meaningful variation across transparency, and the public nature of scorecard by leaders of KPMG’s health systems; used by stakeholders to accounts for healthcare organizations. major health practices effect positive change; and, identified as 4. Governance: open decision making, important by interviewees. — Transparency scorecard data rights and responsibilities, resource collected and analyzed by country Completed transparency scorecards allocation, assurance processes and were received from 32 countries, accountability mechanisms. covering most OECD and G20 Data health warning 5. Personal healthcare data: access, countries. A composite overall ranking — It is not necessarily good to ownership, and safeguarding of score was created by summing each have a high score because patient’s individual health data. country’s score for every indicator. transparency can be harmful as 6. Communication of healthcare data: well as beneficial the extent to which all the above is — The data shows what health presented in an accessible, reliable and systems are currently doing, not useful way to all relevant stakeholders. whether the transparency is well managed, or achieving good or ill

A health system that provides accessible, reliable, useful and up-to-date information to all interested stakeholders so they can acquire meaningful understanding of the quality, patient experience, finance, governance, and individual health data associated with the health system, and make judgements on its fairness. KPMG International definition of healthcare transparency, Through the Looking Glass (2017)

Global health systems transparency index — composite results (%)

1. 2. 3. 4. 5. 6. Overall Quality of Patient Finance Governance Personal Communication Score Healthcare Experience Healthcare of Healthcare Data Data Denmark 74 67 62 83 94 93 50 Finland 72 48 46 83 88 86 93 Sweden 71 81 69 75 69 79 50 Norway 69 67 62 83 81 71 50 UK 69 57 85 83 81 57 57 Australia 68 52 62 83 88 64 64 New Zealand 67 38 54 83 94 64 79 Netherlands 67 57 85 75 69 50 71 Portugal 64 48 46 83 63 86 71 Singapore 63 57 77 83 81 43 43 Israel 62 48 92 50 56 79 57 Brazil 61 48 69 67 81 64 43 Canada 61 57 46 50 81 50 79 Spain 61 76 46 42 75 71 43 France 60 48 62 67 75 50 64 Germany 56 29 54 75 63 64 64 Italy 54 57 31 67 56 64 50 Iceland 53 43 54 75 63 50 43 Switzerland 53 33 69 67 69 57 36 R. of Korea 52 29 31 83 56 50 79 Poland 50 29 46 67 56 57 57 R. of Ireland 49 29 31 67 75 79 43 Luxembourg 47 29 46 50 63 50 50 Russia 47 33 38 67 63 50 36 Austria 46 29 31 58 56 64 43 Japan 46 48 31 67 56 43 29 Greece 43 29 38 50 69 50 29 Mexico 42 33 46 42 50 36 50 K. Saudi Arabia 38 29 31 50 50 43 29 South Africa 37 33 31 33 44 50 29 India 36 29 31 42 44 43 29 China 32 29 31 50 31 29 29 Average Score 55 44 51 66 67 59 52

70% and over 60% and over 50% and over 40% and over Lower than 40%

Globally, the average score on the transparency matrix is 55 percent, which is relatively low and suggests that there is still much more to be done. The high Scandinavian scores (from 69 to 74 percent) reflect specific structural investments by government and institutes to make these systems more transparent. Scandinavian countries score especially high in areas that reflect ‘Finance,’ ‘Governance,’ and ‘Personal Healthcare Data.’ Of course, there is also room for improvement, for example in the way that healthcare data is communicated. Ongoing policy debates in several Scandinavian countries highlight questions over the value being generated from these large investments into transparency. In this chapter we give a brief summary of the results per country and value that transparency brings.

Denmark Overall transparency 74% score =

Brief summary As one of only four countries to provide for instance adjusting vaccination free online access for all patients to their records — and enriches trust between Although Denmark achieved an up-to-date medical records, Denmark doctors and patients. On the other hand, excellent overall score, making it the is well positioned to further expand giving all patients access to all their top performing country in the entire transparency. However, significant data without consultation can create index, its scores vary across the six improvements could be made by better unnecessary anxiety, as the data is only dimensions of transparency measured. navigation methods for users, increased quantitatively filtered against standard It rates particularly high on transparency allocation and publication of patient- measures and does not communicate of ‘Governance’ (94 percent), ‘Personal reported outcomes, and publishing data the full picture (e.g. one parameter falling Healthcare Data’ (93 percent) and in open and machine-readable formats, outside standard measures with all other ‘Finance’ (83 percent). Scores for allowing independent data processing parameters being ‘in the green’). This ‘Quality of Healthcare’ (67 percent) and analysis. consequence will furthermore be biased and ‘Patient Experience’ (62 percent) to different patient groups, possibly were lower but still above average, Upsides and downsides of working against the level of doctor/ whereas transparency around the transparency patient trust established by the same ‘Communication of Healthcare Data’ The transparency of personal healthcare transparency in other patient groups. (50 percent) was the lowest performing data allows patients to report errors — dimension.

Indicator 1. 1. 1.2. 1.3. 1.4. 1.5. 1.6.

Mortality/ All- cause Hospital re- Waiting ‘Adverse Hospital- survival mortality/ admission times for event’ acquired rates for survival rates emergency reporting infections Dimension 1 individual rates care Quality of medical conditions Healthcare & treatments

(total (total (total (total (total (total possible possible possible possible possible possible Total result: score = 4) score = 3) score = 3) score = 3) score = 4) score = 4)

67% Score 3 1 3 3 3 1

Indicator 2.1. 2.2. 2.3. 2.4.

Patient Patient Patient Patient reported satisfaction approval complaints outcome Dimension 2 measures Patient

Experience

(total (total (total (total possible possible possible possible Total result: score = 3) score = 3) score = 3) score = 4)

62% Score 1 3 1 3

Indicator 3.1. 3.2. 3.3. 3.4.

Financial Prices Prices Disclosure performance patients are health of charged insurers/ payments, Dimension 3 payers are gifts and Finance charged hospitality to healthcare staff

(total (total (total (total possible possible possible possible Total result: score = 3) score = 3) score = 3) score = 3)

83% Score 3 3 3 1

Indicator 4.1. 4.2. 4.3. 4.4. 4.5.

Freedom of Patient Procurement Public Patient/ Information rights processes decision Public legislation and decision- making involvement Dimension 4 making

Governance

(total (total (total (total (total possible possible possible possible possible Total result: score = 3) score = 3) score = 4) score = 3) score = 3)

94% Score 3 3 4 2 3

Indicator 5.1. 5.2. 5.3. 5.4.

Electronic Shared clinical Patient data Information patient documentation privacy and on use of records safeguarding patient data Dimension 5 system policy Personal

Healthcare Data

(total (total (total (total possible possible possible possible Total result: score = 4) score = 3) score = 4) score = 3)

93% Score 3 3 4 3

Indicator 6.1. 6.2. 6.3. 6.4.

Accessible Up-to-date Direct Open data data data comparison formats of providers Dimension 6 and Communication services of Healthcare Data

(total (total (total (total possible possible possible possible Total result: score = 3) score = 4) score = 3) score = 4)

50% Score 1 3 2 1

Finland Overall transparency 72% score =

Brief summary for Health and Welfare maintains a Upsides and downsides of national database that includes records transparency Finland’s excellent score of 72 percent of all healthcare visits across the entire placed it in the top tier of countries on The amount of data collected and country. Furthermore, Finland publishes the transparency index. Finland scored available is generally seen as positive, but healthcare data under an open licence exceptionally high on ‘Communication also represents quite an administrative as well as in machine readable formats, of Healthcare Data’ (93 percent), burden. Additionally, stakeholders may allowing independent data processing transparency of ‘Governance’ also be concerned about the relevance and analysis. The database enables (88 percent), ‘Personal Healthcare Data’ of the data collected and the security of decision-making and research based on (86 percent) and ‘Finance’ (83 percent). highly personal information. Questions comprehensive and up-to-date statistics. Whereas transparency scores were far have been raised about the impact of lower on ‘Patient Experience’ On the other hand, Finland is weak in data collection on patient wait lists, and (46 percent), and ‘Quality of Healthcare’ ’Patient Experience’ transparency. There whether Finland should also concentrate (48 percent). is a particular need for measurement more on client experiences. Also, there and publication of patient-reported are fears that security breaches may limit ’Communication of Healthcare Data’ outcomes, and patient satisfaction and the gathering of personal information relies heavily on patients’ free and approval ratings. Public reporting of this in the future. Finland has benefited in easy access to their electronic medical data would further advance transparency several ways from its high transparency, records and on a wide database of of the overall Finnish healthcare system. but needs to ensure that it continues healthcare data available on a national to focus on areas seen as central to the level. The Finnish National Institute development of the country’s healthcare system further.

Indicator 1. 1. 1.2. 1.3. 1.4. 1.5. 1.6.

(total (total (total (total (total (total Total result: possible possible possible possible possible possible score = 4) score = 3) score = 3) score = 3) score = 4) score = 4)

48% Score 3 1 1 1 1 3

Indicator 2.1. 2.2. 2.3. 2.4.

Patient Patient Patient Patient reported satisfaction approval complaints outcome Dimension 2 measures Patient Experience

(total (total (total (total Total result: possible possible possible possible score = 3) score = 3) score = 3) score = 4) 46% Score 1 1 1 3

Indicator 3.1. 3.2. 3.3. 3.4.

Financial Prices Prices Disclosure performance patients are health of charged insurers/ payments, Dimension 3 payers are gifts and Finance charged hospitality to healthcare staff

(total (total (total (total possible possible possible possible Total result: score = 3) score = 3) score = 3) score = 3)

83% Score 3 3 3 1

Indicator 4.1. 4.2. 4.3. 4.4. 4.5.

Freedom of Patient Procurement Public Patient/ Information rights processes decision Public legislation and decision- making involvement Dimension 4 making Governance

(total (total (total (total (total Total result: possible possible possible possible possible score = 3) score = 3) score = 4) score = 3) score = 3)

88% Score 3 3 3 3 2

Indicator 5.1. 5.2. 5.3. 5.4.

Electronic Shared clinical Patient data Information patient documentation privacy and on use of records safeguarding patient data Dimension 5 system policy Personal Healthcare Data

(total (total (total (total Total result: possible possible possible possible score = 4) score = 3) score = 4) score = 3)

86% Score 4 1 4 3

Indicator 6.1. 6.2. 6.3. 6.4.

Accessible Up-to-date Direct Open data data data comparison formats of providers Dimension 6 and Communication services of Healthcare Data

(total (total (total (total Total result: possible possible possible possible 93% score = 3) score = 4) score = 3) score = 4) Score 3 3 3 4

Sweden Overall transparency 71% score =

Brief summary their up-to-date medical records online. service. However, outcomes in terms As yet, there is no national coordinated of medical results in anonymized form Like the other top-performing countries, electronic patient record system. are not yet publicly available. Apart Sweden’s scores vary across the six ‘Finance’ is another positive performer from legislative challenges in publishing dimensions of transparency measured. (scoring 75 percent), with all healthcare outcomes, the practice of connecting The ‘Quality of Healthcare’ dimension providers publishing annual reports care outcomes with providers is viewed (scoring 81 percent) is a particular with independently audited financial by some stakeholders as sensitive and strength, with Sweden being the only accounts. An even higher score could be underdeveloped. country in the index to achieve a bonus achieved on this dimension if there was point for publishing hospital-acquired Upsides and downsides of public reporting of all payments, gifts and infections (HAI) at the ward or clinical transparency hospitality made to healthcare staff. level, thanks to an annual national In Sweden transparency has increased prevalence survey of HAI within all In terms of transparency of ‘Patient pressure on the healthcare sector for hospitals (results are publicly reported). Experience (69 percent), a nationwide clear and continuous improvement. The patient experience survey is conducted The comparatively strong performance fact that patients and other stakeholders bi-annually, covering all primary care, for transparency of ‘Personal Healthcare have become more informed should emergency care, special somatic care Data’ (79 percent) was achieved because be seen as an opportunity rather than a and psychiatric care providers. Although patient data privacy and safeguarding threat. Transparency enables healthcare more frequent surveys are preferable, is a legal obligation in the country, with systems to utilize and involve patients in the results still give an indication of the the law regulating who can access new ways in order to co-create solutions patient experience. Stakeholders can patient data. Transparency could still be and effective care. now compare individual care providers further advanced however, since most in terms of patient experience, through (but not all) patients are able to access the “1177”, national care guidance

Indicator 1. 1. 1.2. 1.3. 1.4. 1.5. 1.6.

(total (total (total (total (total (total Total result: possible possible possible possible possible possible score = 4) score = 3) score = 3) score = 3) score = 4) score = 4)

81% Score 3 1 3 3 3 4

Indicator 2.1. 2.2. 2.3. 2.4.

Patient Patient Patient Patient reported satisfaction approval complaints outcome Dimension 2 measures Patient

Experience

(total (total (total (total Total result: possible possible possible possible score = 3) score = 3) score = 3) score = 4) 69% Score 2 3 1 3

Indicator 3.1. 3.2. 3.3. 3.4.

Financial Prices Prices Disclosure performance patients are health of charged insurers/ payments, Dimension 3 payers are gifts and Finance charged hospitality to healthcare staff

(total (total (total (total possible possible possible possible Total result: score = 3) score = 3) score = 3) score = 3)

75% Score 3 3 2 1

Indicator 4.1. 4.2. 4.3. 4.4. 4.5.

Freedom of Patient Procurement Public Patient/ Information rights processes decision Public legislation and decision- making involvement Dimension 4 making Governance

(total (total (total (total (total Total result: possible possible possible possible possible score = 3) score = 3) score = 4) score = 3) score = 3)

69% Score 2 3 2 3 1

Indicator 5.1. 5.2. 5.3. 5.4.

Electronic Shared clinical Patient data Information patient documentation privacy and on use of records safeguarding patient data Dimension 5 system policy Personal

Healthcare Data

(total (total (total (total Total result: possible possible possible possible score = 4) score = 3) score = 4) score = 3) 79% Score 2 2 4 3

Indicator 6.1. 6.2. 6.3. 6.4.

Accessible Up-to-date Direct Open data data data comparison formats of providers Dimension 6 and Communication services of Healthcare Data

(total (total (total (total possible possible possible possible Total result: score = 3) score = 4) score = 3) score = 4)

50% Score 2 2 1 2

Norway Overall transparency 69% score =

Brief summary notes. Transparency is advancing on this giving patients access to their own dimension as more and more patients medical data; avoidable events are Norway’s overall score of 69 percent get access to their up-to-date electronic discussed and published; even doctors’ places the country fourth in the medical records through the portal ‘My salaries are public information. But there transparency index. Once more, there Health’ at Helsenorge. Access to medical is an ongoing national debate about the is some variation in how Norway records, however, still varies according to downside of this transparency. People performs across the six dimensions of health region. working in healthcare experience a very transparency. Norway recorded very high administrative burden, which has led high scores for transparency of ‘Finance’ Transparency of ‘Patient Experience’ to discussions about the use of the data and ‘Governance’ (83 percent and 81 could be advanced further through and indicators. Although it has enjoyed percent respectively). Relatively good the publication of patient reported improvements in quality and efficiency, scores were achieved for transparency of outcomes (PROMS) for a range of Norway has also seen some adverse ‘Personal Healthcare Data’ (71 percent), inpatient and outpatient medical events. For example the publication ‘Quality of Healthcare’ (67 percent), treatments. There is also room for of wait times, and the monitoring of and ‘Patient Experience’ (62 percent). improvement in ‘Communication of “number of patients that were not However, the transparency score was Healthcare Data.’ While most data on getting an appointment before a certain significantly lower on ‘Communication of quality of healthcare is easily accessible period” appears to have created internal Healthcare Data’ (50 percent). through the Helsenorge portal, and therefore “invisible” waiting lists. patient experience data is not kept In relation to ‘Personal Healthcare Data,’ on a dedicated website and has to be Doctors have also raised concerns about it is encouraging to note that patient accessed through individual hospitals’ the consequences of patients accessing data privacy and safeguarding is a legal websites, with published data not their medical records, as they feel obligation in the country. At the time regularly kept up-to-date. restricted in making notes, fearing that of measurement, about 70 percent they may cause unnecessary anxiety of Norwegian patients were able to Upsides and downsides of amongst patients and their families. access information about their health transparency through a new electronic platform In general, Norway has a transparent ‘kjernejounal.’ Patients are also able to health system. Outcomes are published, add/edit this information and include

Indicator 1. 1. 1.2. 1.3. 1.4. 1.5. 1.6.

Healthcare conditions & treatments

(total (total (total (total (total (total possible possible possible possible possible possible Total result: score = 4) score = 3) score = 3) score = 3) score = 4) score = 4)

67% Score 3 3 1 1 3 3

Indicator 2.1. 2.2. 2.3. 2.4.

Patient Patient Patient Patient reported satisfaction approval complaints outcome Dimension 2 measures Patient

Experience

(total (total (total (total possible possible possible possible Total result: score = 3) score = 3) score = 3) score = 4)

62% Score 1 3 1 3

Indicator 3.1. 3.2. 3.3. 3.4.

Financial Prices Prices Disclosure performance patients are health of charged insurers/ payments, Dimension 3 payers are gifts and Finance charged hospitality to healthcare staff

(total (total (total (total possible possible possible possible Total result: score = 3) score = 3) score = 3) score = 3)

83% Score 3 3 3 1

Indicator 4.1. 4.2. 4.3. 4.4. 4.5.

Freedom of Patient Procurement Public Patient/ Information rights processes decision Public legislation and decision- making involvement Dimension 4 making Governance

(total (total (total (total (total Total result: possible possible possible possible possible score = 3) score = 3) score = 4) score = 3) score = 3) 81% Score 3 3 1 3 3

Indicator 5.1. 5.2. 5.3. 5.4.

Electronic Shared clinical Patient data Information patient documentation privacy and on use of records safeguarding patient data Dimension 5 system policy Personal

Healthcare Data

(total (total (total (total Total result: possible possible possible possible score = 4) score = 3) score = 4) score = 3)

71% Score 1 2 4 3

Indicator 6.1. 6.2. 6.3. 6.4.

Accessible Up-to-date Direct Open data data data comparison formats of providers Dimension 6 and Communication services of Healthcare Data

(total (total (total (total Total result: possible possible possible possible 50% score = 3) score = 4) score = 3) score = 4) Score 2 1 2 2

If transparency is to deliver its future potential, it must be better managed. Our global research identifies seven different features that all health systems should consider more seriously to unlock these benefits — and avoid the risks — of transparency. In this mini report we highlight one case study for each of the four Scandinavian countries.

Case 1: Personal Healthcare data — a consistent strategy from Denmark

The government of Denmark offers a national clinical and administrative In order to make communication a good example of how a consistent standard (known as SKS). Data and information exchange between strategy for data transparency and from LPR is used in several ways, the public sector, businesses, ICT-based interactions between including a number of national and citizens as easy as possible, the public sector and citizens can health registers (like cancer and birth the government supports a wide create transparency across the records), as a basis for central and variety of digital tools and solutions, board. Denmark has successfully local funding models, clinical quality ranging from the implementation of created a positive policy and databases, and health research. an electronic signature to specific legislative environment, supported The breadth and depth of the data websites aimed at citizens. NemID by a governance model that focuses effectively makes the whole nation a (EasyID), a digital signature for single on high quality of services and cohort. log-in for both public and private self- management, which in healthcare service solutions (based on Public Building on this foundation, Denmark translates to quality of care. Key Infrastructure), gives access has seen a significant roll-out of IT to all public authority self-service The high level of transparency of services within the whole healthcare solutions. These include Sundhed.dk, personal healthcare data in Denmark sector, with hospitals, general the official portal for the public Danish is an achievement built on three key practitioners and municipalities Healthcare Services, and enable stepping stones. leading the way. A key player has citizens and healthcare professionals been MedCom, a public funded, Firstly, since 1968 Denmark has to find information and communicate non-profit cooperation that facilitates given all nationals (and people with with the sector. The portal facilitates cooperation between authorities, a residence permit) a personal patient-centered digital services that organizations and private firms linked identification number (Central provide access to and information to the Danish healthcare sector, by Personal Registration (CPR) number) about Danish healthcare services. developing standards and profiles used as a common identifier across regarding exchange of healthcare With a personal registration number the public sector as well as part of related data throughout the entire as identifier, a national registry and the private sector. Danish healthcare sector. administrative standard providing Secondly, in 1977 Denmark the structured data foundation, Thirdly, Denmark has a robust and established a national patient and a consistent cross-national ICT carefully planned information and registry. Every time a patient has infrastructure to make data available communications technology (ICT) recorded contact with a hospital, to the public (in aggregated format) infrastructure, with good, reliable selected data related to the contact and the patient (via micro data), solutions. Since 2001, Denmark has is registered and incorporated into Denmark has established a pathway had a nationwide digitization strategy, the National Patient Registry (LPR). to a high level of transparency in covering increasingly complex parts The data is gathered and reported in personal healthcare data. of the interaction between citizens a strictly structured format based on and the public sector.

Case 2: Meaningful data from Finland

Healthcare in Finland is strongly healthcare data and make up-to- to-date information about the use guided by legislation. This steers date online requests for prescription of healthcare services, availability professionals to systematically renewals. (http://www.kanta.fi/). of treatment, population health register patient information and problems, epidemics, services for Finland has a long tradition of treatment. All healthcare providers promoting health and practices healthcare data collecting, with are obligated to register healthcare of treatment, and responsibilities established procedures for visits into a national register (called of professionals. Information is service providers for reporting and Hilmo and AvoHilmo) provided by available under an open licence and registering healthcare actions. This the National Institute for Health and is used primarily for decision-making, culture of conscientious reporting Welfare. Recent national reforms of research and development. and registering is the basis for a information systems have promoted nationwide database of healthcare All healthcare providers must report the availability of patients’ health data. healthcare actions to the national information and improved the database (Hilmo, Avohilmo). In most processes for data collecting. Today, all The task of collecting healthcare cases data collecting is automated, of the public and most of the private statistics has been entrusted to the with interfaces to patient information healthcare providers use the national National Institute for Health and systems. Standardized and centralized data system, Kanta. Kanta services Welfare, which also maintains the data collecting makes the data include the electronic prescription, national database for healthcare comprehensive and comparable. Pharmaceutical Database, My Kanta visits. All these statistics are part pages, and Patient Data Repository. of a centralized national register for * KPMG in Finland interviewed Mr. The National data system allows healthcare data. The database works Pasi Pohjola, Senior Specialist at patients to view and edit their own on open licence and provides up- Ministry of Social Affairs and Health.

Case 3: Quality of healthcare measuring what matters in Sweden

With its long history of science control costs has been to compare 110 national quality registers in and engineering Sweden remains best practice by exchanging Sweden containing individualized among the world’s top five countries information about outcomes and data about medical interventions, in terms of percentage of gross identifying the best intervention for procedures and outcomes. Apart domestic product (GDP) invested in a given type of diagnosis. Influenced from being integrated into clinical research and development. In parallel by American practices in evidence- workflows, each registry is supported and throughout the 20th century, based medicine, Sweden started its by an organization of healthcare Sweden has promoted and protected first quality register in 1975 within professionals, researchers and patient public health and medical care, knee replacement, shortly followed representatives. through reforms and a political vision. by a registry for hip replacement. National quality registries in Sweden Evidence-based medicine, where Being given access to the growing have had an important and positive measurement is central, has been set of data, Swedish orthopedic impact on healthcare results, where driven by legislation, for instance the professionals could identify what the country has among the best Patient Safety Act, which demands replacement types and working survival rates following heart attacks, that healthcare professionals provide methods were most effective. strokes, breast and colorectal cancer. care in line with scientific and tested Today, Sweden is a world leader in experience. As a result of close orthopedics, thanks in large part to The Swedish example shows that cooperation between science, shared outcomes data. transparency and coordinated entrepreneurs and clinical research, sharing of outcomes can contribute The work with evidence-based innovation in medical technology and significantly to improved nationwide medicine and quality registers pharmaceuticals has accelerated healthcare. To follow the Swedish has continued and expanded. and provides an important basis example, development of quality In the 1990s, initiatives were for development of the Swedish registers should start small, focus on taken to coordinate quality work, healthcare system. a limited number of diagnoses and including registers via a national assure good data governance. Today, However, increasing costs, limited forum, a cooperation between international quality data is starting to resources and lack of coordination The National Board of Health and become available and is sought after have forced medical professions Welfare (Socialstyrelsen) and county by many healthcare systems. to focus on efficiency. One way to councils. Today there are some

Case 4: Taking the lead from innovative providers in Norway

Why is Norway performing so well to account. The hospital even took — strong visionary leadership from on governance? And what is a key the case to the Civil Ombudsman innovative providers is a good success factor in taking the lead from and won; the hospital was blamed basis for national policy, such innovative providers? for the incidents. This sent a clear as the hospitals adverse events message, not just to the workforce system which is now common What we have seen in Norway is but across Norway, that staff would practice across Norway that regulation and legislation alone be protected if they reported errors. do not change hearts and minds; — data can be used effectively to The important lesson was not to healthcare is simply too complex improve care quality if clinicians apportion blame for errors, but to for transparency initiatives to be are ‘on side’ and feel a sense learn from them. successful if they are ‘done to’ of ownership in developing the the system. Most constructive Another great development is measures innovation happens locally by the structural way Sykehuset — to raise care quality, it is more individual organizations that are Østfold now deals with adverse important to focus on the inspired to improve. events. When reported, an event hospital’s internal improvement is discussed in the hospital’s One of the examples is Sykehuset targets and benchmarking, than patient harm group, which agrees Østfold. Their CEO, Just Ebbeson, on comparative performance what should be done differently to personally won the transparency with other Norwegian hospitals prevent a repeat occurrence, and award (åpenhet) in 2016 competing (given the huge variation in size of helps ensure necessary changes against all Norwegian organizations institution and range of medical are implemented. A full report of across all sectors. When Ebbeson situations) the incident and improvement started as CEO in 2009, the hospital policy and practice is placed on — outcomes are determined group did not score well on quality the hospital website. Within a by team competence and performance indicators and he year of the introduction of this organizational systems — not by looked for ‘early wins’ to change practice, other Norwegian hospitals individual performance; and the culture. One of his first actions started following this model, which was to help all staff recognize that — being open and transparent has recently been adopted as mistakes and errors are systemic, changes the approach of the government policy for all hospitals. not individual, failures. When two media; they are less inclined staff members were placed under The experience of Sykehuset Østfold to attack and more prepared to review for malpractice by the national provides some valuable lessons acknowledge steps are being quality inspectorate, the Board in transparency at the individual taken to prevent a re-occurrence. immediately complained that the provider level: hospital, not the staff, should be held

The population is increasingly expecting this kind of transparency. Either we react to it slowly and it happens to us...or we are active and drive it, and shape it ourselves, which helps us to learn and build trust and a better conversation around healthcare. Just Ebbesen, CEO, Sykehuset Østfold, Norway

Denmark: Finland: Sweden: Allan Juhl Pasi Tyvvi Stefan Lundström Head of Health Head of Health Head of Health KPMG in Denmark KPMG in Finland KPMG in Sweden T: +45 2632 9418 T: +358 20 760 3089 T: +46 8 7239652 E: [email protected] E: [email protected] E: [email protected]

Norway: Wencke van der Meijden Head of Health KPMG in Norway T: +47 4063 9345 E: [email protected]

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