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Short report of the EPSO Conference in Porto, May 8th and 9th 2014.


Report by: Jan Vesseur & Dirk Meijer

Date: May 21th 2014/June 25th 2014.


Day 1, May 8th 2014.


        Welcome and opening remarks by Prof. Jorge Simões, president of the board of Portuguese Health Regulation Authority: ‘Entidade Reguladora da Saúde’ (ERS).

The meeting was opened by the acting chairman Glenn Houston. He thanked ERS for hosting the 17th EPSO Conference.

Prof. Jorge Simões welcomed the delegates in Porto.


Economic Regulation and Financial aspects of Inspection

        Introduction highlighting the position of ERS as supervisory organisation in Portugal and recent changes by  Prof. Jorge Simões, Portugal .

Prof. Simões gave an introduction to the health system in Portugal and the ERS. ERS is fully funded by fees. Although the resources are moderate, ERS has a great coverage of the “market”.


        Health policy and health system changes in times of crisis: challenges for regulators and supervisors; A presentation about the health care reforms in Portugal set up by the troika and how they bring new challenges for the health regulator; What are the main changes in health systems under financial and economic stress? Are new challenges for regulatory and supervisory organisations emerging? a Portuguese perspective by Dra. Margarida França, Portugal.

Dra. Margarida França gave a presentation on the changes in the health system in Portugal that were introduced by the financial and economic crisis. Due to the interference of the troika actions were taken. These actions led to successful results, comparable with other troika countries like Ireland.


        Financial Risk – financial and management indicators: financial problems in the social care sector seem to have serious impact on the quality of healthcare and the qualitative results of health care institutions in this sector; if this proves to be the case also in other sectors and other countries this could help supervisory organisations with early detection of quality failure and risk selection by Pieter van Dijk, Netherlands.

Pieter van Dyk introduced a dashboard for monitoring the quality of health care institutions, based on a set of financial parameters. This system is now able to act as a early warning system for situations that may lead to severe management and quality issues in health care institutions. A further feature will be the use of disaster scenario’s to make the predictive capability of the system more precise.


         Presentation of  Results of a Review  on  Financial Misuse in  health institutions in Northern Ireland  by Theresa Nixon , RIQA,Northern Ireland.

Theresa Nixon gives a presentation on financial misuse towards budget users. These people are given a certain budget to get health care, but intermediary organisations abuse these budgets for other purposes. Now a system of checks and safeguards is set up to diminish the financial risks.


        Presentation of the first results of the EPSO survey on Economic regulation and supervision of health services:

-          Missions and responsibilities of EPSO members related to market competition and business relationships in health care;

-          Main problems of health systems in these economic dimensions;

-          Regulatory approaches to such problems.

Cesar Carneiro, ERS, Portugal gives a presentation on the first results of the survey on economic regulation and supervision on health care. It turns out that health inspectorates are barely involved in financial systems and supervision.

The Working Group will continue and try to find partners that are also involved in the financial issues. The EPSO members will be updated on the proceedings of this group.

Ongoing EPSO topics

        Risk Management and Risk indicators Current state of affairs and recent  developments in the area of Risk management and Risk indicators ; Planned activities of the new EPSO working group on Risk management (proposed group members: France – Bruno Lucet (chair) Netherlands–Ine Borghans , Pieter van Dijk, Perry Koevoets ;Sweden –Janna Kokko, Anita Bashir Aréen; UK– Scotland–Steven Wilson; UK–England– CQC; Norway– Geir Sverre Braut; Denmark –Anne Mette Dons, Portugal–César Carneiro , Prof. Álvaro Moreira da Silva; ISQUA– Peter Carter).

This EPSO working group is based on the discussion, in Utrecht and Brussels about the risk matrix and IRIS program of the Dutch health inspectorate which aimed to support evidence and risk based selection of inspection cases. The group is working  on an inventory of the state of affairs in the various EPSO member states (a monograph per country on selected topics), to deepen the conceptual framework and to analyze tools and methods available on the risk assessment topic. Other members with a specific interest or experience in the field of Risk Management and Risk indicators have joined the working group.


Bruno Lucet (France)  will present  results of a recent visit of the French inspectorate to the Netherlands  and effective exchange of ideas and will present  planned activities of the working group in England and Scotland .

Bruno Lucet presented the present situation of the working group on risk management. The focus is now on data handling so data can be transferred into a dashboard. This process needs a good strategy for data aggregation. The experience of Pieter van Dyk can be very usefull in this respect. Now a road map and an action plan are developped by the working group.

Lisa Annaly (England) will set out the direction CQC (England) is taking on Risk issues ;she presents the ‘intelligent monitoring tool ‘ which is a tool that assesses risks to inform CQC on questions regarding  prioritisation of inspections.

Lisa Annaly gave a presentation on how indicators and quality scores are used by CQC to set up a system of intelligent monitoring of health care institutions. The first publication got a lot of media coverage, the second report hardly any. In the first report the word “risk” was used to express potential quality problems in health care institutions, in the second report the word “risk” was replaced by “priorities for inspection”.


        The SINAS (quality ratings) project by the Portuguese Health Regulation Authority; focus on risk indicators by Prof. Álvaro Moreira da Silva, Portugal.

Prof. Álvaro Moreiro da Silva presented the SINAS-system. This system is used to benchmark hospitals and dentists in Portugal. Both State and private health care providers are included in this benchmark system. It is a multi-dimensional system. The results are available for the public.


        Media and Social Media in relation to health inspectorates

-          Impact enhancement and damage control through media management by supervisory organisations. 

Presentation by Jorren Scherpenisse of the first results of the follow up study (current state of affairs of the follow up survey regarding Media and Supervisory Organisations).

This second study regarding Media and Supervisory Organisations is based on dilemmas that emerged from the first study of opinions of EPSO members as presented at the Utrecht Conference by prof. Mark van Twist (NSOB, The Netherlands). The follow up plan was presented in Brussels and Copenhagen by Jorren Scherpenisse. The follow up research is conducted in collaboration with EPSO members in the various EPSO countries who were interested in participating.

The aim of this follow–up study (co–financed by  EPSO members) is  to learn from the dilemma’s found in the first study on reactions and opinions of EPSO members, to deliver answers to dilemma’s that inspectorates have to deal with, and find methods and attitudes to develop the right media strategy in supervisory cases.

Jorren Scherpenisse gave a short presentation of the first results of the consultation of some of the EPSO members on how inspectorates deal with the media. These responses were plot in the system in which several methods on how to deal with the media are described. It seemed that different inspectorates have different criteria on how to manage the media. Decisions on these items are yet not very explicit.

In a later EPSO Conference a full report will be presented.

-          Presentation by Lise Verhoef  regarding the added value of ‘social media’ in health care,  based on her research study and  recently presented report to the Dutch Healthcare inspectorate.

Lise Verhoef presented a study on the use of social media by health inspectorates. A development is seen that on the social media several private initiatives are present in which health care providers are benchmarked, like it is done in many other areas, like consumer products (computers, camera’s, etc), travel and dining.

It would be good for inspectorates to take the lead in these initiatives, like e.g. ZorgkaartNederland.nl, which is the official benchmark site of health care providers in the Netherlands.

Peter Carter of ISQua brought forward that countries that are rather new in using social media use it as a risk model and clinical method. It is certainly necessary to drive the use of social media in benchmarking of health care providers forward.


        The Estonian Pilot of the Restraints and Coercive Methods working group to test the EPSO Assessment and Evaluation Framework in long term nursing care, psychiatric wards and various hospitals in March 2014 in Tartu, Valkla and Rõngu, Estonia.

–          Introduction to the pilot by Eve Pilt (Estonian Board of Health);

        Eve Pilt gave a short introduction of the pilot on coercive methods in Estonia. In the pilot the EPSO framework was used. It certainly led to new developments in Estonia on the use of these methods

–          Presentation of the first results of the Estonian pilot  by Rosemary Smyth (Mental health commission Republic of Ireland).

        Rosemary Smyth gave a first overview of the preliminary results of the pilot in Estonia. In the pilot interviews were held with staff and patients. Also observations were made. The institutions also made comments to the EPSO guide, but these could not be implemented in the presentation. It was clear that some methods are clearly seen as coercive and others are not.

        A full report will be presented in a next EPSO meeting.


Day 2 May 9th 2014.

Directors of Hospital Boards in debate with CEO’s of Inspections and Regulators.  

The first part of the morning session was used to focus on the relation between Inspectorates and health care providers.

First duo-presentations of the CEO’s of an inspectorate and CEO’s of hospitals were given. After these presentation a discussion between the CEOs and the EPSO members took place.


CEO’s from four European countries presented their views on the topic, in which they als o touched on practical issues and situations. The four presentations were:



-          Ronnie van Diemen–Steenvoorde, Inspector–General of the Netherlands’ Health and Care Inspectorate;

-          Piet Hein Buiting, Chief executive at Deventer Hospital. Piet Hein has been CEO of the board and managing director of various large and smaller hospitals in the Netherlands (Santeon, CWZ) and is at present interim director at Deventer Hospital.


UK/ Northern Ireland  

-          Glenn Houston Chief Executive Regulation and Quality Improvement Authority

-          Hugh McCaughey, Chief Executive of the South Eastern Health and Social Care Trust in Northern Ireland. Hugh's organisation manages three acute hospitals including the Ulster, Lagan Valley, and Down Hospitals. The Ulster is a regional hospital and the other two are smaller district general hospitals.


-          Ardita Baraku Chief executive Health inspectorate Kosovo;

-          Skender Dreshaj, Director of Regional Hospital Peja, Kosovo



-          Nuno Castro Marques,  ERS Board member;

-          Artur Vaz, Executive Director of Hospital Beatriz Angelo (SGHL, SA), a NHS hospital run under a public–private partnership; in the past, Artur Vaz has been manager in other public and private hospitals.

In all the presentation the same issues were brought forward, although there are differences between the situations in each country.


In the Netherlands the role of the health insurance companies is substantial.

In the UK the Francis Report has set the stage for how care providers are being inspected. Kosovo as an accessing country has to put a lot of efforts in getting the regulations at a level that is acceptable for the European Commission.

In Portugal the economic situation and the criteria set by the financial troika has had it’s impact.


Furthermore in some countries there are clear differences between State owned care providers and private companies. In

Despite all the differences all presentations underpinned the importance of finding a balance in the relation between the health care provider and the inspectorate. This balance is a five dimensional entity, in which the following dimensions can be recognized:

·         Trust ó  distrust

·         Systematic approach ó reacting on incidents

·         Complying to minimal standards ó striving towards excellence

·         Regulations ó Professional knowledge and experience

·         Distance/Indepedance ó Closeness/Familiarity

It was concluded that all five dimensions play a role in a good relation between the inspectorates and the health care providers. The mix of the five dimensions depends on the specific situation in each country, but the end goal always is to improve the quality of care in the broadest sense.

        Panel discussion with CEO’s of Inspectorates and Hospital directors  on the  future goals of co-operation between inspection and hospitals lead by Geir Sverre Braut.


The main topic of the discussion with the CEO’s was what the best way to improve the quality should be. When plotting the quality of the health care providers from poor to excellent a Gaussian curve will appear, or probably a binominal distribution with a maximum shifted to the ‘good’ side of the distribution.

The question now could be rephrased in how to move the curve to the right and also make it a more narrow one.

In the discussion several methods were brought forward, ranging from compliance assistance to repressive methods. Which method might be most successful will probably depend on the individual situation, that will be determined by the position of the health care provider in the curve and its capability and willingness to improve.



Practical issues of EPSO

Preparing for upcoming Conferences in the future and hosting offers by EPSO members:

        Introduction by our Irish hosts, Phelim Quinn and Patricia Gilheaney , Republic of Ireland of the Dublin conference.

Phelim and Patricia gave an introduction to the setup of the next conference in Dublin and already provided the EPSO members with lesson one in Gaelic.

As far as the agenda was concerned there was a general feeling that the present agenda was to overcrowded with topics, which had a negative influence on the presentations and the ability to have discussions. Therefore the meeting decided to put two main topics on the Dublin agenda. These two topics will be:

-          Information management and risk assessment

-          User participations. For this item organisations of patients will be invited to the conference.


        Introduction of Active Ageing  as a topic for the conference in Dublin and some information about the new Ageing legislation in Finland  (Riitta Aejmelaeus, Finland).

Riitta informed the EPSO members on the situation of the Working Group on Active Aging. This Working Group is still searching for its identity and what activities could be taken up.

Riitta also presented first results on a Finnish study on active aging, which might give more insight into this subject.

In the coming period further developments will be studied, leading to an advice how to proceed with this topic within EPSO.


        Financial topics and draft Work plan EPSO .

Geir Sverre Braut gave a short presentation of the Work Plan, which in his view is more an Operational Plan with Activities and their Outcomes . The EPSO members were requested to give their opinions on this plan, so a more elaborate discussion can take place in Dublin.


        Closing of the Conference by EPSO president Geir Sverre Braut.

EPSO President Geir Sverre Braut announced that there will be elections for a new board in Dublin, partly due to the fact that he will step back as a consequence of his new position.

He thanked all the participants for their involvement.

The president expressed his gratitude to our Portuguese hosts for their hospitality and the flawless organisation of the conference.