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A cooperation between KV Connections BV & Kenniscentrum Zorg Nederland

Introduction

This research is conducted within the framework of a graduation thesis at Rotterdam University for the study Trade Management aimed at Asia. On behalf of the company KV Connections BV is a research done about the medical concept “Benchmarking on outcome for the Mental Health Care in China”. The Chinese government has invested a lot of money over the past years for healthcare reform. They want to improve public health and rural health services, implement initiatives to improve hospital management to raise quality of patient care and develop plans to establish and build a national health infrastructure. In order to raise living standards in China, it is important to improve the health care system. China wants to give its citizen a better medical protection provision and a higher quality of patient care. Beside of this, it is also important to reduce the financial cost so that people in China have an affordable, high-quality health care.

The principal KV Connections BV has more than 20 years of international experience as agent, consultant, project manager and financial advisor in China. They see a lot of potential and opportunities in the Mental Health Care in China. In cooperation with Dr Geert Kampschöer (a medical expert and entrepreneur) of Kenniscentrum Zorg Nederland they started an interesting medical project focus on China. The implementation of this medical project should lead to improving professional quality, better patient care and reducing cost.

The main question for thi. thesis research can be defined as follow:

How can benchmarking on outcome be introduced for the Mental Health Care in China?

Theoretical sub questions:

  • What is the medical concept benchmarking on outcome?
  • What are the advantages and disadvantages of benchmarking?

Empirical sub questions:

  • Where is the market potential in China?
  • What is already present in China with regards to performance indicators and benchmarking outcome?
  • Who pays for the health care in China?
  • How important is the insurance or payor structure in China?
  • Is there a partner who can work together with us for this project?

The purpose of this research is to write a business plan in which the steps are clearly defined that KV Connections BV and Kenniscentrum Zorg Nederland must take for introducing this medical concept in China. The research is limited to the Health Care sector of The Netherlands and China. Other countries are not listed in the research. Since the Health Care sector in big cities are better developed than in the small villages, both companies prefer to focus on the metropolitan cities in China. A region analysis will be done between those major cities. Based on the selected region or city a detailed research will be conducted about the Health Care sector in China. Relevant parties in China will be contacted for this medical project. The contact will be proceed by email and telephone. The Managing Director Mr Nando van Ketwich of KV Connections BV has arranged a business trip to China to discuss about the possibilities for this national medical project.

Verder uitbreiden per chapter en aanpassen volgens opbouw rapport

This report consist of several chapters. In order to get a clear view of this research, chapter 1 will give some general information of the company KV Connections BV. It starts with a short history followed by the company's vision, mission and values. The organisation structure will be further explained in the last part of this chapter.

Chapter 2 describes the theoretical framework of benchmarking on outcome for Mental Health Care. It starts with an introduction of the definition benchmarking.

Chapter 3 describes the literature review. Scientific reports by other researchers will be analysed and used for this thesis research.

Chapter 4 describes the methodology that is capable for providing valid answers to the theoretical and empirical sub questions. The research is based on findings of interviews and several case studies.

Chapter 5 describes the final results and the analysis of the research.

Chapter 6 describes the final conclusions and recommendations.

Thesis author: Lie Fung Cheung

45

Benchmarking on outcome for MHC in China

A cooperation between KV Connections BV & Kenniscentrum Zorg Nederland

Chapter 1. Theoretical framework of benchmarking on outcome for the Mental Health Care

This chapter describes the theory of benchmarking on outcome for the Mental Health Care. The following questions will be answered in this chapter:

  • What is the medical concept benchmarking on outcome?
  • What are the advantages and disadvantages of this medical concept?

1.1 Introduction

The purpose of Kenniscentrum Zorg Nederland (KZN) is improving the professional quality of Mental Health Care (MHC) by an independent party who focuses on treatment outcome and creating transparency in the treatment results. This is achieved through measuring the effect of the treatment by groups of patients with reliable and scientifically valid instruments and comparing results with reference data (benchmarking).

The definition of benchmarking :

“Benchmarkingis the process of comparing one's business processes and performance metrics to industry bests and/or best practices from other industries. Dimensions typically measured are quality, time and cost. Improvements from learning mean doing things better, faster, and cheaper. Benchmarking involves management identifying the best firms in their industry, or any other industry where similar processes exist, and comparing the results and processes of those studied (the “targets”) to one's own results and processes to learn how well the targets perform and, more importantly, how they do it. The outcome of a benchmark is a measurement number that says something about the performance.”

KZN is a “Trusted Third Party” (TTP) and stands as an independent party in the middle of the MHC Market. KZN has two types of customers: health care providers and insurers (payors). KZN provides information about the achieved treatment outcome in MHC to both customer groups. Health care providers get detailed information about the performances. Health care providers can benchmark internally (locations, departments or even comparing practitioners) based on the information provided by KZN and benchmark externally by comparing itself against the national average. Health care insurers (payors) get more aggregate information and they can benchmark the treatment outcome and response level for purchasing care providers.

Benchmarking is not an end in itself but a way to find out in which parts an institution is performing very well and where the institution is performing below average. In most cases there is an identified room for improvement. The benchmark result should provide leads for improving the institution's or department's results.

1.2 Benchmarking and routine outcome monitoring

This type of Benchmarking can be extended into routine outcome monitoring (ROM). With ROM the practitioner can follow the progress of a patient during the treatment and adjust the treatment if necessary. ROM is the finger on the pulse of the individual patient. Benchmarking itself is always

about aggregated data and the finger on the pulse of an institution of department. When an institution has ROM in a good order, the collected data will constitute good basics for benchmarking.

ROM and benchmarking lead together into better quality care: ROM because it becomes faster clear whether a treatment is catching on at an individual client; benchmarking because it is clearer how institutions, departments and practitioners are performing in comparison with a national average. By identifying what above average performing departments or practitioners do differently than departments or practitioners who score under the benchmark, it will become clear what the essential factors are which ensure a better treatment outcome.

1.3 Method of KZN

KZN ensures reliable data and use tools, methods and techniques with a scientific basis. KZN investigates periodically at random the reliability of the data submitted from the field.

KZN stands for:

  • Standardization and harmonization of outcome data so that data from different types of patients, different types of treatment or different health care providers are directly comparable.
  • Creating more value for healthcare providers by giving insight in its own treatment results, both for departments and practitioners of the institution specifically and for the organization as a whole, which are also directly comparable to the national average.
  • Creating more value for health insurers (payors), because outcome data from different providers (according to the same methodology of collecting, delivering and comparing data) can be the main performance indicator of MHC.

The effectiveness of treatment in the healthcare is made visible by determine the level of complaints before and after treatment and the outcome, in terms of decrease in complaints- and to compare it with the national average. The complaint level is measured by scientifically validated questionnaires. In the MHC are various questionnaires in use[3]. KZN makes use of existing traditions in the MHC in the field of formally measuring complaints and create its own instruments. However, there are certain minimum requirements for the instrumentation in terms of reliability and validity. KZN has a Scientific Council which is responsible for the decision to allow new instruments to be added to the set for benchmarking.

This is a broad policy in allowing the different measuring instruments means that scores of different instruments need to be made comparable. KZN does this by using the “normalized T-score”. Scores are converted to a standardized score with a mean of 50 and a standard deviation of 10. The treatment outcome is measured by the decrease of complaints in other words the difference between the score of pre- and post-test.

In order not to compare apples with pears, there are national benchmarks determined for different groups of patients and treatments. Among others, the scheme of DSM-IV is monitored. KZN has the Questionnaire Module (VLM) for patients filling out the questionnaire and managing data and then the Benchmark Report Module (BRM) to provide insight into the treatment outcome in groups of patients. For data transfer, KZN realizes a link between its own platform (software) with the system that is in use at the institution, for example with the Electronic Patient Files or ROM-applications. Because of this automated link, the administrative costs within the institution will not increase.

1.4 KZN reports

KZN provides from the BRM two types of reports, response reports (meta data) and reports relating to the treatment outcome. The response reports provides insight into the proportion of patients in which a pre-test has been realised and proportion which a post-test has been realised. This report provides insight into the degree of measuring activity within the institution. This is also a good indicator whether the data are representative enough for the institution.

The second report of the BRM shows the average effect that is achieved in groups of patients from one institution and compared it with the national average. Both results, response and effect size, support each other: a high response rate increases the reliability of the outcome data. With a high response it is possible that the results are distorted by selective (for example, patients with a disappointing therapy response have not done a post-test).

The MHC institution needs to start the process to adopting a culture of measuring treatment outcomes. The response reports provides insight in the insurer in the degree of success of implementation of measuring (ROM) within the institution.

1.5 Output benchmark report module

Below are reports from the benchmark report module further explained.

Response Report

Below shows an example of the response report, intended for internal use by an institution. The report consists of two graphs and is intended to make visible to what extent the institution is measuring. How successful the measuring process is progressing, will be ultimately noted at the proportion of patients both with a pre- and post-test.

Explanation:

In the graph above it shows the proportions of patients:

  1. Both with a pre- and post-test
  2. Only a pre-test
  3. Only a post-test
  4. No measurement has taken place

In the top bar we see the KZN benchmark with regards to the response (the average among all institutions of KZN) in The Netherlands. And then from top to bottom the results for an individual institution (Institution A), a location (Location P) within the institution, with four practitioners (Practitioner A, B, C, D). Right of the bars is the number of Diagnosis pathways shown of which the data have been collected.

In the above picture of the response report, the progress in time for this institution is made visible as the KZN benchmark line. This reveals that within this institution, the proportion of patients with both a pre- and post-test has increased over time and on a greater extent than the KZN benchmark. This institution is successful in implementing pre- and post-test in relation to all institutions within the KZN database. Besides the graph shows the difference with the KZN benchmark (the yellow line in the graph) which is overtaken for the first time in March.

The above report is based on all patients of the institution. Within the Benchmark Report Module it is also possible to display the same report for a specific selection of patients. It is possible to make selections such as all patients with an anxiety disorder or for example all patients with a mood disorder.

The reports which are available for the health insurer or payor is functionally very similar to that of an institution, even though only institution level data are presented (the breakdown in location, department and practitioner is not provided). The health insurer or payor can make various institutions comparable.

1.6 Report treatment effect

Explanation:

In the graph above are the results of the treatment shown, as presented to the health insurer or payor. The x-line displays the difference score of the outcome indicator for pre- and post-test. The standing line at 9,6 is the KZN benchmark for The Netherlands. The average for the treatment effect is 9,6 points; patients are scoring average for the pre-test T=50 and for the post-test T=40,3. There can be seen that the results for two of these six providers left out of the Dutch average. This is especially clearly visible at institution D. At four institutions are the results right out of the benchmark line, most visible for institution B. Left of the benchmark means an effect left behind the Dutch average, right of the benchmark means better impact than the average.

The colors of the bars in the graph reflects an outcome scores relative to the benchmark. If this difference is less than 5% of the benchmark, the bar has a blue color. If this difference is more than 5%, the color will be respectively green and yellow.

In analogy with the response report, it is also possible for reports regarding to the treatment outcome to demonstrate graphs for specific selection of patients. Certain DSM-IV groups can be selected, but also selections based on specific patient characteristics such as gender, age or ethnicity. In this selection is a KZN benchmark shown, relating to one specific selection of patients. This applies for at least 400 observations (of the selection) which is present in the KZN database. If between 200 and 400 observations are available in the database, the KZN benchmark will be shown as a dotted line. With less than 200 observations, the benchmark line won't be shown because the numbers fall short.

The management of an institution can, in contrary to the health insurer or payor, gain a more detailed overview in the respective treatment effects. Besides the institution in general it is also possible to make the average treatment effect visible at the level of locations, departments and practitioners through the KZN application.

Explanation:

The report above is intended for institution A. In this way  you have a much more detail level of the results. This is an example of the results that a manager of a location can request in order to see which treatment outcomes their practitioners achieved averagely. This example involves four practitioners on location P of the institution A.

This institution achieves an effect which is almost equal (9.4) to the national average (9.6). Location P of this institution scores an average effect that is better than the national average and moreover higher than the average of the institution. In this example it is primarily due to the average treatment effects which is obtained by practitioner A and B.

1.7 Report treatment effect over time

Explanation:

Above graph shows the progress over a period of one year for the average outcome of the treatment offered by 5 providers (“Institution A to E”). This example is once again a report which is only available for the purchaser of health insurance.

The yellow line shows the national average, the KZN benchmark. There can be seen that the results in February 2009 for all providers, except for institution C has been slightly decreased. In the summer are apparently better results achieved, especially for the benchmark. Everywhere is a gradual increase of the effect.

A similar report in time, but with a detailed overview of the institution is delivered by KZN to the providers.

1.8 Advantages of benchmarking

The company will have an objective view of their competitive position

By comparing your company with other successful companies, you can get a good overview of your company's market position. It gives an idea on how this situation has arisen and on what issues you can improve this position.

Internal and external processes can be improved

It is quite possible that processes within your business are going well. However, it is important to remember that this business can always be improved. This also applies to your buying and selling process. The question we often ask is: ‘how do you improve these processes?' You can do this by looking at other companies that perform such process better than your company.

Realistic goals can be achieved through benchmarking

Many companies set their goals based on intuition. There is a risk that the target is based on nothing. By looking at the performance of better performing competitors it helps you to establish realistic goals. Your company is free in specifying the problem that needs to be solved in order to achieve the goals.

Companies look less at themselves

Companies are strongly focused on itself. Benchmarking helps the company gain better understanding of their competitors in the way they are performing. It helps you explaining to employees why and how the competitor has better performances in certain areas.

The company gains better understanding of their strengths and weaknesses

Benchmarking allows you to explain your strengths and weaknesses. For benchmarking you have to demonstrate why a certain point is a strength or a weakness.

1.9 Disadvantages of benchmarking

Benchmarking is not always a success. If you start working with data it can result in many problems. In practice there are many differences between the comparing companies, for example in customer requirements. This is particularly when the benchmark is applied outside its own industry. The bigger these differences, the more difficult it is to apply benchmarking for its own company. Collecting and comparing data can waste a lot of time, because of the following questions:

  • Are we talking about the same business?
  • How can we get the requested information?
  • Which benchmarking performance indicator does the companies applies we want to compare with?
  • Do we really want to implement the actual improvements into the company even when it needs much energy and time?

Thesis author: Lie Fung Cheung

45

Benchmarking on outcome for MHC in China

A cooperation between KV Connections BV & Kenniscentrum Zorg Nederland

Chapter 2. Literature review

This chapter describes the literature review. It will start with the explanation of mental health followed by important news topics related to the health care in China.

http://writing.wisc.edu/Handbook/ReviewofLiterature.html

http://literaturereviewsamples.blogspot.com/search/label/Cancer

http://educatie-en-school.infonu.nl/taal/6663-scriptie-verslag-van-een-literatuuronderzoek.html

http://english.gov.cn/2011-03/23/content_1829806.htm

http://english.gov.cn/2011-03/21/content_1828516.htm

http://www.chinavitae.com/vip/index.php?mode=topic&topic=reform

http://www.hmohelp.ca.gov/dmhc_consumer/br/br_mentalhlth.aspx

http://www.ehow.com/list_7491685_skills-mental-health-care-workers.html

http://www.scriptiebegeleidingingroningen.nl/literatuurstudie-van-de-scriptie/

http://www.skipr.nl/actueel/id4805-ggz-nederland-en-zn-zetten-kwaliteitsbenchmark-op.html

http://countrystudies.us/china/38.htm

http://www.consultancynieuws.nl/whitepapers/benchmark-ziekenhuizen-financiele-positie-zorgwekkend/

http://www.slideshare.net/TechnomicAsia/china-healthcare-overview-3425908

2.1 What is mental health?

http://mentalhealth.about.com/cs/stressmanagement/a/whatismental.htm

http://www.medicalnewstoday.com/articles/154543.php

Mental health can be defined as mental illness, which refer to a wide range of mental disorders that can be diagnosed by a health care professional. It refers to a person's cognitive and emotional well-being; the way we are thinking, feeling and behaving. A person with mental health has an absence of a mental disorder. Mental health can affect a person's daily life, relationships and physical health. Experts often say “we all have the potential for suffering from mental health problems, no matter how old we are, whether we are male or female, rich or poor, or ethic group we belong to”.

Forms of mental illnesses

Examples

Anxiety disorders

This is the most common group of mental illnesses. The patient has a fear or anxiety which is linked to certain objects or situations. Most people try to avoid exposure to whatever triggers their anxiety.

Panic disorder

The person experiences sudden paralysing terror or imminent disaster.

Phobias

The person has disproportionate fear of objects or fear of being subject to the judgment of others.

Obsessive-compulsive disorder (OCD)

The person has constant stressful thoughts (obsessions) and a powerful urge to perform repetitive acts.

Post-traumatic stress disorder (PSTD)

The person thinks that his life or other people's lives are in danger.

Mood disorders

This is also known as affective disorders or depressive disorders. Those patients share disturbances or mood changes. Approximately 80% of patients with depressive disorder improve significantly with treatment.

Major depression

The person has extreme or prolonged periods of sadness.

Bipolar disorder

The person has manic depression.

Dysthymia

The person has a chronic feeling of ill-being and lack of interest in activities he once enjoyed.

Seasonal affective disorder (SAD)

The person has a major depression, which is triggered by lack of daylight.

Schizophrenia disorders

This is a single disorder or a group of related illnesses which has to be fully determined. It is a highly complex illness where most patients are between 15 and 25 years of age.

Positive symptoms

Delusions, thought disorders and hallucinations.

Negative symptoms

Withdrawal, lack of motivation and a flat or inappropriate mood.

Table 3. The most common forms of mental illnesses.

2.2 Ministry of Health (China) promotes measure 7

Ministry of Health requested an appointment clinics to promote medical institutions such as universal measures 7 to achieve "good service". Xinhua Beijing April 12 (Xinhua Zhou Tingyu) 12 Ministry of Health held a national health system carry out "three-good one satisfaction" activities will be deployment of video and telephone, to request an appointment clinic medical institutions in general to promote and optimize service processes and improve service levels, efforts to achieve "good service."

The depth A Good activities to enhance professional style building, the Ministry of Health recently issued notice to the health system in the country decided to carry out the "good service, good quality, ethics is good, people are satisfied", "Miyoshi A satisfactory "activities. Vice Health Minister Ma Xiaowei said that in 2011, "Miyoshi a satisfactory" range of activities, various medical institutions at all levels, focusing on more than two public hospitals. Health surveillance, disease prevention and control and other health institutions should be combined with the actual organization activities.

In 2011 Ministry of Health requires health care institutions through the following seven specific measures to achieve "good service":

  1. First popularized appointment treatment services. In all three A-level general hospitals nationwide to implement a variety of ways appointment clinics, urban community health services a priority referral clinic appointments, and strive to the end of 2011, urban communities, the amount of referral clinic appointments accounted for 20% the proportion of local patients referral appointment rate of 50%, of which dentistry, prenatal care, referral and other postoperative review appointment rate of 60%.
  2. Second is to optimize the Hospital of the environment and processes. Registration by appointment, reasonable arrangements for outpatient and emergency services, outpatient and emergency and simplify the admission, discharge service process, the implementation of "first treatment, after the balance sheet" model, providing convenient access service and other test results, and strive to make reasonable arrangements, enthusiastic service, process smoothly and continuously promote the improvement of medical services.
  3. Third is convenient to carry out extensive outpatient services. Qualified to carry out weekends and holidays tertiary hospital out-patient, out-patient power to enrich, extend clinic hours; to encourage, support tertiary hospitals to primary care medical staff to carry out medical practice and health institutions.
  4. Fourth, the promotion of quality care. National tertiary hospitals to carry out a comprehensive quality care, 50% of the hospitals of quality care ward covers more than 50%, 40% of the prefectural (city) level II hospital and 20% of the county hospital to carry out secondary quality care. Improve the preparation and implementation of professional nursing staff and internal income distribution policy.
  5. Five is to improve the medical examination, mutual recognition of test results mechanism. Quality control in intensive care on the basis of medical examination and vigorously promote the same level, the mutual recognition of test results, and promote reasonable inspection, reduce patient treatment costs.
  6. Sixth, carry out the "volunteer service in the hospital" activities. Gradually improve the volunteer management system and working mechanism suitable for China to actively explore new forms of volunteer service, new content, new models.
  7. Seven is to establish a sound mechanism for third-party mediation of medical disputes, and medical liability insurance system, medical complaints seriously implement the approach, strict implementation of the first complaint responsibility system, in-depth activities to establish "safe hospitals" campaign to crack down on "medical seek "to build a harmonious relationship between doctors and patients.

In addition, Ma Xiaowei also required that all medical institutions should strengthen quality control, standardized treatment behavior, continuous improvement, quality of care, efforts to achieve "good quality"; to strengthen medical ethics education, vigorously carry forward the noble medical ethics, serious industry discipline, efforts to achieve "good ethics"; to deepen professional climate appraisal, and actively accept social supervision, and efforts to achieve "satisfaction of the masses."

2.3 China pledges more efforts to reform health care

BEIJING - Chinese Vice Premier Li Keqiang said the country would fight the toughest battle to reform the health care system in 2011, as he called for practical measures towards accomplishing the reform.

Li made the remarks while addressing a national meeting on deepening China's reform of health care system on Tuesday, according to an official statement sent to Xinhua on Wednesday.

Citing the reform as a key project that involves public interests, Li called for efforts to ensure the people's universal access to basic medical insurance and basic health care services. Li added that China would largely raise the level of government subsidies for medical insurance schemes in both rural and urban areas and increase government spending on public health care services this year.

Efforts would be made to let insured people get a higher ratio of reimbursement for their inpatient medical treatments as well as for their outpatient medical treatments for severe diseases, Li said.

He added that the basic medicine system, which aims to ensure affordable access to crucial drugs for patients, should be implemented across government-run grassroots hospitals and clinics in 2011.

Furthermore, Li said that comprehensive reforms including the separation of medical treatment services and medicine sales would be initiated in government-run hospitals in 16 cities this year.

2.4 Health care in China

China has stunned the world with its rapid economic growth in recent years, showcased through theglittering skyline of Shanghaiand the global events like the 2008 Olympics. But while thecountry has amassed tremendous wealth, China still trails the developed world in its ability to provide even basic health care for its people. With its massive 1.3 billion population, China's health care expenditures are miniscule compared to Western nations. China spent less than 5 percent of its GDP on health care in 2005, compared to roughly 16 percent spent in the United States and 10 percent in Canada, according to theWorld Health Organization.

"The amount of government spending on health care is really low. It's less than $10 per person, per year," said Drew Thompson, director of China studies and Starr senior fellow at the Nixon Center.

Per person expenditures in the U.S. have topped $6,000 in recent years.

Despite China's Communist government, health care remains largely the responsibility of individuals. Out-of-pocket expenses are extremely high in comparison to average earnings. A single hospital visit nearly matches China's annual income per capita.

Health Insurance Not Mandated

Health insurance is not mandated, though the government does have health insurance programs that provide coverage to some 90 percent of the population. The programs include an employer-based system, a program for urban residents, and another program covering the rural population. For the most part, the programs do not cover the basic care. "At the moment, most programs in the provinces across China provide primarily in-patient care service," said Dr. Gordon Liu, professor of economics at Peking University. "Basically, the goal is to protect you from having catastrophic problems."

As a result, much of the Chinese population doesn't even receive basic medical care.

"They're still paying largely out of pocket, which causes them to delay going to the doctor," Thompson said. "People don't go to the hospital until they're really sick. There's no preventative services." But even with the financial disincentive, there still is a shortage of care. "Usually, Chinese people would have to wait many days to get registered, or you have to know someone ... to get registered before you are diagnosed and treated," said Liu. "We have a supply shortage ... meaning beds, the doctors, good hospital facilities are not enough to meet the demand by people."

Health Care in China: Doctors Rarely Have PhD

For those who do seek care, treatment rarely approaches anything close to awestern standard of care. Though quality medicine is available for China's wealthiest people, most residents receive treatment from physicians who have received little medical training. Just one percent of Chinese doctors have actually received a PhD, while many have only basic training, similar to pre-med classes in the U.S. "The quality of education, experience and technology, by and large, is not up to world standards," Thompson said. Part of the reason for the shortage of well-trained doctors is that there's little financial incentive for China's best and brightest to go into the field. While much of China's economy has become market-based in recent years, medicine has not made the same transition and doctors' salaries are tightly controlled by the state.

2.5 China's healthcare is the lowest in the world

Chinese health officials said that those who complain about China's healthcare system policies only see the American healthcare system as superior and fail to notice that healthcare in America suffers from it being “market-oriented” instead of “patient- oriented.” However, China's healthcare system also has faults such as its focus on money instead of service and discrimination.

China's and the United States healthcare systems differ greatly. Hospitals in the United States, for example, must provide emergency medical treatment to "walk-ins," and low-income patients can receive reduced or free medicine. Foreigners who reside in the U.S also have a right to free medical treatment as a "walk-in." Patients in China, however, must pay first before receiving medical treatment, and as a result many dying patients are denied much needed medical treatment. Some patients have even died in front of the hospital because of their inability to pay. In 1998, a report disclosed that about one-third of Chinese people were unable to receive medical treatment, with the statistic being higher in poor, rural areas in China.

Discrimination against the poor is a definite problem in China that precludes many people getting medical attention. Farmers, for example, only receive 15.9% for healthcare expenses from the government even though they comprise 80% of the population. The government spends approximately $130 for citizens living in cities, while farmers only receive $10.70. Qualified medical personnel and updated equipment is also a serious problem in rural areas. Chinese health officials agree that only one-third of the public healthcare system is operational and that huge expenses are caused by poor bureaucratic decisions. The real problem for China's poor healthcare policies is money. The government spends money on project such as the "Shan Zhou No. 5" rocket project, missiles and nuclear weapons and is unwilling to invest in education and healthcare even though improvement in those areas would help our future.

According to the World Health Organization (WHO) the Chinese health system ranked 144 out of 191 countries, and is even below Iraq in providing good medical treatment. (In addition, China ranks 188, the 4th place from the last, for the line item “equity in sharing a doctor” - most likely has something to do with doctors per patient ratio.) The Chinese health system is out-dated, and this was especially noticeable during the outbreak of SARS. The Canadian government, concerned about China's healthcare policies, warned that the outbreak of SARS disease could return for the next spring.

The Chinese government covered up the highly contagious and deadly disease, which caused worldwide panic. After WHO seriously criticized the Chinese government, they donated $100 million in “hush” money to the WHO. Many people cannot help but ask the government: Where is the money to improve our outdated medical and healthcare system?

Chapter 3. Internal analysis

The first part of this chapter begins with a short history of KV Connections BV followed by a description of the company's vision, mission and values in the second part. The organisation structure will be illustrated in the third part and the final part consist the marketing mix of the organisation in order to get a good view of their marketing operations.

3.1 History of KV Connections BV

KV Connections BV (KVC) is established in 1991 by Mr Nando van Ketwich as a private limited company. Their core business is creating business ventures for Interim Management, International Business Development and Project Management with exclusive partnerships in Europe and Asia. KVC understands the value of personal relationship building, which is  an important element of success and for establishing a strong business presence in Asia. During the past 20 years KVC has been acting as an agent, a consultant, project manager and financial advisor in China. More detailed information for the projects they have done is described in table 1.

Projects topics

Examples

Security & Safety

KVC and Beijing Konre assisted Kusters Engineering in setting up a project in China to provide an environmental friendly technology for the disintegration of used banknotes. This project resulted in multi-million dollar contracts for equipment and it has a large spin-off for various Dutch companies. Because of this project, Kusters Engineering has a unique long-term position in China.

Renewable Energy

KVC has been searching for more than 10 years to introduce Dutch technology in renewable energy in China. Finally KVC get in touch with Composite Technology Centre (CTC), who has the know-how in designing and producing high-tech blades for wind turbines of more than 1 MW. Currently, KVC has a leading role in the national wind energy platform which is designed in The Netherlands and produced in China with a long term position.

Land Reclamation & Management

With the help of KVC for engineering, the feasibility studies for land reclamation in the Chinese province Fujian has been completed by famous water management companies. The main purpose for this project is to build a harbour with minimal environmental disturbance. This project has expand on a nationwide basis in China.

Fish & Food

KVC cooperates with their counterparts Shandong Fishery Co. (SNFC), China Aquatic Products Processing and Marketing Association (CAPPMA)  for upgrading the fish quality in China. The purpose of this project is to have better quality food on the market, improve the lifespan of food and develop more international trade of fish and food products.

China Inroads

China Inroads (CI) provide local support for implementing business plans and they act as a personal guide who creates business possibilities for people. Their Chinese partners offering services at local rates. The Chinese and Dutch management team make China more accessible for people who wants to create new business opportunities.

Trade Development

Large volumes of security paper have been sold to China  through KVC's intermediary; printing equipment and service; source of spare parts.

Financial Support & Training

KVC has provide financial training and coaching to government, financial, commercial and private institutes; technical services for financial institutes; financial planning for budgeting, funding and acquisitions.

Table 1. KVC's Projects with examples.

3.2 Mission statement

Vision

“Creating profitable business ventures through mutual understanding between China and Europe.” KVC wants to become the company who cooperates with Chinese partners for profitable projects which has an important contribution to the world. When KVC establish a partnership they will take the values of the organisation into it.

Mission

Doing useful things for a better world.

Values

  • Long term thinking
  • Experience
  • Respecting people and cultures
  • Patience and trust
  • Honest and hardworking people

3.3 Business definition

The business of KVC can be defined by using Abell's business definition model. KVC's business scope is shown as a cube in figure 1. All the elements in table 2 together forms the product-market combinations of KVC.

The three dimensions in figure 1 describes the following:

  1. Customer groups : who are the customers/target group of KVC?
  2. Customer needs : what are the needs of KVC's customers?
  3. Technologies : which products/services will KVC use to satisfy their customer needs?

Customer groups

Customer needs

Technologies

A1

Government institutions

B1

Security

T1

Setting up a project with partners

A2

Banks and large companies

B2

Environment protection

T2

Investing knowledge

A3

Private industries

B3

Renewable energy

T3

Wind energy investing

A4

State owned enterprises

B4

Safety

T4

Cooperating with counterparts in China

A5

SMEs

B5

Training

T5

Providing financial training and coaching

A6

Asian companies

B6

Financial management

T6

Providing support for implementing business plans

A7

Training institutes

B7

Business opportunities in China

T7

Develop better quality food for the market

A8

Hospitals

B8

Management health care system

T8

Benchmarking on outcome

Table 2. Description for figure 1.

3.4 Organisation structure

KVC's organisation structure can be characterised as a line organisation, because of its simplicity and coordination capabilities. Employees within the organisation gets their work from one person, the Managing Director. The Managing Director and founder of KVC is Mr Nando van Ketwich. He has 45 years of international experience, which 30 years in greater China. In addition, he has the knowledge for working with high-level and quality companies in the Netherlands, France, Hong Kong and the USA. There is a unity of command within the organisation which means that employees should report their progress and results to the Managing Director, who has gain a lot of knowledge in the past years in order to control the different departments (projects). The impact of managing multiple department's projects can result in work overload.

KVC has totally 10 employees working in different (partner)offices in:

  • The Netherlands
  • Beijing
  • Shanghai

3.5 Marketing mix

3.5.1 Product

3.5.2 Price

3.5.3 Promotion

3.5.4 Place

3.6 BCG matrix

3.7 Product life cycle

Chapter 4. External analysis

http://www.internationaalondernemen.nl/exporteren/exportplan_intro.asp

http://www.netmba.com/strategy/pest/

4.1 Macro-environmental factors

http://www.netmba.com/strategy/pest/

http://www.intemarketing.nl/marketing-analyses/destep

http://members.fortunecity.com/marwinroije/word.doc/beleidsplan.html

4.1.1 Demographic

4.1.2 Economic

4.1.3 Social-cultural

4.1.4 Technological

4.1.5 Ecological

4.1.6 Political

4.2 Porter's five forces

4.2.1 Supplier power

4.2.2 Buyer power

4.2.3 Threat of substitutes

442.4 Threat of new entrants

2.2.5 Degree of rivalry

4.3 Ansoff's matrix

http://www.marketingteacher.com/lesson-store/lesson-ansoff.html

http://www.mrdashboard.com/AnsoffMatrix.html

4.4 Region analysis in chapter research?

Metropolitan cities in China

Hong Kong

Beijing

Shanghai

Thesis author: Lie Fung Cheung

45

Benchmarking on outcome for MHC in China

A cooperation between KV Connections BV & Kenniscentrum Zorg Nederland

Chapter 5. Research

http://www.sasked.gov.sk.ca/docs/social/psych30/support_materials/research_methods.htm

http://www.jpsimbulan.net/thesis-writing-guide/how-to-write-a-thesis/how-to-write-chapter-3-of-a-thesis-basic-format/

http://educatie-en-school.infonu.nl/diversen/6386-scriptie-beschrijven-van-een-empirisch-onderzoek.html

wat is onderzoek toelichten?

toelichten waarom enquete niet van toepassing is, goed beargumenteren!

Enquete is niet van toepassing, wegens de volgende redenen:

Het gaat om een totaalpakket in de vorm van een dienst/software dat wordt geleverd aan ziekenhuisinstellingen.

5.1 Kinds of research methods

http://www.scn.org/cmp/modules/rsh-krm.htm

http://www.allesovermarktonderzoek.nl/Marktonderzoek/Onderzoeksmethoden/Onderzoeksmethoden.aspx

http://www.wisegeek.com/what-are-the-different-types-of-survey-research.htm

http://managementhelp.org/research/research.htm

http://www.statpac.com/surveys/research-methods.htm

Research methods

Explanation

Interview

The interview method of research involves a face-to-face meeting with an person, who has to answer a series of questions asked by  the interviewer. This method gives you a better understanding of the story behind a participant's experiences and the interviewer can collect in-depth information/data about the topic.

Types of interviews:

1. Informal, conversational interview

The questions are not predetermined because it depends on the individual's priorities. The interviewer goes with the flow during the interview.

2. General interview guide approach

The interviewer collects information from each interview based on questions in the same general areas. This interview allows a degree of freedom in getting information from a person.

3. Standardized, open-ended interview

The interviewer asks the same open-ended questions to all persons. This interview can be easily analysed and compared to others.

4. Closed, fixed-response interview

The interviewer has to ask all persons questions with fixed answers or alternatives. This interview is very useful for people who has less knowledge in conducting interviews.

Types of questions topics:

1. Behaviours

What has the person been doing?

2. Opinions/values

How does the person think about the topic?

3. Feelings

How does the person feel about the topic?

4. Knowledge

What are the facts of the topic?

5. Sensory

What has the person seen, touched, heard, tasted or smelled?

6. Background/demographics

What is the background of the person, such as education?

Survey

The survey method of research involves the use of questionnaires from a potentially large number of respondents. This is the only feasible way to gain statistically analysis of the results.

Steps which are required in order to design and administer a questionnaire:

  • Define the objective of the survey
  • Determine the group/respondents
  • Write the questionnaire
  • Administer the questionnaire
  • Interpretation of the results

Types of surveys:

1. Paper surveys

This survey is mostly used for conducting market research. It contains a list of multiple choice answers what is easier to process.

2. Telephone surveys

This survey is done through the telephone. The telephone survey proceeds electronically and there will be no human-to-human contact. The respondents replies by pressing a number on the phone's dial pad.

3. Online surveys

This survey is printed in electronic form. Most Internet users are familiar with the point and click approach. The telephone and online surveys offers the flexibility in asking questions based on the respondent's answer.

Case study

The case study method of research involves interviews, observations, experiments and tests. It helps us to understand a complex issue or object based on an in-depth investigation case and what might become important in future research.

Techniques for organising and conducting case studies:

  • Determining and defining the research questions
  • Selecting the case studies
  • Preparing to collect the data
  • Evaluating and analysing the data
  • Preparing the report

Types of cases:

1. Illustrative case studies

This case study describes a domain; one or two instances will be used for analysing the situation. It gives readers a common language about the topic.

2. Exploratory/pilot case studies

This case study condenses the process; researchers undertake it before implementing a large-scale investigation. It helps identifying questions, developing measures and serve to safeguard investment in larger studies.

3. Critical instance case studies

4. Program implementation case study

5. Program effects case study

6. Cumulative case studies

Naturalistic observation

Experiments

Topical

Table 4.Research methods.

5.2 Interview

http://www.scriptiebegeleidingingroningen.nl/interviews-analyseren/

5.2.1 Stichting Benchmark GGZ

Afwachting feedback Edwin de Beurs

Company:

Stichting Benchmark GGZ

Website:

http://www.sbggz.nl/

Place:

Bilthoven, The Netherlands

Date:

Thursday 12 May 2011

Time:

11.00am - 12.15pm

Interview with:

Mr Edwin de Beurs

In 2006 Mr Edwin de Beurs was involved in the benchmarking project in cooperation with HSK Groep. The concept of this idea was implemented as a pilot, which they focus on two types of customers groups; health care insurers and health care providers (MHC institutions). The competitiveness between health care insurers (who is the best we can do business with) and health care providers (we are doing well) creates advantages in transparency and quality within the MHC.

Stichting Benchmark GGZ has about 15 employees. The steps they have taken in order to implement the benchmarking on outcome can be described as follow:

  1. Inviting health care insurers for a meeting.
  2. Health care providers has put the impact of health care into a chart; Routine Outcome Monitoring (ROM), adjust the treatment if necessary.
  3. Stichting Benchmark GGZ has collected the data and their objective is to make averages of the data; it is always about groups of patients (homogeneous).
  4. For the exchange of ideas and decisions they will contact the foundation (a representative board of health care insurers and health care providers).

The product of Stichting Benchmark GGZ is the result, that is the most important reason for choosing to work with benchmarking on outcome. The main purpose is to compare the quality of institutions. In order to improve the quality of health care, institutions have to learn by measuring; the way of treatment is not important for benchmarking because the result is the final goal. The choice to start with focussing benchmarking in the MHC is because the MHC institutions has already started with measuring in the framework of ROM using the Symptom Checklist. This all makes it a bigger chance for Stichting Benchmark GGZ to implement benchmarking on outcome and they only need to find the consensus about how they are going to measuring it. There are different performance indicators, such as satisfaction of the patient. For this benchmarking concept there will be focussed on the outcome (result).  It can also be divided into primary and secondary  performance indicator, which depends on the problem.

The advantages of benchmarking on outcome can be defined as follow:

  • Medical doctors can specialise further in their field, which can result into a better quality of health care.
  • Working according to the Symptom Checklist helps reducing problems.

The disadvantages of benchmarking on outcome can be defined as follow:

  • The benchmarking on outcome must be performed properly. If no value is given to it, the product is worthless. It is important to demonstrate that there will be focused on the result.
  • People wants to quickly use the data what can result into a blame culture. For example, institution A is performing better than institution B so we will work with institution A. The outcome data represents the quality of health care.
  • Centralise the health care may result into longer distance travel for patients.

In the case of implementing benchmarking on outcome in the MHC in China it is necessarily to make a start with measuring in the framework of ROM; institutions have to use measuring instruments. According to the law of arrears is China far behind the development of medical technology. The culture of measuring treatment outcomes has to be present in China before implementing the benchmarking concept. It is better to focus on the metropolitan cities such as Hong Kong, Shanghai and Beijing. There must be an independent Third Trusted Party (TTP) presented who is going to compare the results and this TTP have no interest in the outcome, for example the government. To make a good start it might be an option to implement a pilot for the upcoming two years in the metropolitan cities in China. If there is no culture of measuring treatment, we can help China establish one.

The MHC in The Netherlands has approximately 1 million patients (16% of 16.5 million residents). Currently not every MHC institution is working with benchmarking on outcome. One of Stichting Benchmark GGZ's objective for the year 2014 it to persuade at least 50% of MHC institutions to work with benchmarking on outcome. Beside of this, they will also continuously focus on perfecting their system and showing results. In the future there will be a possibility to expand the benchmarking on outcome to other health care sectors within The Netherlands if there is a culture of measuring treatment outcomes.

5.2.2 Shanghai University of Traditional Chinese Medicine

Company:

Shanghai University of Traditional Chinese Medicine (TCM)

Website:

http://www.shutcm.edu.cn/English/

Place:

Shanghai, China

Date:

Monday 28 February 2011

Time:

09.00am - 10.30am

Interview with:

Ms Wang Tianjun

Dr Chian (Director of the International Cooperation Division)

Dear Mrs Wang, dear Pany,

Many thanks for organising the meeting a.o. with Dr. Chian at the TMF University in Shanghai. It was a great pleasure together with my partners to make aquaintance with a so prestigious Institute and talk with a famous Doctor in China. We in Holland also like to learn more from the Chinese side. I send a very short summary, copy the the famous Doctor in Holland with whom we are working at this end : Dr Geert Kampschoer. Pse correct me if I am wrong in my summary: I am not a medical doctor but a simple business man with long experience in China and Asia and by the way: as I was ill myself when in Shanghai and we went to the Rui Jin Hospital related to the Jiao Tong University School of Medicine my wife and me were very impressed by the excellent and professional way I was treatened in a very efficient way! I believe we can learn a lot from this in Holland and Europe..

After introductions we spoke about:

--there are 5 Hospitals like in Shuguan in China acting in the top of TCM,

--strategic and national decisions are made mainly by the National Healthcare Ministry in Beijing,

--in Beijing we had also contacted the China Medical Association who are quite active in organising exchange with Doctors on an international basis,

--the Ministry is acting mainly for healthcare services and wishes to develop more differentiation with medical doctors,

--that does not mean that there is not an open and flexible system in China, openness to private Institutions and people is increasing rapidly,

--the next 5 year Planning is further increasing the exchange between private and government regarding a national healthcare system, in which several private forces like producers of phamrmaceuticals and equipment are helping a lot,

--national concensis for healthcare in China is very strong and in some cases there is an increaesed international co-operation,

--Shanghai plays a prominent role in all this and privatisation becomes much more important , however national control remains essential as well,

--costs are mounting and some private parties are contributing on funding programmes,

--areas that are advanced right now in this connection is in dental, eye and heart curing,

--after I introduced the benchmarking it became clear that in China there is a KZN mainly on an academical basis,

--in the near future we could get access to this party for which we have to come up with some suggestions from this end about how we could co-operate,

--we have to take a view with hospital to hospital and institue to institute.......

--I mentioned that recently a TCM club has started business in The Hague but this is 99% for acupuncture,

--after discussions with partners In Holland we shall be back soon!

5.2.3 Joining Minds

Company:

Joining Minds / Kenniscentrum Zorg Nederland

Website:

http://www.joiningminds.nl/

Place:

The Hague, The Netherlands

Date:

Thursday 7 April 2011

Time:

10.30am - 12.00am

Interview with:

Dr Geert Kampschöer

Geert Kampschöer is a medical expert and entrepreneur who have successfully implemented the following projects in Holland in close cooperation with various partners:

1. NederlandseObesitasKliniek (NOK)

The first centre in The Netherlands which offers integrated solutions for obesity prevention and treatment.

2. www.medischegegevens.nl

Exchanging and sharing medical information has always been sensitive. Although patients own their medical records, they don't have readily access to it. In 2006 the founders Dr. Alexander de Vries and Dr. Geert Kampschöer started the development of www.medischegegevens.nl. Patients have access to their medical records by logging into this secure website. The Medical Center Haaglanden has functioned successfully under this Pilot Programme by helping patients achieve a better understanding of their disease.

3. Benchmarking for mental healthcare

The orientation of Western medicine has always been on professionalism and effort. Nowadays it becomes ever more important to focus on results and therefore outcome-oriented health care. Currently,only within Mental healthcare scientifical valid instruments (questionaires) are available to measure treatment. The Netherlands is the first country that was able to have a national transparent benchmarking on outcome.

Geert Kampschöer together with KV Connections BV would like to develop benchmarking for mental healthcare in China.  Contact with Shanghai University of Traditional Chinese Medicine and the Chinese Medical Association (Beijing) - a non-profit organisation formed by Chinese medical science and technology professionals- has been established during Nando's visit to China in Feb 2011. In order to find the right counterpart in China and before we can define our strategy we need to have a better overview of the current healthcare situation in China and therefore answers to the following questions need to be covered:

4. Given the development state of MHC, it seems better to focus on the metropolitan cities in China, such as Shanghai, Beijing and Hong Kong.

5. Who pays for the healthcare in China? This counterparty is the one who is most interested in the project, because they are able to choose and guide the quality development by using outcome benchmarking. Is there a local or national Health Authority in China?

Normally healthcare is paid through medical insurance for which the employer and employee pay their individual shares. There is National Health Ministry and local municipal heath bureaus in China.

6. The implementation of benchmark outcome leads to better healthcare. The results of the medical specialist or psychologist will be made transparant and compared with his colleagues. Are they doing it good or bad and what can be improved?

There is benchmarek systems in hospitals, but since I work for university instead of hospital, I am not clear about how they are doing.

7. What is already present in China with regards to performance indicators and  benchmarking outcome? How many patients? If there is a problem, how did you solve that? Is there a partner who can work together with us for this project? Maybe the local government or Ministry of Health? How important is the insurance structure or payer structure in China?

There is a department in each hospital that is responsible for assesing medical performance. Better contact someone from hospital for more information.Medical insurance is covered for almost all employeed and retired people in China. Employer pay a larger share than the emplyee.

8. We can offer the concept benchmarking outcome based on scientifically valid methodology and the technology of data infrastructure, calculations and reporting.

Actions:

  • An interview for Lie Fung Cheung with Mr Edwin de Beurs (Director - KZN Benchmarking) will be planned in the next weeks in order to have a better understanding of the concept;
  • For answers to above questions KV Connections BV will contact people in her network in China.

5.3 Case study

Thesis author: Lie Fung Cheung

45

Benchmarking on outcome for MHC in China

A cooperation between KV Connections BV & Kenniscentrum Zorg Nederland

Chapter 6. Results and analysis

http://ivythesis.typepad.com/term_paper_topics/2009/04/thesis-analysis-and-interpretation-of-data.html

http://hubpages.com/hub/Data-Analysis-Interpretation

6.1 SWOT analysis

6.1.1 Confrontation matrix

http://www.scribd.com/doc/20204288/18/Confrontation-Matrix

6.2 Options

6.3 Implementation

6.4 Monitoring / auditing?

Thesis author: Lie Fung Cheung

45

Benchmarking on outcome for MHC in China

A cooperation between KV Connections BV & Kenniscentrum Zorg Nederland

Chapter 7. Conclusions and recommendations

7.1 Conclusion

7.2 Recommendations

Korte termijn

Middellange termijn

Lange termijn

Thesis author: Lie Fung Cheung

45

Benchmarking on outcome for MHC in China

A cooperation between KV Connections BV & Kenniscentrum Zorg Nederland

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