Summary
The EQuiP Case Report Interview identified recent developments in Swiss healthcare, highlighting the establishment of the National Quality Commission and the implementation of quality contracts between health insurance companies and doctors. Key projects include a database for primary health care data, interprofessional care initiatives, and efforts to reduce antibiotic prescription. The conversation also covered the importance of patient involvement, with initiatives like shared decision-making and the integration of patient-reported outcomes (PROMs) into primary care. The shift towards interprofessional teamwork and patient engagement was emphasized, with a focus on enabling patients to contribute actively to their healthcare.

Ulrik Bak Kirk:
Thank you very much, Joel and Adrian, representing Switzerland in EQIP. Today, we are going to have a little overview of the Swiss context in quality improvement and patient safety.

First, I would really like to ask you, Joel, whether there has been any important policy development with regards to quality in primary care and family medicine in Switzerland?

Joel Lehmann:
So in the last few years, I think since 2021-2022, there has been quite an important change in the national law in Switzerland. As you might know, healthcare is normally regulated on the cantonal level, but on the national level in Switzerland, we have the health insurance law for the basic benefit package - and there's a new law about quality of care. This particular law has two main elements:

1) The 'National Quality Commission' was established. This quality commission is composed of 15 people, like from provider side, health, insurer side, cantons and also researchers, and they have certain instruments for financing quality development. And so they have been learning, like in the beginning, I think they they struggled a bit sometimes, but now there have some routine and most of the projects that have been funded are, of course, more in stationary like hospital care, but there have been a few in primary care and that touch on Family Medicine, like one project related to a database for primary health care data at the University Institute in Zurich. Another one around monitoring of quality that still in the very beginning, including 'Interprofessional Care', like pharmacists and primary care doctors having better information exchange about medication.

2) The other important element of this new law is that there have to be 'Quality Contracts' between health insurance companies and the Medical Association - this has been very political, actually. So even though the contract should have been in place, like two years ago, there are still not in place. There have been disagreements about financing of quality activities. There's been lots of discussion about terminology, and yeah, but ultimately, there will be certain number of quality improvement measures that should be carried out by practitioners that could include, like, for example, quality circles or critical incidents reporting or patient surveys, a range of different quality improvements, and someone can then probably choose one or the other improvement method so that those that's what has been happening. So it has been quite dynamic, actually when it comes to policy development.

Ulrik Bak Kirk:
Thank you for sharing that, Joel! Sounds like a lot of policy deployment is going on.

Now, trying to break that down - maybe to a more practical level - Adrian, could you say something about any quality-related activities going on on the National Academy level or at a Research Institute for Family Medicine?

Adrian Rohrbasser:
We are working with different projects. On the one hand, we are working on a project in all language regions with the Federal Office of Public Health. It's about multi-resistant bacteria - that increase in Switzerland as well - and leads to death and mutilation every year. We started with a small project looking at what actually does cause prescriptions of antibiotics within primary care, because it's 80% of all antibiotics are prescribed within primary care.

So, we had a close look at that and saw that 'audit and feedback' and 'guidelines' on themselves don't really work, but they need to be translated within 'Quality Circles' and distort work - and when we actually involve patients in shared decision-making, it works even better.

We started out with qualitative work to develop these tools, and now we're testing these tools using claims data from health insurance, comparing different groups, using a difference in difference analysis; and now we see whether it really works.

Then, in the second step, we would like to know why it works. We plan on doing a realist analysis too. It covered only a small part of Switzerland and then spread onto the eastern and western part of Switzerland, which is quite nice.

In addition, we have some projects for chronically ill people. We started in 2017 with a cohort of diabetes patients and follow the clinical data as well as the healthcare costs, and these are evaluated at the healthcare institute at ZHAW. So, in collaboration with the University of Bern, we try to figure out why they actually work, and then we have a look at this interprofessional work, but it's about task sharing. It's about task shifting. So we involve other professions than 'just' primary care physicians.

Joel Lehmann:
....maybe I can jump in and add, it's not actually a research institution, but the professional society for general and internal medicine. Both Adrian and I are part of the 'Quality Commission' of that society. Currently, we are in the process of producing a 'White Book' - a bit similar to what I think Denmark has published a few years ago - which discusses different practical aspects of quality work.

Also, we are working on a new strategy for the next three years which includes also primary care, GP care. And we have not yet gone very far, but it will look at different elements of quality, according to structure, processes and especially also outcomes. One element that also came out is the question of fear and uncertainty - or like health literacy to some extent.

Ulrik Bak Kirk:
Thank you, Adrian and Joel for enlightening us. Definitely, the whole AMR agenda is a very, very hot topic, also at European level. We have a Danish politician stepping into her term of office in the EU now, and I actually discussed a little bit with her online, that one thing is, of course, to develop guidelines, but the other part is how to implement them, and we talked about the whole problem with navigating uncertainty, rather than trying to just condense and synthesize knowledge. Great to hear your experiences from Switzerland about this.

Also you mentioned, Joel, the intersection between various stakeholders. Any thoughts about this? Do you have any examples of any initiatives going on? Let's say both in private sector and with involvement of patients?

Joel Lehmann:
Well, in the private sector, one initiative that is currently going on is around having better access to data that is kept in the practice medical record systems. And we have very many different systems in Switzerland, like probably 50 or so, some of which are very few users, and the information exchange and interoperability has been a huge issue.

So, there's one initiative of a company that has started to map all the different data points from different systems, I think the 10 biggest systems to the PHIRE standard - the HL7 standard - which will then allow them to actually access them with an API, without the software developers themselves having to build new APIs.

It's quite an interesting and innovative business model, which I think will really make a difference, for example, to provide access to medication lists or diagnosis lists to telehealth providers. That's like sort of the first use case.

Another one was that the organization I work with (EQUAM), which is a health accreditation provider, we are currently revising our standards for accreditation, and we are trying to do it in a really inclusive way, including different stakeholders, both from the practitioners – the Doctors' networks – as well as health insurance companies, for example, because within the managed care contracts, those accreditations play a certain role.

Adrian Rohrbasser:
Yes, we do it at the very basic level; we're using the shared decision-making communication technique when we prescribe antibiotics, but we actually started introducing it within primary healthcare more often, when we gave advice about colorectal carcinoma screening (CRC).

As I said, we had the antibiotic project, but now we're only involving people, who have more than four or five drugs, and encourage them to talk to their pharmacists about this. We want to increase collaboration between pharmacists and primary care physicians and the way of communication to improve medication safety, so that they can teach each other how to maybe reduce the amount of drugs or inform each other about possible interactions. This is a project at the national level funded by the national Quality Commission and is a research project between MedBase (network providing primary health care) and the pharmacists at the University of Basel.

So, I think that's a quite nice way of starting with the patient. The patient goes to his primary care physician, but also to the pharmacists, and they start talking to each other. It's like another kind of interprofessional work that should start.

Joel Lehmann:
One more thing to add about patient involvement: Switzerland has been participating in the Paris Survey of OECD. We had about 100 practices from all language regions participating. We have the data (PROMs and PREMs), and I really hope there will be a good analysis that can inform also national policy.

In a similar regard, we have just started last week actually a project called 'Primary PROMs', which seems to integrate patient reported outcomes to primary care with four health insurance companies and two networks on board. We really, of course, hope to do it very practitioner-led, like, I know they have been like, there's a lot of talk about those patient reported outcomes, but in practice, it's not quite the same as it is in theory.

So, we hope to learn from European countries, of course, what they're doing in all those different quality topics.

Adrian Rohrbasser:
I think it's like a shift in culture, from where the primary care physician was the center of healthcare in primary care, now it goes over to an interprofessional work. You have different professions involved in this work, and the next step is that the patient is actually part of the team, too. So it's not just healthcare workers, but it's actually the patient, who should participate as a active member in this teamwork. Because it's actually her needs that should be covered, not the healthcare professional's needs.

So, I think it's a shift in culture from this predominant primary care physician-centered work to team work, and now involving the patient into the team too. Then you have these different aspects from interprofessional work and shared decision-making and PROMs and PREMs, etc., but I think it's a mindset. First, you have to change your mindset, and then I think it's going to work, but it's going to take some years.

Joel Lehmann:
I think we are still in the process of shifting from having this 'one' person you know and you always see – the lifelong family doctor – to a system of group practices, where people don't always see the exact same person. I think that whole big change of the model from 1:1 to teams, as you said, is still ongoing in Switzerland.

Adrian Rohrbasser:
Actually, I think it's a bit dangerous to have just one single person being responsible as a lifelong company for one's health. I think it's good if you have a team and that you actually participate actively in this team yourself. I think that's something that has to change in the Swiss population, too, that they don't go there and buy something – like a piece of whatever – it's actually their lives, they're treating or improving quality of life or whatever, but that means that they have to take actively part in the decisions, in the whole process as well.

Joel Lehmann:
Yes! But how can we enable the patient to contribute? Because I think every patient wants to contribute and be part of that treatment. But it's not about saying it's your fault that you didn't take your medicine, but it's about allowing them to contribute.

Ulrik Bak Kirk:
What a beautiful way to to finish this Case Report from Switzerland. I just want to thank you very much for sharing your inputs, Adrian and Joel.