CONTENTS
| SUMMARY |
3 |
| INTRODUCTION |
5 |
| DEFINITION
OF QUALITY IMPROVEMENT |
5 |
| Quality
improvement and health for all |
5 |
| RATIONALE
FOR NATIONAL POLICY |
5 |
| PRINCIPLES
OF QUALITY IMPROVEMENT |
6 |
| DEFINITION
OF QUALITY HEALTH CARE |
6 |
| MAIN
COMPONENTS OF HEALTH CARE |
6 |
| BASIC
PRINCIPLES OF CONTINUOS QUALITY IMPROVEMENT |
7 |
| The
process of quality improvement |
7 |
| Theory
of good apples |
7 |
| Quality
goals |
8 |
| ROLES
OF THE PARTNERS |
8 |
| Patients
and the society |
8 |
| Health
care providers |
8 |
| Managers
|
8 |
| LEVELS
OF RESPONSIBILITIES |
10 |
| COMMON
RESPONSIBILITIES |
10 |
| Patients'
involvement |
10 |
| Information
system |
10 |
| Education
|
11 |
| Resources
|
11 |
| RESPONSIBILITIES
ON VARIOUS LEVELS |
11 |
| The
national level |
11 |
| The
regional level |
11 |
| Local
level |
12 |
| Care
providers their professional associations |
12 |
| Agency
for health care insurance and other health care insurance
companies |
12 |
| ACTIVITIES
IN SLOVENIA |
13 |
| NATIONAL
LEVEL |
13 |
| Partners
in quality |
13 |
Summary
Quality
improvement is a must in health care services. The strategy of
WHO: Health for all by the year 2000 and the Plan of health care
in Republic Slovenia by the year 2000 include obligation for all
parties in the country to develop a quality improvement systems.
National policy on quality in health care is one of the means
of connecting existing and new quality activities in at all levels
in a network directed towards quality improvement of the whole
health care system. The policy should reflect the possibilities
of the respected country and the health care needs of the population.
Principles of quality improvement are basis of all activities
at all levels of health care services.
Quality
improvement is a continuos process that encompasses:
¨ setting quality goals,
¨ collecting and analysing data,
¨ quality assessment, identifying the best results, implementing
change,
¨ follow-up (continuos).
Patients'
experiences and preferences should be taken into account.
Activities
at the local level are the core of quality improvement. Quality
improvement should be an integral part of the daily activities
of all health care professionals.
Health
care providers are the key partners in quality improvement. Health
care providers are responsible for quality of care rendered but
health care managers at all levels are ultimately responsible
for designing and the operation of quality improvement systems.
Quality
improvement should be based on selfassessment and selfregulation,
rather than on control and administrative measures.
For
the success every level of health care system has its own, but
all levels share some common responsibilities:
¨ using all steps of quality improvement process,
¨ incorporate the needs of the patients and the population,
¨ designing information system,
¨ creating basic minimal data set for each profession,
¨ providing education on the concept and the methods for quality
improvement,
¨ setting priorities for allocation of resources devoted to quality
improvement,
¨ designing systems of incentives.
On
the national level Ministry of health is responsible for creating
and implementing policy in health care:
¨ setting priorities and quality targets,
¨ establishing of health care databases,
¨ appropriate feedback to providers,
¨ quality research,
¨ legislation and national network for quality improvement system.
Professional
associations have to take part in promoting and implementing quality
improvement in their fields. They choose priorities, quality goals
and quality indicators. They play a major role in developing practice
guidelines.
At
the regional level health authorities should:
¨ set goals and strategy for implementation of them,
¨ create quality improvement system for the region,
¨ regional data collection of basic minimal data sets for quality
improvement within each profession,
¨ monitor of achievements,
¨ feedback to health care providers
¨ facilitate co-operation in the region,
¨ plan and providing education on quality improvement,
¨ set priorities for resource allocation for quality improvement
in the region.
On
the local level managers of the hospitals, primary health canters
and other health care organisations are responsible for implementing
quality improvement. They have to establish quality systems in
their organisations. Quality policy is one element of such system
and should be written down in quality manual of the organisation.
Top management has to be the most active partner in quality improvement
process and must take the leading role by:
¨ defining responsibilities for quality at all levels of management
in the organisation,
¨ establishing effective organisation for quality
¨ establishing effective information system to support quality
improvement,
¨ engaging quality professionals for quality directors and key
quality management responsibilities within the organisation,
¨ creating quality improvement system.
Every
health care provider has to be informed on quality policy and
its quality goals of the organisation in order to improve quality.
Everybody has to get regularly appropriate feedback on quality
achievements. Health care providers in their daily practice use
tools and methods for quality improvement.
Introduction
Definition
of quality improvement
Quality
improvement is a dynamic process that identifies the best health
care outcomes to achieve excellence. It encompasses concepts and
methods of quality control, assessment, assurance and improvement.
The
word improvement is preferred as it implies the nature of the
process; besides controlling, assessing and assuring quality it
depicts continuos quality development or improvement of care.
Quality
improvement and health for all
Strategy
of the who health for all in the target 31 says:
"By
the year 2000, there should be structures and processes in all
member states to ensure continuos improvement in the quality of
health care and appropriate development and use of health technologies."
This
could be achieved by establishing methods and processes for systematic
monitoring, assessment and promoting quality of health care. Quality
improvement has to become a permanent part of health care professionals
daily practice. The providers should be provided with adequate
education and training in quality improvement.
This
target is essential for achieving targets 26 - 30. These targets
address appropriate care and strategies for improvement of the
health status of the population. They focus on effective management
of health care resources taking into account quality and cost
of the care rendered.
Target
35 calls for effective health information system that will support
achieving of other targets. Target 38 calls for incorporating
public needs and perspectives in the decisions in health care
system.
Rationale
for national policy
Quality
in health care is becoming an important issue in the debates on
health care systems in our country and throughout the world. There
are some points in common:
Patients
and public are increasingly aware of quality of health care. They
demand quality improvement of all functions of health care systems
with special attention to health care services.
Politicians,
health care policy makers and payers of health care expenditures
demand the equity, availability, accessibility, documentation
of the care rendered, quality improvement and cost containment.
All
profiles of health care professionals want to improve their performance.
Variations
in processes, outcomes and in the delivery of care rise the discussions
on quality. This is even more evident in the absence of agreed
standards for structures, processes and outcomes of care. There
is also lacking the explicit definition of acceptability in health
care.
Health
care budgets are limited and quality improvement is no more expected
by expanding health care budgets. Quality improvement requires
the use of other tools in methods to achieve targets of quality.
Quality policy sets quality targets on the national level and
responsibilities for achieving these targets on national, regional
and local level. Through this quality improvement becomes a continuos
part of daily activities of all health care professionals.
Feedback
to all individual providers proved itself as effective tool for
incremental continuous quality improvement in health care.
Besides
quality improvement of health care provision, the following activities
are closely related to quality of care:
¨ technology assessment of new and established health care technologies,
¨ developing guidelines,
¨ equity, accessibility and affordability of health care for the
population,
¨ the appropriate distribution of tasks and responsibilities to
various health care professionals,
¨ education for quality, and
¨ reassert on methods and quality interventions.
Principles
of quality improvement
Definition of quality health care
Components
of quality health care are:
¨ high degree of professional excellence,
¨ effective use of health care resources,
¨ minimal risk for the patients,
¨ patient satisfaction,
¨ impact on health status of the individuals and the population.
Quality
health care meets predefined requirements and in with current
state of knowledge fulfil expectations for maximising benefits
and minimising the risks to the health and well-being of the patients.
Besides professional quality, quality of service functions of
health care provision is important (lay quality). By this definition
all the staff of health care organisations is involved.
Main
components of health care
Some
activities are directly related to health (health promotion, disease
prevention, diagnosis, treatment and rehabilitation) (so called
professional or technical quality), other activities are related
to service functions of health care provision (lay quality). Accessibility,
availability, affordability end equity are concern of health care
system management (societal quality). All this aspects of health
care provision build up the integral quality of health care system
of the country.
Quality
improvement addresses three parts of health care: structure, process
and outcome.
Structure
refers to the organisational setting of care, including economic
conditions, management, staff, equipment, facilities, education
and information system.
Process
refers to provision of preventive, diagnostic, therapeutic and
rehabilitative services including communication between doctor
and patient.
Outcome
refers to the effects of care on health status of the patient
or the population as a whole and on patient satisfaction. It relates
to the effectiveness of resource utilisation, too.
All
aspects of care are important, but a positive outcome is the most
important aspect for the patient and the population. This is also
a rationale for identification of the best outcomes and learning
from the experience of the best providers. Identifying the best
providers tell the others which structures and processes are capable
to produce good outcomes in the certain circumstances.
Patient
satisfaction is an outcome in itself. Outcomes in terms of improved
health status nevertheless outweigh the outcomes in terms of patient
satisfaction.
Information
on outcomes, structures and processes must be available at all
levels. Information system has to aggregate and analyse relevant
data for feedback to providers.
Basic
principles of continuos quality improvement
Quality
improvement is a dynamic process based on the following principles:
¨ identification and use of the best outcomes to achieve superlative
practices,
¨ the explicit definition of quality targets,
¨ continuos professional selfassessment and selfregulation,
¨ committed leadership and patient involvement,
The
process of quality improvement
A
variety of methods for quality improvement exists, including quality
circles, audit, per review, information supported quality improvement
etc. They use common steps:
¨ setting priorities and quality targets,
¨ quality assessment,
¨ implementing change,
¨ follow up (repeating the process).
Setting
priorities means a definition of indicators, criteria and standards
for quality. Quality assessment includes data collection and analysis
of data on quality indicators and feeding back the providers.
This step is followed by implementing change in the practice where
deficiencies in quality of rendered care were detected. Follow
up relates to the evaluation of the impact of quality improvement
activities. Follow up should be repeated at certain intervals
to monitor the level of quality of care. The process should be
oriented toward achieving agreed standards by incremental improvement
of quality.
The
ultimate goal of quality improvement is in the use of new research
knowledge that has proven in the practice.
Theory
of good apples
The
theory of quality improvement is sometimes called theory of good
apples. The goal of quality improvement lies in identification
of the best results and use of them to improve the practice as
a whole, rather than to identify, punish and eliminate poor outcomes
(bad apples).
The
theory of good apples is applied by examining the curve of outcomes
in the particular area of care. Theoretically 5% will be very
good, 90% good and 5% poor. In the next step we compare the outcomes
and identify the best outcomes. The analysis reveals the structures
and processes by which the best outcomes were achieved. On this
basis practice guidelines can be developed.
Definition
of profession specific indicators and comparing the outcomes allows
the identification of the centres of excellence. These institutions
can provide teaching and training on the topic. The method can
be applied on all levels. International experiences confirmed
that exchange of the ideas and positive incentives have been more
effective than disincentives, administrative or punitive measures.
The identification of bad outcomes remains necessary to eliminate
them or to shift them towards the better care.
Quality goals
Besides
assessment of performance, setting quality goals is essential
for quality improvement in health care provision. Health care
policy makers, payers and health care authorities together with
patients' representatives are responsible to decide on quality
goals. Quality goals are often defined as standards of care that
means the agreed level of performance for selected criteria. Standards
draw the borderline between acceptable and unacceptable care in
given circumstances. Standards undergo the consensus development
processes. Criteria are measurable elements of care that can be
used for quality assessment. Quality indicators of health care
are needed for comparing the quality of health care. Mortality,
specific morbidity, complication rate and health status are quality
indicators of the outcome. Providers have to develop reliable,
scientifically valid, disease specific and sensitive quality indicators.
Roles of the partners
Patients
and the society
Patients
and the society benefit from the health care services. Patients'
experiences and preferences on the structure, processes and outcomes
of care in terms of health status and patients satisfaction can
be a valuable indicator of quality improvement.
Health
care providers
The
basis of quality improvement are activities on local level (institution,
departments, wards practices). Quality improvement must be an
integral part of daily routine of all categories of the staff.
Quality improvement must be understood as a tool for improvement
their job satisfaction.
Managers
Ultimate
responsibility for quality lies with the managers at all levels
of the health care system. They can assure the integration of
quality improvement concepts, methods and tools in daily practice.
They have following tasks:
¨ Create quality policy in the institution, that stress the importance
of quality and define responsibilities for quality within the
institution.
¨ They establish quality improvement system of the institution
for planning, implementing, controlling and documenting all quality
activities in the institution.
¨ Together with providers they set general goals and strategies
for implementation of chosen qualify policy.
¨ They facilitate developing criteria and setting standards.
¨ They demand the definition of quality indicators.
¨ They take action to improve quality.
¨ They feedback the information to providers.
¨ They assess and monitor the outcomes.
¨ They make decisions on education and training.
They
foster staff's commitment and involvement in processes of quality
improvement by:
¨ advocating the principles of quality improvement,
¨ creating effective incentives for participation in quality improvement
activities,
¨
facilitating multiprofessional and intersectorial quality improvement
activities.
Levels of responsibilities
All levels of health care system are responsible for quality improvement.
The mangers of health care system on national, regional and local
level including managers of health care institutions and managers
of the departments and wards have the main responsibility. Key
role for quality improvement lies with professionals that render
health care to the patients.
Common responsibilities
1)
Supporting quality improvement:
¨ identifying quality problems and areas of top priority for quality
improvement,
¨ setting realistic short- and long-term goals in these areas,
2) Monitoring the process:
¨ defining quality indicators,
¨ collecting data for usage inside the institution and between
the institutions,
3) Information:
¨ feed back information to the providers for comparisons,
¨ sharing information and experience within and between levels.
This is achieved publishing and distribution of the reports on
practical experiences including both the success stories and problems.
4) Creating incentives:
¨ making quality improvement activities conditions for employment
and promotion,
¨ making agreement on the use of eventual savings.
5) Evaluation and follow up:
¨ reporting the results,
¨ dissemination of the information.
Patients'
involvement
Patients'
influence on health care is an important part of quality improvement.
Managers and health care providers at all levels have to create
opportunities to involve patients, patent's organisations and
the community in quality improvement activities. They have to
take into account their needs, problems and expectations on quality
of health care.
Information
system
Quality
improvement requires a continuous collection of data. Information
system serves as a basic requirement for that. Data collection
is a daily routine facilitated by upgraded software.
Each
health care profession must create minimal data set that serves
for comparing outcomes through the time and between institutions.
Existing
data bases should be incorporated in the system. The majority
of data have to be collected by the professionals themselves.
Validity,
reliability, costs and medicolegal aspects of data collection
should be regarded.
Education
Education
should be available for all providers. Courses and other teaching
methods on the concepts, methods, tools, use of feedback and other
activities on quality improvement have to be part of inservice
training. The staff must be encouraged to take quality improvement
activities as their privilege. Team work and multidisciplinary
activities are part of the process.
Quality
improvement courses have to be part of every curriculum for health
care providers at all levels of their education.
Resources
Time
to get familiar with the principles and methods of quality improvement
is necessary. Time and money is needed for data bases creation.
Resources for quality improvement have to be foreseen in health
care budgets. Quality improvement activities bring additional
costs that can be easily earned back by avoiding high costs of
bad quality (unnecessary and inappropriate treatment, fallacies,
avoidable complications, etc.). Management and staff have to decide
on the use of eventual savings. Cost-effectiveness of the process
and patient satisfaction are important issues for all patients
in the health care system.
Responsibilities on various levels
The
national level
Primary
task of health care policy makers on the national l level is the
development and implementation of explicit national policy on
quality in health care. Health administration has following tasks:
¨ supporting research, development of principles and methods for
quality improvement,
¨ encouraging regional authorities, managers and all providers
to initiate and maintain the process,
¨ setting priorities, facilitating creation of national criteria,
developing standards and chosen quality indicators,
¨ statistical support,
¨ national databases,
¨ technology assessment on the national level,
¨ co-ordination of quality activities in the country,
¨ counselling and guiding activities on regional and local level,
¨ stimulating international collaboration,
¨ participation in international comparative studies.
Existing institutions (Institute of public health) and/or new
bodies should be involved to complete these tasks. Supportive
legislation and other elements of quality improvement have to
ensure the process.
The
regional level
In
spite of (at the present) not strongly defined regional health
authorities encouraging activities at this level. It provides
a realistic network for co-operation and comparison between providers.
Special
tasks are:
¨ data collection on quality indicators,
¨ monitoring the effectiveness of each institution,
¨
feedback of the results to the providers
Local level
Managers
of health care institutions are responsible for planning and implementation
of quality improvement. They design quality improvement system
for their organisation. They monitor the performance and outcomes
and take actions. They encourage the co-operation between professionals
and wards.
Care
providers their professional associations
Professionals
are the key for quality improvement. The success lies on multiprofessional
approach. The providers must be informed on quality to become
aware of their responsibilities.
Professional
organisations have professional and ethical obligation to implement
the process. Technology assessment and developing guidelines are
the core of their action. Professional organisations have the
privilege to reach consensus on quality indicators that reflect
the quality of care provided.
Profession
chambers of different profiles of health care workers play an
important role in providing external quality control, medical
education, vocational training and continuing medical education.
Agency for health care insurance and other health care insurance
companies
Payers
play an important role in two areas:
¨ existing data bases enables comparisons in some areas of health
care provisions,
¨ with respect to some health authority role it has responsibilities
for initiating and implementing quality improvement on all levels.
Activities in Slovenia
Quality
is becoming an important issue in health care debates in Slovenia.
Professional are becoming aware of improving quality of their
work. Health care reforms encompasses quality improvement initiatives.
Health care institutions and professional associations play an
important role in quality improvement activities.
National level
Partners
in quality
Ministry
of health is responsible for quality in health care. Activities
are part of the routines of professional associations, health
care institutions and Institute of public health, that monitors
the activities and provides co-ordination. Legislation supports
quality improvement in health care.
Every
citizen has the right of quality care. The patient is free to
choose the primary care physician, (after referral) a specialist
or hospital. A wide variety of preventive, curative and rehabilitative
services are enclosed in the universal coverage that assures affordability
of health care services.
On
the national level agreed network of services assures equity to
all patients and accessibility of the services. Primary health
care is evenly distributed throughout the country to serve the
needs of the population. Specialists and hospitals are regionally
distributed with tertiary health care in a few centres.
For
planning and implementation of quality improvement the Committee
for quality was established at Ministry of health. Co-ordinator
for quality in health care is responsible for co-ordination of
the activities.
Structures
for external quality control exist. Medical chamber provides quality
control, certification and rectification schemes for physicians.
Ministry of health is responsible for audit and Agency for coverage
of health care costs provides financial control. Technology assessment
and accreditation is brought out by the bodies appointed by the
Ministry of health. Institute of public health has an importune
co-ordinate role.
Quality policy in family medicine
