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Comparing Quality efforts Comparing Quality efforts across Europe: now and in across Europe: now and in
the futurethe future
Rosa Suñol, MD, Ph.D.Director, Avedis Donabedian FoundationDirector AD Quality Chair. Fac. of Medicine. Autonomous University of Barcelona
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Quality efforts in Europe. Quality efforts in Europe. First developmentsFirst developments
1979 CBO in the Netherlands 1981 First QA programs in Spain 1982 First WHO meeting “Principles
for Quality Assurance 1983-5 First European Societies and
ISQua Foundation
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Common trends ofCommon trends ofthe first effortsthe first efforts
Leaded by health professionals
(doctors and nurses) Based on audit Hospital oriented (clinical and
organizational). Spread initiatives in PHC in some countries
Majority of initiatives taken in public centers
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Present situationPresent situation Laws Public accountability (accreditation and certification) Total Quality management Cost of technology, clinical guidelines
and evidence based medicine Indicators Patients’ opinion
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Legal framework Legal framework (80 -02)(80 -02)
Patients’ rights (access, general coverage, “good quality care”, )
Medical/professional competence (re-certification etc)
Quality efforts (accreditation,
measurement or improvement. Not quality level, few quality compromises)
Risk protection (radiation, etc)
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Public accountabilityPublic accountabilityefforts efforts (95 - 02)(95 - 02)
Accreditation (optimal processes and functioning with pre-determined professional standards specifically health oriented)
ISO certification (based on documented quality system, process management and decreasing variation. Applicable to all sectors)
Public disclosure of information indicators
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AccreditationAccreditation 18 different programs identified
Relationship togovernment
Programme
Managed within Ministryof Health
Bosnia RS, Italy, Malta,Portugal, Slovakia
Separate governmentagency
UK CSBS, France, Ireland
independent agency withgovernmentrepresentation
Bosnia FBiH, Bulgaria,Czech Rep., Hungary,Latvia, Netherlands
Totally independent Denmark, Finland, UK HAP,UK HQS, Switzerland,Spain
Accreditation in Europe: survey 2001. CD Accreditation in Europe: survey 2001. CD ShawShaw
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Accreditation growthAccreditation growthin Europein Europe
0
2
4
6
8
10
12
14
16
18
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Accreditation in Europe: survey 2001. CD Accreditation in Europe: survey 2001. CD ShawShaw
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ISO certification in European ISO certification in European healthcare sector (2000)healthcare sector (2000)
Country CompaniessanitaryBelgium 76 2,0%
Denmark 46 1,2%Findland 44 1,2%France 347 9,1%Germany 657 17,2%Greece 44 1,2%Ireland 67 1,8%Italy 614 16,1%Luxembourg 3 0,1%The Netherlands 223 5.8%Norway 32 0,8%Portugal 34 0,9%Spain 254 6,7%Sweden 88 2,3%United Kingdom 1.289 33,7%
Total 3.820www.iso.orgwww.iso.org
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TQM. EFQM modelTQM. EFQM model
(91 -02)(91 -02)
General framework Based on a developmental approach
(goal: excellence) Useful to develop comprehensive managerial model Need of specific adaptation (process and out-comes) Possibility of combination with
accreditation and ISO
Liderazgo
Liderazgo Procesos Resultados clave
Resultados en las personas
Resultados en los clientes
Resultados en la sociedad
Personas
Política yestrategia
Alianzas yrecursos
Agentes facilitadoresAgentes facilitadores ResultadosResultados
Innovación y aprendizajeInnovación y aprendizaje
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Cost of technology, clinical Cost of technology, clinical guidelines. Evidence basedguidelines. Evidence basedmedicine medicine (92 -02)(92 -02)
Structured initiatives in almost all countries Awareness on unexplained variability and
research on clinical effectiveness Different guidelines for the same condition Present interests:
– Strategies for implementing – recommendations)– Cost effectiveness recommendations– Client preferences
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Indicators Indicators
Indicator 1999 2000 National %Improvement
Six month inpatient waits73.4% 73.2% -0.2%
Returning home followinghospital treatment forfractured hip
46.6% 46.1% -1.0%
Generic prescribing70.2% 73.6% 4.9%
NHS Performance indicators Feb. 2002NHS Performance indicators Feb. 2002
Initiatives in most countries. Interest in out- comes or key processes Public availability of data (UK,...)
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IndicatorsIndicators
Indicator 1999(/ 100.000)
2000(/ 100.000)
National %Improvement
Deaths from circulatorydiseases 127.0 120.4 5.2%
Surgery rates for jointreplacement 121.8 129.5 6.4%
Returning home followinghospital treatment forfractured hip
46.6 46.1 -1.0%
Four-week smokingquitters No data 162 No comparison
available
NHS Performance indicators Feb. 2002NHS Performance indicators Feb. 2002
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Patients’ opinionPatients’ opinion Few countries with national data Few comparative initiatives
% PHC patients satisfied with the possibility of getting a suitable appointment (N=24.000)
71%
94%
77%
89%
78% 81%
62%
78%85%84%
Denm Germ Nethe Norw UK Belg F Belg W Switz Slove Spain
Wensing M, Vedsted P, Kersnik J et al. “Patient satisfaction with availability of general practice: an international comparison”Wensing M, Vedsted P, Kersnik J et al. “Patient satisfaction with availability of general practice: an international comparison”International Journal for Quality in Health Care 2002 (14) 111-18International Journal for Quality in Health Care 2002 (14) 111-18
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Present situationPresent situation
Added governmental initiatives (top -down) QI in contracts (hospitals and PHC Extensive programs with important investments
( accreditation, indicators..) Begining of information disclosure to the
patients
Less clinical Less clinical involvement ??involvement ??
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Last 5 years topicsLast 5 years topics
Clinical guide -lines Accreditation/ISO/ EFQM
Indicators
Technology assessment
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Agenda for theAgenda for thefuture: coordination ?future: coordination ?
1. Globalization: European model
and sustainability 2. Health Agenda. Clients´ priorities and
participation3. New systems of providing health care
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1. Globalization.1. Globalization.European model andsustainability
Values: Diversity and role of ethics in
management and rationing priorities New concept of effectiveness (undercoverage,
underuse, quality of life) will force to rethink efficiency measures
Citizens mobility: Accreditation and certification
Important issues: Safety, Public Health
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2. Health Agenda. 2. Health Agenda. Clients: priorities in QI Clients: priorities in QI programsprograms
Patients’ Priorities / expectationsPatients’ Priorities / expectations(% patients with maximum score)(% patients with maximum score)
Questions % Punt. 7
Professionals are interested in solvingpatient’s problems.
88,2
The correct medication is delivered. 87,6
Personalized manner of treating patients. 82,2
No diagnostic errors. 80,5
Doctor dedicate sufficient time to patients. 79,0
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Information and health decisions.• Patient access to large amounts of • information (Internet…)• Public disclosure of clinical indicators
• Shared consent (anxiety support, language adaptation)• Risk of loosing the philosophy of continuous
improvement excellence• Risk of the professionals feeling overwhelmed and not
reporting all information
2. Health Agenda. 2. Health Agenda. Clients Clients
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2. Health Agenda. 2. Health Agenda. Clients participation Clients participation
Participation of citizens in deciding priorities
• Lack of technical knowledge and little inclination to share difficult decision-making
• Difficulty in feeling represented. Government role
• Research and introduction of new ways allowing effective participation
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3. New Systems of3. New Systems ofproviding of Health Careproviding of Health Care
Social changes linked to scientific developments
Integrated care of patients (disease management)
• Less importance of health centers• Mix between health (PHC, Hospitals and LTC)
and social care
• Integrated Quality programsQQ
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3. New Systems of3. New Systems ofproviding of Healthproviding of HealthCareCare
Change as organizations basis – From “making things” better to “making
better things”.– Knowledge organizations– Influence of the center on– the society
Increasing importance of providers’ satisfaction (change in recognition criteria)
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Common language shared
by patients, professionals,managers, providers andadministration
5. Future of the Quality5. Future of the Quality programs programs
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IHC TURP QUE StudyIHC TURP QUE Study
Average Hospital Cost
16181697
1913
2233
1598
1164
1549
12691552
1556
1662
1500 1568 1543
21402156
0
500
1.000
1.500
2.000
2.500
A B C D E F G H I J K L M N O P
Dolla
rs
Brendt James 1999
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IHC TUPR QUE StudyIHC TUPR QUE Study
Average Length of Stay
3,8 3,8
3,3
3,9
3,1
3,9
4,5 4,64,9
4,6 4,6
3,22,7
3,4
4,3 4,5
0
1
2
3
4
5
6
A B C D E F G H I J K L M N O P
Attending Physician
Day
s
Brendt James 1999
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Outcomes chain:Outcomes chain:TUPR costsTUPR costs
CostCostRetrogradepyelograms
Length of stayLength of stayDay of admitsurgery
Foley catheterFoley cathetermanagementmanagement
Perceived risk ofPerceived risk ofobstruction from blood clotsobstruction from blood clots
Brendt James 1999
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FutureFuture
2002-052002-052002-052002-05
1995-001995-001995-001995-001980-851980-851980-851980-85
2005-082005-082005-082005-08
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Some questions for discussionSome questions for discussion
What are the most effective ways to develop the new QI stage in Europe ?
How ca we ensure that patient/citizens´ agenda is accomplish?
What are the advantages and disadvantges of government leadership ?
Regional versus national versus European versus global approach ?