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

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

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

Present situationPresent situation Laws Public accountability (accreditation and certification) Total Quality management Cost of technology, clinical guidelines

and evidence based medicine Indicators Patients’ opinion

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)

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

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

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

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

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

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

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,...)

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

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

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 ??

Last 5 years topicsLast 5 years topics

Clinical guide -lines Accreditation/ISO/ EFQM

Indicators

Technology assessment

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

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

QQ

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

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

QQ

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

QQ

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

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)

QQ

Common language shared

by patients, professionals,managers, providers andadministration

5. Future of the Quality5. Future of the Quality programs programs

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

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

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

FutureFuture

2002-052002-052002-052002-05

1995-001995-001995-001995-001980-851980-851980-851980-85

2005-082005-082005-082005-08

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 ?