Health care quality Health care quality indicatorsindicators

Health care quality Health care quality indicatorsindicators

m. Prof. MUDr. M.Dragula, PhD.m. Prof. MUDr. M.Dragula, PhD.

Slovak Medical ChamberSlovak Medical Chamber

MediMedicinecine – – science andscience and artart – – do we do we need normsneed norms??

Aversion to the normsAversion to the norms Other indefinitely defined criterionsOther indefinitely defined criterions Non-measurableNon-measurable and and non-comparablenon-comparable

parameterparameterss

Can everybody really make the rightCan everybody really make the right individual decisionindividual decision inin treatment?treatment?

Patient as an individualPatient as an individual

personperson Also individual procedureAlso individual procedure ForensicForensic consequencesconsequences

IndicatorIndicator – – judgesjudges correctness of the correctness of the processprocess

DiagnosisDiagnosis and treatment is a processand treatment is a process It has its input and outputIt has its input and output ProcessProcess has its ownerhas its owner It should have a certain procedure with the It should have a certain procedure with the

possibility of an individual decision makingpossibility of an individual decision making Minimal standard level of the diagnosis and Minimal standard level of the diagnosis and

treatmenttreatment Then the indicator shows the correctness of the Then the indicator shows the correctness of the

outputoutput

Have there been defined the right processes Have there been defined the right processes of the diagnosis and treatmentof the diagnosis and treatment??

In Slovakia there have not been defined any In Slovakia there have not been defined any standardized standardized procedures of the diagnosis and procedures of the diagnosis and treatmenttreatment

Can we then talk about the process indicators?Can we then talk about the process indicators?

Can the indicators be used as the Can the indicators be used as the correctness quality-markerscorrectness quality-markers if the if the

previousprevious ones haveones have not been defined not been defined?? We have indicators saying nothing about previous We have indicators saying nothing about previous

onesones Their collection and evaluation is not transparent Their collection and evaluation is not transparent Are the drawn upAre the drawn up charts charts really really – – of the qualityof the quality??

Does everyone have the equal Does everyone have the equal opportunitiesopportunities – – materialmaterial, , personalpersonal – –

to apply defined processesto apply defined processes?? Minimal standards Minimal standards –– assumption of personnel assumption of personnel

and gadget equipmentand gadget equipment Do we have themDo we have them?? Or will it be solved byOr will it be solved by

means of our standardsmeans of our standards

to adapt them at the to adapt them at the

accessible personnel accessible personnel

and material equipmentand material equipment??

What should be done to make it What should be done to make it happen in the Slovak Republic and happen in the Slovak Republic and

EU countriesEU countries??

EU citizenEU citizen – – equal health care quality in the EU equal health care quality in the EU countriescountries

Two waysTwo ways

The firstThe first

Into EuropeInto Europe – –internationally internationally

accepted accepted standardsstandards

The secondThe second

To the “hell”To the “hell” – – own own standardsstandards

Key-term definitionsKey-term definitionsIndicatorsIndicators//quality characteristicsquality characteristics = = requiredrequired//specified characteristics specified characteristics and and conformity criterionsconformity criterions mainly for process outcomes or the whole quality mainly for process outcomes or the whole quality management system, which are guaranteed to the customer by the process – management system, which are guaranteed to the customer by the process – system ownersystem owner, , that they will be achieved by mutually agreed and determined that they will be achieved by mutually agreed and determined terms.terms.

HealthHealth = = status of total physical, emotional and social well-being, not only the status of total physical, emotional and social well-being, not only the absence of deceaseabsence of decease; ; the result of interaction among human body and social-the result of interaction among human body and social-economic, physical, chemical and biological factors of living and working economic, physical, chemical and biological factors of living and working environment likewise the way of lifeenvironment likewise the way of life. .

Definition has got many imperfections 1. Health is not to be valuated; definition doesn’t enable to define quality characteristics (indicators) for certain gender, age categories / periods of life nor for specific health status; 2. Into the health status it includes satisfaction of needs, claims and expectations of man in the material and social field which exceeds the borders of health and is rather related to the total life quality; 3. It does not consider that many processes and functions in the human body can be interferenced without man noticing it or feeling discomfort or illness; 4. Status of well-being and satisfaction can be experienced by individual with distorted dimension of health and vice versa; physically and emotionally healthy individual suffering by hunger, bad weather or troubles and worries, does not cease to be healthy; on the other hand a physically handicapped individual can be on a considerably higher quality level of health, social, emotional and spiritual status rather than physically healthy psychopath, murderer etc. 5. Spiritual dimension of health connected with the right decision making, creative abilities, correct list of values is missing in the definition, ...

Health qualityHealth quality = = global result indicator of global result indicator of provided health care service provided health care service

Health quality Health quality (QH)(QH) = = complex individual characteristics of all complex individual characteristics of all dimensions includingdimensions including: : physical, psychophysical, psycho--social and cognitive-spiritual social and cognitive-spiritual ((related related to their mutual interconnection and interconditionality to their mutual interconnection and interconditionality ) ) throughout which the throughout which the individual gains the ability to satisfyindividual gains the ability to satisfy specified or anticipated needs for specified or anticipated needs for fulfilling of hisfulfilling of his//her mission, during the particular periods of life, which would her mission, during the particular periods of life, which would be in accordance with the model of be in accordance with the model of the free decision making the free decision making and the life quality compassand the life quality compass..

NoteNote: : This health quality definition isThis health quality definition is in accordance with not only the quality in accordance with not only the quality definition according to definition according to ISO 9000/8402, ISO 9000/8402, but alsobut also::

- - With the research results of With the research results of WHO QoL Group ´93 (WHO QoL Group ´93 (life qualitylife quality););

- - With the total approach to the health care which is being gradually applied With the total approach to the health care which is being gradually applied

HistoryHistory, , presentpresent and trend and trend of developmentof development

Generally on the development of quality as a method for perception of the change Generally on the development of quality as a method for perception of the change of valuesof values

ValueValue as a measurable/ evaluated level of product quality /result of the service as a measurable/ evaluated level of product quality /result of the service Basic scheme of the quality management system of the health care service and Basic scheme of the quality management system of the health care service and

alive cell with the processes alive cell with the processes as an example ofas an example of QMS QMS Partial results Partial results ((Review of results and methods known to usReview of results and methods known to us) ) as the solution for as the solution for

indicators of quality – characteristic features indicators of quality – characteristic features MATRA MATRA ProjectProject ( (HollandHolland – SR) – SR) NIP NIP Project (DenmarkProject (Denmark) ) CEEQNET CEEQNET ProjectProject ( (Czech RepublicCzech Republic, SR, , SR, HungaryHungary, , PolandPoland, , AustriaAustria)) Faculty hospitals of Czech Republic and Slovak Medical Chamber Association Faculty hospitals of Czech Republic and Slovak Medical Chamber Association PATH PATH ProjectProject – WHO – WHO USA USA Standards (The Merck Manual of diagnosis and therapy)Standards (The Merck Manual of diagnosis and therapy) Canadian Standards Canadian Standards The SR government regulations onThe SR government regulations on health care quality indicators health care quality indicators

Result of our effort isResult of our effort is:: The present system approach to be unifiedThe present system approach to be unified, , basic starting-point and outcomes basic starting-point and outcomes (QH a (QH a

QL)QL) to be determined to be determined To achieve the price of health care service to be monetary expression of value To achieve the price of health care service to be monetary expression of value

((evaluation of quality level evaluation of quality level )) of the provided health care services all over the world, of the provided health care services all over the world, which is customer/health insurance company willing to pay to a health care providerwhich is customer/health insurance company willing to pay to a health care provider

Key problems of the health serviceKey problems of the health service1.1. Old paradigmOld paradigm – – health care is focused on treatmenthealth care is focused on treatment, , not on maintaining and not on maintaining and

restoring people’s healthrestoring people’s health2.2. Disconnection between state/regional economy and health care financing Disconnection between state/regional economy and health care financing

and obscure cash flows and obscure cash flows ((budgets without criteriabudgets without criteria, ...), ...)3.3. Evaluation of health care outcomes does not take into consideration the Evaluation of health care outcomes does not take into consideration the

level of health care quality not even its resultslevel of health care quality not even its results – –statusstatus ( (level of qualitylevel of quality) ) of of health health

4.4. System management including health marketing and health monitoring are System management including health marketing and health monitoring are absent in health serviceabsent in health service

5.5. Health care quality is decreasing, morbidity is increasingHealth care quality is decreasing, morbidity is increasing6.6. Responsibility for the status (quality level) of health is not clear not even the Responsibility for the status (quality level) of health is not clear not even the

interconnection between life quality and health quality interconnection between life quality and health quality 7.7. The mission of the health facilities is not explicit and their network is not The mission of the health facilities is not explicit and their network is not

being managedbeing managed

Two of these problems characterize the situation in health service (also in Two of these problems characterize the situation in health service (also in international range)international range)::a) a) financial problemsfinancial problems, , it is obvious that the investment into health service is a good it is obvious that the investment into health service is a good investment, the question is how to invest into health service effectivelyinvestment, the question is how to invest into health service effectively; ; b) b) absent of system management and process approachabsent of system management and process approach, , excluding the health excluding the health care facilities in which the quality management system is being usedcare facilities in which the quality management system is being used

Financial indicators of provided health care Financial indicators of provided health care and efficiency of health care systemand efficiency of health care system

10 % 10 % of GDPof GDP for health care system in for health care system in OECD OECD countriescountries 8,9 % 8,9 % ofof GDPGDP – average in the EU countries– average in the EU countries ( (before before pred rozšírením EÚ) pred rozšírením EÚ) 5,6 % 5,6 % of GDP for health care system in the Slovak Republicof GDP for health care system in the Slovak Republic

50 – 75 %50 – 75 % out of the whole financial budget in health service goes into out of the whole financial budget in health service goes into hospitalshospitals..

The only income (apart from the sponsor giftsThe only income (apart from the sponsor gifts) ) is the price of health care is the price of health care outcomesoutcomes. . Other processes can be classified as expenses.Other processes can be classified as expenses.

If the price of outcomes is not the financial expression of value of the result/ restored, maintained If the price of outcomes is not the financial expression of value of the result/ restored, maintained or improved health qualityor improved health quality, , the whole effort for effective motivation of medical institutions, for the whole effort for effective motivation of medical institutions, for interconnection of health care financing with regional economics would have been meaninglessinterconnection of health care financing with regional economics would have been meaningless..

The lower the level of quality of health care provided by primary outpatient clinicsThe lower the level of quality of health care provided by primary outpatient clinics, , the the higher portion of finances being used by hospitals.higher portion of finances being used by hospitals.The lower the level of preventive health care:The lower the level of preventive health care:

the lower the lower QHQH as well as the level of QL as well as the level of QL the shorter life expectancy the shorter life expectancy the higher portion of finances needed for provided health carethe higher portion of finances needed for provided health care – – that means the that means the

provided health care is being less effectiveprovided health care is being less effective!!

Key processesKey processes//sub processes according to sub processes according to ISO 9001:2000 ISO 9001:2000 focused on health care quality and quality of health indicatorsfocused on health care quality and quality of health indicators

Health care service realizationHealth care service realization Basic inputs into the health care service realization process and into its seven below Basic inputs into the health care service realization process and into its seven below

mentioned sub processes should be thementioned sub processes should be the results of health care marketingresults of health care marketing. . Planning of realization of health care service execution processes Planning of realization of health care service execution processes

Quality objectives and requirements for Quality objectives and requirements for QH QH Processes, specific documents and resources needed to achieve planned results Processes, specific documents and resources needed to achieve planned results Required verification, validation, monitoring, inspection and test activities specific to the QH and the Required verification, validation, monitoring, inspection and test activities specific to the QH and the

criteria for QH acceptancecriteria for QH acceptance Customer-related processesCustomer-related processes – – activities during the period of health restoring and obtaining activities during the period of health restoring and obtaining

good habits for health quality maintenancegood habits for health quality maintenance Design and developmentDesign and development

Design and development of new method of prevention, treatment focused on restoring, maintaining Design and development of new method of prevention, treatment focused on restoring, maintaining or improving health qualityor improving health quality

verificationverification ( (confirmationconfirmation that the specific requirements have been met by providing the objective that the specific requirements have been met by providing the objective evidenceevidence) ) of design and developmentof design and development

Validation of design and developmentValidation of design and development Process of inputs purchasing Process of inputs purchasing Realization of health care services execution processesRealization of health care services execution processes

Validation of realization processesValidation of realization processes Control of diagnostic, monitoring and measuring devicesControl of diagnostic, monitoring and measuring devices Health care facilityHealth care facility shall plan and implement the monitoring, measurement, analysis and shall plan and implement the monitoring, measurement, analysis and

improvement processes improvement processes

Key processesKey processes//sub processes according to sub processes according to ISO ISO 9001:2000 9001:2000 focused on health care quality and quality of focused on health care quality and quality of

health indicatorshealth indicators MeasurementMeasurement, , monitoring and improvementmonitoring and improvement Monitoring and measuring of provided health care outcomesMonitoring and measuring of provided health care outcomes

Customer satisfactionCustomer satisfaction Internal auditInternal audit Monitoring and measurement of processMonitoring and measurement of process Monitoring and measurement of product (provided health care outcome) Monitoring and measurement of product (provided health care outcome) Control of nonconforming quality of health status Control of nonconforming quality of health status

Validation of data/quality indicators and indicators of conformity in Validation of data/quality indicators and indicators of conformity in relation to achieved results and progress of health allrelation to achieved results and progress of health all over the worldover the world

ImprovementImprovement Continual improvementContinual improvement Corrective actionCorrective action Preventive actionPreventive action

Partial resultsPartial results – – characteristics of the solutions of characteristics of the solutions of health care quality indicator projectshealth care quality indicator projects

NIP NIP project project ((DenmarkDenmark): ):

Very good access to solution processVery good access to solution process, , results are arranged according to medical results are arranged according to medical fields or selected areas, e.g.: fields or selected areas, e.g.: treatment and rehabilitation of patients after stroke indicator standardstreatment and rehabilitation of patients after stroke indicator standardship fracture indicator standards hip fracture indicator standards Results are processed as followsResults are processed as follows::

INDICATOR INDICATOR CONCEPTCONCEPT

INDICATORINDICATOR TYPETYPE STANDARDSTANDARD/ / COMFORMITY COMFORMITY

CRITERIONCRITERION

TIMETIME

Organization of Organization of treatment and treatment and rehabilitationsrehabilitations

Proportion of Proportion of patients patients treated/rehabilitated treated/rehabilitated in stroke unitsin stroke units

processprocess >90>90% % <48 hours after <48 hours after admissionadmission

MortalityMortality 30 30 days and 3,6 days and 3,6 and 12 months and 12 months mortality mortality

outcomeoutcome ((not not desireddesired))

30 days mortality 30 days mortality <20<20%%

30 days30 days; 3, 6, ; 3, 6, 12 12 months after months after strokestroke

Danish NIP was established in 2000Danish NIP was established in 2000;;

Partial resultsPartial results – – characteristics of the solutions of characteristics of the solutions of health care quality indicator project MATRAhealth care quality indicator project MATRA

MATRAMATRA project project – – as the basic tools are usedas the basic tools are used quality management system quality management system (QMS) (QMS) according toaccording to ISO 9000:2000 ISO 9000:2000 and and extensive models extensive models EFQM/CAF. EFQM/CAF. Health qualityHealth quality (QH) (QH) and quality of life and quality of life (QL)(QL) are mentioned as the main are mentioned as the main outcomesoutcomes. . This is fully in accordance with the results of This is fully in accordance with the results of WHO QoL GroupWHO QoL Group´93 ´93 research as well as with the solution of research as well as with the solution of MFN 05/2000MFN 05/2000 grant grant. . However proclaimedHowever proclaimed „ „health qualityhealth quality“ “ has not been definedhas not been defined. . Outcomes of health care quality indicators are shown in four classesOutcomes of health care quality indicators are shown in four classes::1.1. demographic and socio-economic factorsdemographic and socio-economic factors 2.2. health statushealth status 3.3. determinants of healthdeterminants of health4.4. health systemshealth systemsThese classes has been further divided into groups and subgroups. These classes has been further divided into groups and subgroups. Specific quality indicators are mentioned later. Specific quality indicators are mentioned later. It is undoubtedly It is undoubtedly the most the most sophisticated and systematically best donesophisticated and systematically best done solution of this complex issuesolution of this complex issue. . This has to be a reason why WHO has chosen the results of MATRA This has to be a reason why WHO has chosen the results of MATRA project as a base for PATH project. project as a base for PATH project.

What the health population depends onWhat the health population depends on??

www.reformazdravotníctva.skwww.reformazdravotníctva.skZdroj: WHO, 1999Zdroj: WHO, 1999

Life style 51%

Other7%

Healthsystem

17%

Genetics 25%

What the health of population depends on?

Thank you for your Thank you for your attentionattention