Comparing Quality efforts
across Europe: now and in
the future
Rosa Suñol, MD, Ph.D.
Director, Avedis Donabedian Foundation
Director AD Quality Chair. Fac. of Medicine. Autonomous
University of Barcelona
Quality efforts in Europe.
First 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 of
the 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 situation
Laws
 Public accountability
(accreditation and certification)
 Total Quality management
 Cost of technology, clinical guidelines
and evidence based medicine
 Indicators
 Patients’ opinion

Legal framework (80 -02)

Patients’ rights
(access, general coverage, “good
quality care”, )

Medical/professional competence
certification etc)

Quality efforts
(accreditation,
measurement or improvement. Not
quality level, few quality compromises)

Risk protection
(radiation, etc)
(re-
Public accountability
efforts (95 - 02)

Accreditation

ISO certification

Public disclosure of information
indicators
(optimal processes and functioning
with pre-determined professional standards specifically
health oriented)
(based on documented quality
system, process management and decreasing
variation. Applicable to all sectors)
Accreditation
 1 8 d iffe re n t p ro g ra m s id e n tifie d
R e la tio n sh ip to
g o v e rn m e n t
M a n a g e d w ith in M in istry
o f H e a lth
S e p a ra te g o v e rn m e n t
agency
in d e p e n d e n t a g e n c y w ith
g o v e rn m e n t
re p re se n ta tio n
T o ta lly in d e p e n d e n t
P ro g ra m m e
B o sn ia R S , Ita ly , M a lta ,
P o rtu g a l, S lo v a k ia
U K C S B S , F ra n ce , Ire la n d
B o sn ia F B iH , B u lg a ria ,
C ze c h R e p ., H u n g a ry ,
L a tv ia , N e th e rla n d s
D e n m a rk , F in la n d , U K H A P ,
U K H Q S , S w itze rla n d ,
S p a in
Accreditation in Europe: survey 2001. CD Shaw
Accreditation growth
in Europe
18
16
14
12
10
8
6
4
2
0
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
Accreditation in Europe: survey 2001. CD Shaw
ISO certification in European
healthcare sector (2000)
C o m p a n ie s
6 ry
s a n7ita
2 ,0 %
D e n m a rk
46
1 ,2 %
F in d la n d
F ra n c e
44
347
1 ,2 %
9 ,1 %
G e rm a n y
657
1 7 ,2 %
44
67
1 ,2 %
1 ,8 %
Ita ly
614
1 6 ,1 %
L u x e m b o u rg
T h e N e th e rla n d s
3
223
0 ,1 %
5 .8 %
N o rw a y
32
0 ,8 %
P o rtu g a l
S p a in
34
254
0 ,9 %
6 ,7 %
Sw eden
88
2 ,3 %
1 .2 8 9
3 3 ,7 %
C o u n try
B e lg iu m
G re e c e
Ire la n d
U n ite d K in g d o m
T o ta l
3 .8 2 0
www.iso.org
TQM. EFQM model
Agentes facilitadores
(91 -02)
Política y
estrategia
Alianzas y
recursos






Resultados
en las
personas
Personas
Liderazgo

Resultados
Procesos
Resultados
en los
clientes
Resultados
en la
sociedad
Resultados
clave
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
Innovación y aprendizaje
Liderazgo
Cost of technology, clinical
guidelines. Evidence based
medicine (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
Initiatives in most countries. Interest in outcomes or key processes
 Public availability of data (UK,...)

In d ic a to r
S ix m o n th in p a tie n t w a its
R e tu rn in g h o m e fo llo w in g
h o s p ita l tre a tm e n t fo r
fra c tu re d h ip
G e n e r ic p re s c rib in g
1999
2000
N a tio n a l %
Im p ro v e m e n t
7 3 .4 %
7 3 .2 %
-0 .2 %
4 6 .6 %
4 6 .1 %
-1 .0 %
7 0 .2 %
7 3 .6 %
4 .9 %
NHS Performance indicators Feb. 2002
Indicators
1999
2000
(/ 1 0 0 .0 0 0 )
(/ 1 0 0 .0 0 0 )
N a tio n a l %
Im p ro v e m e n t
D e a th s fro m c irc u la to ry
d is e a s e s
1 2 7 .0
1 2 0 .4
5 .2 %
S u rg e ry ra te s fo r jo in t
re p la c e m e n t
1 2 1 .8
1 2 9 .5
6 .4 %
4 6 .6
4 6 .1
-1 .0 %
N o d a ta
162
N o c o m p a ris o n
a v a ila b le
In d ic a to r
R e tu rn in g h o m e fo llo w in g
h o s p ita l tre a tm e n t fo r
fra c tu re d h ip
F o u r-w e e k s m o k in g
q u itte rs
NHS Performance indicators Feb. 2002
Patients’ opinion


Few countries with national data
Few comparative initiatives
% PHC patients satisfied with the possibility of getting a
suitable appointment (N=24.000)
94%
89%
78%
71%
77%
84%
85%
78%
81%
62%
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”
International Journal for Quality in Health Care 2002 (14) 111-18
Present 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 involvement ??
Last 5 years topics
Clinical guide -lines
 Accreditation/ISO/ EFQM


Indicators

Technology assessment
Agenda for the
future: coordination ?
1. Globalization: European model
and sustainability
2. Health Agenda. Clients´ priorities and
participation
3. New systems of providing health care
1. Globalization.
European model and
sustainability
Q
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

2. Health Agenda.
Clients: priorities in QI programs

Patients’ Priorities / expectations
(% patients with maximum score)
Q u e stio n s
% P u n t. 7
P ro fe ssio n als are in te re ste d in so lvin g
p atie n t’s p ro b le m s.
8 8 ,2
T h e co rre ct m e d ica tio n is d e live re d .
8 7 ,6
P e rso n alize d m an n e r o f tre atin g p a tie n ts.
8 2 ,2
N o d iag n o stic e rro rs.
8 0 ,5
D o cto r d e d icate su fficie n t tim e to p atie n ts.
7 9 ,0
2. Health Agenda.
Clients

Information and health decisions.
• Patient access to large amounts of
• information (Internet…)
• Public disclosure of clinical indicators
Q
• 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.
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
Q
• Research and introduction of new ways
allowing effective participation
3. New Systems of
providing 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
Q • Integrated Quality programs
3. New Systems of
providing of Health
Care

Q
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)
5. Future of the Quality
programs
Common language shared
by patients, professionals,
managers, providers and
administration

IHC TURP QUE Study
Average Hospital Cost
2.500
2233
2140
2156
1913
2.000
1549
1500
1568
1662
1697
1618
1543
1552
1269
1.500
Dollars
1556
1598
1164
1.000
500
0
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Brendt James 1999
IHC TUPR QUE Study
Average Length of Stay
6
4,5 4,6
5
Days
4
3,9
3,8 3,8
3,3
4,9
4,6 4,6
4,3
3,9
3,4
3,2
3,1
4,5
2,7
3
2
1
0
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Attending Physician
Brendt James 1999
Outcomes chain:
TUPR costs
Cost
Retrograde
pyelograms
Length of stay
Day of admit
surgery
Foley catheter
management
Perceived risk of
obstruction from blood clots
Brendt James 1999
Future
1980-85
1995-00
2002-05
2005-08
Some 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 ?

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