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 ?