Quality of health care_e694b5d9-62d8-4721-9a87-5ca85f054215.pptx

Quality of health care

1. Quality of health care University of Belgrade Faculty of Medicine Institute for Social Medicine Prof. ​Dr. Janko Janković

2. Content Definitions of the quality of health care Dimensions of quality Measuring the quality of health care Creating a culture of patient safety Continous quality improvement in health care

3. Quality (definitions) Health care quality is the type of care that is expected to improve all aspects of a patient's well-being, after taking into account the balance of expected benefits and losses that accompany the overall health care delivery process. In general, quality is: "the ability to achieve desired objectives using legitimate means" (Donabedian, 1980). The quality of health care is the degree to which health services intended for individuals and population increase the probability of desired health outcomes and are consistent with current expert knowledge (IOM, 1990).

4. IOM, 1990 Quality is assessed on a scale (degree), rarely dichotomously It covers all aspects of health care provided by the health service It can be evaluated from the aspect of the individual, but also from the aspect of the entire population The relationship between quality and human health outcomes is rarely causal, and what is measured is the probability of the desired outcomes The phrase "in accordance with current professional knowledge" indicates that what is assessed as quality is relative, and depends on the current knowledge available in diagnosis and treatment.

5. Quality (definitions) Quality healthcare is healthcare that is effective, safe and meets the needs and wishes of patients (European Commission, 2010). Quality health services worldwide should be: effective, safe, people-oriented ...to realize the benefits of quality health care, health services must be timely, equitable, integrated and efficient (WHO, 2018).

6. Significance The quality of health care is one of the most frequently mentioned principles of health policy. One of the basic values widely accepted in the work of various EU institutions is access to quality health care. European Commission recognizes quality as an important component of the performance (effect) of the health system . Sustainable Development Goal 3.8 (UN) calls on countries to "achieve universal health coverage including financial risk protection and access to quality and affordable essential health services".

7. Dimensions of quality In short, the dimensions of quality are about doing the right thing, to the right person, in the right place, at the right time, in the right way, at the right price. According to the IOM , there are the following six dimensions of quality health care : safety, effectiveness, patient-centeredness, timeliness, efficiency and equity. Safety: Avoiding harm to patients during the provision of health care services. Effectiveness: Providing health care services that work, based on evidence/scientific knowledge to all who could benefit from them and not providing services to those who are unlikely to benefit Patient-centeredness: Providing health care that responds to the individual wishes, needs, and values of patients and ensuring that all clinical decisions are made with respect for patient values.

8. Dimensions of quality Timeliness: Reduction of waiting and sometimes harmful delays, both for users and providers of health care services. Efficiency (cost-effectiveness): Achieving the best possible results with available resources and avoiding unnecessary waste of equipment, supplies, ideas and energy. Equity: Providing health care services of the same quality regardless of personal characteristics of patients such as gender, race, religion, language, ethnicity, geographic location, socioeconomic status, or political affiliation. Integration (WHO) : Health services must be integrated to provide care that is coordinated at all levels and among providers and is available in the full spectrum of health services across the lifespan.

9. Quality measurement A quality indicator is "a measure used to determine in a period of time whether process or outcome functions have been performed" (Calhoun, 2002). The quality of health care is difficult to measure directly. Implementation of the concept of quality measurement refers to a limited set of quality aspects for a specific group of patients (for example, quality measurement may focus on hip fracture patients treated in hospitals and cover different aspects of health care). The choice of indicators depends on the exact purpose of the measurement

10. Quality indicators Simple indicators represented by absolute numbers (usually used for rare “sentinel" events such as death, accident, for court process, etc.) Indicators expressed as the ratio of two absolute numbers are the more common type of indicator and are expressed as proportions or rates (for example, the proportion of patients with a hip fracture who receive antibiotic prophylaxis before surgery, intrahospital infection). There is a classification of indicators into generic indicators and indicators specific to a disease or specific to a department or service of a health institution.

11. Quality indicators Indicators can be classified depending on the quality dimension they assess and in terms of the assessed area (whether quality is measured in preventive, acute, chronic and/or palliative health care). Complex, composite indicators for comprehensive quality assessment However, the most commonly used framework for distinguishing different types of quality indicators is Donabedian's classification into structure, process and outcome indicators.

12. Donabedian's structure-process- outcome framework for quality assessment

13. Clinical indicators of health care quality Injuries to patients during hospital stay Patient complaints Inadequate documentation of the care and treatment process, in the medical history or other medical documentation Formation or worsening of pressure ulcers during hospital stay Occurrence of intrahospital infections in healthcare institution Rehospitalization (re-admission) within 30 days of discharge

14. Rulebook on health care quality indicators and quality assessment of professional work Health care quality indicators at the primary level of health care : which are followed in health care service for adult population (13 indicators), in the pediatrics area (8 indicators), in the field of gynecology (5 indicators), in the field of dental medicine (8 indicators) and in the emergency medical service at the health care center and the institute for urgent medicine (13 indicators) Quality indicators in inpatient health care : which are monitored in internal medicine (14 indicators), in surgery (11 indicators), in gynecology and obstetrics (11 indicators) Quality indicators related to patient safety (15 indicators) Quality indicators in the pharmacy care : Pharmacies at the primary level of health care (5 indicators) and pharmacies in health institutions that perform inpatient care (5 indicators) Quality indicators of waiting list management (6 indicators)

15. User/patient satisfaction An important measure of the quality of health care because it provides information about the success of the service provider in meeting the patient's expectations Patient satisfaction correlates with important outcomes, such as reduced use of health services and better prognosis In Serbia, national surveys of user satisfaction in primary, secondary and tertiary health care institutions are conducted on an annual basis The Rulebook on health care quality indicators and the quality assessment of professional work defines the obligations of health care institutions in the domain of user satisfaction with health care services (e.g. highlighting the type of health care services that are provided to the patient as an insured person from the funds of the mandatory health insurance, the price list of health care services, setting up boxes for objections and remarks, etc.)

16. Mechanisms for assessing the quality of health care Internal (self-assessment and peer review) Internal methods of quality assessment are carried out by health workers within their health institutions and refer to estimation of standards and criteria of clinical practices. Immediate methods: D aily observation of doctors' work (disadvantage: it is expensive, applies only on some aspects of structure and process) Intermediate methods: Conversations with patients, their families, doctors, review of medical documentation, collegial review, medical audit and survey of patients' satisfaction with the health care provided.

17. Mechanisms for assessing the quality of health care External (accreditation, certification, visitation, supervision, TQM) Accreditation refers to the external assessment of an organization by an accreditation body, which leads to public recognition of the organization's compliance with predetermined standards. The term certification usually refers to an external assessment of compliance with standards published by the International Organization for Standardization (ISO). Visitation is performed by teams outside of the health institutions, they estimate performances of their colleague with a goal of quality improvement. Oversight or supervision refers to the monitoring of the health care provider's compliance with the minimum standards required for legal registration, authorization, or licensing (fire protection, hygiene maintenance, intrahospital infection control, medication management, or adverse events reporting).

18. Accreditation Agency for health institutions of Serbia It was founded in 2008. Accreditation standards are established for all three levels of health care. For the primary level, there are, along with the criteria of a general approach to patient treatment, special chapters of standards for patient treatment that refer to general medicine, gynecology, pediatrics, specialist-consultative services and polyvalent patronage. So far it has been accredited about 45% of health institutions from the Network Plan of health institutions in the Republic of Serbia (the largest number on primary health care level.

19. Patient safety Patient safety has long been considered only one of the dimensions of quality, but today it is recognized as the key to the overall quality of health care. According to the strategy for continuous improvement of the quality of health care and patient safety in the Republic of Serbia, patient safety represents: "identification, analysis and correction of risky events, with the aim of making health care safer and reducing risks to the patient's health to a minimum."

20. Creating a culture of patient safety The European Society for Quality in Health Care has defined patient safety culture as " an integrated pattern of individual and organizational behavior, based on common beliefs and values, which continuously seeks ways to minimize harm to the patient that may result from the use of health care." One of the most prominent advocates of safe healthcare practice is nurse Florence Nightingale. Ignaz Semmelweis calculated maternal mortality rates from sepsis in women giving birth in the maternity hospital, with a proposal for measures to reduce it. Dr. Ernest Codman , who advocated monitoring and comparing the results of hospital work, while Harvey Cushing published detailed descriptions of the damage caused after surgical interventions.

21. Adverse events and medical errors (1) About 10% of patients suffer damage to their health during the provision of hospital health care, of which half are preventable. L ead to increased health care costs and indicate that patients receive poor quality health care services. According to the WHO dictionary of patient safety concepts, an adverse event is seen as "an injury that was caused by the provided health care or its complications, independent of the underlying disease, which leads to prolonged hospitalization and/or disability at the time of discharge from medical care, or both“. Adverse events can occur as a result of an error or as a result of a negative reaction unrelated to the error.

22. Adverse events and medical errors (2) Examples of adverse events are: intra-hospital infection, post-operative wound infection, post-operative pulmonary embolism, venous thromboembolism, medication errors, adverse events during anesthesia, decubitus ulcer, patient falls during hospital stay (e.g. bed fall) and unexpected deaths. A medical error is defined as "the failure of a planned action to be completed as intended (an error of execution) or the use of a wrong plan to achieve an aim (an error of planning)" (Brennan et al, 1991). According to Leape (1994), a medical error is an unintended act (either of omission or commission) or one that does not achieve the desired outcome. Medical errors can occur at various stages during the provision of health care, prevention, diagnostic procedures, treatment or monitoring.

23. Types of medical errors Examples are: misdiagnosis or late diagnosis, administration of the wrong drug, administration of two or more drugs that adversely interact or create toxic metabolites, surgery at the wrong site, surgical swab left after a surgical procedure, the absence of a diagnosis due to the lack of knowledge of the doctor about a rare or newly described disease. The error in prescribing medicine is one of the most studied and most common errors ( prescribing errors, omitting the administration of the drug, giving the wrong drug, giving too much or too little of the drug, not issuing the order for the drug, giving the drug by the wrong route or at the wrong pace ).

24. Causes of adverse events a nd medical errors Can be classified into three categories: Human factors (variations in the experience and knowledge of health workers, psychophysical condition, personal problems), The complexity of the work process (complicated technologies, drugs, extended time of hospital treatment, stay in the intensive care unit) and System deficiencies (lack of adequate communication, insufficient number of medical staff, equipment failures, inadequate reporting system within the health facility, similar packaging or drug names, reliance on automated systems, inadequate policies/procedures and poor infrastructure).

25. Improving safety It includes professional education and training, clinical management systems, safety standards and staff and patient engagement strategies. WHO described an integrative approach to safety improvement as a cycle consisting of several steps: measuring adverse events, determining the causes of adverse events, finding solutions, implementing safety improvement projects, and evaluating their impact. Important prerequisites for the implementation of such an approach are systems for reporting and analyzing events that have occurred, then performing prospective analyzes to identify risks within the organization, proactively strengthening a culture of patient safety that implies open communication and reflection, and ensuring multidisciplinary workforce training.

26. Con tinuous improvement of the quality A management philosophy that implies that most services can be improved A number of activities that are carried out at all levels of health care Introducing a culture of continuous quality improvement in health care contributes to: reducing errors resulting from ignorance, lack of skills, negligence or carelessness defining the level of differences that are acceptable and that do not threaten professional autonomy response to the user's legitimate expectations from the system It takes place on three levels: macro level (health care system), meso level (health care institutions) and micro level (clinical practice)

27. Quality improvement approaches The best-known model that helps us when introducing changes in healthcare institutions with the aim of improving quality is the "Plan - do - study - act" model. Sometimes the "study" phase can be interchanged with the "check" phase, forming a Plan - do - check - act cycle. However, the principles for both models/cycles remain the same. Clinical audit and feedback on performance are strategies that aim to encourage healthcare professionals to change their clinical practice. Both strategies together form a cyclical process consisting of five steps : preparation for audit, selection of criteria, performance measurement, the actual act of improvement, and sustainability of improvement.

28. Quality improvement approaches Statistical process control is a philosophy, strategy and set of methods for continuous improvement of systems, processes and outcomes and is based on learning through data. It consists of measurement phases, data collection methods and planned experimentation. Strategies used in this approach include the concepts of analytical studies, process thinking, prevention, stratification, stability, ability (to meet certain goals and standards), and prediction. Pay-for-performance programs refer to financial incentives to healthcare providers for meeting goals measured against a set of performance indicators. Some of the payment modalities are: value-based purchasing, stopping payments for medical errors and performance programs aimed at strengthening primary care.

29. Good clinical practice guides Systematically developed evidence to assist physicians and patients in making decisions about appropriate health care in a specific clinical situation. Shekelle et al, 1999

30. Thank you for your attention!