Health care quality indicators

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Health care quality indicators

• m. Prof. MUDr. M.Dragula, PhD.
• Slovak Medical Chamber

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Medicine science and art do we need norms?

• Aversion to the norms
• Other indefinitely defined criterions
• Non-measurable and non-comparable parameters

3
Can everybody really make the right individual
decision in treatment?

• Patient as an individual
• person
• Also individual procedure
• Forensic consequences

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Indicator judges correctness of the process

• Diagnosis and treatment is a process
• It has its input and output
• Process has its owner
• It should have a certain procedure with the
  possibility of an individual decision making
• Minimal standard level of the diagnosis and
  treatment
• Then the indicator shows the correctness of the
  output

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

• In Slovakia there have not been defined any
  standardized procedures of the diagnosis and
  treatment
• Can we then talk about the process indicators?

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Can the indicators be used as the correctness
quality-markers if the previous ones have not
been defined?

• We have indicators saying nothing about previous
  ones
• Their collection and evaluation is not
  transparent
• Are the drawn up charts really of the quality?

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Does everyone have the equal opportunities
material, personal to apply defined processes?

• Minimal standards assumption of personnel and
  gadget equipment
• Do we have them?
• Or will it be solved by
• means of our standards
• to adapt them at the
• accessible personnel
• and material equipment?

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What should be done to make it happen in the
Slovak Republic and EU countries?
Two ways
The first Into Europe internationally accepted
standards
The second To the hell own standards

• EU citizen equal health care quality in the EU
  countries

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Key-term definitions

• Indicators/quality characteristics
  required/specified characteristics and
  conformity criterions mainly for process outcomes
  or the whole quality management system, which are
  guaranteed to the customer by the process
  system owner, that they will be achieved by
  mutually agreed and determined terms.
• Health status of total physical, emotional and
  social well-being, not only the absence of
  decease the result of interaction among human
  body and social-economic, physical, chemical and
  biological factors of living and working
  environment likewise the way of life.
• Definition has got many imperfections
• 1. Health is not to be valuated definition
  doesnt 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, ...

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Health quality global result indicator of
provided health care service

• Health quality (QH) complex individual
  characteristics of all dimensions including
  physical, psycho-social and cognitive-spiritual
  (related to their mutual interconnection and
  interconditionality ) throughout which the
  individual gains the ability to satisfy specified
  or anticipated needs for fulfilling of his/her
  mission, during the particular periods of life,
  which would be in accordance with the model of
• the free decision making
• and the life quality compass.
• Note This health quality definition is in
  accordance with not only the quality definition
  according to ISO 9000/8402, but also
• - With the research results of WHO QoL Group 93
  (life quality)
• - With the total approach to the health care
  which is being gradually applied

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History, present and trend of development

• Generally on the development of quality as a
  method for perception of the change of values
• Value 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 alive cell with the
  processes as an example of QMS
• Partial results (Review of results and methods
  known to us) as the solution for indicators of
  quality characteristic features
• MATRA Project (Holland SR)
• NIP Project (Denmark)
• CEEQNET Project (Czech Republic, SR, Hungary,
  Poland, Austria)
• Faculty hospitals of Czech Republic and Slovak
  Medical Chamber Association
• PATH Project WHO
• USA Standards (The Merck Manual of diagnosis and
  therapy)
• Canadian Standards
• The SR government regulations on health care
  quality indicators
• Result of our effort is
• The present system approach to be unified, basic
  starting-point and outcomes (QH a QL) to be
  determined
• To achieve the price of health care service to be
  monetary expression of value (evaluation of
  quality level ) of the provided health care
  services all over the world, which is
  customer/health insurance company willing to pay
  to a health care provider

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Key problems of the health service

1. Old paradigm health care is focused on
   treatment, not on maintaining and restoring
   peoples health
2. Disconnection between state/regional economy and
   health care financing and obscure cash flows
   (budgets without criteria, ...)
3. Evaluation of health care outcomes does not take
   into consideration the level of health care
   quality not even its results status (level of
   quality) of health
4. System management including health marketing and
   health monitoring are absent in health service
5. Health care quality is decreasing, morbidity is
   increasing
6. Responsibility for the status (quality level) of
   health is not clear not even the interconnection
   between life quality and health quality
7. The mission of the health facilities is not
   explicit and their network is not being managed

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

• 10 of GDP for health care system in OECD
  countries
• 8,9 of GDP average in the EU countries
  (before pred rozšírením EÚ)
• 5,6 of GDP for health care system in the
  Slovak Republic
• 50 75 out of the whole financial budget in
  health service goes into hospitals.
• The only income (apart from the sponsor gifts) is
  the price of health care outcomes. Other
  processes can be classified as expenses.
• If the price of outcomes is not the financial
  expression of value of the result/ restored,
  maintained or improved health quality, the whole
  effort for effective motivation of medical
  institutions, for interconnection of health care
  financing with regional economics would have been
  meaningless.
• The lower the level of quality of health care
  provided by primary outpatient clinics, the
  higher portion of finances being used by
  hospitals.
• The lower the level of preventive health care
• the lower QH as well as the level of QL
• the shorter life expectancy
• the higher portion of finances needed for
  provided health care that means the provided
  health care is being less effective!

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Key processes/sub processes according to ISO
90012000 focused on health care quality and
quality of health indicators

• Health care service realization
• Basic inputs into the health care service
  realization process and into its seven below
  mentioned sub processes should be the results of
  health care marketing.
• Planning of realization of health care service
  execution processes
• Quality objectives and requirements for QH
• Processes, specific documents and resources
  needed to achieve planned results
• Required verification, validation, monitoring,
  inspection and test activities specific to the QH
  and the criteria for QH acceptance
• Customer-related processes activities during
  the period of health restoring and obtaining good
  habits for health quality maintenance
• Design and development
• Design and development of new method of
  prevention, treatment focused on restoring,
  maintaining or improving health quality
• verification (confirmation that the specific
  requirements have been met by providing the
  objective evidence) of design and development
• Validation of design and development
• Process of inputs purchasing
• Realization of health care services execution
  processes
• Validation of realization processes
• Control of diagnostic, monitoring and measuring
  devices
• Health care facility shall plan and implement the
  monitoring, measurement, analysis and improvement
  processes

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Key processes/sub processes according to ISO
90012000 focused on health care quality and
quality of health indicators

• Measurement, monitoring and improvement
• Monitoring and measuring of provided health care
  outcomes
• Customer satisfaction
• Internal audit
• Monitoring and measurement of process
• Monitoring and measurement of product (provided
  health care outcome)
• Control of nonconforming quality of health status
  
• Validation of data/quality indicators and
  indicators of conformity in relation to achieved
  results and progress of health all over the world
  
• Improvement
• Continual improvement
• Corrective action
• Preventive action

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Partial results characteristics of the
solutions of health care quality indicator
projects

• NIP project (Denmark)
• Very good access to solution process, results are
  arranged according to medical fields or selected
  areas, e.g.
• treatment and rehabilitation of patients after
  stroke indicator standards
• hip fracture indicator standards
• Results are processed as follows

INDICATOR CONCEPT INDICATOR TYPE STANDARD/ COMFORMITY CRITERION TIME
Organization of treatment and rehabilitations Proportion of patients treated/rehabilitated in stroke units process gt90 lt48 hours after admission
Mortality 30 days and 3,6 and 12 months mortality outcome (not desired) 30 days mortality lt20 30 days 3, 6, 12 months after stroke
Danish NIP was established in 2000
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Partial results characteristics of the
solutions of health care quality indicator
project MATRA

• MATRA project as the basic tools are used
  quality management system (QMS) according to ISO
  90002000 and extensive models EFQM/CAF. Health
  quality (QH) and quality of life (QL) are
  mentioned as the main outcomes. This is fully in
  accordance with the results of WHO QoL Group93
  research as well as with the solution of MFN
  05/2000 grant.
• However proclaimed health quality has not been
  defined.
• Outcomes of health care quality indicators are
  shown in four classes
• demographic and socio-economic factors
• health status
• determinants of health
• health systems
• These classes has been further divided into
  groups and subgroups. Specific quality indicators
  are mentioned later. It is undoubtedly the most
  sophisticated and systematically best done
  solution of this complex issue. This has to be a
  reason why WHO has chosen the results of MATRA
  project as a base for PATH project.

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What the health population depends on?
What the health of population depends on?
Other 7
Health system 17
Life style 51
Genetics 25

• www.reformazdravotníctva.sk
• Zdroj WHO, 1999

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Thank you for your attention