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Finance and quality in health care: assessment, contracting and accreditation in Albanian context Health Policy Dialog “Challenges in reforming the health.

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Presentation on theme: "Finance and quality in health care: assessment, contracting and accreditation in Albanian context Health Policy Dialog “Challenges in reforming the health."— Presentation transcript:

1 Finance and quality in health care: assessment, contracting and accreditation in Albanian context Health Policy Dialog “Challenges in reforming the health financing system in Albania“ Durres February 2006 Isuf Kalo NATIONAL CENTRE OF QUALITY, SAFETY, AND ACCREDITATION OF HEALTH INSTITUTIONS

2 What we already know: “Bad quality in health care “Bad quality in health care is very expensive” is very expensive” NATIONAL CENTRE OF QUALITY, SAFETY, AND ACCREDITATION OF HEALTH INSTITUTIONS

3 Quality in Albanian Health care system: not known not known not reported not reported not measured not measured not systematically required by - governments - users - providers - payers not systematically required by - governments - users - providers - payers Not rewarded Not rewarded ? NATIONAL CENTRE OF QUALITY, SAFETY, AND ACCREDITATION OF HEALTH INSTITUTIONS

4 What is quality of care about? Safety Safety Effectiveness Effectiveness Patient-centeredness Patient-centeredness Timeliness Timeliness Efficiency Efficiency Equity IOM USA 2001 Crossing the quality chasm: A new health system for the 21 st century Equity IOM USA 2001 Crossing the quality chasm: A new health system for the 21 st century NATIONAL CENTRE OF QUALITY, SAFETY, AND ACCREDITATION OF HEALTH INSTITUTIONS

5 Health system goals Health improvement Responsiveness to people expectations Fairness in financing LevelDistribution QualityEquity Efficiency } __________________      NATIONAL CENTRE OF QUALITY, SAFETY, AND ACCREDITATION OF HEALTH INSTITUTIONS

6 Health Systems have a responsibility not just to improve people’s health, but to protect them against the financial burden of illness and to treat them with dignity and appropriate quality NATIONAL CENTRE OF QUALITY, SAFETY, AND ACCREDITATION OF HEALTH INSTITUTIONS

7 Responsiveness Respect for persons Dignity – not humiliation Dignity – not humiliation Confidentiality for one’s health information Confidentiality for one’s health information Choice Choice Client orientation Prompt attention Prompt attention Amenities of adequate quality Amenities of adequate quality Access to social support networks Access to social support networks NATIONAL CENTRE OF QUALITY, SAFETY, AND ACCREDITATION OF HEALTH INSTITUTIONS

8 Accountability in Health system Includes: The quality of answerability (the right to receive relevant information and explanation for actions) The quality of answerability (the right to receive relevant information and explanation for actions) The quality of enforceability (the right to impose sanctions if the information or rationale is deemed inappropriate The quality of enforceability (the right to impose sanctions if the information or rationale is deemed inappropriate NATIONAL CENTRE OF QUALITY, SAFETY, AND ACCREDITATION OF HEALTH INSTITUTIONS

9 Evolution of health systems Classical universalism: “All services for all” New universalism: Select : “Only effective interventions for all” (less for better and more…!) WHO: World Health Report 2000 WHO: World Health Report 2000 NATIONAL CENTRE OF QUALITY, SAFETY, AND ACCREDITATION OF HEALTH INSTITUTIONS

10 Active Purchasing  Requires active consideration of costs and effects of competing interventions.  Need for technology assessment, broader concept. NATIONAL CENTRE OF QUALITY, SAFETY, AND ACCREDITATION OF HEALTH INSTITUTIONS

11 “… if we do not have measures on health outcome our reforms are doomed to fail …” Alan Maynard NATIONAL CENTRE OF QUALITY, SAFETY, AND ACCREDITATION OF HEALTH INSTITUTIONS

12 Health Technology Assessment Public & community health Utilization Utilization Promotion Promotion Prevention Prevention Protection Protection Environmental health Individual care provision Clinical procedures Clinical procedures Drugs Drugs Devices Devices Supportive technology Organization / mechanisms Organization / mechanisms Information Information Infrastructure and equipment Infrastructure and equipment NATIONAL CENTRE OF QUALITY, SAFETY, AND ACCREDITATION OF HEALTH INSTITUTIONS Outcomes Cost Use

13 “In God we trust” Everyone else must provide evidence! NATIONAL CENTRE OF QUALITY, SAFETY, AND ACCREDITATION OF HEALTH INSTITUTIONS

14 A legitimate request from the Minister of Health I expect from you the truth and nothing but the truth. I expect from you the truth and nothing but the truth. How to distinguish the truth from advertising? How to distinguish the truth from advertising? I expect you to produce evidence for, or against, the policy. I expect you to produce evidence for, or against, the policy. NATIONAL CENTRE OF QUALITY, SAFETY, AND ACCREDITATION OF HEALTH INSTITUTIONS

15 Is Free market in public health system so free ? Common market Freedom to Offer Freedom to Offer Freedom in Demands Freedom in Demands Disregards to the real needs Disregards to the real needs Health care market Health care market Offers Offers - Freedom in Private sector - Freedom in Private sector - Planed offer in Public sector - Planed offer in Public sector Demands Demands - In private sector: Freedom - In private sector: Freedom - In public sector : - In public sector : most cost effective most cost effective interventions ( according interventions ( according to the agreed package) to the agreed package) Based on Real Needs Based on Real Needs HTA, EBM, Clinical guidelines HTA, EBM, Clinical guidelines NATIONAL CENTRE OF QUALITY, SAFETY, AND ACCREDITATION OF HEALTH INSTITUTIONS

16 Health technology regulation Develop, implement and enforce regulation and standards to ensure the safety, effectiveness and quality of health services and medical devices Market country notification, registration Market country notification, registration Post-market vigilance, adverse events and problem reporting Post-market vigilance, adverse events and problem reporting Dissatisfaction/importer control & inspection Dissatisfaction/importer control & inspection Safety and efficiency performance assessment Safety and efficiency performance assessment Harmonization of regulatory procedures Harmonization of regulatory procedures NATIONAL CENTRE OF QUALITY, SAFETY, AND ACCREDITATION OF HEALTH INSTITUTIONS

17 Health Technology Management Provide the appropriate physical and technological infrastructure in accordance with the level of attention of the health facility and resource availability Planning Planning Procurement Procurement Use Use Maintenance Maintenance Evaluation Evaluation Discharge Discharge Replacement Replacement Introduction of new tech Introduction of new tech NATIONAL CENTRE OF QUALITY, SAFETY, AND ACCREDITATION OF HEALTH INSTITUTIONS

18 The Albanian health system Under pressure to change: From the inside - new socio-economic situation - democratization (people’s civil and political rights) - free initiative/market, privatization, competition From the outside - regional and European integration - international commitments and standards - globalization (“death of borders” ) NATIONAL CENTRE OF QUALITY, SAFETY, AND ACCREDITATION OF HEALTH INSTITUTIONS

19 “Children of bondage, have weak wings in the freedom…” E. Jevtushenko NATIONAL CENTRE OF QUALITY, SAFETY, AND ACCREDITATION OF HEALTH INSTITUTIONS

20 Are Albanian patients real ”consumers“ in the free health care market? Not aware about their real health care needs Not aware about their real health care needs Not informed on the quality and the appropriateness of the heath care services they are paying for Not informed on the quality and the appropriateness of the heath care services they are paying for Not able to make informed choices due to the lack of the awareness about the alternatives and costs Not able to make informed choices due to the lack of the awareness about the alternatives and costs Not information about the real risk or the potential medical error Not information about the real risk or the potential medical error Non compensated for the damage or bad quality of care Non compensated for the damage or bad quality of care Not protected from the charlatans or corruptive health services approaches Not protected from the charlatans or corruptive health services approaches NATIONAL CENTRE OF QUALITY, SAFETY, AND ACCREDITATION OF HEALTH INSTITUTIONS

21 Quality of care and financing in ALB Total health expenditures 1998 : 7.7 Billion Leke 1998 : 7.7 Billion Leke 2002 : 14 Billion Leke 2002 : 14 Billion Leke 2004 : 18 Billion Leke 2004 : 18 Billion Leke Donations Donations :143 Million € :143 Million € Drugs expenditures / year 47 % of Total HB 47 % of Total HB 51% of HII budgets 51% of HII budgets What Impact ? What Impact ? Any data on health gain? Any data on health gain? Is health care performance or quality of care improved ? Is health care performance or quality of care improved ? NATIONAL CENTRE OF QUALITY, SAFETY, AND ACCREDITATION OF HEALTH INSTITUTIONS

22 Major directions for improvement of the quality in health care in Albania Professional: the way care is delivered Professional: the way care is delivered - HTA to reduce waist: overuse, under use, misuse - HTA to reduce waist: overuse, under use, misuse - EBM: clinical guidelines to promote the best practise - EBM: clinical guidelines to promote the best practise Mandatory Licensing and Re-licensing for Mandatory Licensing and Re-licensing for systematic assessment of the health professionals competences systematic assessment of the health professionals competences Organization: the way care is organized Organization: the way care is organized - Standards: in access, safety mechanisms, waiting time, - Standards: in access, safety mechanisms, waiting time, coordination, staff communication gaps. coordination, staff communication gaps. Internal and External quality assessment schemes in heath organizations Internal and External quality assessment schemes in heath organizations Relationship: the way care is provided Relationship: the way care is provided - co-decision-making, empathy, patient rights, information and empowerment NATIONAL CENTRE OF QUALITY, SAFETY, AND ACCREDITATION OF HEALTH INSTITUTIONS

23 Examples of the Overuse in Albanian health care system Drug therapy ( Antibiotics…) Drug therapy ( Antibiotics…) Surgery (Cesarean..) Surgery (Cesarean..) Unnecessary Lab examinations Unnecessary Lab examinations Unnecessary Imageries ( ultrasound,Rx) Unnecessary Imageries ( ultrasound,Rx) Length of hospitalization Length of hospitalization NATIONAL CENTRE OF QUALITY, SAFETY, AND ACCREDITATION OF HEALTH INSTITUTIONS

24 Examples of the Misuses Devices Devices Hospitalization Hospitalization Patient following up Patient following up Drugs use in chronic disease Drugs use in chronic disease Labs and Imagery findings Labs and Imagery findings Blood transfusion Blood transfusion Patient Data records Patient Data records Nursing skills Nursing skills Found allocations Found allocations Management and Leadership Management and Leadership NATIONAL CENTRE OF QUALITY, SAFETY, AND ACCREDITATION OF HEALTH INSTITUTIONS

25 Examples of the under use Staff Working time Staff Working time Staff skills, expertise Staff skills, expertise Experiences gained in the training abroad Experiences gained in the training abroad Scientific Research findings Scientific Research findings Health promotion interventions Health promotion interventions Preventive interventions, healthy diet and life style Preventive interventions, healthy diet and life style Hospital beds (50 % occupancy) Hospital beds (50 % occupancy) Coordination and teem work Coordination and teem work Therapeutic patient education, psychological support Therapeutic patient education, psychological support Anti tabagisme interventions (and other health risks factors) Anti tabagisme interventions (and other health risks factors) Organs prosthesis and transplants Organs prosthesis and transplants Invasive heart interventions Invasive heart interventions Cost -effectives High Tech Cost -effectives High Tech Promotion of the Physical activity Promotion of the Physical activity NATIONAL CENTRE OF QUALITY, SAFETY, AND ACCREDITATION OF HEALTH INSTITUTIONS

26 Ethical quality principles of Health Care in free market. “Money for quality, or quality for money“ ? Health care centers Money is a tool not the goal Money is a tool not the goal The new research findings are shared openly as public propriety The new research findings are shared openly as public propriety Rivalries among institution or colleagues are unethical Rivalries among institution or colleagues are unethical Money, Competition are needed to insure the best quality and most cost effective care for patients Money, Competition are needed to insure the best quality and most cost effective care for patients Emergency care for life saving is, always free of charche for all Emergency care for life saving is, always free of charche for all Usual business enterprises Usual business enterprises Money ( financial profit ) is the main goal Money ( financial profit ) is the main goal The new research novelties are private propriety and protected by copy rights The new research novelties are private propriety and protected by copy rights Rivalry is a rule Rivalry is a rule Selling and earning is the main aim, despite the quality or prices Selling and earning is the main aim, despite the quality or prices No any services is free for any body No any services is free for any body NATIONAL CENTRE OF QUALITY, SAFETY, AND ACCREDITATION OF HEALTH INSTITUTIONS

27 What financing needs for quality of care improvement in Albania Improve Providers competence Improve Providers competence A continuous education system, evidence- based, to be established Provider motivation: promoting the best quality practise in terms of the outcomes, patient satisfaction and cost effectiveness contracting based on performance and quality indicators providing rewarding Incentives to teams and centres rather than individuals Sufficient resources for providers and patients Essential drugs, tools, devices, staff, time, information Promote patients’ safety, patient centeredness : rights and roles Patients Bill of Rights; structures for complaints, therapeutic education, empowerment EBM for quality improvement: policy making and clinical use A national centre for EBM to be established Monitoring and evaluation for quality improvement Performance & Q. monitoring system,, HTA, standards, indicators, quality measurements methods by NCQSA Use of quality improvement techniques Training of providers on quality development approach External quality measurement schemes Regulation and legislation Hospital/PHC accreditation system, AimsActivities NATIONAL CENTRE OF QUALITY, SAFETY, AND ACCREDITATION OF HEALTH INSTITUTIONS

28 National Centre of Quality, Safety and Accreditation of Health Institutions in ALB National Centre of Quality, Safety and Accreditation of Health Institutions in ALB Patients Rights, Roles Patients Rights, Roles Safety,Risk management Safety,Risk management Rilicensing of health professionals Rilicensing of health professionals HTA and EBM HTA and EBM Clinical guidelines Clinical guidelines Accreditations of health care institutions Accreditations of health care institutions Coordination, quality networking,partnership Coordination, quality networking,partnership NATIONAL CENTRE OF QUALITY, SAFETY, AND ACCREDITATION OF HEALTH INSTITUTIONS

29 Suggested priorities for ALB health financing reform related to quality Reduction of the waste Reduction of the waste (Money liking due to the overuse and misuse) by promoting HTA and EBM (Money liking due to the overuse and misuse) by promoting HTA and EBM Establish safety mechanisms to reduce risks, errors in order to minimize the litigations and patients damage compensations Establish safety mechanisms to reduce risks, errors in order to minimize the litigations and patients damage compensations Reallocation of existing resources ( HII as single purchaser covering whole health care system ) Reallocation of existing resources ( HII as single purchaser covering whole health care system ) Institutionalization of the cooperation between the HII and NCQSA-HI in standardization and in identification of the most cost effective care practices Institutionalization of the cooperation between the HII and NCQSA-HI in standardization and in identification of the most cost effective care practices Active purchasing by selecting and contracting based on Licensing, Rilicensing, Accreditation and in the HTA -EBM findings (less for more )in public and private PHC and Hospitals Active purchasing by selecting and contracting based on Licensing, Rilicensing, Accreditation and in the HTA -EBM findings (less for more )in public and private PHC and Hospitals Developing motivating incentives by Rewarding the best quality practice Developing motivating incentives by Rewarding the best quality practice Promoting partnership for multiplicity of resources founding Promoting partnership for multiplicity of resources founding NATIONAL CENTRE OF QUALITY, SAFETY, AND ACCREDITATION OF HEALTH INSTITUTIONS

30 We all must think to find new ways to correct problems, that we have created with our previous ways of working. Albert Einstein NATIONAL CENTRE OF QUALITY, SAFETY, AND ACCREDITATION OF HEALTH INSTITUTIONS


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