1. The Annual Quality Report A dynamic tool for quality management and accountability

2. 25 November 2005Final Conference Matra Project2 Quality System in Health Care National level Government legislation, regulation Monitoring by HCSA, insurance companies Certification, accreditation Institution level Implementation of quality systems Monitoring of quality of services Provision of information to national level

3. 25 November 2005Final Conference Matra Project3 Implementation of quality systems in health institutions Adherence to standards defined by MOH, insurance companies, HCSA Adherence to standards and systems defined in accreditation/certification Adherence to clinical practice guidelines (evidence based medicine/nursing) Achieving maximum patient satisfaction possible

4. 25 November 2005Final Conference Matra Project4 Internal monitoring of quality systems Quality committee and quality manager Multidisciplinary composition Formulate priorities and targets Joint activity with management and owner Keep track of achievements/constraints Data collection and analysis Motivate staff showing results Feedback mechanisms to be developed

5. 25 November 2005Final Conference Matra Project5 Accounting to external stakeholders Legal obligation Indicators formulated by MOH Contractual obligation insurance companies Accounting to owners Regional government, municipality Accounting to general public Patient organisations, patient panels

6. 25 November 2005Final Conference Matra Project6 The Annual Quality Report Reflects the vision on the organisation, its environment and its tasks Is more then a representation of data; it provides an analysis Is part of a planning and reporting cycle it reflects on achievements and constraints Is part of a quality system Defining new goals for coming period

7. 25 November 2005Final Conference Matra Project7 The Annual Quality Report Contents Mission of the organisation regard to quality Report over past year Priorities and plans over past year Resources used (human resources, finances) Activities implemented, e.g. surveys Data on core indicators and analysis Clinical guidelines and protocols in place Education and training provided in organisation Planning for next year

8. 25 November 2005Final Conference Matra Project8 International Experiences Quality reporting hospitals obligatory in many European countries UK: NHS monitoring system Germany: federal government body monitors Reports at www.bqs-outcome.dewww.bqs-outcome.de Netherlands and Belgium: quality reports in legislation, health inspection checks Lessons learned: Comparison between hospitals: triggers debate Increased awareness under hospital staffs

9. 25 November 2005Final Conference Matra Project9 Pilot in Matra project 10 hospitals approached Hospitals with experience in PATH project Basic format for report provided Report over first six months 2005 Presentation of reports following this introduction Proposal to MOH to introduce mandatory quality reporting for hospitals Putting data on MOH indicators in a context Comprehensive information on activities