1. 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

2. Quality efforts in Europe. First developments n n 1979 CBO in the Netherlands n n 1981 First QA programs in Spain n n 1982 First WHO meeting “Principles for Quality Assurance n n 1983-5 First European Societies and ISQua Foundation

3. Common trends of the first efforts n n Leaded by health professionals (doctors and nurses) n n Based on audit n n Hospital oriented (clinical and organizational). Spread initiatives in PHC in some countries n n Majority of initiatives taken in public centers

4. Present situation n n Laws n n Public accountability (accreditation and certification) n n Total Quality management n n Cost of technology, clinical guidelines and evidence based medicine n n Indicators n n Patients’ opinion

5. Legal framework (80 -02) n n Patients’ rights (access, general coverage, “good quality care”, ) n n Medical/professional competence (re- certification etc) n n Quality efforts (accreditation, measurement or improvement. Not quality level, few quality compromises) n n Risk protection (radiation, etc)

6. Public accountability efforts (95 - 02) n n Accreditation (optimal processes and functioning with pre-determined professional standards specifically health oriented) n n ISO certification (based on documented quality system, process management and decreasing variation. Applicable to all sectors) n n Public disclosure of information indicators

7. Accreditation Accreditation in Europe: survey 2001. CD Shaw

8. Accreditation growth in Europe Accreditation in Europe: survey 2001. CD Shaw

9. ISO certification in European healthcare sector (2000) www.iso.org

10. TQM. EFQM model (91 -02) n n General framework n n Based on a developmental approach (goal: excellence) n n Useful to develop comprehensive n n managerial model n n Need of specific adaptation n n (process and out-comes) n n Possibility of combination with accreditation and ISO Liderazgo ProcesosResultados clave Resultados en las personas Resultados en los clientes Resultados en la sociedad Personas Política y estrategia Alianzas y recursos Agentes facilitadores Resultados Innovación y aprendizaje

11. Cost of technology, clinical guidelines. Evidence based medicine (92 -02) n n Structured initiatives in almost all countries n n Awareness on unexplained variability and research on clinical effectiveness n n Different guidelines for the same condition n n Present interests : – –Strategies for implementing – – recommendations) – –Cost effectiveness recommendations – –Client preferences

12. Indicators NHS Performance indicators Feb. 2002 Initiatives in most countries. Interest in out- comes or key processes n n Public availability of data (UK,...)

13. Indicators NHS Performance indicators Feb. 2002

14. Patients’ opinion n n Few countries with national data n n Few comparative initiatives 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

15. Present situation n n Added governmental initiatives (top -down) 4 4 QI in contracts (hospitals and PHC 4 4 Extensive programs with important investments ( accreditation, indicators..) 4 4 Begining of information disclosure to the patients Less clinical involvement ?? Less clinical involvement ??

16. Last 5 years topics n n Clinical guide -lines n n Accreditation/ISO/ EFQM n n Indicators n n Technology assessment

17. 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

18. 1. Globalization. 1. Globalization. European model and sustainability n n Values: Diversity and role of ethics in management and rationing priorities n n New concept of effectiveness (undercoverage, underuse, quality of life) will force to rethink efficiency measures n n Citizens mobility: Accreditation and certification n n Important issues: Safety, Public Health Q

19. 2. Health Agenda. Clients: priorities in QI programs n Patients’ Priorities / expectations (% patients with maximum score)

20. n n Information and health decisions. Patient access to large amounts of information (Internet…) Public disclosure of clinical indicators 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 Q

21. 2. Health Agenda. Clients participation n n Participation of citizens in deciding priorities Lack of technical knowledge and little inclination to share difficult decision-making Difficulty in feeling represented. Government role Research and introduction of new ways allowing effective participation Q

22. 3. New Systems of providing of Health Care n n Social changes linked to scientific developments n n Integrated care of patients (disease management) Less importance of health centers Mix between health (PHC, Hospitals and LTC) and social care Integrated Quality programs Q

23. 3. New Systems of providing of Health Care n n 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) Q

24. n n Common language shared by patients, professionals, managers, providers and administration 5. Future of the Quality programs

25. IHC TURP QUE Study Brendt James 1999

26. IHC TUPR QUE Study Brendt James 1999

27. 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

28. Future 2002-052002-05 1995-001995-00 1980-851980-85 2005-082005-08

29. Some questions for discussion n n What are the most effective ways to develop the new QI stage in Europe ? n n How ca we ensure that patient/citizens´ agenda is accomplish? n n What are the advantages and disadvantges of government leadership ? n n Regional versus national versus European versus global approach ?