09 Isuf Kalo En

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					                                               First Central Asia Conference on
                                              Quality Improvement in Healthcare
                                                  29-30 June, 2004, Tashkent


                                         The challenge to improve the
                                          quality of health systems
                                                   in Europe
Quality of Health Systems Programme
Isuf Kalo, M.D., PhD, Regional Adviser




                                                          Prof.Dr Isuf Kalo
                                                         Regional Adviser
                                                      Quality of Health Systems
                                                             ika@who.dk
                                         Quality in health systems:
                                           a neglected “orphan”
                                              Quality is:
                                              • not known
                                              • not reported
                                              • not measured
Quality of Health Systems Programme
Isuf Kalo, M.D., PhD, Regional Adviser




                                              • not required by
                                                - governments
                                                - users
                                                - providers
                                                - payers
                                              • not rewarded
                                             Prioritization of Quality Values

                                         •   Safety
                                         •   Effectiveness
                                         •   Patient-centeredness
                                         •   Timeliness
Quality of Health Systems Programme
Isuf Kalo, M.D., PhD, Regional Adviser




                                         •   Efficiency
                                         •   Equity

                                                                                           IOM USA 2001
                                               Crossing the quality chasm: A new health system for the 21st
                                                                                                   century
                                                  Health system goals

                                                            Level Distribution
                                         Health
                                                                         




                                                                                   Efficiency
                                                                              }
Quality of Health Systems Programme
Isuf Kalo, M.D., PhD, Regional Adviser




                                         Responsiveness
                                                                         

                                         Fairness in financing            
                                                           __________   ________
                                                            Quality     Equity
                                           Functions the system performs            Objectives of the system


                                         Stewardship
                                            (oversight)
                                                                              Responsiveness
                                                                                to people’s non-
                                                                              medical expectations




                                           Creating resources          Delivering services           Health
                                           (investment and training)        (provision)
Quality of Health Systems Programme
Isuf Kalo, M.D., PhD, Regional Adviser




                                                                                 Fair (financial)
                                                                                 contribution
                                         Financing (collecting,
                                         pooling and purchasing)
                                         Accountability: What is it about ?


                                                              Delegation



                                                              Financing
                                           Actors (clients,
Quality of Health Systems Programme
Isuf Kalo, M.D., PhD, Regional Adviser




                                           citizens,                                     Accountable
                                           communities,                                  Actors
                                           organizations,      Performance
                                           policymakers)

                                                               Information



                                                              Enforceability

                                                                               World Development Report: Making
                                                                               services work for poor people
                                                Overall Health System Performance
                                                         in Member States
                                         No. of countries
                                           25


                                                                                                            Western
                                           20
                                                                                                            CCEE

                                                                                                            NIS
                                           15
                                                                                                            Rest of World
Quality of Health Systems Programme
Isuf Kalo, M.D., PhD, Regional Adviser




                                           10



                                            5



                                                                                                          Performance
                                                    TOP     26-   51-   76-   101-   126-   151-   176-   ranking
                                                     25     50    75    100   125    150    175    200
                                                   New WHO concepts on QHS:
                                             Shift from disease model to “holistic approach”

                                         •   Service organizations (standards, accreditation)

                                         •   Finance (budget reports, payment systems)

                                         •   Technical performance (external quality assurance systems)
Quality of Health Systems Programme
Isuf Kalo, M.D., PhD, Regional Adviser




                                         •   Clinical training (curriculum, licensing, certification, citizens’
                                             and patients’ satisfaction (well-being, rights, empowerment)

                                         •   Safety & health protection (legislation, inspection, risk
                                             management)

                                         •   Linked Q.I.S. (indicators, databases, tools, evidence)
                                           Major directions for improvement of
                                           the quality in health care provision
                                         • Professional: the way care is delivered
                                           - overuse, under-use, misuse.

                                         • Organization: the way care is organized
                                           - access, waiting time, communication gap,
Quality of Health Systems Programme
Isuf Kalo, M.D., PhD, Regional Adviser




                                             coordination.

                                         • Relationship: the way care is provided
                                           - co-decision-making, empathy, information.
                                                         Quality Tools
                                         • Policy                 • Quality assessment
                                                                    - self-assessment
                                         • Legislation              - external assessment
Quality of Health Systems Programme
Isuf Kalo, M.D., PhD, Regional Adviser




                                         • Standards              • Guidelines

                                         • Quality indicators     • HTA, evidence

                                         • Adequate information   • Rewarding mechanisms
                                           systems
                                         Evolution of health systems

                                          Classical universalism:
                                            All services for all

                                          New universalism:
Quality of Health Systems Programme
Isuf Kalo, M.D., PhD, Regional Adviser




                                           Most cost-effective interventions only
                                           (less is more)
                                                        Health Technology
                                                        Assessment (HTA)
                                         Public & community                   Individual care provision
                                           health                             • Clinical procedures
                                                                Utilization   • Drugs
                                         • Promotion                          • Devices
                                         • Prevention           Outcomes
Quality of Health Systems Programme
Isuf Kalo, M.D., PhD, Regional Adviser




                                         • Protection                         Supportive technology
                                                                  Cost        • Organization/
                                         Environmental health                   mechanisms
                                                                              • Information
                                                                              • Infrastructure and
                                                                                equipment
                                                Comparison of diverse financial
                                                   schemes for hospitals
                                           Payment                 Pros                      Cons
                                         Line-item budget   Strong control         No incentives for efficiency
                                                                                   and quality
                                         Fee for services   Rewards productivity   Over service
                                         Payment per case   Easy to administrate   Encourages hospitalization
                                         (basic)                                   of less severe cases
Quality of Health Systems Programme
Isuf Kalo, M.D., PhD, Regional Adviser




                                         Payment per case   Keep costs within      Upgrades severity,
                                         (DRG)              limits                 discharge patients earlier

                                         Global budgeting   Good efficiency and    Without monitoring, quality
                                                            flexibility            falls
                                         Capitation per     Community-oriented     Needs comprehensive data,
                                         population                                most difficult and most risky
                                                                                   for management
                                                The AGREE Instrument
                                                    (co-sponsored by WHO)

                                         Systematic international framework for
                                           appraising the quality of clinical
                                           guidelines in six domains and 23 items:
                                           - scope and purpose (3)
Quality of Health Systems Programme
Isuf Kalo, M.D., PhD, Regional Adviser




                                          - stakeholder involvement (4)
                                          - rigour of development (7)
                                          - clarity of presentation (4)
                                          - applicability (3)
                                          - editorial independence (2)

                                                          http://www.agreecollaboration.org
                                          People involved in
                                         development of QHS

                                          •   Citizens/community
                                          •   Patients/families
                                          •   Health care providers
Quality of Health Systems Programme
Isuf Kalo, M.D., PhD, Regional Adviser




                                          •   Health administrators
                                          •   Third party payers
                                          •   Policy makers
                                         A national strategy for QHS -
                                                     Who?

                                         “Ultimate responsibility for
                                            the performance of a
                                          country’s health system
Quality of Health Systems Programme
Isuf Kalo, M.D., PhD, Regional Adviser




                                           lies with government”
                                                     Gro Harlem Brundtland
                                                     Former Director General, WHO
                                                                Financial resources

                                              % of GDP invested in                Total Health Expenditure
                                             National Health System                  per capita in $US
                                                                                  900


                                         9                                        800

                                         8
                                                                                  700

                                         7
                                                                                  600
                                         6
                                                                                  500
Quality of Health Systems Programme
Isuf Kalo, M.D., PhD, Regional Adviser




                                         5
                                                                                  400
                                         4

                                                                                  300
                                         3

                                         2                                        200


                                         1                                        100

                                         0
                                              KAZ   KGZ   TJK   TKM   UZB   SVN    0
                                                                                          KAZ   KGZ   TJK   TKM   UZB   SVN

                                                                                           1997
                                                                                           2001

                                                                                        World Health Report 2004, WHO
                                                    Resources/costs
                                          What is a country expected to pay for?

                                         • Capacity building     • Designing policy/
                                                                   legislation
                                         • Under use
                                                                 • Institutionalization
Quality of Health Systems Programme
Isuf Kalo, M.D., PhD, Regional Adviser




                                         • Quality tools
                                                                 • Monitoring systems
                                         • Search for evidence
                                                                 • Time
                                             Major WHO/EURO principles of a national
                                              strategy for quality in health systems

                                         • Values and priorities for quality explicitly stated and
                                             disseminated to the public, providers and purchasers

                                         •   A comprehensive policy in quality is designed consistently with
                                             other policies and legislation

                                         •   Effective mechanisms to implement the policy on quality to be
                                             established at national or local level and between all stakeholders
Quality of Health Systems Programme
Isuf Kalo, M.D., PhD, Regional Adviser




                                         •   Methods, techniques and tools for development of quality are
                                             promoted systematically and are consistent with scientific evidence

                                         •   Adoption of demonstrated quality methods is recognized in
                                             organizations and individuals

                                         •   Resources for quality improvement are identified and allocated into
                                             agreed budgets
                                                              WHO Europe: A background of national quality policies in health systems. 2002
                                             Institutionalisation of the Quality in health systems

                                                                           GOVERNMENT                  PARLIAMENT


                                                                            MoH      Quality Advisory Council
                                                                            (Major Stakeholders represented)


                                             Legislation (Regulatory)                                            Policy Development


                                         Licensing       Registration      Standards           Guidelines       Measurement       Accreditation      Training
                                                         Certification                                          Q indicators
                                                                                               EBM & HTA
                                                                                                                    Audit
Quality of Health Systems Programme
Isuf Kalo, M.D., PhD, Regional Adviser




                                                                                                  HTA, EBM
                                          Licensing                        Standards, Drugs       Guideline        Quality Ind.                      Training
                                                          Certifications
                                         Re-licensing                      HT Administration      Development       Data Mgt.     Accreditation     Education

                                                                     National Centre for Implementation of Quality
                                                                                 Development Policy

                                                        Complaint system       Quality Networks              Quality              Risk Management
                                                                              Local & International    research/academic            Alert System




                                                                                                                                     Isuf Kalo, WHO EURO, 2001
                                                       UK National Strategy for
                                                        Quality Development

                                           Patient &            National Service                 Clear
                                            Public               Frameworks                   Standards
                                         Involvement          National Institute for          of Service
                                                              Clinical Excellence


                                                                                              Dependable
                                                   Prof. Self                      Lifelong
Quality of Health Systems Programme
Isuf Kalo, M.D., PhD, Regional Adviser




                                                                   Clinical                     Local
                                                   regulation    Governance        Learning
                                                                                               Delivery



                                                       •National Performance Framework
                                                       •Commission for Health Improvement       Monitored
                                                                                                Standards
                                                       •National Patient and User Survey
                                                                  Denmark
                                         1993:   First Danish national strategy for QD

                                         1995:   National strategy for databases on clinical quality

                                         1998:   81 databases working with quality development
                                                 Committee established for quality measurement and data registry

                                         1999:   National Council for Quality Development
                                                 Revision of national strategy for quality development
                                                 National indicator project
Quality of Health Systems Programme
Isuf Kalo, M.D., PhD, Regional Adviser




                                                 Best Practice Department of Internal Medicine
                                                 Advisory Board for revision of database strategy

                                         2001    Accreditation of the Copenhagen Hospitals (Joint Commission
                                                 International)
                                                 Private hospital introduces ISO 9000 certification in patient care

                                         2003    National Strategy on Quality Improvement in Health Care –
                                                 Common goals and action plan 2002-2006
                                         Institutionalisation of Quality in the Slovenian Health System

                                                                                      Ministry of Health
                                                                              National Health Board
                                                                             Vice Secretary for quality
                                                                    National Board for Quality in Health Care




                                            Drug                     Centre for quality assurance, research                        Central Complaint
                                         Administration                     and education in quality                                    Office



                                          Guidelines Development and Implementation                              Health Technology Assessment
Quality of Health Systems Programme
Isuf Kalo, M.D., PhD, Regional Adviser




                                                      Quality Assurance                                        Accreditation and Reaccreditations


                                                    Education for Quality                                          Licensing and Relicensing



                                                     Academic Detailing                                                 Complaint Systems



                                                                            Quality Assurance and Quality Improvement
                                                                                       Research and projects


                                                                                                                                         Kersnik 2001
                                              Council of Europe and QHS


                                         • European Social Charter (article 11):
                                           receiving health care of good quality is a
                                           fundamental right of every individual and
                                           each community
Quality of Health Systems Programme
Isuf Kalo, M.D., PhD, Regional Adviser




                                         • Committee of Experts on Quality (1995)
                                         • Recommendation to Health Ministers (1997)
                                         • 17 Practical Guidelines for a National Quality
                                           Improvement System
                                                         EU and QHS


                                         • Agreement of Ministers of Health to
                                           collaborate on quality in health care (1998)
                                         • Quality policy in EU Member States (1998)
Quality of Health Systems Programme
Isuf Kalo, M.D., PhD, Regional Adviser




                                         • Quality policy in Accession States (2001)
                                         • COMOC Project: Quality assurance in 262
                                           hospitals across the EU countries
                                                             Existing European Resources for
                                                         Development of Quality in Health Systems
                                         Interest        Pan-European                               National
                                         Governmental    WHO/EURO, Council of Europe, EU            Ministries of Health

                                         Legislation     EU public health, medical devices, blood   Regulations – radiation, safety, environment
                                                                                                    Quality systems
                                         Quality in      Euro Organization for Quality (EOQ)        Academic centres: CBO (NET), Istituto Superiore
                                         general         Golden Helix Awards                        (ITA), CERFE (ITA)

                                         Membership      Euro Society for Quality in Health Care    National societies for QHC
                                         organisations   (ESQHC)
                                         External        Euro Accreditation Forum                   Agencies: FAC (SPA), KTQ (DEU), NIAZ (NET),
                                         assessment      Euro Accreditation ISO                     HQS (UNK), ANAES (FRA)
                                                         EFQM                                       Inspectorates ITA, FRA, UNK
Quality of Health Systems Programme
Isuf Kalo, M.D., PhD, Regional Adviser




                                                         Euro Laboratories                          ISO Agencies
                                                         European Council for Standardization       Awards DEN, SWE
                                                         (CEN)                                      Programmes CPA (UNK)
                                                                                                    Agencies for Standardization
                                         Clinical        Council of Europe, AGREE                   Cochrane Centres
                                         guidelines                                                 NICE, CSBS, SIGN (UNK)
                                                                                                    ANAES (FRA)
                                         Tech.Assess.    ISTAHC                                     Several European countries
                                         Indicators      EUPHIN, ECHHO, OECD                        DKI, GSF-EDIS (DEU)
                                         Consumers       Social Chapter EU                          Patients’ charters
                                         Conferences     ISQua, BMJ/IHI, Forum
                                                                  Quality Networks


                                         •   European Forum of Medical Associations EFMA. www.who.dk/tech/cor/efma
                                         •   International Society for Technology Assessment (ISTAHC). www.istahc.org
                                         •   International Society for quality in Health Care (ISQua). www.isqua.org.au
                                         •   European Society for Quality in Health care (ESQH). www.esqh.net
                                         •   European Organization for Quality (EOQ). http://www.eoq.org/start.html
                                         •   European Foundation for Quality Management (EFQM). http://www.efqm.org
                                         •   Cochrane collaboration. http://hiru.mcmaster.ca/cochrane/
                                         •   World Health Organization. www.who.int
                                         •   National recommendations on quality management in health care. Germany, 1998.
Quality of Health Systems Programme
Isuf Kalo, M.D., PhD, Regional Adviser




                                             www.aezq.de/gmk3010.pdf
                                         •   Russian Federal Methodological Center. www.healthquality.ru
                                         •   Appraisal of Guidelines Research and Evaluation (AGREE) project.
                                             http://www.agreecollaboration.org
                                         •   Quality Assurance Project (QAP). http://www.qaproject.org/
                                         •   Joint Commission International Accreditation. www.jcrinc.com
                                         •   ALPHA standards for accreditation and external assessment. www.isqua.org.au
                                         •   ANAES Service Evaluation. http://www.anaes.fr/ANAES/anaesparametrage.nsf/
                                         •   A background of national quality policies in health systems.
                                             http://www.euro.who.int/document/e77983.pdf
                                             QHS: Obstacles/Problems


                                         •   Operational research
                                         •   Resistance (“barriers of the mind”)
                                         •   Insufficient coordination
Quality of Health Systems Programme
Isuf Kalo, M.D., PhD, Regional Adviser




                                         •   Lack of incentives
                                         •   Insufficient resources
                                              Developing activities to
                                            support the change process
                                                  Stages in the change process

                                         Pre-contemplation   Contemplation    Preparation   Action   Maintenance
Quality of Health Systems Programme
Isuf Kalo, M.D., PhD, Regional Adviser




                                           Predisposing events

                                                                 Enabling events

                                                                                   Reinforcing events
                                                  WHO EURO ROLE

                                         • Advocacy and Support on Policy Design
                                         • Mapping and Data Gathering
                                         • Capacity Building on QM
                                         • Networking and Cooperation with Local
Quality of Health Systems Programme
Isuf Kalo, M.D., PhD, Regional Adviser




                                           and International Partners
                                         • Support Implementation Activities

				
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