Strategies for the improvement and control of Quality Management in Health: IMPLICATIONS FOR CHILEAN HEALTH CARE SYSTEM

Transcription

1 Strategies for the improvement and control of Quality Management in Health: IMPLICATIONS FOR CHILEAN HEALTH CARE SYSTEM Estrategias para el mejoramiento y el control de la Gestión de Calidad en Salud: Implicancias en el sistema de Salud Chileno Rajesh Balkrishnan, PhD Associate Professor of Public Health, Pharmacy and Medicine, UniversIty of Michigan, USA rbalkris@umich.edu

2 Health Care Quality Evaluation and Reporting is becoming for healthcare administrators and it is becoming important to understand processes and methods for accomplishing this. The Chilean government has established national accreditation standards and more organizations are seeking international quality of care approvals to justify insurance covering health care services. The healthcare system in Chile is experiencing high utilization and costs prompting interest of both government and private insurance in cost effective high quality medical care. Implementing process of care controls, measuring and reporting patient outcomes, and gathering evidence to ensure international accreditation of health care facilities will be increasingly required in Chile. Background

3 The presentation will review the state of the art of quality management for healthcare delivery for managers in hospital and other health care settings. This presentation will next focus on practical tools which can assist health care administrators in providing cost effective high quality medical care in hospital and clinica settings by examining various strategies such as implementing process of care controls, measuring and reporting patient outcomes, and gathering evidence to ensure international accreditation of health care facilities by agencies like the ISO and the Chilean National Accreditation Standards for Providers of Health. Objectives

4 Effectiveness is the degree to which improvements in health now attainable are, in fact, attained. Effectiveness concerns the results achieved in the actual practice of healthcare with typical patients and providers, in contrast to efficacy, which is assessed by the benefits achieved under ideal conditions. Effectiveness focuses on the benefits produced by healthcare, as measured by improvements in people's health. Healthcare Effectiveness

5 Structure refers in this case to elements of medical care that are associated with the receipt of services. These may include factors such as availability of insurance coverage and access to facilities. Process refers to the intervention being tested for effectiveness, such as mammography screening. Finally, both structure as well as process results in Outcomes. In the breast cancer example, the intermediate outcome is the early detection of breast cancer, and the final outcome is the improved life expectancy, as a result of early detection. Structure, process, and outcomes are linked conceptually in a research paradigm that assumes structural elements of healthcare as having an influence on what is and is not done in the process as well as how well it is done; this process in turn influences the health outcomes people experience as a result of their encounters with the care delivery process. The SPO framework

6 Consequences to health and welfare of individuals and society (Donabedian, 1980) Include at least clinical endpoints, health-related quality of life, and satisfaction with care. Outcomes Evaluation is focused on studying interventions based upon their clinical effect, their effect on patients' sense of health and well-being, and their economic effects. The results of Outcomes Evaluation should allow patients, payers and healthcare providers to make rational choices about their medical care by allocating funds to the most cost-effective treatments. Healthcare Outcomes

7 Escalating Costs of Medical Care and demonstration of wide variations in level and medical resources across geographic regions Population-based evidence showing limited effectiveness of medical care in improving health and well being of populations and clinical evidence revealing potential for increasing medical care effectiveness Rise of managed care, with its emphasis on productivity and accountability Outcomes revolution in healthcare Why?

8 An evaluation of the attributes of the process within the SPO framework which is comprised of Input Action Output A perception based on an individuals value system relies on culture, life experiences and expectations of each individual. High quality is achieved by continual improvement in terms of customers expectations with health care they receive based on content and delivery. Medicine a learned profession sets its own expectations regarding medical outcomes (content quality) However this is eroding as patients and payers becoming more active movement towards patient centered care. What is Healthcare Quality?

9 Medicine and medical care would not exist without patients Lot of subjectivity in treatment based on clinical staffs knowledge and use of medical treatments Customers quality perceptions becoming increasingly important for justifying costs of medical care What customers want Cleanliness, smoothness of facility 0peration, Courtesy, Speedy Response Time, Best Technology, Competency of Professionals, Accuracy of Billing, Availability of specialized care Medical Customers and Quality

10 Rare and frightening experience for most people Patient education is informal, uneven and incomplete Patient satisfaction and perception of quality directly related to patient education Increased participation in treatment decisions leads to better patient compliance and medical outcomes Patient risk management is becoming essential for cost management in healthcare Patient Education Why is it Important

11 Intimately related High value clinical care results from most efficient resource expenditure to achieve established high level of clinical quality. Reducing waste or having high quality waste reduces costs Doing things right the first time helps Health care finances need some type of control in era of high costs without compromising essential care access. Quality and Cost

12 The Quality Improvement Cycle

13 Improving productivity among health care professionals is the need of the hour But at what cost reduced access and satisfaction? Productivity can be increased by eliminating inappropriate variation technologies and processes that increase costs but do not improve outcomes Focus on additions to care that are maximally effective Perform cost benefit of newer technologies Consider environmental and personal lifestyle factors Productivity

14 Continuous Quality Improvement (CQI), sometimes referred to as Performance and Quality Improvement (PQI), is a process of creating an environment in which management and workers strive to create constantly improving quality. Continuous Quality Improvement (CQI) is: A theory-based management system that looks at processes/outcomes Culture change Client-centered philosophy Tools to help quantify what we do A search for common causes of variation Driven by data System, process and client feedback Shared success Long-term approach Factors that drive CQI include key accountability, driven by good management...not crisis, driven by input from all levels of staff and stakeholders, teamwork and continuous review of progress Continuous Quality Improvement

15 Total Quality Management

16 Top management vigorously committed to quality and productivity as evidenced by practical actions. Customer orientation permeates the organization, and is reflected in customer satisfaction and quality ratings Teamwork at all levels is seen as key to improving processes and services Quality management and improvement training are provided at all levels of organization Accountability for quality and productivity improvement is tied to managers performance evaluation. Attributes of TQM Managers

17 Lean Six Sigma Approach

18 Key Differences

19 Getting accredited by organizations like the ISO and the Joint Commission is becoming the norm rather than a choice in health care Successful medical CQI systems always usually have an excellent Quality Assurance (QA) system that ensures adherence to accreditation guidelines. Good systems generate good data by avoiding inherent arbitrariness in patient outcomes avoiding inherent misclassification of processes and outcomes avoiding artificial floors and ceilings in measurement of outcomes generating accurate primary data recognizing errors will occur avoiding dependence on dichotomous standards related to quality improvement. Specifications and Standards

20 Quality has to be accomplished in 4 major divisions of the healthcare organization Quality of healthcare organization and its management Quality in measurement, specifications and reporting Quality of service [delivery quality] Value of care [Content Quality] Operationalizing Quality in Healthcare

21 Organizational Quality

22 Quality of Evaluation

23 Quality of Service

24 Value of care is established by Having infrastructure for high quality clinical care Reducing inappropriate variation in indications for treatment Reducing inappropriate variation in patterns of care Avoiding or mitigating medical errors Screening using risk adjusted outcomes Improving underlying medical science through clinical research Improving the healthcare delivery process Disseminating information and monitoring performance Value of Care

25 Program Evaluation

26 Health care in Chile is very advanced and state-of-the-art on the high end. The national health care system (FONASA) provides basic medical service and coverage to all levels of society. Quality is better at private clinics and hospitals around Chile and citizens can voluntarily select between private or public care. Doctors are well-trained and professional. Hospitals are generally run as professional businesses, with national regulation of standards that meet or exceed international standards of care. Chile tends to rank well on international benchmarks comparing metrics such as life expectancy at birth or infant mortality. Chile's health care system is funded by a universal income tax deduction equal to 7% of every worker's wage. Whereas the National Health Insurance Fund is wholly supported by the government using general tax revenue, many private health insurance companies encourage people to pay a variable extra on top of the 7% premium to upgrade their basic health plans. Because of this arrangement, the public and private health subsystems in Chile have existed almost completely separate from each other rather than coordinating to achieve common health objectives. Chilean Healthcare and Quality Focus

27 Since 2000, Chile has implemented a Health Care Reform to reduce the great inequalities in health care provision that affects the low- income, high-risk segment of its population. A universal care plan ("AUGE") was designed to make medical coverage available to all Chilean citizens suffering from one of a specified, growing list of diseases (80 at present time). The diseases are prioritized by the Ministry of Health and its inclusion in the plan is revised periodically by an Advisory Committee according to four cardinal criteria: burden of disease, effectiveness of treatment, specific capacity of the health system and financial costs. The plan is funded by the state and enforced by law through a set of four specific guarantees: access, opportunity, quality and financial protection. Evidence from the public on its success has been mixed with primary concerns related to access to quality care. Healthcare Reform in Chile

28 Accreditation is a process of periodic evaluation, which undergo institutional providers authorized by the Health Authority-hospitals, clinics, outpatient centers and laboratories, to verify compliance with a set of quality standards set and regulated by the Ministry of Health. This evaluation process is executed by Accrediting Entities that are subject to an approval process by the Superintendency of Health, later to be registered in the Public Registry of Accrediting Entities. It is aimed at legal representatives of institutional health care providers and institutional providers of health care open and closed. Healthcare Accreditation in Chile

29 Healthcare reform process has emphasized the implementation and measurement of all of the health plan's guarantees except that related to quality. Although there has been focus on need for accreditation of health care organizations that deliver services under the plan through the Ministerio de Salud, which seems more related to the issue of safety than to guaranteeing quality. A number of clinical guidelines aimed at directing and improving the clinical decision-making process have been issued, which seems to be a step closer to a guarantee of quality of care. Joint Commission accredited organizations are few: Clinica Alemana de Santiago S. A. in Santiago and Clinica Las Condes also in Santiago Standards and Implementation

30 Quality Evaluations

31 Consumer Perceptions of Healthcare Facilities

32 Strategies for CQI

33 Movement towards evidence-based care. Using gold standards Monitoring service delivery to detect variation and provide feedback to healthcare professionals Increasing dissemination of evidence Identifying conditions that can be targeted for safer and more effective treatments Professional standards review organizations and accrediting bodies and their role Tool 1 Implementing Process of Care Controls

34 Better patient outcomes translate to increased efficiency in the health care system, cost savings, and increased revenues in the long term for the organization Better patient outcomes lead to better recognition in the community as well as with accrediting bodies and regulatory agencies Tool 2 Patient Outcomes and why they matter.

35 This is going to produce the best outcome and ensure your organizations accreditation! Tool 3 Evidence-Based Accreditation

36 Tool 4 Building a Culture of Quality

37 Clínica Dávila es el primer establecimiento de salud que obtiene por segunda vez la Acreditación de Calidad El centro asistencial ubicado en la Región Metropolitana, se reacreditó por tres años más bajo el Estándar General de Acreditación para Prestadores Institucionales de Atención Cerrada.

38 Hospital San Camilo de San Felipe se convierte en el 7 hospital público en certificarse El reconocimiento fue entregado en una ceremonia que contó con la presencia del subsecretario de Redes Asistenciales Luis Castillo y la superintendenta de Salud Liliana Escobar.

39 Quality in health care provision and delivery is being highly emphasized Better quality of medical care translates to savings in costs and increased health care efficiency An organization wide commitment to quality is needed to deliver cost effective high quality health care High variation in quality of care can be traced to factors such as insufficient data as well as quality waste and low productivity A commitment to quality principles such as CQI, TQM and Lean Six Sigma at an organizational level has shown to improve quality of healthcare delivery. Take Home Points

40 The Chilean government has established national accreditation standards and more organizations are seeking international quality of care approvals to justify insurance covering health care services. The healthcare system in Chile is experiencing high utilization and costs prompting interest of both government and private insurance in cost effective high quality medical care. Implementing process of care controls, measuring and reporting patient outcomes, and gathering evidence to ensure international accreditation of health care facilities will be increasingly required in Chile. Conclusion

41 Here is the place to go!