Managing for quality in health outcomes

Health development is intended to contribute to health improvement, and systematic measurement of health outcomes for the Region as a whole and for each Member State has taken place since 1984, using outcome-oriented HFA indicators tailored to each regional HFA target. However, only some countries have set their own specific targets and indicators, and far too few use health outcomes as the main parameter for managing the health sector. In fewer countries still are health outcomes used as the main parameter for managing individual health service institutions. No country, either in the European Region or elsewhere, has a system where all clinicians receive continuous feedback on the results of their own patient care.

This situation reveals a very serious flaw in health care management philosophy and practice. This flaw prevents the health system from being properly focused and leads to much current practice in the European Region being below the assumed quality; it is also wasteful of its resources. The major challenge in health care for all Member States in the European Region is therefore to refocus the management of health services and care towards measuring the true impact of different interventions on the health of the population; the use of health outcome indicators offers a unifying concept for doing this.

Until recently, it was generally assumed that well trained physicians and other health care providers, who had systematic information about scientific innovations and who were working in well equipped health care institutions, would automatically produce homogenous and high-quality health care. However, a steadily mounting body of evidence shows that this is not the case and that, in spite of existing knowledge, there are wide (and sometimes very large) variations in the outcomes of care. Such differences in outcome are found not only between countries or regions within countries, but also between institutions, hospital departments and individual health care providers.

Information systems at all levels should clearly support informed management and continuous quality development. However, in the European Region, almost all individual health service institutions

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and providers currently lack basic information about the quality of the care they provide in their daily practice. The situation is much better with regard to population-based information, since the (over 200) regional HFA indicators agreed on by Member States since 1984 have enabled a unique database to be built up for comparing different health strategies.

TARGET16 – MANAGING FOR QUALITY OF CARE

BY THE YEAR 2010, MEMBERSTATES SHOULD ENSURE THAT THE MANAGEMENT OF THE HEALTH SECTOR, FROM POPULATION-BASED HEALTH PROGRAMMES TO INDIVIDUAL PATIENT CARE AT THE CLINICAL LEVEL,IS ORIENTED TOWARDS HEALTH OUTCOMES.

In particular:

16.1 the effectiveness of major public health strategies should be assessed in terms of health outcomes, and decisions regarding alternative strategies for dealing with individual health problems should increasingly be taken by comparing health outcomes and their cost–effectiveness;

16.2 all countries should have a nationwide mechanism for continuous monitoring and development of the quality of care for at least ten major health conditions, including measurement of health impact, cost–effectiveness and patient satisfaction;

16.3 health outcomes in at least five of the above health conditions should show a significant improvement, and surveys should show an increase in patient’s satisfaction with the quality of services received and heightened respect for their rights.

PROPOSED STRATEGIES

Quality means degree of excellence, and quality development should not be seen as an administrative control to ensure the attainment of a predetermined quality level – rather, it is a dynamic process that encourages a continuous, innovative improvement in health care outcome. It is therefore essential that health services should be organized in such a way that health outcome will be the main concern in identifying inputs, defining processes and evaluating outputs. The whole process should target health improvement, patient satisfaction and cost–effectiveness, as opposed to traditional management practices in which the system has been viewed from an input perspective, with plans developed according to inputs.

National and professional policies

A first requirement is to develop a common policy for a country that adheres to these principles, and WHO’ s Regional Office for Europe has worked with national administrations and professional organizations to develop such models (see below).

NATIONAL POLICIES FOR CONTINUOUS QUALITY OF CARE DEVELOPMENT

Continuous quality of care development has been taken up by several countries on the basis of national policies on the quality of care. Such policies have been developed with WHO assistance in Denmark (1993), Belgium (1995), Slovenia and Poland, and are under implementation and/or development in, Hungary and Lithuania, among others. In Denmark, formulation of the policy has been followed with the establishment of numerous new databases and development of evidence-based quality criteria. The European Forum of National Medical Associations (NMAs) and WHO have developed and endorsed a model quality of care development policy for NMAs which is in accordance with national policies and are promoting their development among its members.

Sources: Blomhøj, G. et al. Continuous quality development: a proposed national policy. Copenhagen, WHO Regional Office for Europe, 1995 (document EUR/ICP/CLR 059); Borgions, J. et al. Développement continu de la qualité des soins: Proposition de politique nationale. Brussels, Ministère de la santé publique et de l’environnement, and Copenhagen, WHO Regional Office for Europe, 1995; Recommendations for national medical associations regarding quality of care development. Medisch Contact,38: 166 (1993).

Outcome indicators

A basic minimum of relevant and measurable outcome indicators – particularly health outcome indicators – need to be developed to support the whole range of action between public health work and individual clinical care, and they should be internationally agreed on (so as to learn from international comparisons), regularly monitored and evaluated as part of the health services’ routine operations. For any health programme such outcome indicators, scientifically valid and based on practical experience, should cover the various aspects of health care (health promotion, disease prevention, treatment and rehabilitation) and be used to compare the relative value of each when planning and managing such programmes.

Outcome indicators help to measure which interventions are effective, and they should be used for monitoring daily patient care and for assessing new diagnostic and therapeutic technologies (including new pharmaceutical products and medical equipment), during both initial trials and subsequent routine use. They can also become an important tool in new management techniques, such as monitoring the implementation of contracts between purchasers and providers of health services and care. This has implication for the work of public health management experts (see section 6.5 below).

Continuous quality development using documented outcome measurement and evidence-based medicine contributes to more effective application of diagnostic and curative interventions and to a reduction of unnecessary expenditure on procedures and pharmaceuticals.

The education and training of health professionals must equip them with the skills required to be active participants in this process, providing them with the means to assess the quality and outcome of their clinical work as a necessary step in improving health care delivery.

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Evidence-based care

Quality is assessed on the basis of evidence and achievement of the best results is identified using scientific knowledge. Interventions (whether in the health services or in health care itself) must always be based on scientifically validated evidence. Efforts to systematically sample such evidence for different interventions and to ensure its acceptance by health care providers are therefore an important concern.

In this context, reviewing and synthesizing the results of research, maintaining registers and databases based on agreed outcome indicators, and disseminating findings to decision-makers and to providers and users of services are important functions. These findings can be seen as providing

“benchmarks” of best practice for others to match or surpass.

Guidelines for clinical practice should be developed on the basis of best measured outcomes; they should be “owned” by those who will use them, and they should be frequently updated in order not to lead to stagnation. A dynamic search for better ways forward must come both from basic research and from innovations in daily practice.

TARGETED PROGRAMMES BASED ON SOUND DATA LEAD TO SUSTAINABLE HEALTH IMPROVEMENTS In Stockholm, Sweden, a programme for detection and treatment of diabetes retinopathy in line with the objectives of the St Vincent Declaration has shown remarkable results: during a period of ten years, the blindness rates in this region were reduced by 60%. It is suggested that this programme can be as successful in many more regions, since the project demonstrates that an improvement has been made even in a country which has already a good and modern health care delivery system.

Such programmes have to be developed on sound clinical data. The Norwegian hip register, which is run by the Norwegian Orthopedic Society, has led to a continuous registration of all surgical procedures related to the implantation and later revision surgery of all hip prothesis. The data are fed back in anonymized form to all participating centres. This leads to a much more focused approach in the development and provision of hip surgery in Norway, as discussions are based on “ real data” . For instance, the database has contributed strongly to the streamlining of medical procedures in hip surgery, thus providing better quality of care.

Sources: Stæhr Johansen, K. et al. Improving health of people with diabetes: The “ End of the beginning” . Diabetes nutrition and metabolism,10(3): (1997); Bäcklund, L.B. et al. New blindness in diabetes reduced by more than one-third in Stockholm county. Diabetic medicine,14: 732–740 (1997); L.I. Havelin, Chairman, Norwegian Hip Register, personal communication, 1998.

Information systems

A major strategy for quality development is to establish an information system at the clinical level, providing feedback to individual health professionals on the outcomes of the care they deliver. (See also 7.2.2.) An information system of this kind should be designed to allow the individual providers to compare each others’ outcomes on an anonymous basis (as otherwise information given will

tend to be less correct and the system resisted); experience has shown that this can have an immediate and major positive effect on the quality of care provided by individual health professionals who, when they realize that their performance and use of technology may not be optimal, have a major ethical incentive to change.

Such systems also provide a unique opportunity to identify those who really are the best achievers in terms of health care outcomes. Surprisingly, they are not always those thought to be the best, but instead may be more innovative, more concerned with their patients or more thorough in their work. This changes the whole concept from one of quality assurance to quality development, whereby the results of the best achievers constantly “pull” the rest of the field forward. This approach opens up the search for new ideas and turns the quest for better quality into a continuous and dynamic process, where superior performance can quickly be recognized.

Based on information on quality compiled in aggregate at population levels (e.g. the local community, the county or region, or the country as a whole), quality improvement targets should be set for a given period and quality indicators agreed upon.

Patient satisfaction

Citizens may be empowered by providing the necessary information to enable them to participate in evaluating the quality of care. Community participation in decision-making for health care should be ensured at all levels. Many self-help groups and patients’ organizations have been set up (associations of patients with chronic renal failure, haemophilia, thalassaemia, diabetes and asthma, and associations of relatives of patients suffering from mental disorders, for instance) and they play a very valuable role as advocates of improvement in the services provided. They make a noteworthy contribution to monitoring the quality of services and to improving the management of the condition concerned; this parallels and sometimes overlaps with the outcomes and quality movement within the health sector itself.

Like health care providers and purchasers, the public need good information, in particular about what they can reasonably expect in terms of quality and outcome of care, in order to make meaningful choices, to have an informed dialogue with health care providers and to decide how to arrange their lives when they are ill or under treatment. One explicit aim of health care systems in the future should be to provide citizens and patients with information, in order to empower them and improve their health.

Many European countries have chosen to adopt special legislation on patients’ rights. Another approach is to implement a widely accepted patients’ charter. The Declaration on the Promotion of Patients’ Rights in Europe (Amsterdam, 1994) provides a useful framework for countries wishing to take action in this area. Possibly the most significant effects of this trend are that patients will understand more about their health condition and treatment, and health care workers will become more respectful of patients’ needs and views and be more supportive in helping them to manage their own disease in a better way.

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6.3.1 Application of management tools to obtain outcomes

Management flexibility

A greater degree of decentralization in management has much to offer in terms of improving the performance of the health service. Increased autonomy is also compatible with competition; the latter can be encouraged through a greater degree of patient choice and through mechanisms for allocating resources in the light of quality indicators.

Contracting arrangements between purchasers and providers of health care can also be useful tools in this respect. They can enable purchasers to concentrate on identifying the population’ s health needs and on meeting them through coordinated contracts with a range of service and care providers. Such competition between providers is also compatible with a regionalized system, but only if purchasers have a coherent strategic framework and there is reasonable cooperation between providers. Contracts can also support quality development, if agreed quality indicators are incorporated in the bills that providers submit to third-party payers. In such situations the confidentiality of individual providers must be safeguarded. Aggregates of data at population level will serve as one input for health and health care assessments and for future target-setting and contracting in a context of continuous quality development.

It is, however, health care professionals, not managers, who ultimately decide what is to be done in their daily clinical work with individual patients, so managers must be sensitive to the views of both patients and professionals. Information technology should be harnessed to improve the quality of care and the efficiency of diagnostic and therapeutic departments. Better communication between hospitals and PHC can ensure continuity of care.

6.3.2 Planning inputs for outcomes

Sound planning mechanisms need to be in place that take good outcomes as their fundamental goal.

Inputs and processes should be planned in order to ensure health outcome, patient satisfaction and cost–effectiveness. Among these three quality spheres, an explicit choice is made in favour of health outcomes as the most effective tool with which to achieve the other two. An approach designed to foster continuous quality development requires health professionals to be trained as communicators, working towards patient satisfaction, and to be concerned about the cost implications of their interventions.

Human resources should be planned with the appropriate skill mix to ensure the desired outcomes.

Their education and training will provide them with the necessary knowledge to perform their tasks, as well as with the skills to measure and evaluate their outcomes.

The allocation of financial resources should reflect the outcomes achieved, and include incentives for improving the quality of care. Selection of the appropriate technology, the provision of pharmaceuticals and the physical infrastructure should be planned accordingly.