The overarching strategy for ensuring quality of care is captured in the National Healthcare Agreement of the COAG (2012). The agreement sets out the common objective of Australian governments in providing health care — a sustainable system with improved outcomes for all — and the performance indicators and benchmarks on which progress is assessed. It also sets out national-priority policy directions, programs, and areas for reform, such as addressing major chronic diseases and their risk factors. Indicators and benchmarks in the agreement address issues of quality from primary to tertiary care and include disease-specific targets of high priority, as well as general benchmarks.
The Australian Commission on Safety and Quality in Health Care (ACSQHC) is the main body responsible for safety and quality improvement in health care. The ACSQH has developed service standards that have been endorsed by health ministers. These include standards for conducting patient surveys, which must be met by hospitals and day surgery centers to ensure accreditation. The Australian Bureau of Statistics, the national government statistical body, also undertakes an annual patient experience survey.
The Australian Council on Healthcare Standards is the (nongovernment) agency authorized to accredit provider institutions. States license and register private hospitals and the health workforce, legislate on the operation of public hospitals, and work collaboratively through the National Registration and Accreditation Scheme to facilitate workforce mobility across jurisdictions while maintaining patient protections. States also ensure that the workforce maintains minimum hours and standards of continuing education to maintain accreditation.
The Royal Australian College of General Practitioners has responsibility for accrediting GPs. To be eligible for government subsidies, aged-care services must be accredited by the government-owned Aged Care Standards and Accreditation Agency. Beginning in January 2019, the new Aged Care Quality and Safety Commission will be responsible for regulation, compliance, and complaints for aged care.
There are a number of disease and device registries. Government-funded registries are housed in universities and nongovernmental organizations, as well as within state governments. The ACSQH has developed a national framework to support consistent registries.
The National Health Performance Authority reports on the comparable performance of Local Hospital Networks, public and private hospitals, and other key health service providers, but not nursing homes or home care agencies. The reporting framework, agreed to by the Council of Australian Governments, includes measures of equity, effectiveness, and efficiency.
The federal government has regulatory oversight of quarantine, blood supply, pharmaceuticals, and therapeutic goods and appliances.30 In addition, there are a number of national bodies that promote quality and safety of care through evidence-based clinical guidelines and best-practice advice. They include the National Health and Medical Research Council and Cancer Australia.
Over the years, several initiatives were developed within SUS to better evaluate health system performance, protect patients, and improve quality of care.
In 2012, the Ministry of Health launched SUS Performance Index, which tracks indicators related to access, effectiveness, equity, and other improvement goals. However, political and policy changes have hampered the use of these evaluations for improving quality of care.
In 2011, the Ministry of Health created a national program for improving access and quality in primary care. Although voluntary, the program included nearly 39,000 family health teams. As a financial incentive to improve quality, family health teams receive additional payments based on a facility evaluation, performance on health indicators, and interviews with health care professionals, municipal managers, and service users.25
In the hospital sector, the Brazilian Accreditation System was created in the late 1990s with the aim of promoting the improvement of quality of care. The National Accreditation Organization leads hospital accreditation. According to a 2009 survey, many accredited hospitals were private, had more than 150 beds, and were in Brazil’s southeast.
In 2013, the Ministry of Health established the National Patient Safety Program, which follows the World Alliance for Patient Safety’s guidelines. Patient-safety centers have been established in public and private hospital services, and it is mandatory to report adverse events, including inpatient falls and misapplications of medication.
Many provinces have agencies responsible for producing health care system reports and for monitoring system performance. In addition, the Canadian Institute for Health Information produces regular public reports on health system performance, including indicators of hospital and long-term care facility performance. To date, there is no information publicly available on doctors’ performance across the country. Most provinces post summary inspection reports online.
Home care agencies do not have reporting standards similar to those for residential long-term care. The Canadian Institute for Health Information has the Home Care Reporting System, which contains demographic, clinical, functional, and resource utilization data for clients served by publicly funded programs across Canada. However, in 2018, only eight jurisdictions were submitting data.36
The use of financial incentives to improve quality is limited. At the physician level, they have had, to date, little demonstrable effect on quality.37 Professional revalidation requirements for physicians, including those for continuing education and peer review, vary across provinces.
A variety of other quality initiatives are in progress:
- The federally funded Canadian Patient Safety Institute promotes best practices and develops strategies, standards, and tools.
- Provincial quality councils facilitate process improvements to produce higher-quality health care.
- The Optimal Use Projects program, operated by the Canadian Agency for Drugs and Technologies in Health, provides recommendations (though not formal clinical guidelines) to providers and consumers to encourage the appropriate prescribing, purchasing, and use of medications.
- The federally funded Canadian Foundation for Healthcare Improvement works with P/T governments to implement performance improvement initiatives.
- Accreditation Canada — a nongovernmental organization — provides voluntary accreditation services to about 1,200 health care organizations across Canada, including regional health authorities, hospitals, long-term care facilities, and community organizations.
- Provincial cancer registries feed data to the Canadian Cancer Registry, a national administrative survey that tracks cancer incidence.
- There is no national patient survey, although a standardized acute-care hospital inpatient survey developed by the Canadian Institute for Health Information has been implemented in several provinces. Each province has its own strategies and programs to address chronic disease.
- The P/T premiers, or prime ministers, established the Health Care Innovation Work Group in 2012 to improve quality by, for example, promoting guidelines for treating heart disease and diabetes and reducing costs.
The Department of Health Care Quality, which is within the Bureau of Health Politics and Hospital Administration and is overseen by the National Health Commission, is responsible at the national level for the quality of care. The National Health Service Survey for patients and providers is conducted every five years (the latest was in 2018), and a report is published after each survey highlighting data on selected quality indicators. Management programs for chronic diseases are included in the Essential Public Health Equalization Program and are free to every Chinese citizen.
To be accredited, hospitals must obtain a license from the local health authority. Physicians get their practice licenses through hospitals; licenses are subject to renewal. Local health authorities are responsible for physician recertification and revalidation and for hospital accreditation to ensure competency. Several national rankings of hospitals are published by third parties, although there are no financial incentives for hospitals to meet quality targets.18 No public information about individual doctors, nursing homes, or home care agencies is made available.
Following release of the “Temporary Directing Principles of Clinical Pathway Management” by the former Ministry of Health in 2009, clinical pathways are now regulated nationally and used similarly to clinical guidelines in Western countries. Previously, pathways were created at the hospital, rather than the national, level.
Quality improvement is a major priority area in health policy, as is reflected in the Danish Health Law.
The Danish Institute for Quality and Accreditation in Healthcare (IKAS) was instrumental in implementing accreditation in hospitals and in primary and municipal health care through the Danish Healthcare Quality Program.16 The program, in operation between 2004 and 2015, was phased out for hospitals and replaced by a new system in which regions are responsible for developing schemes that enable them to meet eight national quality targets and related indicators. These targets have been decided in negotiated agreements between the state, the Danish Regions, and Local Government Denmark. Regional performance on the targets is monitored and published annually.17 Accreditation for primary care is gradually being replaced by a system of collegial collaboration based on quality data. Accreditation is still available for municipal health services on a voluntary basis.
Other transparency efforts are underway. The Ministry of Health, the Ministry of Finance, and the Danish Regions regularly publish comparative-effectiveness (productivity) studies, which help regions and hospital managers benchmark individual hospital department performance.18 Quality data for a number of treatment areas are also captured in clinical registries and made available to institutions (but not individual health providers at the hospital level) through the national online health portal, www.esundhed.dk.19 In addition, patient experiences are collected through biannual national, regional, and local surveys.
To reduce variation in care quality, the Danish Health Authority has laid out standard treatment pathways, with priorities including chronic disease prevention and follow-up interventions. Pathways for 34 cancers have been in place since 2008, covering nearly all cancer patients. The Health Authority monitors the pathways and the speed with which patients are diagnosed and treated. National guidelines and reference programs also enforce the use of pathway programs and national clinical guidelines for all major disease types. The regions develop more specific practice guidelines for hospitals and other organizations, based on general national recommendations.
There are no explicit national economic incentives tied to quality, but all five regions are experimenting with such schemes by including indicators related to waiting times, adherence to guidelines, readmission rates, and patient satisfaction in the evaluation structure. In general, regions are obliged to act in the event of poor results. The Danish Health Authority can step in if regions fail to live up to standards.
Nursing homes and home care agencies are subject to quality inspections by the municipalities and by the Danish Patient Safety Authority. Results of municipal inspections are typically published online, while the authority publishes thematic overview reports on its risk-based inspections.
The Care Quality Commission regulates all health and adult social care in England. All providers, including institutions, individual partnerships, and sole practitioners, must be registered with the commission, which monitors performance using nationally set quality standards and investigates individual providers when concerns are raised by patients and others. It rates hospitals’ inspection results and can close down poorly performing services. The monitoring process includes results of annual national patient experience surveys for hospital, mental health, community, primary care, and ambulance services.
The National Institute for Health and Care Excellence develops quality standards, guidance, and guidelines for a large range of clinical conditions, safe staffing levels, technologies, medicine handling, antimicrobial prescribing, and diagnostics, which span primary, secondary, and social care services. National strategies have been published for a range of conditions, from cancer to trauma. There are national registries for key disease groups and procedures. Maximum waiting times have been set for cancer treatment, elective treatments, and emergency treatment. A website, NHS Evidence, provides professionals and patients with up-to-date clinical guidelines.
Information on the quality of services at the organization, department, and (for some procedures) physician levels is published on the NHS website. Results of inspections by the Care Quality Commission are also publicly accessible.
The Quality and Outcomes Framework provides general practices with financial incentives to improve quality. General practices are awarded points (which determine a portion of their remuneration) for keeping a disease registry of patients with certain diseases or conditions, including data on patient management and treatment. For hospitals, 2.5 percent of contract value is linked to the achievement of a limited number of quality goals through the Commissioning for Quality and Innovation initiative. In addition, DRG rates for some procedures are linked to compliance with best practices.
All doctors are required by law to have a license from the General Medical Council to practice. Similar requirements apply to all professions working in the health sector. A revalidation process every five years has been introduced for doctors, nurses, and midwives.
Healthwatch England promotes patient interests nationally. In each community, local Healthwatches support people who make complaints about services; quality concerns may be reported to Healthwatch England, which can then recommend that the Care Quality Commission act. In addition, local NHS bodies, including general practices, hospital trusts, and CCGs, are expected to support their own patient engagement groups and initiatives.
An average of EUR 5,000 (USD 6,330) per physician annually is provided for achieving pay-for-performance targets related to the following:
- use of computerized medical charts
- adoption of electronic claims transmission
- delivery of preventive services, such as immunizations
- compliance with guidelines for diabetic and hypertensive patients
- generic prescribing
- limited use of psychoactive drugs for elderly patients.
Population health surveys are undertaken based on disease, population segment (such as newborns, students, elderly patients), or theme (like nutrition). In addition, there are regional disease-based registries for specific conditions, including cancer, multiple sclerosis, and congenital abnormalities. The CONSTANCES Cohort is a 200,000-person representative sample of the population, surveyed yearly with linkages to the national claims database. National surveys showing regional variations in health and access to health care are publicly reported.
There are national strategies for the treatment of chronic conditions like cancer and for rare diseases, as well as for prevention and healthy aging. These plans establish governance, develop tools, and coordinate participating organizations. For example, the national cancer plan sets goals for coordinating cancer research and treatment and establishes medical practice guidelines as well as minimum volume thresholds for complex procedures. All plans emphasize the importance of supporting caregivers and ensuring patients’ quality of life, in addition to enforcing compliance with guidelines and promoting evidence-based practice.
To date, the National Health Authority has published evidence-based basic benefit packages for 32 chronic conditions. These benefit packages describe all the services needed for patients with those chronic conditions. Further guidance on recommended care pathways covers chronic obstructive pulmonary disease, heart failure, Parkinson’s, and end-stage renal disease.
Provider networks of participating professionals share clinical guidelines and protocols, agree on best practices, and have access to a common patient record. In addition, telemedicine pilot programs aim to improve care coordination and access to care for specific conditions or populations, like newborns or the elderly.
For self-employed physicians, certification and revalidation are organized by independent bodies, such as medical societies approved by the National Health Authority. For hospital physicians, certification and revalidation can be performed as part of the hospital accreditation process.
Doctors, midwives, nurses, and other professionals must participate in continuous medical education activities, which are audited every fourth or fifth year. Optional accreditation exists for a number of high-risk medical specialties, such as obstetrics, surgery, and cardiology. Accredited physicians can claim a deduction on their professional insurance premiums.
Hospitals must be accredited every four years; criteria and accreditation reports are publicly available on the National Health Authority website ( www.has-sante.fr). CompaqH, a national program of performance indicators, also reports results on selected indicators. Quality assurance and risk management in hospitals are monitored nationally by the Ministry of Social Affairs, Health, and Women’s Rights, which posts hospital-acquired infection rates and other information online. Information on individual physicians is not available. Currently, financial rewards or penalties are not linked to public reporting, although the issue remains contested.
Nursing homes are also accredited by the National Health Authority (formerly by the Agence Nationale d’Evaluation Sociale et Médico-sociale) with a specific focus on preventing elder abuse. Home care provided by hospital subsidiaries is accredited by the National Health Authority with public reporting available online.
Quality of care is addressed through a range of measures broadly defined by law and in more detail by the Federal Joint Committee. The Institute for Quality Assurance and Transparency (IQTiG) is responsible for measuring and reporting on quality of care and provider performance on behalf of the Federal Joint Committee. In addition, the institute develops criteria for evaluating certificates and quality targets and ensures that the published results are comprehensible to the public. All hospitals are required to publish findings on selected indicators, as defined by the IQTiG, to enable hospital comparisons. There is a mandatory quality reporting system for the roughly 1,600 acute-care hospitals, in which data of 290 publicized process and outcome indicators across 30 treatment areas are collected. Based on these data, sickness funds and the White List (Weisse Liste), a nonpartisan online tool, report outcomes to help patients choose hospitals. Indicators for quality-related hospital accreditation and payment are currently being developed.
Nursing homes and home care agencies are assessed by the regional SHI Medical Review Boards for, among other things, care deficits. The results of these quality checks are published in transparency reports. In addition, scores in nursing care are created based on these checks and surveys of nursing home residents and employees.
Structural quality is further assured by the requirement that providers have a quality management system, by the stipulation that all physicians continue their medical education, and by health technology assessments for drugs and procedures. For instance, all new diagnostic and therapeutic procedures applied in ambulatory care must receive a positive evaluation for benefit and efficiency before they can be reimbursed by sickness funds. In addition, the Institute for Quality and Efficiency in Health Care (IQWiG), an independent scientific institute, is legally charged with evaluating the cost-effectiveness of drugs with added therapeutic benefits.
Although there is no revalidation requirement for physicians, many institutions and health service providers include complaint management systems as part of their quality management programs. This system became obligatory for hospitals in 2013. At the state level, professional providers’ organizations are urged to establish complaint systems and arbitration boards for the extrajudicial resolution of medical malpractice claims.
The Robert Koch Institute, a governmental agency subordinate to the Federal Ministry of Health and responsible for the control of infectious diseases and for health reporting, has conducted national patient surveys and published epidemiological, public health, and health care data. Disease registries for specific diseases, such as certain cancers, are usually organized regionally. As part of the National Cancer Plan, the federal government passed a bill that mandated implementation of standardized cancer registries in all states by 2018 to improve the quality of cancer care. Full implementation, however, has yet to occur.
Disease management programs ensure quality of care for people with chronic illness. These programs are modeled on evidence-based treatment recommendations, with mandatory documentation and quality assurance.
Nonbinding clinical guidelines are produced by the Physicians’ Agency for Quality in Medicine and other professional societies.
Quality of care is addressed through legal and policy measures defined by the central and state governments.
Currently, there is no single entity that is responsible for measuring all aspects of quality of care at health care facilities. Most efforts have been focused on structural elements, such as tracking the availability of health care resources.49 Over the years, several regulations have been enacted and authorities created at the state and national levels with the aim of protecting patients and improving quality of care.
In 2017, a centralized tracking system for district hospital performance was introduced along with public rankings of hospitals in the system based on performance.50 However, the system’s indicators for quality of care are largely based on resource availability and patient satisfaction.51
Health care facility accreditation is well-developed in India. The National Accreditation Board for Hospitals and Healthcare Providers is responsible for accrediting all types of health facilities. This board is a member of the International Society for Quality in Health Care, along with countries such as Australia, Canada, Egypt, Hong Kong, and the United Kingdom.52 The accreditation criteria are based on international best practices from these member countries.
Structural quality is also ensured through mandatory continuing medical education (CME), instituted by the Medical Council of India. However, some state governments do not enforce this policy; only nine of the 26 states mandate physician participation in CME.53
Efforts have been made over the past decade to define standards for a number of areas related to patient care. Specifically, the National Health Systems Resource Centre provides a quality certification for all facility types in the health system. The certification is based on the National Quality Framework for Public Health Facilities, created by the Ministry of Health and Family Welfare, which has eight broad “areas of concern.”54
Facilities that earn certifications receive financial incentives. Facilities can also get technical and capacity-building support to improve their performance through training, workshops, and courses offered by the National Health Systems Resource Centre.
The Clinical Establishments (Registration and Regulation) Act of 2010 was passed into law by the central government to register and regulate clinical establishments, while prescribing a minimum set of standards for them to adhere to. However, many states have yet to implement the law.
Other frameworks that are being used to support quality control and improvement include:
- India Public Health Standards (2008)
- My Hospital (Mera-Aspataal) (2016)
- Labour Room Quality Improvement Initiative (LaQshya) (2017)
- National Patient Safety Implementation Framework (2018–2025).
The Ministry of Health and Family Welfare has published some national standard treatment guidelines related to hospital planning, blood transfusion, and electronic health records (see “What is the status of electronic health records?”, below). The National Centre for Disease Control has also published some national guidelines for the management and control of infectious diseases, as well as operational manuals for health care workers treating patients with infectious diseases. It is unclear, however, how well the guidelines are being enforced throughout the country.
The Ministry of Health and Family Welfare, in collaboration with state health departments, has developed a comprehensive quality assurance framework for public health facilities and programs. The framework comprises four interrelated activities to achieve a patient-centered health system55:
- instituting an organizational framework for quality improvement
- defining standards of service delivery and patient care
- continually assessing services against set standards
- improving quality by closing gaps and implementing opportunities for Improvement.
Israel has a well-established system for monitoring the quality of primary care. Comparative quality data for individual health plans has been made public since 2014.19 While the published data relate to the health plans at the national level, the plans also maintain internal data on regions, clinics, and individual physicians.20 Plans monitor the care provided by their GPs and work closely with them to improve quality.21
The Ministry of Health publishes comparative, hospital-specific quality data. The number of quality indicators and of the types of services covered has been growing rapidly. Currently, explicit financial incentives for hospitals to improve quality exist only for timely care of hip fractures or stroke.
The Ministry of Health also has a well-developed system for monitoring the quality of care in nursing homes and mother-and-child clinics, and is sharing this performance information with the public. There is no parallel system for home care services.
Practice guidelines exist for some clinical areas. These have been developed by professional medical associations, often in collaboration with the Ministry of Health.
All Israeli general hospitals are required to have received, or to be working toward, accreditation by Joint Commission International. As of June 2018, almost all of the general hospitals were accredited.
An independent research institute carries out biannual surveys of the general population regarding the service level provided by NHI health plans and the level of satisfaction with the health system. The Ministry of Health recently launched an annual survey of hospitalized patients, publishing results for individual hospitals.
National registries are maintained by the Ministry of Health for certain expensive medical devices and for a broad range of diseases and conditions, including cancer, low birth weight, trauma, and occupational diseases.
Government at both the national and the regional level is responsible for upholding quality and for ensuring that services included in the list of essential benefits are provided and that waiting times are monitored. Quality-improvement goals are usually set out in “Pacts for Health” (Patto per la salute) between the regions and the central government that link additional resources to the achievement of goals.
The Ministry of Health’s 2015 decree concerning the reorganization of hospital care introduced, for a few procedures, minimum levels of activity and quality thresholds. Many of the law’s provisions are in the process of being implemented, and the effects have not yet been evaluated. In addition, several regions have introduced programs for prioritizing the delivery of care on the basis of patient severity and clinical appropriateness of services prescribed.11
All health care professionals under contract with the National Health Service must be certified by the central or a regional government, and all SSN staff must participate in compulsory continuing education (150 continuing medical education (CME) credits every three years). The National Commission for Accreditation and Quality of Care is responsible for outlining the criteria used to determine which providers are allowed to provide care on behalf of the SSN and for evaluating regional accreditation models (including private hospitals), which vary considerably across the system.
SSN accreditation hinges on extensive quality criteria, including the appropriateness and timeliness of interventions, health status, and patient satisfaction. It also encompasses management of human and technical resources, consistency of the provider’s activity with regional health planning, and an evaluation of the activities conducted and results achieved. Regions have the freedom to set their own accreditation criteria and procedures, as long as the LEA (essential benefits package), is guaranteed. At present, significant variability exists in regional accreditation policies.
National legislation requires all publicly contracted health care providers (hospitals) to issue a “health service chart” with information on service performance, quality indicators, waiting times, quality assurance strategies, and the process for patient complaints. These charts have also been adopted by the private sector for its accreditation process and must be published annually, although dissemination methods are decided regionally. Most providers disseminate these charts through leaflets and the Internet. Nurses and other medical staff are offered financial performance incentives (linked to manager evaluations but not to publicly reported data).
No national patient surveys exist; however, some regions carry out patient satisfaction surveys on a voluntary basis.
The only public reporting on outcomes is the National Outcomes Program, which calculates and reports yearly on a set of hospital outcomes, such as 30-day mortality rates for acute myocardial infarction and admissions for ambulatory care–sensitive conditions.
The National Plan for Clinical Guidelines, implemented in recent years, has produced guidelines on topics ranging from cardiology to cancer prevention and from the appropriate use of antibiotics to cesarean delivery.
Some regions have introduced disease management programs and are experimenting with chronic-care models. Some are maintaining registries, mainly for cancer and diabetes patients. No national registries exist.
At the national level, no public reporting exists on the performance of nursing homes or home care agencies.
By law, prefectures are responsible for making health care delivery “visions,” which include detailed service plans for treating cancer, stroke, acute myocardial infarction, diabetes mellitus, and psychiatric disease. These delivery visions also include plans for developing pediatric care, home care, emergency care, prenatal care, rural care, and disaster medicine. Structural, process, and outcome indicators are identified, as well as strategies for effective and high-quality delivery. Prefectures promote collaboration among providers to achieve these plans, with or without subsidies as financial incentives.
Prefectures are in charge of the annual inspection of hospitals. Penalties include reduced reimbursement rates if staffing per bed falls below a certain ratio. Hospital accreditation is voluntary. As of 2016, 26 percent of hospitals were accredited by the Japan Council for Quality Health Care, a nonprofit organization.28 The names of hospitals that fail the accreditation process are not disclosed.
Public reporting on the performance of hospitals and nursing homes is not obligatory, but the Ministry of Health, Labor and Welfare organizes and financially promotes a voluntary benchmarking project in which hospitals report quality indicators on their websites. National and local government facilitate mandatory third-party evaluations of welfare institutions, including nursing homes and group homes for people with dementia, to improve care.
To practice, physicians are required to obtain a license by passing a national exam. Although physicians are not subject to revalidation, specialist societies have introduced revalidation for qualified specialists. Some physician fees are paid on the condition that physicians have completed continuing medical education credits. Public reporting on physician performance is voluntary.
Every prefecture has a Medical Safety Support Center for handling complaints and promoting safety. Since 2004, advanced treatment hospitals have been required to report adverse events to the Japan Council for Quality Health Care. The council works to improve quality throughout the health system and develops clinical guidelines, although it does not have any regulatory power to penalize poorly performing providers.
The Japanese Medical Specialty Board, a physician-led nonprofit body, established a new framework for standards and requirements of medical specialty certification; it was implemented in 2018.
The government promotes the development of disease and medical device registries, mostly for research and development.
Surveys of inpatients’ and outpatients’ experiences are conducted and publicly reported every three years. Nonprofit organizations work toward public engagement and patient advocacy, and every prefecture establishes a health care council to discuss the local health care plan. Under the Medical Care Law, these councils must have members representing patients.
Private, statutory insurers are expected to engage in strategic purchasing, and contracted providers are expected to compete on both quality and cost. At the system level, quality is ensured through legislation governing professional performance, quality in health care institutions, patient rights, and health technologies.
The Dutch Health Care Inspectorate is responsible for monitoring quality and safety. In 2014, the National Health Care Institute was established to further accelerate the process of quality improvement and evidence-based practice. As part of the National Health Care Institute, the National Quality Institute promotes quality measurement and transparency. Most quality assurance is carried out by providers, sometimes in close cooperation with patient and consumer organizations and insurers. There are ongoing experiments with disease management and integrated care programs for the chronically ill.
In the past few years, many parties have been working on quality registries. Most prominent among these are several cancer registries and surgical and orthopedic (implant) registries.
Mechanisms to ensure the quality of care provided by individual professionals include:
- a government-based national registry certifying completion, every five years, of compulsory continuous medical education
- regular on-site peer assessments by professional bodies
- professional clinical guidelines, indicators, and peer review.
The main methods used to ensure quality in hospitals, nursing homes, and other health care institutions include:
- voluntary accreditation and certification granted by independent organizations
- compulsory and voluntary performance assessments based on indicators
- national quality-improvement programs.
Furthermore, quality of care is supposed to be enhanced by selective contracting. For example, insurers should contract only with providers that meet minimum standards for volumes of procedures performed.
Patient experiences are tracked primarily through the Commonwealth Fund’s regularly conducted international health policy surveys,33 but are otherwise not systematically assessed. Although progress has been made, public reporting on quality of care and provider performance is still in its infancy in the Netherlands. Patients may report individual experiences with health care providers and institutions in any sector to the website Zorgkaartnederland.nl on a voluntary basis. Furthermore, several websites provide comparative information about institutions and providers (including hospitals and nursing homes), based primarily on quality indicators obtained from the National Quality Institute and the Dutch Healthcare Inspectorate.
The Health and Disability Commissioner, which serves as a national patient advocate, investigates patients’ complaints, reports directly to New Zealand’s parliament, and has been active in promoting quality and patient safety. A culture of openness and transparency is supported by New Zealand’s no-fault medical malpractice laws and accident compensation system.
District health boards are held formally accountable to the government for delivering efficient, high-quality care in hospitals, as measured by the achievement of targets across a range of indicators. These include six health targets, published quarterly, that aim to stimulate competition among district health boards. In addition, district performance on waiting times, access to primary care, and mental health outcomes is publicly disclosed. Also publicly reported are performance data on primary health organizations, including screening rates for chronic disease. Data on individual doctors’ performance, however, are not routinely made available. As noted above, primary health organizations and GPs receive performance payments for achieving various targets. There are currently no publicly available data on nursing home or home care agency performance.
District health boards and individual GP clinics and networks run various chronic disease management programs. There are national registries for some diseases, including diabetes, cardiovascular disease, and cancer.
Since 2014, public hospitals have been required to conduct patient experience surveys of randomly selected patients. The Health Quality and Safety Commission publishes the findings.
Certification by the Ministry of Health is mandatory for hospitals, nursing homes, and assisted-living facilities. All practicing health professionals must be certified annually by the relevant registration authority (e.g., for doctors, the Medical Council of New Zealand), which has ongoing responsibility for ensuring professional standards and providing accreditation. Registration authorities supervise individual professionals where appropriate.
The Ministry of Health is also working on quality improvement in district health boards. Most boards have implemented clinical governance, which means that management and health professionals have assumed joint accountability for quality, patient safety, and financial performance.7
The Health Quality and Safety Commission aims to increase the focus on quality and to coordinate district health board activities, such as those aimed at improving the patient journey, managing medications more safely, reducing rates of health care–associated infection, and standardizing national incident reporting. Other initiatives include the following:
- The ongoing development of the Atlas of Healthcare Variation, an online tool aimed at highlighting variations in the provision and use of services by geographic area.
- A series of standard quality and safety indicators for district health boards based on routinely collected data.
- A program for consumer involvement in service design.
- Advice for district health boards on how to prepare annual “Quality Accounts,” required since 2012–2013; these Quality Accounts report on how a district health board approaches quality improvement, including descriptions of key initiatives and their results.
- A national patient safety campaign launched in 2013, called “Open for Better Care,” which is focused on reducing harm associated with falls, surgery, health care–associated infections, and medications. Since 2015, the campaign has collated routine data in an annual report aimed at providing a window on the quality of New Zealand health care.8
Lastly, New Zealand is a partner in the global Choosing Wisely initiative, aimed at reducing low-value and potentially harmful care.
The National Board of Health Supervision audits the different areas of the health system, both systematically across the nation and at individual organizations and professional practices. An alert system ensures that hospitals inform the board of serious adverse events, and the board may then decide to investigate particular incidents. The board can issue fines to institutions and warnings to health personnel and can revoke health care professionals’ authorization to practice in cases of misconduct. Local audits are performed by the county governors.
Accountability systems are changing. In 2017, regulation for “internal control for health services” was replaced with regulation for “leadership and quality improvement in the health services.” The change requires hospitals to undertake quality and safety improvement activities as well as to measure, and assume accountability for, performance.
National evidence-based guidelines, patient pathways, and bundles of care exist for several conditions, including stroke and cancer. Patient pathways are also being developed for mental health and addiction treatment. A five-year national safety program aims to improve patient safety, and a national reporting and learning system for adverse events in hospitals has been established.
Norway has 54 national clinical registries and 17 national health registries. Clinical registries, which are initiated by individuals, hospitals, or educational institutions, provide information for assessing the effects of treatments, including sometimes at the hospital ward level. They are used for quality assurance, research, and improvement activities. The national, statutory registries cover the entire population and, unlike the clinical registries, do not require patient consent (some are based on anonymous data). Since 2018, these registries and other health-related databases are the responsibility of the eHealth Directorate.
The Directorate of Health oversees a national program tracking health care quality indicators.14 The program includes results from national patient experience surveys, as well as such quality indicators as survival rates, infection rates, and wait times. No information is gathered or disseminated regarding the results or quality of individual health care professionals’ performance. Indicators for nursing homes are scarce and incomplete.
The Directorate of Health is also responsible for the licensing and authorizing of health care professionals. There is no system for reevaluation or reauthorization. The authority issues certificates of specialization to medical doctors in accordance with specific and transparent requirements. Only the specialization of GPs requires recertification.
RHAs, hospitals, municipal providers, and private practitioners are themselves responsible for ensuring the quality of their services. There is no requirement for accreditation or reaccreditation, although some hospitals or hospital departments are accredited.
A five-year developmental program for quality-based financing of RHAs, based on performance and improvement, ran from 2013 to 2017. This program measured 32 indicators, with patient experience constituting about 30 percent of metrics. Quality-based performance payments account for only about 0.5 percent of the RHAs’ budgets. A 2015 evaluation did not identify any disadvantages of this quality-based financing scheme, but did identify several areas for improvement.15 In 2016, the government decided to continue with quality-based financing at the current level.
The NIPH uses the Norwegian Prescription Database to produce annual reports on prescribing trends, giving national health authorities a statistical base for planning and monitoring drug prescriptions and use.
The Ministry of Health’s key legislative tool for regulating health care providers is the Private Hospitals and Medical Clinics Act. Health care facilities, such as hospitals, nursing homes, clinics, and clinical laboratories, are required to obtain a license before they can commence operations. They are also subject to regular compliance audits and relicensing.
Health care professionals are regulated by their respective professional boards, which are set up as statutory bodies under the Ministry of Health. In addition, hospitals are required to put in place a clinical privileging system that grants doctors the appropriate scope of practice commensurate with their areas of competence. There are also additional requirements for specific high-risk specialized procedures or services; doctors are required to apply for authorization before providing these procedures or services. Hospitals must establish quality assurance committees to monitor and evaluate the safety and quality of their practices, procedures, and services.
The ministry benchmarks the performance of Singapore’s system against international counterparts, and conducts annual patient experience surveys of public health care institutions. Some health care institutions have voluntarily undertaken external accreditations, such as those provided by the Joint Commission International.
Under the Chronic Disease Management Program, participating primary care clinics and medical institutions are expected to provide care in line with the latest clinical practice guidelines or best available evidence-based practice, as well as to track clinical data to monitor outcomes.48 Participation is a prerequisite for joining the Community Health Assist Scheme.49
Regions are responsible for ensuring that health care providers deliver services of high quality and adhere to national therapeutic guidelines. Providers are evaluated for meeting quality targets associated with a pay-for-performance scheme or accreditation requirements. They are also assessed based on information from patient registries and national quality registries, patient satisfaction surveys, and dialogue meetings between providers and regions.
Concern for patient safety has increased during the past decade. Patient safety indicators are compared regionally by SALAR, and the results are publicly disseminated in many cases. Eight priority target areas for preventing adverse events have been specified13:
- Health care–associated urinary tract infections
- Central line infections
- Surgical site infections
- Falls and fall injuries
- Pressure ulcers
- Medication errors in health care transitions
- Drug-related complications.
Disease management programs, developed at the regional level, also encompass quality and patient safety targets and strategies.
To reduce unnecessary variation in clinical practice, there has been a trend toward development of regional guidelines. For example, the National Cancer Strategy was established in 2009, and six Regional Cancer Centers (RCCs) were formed in 2011. The RCCs’ role is to contribute to more equitable, safe, and effective cancer care through regional and national collaboration.
More than 100 national quality registries are used for monitoring and evaluating quality among providers and for assessing treatment options and clinical practice. Registries store individualized data on diagnosis, treatment, and treatment outcomes in inpatient and outpatient care (including primary care) and nursing homes. The registries are funded by the central government and by the regions, are managed by specialist organizations, and are monitored annually by an executive committee.
Since 2006, the government has published annual performance comparisons and rankings of the regions’ health care services, using data from the national quality registers, the National Health Care Barometer Survey, the National Waiting Time Survey, and the National Patient Surveys. Performance comparisons for specialty care, primary care, nursing homes, and home care are publicly released. The 2015 publication included 350 indicators organized into various categories, such as prevention, patient satisfaction, wait times, trust, access, surgical treatment, and drug treatment. In addition, some 100 indicators for hospitals are tracked, but without rankings. Statistics on patient experience and wait times in primary care are also made available online by SALAR ( www.skl.se) to help guide people in their choice of provider.
Providers must be licensed to practice medicine and are required to meet educational and regulatory standards; continuing medical education for doctors is compulsory. The Swiss Institute for Continuing Medical Education is responsible for accreditation.
Professional self-regulation has been the traditional approach to quality improvement. This is increasingly being challenged. Local quality initiatives, often at the provider level, include the development of clinical pathways, medical peer groups, and consensus guidelines. However, there are no explicit financial incentives for providers to meet quality targets.
Increasing the quality of care is a priority of the federal Health2020 initiative. The strategy includes the implementation of a national network for quality and national quality programs in fields like medication safety and hospital infections.21
In 2008, the Swiss Inpatient Quality Indicators were introduced to monitor and evaluate the quality of care provided by acute-care hospitals. In addition, the National Association for Quality Improvement in Hospitals and Clinics publishes quality indicators for hospital inpatient care based on registries or patient satisfaction surveys. Some registries are the result of private initiatives; others, such as the cantonal cancer registries, are organized by the cantons. There are currently no publicly available data regarding physician or nursing home performance.
Since the association Smarter Medicine – Choosing Wisely Switzerland was founded in 2017, several medical societies have published top-five lists of treatments that are unnecessary and should therefore no longer be performed or reimbursed.
Major NHIA strategies to ensure quality of care fall into three broad categories:
Payment incentives. A number of programs aim to improve access and quality, such as the pay-for-performance schemes. Since 2001, pay-for-performance programs have been implemented for 12 diseases and conditions including cervical cancer, tuberculosis, diabetes, asthma, schizophrenia, early-stage chronic kidney disease, and maternity care. Care teams consisting of nurses, dieticians, and other nonphysician clinicians provide integrated and coordinated care to improve quality and outcomes.
The program is reaching many of Taiwan’s people. For instance, as of 2017, 68 percent of schizophrenia patients are cared for under the pay-for-performance plan.28
The annual budgeting process is also incentivized. Taiwan has five sectoral global budgets, for dentistry, Chinese medicine, primary care clinics, hospitals, and dialysis. Each July, the NHI Committee meets with scholars and experts to review and grade the performance of each sectoral global budget in terms of service delivery, quality, public satisfaction, appropriate use of resources, and other criteria. There are five grades: “exceptional,” “excellent,” “good,” “fair,” and “bad.” (A “bad” grade has never been assigned.)
The annual increase for each sectoral global budget is based on the grade received: a 0.5 percent increase for “exceptional,” 0.3 percent for “excellent,” and so on.
Claims management and reviews: Taiwan has a fully automated claims review system to ensure that claims meet specific medical appropriateness criteria. In addition, randomly selected claims are peer-reviewed for consistency in billing and for the clinical appropriateness of treatments.
Information-sharing and transparency: Since 2005, the NHIA has publicly reported provider performance data on specific quality and cost metrics, including registration fees charged, health care services provided, and the quality of services (including hospital-acquired infection rates) to facilitate patient decision-making on where to seek care.
The NHIA has developed several hundred quality indicators, some of which are used in pay-for-performance programs, some for calculating global budgets, and others for public transparency efforts and claims review.29 Many of these metrics serve the dual purpose of improving quality and reducing costs.
Other important national programs for quality assurance and improvement include:
- The Post-Acute Care Pilot Project for stroke patients
- The Integrated Post-Acute Care program for burn patients
- The Artificial Joints Registry System, which was launched in 2016 to improve patient safety and quality of care and reduce mortality from unsafe artificial joints.
The ACA required the U.S. Department of Health and Human Services to establish a National Quality Strategy,32 a set of national aims and priorities to guide local, state, and national quality improvement efforts, supported by partnerships with public and private stakeholders. The strategy includes annual reporting on a selected set of quality measures.33
Since 2003, the Agency for Healthcare Research and Quality has published the annual National Healthcare Quality and Disparities Report, which reports on national progress in health care quality improvement. The 2018 report found that the quality of U.S. health care had improved overall from 2000 to 2016, but that improvement was inconsistent. For example, while most person-centered care and patient-safety measures improved, affordability did not.34
Federal law requires certain providers to report data on the quality of their care, and the Centers for Medicare and Medicaid Services to publicly report performance on quality measures. For example, Hospital Compare is an online public resource summarizing the performance of more than 4,000 hospitals on measures of care processes, care outcomes, and patient experiences. Related quality-reporting programs include Nursing Home Compare and Physician Compare.
The Healthcare Effectiveness Data and Information Set is one of the most widely used tools for rating provider quality. It is used by health plans to rate provider quality. The set includes rates of cancer screenings, medication management for chronic conditions, follow-up visits, and other metrics. The nonprofit National Quality Forum builds consensus on national performance measurement and priorities, including the submission of recommendations for measures to be used in Medicare.