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.
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.
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.
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.
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. 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. 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.
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.
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.
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.
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. 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.
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. 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. Plans monitor the care provided by their GPs and work closely with them to improve quality.
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.
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.
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 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.
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.
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.
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.
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.
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 ACA required the U.S. Department of Health and Human Services to establish a National Quality Strategy, 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.