Handbook for national quality policy and strategy: a practical approach for developing policy and strategy to improve quality of care

HANDBOOK FOR NATIONAL QUALITY POLICY AND STRATEGY A practical approach for developing policy and strategy to improve quality of care HANDBOOK FOR NATIONAL QUALITY POLICY AND STRATEGY A practical approach for developing policy and strategy to improve quality of care Co-developed by the World Health Organization and countries pursuing national quality initiatives Handbook for national quality policy and strategy: a practical approach for developing policy and strategy to improve quality of care ISBN 978-92-4-156556-1 © World Health Organization 2018 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc- sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation. Handbook for national quality policy and strategy: a practical approach for developing policy and strategy to improve quality of care. Geneva: World Health Organization; 2018. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/ about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Designed by CommonSense, Greece Printed by the WHO Document Production Services, Geneva, Switzerland 3 CONTENTS Foreword ................................................................................................................... 5 Acknowledgements .................................................................................................... 6 Abbreviations ............................................................................................................ 7 INTRODUCTION .......................................................................................................9 What is a national quality policy and strategy? ...........................................................10 Importance and integration of policy and strategy ......................................................11 Making the case for quality ........................................................................................12 Defining the concept of quality .................................................................................13 A culture of quality ...................................................................................................14 Quality across the health system ...............................................................................15 NQPS within the context of universal health coverage and the SDGs ..........................16 Handbook for national quality policy and strategy .....................................................17 NQPS initiative .........................................................................................................18 PART I. POLICY DEVELOPMENT ............................................................................ 19 Development of a national quality policy ................................................................ 21 1. National health goals and priorities ...................................................................... 21 2. Local definition of quality..................................................................................... 23 3. Stakeholder mapping and engagement .................................................................. 24 4. Situational analysis: state of quality ......................................................................25 5. Governance and organizational structure for quality .............................................. 26 6. Improvement methods and interventions ............................................................... 28 7. Health management information systems and data systems ................................... 30 8. Quality indicators and core measures .................................................................... 30 PART II. STRATEGY DEVELOPMENT ...................................................................... 32 Development of a national quality strategy ............................................................. 34 1. National health goals and priorities ...................................................................... 34 2. Local definition of quality..................................................................................... 36 3. Stakeholder mapping and engagement .................................................................. 37 4. Situational analysis: state of quality ..................................................................... 40 5. Governance and organizational structure for quality .............................................. 42 6. Improvement methods and interventions ................................................................45 7. Health management information systems and data systems ................................... 52 8. Quality indicators and core measures .................................................................... 55 Developing an operational plan for implementation ................................................. 58 Overview and rationale ............................................................................................ 58 When and how should the operational plan be developed? ........................................ 58 What elements should the operational plan include? ................................................. 58 Integrating technical programmes with NQPS .......................................................... 59 4 PART III. TOOLS AND RESOURCES ...................................................................... 61 Background ............................................................................................................. 62 Finding, selecting and using tools to support the NQPS process ................................. 62 Tools and resources compendium ............................................................................. 64 Glossary .............................................................................................................66 References ..........................................................................................................70 Boxes Box 1. Policy and strategy informed by implementation ......................................................11 Box 2. Defining quality health care .....................................................................................13 Box 3. Culture of quality: key features ................................................................................14 Box 4. Water, sanitation and hygiene: a critical foundation for quality across health systems ...16 Box 5. Goals and priorities ................................................................................................ 22 Box 6. Health security and quality: closely linked priorities ................................................. 22 Box 7. Illustrative list of potential stakeholders ................................................................. 25 Box 8. Health care quality: roles and responsibilities of selected stakeholders ..................... 27 Box 9. Basic elements essential for systemwide quality ...................................................... 29 Box 10. Variations in national quality strategies................................................................. 35 Box 11. Case study: defining quality in Sudan .................................................................... 36 Box 12. Community and patient engagement: the Ugandan experience .............................. 39 Box 13. External evaluation, licensing and certification ...................................................... 46 Box 14. Applying the Juran Trilogy to guide selection of interventions ................................ 47 Box 15. Sample key questions to assess current data sources ............................................. 52 Box 16. Potential sources of quality measurement available in many countries ................... 53 Box 17. Ten criteria for assessing quality indicators for a core set ....................................... 56 Box 18. Potential sources of tools and resources ............................................................... 62 Figures Figure 1. Shift from linear models to implementation-informed policy and strategy development .................................................................................................................... 12 Figure 2. Sample organigram for national quality efforts .................................................... 43 Figure 3. Illustrative activities across five levels of hierarchy ............................................... 50 Figure 4. Framework of interventions at each level of hierarchy: Mexico ............................. 51 Figure 5. Tools and resources: sources and relevance to the NQPS process ......................... 65 Tables Table 1. Framing the dimensions of quality ........................................................................ 23 Table 2. Stakeholders and related tasks ............................................................................. 38 Table 3. Illustrative quality interventions .......................................................................... 48 5 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y FOREWORD The Sustainable Development Goals place a clear emphasis on achieving universal health coverage, which means “ensuring that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship”. The WHO Framework on Integrated People-centred Health Services presents a vision for the future in which “all people have access to health services that are provided in a way that responds to their preferences, are coordinated around their needs and are safe, effective, timely, efficient and of an acceptable quality”. The proposed action within the WHO Framework places a clear emphasis on policy levers to enhance quality. The development, refinement and execution of a national quality policy and strategy is a priority for countries as they strive to improve the performance of their health care systems. With the growing momentum towards universal health coverage, there is a corresponding awareness that improved access must be accompanied by focused efforts to improve the quality of health services to achieve the desired improvements in health outcomes. Countries are seeking advice to inform their efforts on national quality policy and strategy. They are taking diverse approaches with multiple entry points for improving quality, and many are also looking to the subnational level as a focus for action. However, the objective remains the same: improvement in quality of health care as a pivotal entry point for health systems strengthening, and ultimately achieving enhanced population health. In recognition of this critical need, the WHO initiative on national quality policy and strategy has four objectives: (a) to raise awareness, knowledge and skills concerning national quality policy and strategy in low- and middle-income countries; (b) to outline key processes for the planning, development and implementation of national quality policy and strategy; (c) to provide support to countries in this arena; and (d) to continue co-development and documentation of processes related to the development and implementation of national quality policies and strategies within a learning laboratory arrangement. This document provides a foundation for this initiative, building on an existing body of work from WHO and others. It provides structure around the subject area, outlines some of the key issues for consideration and presents a starting point for the action that needs to follow. It will continue to be refined through a co-development process involving countries and technical partners, which will also yield a number of complementary resources. This handbook is one output of a larger initiative that seeks to respond to the needs of countries for strategic and practical counsel around national quality policies and strategies. The linkages with wider health policy and planning are central to this approach. The audience for this foundation document is diverse. The primary audience is those responsible for leading the development and implementation of national quality policies and strategies. A much wider set of stakeholders who actively participate in the national process will benefit. Partners at the national, regional and global level that are involved in providing support in quality improvement efforts will also stand to benefit from the content provided. Each country must pursue its own pathway to universal health coverage guided by multiple and complex considerations. A carefully designed national approach to quality can be a pivotal entry point for countries as they work to achieve better health outcomes. 6 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y ACKNOWLEDGEMENTS The WHO Handbook for national quality policy and strategy was produced under the overall direction of Edward Kelley and Shams Syed from the Service Delivery and Safety Department, WHO headquarters, Geneva. The principal writing team consisted of Sheila Leatherman, Shams Syed, Ruben Frescas and Matthew Neilson. Sheila Leatherman provided substantial content to the handbook, given her role as lead adviser to the WHO initiative on national quality policy and strategy. Previous research and publications of Sheila Leatherman and co-authors have contributed throughout all sections of the handbook. Previous work of WHO related to quality and patient safety policy and strategy, both at WHO headquarters and in the WHO regions, has contributed significantly in shaping the handbook. Preparation of the handbook was informed by country examples of development of national quality policy and strategy, many of which are featured in the text. We would like in particular to acknowledge the contribution of a number of countries to the emerging body of knowledge captured in the handbook – Colombia, Ethiopia, Ghana, Indonesia, Liberia, Malawi, Mexico and Sudan. We would also like to acknowledge the work of a range of technical partners, including the International Society for Quality in Health Care, the Institute for Healthcare Improvement, the USAID Applying Science to Strengthen and Improve Systems Project (ASSIST), and HealthQual, which has influenced the field and informed this work. We acknowledge Bruce Agins and Josh Bardfield for their contribution to the section on integrating technical programmes with national quality policy and strategy; Lisa Hirschhorn and Sun Mean Kim for their assistance in the sections on health management information systems, data and measurement; Liana Rosenkrantz Woskie, Anthony Moccia and Ruma Rajbhandari for their work on quality interventions; and Julie Storr, Lopa Basu, Nana Mensah Abrampah, Rhea Bright, Breda Cosgrove and Laura Simpson for review of the handbook. Valuable inputs in the form of contributions, peer reviews and suggestions were provided by Kehinde Balogun, Stephen Balogun, Pierre Barker, Jeffrey Braithwaite, Lucky Chikaura, Susan Davis, Paulina Pacheco Estrello, Raghavendra Guru, Maki Kajiwara, Pierre Claver Kariyo, Manuel Kassaye Sibhatu, Samuel Kidane, Jason Leitch, Garth Manning, Rashad Massoud, Mohamed A. Mohamed, Margaret Montgomery, Zainab Naimy, Edgar Necochea, Wendy Nicklin, Robbie Pearson, Charles Shaw, Sylvia Sax, Sodzi Sodzi-Tettey, David Weakliam and Albert Wu. A first working draft of the handbook was peer-reviewed at a meeting in Geneva, Switzerland, in June 2017 with the following country participants: Hind Babekir Hassan Abdallatif, Philip Kerkula Bemah, Daniel Gebremichael Burssa, Andrew Likaka, German Escobar Morales, Benjamin Nyakutsey, Sebastian Garcia Saisό and Eka Viora. Also attending were the following WHO country and regional experts: Salma Burton, Nino Dal Dayanghirang, Jonas Gonseth-Garcia, Mondher Letaief and Juan Eduardo Tello. The meeting was also attended by the following WHO experts from headquarters: Benedetta Allegranzi, Giorgio Cometto, Neelam Dhingra-Kumar, Bruce Gordon, Ann-Lise Guisett, Heather Harmon, Lauren Hoisl, Dirk Horemans, Sun Mean Kim, Blerta Maliqi, Asiya Odugleh-Kolev, Archana Shah and Satvinder (Vindi) Singh. The development of the document was kindly supported by the Japanese Ministry of Health, Labour and Welfare through a contribution to the World Health Organization. 7 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y ABBREVIATIONS GLL Global Learning Laboratory for Quality Universal Health Coverage HMIS health management information system MDG Millennium Development Goal NQPS national quality policy and strategy OECD Organisation for Economic Co-operation and Development SDG Sustainable Development Goal WASH water, sanitation and hygiene WHO World Health Organization 8 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y The handbook at a glance What is this document? A handbook outlining the case for developing national policy and strategy on quality of health care, the process required to do so, and supporting tools Policy Strategy The policy is based upon an agreed ambition with explicit statement of intention, and becomes the agreed “course of action”. This section describes how to develop a national quality policy, either as a stand-alone document or as part of wider national health policy. The strategy provides a clear roadmap and outlines “how” the policy will come to fruition. Many aspects of the strategy process will take place simultaneously with policy development. This section outlines a structured, multistakeholder, data-driven process. Tools A number of further tools and resources can support the NQPS process. This section describes how to access and select such tools, and introduces an accompanying compendium of tools available on the WHO Global Learning Laboratory for Quality UHC. Operational planning National health priorities Situational analysis Stakeholder mapping & engagement Governance and organizational structure Improvement methods & interventions Quality indicators & core measures Health management information systems & data systems Strategy implementation can be outlined in a detailed operational plan, which defines key tasks, assigns responsibilities, identifies milestones, and considers practical aspects of implementation, such as funding. Integrating technical programmes Countries often have existing quality initiatives focused around specific technical areas (such as HIV or water, sanitation and hygiene) or population groups (such as mothers and children). Successfully integrating these efforts with overarching work on national quality necessitates careful planning. Who is it for? Authorities developing national policies and strategies on quality, stakeholders involved in the process, and external partners supporting ministries of health How should it be used? As a structured approach to support development of national quality policy and strategy, to complement existing national expertise and external support Universal health coverage means all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship. Many countries are making efforts to improve quality of care and institutionalize a culture of quality across their health system. These efforts can be strengthened through the development ofNational Quality Policy and Strategy (NQPS). This handbook provides an overview of eight key elements required to produce such policy and strategy documents, and is presented in three main sections: policy, strategy and tools. Ministry Ministry Ministry Th e ei gh t el em en ts o f N Q PS Government Local definition of quality Committee INTRODUCTION 10 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y Section overview • What is a national quality policy and strategy (NQPS)? • Importance and integration of policy and strategy • Making the case for quality • Defining the concept of quality • A culture of quality • Quality across the health system • NQPS within the context of universal health coverage and the SDGs • How to use this resource Each country is motivated to address the issue of health care quality for various reasons. These include a belief in and commitment to quality health care as a public good; growing awareness of gaps in safe, effective and person-centred care; a drive towards universal health coverage and the understanding that improvements in access without appropriate attention to quality will not lead to the desired population health outcomes; cost pressures and a push for greater efficiency and value for money across the health system; growing recognition of the need to align the performance of public and private health care delivery in fragmented and mixed health markets; an increasing understanding of the critical importance of trusted services for effective preparedness for outbreaks or other complex emergencies; and finally, expectations from the public, media and civil society with a growing public demand for transparency and accountability. Though reasons for national efforts on quality may vary, countries will encounter common issues as they develop or refine their quality-related policies and strategies, and the basic tasks are similar. While it is clear that the ability of countries to provide quality care will be affected by available resources, national efforts to improve quality of care must not be seen as solely the concern of high-income countries or as an issue only to be addressed when access has been expanded. Each domain of quality has clear relevance to any health care system, and while different countries may have the resources to address each to a different degree, there will almost always be a number of low-resource starting points for action. Indeed, as a focus on quality promotes more efficient, effective and integrated services that respond to population need, national efforts to improve quality of care can themselves help any health system to increase the value for money it provides. What is a national quality policy and strategy? A national quality policy and strategy (NQPS) is an organized effort by a country to promote and plan for improved quality of care. It will often be outlined in a document, providing an official, explicit statement of the approach and actions required to enhance the quality of health care across a country’s health system, and needs to be linked closely with the wider national health policy and planning process. Responsibility for the development of such documents is commonly held by the ministry of health, working in close collaboration with a range of policy- makers and implementers. Experiences from countries with national quality policies and strategies have highlighted the benefits of one coherent plan that provides guidance and direction on quality at all levels of the system. However, quality-related policies exist within the context of wider national governance arrangements. The NQPS can help clarify the linkages with national health – and non-health – policies, plans and priorities, highlight the importance of quality-focused processes in realizing overall health priorities, and define lines of accountability to work towards more people-centred health services. 11 I N T R O D U C T I O N Importance and integration of policy and strategy Many countries choose to focus on a national quality strategy; however, there is benefit in also elaborating a national quality policy that secures political buy-in, helps drive the strategy and its implementation, and places national quality efforts within the wider policy environment. While there may be significant overlap in the development process and content, there is a clear distinction between the two: the policy is based upon an agreed ambition with explicit statement of intention and becomes the agreed “course of action”. It may make the case for action and outline broad priorities to be addressed. The strategy provides a clear roadmap and outlines “how” the policy will come to fruition, and may be refined during the longer term of the policy. The “quality strategy” is a bridge that helps a health system accelerate achievement of health goals and priorities, using quality management principles that incorporate quality planning, control and improvement. While this document outlines a process of simultaneous development of policy and strategy, country needs may drive a focus on either policy or strategy. Irrespective, it is important to consider both when making an informed decision. The policy and strategy should of course be thought of in an integrated manner: commonly just one document or, in some cases, complementary and co-dependent documents developed as part of a systemwide effort to improve quality of care. Indeed, it is entirely reasonable to also consider whether the most appropriate mechanism for development and publication of national quality policy, strategy, or both is as part of broader integrated national health planning. There are benefits and disadvantages of both approaches. For example, while integration of quality efforts within national health policy and strategy may bring benefits such as increased political buy-in, integrated implementation efforts, and opportunity for systemwide consideration of quality, stand-alone documents may allow for greater detail, higher profile of quality, and use of different planning and implementation timescales. Whichever approach is used, care should be taken to ensure development of the NQPS is aligned with broader national health planning, whether by fully integrating the development and publication processes or simply aligning the goals, priorities and actions and cross-referencing documents. Policy and strategy may have a particular focus on health care services that are publicly funded or provided, though consideration should be given to how they can impact the full health care system. Working across the full continuum of care, the national direction on quality needs to also include the private sector, including faith-based organizations, and there may be key roles for cross-sectoral organizations such as professional bodies, local governments and academia. Box 1. Policy and strategy informed by implementation Traditionally, policy, strategy and implementation are thought of as a linear process. However, moving to a triangular process (see Figure 1) where implementation experience drives policy and strategy development can build a sense of ownership among those implementing and ensure products are grounded in the realities of service delivery and patient and community experience. In practice, implementation-informed policy and strategy development requires sustained and meaningful engagement with stakeholders across the health system throughout the process, recognizing there need not be an inherent dichotomy between “top-down” and “bottom-up” approaches to improve quality. 12 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y Making the case for quality The process of developing and implementing national policy and strategy on quality of care can itself be a key mechanism for advocating improvements in quality of care, as it can engage and secure buy-in from key stakeholders (notably at national government level), bring the issue to public and professional prominence, and provide an opportunity to demonstrate the value to the health system of such initiatives. However, even to arrive at the point of securing adequate support to start developing national policies and strategies may require intensive efforts. In a resource-constrained environment with competing health priorities, advocacy for a focus on a particular issue can be challenging. Initial steps to lay the groundwork for a national effort on quality may include: • identifying and engaging key decision-makers and policy influencers; • demonstrating potential for impact, for example through evidence, or sharing of case examples from other countries; • involvement of external advocates such as technical agencies and academia; • building support among health care staff and the public, for example through engagement of media, small-scale capacity-building in quality improvement, promoting sharing of learning and generation of evidence, and mobilization of civil society; • securing seed funding for initial efforts to enhance quality, for example from donor agencies or professional bodies, to allow momentum to be built and encourage domestic investment; • seeking opportunities to influence broader health system planning to incorporate a focus on quality, for example during development of national health strategic plans or national health budgeting. It is also important to recognize that most countries will have existing relevant initiatives that can be built upon, and which may help to catalyse a broader initiative on NQPS. Examples of common entry points include existing technical programmes such as HIV or maternal and child health, external evaluation programmes such as accreditation, and subnational or facility-level quality improvement initiatives. Figure 1. Shift from linear models to implementation-informed policy and strategy development 13 I N T R O D U C T I O N Defining the concept of quality To date, there is no single universally accepted definition of “quality”, though there is a commonly shared understanding of basic concepts and defining dimensions (1). Within the global health community, the definition below from the United States Institute of Medicine has been widely used. It establishes the basic goal of positively impacting health outcomes at both the individual and population levels, and emphasizes the central importance of evidence and professional knowledge. By the definition, quality is: The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (2). In addition, the Institute of Medicine lays out six general dimensions, or aims, of quality by stating that care should be safe, effective, patient-centred, timely, efficient, and equitable. This set of dimensions or attributes has also been adopted and adapted in countries outside the United States of America (2). In 2006, the World Health Organization (WHO) similarly defined the basic concepts of quality in stating that care should be effective, efficient, accessible, acceptable, patient-centred, equitable, and safe. Significantly, this definition introduced the dimension of “accessible” as a broader aim than just “timely” (1). Over the last decade the Organisation for Economic Co-operation and Development (OECD) has chosen to highlight three dimensions of quality – effectiveness, safety and patient-centredness – thus bringing domains together. This more concise conceptualization has also influenced thinking in a number of countries (3). More recently, the WHO Framework on Integrated People-centred Health Services has described “high quality care” as “care that is safe, effective, people-centred, timely, efficient, equitable and integrated”. And of course, access to health services underpins all quality efforts, especially in the era of universal health coverage and the drive for equitable population coverage and financial protection. Notably, patient safety has long been seen as an entry point for efforts to improve quality of care, and safe care can be seen as a barometer of the success of basic systems to improve quality. Box 2 summarises a selection of the main components of definitions of quality health care. Box 2. Defining quality health care Quality health care can be defined in many ways but there is growing acknowledgement that quality health services across the world should be: • Effective: providing evidence-based health care services to those who need them. • Safe: avoiding harm to people for whom the care is intended. • People-centred: providing care that responds to individual preferences, needs and values. In addition, in order to realize the benefits of quality health care, health services must be: • Timely: reducing waiting times and sometimes harmful delays for both those who receive and those who give care. • Equitable: providing care that does not vary in quality on account of age, sex, gender, race, ethnicity, geographical location, religion, socioeconomic status, linguistic or political affiliation. • Integrated: providing care that is coordinated across levels and providers and makes available the full range of health services throughout the life course. • Efficient: maximizing the benefit of available resources and avoiding waste. 14 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y Although there is significant convergence now on what the essential dimensions of quality are within the health sector, each country will probably have its own local understanding or definition of quality. The process of defining quality through stakeholder engagement and consensus building is crucial in establishing a shared intention and understanding for the national approach to quality. Recognizing the importance of contextualizing quality is critical, as it will help to further guide the focus and creation of a quality policy and accompanying strategy that responds to local needs. A culture of quality When planning a national effort to improve quality of care, it is useful to consider the importance of developing and institutionalizing a “culture of quality” in organizations and across the health system as a means to sustainable and meaningful change. There is no single definition of what a culture of quality entails, but it has been described as “an organization which creates a working environment which is open and participative, where ideas and good practices are shared, where education and research are valued and where blame is used exceptionally” (4). It is generally understood to mean that, at all levels of a health system, there is an inherent and explicit recognition of the value of efforts to improve the quality of care provided, and such efforts are systematically promoted within an enabling environment that encourages engagement, dialogue, openness and accountability. Some of the features of a health system with an embedded culture of quality are outlined in Box 3. However, culture within organizations and health systems is set and maintained by a complex set of factors, including prevailing wider cultural norms, community expectations, health system leadership, health system structures and networks, and the medico-legal environment. Understandably, effecting change within such cultures may therefore be a slow and challenging process, and may be opposed by those threatened by cultural change. There is a key role for political and health system leadership in defining and promoting a culture of quality, refining the legal environment, and leading by example to embed the required values throughout the system. Stakeholder engagement and situational analysis, as described in more detail in Parts I and II, can be used to help understand the current culture within the system and identify barriers and facilitators for cultural change. Indeed, the whole process of developing and implementing an NQPS can support broader cultural change across the health system, providing an explicit statement of the desired culture and a set of actions that can aid its institutionalization. Box 3. Culture of quality: key features • Leadership for quality at all levels • Openness and transparency • Emphasis on teamwork • Accountability at all levels • Learning embedded in system • Active feedback loops for improvement • Meaningful staff, service user and community engagement • Empowering individuals while recognizing complex systems • Alignment of professional and organizational values • Fostering pride in care • Valuing compassionate care • Coherence of quality efforts with service organization and planning 15 I N T R O D U C T I O N When discussing the intended culture to be supported by the NQPS, it may be worth considering the desired balance between a “no blame” and a “just” culture (5, 6). A “no blame” culture recognizes that errors inevitably occur within a health care system, often due to multiple factors and system failures, and that a response that seeks only to blame the well intentioned will not adequately address system deficiencies. In order to continually identify and address system errors, a “just” culture attempts to promote a safe environment for quality improvement by encouraging identification and correction of systemic failures while still acknowledging personal accountability (7). Personal accountability may be seen to discourage careless or deficient practice, but may also encourage clinicians to practice defensively or fail to report mistakes. These concepts are of course not mutually exclusive; instead, policy-makers should be aware of the impact that differences in culture can have on quality of care across a health system. There are also important considerations for policy and strategy development around how the culture of teams responsible for implementation across the health system can impact its success. Delivering reforms to health care provision that are inclusive, equitable, and promote a culture of improvement requires that clinical and managerial teams responsible for implementation reflect these principles in their own approach and values. Health care systems exist to serve the population, so it is critical that people are at the heart of efforts to institutionalize a culture of quality. Such a culture must embrace and enable meaningful engagement of the communities served by the system, and the system must be fit for purpose to perform this engagement. For example, involving patients, families and communities in the planning, management, delivery and evaluation of health services helps ensure that priorities reflect what matters to them, and introduces a new level of accountability for quality care. Hence, investment in the structures and skills required for engagement can be a powerful means to set and institutionalize a culture of quality within a health system. Quality across the health system While quality of care is predominantly expressed at the level of the interaction between the provider and receiver, it takes place within a much broader, complex health system, and this context should be considered by those planning national efforts to improve quality of care. The WHO health system building blocks (8) are often used by countries to examine the interface of national quality efforts with different parts of the health system within their specific context. This can help to ensure that some of the basic structures and processes that will underpin the policy and strategy are in place, and that their influence on delivery of quality care is accounted for. For example, service delivery in many countries may still be based on traditional hierarchical provider–patient relationships. Reorienting care around the needs, preferences and engagement of the people served by health providers can be a powerful step to institutionalize quality of care. High turnover of the health workforce may provide a challenge to maintenance of institutional quality structures and knowledge, and may itself result from working environments that are not conducive to quality care. Adherence to evidence-based quality standards requires reliable access to essential medicines and commodities; endeavours to enhance quality of service provision thus require examination of supply chains and quality of medicines. Applying a quality lens to health financing reforms can help ensure that in expanding access to services other domains of quality, such as equity and efficiency of service provision, are not compromised. Leadership and governance is critical to the success of NQPS. To avoid such efforts becoming a vertical, stand-alone initiative, strong support for quality is required among existing health system leadership at all levels, which may be aided by building quality improvement capacity among leaders themselves. Alignment between quality policy and strategy and wider health governance is – as stated previously – of paramount importance. 16 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y Box 4. Water, sanitation and hygiene: a critical foundation for quality across health systems Multiple cross-cutting entry points require careful attention when linking quality to health systems. For example, water, sanitation and hygiene (WASH) in health care facilities is a fundamental aspect of strong, resilient health systems. This is especially true in low- and middle-income settings where WASH is often lacking and even absent. As a key component of safe and quality services, WASH improves not only health outcomes and the experience of care, but also staff morale and the efficiency of services. Improving WASH services can immediately address inequity, as such services are often lacking in the facilities serving the most vulnerable communities. For example, in Liberia, WASH in health care facilities is a key component of the national post-Ebola health systems strengthening and quality efforts, involving mentoring, supportive supervision, and monitoring alongside infrastructure improvements. This is critically linked to the core components of infection prevention and control, which are also being implemented in Liberia. Both WASH and infection prevention and control are required to ensure patient and health worker safety, and where their provision is insufficient, community trust in services is likely to be damaged. Given the fundamental role of these key health service capabilities in provision of safe, quality care, assessing and addressing them in the context of national directions on quality is an important step. NQPS within the context of universal health coverage and the SDGs The adoption of the Sustainable Development Goals (SDGs) (9) and the focus on universal health coverage (10, 11) provide a critical entry point for the activation of NQPS in low- and middle-income countries. SDG 3 – “ensure healthy lives and promote well-being for all at all ages” – will drive action at the local and global levels (9) Within this goal, target 3.8 highlights the importance of quality essential health care services. How this is achieved is of course complex, requiring multiple considerations and inputs. However, one important success factor is a governance structure for quality with clearly articulated policies and strategies. Progress towards universal health coverage can be driven by a move towards integrated people- centred health services that can respond effectively to the emerging and varied health challenges of the 21st century. A WHO framework on the subject was approved by all Member States at the World Health Assembly in 2016 (12, 13). One of the five strategic directions provides specific focus on the need to strengthen governance and accountability (12, 13). As part of this strategic direction, there needs to be a strong emphasis on the development of policies and strategies that enhance quality of service delivery at the point of care. This requires careful consideration of how national direction and structure can help support subnational and local services that populations engage with to meet their health care needs. Within the context of achieving the SDGs, the global universal health coverage movement is resulting in many countries considering not only their financial and provider payment structures but also their quality structures as a means of improving health outcomes while also reducing waste and redundancy, thus promoting more efficient use of effective services to meet health sector priorities (14). Indeed, among all countries, but particularly those facing significant resource limitations, there is an urgent need to develop processes and structures for quality that can best utilize the resources available and continuously seek to evaluate and improve upon practices and services provided. Universal health coverage: Ensuring that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship (10) TARGET 3.8 Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all (9). 17 I N T R O D U C T I O N Handbook for national quality policy and strategy This document aims to support the development of NQPS. In particular, it supports the efforts of countries to design, implement, refine and sustain their strategic approach to quality health service delivery. This handbook is not an extensive manual of all actions required to implement a national initiative on quality, but describes the elementary steps to develop NQPS as a foundation. A number of further resources on quality of care are available from WHO and other organizations. Who should use this resource? This handbook is designed to support governments and policy-makers (at the national, state, and provincial levels) who are considering whether and how to develop an NQPS or are currently in the process of developing one. It may also be helpful for technical advisers, donors and other stakeholders supporting governments in areas related to NQPS. While much of this handbook has been designed to support development of NQPS in low- and middle-income countries, which may face particular challenges to improving quality of care, the processes outlined are relevant to any national or subnational authority preparing or reviewing their national efforts on quality of care. How to use this resource This handbook and accompanying compendium of tools provides direction on both the development process and content of national quality policies and strategies, and will facilitate development or refinement of these policies and strategies by policy-makers and practitioners who best know their unique country complexities. Users should see this document as a resource to help inform and structure quality policies and strategies responsive to the specific country needs while building on the guidance from existing literature, lessons from the field and expert consultation. The handbook is not a prescriptive guide, but rather a structured approach that helps ensure that development and implementation are as comprehensive as possible. To help users identify and access information that they may require, the handbook is divided into three colour-coordinated parts, as follows. • Part I focuses on quality policy development. • Part II focuses on linked processes of strategy development. • Part III describes how to access and use supplementary tools to support the NQPS process. There is significant overlap between the processes outlined in parts I and II of the handbook. This is to allow for the fact that not all users of the handbook will be developing both policy and strategy. It is suggested that these sections are read together, so an appropriate process specific to the needs of the user can be developed. Accompanying this handbook is a supplementary document entitled Compendium of tools for national quality policy and strategy, which presents a number of tools developed to support the NQPS process. 18 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y How was this resource developed? The content of this handbook has been developed based on work supporting countries in the development and execution of NQPS, as well as a review of a sampling of over 20 existing quality strategies across low-, middle-, and high-income countries globally. As this field continues to evolve and grow, there will be an increasing need to further refine this document and to build on the cross-country exchange of knowledge and best practices. The work will continue to be informed by partnering with individual countries, WHO regions, and expert partners. NQPS initiative This handbook and compendium of tools forms one part of a wider WHO-led effort to support development of national policies and strategies on quality of care. Recognizing that countries are at different stages in the process of developing and implementing national initiatives to improve quality of care, the NQPS initiative focuses on three main activities, as outlined in the following paragraphs. 1. Co-development of technical resources This activity encompasses the handbook, compendium, and associated tools and resources to support development of national policies and strategies on quality of care. There is a focus on true co-development, recognizing the significant experience and expertise injected into resource development by country authorities that have planned, developed and imple- mented national quality policies and strategies. It is intended that the need for further re- sources will continue to be assessed, and that existing tools and resources will be continually refined based on the experience and needs of country authorities using them. 2. Catalysing national action through technical cooperation To supplement the information provided in the written resources, WHO is coordinating fo- cused technical support to countries at different stages of the policy and strategy develop- ment process. This support aims to build in-country capacity for effective development, im- plementation and monitoring of national quality policies and strategies, as well as allowing future resource development to be informed by country engagement. 3. Learning agenda A number of academic and technical organizations around the world are engaged in sup- porting national quality initiatives. The NQPS initiative aims to engage with these efforts to ensure maximum effectiveness and promote shared learning. NQPS is a key focus of a related WHO initiative, the Global Learning Laboratory (GLL) for Quality Universal Health Cover- age. The GLL links the experiences, expertise, passion and wisdom of people from across the globe, representing multiple disciplines, on important issues relating to quality in the context of universal health coverage. The focus is accelerated global learning informed by local action in recognition of the importance of connecting people to facilitate dynamic, multidi- rectional sharing of knowledge and practice. A focused community on NQPS within the GLL has been created to link up experiences, facilitate knowledge sharing between countries and provide tools and resources to support NQPS. An overview of the GLL is available at http:// www.who.int/servicedeliverysafety/areas/qhc/gll/en/. PART I POLICY DEVELOPMENT 20 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y Section overview: Part I. Policy development Development of a national quality policy: National health goals and priorities Local definition of quality Stakeholder mapping and engagement Situational analysis: state of quality Governance and organizational structure for quality Improvement methods and interventions Health management information systems and data systems Quality indicators and core measures This section focuses on important aspects of the policy development process, with steps to consider when drafting a national quality policy. The factors influencing each country in their policy development process and content will vary widely; thus this section focuses on commonalities. Subsequent sections will further discuss how this policy should be implemented through a more defined strategy and operational plan. How the national quality policy is developed, written and ratified should be decided by each country (or subnational authority) in accordance with their respective governmental structures and taking into consideration their unique context and population needs. In some countries enabling legislation will be needed, for example to establish new governmental or parastatal bodies or to establish new forms of mandatory action (for example, registration and licensing of health professionals) or to define new forms of regulation (provider licensing or accreditation). This may trigger the need for an explicit national quality policy document. In other situations, the implementation of a national quality policy or strategy may be part of the routine five-year health sector plan or an internal ministry of health policy document. In this instance, it would be important to engage early with the department and individuals responsible for this broader national health planning to design a process that incorporates the necessary aspects for quality policy. There are a number of different approaches, but the most common forms would be one or a combination of the following: • quality policy and strategy as part of the formal long-term health sector national policies and plans; • a quality policy document developed as a stand-alone national document, usually within a multistakeholder process and often led or supported by the ministry of health; • a national quality strategy with a detailed action agenda, including a section on essential policy issues; • a national quality statement drawing on existing relevant policies and national health documents; • a constitution or terms of reference for the responsible ministry of health department or national quality body, outlining agreed policy direction; • enabling legislation or regulatory statute to support the national efforts to improve quality of health care. Each of the above options for national quality policy requires similar development processes to ensure policy is responsive to local needs, achievable, and well governed. 21 P A R T I . P O L I C Y D E V E L O P M E N T To take forward policy development, it is important to define and understand the organizational structures of the process. As noted earlier, the ultimate responsibility for such policies usually falls under the ministry of health, but this should be tailored to each country’s ultimate designated governing body. The ministry of health may, however, delegate or establish a task force or committee to author the policy with relevant stakeholder contributions and review. There will probably be a need for relevant consultations to help with technical aspects of policy development on a wide range of issues. Consultation and vetting of the policy development through the help of experts looking critically at the document will be important not only to inform its development, but also to anticipate and help correct its weaknesses and flaws. This is an important process in the development of the policy, and it is recommended that it should undergo various rounds of review before a final version is drafted. These policies will deal with multiple health-related fields and disciplines, each of which may already have existing policies, legislation or technical documents (such as standards) that address certain factors within the quality policy domain. Thoroughly examining and integrating the existing policies, standards and laws where possible may help in the drafting process and may even strengthen other programmes through this process. Existing and relevant policies may be diverse, including, for example, standards in specific technical programmes (maternal and child health, HIV, tuberculosis, etc.) or regulations for health care facilities and requirements for professional licensing. Further discussion of how to integrate technical programmes is presented at the end of Part II of this document. Co-developing a national policy allows national health authorities to identify and maximize quality synergies in systems with limited capacity. Further, the policy-making process can be strengthened by ensuring a strong focus on implementation through involvement of those directly involved in health service delivery in a wide range of technical areas, including those with a focus on certain diseases or population groups. Once the policy has undergone both internal and external expert review in several iterations, it should undergo the formal ratification or approval process customary in the respective country to become an official policy. Steps can be taken proactively to ensure the political support required to enable the completed policy to be ratified. This policy, and the responsible structures outlined within it, should then have the authority to meet the intended goals and guide the development of strategy. However, as mentioned previously, development of both national quality policy and strategy often occur concurrently in an integrated process. Part II will discuss functional tasks to consider when developing a strategy for enacting the policy. DEVELOPMENT OF A NATIONAL QUALITY POLICY The following eight elements can be considered important in developing a national quality policy. These elements will also be reflected in the final policy document itself. This material is based on expert input, field experience and the background analysis conducted for the foundation of the NQPS project, including interviews and review of a sample of national policy and strategy documents examined to identify the common content areas and topics. Attention to these eight elements within the national quality policy also serves as the foundation for developing a national quality strategy, described in detail in Part II, on strategy development. 1. National health goals and priorities Most countries have national health goals and priorities (see Box 5) that help to direct resources to meet the most pressing demands of the population. Where these goals or priorities exist, the national quality policy should aim to align the quality agenda accordingly. It should also be understood that the development of goals and priorities for the quality policy – for example, the traditional focus on maternal and child health – does not mean that other areas not explicitly included are unimportant, but that the selected areas are of pressing concern within the national context. There should be a clear and continuous process to address additional priority areas and goals as necessary to meet the changing needs of the population. 22 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y Box 5. Goals and priorities There is a distinction between goals and priorities, although they are at times used inter- changeably. Goals are usually more general aspirations or targets that set the course for future activities. They should be clear and meet a particular need, and should also be time bound, with a means to assess progress and achievement. In the case of international goals, such as the SDGs and the previous Millennium Development Goals (MDGs), countries may ratify these but add specific country context and ambition. While there are no limits to the number of goals or aims that should be included in the document, most countries generally include a maximum of five goals across a specified period of time. Priorities help direct attention more specifically to a number of critical areas. These areas are usually identified through national health data (for example, on burden of disease), sentinel events, or national research, and may be long-term or emerging priorities (for example, based on anticipated or changing population, health threats, or political and economic environment). National health priorities can be widely defined to include priority clinical conditions (for example, multidrug resistant tuberculosis, cardiovascular disease), populations (for example, women and children, slum dwellers or migrant populations), or targeted geographical regions (for example, rural areas or border regions ). Usually, these goals and priorities are defined by the ministry of health, through the contributions of various technical experts and stakeholders throughout the health sector. When reflecting on what the goals and priorities should be, it is important to consider the needs of the people alongside the capacity of the health system to deliver. This requires a careful balance of need versus resourcing, which becomes a topic for debate when trying to improve quality while also striving for expanded access to care. If the goals and priorities try to tackle too much without being counterbalanced with the resources needed to meet those demands, the policy is set for failure. Conversely, if the goals and priorities are not expansive enough to meet the needs of the people, the benefit of such a policy may not be evident and can lead to stakeholder disappointment, or even mistrust. Therefore, it is important to have a balanced approach to focusing on the priorities and goals that both meet the specified needs of the pop- ulation and acknowledge the realistic capacity of the system to deliver. It is, however, critical to focus on the long term in developing policy; sufficient capacity may not currently exist but it may be possible to reduce the gap through effective policy-making and structured efforts to seek further priority resources and technical support. The accompanying compendium contains a tool to shape thinking on goals and priorities that can help in framing the policy. Box 6. Health security and quality: closely linked priorities Major public health crises, such as outbreaks of highly infectious disease like Ebola virus, are an increasing national health priority for many low- and middle-income countries. While emergency response might prioritize access to services over quality, if those services are not trusted and utilized by communities, are not equipped to safely and effectively manage cases, do not provide adequate protection to their health workers, and cannot maintain routine care during surges of demand, then resources will be inefficiently used and emergency response will be jeopardized. Aligning quality efforts with existing priorities such as health security may help secure political capital and financial resources, bolstering both agendas. 23 P A R T I . P O L I C Y D E V E L O P M E N T Summary: national health goals and priorities Actions for the policy development team Content of the policy document • Identify existing national health sector goals and priorities • Develop and align goals and priorities for quality policy, including review of existing data where applicable • Outline of identified goals and priorities • Explicit reference to existing national health policy and strategic plans 2. Local definition of quality Numerous definitions of quality can be found in the global literature. In development of the national quality policy, it is critical to state the definition of quality that will underpin the national approach in order to ensure a shared understanding and language that is acceptable to local country context. Furthermore, the exercise of developing a local definition of quality in itself is useful to the policy-making process as it can open a dialogue about the reach and importance of quality, elicit what is important to stakeholders and how interventions might be targeted to meet local priorities, and prompt policy-makers to learn more about the meaning of quality and its implications. As highlighted earlier, there are a number of widely used definitions of quality. However, these definitions may leave a fair amount of interpretation open for defining what quality looks like from national, subnational and facility levels. Table 1 offers a structured approach for helping to tailor a definition that meets the contextual needs and aligns with national goals and priorities. Table 1. Framing the dimensions of quality Questions that help to frame the dimensions of quality to local needs, in the context of national goals and priorities Effective Is care appropriate for the health needs of the population and consistent with knowledge and evidence for achieving the best possible health outcomes? Safe Does the delivery of health services utilize the safest means possible and reduce avoidable harm? People-centred Is the experience of care positive through the eyes of patients and families? Is there a sense of trust among communities in the quality of care available? Do patients, families and communities feel empowered as partners in designing and refining the delivery of health services? Timely Are waiting times for treatment acceptable to the population and sufficiently short to avoid unnecessary harm? Equitable Are there barriers to or disparities in factors related to age, sex, gender, race, ethnicity, geographical location, religion, socioeconomic status, linguistic or political affiliation? Integrated Are there gaps in patient care between clinical settings? Do components across the health sector communicate to maintain seamless transition of patient care? Efficient Are resources allocated and used in the best possible manner to achieve outcomes? 24 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y Policy drafters can utilize Table 1 as a check to stimulate thinking on these dimensions for incorporation in the policy document. While countries are encouraged to consider how each of these dimensions can be reflected in the policy and strategy, they may choose to focus on a subset, or to introduce locally agreed dimensions. Indeed, countries are encouraged not to default to use of existing global definitions on quality, but to instead be informed by these and craft a local definition that is owned and championed by their constituents. When available, additional consultation and mutual agreement on the proposed definition should be sought from a multidisciplinary group that may include providers, academics, quality experts, health service managers, community advocates and regulators. Although this definition will provide an essential starting point, throughout the quality journey of a particular country the accepted definition may be revised according to country progress and needs. Summary: local definition of quality Actions for the policy development team Content of the policy document • Identify previously developed or published local definitions of quality and consider content from the introduction section of this handbook • Develop locally owned definition to support development and implementation of the policy and strategy • Consider stakeholder consultation to refine or co-develop definition • Statement of local definition • Reference to original source of local definition or brief description of process of development 3. Stakeholder mapping and engagement Quality of care is a product of the wider health system. By including key stakeholders in the policy development, the comprehensive nature of the factors that influence quality of health services can best be addressed. Indeed, a wide range of stakeholders needs to contribute to the policy development. Given that health care in most countries is viewed as a public good and a right of the people, governments are expected to ensure adequate funding, resourcing and provision of a basic level of services. The government is in many respects the architect of the policy but should be guided and informed by those involved in the management and provision of health services. Careful stakeholder mapping and analysis can ensure the right people are contributing, facilitate effective engagement, and account for the impact of stakeholder power and relationships. Engaging with both public and private sectors is necessary to cover all populations and to stimulate the necessary change in “quality culture” across the health sector. Just as important is the contribution of communities and people who are receiving services – especially vulnerable and marginalized populations and patient groups. The ministry of health will also have to engage across other government ministries, national bodies, local authorities and development partners. A direct benefit of including a wide range of stakeholders is to better tailor the policy to the various users and beneficiaries of the policy, as well as harnessing buy-in. The global health community should be considered in how they are to be engaged and coordinated, particularly in sharing cross-country lessons and providing specific technical assistance. Box 7 lists some potential stakeholders that could be targeted for consultation and for co-development of the policy. Each country will need to carefully consider and select the stakeholders needed to author its respective policy. This list is not comprehensive, but provides some general considerations. The headings and categories within the list may differ by country. 25 P A R T I . P O L I C Y D E V E L O P M E N T Box 7. Illustrative list of potential stakeholders (note: non-exhaustive list) Government health organizations o Ministry of health o Health professional council o Provincial health offices o District offices and hospitals o National data/informatics specialists Health service organizations o Public sector health services o Faith-based health services o Private sector health services o Traditional and complementary health services Professional bodies o Health care professional councils o Specialty societies o Medical academies Line ministries o Finance o Social affairs o Education Cooperating partners o Insurance entities o Financial support o Communications/media support Civil society o Advocates o Health promoters o Delivery programmes and services Communities o Advocates/outreach o Patient societies Source: Adapted from stakeholder mapping tool used in development of Ghana quality strategy. Once a diverse team has been assembled, clear roles need to be defined for lead architects and the core team as well as for others who will support the creation of the policy. The team will collectively have to identify and address important issues and actions focused on strengthening the quality of care being delivered by the health system. These roles and responsibilities are described below in Box 8. Of further note is the critical importance of embedded community engagement approaches that cut across many of the roles and responsibilities described for specific stakeholders. Summary: stakeholder mapping and engagement Actions for the policy development team Content of the policy document • Identify relevant stakeholders • Map stakeholder roles and plan stakeholder involvement in policy development process • Brief outline of stakeholder engagement process • Acknowledgement of contribution of stakeholders 4. Situational analysis: state of quality The situational analysis, which should be country owned and led but may be supplemented by inclusion of outside experts, is further described in Part II. Its importance as part of the policy document is to establish the current “state of quality” in the nation, encompassing relevant priorities, challenges and problems, related programmes and policies, organizational capabilities and capacity, leadership and governance, and related resources. This will serve to define the gaps identified between population needs and the capacity to reliably deliver quality health services. The linkages with national efforts to move towards universal health coverage may be particularly important to describe within this situational analysis. It is helpful to describe both a nation’s historical quality journey and its current state of quality – including strengths and weaknesses. Historical information can date as far back as necessary. For example, one such country document outlined a timeline starting in the 1980s in order to provide an overview of the initial structure of the health system and how it has evolved over the years. 26 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y When considering the historical perspective, it may be useful to identify not only whether there have been previous national efforts to improve quality, but to examine why these have succeeded or failed, and whether there can be any lessons taken from other policy initiatives across the health sector. Where the situational analysis identifies ongoing quality-related initiatives and structures, it may be possible to refine or build on these in the context of the new policy. The situational analysis provides information from multiple data sources – interviews, focus groups, review of relevant documents and analyses of secondary data – to describe the current landscape and clearly identify the performance gaps between what is actual and what is achievable. This step will be key to grounding the policy to address the real challenges that exist at the front line, and to identifying what actions could have the most impact. Knowledge, behaviours, beliefs and attitudes about quality will all be important to understand as the policy and strategy are being developed. The situational analysis also allows careful consideration of key focus areas within quality efforts; for example, some countries have utilized patient safety as an entry point to stimulate national action on quality of care, while others might emphasize effectiveness and people-centredness. Existing technical programmes (for example, disease- specific initiatives or those focused on specific populations such as mothers and newborns) may also provide rich experience and resources that can catalyse a broader national effort and inform systemwide quality of care efforts. Situational analysis can also reveal important intelligence about how best the policy-making process can be navigated, for example by eliciting why previous health policies have succeeded or failed and what current contextual factors may affect success. Tools to support this situational analysis process are described in the accompanying compendium. Summary: situational analysis Actions for the policy development team Content of the policy document • Plan situational analysis process • Collect relevant data from multiple sources on state of quality, contextual factors, and historical quality journey • Multistakeholder analysis of findings to translate into priorities and strategy • Description of methods of situational analysis • Summary of comprehensive findings • Identification of key findings • Statement of priorities and targeted areas of interventions and action 5. Governance and organizational structure for quality Governance, leadership and technical capacity across the health system are all necessary factors for improving quality and should be discussed explicitly. It is important to understand where and how policy will be developed, enacted, implemented and monitored among existing or newly proposed structures, and how this will be affected by the wider political environment. As an initial step, it may be helpful to identify the key authorities, organizations and individuals that will be involved in establishment and implementation of quality policy and strategy at the national level and at subnational and local levels. The governing body or structures will differ from country to country. Early on in the process of developing policy, it is helpful to understand how the policy will progress from the conceptual stage to being fully endorsed and enacted. To begin with, it should be decided what form the policy will take, as discussed earlier in this document. Once that has been determined, the policy development team must identify which individuals or groups should be involved, clarify which people and organizations need to approve the policy, the process through which the policy is officially adopted, and how the policy will interface with existing health system policy and legislation. 27 P A R T I . P O L I C Y D E V E L O P M E N T Box 8 identifies some of the common roles and responsibilities. In a growing number of countries, some form of unit or department with responsibility for quality efforts is in place. This department may or may not have the power to enforce certain policies, but may bear the responsibility to assess and make revisions to the approach or address matters related to gaps identified in quality care. It is important to ensure that policies clearly define the organizational structure, roles and responsibilities of these departments to fully utilize the capacity of the group, and recognize where responsibilities can be shared across the health sector. The role of community engagement and empowerment is a further critical consideration within the context of governance and accountability; for example, it should be determined how patients, health care staff and wider communities can be meaningfully involved in development, implementation and monitoring of the policy and strategy. Box 8. Health care quality: roles and responsibilities of selected stakeholders Clear description of roles and responsibilities is essential to delineate expectations and hold various stakeholders accountable. The policy can help define these roles and responsibilities. Some examples include: Ministry of health Provide leadership and direction of national efforts Quality department or directorate (usually within ministry of health) Support development and implementation of national policy and strategy National coordination committee Monitor and evaluate progress, identify gaps in quality, and coordinate and align inputs of multiple stakeholders to policy and strategy Subnational quality committee / management teams (regional and district) Monitor and evaluate regional- or district-level progress and address quality issues Professional bodies Assist and support training, professional education and setting standards Insurance entity Fund and monitor incentive programmes and integrate measures for quality improvement in payment mechanisms Institutional boards Review institutional quality improvement programmes and initiatives and engage community in improving service delivery Health facility teams Carry out quality care practices and standards, and report the relevant health data for continuous quality improvement Existing disease-specific or population programmes – for example HIV or maternal and child health – may also have well established governance structures. As part of the policy development process, it is useful to map the structures of programmes with particular relevance to ensure alignment. It is of critical importance that consideration be given to the levers available to ensure the policy is implemented as intended. Thus requires identification and development of structures for accountability and enforcement. This can be a complex endeavour, as the degree to which a policy is successfully implemented relies not only on specific measures but also on the culture within the system, how well the policy is received, and the relationships between key stakeholders. At the heart of successful policy implementation are empowered stakeholders across the system, who should be enthusiastic partners with an interest in the success of the policy. In some circumstances, there may be a case for mandatory adherence to standards, with 28 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y remedial action or sanctions for any violation or failure to comply. Various forms of sanctions may affect licensing, accreditation or funding, and there may be recourse to legal mechanisms, including fines or other action through the legal systems. However, the need for, and use of, such mechanisms should be carefully considered within the context of creating a policy environment suitable to the particular circumstances of each country. Proposed governance mechanisms should be agreed upon by all stakeholders, and delegated as necessary to the appropriate responsible agencies. Each country, in consultation with their respective professional bodies, can identify the best mechanisms for policy enforcement. The subsequent strategy development discussed in Part II will help to address the question of governance for quality through a systematic approach. Summary: governance and organizational structure for quality Actions for the policy development team Content of the policy document • Map existing structures for governance across the health system • Identify mechanisms for policy enactment and enforcement • Decide upon governance structure for both policy development and wider quality efforts • Outline of proposed governance structure for national quality efforts, including requirements to implement this • Description of existing and proposed levers for policy enforcement (e.g. legislation, licensing systems) 6. Improvement methods and interventions This section outlines the set of improvement concepts and principles to be considered to achieve the overall goals of the policy. It is often helpful additionally to state assumptions around these improvement interventions as well as the resources required and risk mitigation strategies to be put in place. A short list of actions commonly considered by governments in establishing the national policy and the accompanying strategy is presented in Box 9. These are common elements for implementing successful systemwide quality efforts. They include strong leadership with the ability to set priorities relevant to the needs of the people and foster an environment conducive to addressing those needs. The ability to assess and regulate the delivery of established standards of care is also important, and may encompass both professional and institutional licensure and inspection and external evaluation of providers. While external evaluation programmes such as accreditation are often early entry points for national improvement efforts, the evidence for their impact on quality is variable; it is important to recognize that these approaches should be embedded within a broader structured effort encompassing the required governance structures and a suite of effective interventions that is appropriate for the local context. 29 P A R T I . P O L I C Y D E V E L O P M E N T Box 9. Basic elements essential for systemwide quality o Leadership to set priorities and shape environment for quality o Establishment of standards and targets o Professional and institutional licensure o Inspection and external evaluation o Workforce development and retention o Incentive mechanisms (financial and non-financial) o Measurement, benchmarking and feedback o Large-scale improvement initiatives by target population, clinical condition, etc. o Patient, family and community engagement (including participation, education, choice and feedback) o Transparency with public performance reporting The well known Donabedian model (15) describes three parameters for evaluating quality of care: structure, process and outcome. This can be a useful approach in the policy planning process to conceptualize the wide range of potential improvement methods and interventions and to ensure that the policy considers key determinants of quality. Structure relates to the setting within which care is delivered, for example the health facility and the human and financial resources underpinning it; process relates to the provision of care itself, including all aspects of the transaction between receivers and providers of care; and outcome is the measurable effect on health status, which may be affected by a wide range of factors. Those developing national policy on quality of care should consider how it can incorporate interventions addressing both structure and process, and how the policy will ultimately affect health outcomes. Training and engagement of the workforce may present an opportunity to overcome limitations in capacity. Incentive mechanisms can be used to influence behaviour towards quality processes, but this will also have to be incorporated into more sustainable norms of practice. In places where certain practices and interventions have led to improved quality care, these efforts should be reviewed to assess their potential for scale-up within the country. In this regard, it is important that the evidence generation and learning agenda is promoted as an essential support mechanism for selecting and refining interventions. An important requirement for achieving both scale-up and sustainability is the intentional engagement of people (patients, families and communities). This empowerment will require education and awareness of the importance for both providers and the general public of these concepts, principles and skills. As part of this engagement, the public should be empowered to access and understand performance reporting to hold the health system accountable, and to facilitate the demand for change. An approach to thinking through selection and implementation of discrete quality-related interventions is discussed in Part II on strategy development. Summary: improvement methods and interventions Actions for the policy development team Content of the policy document • Discuss and select broad priority intervention areas • Outline of broad intervention areas to be addressed by policy and strategy • Discussion of justification, assumptions, resources required and risk mitigation strategies 30 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y 7. Health management information systems and data systems Improving quality relies on the presence of clear and accurate performance data. With the development of a national quality policy, there will inevitably be a necessary emphasis on the systems required for measurement and reporting, including the feedback loop in place to stimulate and measure improvement. There are at least five integrated data and analysis capabilities needed to support a comprehensive national quality programme: • a national hierarchical data collection and reporting system; • department of health/ministry of health executive information system and quality database; • clinical decision support and patient recording systems at the front line; • quality monitoring and feedback systems to assess individual performance against standards or targets and comparative benchmarking data; • public and comparative reporting for transparency and accountability. Clearly, countries will be at different stages in development of these capacities. The policy document will provide an outline assessment of the current status of capacity and the intended course of action to build the capabilities required, including how improvements in data capacity should be prioritized. Key items to be provided include a description of existing possible data sources; identification of data gaps; and actions required to develop the necessary data infrastructure to deliver better quality and to monitor and report on performance. A clear policy direction on the need for quality efforts to be integrated with health management and information systems is critical, given the tendency for quality initiatives to run parallel to routine systems in many cases. Summary: health management information systems and data systems Actions for the policy development team Content of the policy document • Map existing data sources and capabilities • Identify gaps in current health information systems related to quality • Propose directions to optimize health information systems for quality • Identify existing health sector policy and plans related to data systems and health information • Brief overview of available health information and data systems • Outline of proposed health information and data systems to support national quality efforts • Explicit reference to integration of quality efforts with health management and information systems 8. Quality indicators and core measures A comprehensive policy will include the aims for routine quality monitoring and feedback of health service providers and managers, as well as the aggregation of data and overall evaluation of what progress is being made against the national goals for priority areas. This requires the identification of a core set of quality indicators with the necessary policies and processes to support multiple purposes, such as feedback to providers; transparency to the public; benchmarking to understand comparative performance and unjustified variations in quality; analysis of cost-effectiveness; and assessment of the effectiveness of discrete quality interventions and the overall national approach to quality. Quality measures are critically important in judging whether quality improvement activities are effective or not. Without measurement, it is impossible to know whether improvement actions are actually producing better quality of care and leading to any significant change in health 31 P A R T I . P O L I C Y D E V E L O P M E N T outcomes. Quality measurement – through the use of standardized indicators – allows health care providers and policy-makers to assess progress across all levels of health care: national, regional, local, facility and individual. This level of information can also support better reporting to the general public to improve transparency and trust, even when results may fall short of targets. Further detail on the process of developing a comprehensive framework for quality measurement is provided in Part II on strategy development. Summary: quality indicators and core measures Actions for the policy development team Content of the policy document • Appraise relevant indicators already collected and reported by the health sector • Set policy direction on the development of the core indicator set (see parts II and III) • Presentation of indicators and justification for selection • Overview of how indicators will be used PART II STRATEGY DEVELOPMENT 33 P A R T I I . S T R A T E G Y D E V E L O P M E N T Section overview: Part II. Strategy development • Development of national quality strategy National health goals and priorities Local definition of quality Stakeholder mapping and engagement Situational analysis: state of quality Governance and organizational structure for quality Improvement methods and interventions Health management information systems and data systems Quality indicators and core measures • Developing an operational plan for implementation • Integrating technical programmes with national quality policy and strategy As previously described, national quality policy and strategy may often be developed simultaneously as part of a national quality programme, and may exist in one integrated document. Further to this, while the strategy outlines the process by which the policy is enacted, a more detailed operational plan is often required. Such a plan outlines the practical aspects of execution of priority actions, including roles, responsibilities and timelines. Further detail is provided at the end of Part II. This section will review some practical components to consider when moving policy into action through the development of a quality strategy. The suggested process and content of the final document mirrors closely the policy development process, and is based on the same eight elements. In addition, development of a national strategy facilitates integration of existing programmes and initiatives within a coherent national quality framework; this may include existing technical programmes (such as those on HIV or maternal and child health). Further detail on how to approach integration is provided at the end of Part II. The strategy should provide a timeframe for the various activities to be launched, with enough time for logistics and support to be put in place to support those initiatives. This will probably include allocating resources, reorganizing agencies or reorienting personnel, broad awareness building and communication, and associated training and workforce development. As mentioned, the strategy may include an operational plan that provides a detailed roadmap for pertinent intermediate steps. Often, in early implementation, some level of organizational change among stakeholders, including the responsible ministry or agency, will be required to comply with policy regulations, and there may also be a need for technical assistance to help stakeholders define the processes that are required logistically for compliance. External consultancy agencies may be sought, or a task force or committee may be established in the interim, prior to the policy taking full effect, to help facilitate the required changes. The objective of this National Strategy is to articulate multiple inter- ventions that have been developed during the past fifteen years, into a single group of coherent actions that lead towards a strengthened and common aim for all health care institutions in this country, public and private, into a new era of quality improvement for the health of the Mexican people through the convergence of all towards an effective universal health coverage. National Quality Strategy of Mexico, 2016 “ ” 34 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y The process of enacting policies may expose unforeseen challenges that necessitate amend- ments to the strategy – although a vetting and consulting period during the development of the strategy should mitigate much of this. Therefore, in the operational plan there should be consideration of how to monitor and troubleshoot early challenges during the implementation phase of a strategy, for example through formal process evaluation or governance measures such as strategy oversight committees. This should be well documented and there should be a channel to feed that information back to the appropriate overseeing agency or individual for prompt attention and correction. DEVELOPMENT OF A NATIONAL QUALITY STRATEGY Despite the many ways countries differ, review of current knowledge and practices has identified similarities from country to country on how to design and operationalize strategies for national quality improvement efforts. Eight elements in the process are outlined here; these are the same eight elements outlined in the policy process in Part I, and many may be performed simultaneously where appropriate. At other times, national quality policy can drive the development of a quality strategy. These elements are described below to help facilitate strategy development, although not all countries will pass through every element, or in the same order. 1. National health goals and priorities A “quality strategy” is a bridge that helps a health system accelerate the achievement of its health goals and priorities, using quality concepts and evidence-based methods and principles that incorporate quality planning, control and improvement. A crucial first step is understanding the country’s existing national health goals and priorities, identifying potential gaps, and proposing any new goals and priorities that should be included in the national quality strategy. The purpose of this exercise is to identify and prioritize national health goals and priorities so that the quality strategy is fully aligned rather than being developed separately in parallel. The quality policy and strategy – and their implementation – should be across the health system, avoiding the risk of creating a vertical quality programme. Linking the strategy to existing goals and priorities also helps the process of buy-in across various stakeholder groups towards the development of a national quality strategy. Existing goals and priorities will inevitably differ among countries, and will be expressed in different formats and levels of detail. While many national health goals and priorities may be explicitly relevant to quality of care provided by health services, a number may have indirect contributions, for example focusing on determinants of health, prevention of risk, and expansion of access to services. Where the existing goals have a clear focus on quality of care, it is helpful to directly draw on these during formation of the strategy; where a quality focus is lacking, it may be necessary to propose and advocate setting of new goals and priorities in national health planning. The national quality strategy may follow the content and structure outlined in an existing policy document, such as a five-year national health plan, and may specify additional relevant health goals with targeted achievement dates. Goals that link to broader global health initiatives (such as the SDGs) or goals linked to major in-country donor programmes may also be included. Sometimes a national health goal may be specifically linked to a sentinel event or public outcry for greater quality in the health care system, for example reduction of maternal mortality or reduction of health care-associated infections. It may be a useful exercise to explore in greater detail the existing national goals and priorities, assessing how they came to be prioritized, what implications they might have for health service provision, and the logical case for how national quality efforts might help to achieve them. While it is always possible to specify new goals and priorities for the national quality strategy, demonstrating clear alignment with previously stated goals can help build political support and ensure integration of quality efforts within wider health system strengthening. Health system budgeting may also be linked to existing national 35 P A R T I I . S T R A T E G Y D E V E L O P M E N T health goals and priorities; it is important to clarify this linkage and assess the implications for funding of the national quality strategy. Setting priorities may be accomplished by various methods, often starting with analysis of the disease burden and avoidable morbidity and mortality. The rationale for this method is to pro- vide a common language that can be well understood and supported by various audiences. How- ever, countries are increasingly moving away from looking at just the disease burden to more proactively defining priorities in terms of population health and well-being. Principles such as more equitable access and universal health coverage may also be statements of priority that shape the quality strategy. The development of priorities and goals for the national quality strategy can be done in a straightforward and transparent manner, taking account of the following. • National goals and priorities will be drawn from the principal national health plan docu- ments and policies. • Additional goals and priorities may emerge from other areas, including the situational analysis, global SDGs and donor programmes. • If the list of goals and priorities exceeds what can reasonably be included in a national quality strategy (that is, numbering more than can be realistically monitored and translated into actionable activities within available resources and timeframe), two pathways can be followed: reduce the list of priorities by applying explicit criteria, or divide the list of priorities into short and long term. • Once a list is established, feedback should be sought from diverse stakeholders before finalization. • Timelines and criteria for future review and revision should be made explicit. Box 10. Variations in national quality strategies Variations do not only occur in the structure of national quality strategies – but also in the emphasis placed on certain areas identified as priorities by countries. This underscores the importance of understanding quality gaps that require attention within strategies. Ethiopia The ultimate aim of the National Health Care Quality Strategy is to consistently ensure and improve the outcomes of clinical care, patient safety, and patient-centredness, while increasing access and equity for all segments of the Ethiopian population, by 2020. Namibia The quality strategy in Namibia aims to provide a framework for implementation of quality management initiatives at all levels of health service delivery through four strategic objectives: (a) improve quality management systems and accountability; (b) ensure client-centred care and empowerment of consumers; (c) improve patient and health worker safety; and (d) improve clinical practice. Goals of national quality strategies may relate to specific dimensions of quality that are priority areas for that country, though many will touch on all or a number of quality dimensions. Selection of goals may also be influenced by current or recent major public health events, for example outbreaks of infectious disease or mass migration, which can impact health service capacity and priorities. Indeed, during the implementation phase of a strategy, such events might prompt revision of goals; this can help align the strategy with emerging critical needs, and should again be done in consultation with key stakeholders. The statement of goals might focus on desired and specific high-level health and health care outcomes, such as “reducing avoidable mortality by x% over five years”. The means by which the 36 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y high-level goal will be reached can be stated, for example through pursuing universal health coverage or addressing health worker shortages. Another type of goal statement might focus on improvement in specific dimensions of quality, such as effectiveness, safety or people- centredness. Advocacy efforts may be required to embed goals and priorities related to quality across the health system and ensure they are reflected in national health planning and budgeting as well as in the dedicated strategy. Summary: national health goals and priorities Actions for the strategy development team Content of the strategy document • Identify existing sources of published or expressed national health goals and priorities • Appraise existing goals for relevance to quality strategy • Consider, as part of situational analysis and strategy planning process, the need for additional goals and priorities • Develop a statement of goals and priorities for the national quality strategy • Statement of national goals and priorities for quality of care • Reference sources of existing national health goals and priorities 2. Local definition of quality It is important to ensure that the strategy reflects the quality definition adopted to anchor activities and processes. These definitions provide the context in which the strategy will function and be evaluated. Although this should already be established in preceding policy, if it does not exist, then it should be strongly considered early in the process of strategy development. Development of a local definition can be an early task for the team developing the strategy and can also be a useful exercise for engagement of key stakeholders in debate about what the local priorities should be (Box 11). Further information on defining and contextualizing quality is found in the equivalent section on local definition of quality in Part I of this handbook, and in the introductory section. Box 11. Case study: defining quality in Sudan “Providing the best possible patient-centred care using available resources and evidence-based practice.” Definition of quality, Sudan Quality Strategy, 2017 In 2016, Sudan began the process of developing a national quality strategy, and invited a wide range of stakeholders to offer input to the strategic planning. Drawing on stakeholder inputs, the strategy development team drafted a local definition setting out what quality would mean in the context of this renewed national effort to improve services. The team selected a definition that is succinct and easily meaningful to a range of stakeholders from politicians to health professionals. It reflects not only the need for effective patient-centred care, but also the imperative to use limited resources wisely. 37 P A R T I I . S T R A T E G Y D E V E L O P M E N T Summary: local definition of quality Actions for the strategy development team Content of the strategy document • Identify existing quality definitions from national health publications or previous quality efforts and consider content from the introduction section of this handbook • As part of strategy planning or stakeholder engagement process, refine and decide upon suitable local definition to guide strategy process. This may have already been done if national quality policy is already developed • Explicit quality definition, and how this will be reflected in the actions set out in the strategy 3. Stakeholder mapping and engagement For the quality strategy to be successful, meaningful stakeholder collaboration and engagement is crucial across the design, implementation and evaluation phases. While the development of the strategy may be driven from a particular lead organization, often a unit or directorate within the ministry of health, it is important to work with a broad set of key stakeholders from across the health care system at the federal, state, community and local levels. Structured engagement will help to build shared understanding as well as mutual ambition and commitment; this can help to identify the resources and assets available to support strategy development and implementation. Engagement for policy and strategy can be performed as part of the same process. Though particular stakeholder groups may vary by country, in general, they consist of at least the following: • government: ministries (health and related non-health, such as finance), quasi-governmental arms-length bodies and key elected officials; • regulators and other external evaluators and standard-setting bodies; • public and private insurance entities and authorities; • professional societies; • providers (community, primary, secondary and tertiary care, traditional medicine providers, public and private sectors); • civil society organizations, large faith-based organizations, patient groups and patients; • nongovernmental organizations and community-based organizations; • payers, funders and donors. In many countries, small-scale (and in some instances large-scale) quality improvement efforts will already be taking place in health facilities and community providers across the health system, sometimes supported by external technical agencies. This front-line expertise in quality improvement is likely to have yielded useful experience on what works locally, and this should be captured within the stakeholder engagement process. Conducting stakeholder mapping or a stakeholder analysis can identify which organizations or individuals might be drivers, catalysts or blockers in relation to a national quality strategy. When deciding which stakeholder groups to actively include, a set of questions can clarify who should be “at the table” to understand the current state of quality, identify salient issues and gaps, and formulate strategy for advancement. Essential questions to consider when identifying key stakeholders include the following. • Who is responsible for quality at each level of the health care system? • Who or what influences quality at each level of the health care system? • What are the critical levers or drivers to achieve better health outcomes and who drives these? 38 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y • What groups will be champions and what groups will be detractors of a national quality strategy? • What are the key organizations responsible for delivering services across the health system? • Which organizations or individuals support the ministry of health in developing strategic plans? These questions help clarify the key actors that should be involved, in what role – such as developer, reviewer, expert consultant or implementer – and at what stages of the process. Table 2 provides some examples of how stakeholders can be identified and the specific tasks that they can either support or lead. Table 2. Stakeholders and related tasks Stakeholder Task(s) Ministry of health • Lead author • Lead directorate for NQPS Other relevant government ministries (such as finance, social affairs, education) • Provide strategic input to strategy development process • Identify related policy issues, finance requirements and legal instruments • Integrate actions with initiatives from other sectors (for example medical training) Health professional councils and specialty societies • Identify improvement interventions • Technical support for situational analysis and external evaluation National health insurance agency • Review the payment implications • Integrate incentives for improvement Provincial, regional, district health management teams • Engage health facilities and integrate management and quality functions • Disseminate action items and technical support for implementation • Monitor and evaluate progress of quality initiatives through effective management processes Faith-based, private, and traditional health providers • Engage the network of faith-based organizations • Disseminate action items and technical support for implementation • Support the district health management team in monitoring and evaluation of progress of quality initiatives Public sector health providers and hospitals • Full engagement in situational analysis • Provide technical guidance and expertise towards improved clinical practices Nongovernmental organizations and development partners • Provide technical support on strategic planning and implementation of quality interventions based on the quality strategy Civil society organizations, community stakeholders • Contribute to situational analysis • Review strategy development process to ensure it is appropriate and meaningful to the public and patients • Contribute to selection of meaningful local indicators 39 P A R T I I . S T R A T E G Y D E V E L O P M E N T How: a process for engaging stakeholders Feedback from the stakeholder groups throughout the process is required to ensure alignment across the health care system. A variety of approaches exist around stakeholder engagement; the most common methods involve stakeholder interviews, meetings, working group development, and soliciting feedback. As a first step, interviews with key stakeholders can help gather input, such as local quality definitions, perceptions and objective data regarding the current state of quality, what an “ideal” state of quality looks like, existing gaps, and ideas on closing these gaps. As the team progresses, groups of stakeholders may be convened to test, refine and finalize various elements of the national quality strategy. The development of specific working groups may also be helpful; for example, people with clinical and measurement expertise could develop a proposed set of quality indicators to be brought to a wider group of stakeholders for review and ratification. Development of national quality strategy often tends to use a top-down approach designed and planned by the government and launched across the health system; it is, however, crucial to involve and engage the front line, utilizing a bottom-up approach, to inform development of the overall strategy in light of the strengths and challenges that exist, and to help direct resources. This is important due to the chasm that often exists between front-line realities and high-level strategic planning. Given the intimate knowledge of practitioners and managers, their input is critical. Implementation-informed strategy requires connecting with providers at the point of care directly, or through their professional associations or societies, and ensuring that the strategy is meaningful and comprehensible to front-line providers. It is their behaviour that will determine the success or failure of the strategy, so securing early buy-in from those providing care can be crucial. However, even with sufficient buy-in, health care providers must be resourced with an enabling environment conducive to the required behaviour change for improvements in care. Stakeholder engagement can help elicit the supporting structures required for such an environment, and the challenges to be overcome in its creation. Box 12. Community and patient engagement: the Ugandan experience Uganda has a long history of national efforts to improve quality of care, having first embarked on a quality improvement programme in the mid-1990s. Throughout these initiatives, patient and community engagement has been increasingly recognized as an essential component. Uganda has established health unit management committees to give community members meaningful input to facility management and oversight of performance, introduced a patient charter outlining the rights of service users, and in the most recent national quality strategy involved civil society and health consumer representation in the task force coordinating development and implementation. Of vital importance is the community and patient perspective, which may be captured from site visits to facilities and engaging in public meetings to capture the voices of patients, families and communities in the process of strategy development (Box 12). Community and patient representatives can also be involved directly in both the policy and strategy development processes and the subsequent implementation and governance arrangements, helping to ensure that efforts are grounded in “what matters” to the people ultimately using the services. However, this process requires careful planning to ensure communities are appropriately engaged and empowered. For example, challenges such as linguistic barriers or low health literacy may have to be overcome to allow effective dialogue during the process. Health services need to be reoriented towards patient needs and preferences, and this can only be achieved through meaningful engagement. Community and patient engagement, while adding a further resource 40 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y requirement to programmes to improve quality of care, allows the community to be used as a key asset in situational analysis, development of appropriate interventions, governance and accountability, and evaluation of success. These perspectives and engagements will empower people, and provide a layer of accountability at the community level. Summary: stakeholder mapping and engagement Actions for the strategy development team Content of the strategy document • Identify key stakeholders from across the health system • Map stakeholder roles and influence on the strategy development • In a collaborative process, assign responsibility to selected stakeholders f or input to relevant aspects of the quality strategy • Plan for active engagement of stakeholders to maximize useful input and minimize barriers to strategy development and implementation • Schedule multistakeholder meetings as required for strategy development (may include writing groups, situational analysis processes, a steering group, and a validation meeting) • Outline of stakeholder engagement process with acknowledgement of stakeholder input • Outline of key stakeholder roles for suggested actions within strategy 4. Situational analysis: state of quality In most cases, the first phase of developing the NQPS includes a well structured and thorough situational analysis of the state of quality in the health care system at the national, state or provincial, local, institutional and community levels. This situational analysis will build a better understanding of the current state of quality, the existing strengths of the health care system to leverage quality improvement, the anticipated barriers and facilitators for the strategy development process, the major challenges and pressing priorities facing the health system, and the current status of important contextual factors such as infrastructure, capacity and political climate. It can be used to guide the approach taken by the team developing and implementing the strategy, and may also be shared with other key stakeholders to facilitate their engagement. Conducting a full situational analysis will probably take several months and combine a number of important activities, including convening stakeholders, holding briefings, desk research of a wide variety of documents (described below), conducting individual interviews and focus groups for information gathering, and writing up summary reports. This range of activities should draw on perspectives and expertise from the national level right down to health care providers on the front line of service delivery. Inclusion of a wide variety of stakeholders, as outlined in the previous section on stakeholder mapping and engagement, is essential for understanding the collective attitudes, experience and aspirations that will be foundational to future efforts. The comprehensive situational analysis will include a review of historical and current information as well as the collection and collation of new data. The following generic information is likely to be important and useful. 41 P A R T I I . S T R A T E G Y D E V E L O P M E N T • Review of all relevant documents. These will include the national health policy and five-year national health plan, which will provide vital information on country priorities, resources and context. The national quality strategy should be fully aligned with and supportive of existing national policies and plans. • Review of quality-related legislation, regulation and statutes. This will provide information about licensing requirements, medication quality and safety control, and inspection of facilities. • Quality-related government and public sector documents. Examples include professional training materials, protocols and guidelines relevant to health care quality. Relevant documents will reside in such settings as the ministry of health or the national health insurance entity and will include information as varied as environmental and medical waste management requirements or patient rights charters. • Performance data about quality from the health care system. Sources will include hospitals, primary care facilities, and outpatient centres and clinics, from which can be obtained routinely collected health management information system (HMIS) data as well as special-purpose data sets. These data will allow for a detailed understanding of the actual performance across the health system in such areas as access, effectiveness, safety, efficiency, equity and patient- centredness. • Technical and vertical programme reports. These will provide useful quality-related data on the appropriateness of processes and health outcomes of specific populations. • Mapping of available resources to support national quality efforts. Relevant resources can be obtained from domestic budgets, local implementation partners, external agencies, and aligned technical programmes. • State of quality survey (described below). While collection and analysis of such a wide range of data might be challenging in some contexts, the process does not always need to be lengthy and resource intensive. In countries where resources for such exercises are limited, it may be possible to use as a starting point existing analyses that have been done for other health system planning needs, for example to inform development of a national health strategic plan. Aspects of the situational analysis can also be combined with other elements of the national quality process, for example using stakeholder engagement processes to collect important data. Support for the situational analysis may be available from other agencies active in quality of care, for example national professional bodies or external technical agencies. The more comprehensive an analysis that can be done, the more the strategy will benefit, but the important point here is that the strategy should be grounded as far as possible in the identified needs of the country and the assets available to tackle these. Even with few resources, such an approach is possible. A number of tools to support this process are outlined in the compendium of tools accompanying this handbook. A questionnaire to conduct semi-structured interviews or elicit written responses can provide important background information, including stakeholder experience, and supplement the information gleaned from the data sources and analyses described above. Through this data collection activity – which will be based on individual and small group interviews (or in some cases written responses) – the team can better understand the attitudes and perspectives of stakeholders based on their experience. The four basic content areas, and their rationale, of the survey on the current state of quality are as follows. • National quality context. To ground the national quality strategy, it is helpful to know the related history, events and initiatives that led to its formation. This consists of understanding what has already been done around quality planning, control and assurance, and improvement, including in relevant disease- or population-specific programmes. Depending on how centralized 42 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y or fragmented the country’s health system is, these initiatives may be coming from a range of different places, for example the private sector, donor funding or local initiatives, and will be influenced by a host of political, economic, demographic and other factors. • Policy and planning. Health care quality in all countries is driven by policy and enacted through some kind of structured planning functions. For example, national priorities are explicitly identified and then determine macro-level resource allocation, affecting clinical delivery of services at the local level. In parallel form, national standard setting can highly influence the appropriateness of clinical decision-making and the safety of the institutions where people seek care. • Regulation, governance and oversight. This is a descriptive analysis of how the formal and informal functions related to leadership, governance and oversight influence quality. It is important to conduct this assessment across all levels of the health system, including national, state or provincial, local, institutional and community levels, ensuring that both the public and private sectors are included. The main elements to consider are the structures and accountabilities for quality, while carefully identifying the strengths and weaknesses of legislative, policy and regulatory factors. • Existing quality measurement and improvement activities. It is important to take stock of current quality-related initiatives taking place across the country at national, state or provincial, local, institutional and community levels. This analysis can lead to an insightful assessment of present capacity and competencies, while identifying “shining lights” as well as gaps. Summary: situational analysis Actions for the strategy development team Content of the strategy document • Select and develop tools for situational analysis process • Identify key stakeholders to be engaged • Collect data on existing activities, health system planning, governance and oversight, contextual factors, and the historical quality journey • In a multistakeholder process, analyse the data to inform selection of priorities, clarification of governance and structures, development of interventions, and practical plans for monitoring and evaluation • Summary of situational analysis process • Headline situational analysis findings 5. Governance and organizational structure for quality There are two governance structures that must be considered. The first will be a governance structure that will create, establish and enforce the national policy direction on quality. The second will be the governance and organizational structure that bears the responsibility of fulfilling the strategy and ensuring its intended purpose. Part I discusses the former, but this section will focus more on the latter. Those who took part in the drafting of the strategy usually have tactical roles in catalysing its implementation. This requires defining clear roles and responsibilities of key named individuals and organizations who will oversee particular aspects of the strategy and will execute it on the ground. 43 P A R T I I . S T R A T E G Y D E V E L O P M E N T The governance of the strategy will also depend on dedicated leadership and management, especially for national-level initiatives that are meant to reach regions, facilities and local communities. Communication flow must have a clear path from central to decentralized end points, and vice versa; clarifying governance structures can ensure that local quality improvement champions and facility teams can meaningfully feed into subnational and national processes. Existing mechanisms for health sector leadership, outreach and communication should facilitate the strategic implementation of the policy to avoid parallel systems. If these channels do not exist, having them written within a strategic plan and then institutionalized is strongly advised. Organigrams are important as a visual tool that helps both internal and external actors understand the process and flow of the governance structure (see the compendium for examples of organigrams) (Figure 2). Figure 2. Sample organigram for national quality efforts Ministry of health Hospital quality committee Community Ql team Hospital quality committee Department Ql team Department Ql team Community Ql team National quality assurance/improvement committee Quality assurance/ improvement/management committee Subnational quality committee Subnational quality committee To help the strategy development team assess both current governance assets and gaps, and to conceptualize the desired structure, it may be helpful to consider the following questions. Who is currently responsible for quality-related functions? This may be addressed during the situational analysis and stakeholder engagement elements of the process, but often there will be a complex or unclear picture. Of note, it may be important to clarify relationships between ministries of health, accreditation or licensing bodies, and 44 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y professional bodies, and what agreements are in place to manage these relationships. It may be helpful to map not just which individuals and organizations are responsible throughout the system, but also what resources and power they have at their disposal to discharge these responsibilities. The strategy can then be used to clarify roles and responsibilities, fill important gaps, plan for adequate resource allocation and outline how the system will work together. Is there an organigram? Organigrams can be a useful tool to map out the processes, accountability and flow of information within a health system. There may be existing organigrams showing how current national quality efforts are organized or how they fit in with the broader health system. As part of the stakeholder engagement process, it may be useful to determine whether there is a common understanding of the quality structures across the system, as different actors may have alternative perspectives. When planning the strategy, it is helpful to agree upon and publish an organigram, and to encourage this exercise to be repeated at subnational and facility levels as a means of clarifying roles and responsibilities. The confirmation of such organigrams can also be used to promote discussion on how each relationship within the structure will function, and whether any measures need to be put in place to strengthen each designated body. Is there clear accountability for quality at all levels of service delivery? This requires consideration of what accountability means at different levels of the health system, how quality of care is being measured to facilitate accountability, and what measures are in place or are feasible for addressing deficiencies in care identified through accountability processes. Addressing this question might reveal the need for the strategy to establish new or strengthen current accountability structures, and can help ensure the strategy is implementable at all levels. It is important to recognize here that accountability is not a unidirectional process, and that in developing the governance structure and processes there is a need to ensure they facilitate both top-down performance management and strengthen bottom-up linkages between quality improvement teams, subnational bodies and national authorities. What are the specific responsibilities of each major body or position? Answering this may again form part of the stakeholder engagement or situational analysis ele- ments of the process. In particular, it may be helpful not only to map the current situation, but also to identify any gaps or challenges in relation to the required roles and responsibilities for the intended core elements of the strategy. Specifically, it will be helpful to examine the roles, mandates, and capabilities of professional societies, councils, and similar official bodies, includ- ing their relationships with the ministry of health, providers, and each other. What resources exist and will be required? Organizational change and strengthening of organizational capacity across the health system may require significant resources. It is useful to determine what resources are currently available to support governance efforts, including within existing budgets of key stakeholders (for example professional bodies), and how resource use can be prioritized if necessary. Is the current legislative environment fit for purpose to support the strategy? Successful operation of the proposed governance structure relies on a supportive legislative environment. This may already exist in the form of specific health sector legislation, statutory responsibilities of professional and regulatory bodies, and established legal precedent on key issues. However, a case may have to be made for revision or strengthening of existing laws or creation of new legal instruments to enable effective strategy implementation. This may be a difficult or protracted process, and indeed may not be an initial priority, but it is important within the strategy development process to consider the impact of the current legislative environment and the potential value of any refinements. 45 P A R T I I . S T R A T E G Y D E V E L O P M E N T How are communities, patient organizations, and community- and faith-based organizations represented within existing health system governance structures? Although governance structures will vary in their composition, one particular group that should be represented is the “community” – the general population or the beneficiaries of the quality strategy. Although support from leadership and government structures is important, the end-users are an essential contributor to the broader process of quality improvement. Having a mechanism for including that voice in the development of the strategy is important, but its presence is equally as important when implementing the strategy and for ensuring accountability. Throughout the proposed governance structure there should be embedded mechanisms for community engagement; this requires dedicated activities to build the capacity of the health system to facilitate engagement. Patient charters may be a tool to help empower the role of patients and families interfacing at the community level. This should be aligned with existing national, regional and local laws and regulations that protect health consumers. Consideration should also be given to systematic inclusion of community representation on national, subnational and facility-level health management bodies, and there should also be a mechanism for assessing feedback from the community level. More detail regarding feedback and monitoring mechanisms will be discussed in subsection 8 below on quality indicators and core measures. Summary: governance and organizational structure for quality Actions for the strategy development team Content of the strategy document • Carefully consider the questions posed above to ensure effective examination of existing and proposed governance and organizational structures for quality • Develop appropriate and practical measures to ensure accountability • Identify levers for enforcement of strategy implementation at different levels of the health system • Specification of governance and accountability arrangements for the strategy, including organigram if appropriate and explicit statement of role of the community 6. Improvement methods and interventions Strategy can be defined as a plan chosen to bring about a desired future for achieving partic- ular goals. Strategic planning will need to identify quality improvement interventions that can address the national priorities and accomplish the explicit quality goals. Selection of quality improvement interventions must be accompanied by an implementation plan that is practical, effective and sustainable. The task of designing and implementing a national strategy can increasingly be guided by a growing evidence base on the impact of discrete and combined interventions. Literature from health service research, clinical medicine and social sciences refers to a large number of inter- ventions that vary widely in underlying assumptions, required resources and the context in which they have been implemented. However, much of the published evidence comes from higher-in- come countries and requires careful consideration based on varying contexts of countries, re- gions, states or provinces, and communities. Unfortunately, evidence is still scant in low- and middle-income countries and is often focused more on the structural aspects of quality, such as stock of medicines, which does not necessarily shed light on quality of medical care (16). There- fore, it is important to understand that this is an iterative and evolving process requiring ongoing assessment of what interventions and levers are working to improve health outcomes while identifying those that do not have positive results or that may even be causing untoward and 46 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y unintended consequences. Even with acknowledged gaps in evidence, it is still possible to use available experience, knowledge and science to identify those interventions most likely to pro- duce improvements in quality. Such an approach emphasizes the value of implementation-based strategy development, in which the strategy can be a dynamic document that incorporates real experience of implementation and previous quality efforts. Local quality improvement cham- pions and facility teams may already be operating within a number of countries, and can be a source of local intelligence on what is likely to work and where the challenges may be in use of certain interventions. Given the often limited evidence on interventions, developing an active learning agenda is a key support function for a national quality programme. Within the strategy, consideration should be given to how evidence can be generated, and how learning can best be captured, documented and shared. Box 13. External evaluation, licensing and certification As governments fund efforts towards universal health coverage, there is increasing demand that the quality of services paid for by public funds should be assessed and assured. External evaluation, such as accreditation, may consist of both self-assessment and external review of performance against standards, and is often an early step in national efforts to improve quality. Licensing describes a government-endorsed regulatory process to grant permission and specify scope for the health care practice of an individual or organization, usually preceding accreditation. Certification provides recognition – from state, private or nongovernmental bodies – for organizations, people, processes or objects that meet defined conditions developed for the certification process. More information is available from International Society for Quality in Health Care (https:// isqua.org). While each country will have different interventions and activities, there are a number of high-level concepts that are relevant across nations’ health care systems and that can help communicate and organize a national strategy. Though others exist, three practical approaches for designing, organizing and delivering national-driven quality intervention are outlined here: • Juran Trilogy: a concept for understanding the “big picture”; • selecting interventions: identifying the purpose, type of action and discrete intervention; • national multi-tiered approach: designing actions at all levels of the health care system. The Juran Trilogy: the big picture A commonly cited concept in health care improvement efforts is the Juran Trilogy. The Juran Trilogy comprises three separate but related approaches that must all be present in a national strategy: quality planning, quality control, and quality improvement.1 This can be a useful structure to conceptualize the different domains that can be addressed when selecting interventions. In the context of health, the Juran Trilogy highlights the need for coherent national planning and policy formulation to set direction, accompanied by operational methods to ensure that the critical processes of health service delivery are designed to work and that the target levels of performance are being achieved and sustained. 1. Definitions of quality planning, quality control and quality improvement are provided in the glossary. 47 P A R T I I . S T R A T E G Y D E V E L O P M E N T This concept can be particularly helpful for nations as they build their quality strategies, recognizing that all three functions – planning, control and improvement – are necessary and complementary. For example, in the development of its national health quality strategy Liberia used the three components of the Juran Trilogy to examine previous and ongoing health sector quality efforts and guide thinking on where to focus resources for identified priorities. While quality improvement has historically often taken precedence in national quality programmes, it is important that methods and interventions address all three imperatives – planning, control and improvement – in a complementary manner. For example, reducing health care-associated infections is not likely to be possible without having the right policies in place (planning), robust infection prevention and control mechanisms properly conducted (control) and appropriate approaches for changing institutional and individual behaviours (improvement). Box 14. Applying the Juran Trilogy to guide selection of interventions Quality planning • How can patient and provider voices be captured in planning quality initiatives? • What new products and policies are required at different health system levels? Quality control • Are there published standards or guidelines? • What systems can be used to promote and assure provider and system performance? Quality improvement • What capacity is there at different health system levels for identifying and correcting deficiencies in performance? Selecting interventions Perhaps the most daunting challenge to safeguarding and improving quality is the judicious selection of “interventions” – the policies, programmes, structures and other actions implemented across all levels of the health care system to impact health outcomes. This is admittedly a difficult task for all countries, for multiple reasons. • The evidence is often hard to interpret regarding the effectiveness and impact of interventions. • Ideologies and beliefs often prevail over evidence, even where it exists. • Expertise may not be readily available for designing specific interventions. • Stakeholders may resist certain actions (such as public reporting of performance data). • Resources may not be available. The universe of interventions to impact quality is large and difficult to fully conceptualize. Organizing these interventions can enhance a common understanding and allow better choices about which of the interdependent interventions to select across all countries and across diverse health systems. We do know there are no “silver bullets” or fail-safe solutions and that a combination of interventions used simultaneously in a complementary and integrated strategy is needed for quality improvement to prevail. A quality improvement intervention is a change process in health care systems, services, or suppliers for the purpose of increasing the likelihood of optimal clinical quality of care measured by positive health outcomes for individuals and populations (Agency for Healthcare Research and Quality) “ ” 48 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y The list of illustrative interventions in Table 3 has been selected for several reasons. The quality- related interventions cited are relevant in a wide variety of countries globally; are commonly considered as options for action; have some evidence to guide selection and use; are intuitively reasonable; and can be implemented at multiple levels, from small primary care clinics to the level of a national programme. That being said, quality interventions need to be examined carefully. The list presented is by no means exhaustive; there are other interventions that could easily have been included. This set of interventions has been selected for their potential impact on quality by reducing harm, improving front-line delivery of health care services, and building systemwide capacity for quality improvement. The illustrative interventions are intended to point to some of the options and possibilities available to the managers, practitioners or policy-makers keen to advance quality of care. The interventions are presented as simply as possible, highlighting the salient issues. However, none is simple to implement, and they should not be viewed in isolation – some of these interventions are interrelated and thus when implemented in combination can have greater impact. As more countries work to improve quality of care, more context-specific evidence for “what works” is expected to emerge, so it is recommended that the latest evidence, experience and contextual knowledge is taken into account when selecting interventions. Table 3. Illustrative quality interventions Intervention Definition and application System environment • Registration and licensing of doctors and other health professionals, and of health organizations, is often considered a key determinant and foundation of a well performing health system. • External evaluation and accreditation is the public recognition, by an external body (public sector, non-profit or for profit), of an organization’s level of performance across a core set of prespecified standards. • Clinical governance is a concept used to improve management, accountability and the provision of quality health care. It incorporates clinical audit; clinical risk management; patient or service user involvement; professional education and development; clinical effectiveness research and development; use of information systems; and institutional clinical governance committees. • Public reporting and comparative benchmarking is a strategy often used to increase transparency and accountability on issues of quality and cost in the health care system by providing consumers, payers, health care organizations and providers with comparative information on performance. • Performance-based financing and contracting is a broad term for the payment of health providers based on some set of performance measures. It is increasingly used as a quality lever. The amount contingent on performance is often a subcomponent of the full payment, which may be based on a range of financing es. • Training and supervision of the workforce are among the most common interventions to improve the quality of health care in low- and middle-income countries. • Medicines regulation to ensure quality-assured, safe and effective medicines, vaccines and medical devices is fundamental to a functioning health system. Regulation, including post-marketing surveillance, is needed to eliminate substandard and falsified medicines based on international norms and standards. 49 P A R T I I . S T R A T E G Y D E V E L O P M E N T Reducing harm • Inspection of institutions for minimum safety standards can be used as a mechanism to ensure there is a baseline capacity and resources to maintain a safe clinical environment. • Safety protocols, such as those for hand hygiene, address many avoidable risks that threaten the well-being of patients and cause suffering and harm. • Safety checklists such as the WHO Surgical Safety Checklist and WHO Trauma Care Checklist can have a positive impact on reducing both clinical complications and mortality. • Adverse event reporting documents an unwanted medical occurrence in a patient resulting from specific health services or during patient medical encounters in a medical care setting. It should be linked to a learning system. Improvement in clinical care • Clinical decision support tools provide knowledge and patient-specific information (automated or paper based) at appropriate times to enhance front-line health care delivery. • Clinical standards, pathways and protocols are tools used to guide evidence-based health care that have been implemented internationally for decades. Clinical pathways are increasingly used to improve care for diverse high-volume conditions. • Clinical audit and feedback is a strategy to improve patient care through tracking adherence to explicit standards and guidelines coupled with provision of actionable feedback on clinical practice. • Morbidity and mortality reviews provide a collaborative learning mechanism and transparent review process for clinicians to examine their practice and identify areas of improvement such as patient outcomes and adverse events without fear of blame. • Collaborative and team-based improvement cycles are a formalized method that brings together multiple teams from hospitals or clinics to work together on improvement around a focused topic area over a fixed period of time. Mutual learning mechanisms across health care organizations are increasingly prominent. Patient, family, and community engagement and empower- ment • Formalized community engagement and empowerment refers to the active and intentional contribution of community members to the health of a community’s population and the performance of the health delivery system. It can function as an additional accountability mechanism. • Health literacy is the capacity to obtain and understand basic health information required to make appropriate health decisions on the part of patients, families and wider communities consistently. It is intimately linked with quality of care. • Shared decision-making is often employed to more appropriately tailor care to patient needs and preferences, with the goal of better patient adherence and minimizing unnecessary future care. • Peer support and expert patient groups link people living with similar clinical conditions in order to share knowledge and experiences. It creates the emotional, social and practical support for improving clinical care. • Patient experience of care has received significant attention as the basis of designing improvements in clinical care. Patient-reported measures are important in themselves; patients who have better experience are more engaged with their care, which may contribute to better outcomes. • Patient self-management tools are technologies and techniques used by patients and families to manage health issues outside formal medical institutions. They are increasingly viewed as a means to improve clinical care. 50 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y National multi-tiered approach to quality Responsibility for the quality of health care services is present at multiple hierarchical levels in every country. Generally, there are at least five levels where activities take place and accountability for quality exists (17-19), though others may be identified depending on the particular setting, for example in countries with significant subregional health system management. In selecting interventions, an exercise can be performed to identify required functions by health system level, helping ensure strategies are comprehensive and locally appropriate. The five levels can be described as follows (Figure 3). • National-level functions include policy formulation, infrastructure building, resourcing and accountability to the public. • At a subnational level (region, province, state) there are usually functions of rationalizing national policy to the contextual needs of a region, as well as macro-management and monitoring of performance. • Communities are often uniquely able to act in the collective interest of the individual patients and citizens by providing voice, performing governance within civil society mech- anisms, and monitoring and assuring accountability. • Institutional entities such as hospitals, clinics and dispensaries are responsible for good governance, competent operations and management to meet the needs of patients, fami- lies and the community. • Individual encounters between the health care worker and the patient are where the care must be effective, safe and people-centred. Some functions may feature across multiple levels, for example the learning agenda, leadership and data management. Figure 3. Illustrative activities across five levels of hierarchy Source: Adapted from Leatherman and Sutherland. • Legislation • National Goal Setting • Regulation and Oversight • Public Performance Reporting • External Evaluation • Accreditation • Targets and Standards • Performance Contracting • Benchmarking • Outreach and Advocacy • Education and Awareness • Provide Input to Health System • Leadership and Governance • Incentives • Traditional QA Functions • IT Decision Support • Performance Contracts • Professional Appraisal • Patient Education • Supervision • Shared Decision Making Regional/ State Community National Institutional Individual 51 P A R T I I . S T R A T E G Y D E V E L O P M E N T Figure 4 shows an example “pyramid” of the levels in a health care system from Mexico’s draft national quality strategy, published in 2016. The framework for interventions can be applied in such a pyramid to understand how specific actions at all five levels create a comprehensive systemwide strategy for quality. Figure 4. Framework of interventions at each level of hierarchy: Mexico • Vice-ministry for integration and development • Directorship for quality and education • National quality steering committee • National center for technology excellence (CENETEC) • National quality award • Regulation for accreditation of schools of medicine • National population satisfaction surveys • Essential actions on patient safety • 9 indexes composed of 33 quality indicators • Monitoring system (INDICAS) • Accrediatation of healthcare facilities • Hospital patient quality and safety committees • Code of ethics for hospitals • Patient satisfaction surveys per unit • Benchmarking of safety culture in units • Pharmacy and therapeutic committee COFAT • Patient satisfaction survey by citizen endorsement groups (Aval Cindadano) • Quality management projects and research in priority diseases • Self-evaluation survey of WHO multimodal strategy and questionnaire of knowledge and perception of hand hygiene • Adverse event registration system • State quality committees • Patients’ rights • Doctors’ rights • Nurses’ rights • Code of ethics for doctors • Code of ethics for nurses • Ql training for healthcare professionals • Management training for top healthcare executives • General practitioner certification • Clinical guidelines • Healthcare algorithms on priority diseases Community National Institutional Individual Regional/State • Citizen endorsement groups • Code of ethics for citizen endorsement groups Summary: interventions for improvement Actions for the strategy development team Content of the strategy document • Plan process of selecting interventions for improvement. This may involve review of current evidence; stakeholder engagement to elicit knowledge of current implementation; and use of approaches such as the Juran Trilogy alongside expert technical input • Map interventions against identified goals and priorities to ensure action is directed towards meeting these • Conduct detailed analysis of illustrative interventions to ensure they are practical and achievable • Identify who is responsible for implementation • Outline of the interventions that have been chosen, and how these address the identified priorities • Detailed description of interventions, including resource requirements, timescales, and responsibility for implementation; this can be further detailed in an operational plan Source: National quality strategy, Mexico, 2016. 52 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y 7. Health management information systems and data systems Health information systems are a necessary component for transformation of health service delivery (20), which is fundamentally the aim of any national quality strategy. Therefore, a robust understanding of data systems is fundamental to the development of a quality strategy. Improving quality is always reliant on the presence of clear and accurate performance measurement data, whether at the level of individual practitioners and providers, or on a broader population level. Thus, the development of a national quality strategy will inevitably entail emphasis on the systems necessary for data collection, measuring and reporting, and the feedback loop in place for improvement. Most countries around the world, including many high-income countries, recognize that their health information systems data sources and metrics are not ideal. Conversely, it is also true that there are always enough data to at least get started. The essential data inputs usually exist in some form and to some degree, but the completeness and accuracy are uneven across geographies and levels of the health care system; for example, hospital data are often better than primary care data. Box 15 provides sample questions that can be applied to assess the current data sources. Box 15. Sample key questions to assess current data sources • What are the current health care data sources (e.g. HMIS, donors)? • What is the accuracy and completeness of the data? • What metrics are being collected within each data source? • What factors need to be considered when using the patient medical records (e.g. availability, accuracy)? • What is the “movement” of data (who is collecting, for what purpose and where is it being reported)? • Is there feedback to facilities and individual providers? • Are there any existing measurement frameworks? • What existing standards of care or protocols have specific metrics accompanied by numerical targets? Feedback and reporting of data are rapidly evolving across the world with increasing public expectations of transparency and accountability regarding health systems. Given the complexity, cost and goodwill at stake in evaluating and reporting performance data, it is critical to establish clear aims and principles, such as (a) primary intended audience (for example, regulators, providers, patients who would be impacted or implicated; (b) intended use (for example, by providers to improve patient care, or for regulators to assess adherence to standards); and (c) data protection (for example, protecting individual providers being disclosed and identified with performance data, while also balancing accountability in the system). Tackling deficits in data, and the complexities of health information systems, can quickly over- whelm those who are responsible for the formulation and implementation of an information system capable of supporting the national quality strategy. Policy-makers and strategists will require significant technical input at this stage. Breaking the task down to manageable pieces can help define strategic action. This involves understanding the current state; mapping out the ideal state; and then developing a plan to bridge the current and ideal future states related to data and measurement throughout the various levels of the health care system. 53 P A R T I I . S T R A T E G Y D E V E L O P M E N T Current state of data and measurement through various levels of health care system The first step is mapping what data are being collected and how they can be accessed and, importantly, made to connect with each other (interoperability) so that quality can be measured across areas. For example, linkages are required between the supply chain, facility-based stock- outs and quality of care delivery. A major potential source of data to monitor quality is the routine HMIS, which may be in the form of an electronic system that can be interrogated to access a range of data across health system levels (for example the widely used DHIS 2). Other routinely collected data to measure and identify gaps for improvement in quality could include data from supervision visits or financial data from insurance. Other useful data sources collected less regularly include standardized surveys measuring facility readiness (for example, service provision assessment, service availability and readiness assessment, service delivery indicators), household surveys of coverage of targeted services or diseases (for example, multiple indicator cluster survey, WASH), or data sources that are more broad (for example, demographic and health surveys). Furthermore, ad hoc data reporting systems that support improvement may exist, for example, local health surveys that explore particular issues in more detail. Box 16 summarizes the various sources of quality measurement that are available in most or all countries. Box 16. Potential sources of quality measurement available in many countries Individual patient medical records (paper or electronic) Routine HMIS Facility surveys: • sampled national standardized survey • routine supervision or monitoring surveys • external evaluation, inspection and accreditation Household surveys Insurance programmes Patient and public questionnaires and online reviews or surveys Medical registries (facility or community) Other routinely collected data, including performance appraisals and supportive supervision There are however areas where data are often missing in existing data sources. These include experiential quality and patient satisfaction; health care worker competence; management, coordination and continuity across care sites; quality in the private sector; and quality of community-delivered care. Work to ensure that these are measured more routinely is an important area for strengthening HMIS as part of an overarching quality strategy. When assessing the current status of data and measurement systems, it is important to consider not only what sources exist, but also how data are being used. For example, at which health system levels are data collated and analysed, and is there feedback into the system to allow modification of behaviours, goals, priorities and measures? It is also important to note whether the various parts of the current system, including individual disease programme data systems, are complementary and compatible, and whether there is a burden on the system from conflicting or duplicative data from different stakeholders. 54 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y Mapping what the “ideal” state would look like There are five basic integrated analytic and reporting capabilities needed to support national quality strategy: • a national hierarchical data collection and reporting system (HMIS); • data sets that reflect the state of quality at the different levels of the health system; • clinical decision support and knowledge management systems for the workforce; • quality monitoring and feedback systems to assess individual performance against standards or targets and comparative benchmarking data; • reporting for transparency and accountability. Strategy development teams, supported by data and information specialists, can identify minimum information system requirements under each of these capabilities, cross-referencing against identified priorities for the strategy. Development of a plan to bridge the current and ideal future states There is no need to wait for the “fix” of flawed information systems and deficiencies in data that are ubiquitous. It is possible to get started on what is available while working within a defined long-term plan for the necessary evolution of data collection and analysis. While existing health information and data systems, however limited, can inform identification of priorities and formation of the strategy, plans can also be put in place, as part of the strategy, for further data system strengthening to meet any gaps between currently available sources and those needed for the ideal state. Clearly, achievement of the ideal state may be a complex and resource-intensive process, so such plans may need to prioritize the development of new systems required to achieve the successful implementation of the quality strategy, and should assess the resources required. Priority may be given to those measures that strengthen existing systems rather than create new processes, and to those that are critical to support other priority interventions outlined in the strategy (for example, performance-based financing requires reliable measurement of provider performance). The major challenge for many countries is too many data of variable quality with gaps in measuring important areas, including provider competence and the patient experience of quality. There is an urgent need to make the data better (data quality) – more accurate, complete, meaningful and actionable. Many countries must also work to better identify and measure critical areas where data are not now being captured while also reducing the burden of data by ceasing collection and measurement where data are not used and are of low priority. Fully appraising existing data and information systems and planning for improvements is likely to require specialist technical support that may be beyond the capability of teams preparing the national quality strategy. In this regard, the role of the strategy is not to provide a detailed plan for improving such systems, but to ensure their importance is clearly recognized and that initial steps are taken to identify and address critical gaps. Summary: health management information systems and data systems Actions for the strategy development team Content of the strategy document • Produce inventory of the current state of data and measurement throughout the various levels of the health care system • Map what the “ideal” state would look like • Develop a plan to bridge the current and ideal future states • Outline of data and information system improvements needed, and timeline for achieving this • Description of how current systems will be used for measuring quality, monitoring provider and professional performance, and supporting decision-making 55 P A R T I I . S T R A T E G Y D E V E L O P M E N T 8. Quality indicators and core measures Translating policy into practice requires that countries identify core measures of quality across the levels of care and dimensions of quality. All countries are currently measuring many components of their health system, often through monitoring and evaluation and routine HMIS, as described in subsection 7 above, and not infrequently through parallel donor-mandated systems. However, there is a growing recognition of the need for harmonization of indicators and systems to create better information to drive policy, decision-making and improvement of health services. To do this effectively will require input and coordination between a number of key stakeholders with a range of skills. These include policy-makers, service delivery managers, the health professions, HMIS/IT with monitoring and evaluation teams, and importantly the broader community of patients and civil society. In addition, there is a growing recognition of the importance of fully including the private sector to ensure that measurement and reporting of quality applies to all populations being served. This section, which should be read in conjunction with subsection 7 above, provides insights on how to define strategic direction on the measurement of quality, examples of quality indicator sets, emerging work on how to maximize data use, and consideration of some areas where more exploration is needed in measuring what matters. Measuring quality of care is a rapidly evolving area; tools and resources will be continuously emerging to increase the utility of data collec- tion, measurement and reporting. A comprehensive quality strategy includes a plan for quality monitoring, feedback and overall evaluation of what progress is being made against the national goals. The objective of national quality indicators is to assess the high-level goals through a set of specific indicators, which can be used to measure the success of the strategy itself and to support efforts at every level of the health care system to pursue actions for improvement. The role of measurement in national quality efforts includes: • monitoring for adherence against standards and guidelines • feedback to providers on quality improvement activities • transparency and accountability to the public • benchmarking to understand comparative performance • strategic or value-based purchasing and contracting • monitoring of the effectiveness of quality interventions. A key task of any national quality strategy is to build measurement and evaluation capability, which requires definition of a national framework of quality indicators. Selection of indicators for such a framework should be based on country priorities, needs and existing data capabilities. The process for framework development will vary between countries. However, a number of important steps are outlined below, which can help with development of such a framework. Review of global and expert illustrative indicators Many countries have struggled to select indicators that can be reliably and efficiently collected, truly reflect the state of quality of care, and are useful in efforts to improve quality of care. To support such efforts, a number of organizations have convened expert groups to propose sets of indicators, including information on how these can be collected and used. It may be useful for national quality strategy development teams to access these illustrative lists to provide direc- tion on how to select indicators that align with the goals and priorities set out in the strategy. Further information on illustrative sets of indicators is available in resources included in the com- pendium. It is likely that further sets of indicators will be developed as part of ongoing global efforts on quality of care. 56 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y Cataloguing and assessing existing quality indicators To ensure best use of existing systems and alignment with current national health priorities, it is important to catalogue and understand the existing quality indicators collected within countries and the data systems within which these indicators are embedded or from which the data are drawn. It is vital to understand whether there is current effective use, meaning that data are collected for valid measurement of an indicator, and whether there is a feedback loop of analysing, reporting, learning and making changes to improve performance. To understand the current state of data systems and quality indicators, the following steps are crucial. 1. Catalogue the various current data sources that can be used for quality indicators. This can include HMIS data sources, donor data, clinical registries, patient surveys and accreditation reports. 2. Clarify what existing frameworks for quality metrics and indicators are currently being used. 3. Within each data source, catalogue specific quality metrics that are currently being collected. 4. Grade the data by assessing their accuracy and completeness. Once the current state of data systems and quality indicators is analysed and assessed, a new or revised framework to correspond with the national quality strategy can be developed. In building a national framework of quality measures, as part of the national quality strategy, it is recommended that existing quality metrics be used to the extent possible in order to best align with current reporting systems and reduce, or minimize, the data burden. To support this process, 10 criteria are presented in Box 17 that can be used to prioritize existing quality indicators or measures for inclusion in a national quality indicator framework. Box 17. Ten criteria for assessing quality indicators for a core set Health priority. Does the indicator measure a specific health priority? Scope of impact. What is the scope of impact in measuring this indicator (e.g. population-size clinical outcomes)? Evidence base. Is there sufficient available and credible evidence for this indicator to be consensual? Defensibility. Is this indicator defensible both from a scientific point of view and from the perspective of what key decision-makers view as important? Feasibility. What is feasible given the data that are already collected; how easy will this be to implement? Accuracy. Are the data collected through this indicator accurate? Actionability. Are clear actions and change in individual, institutional or system behaviours possible from looking at this indicator? Comparability. Can this indicator be compared against a gold standard or with other countries or across regions? Credibility. Is the indicator credible for those who need to take action and those whose performance is being measured and compared? Clarity. Is the indicator described in clear and unambiguous terms? 57 P A R T I I . S T R A T E G Y D E V E L O P M E N T Conceptual frameworks for quality indicator selection To support development of a comprehensive quality measurement framework, there are a number of ways to conceptualize measurement of quality across a health system. These include: • dimensions of quality: for example, those from the definition section in this handbook, or a locally defined set of domains; • Structure/process/outcome: Donabedian’s three areas of structure (including systems), process and outcomes (health and patient experience and satisfaction) (21); • health system organization: including level of care (primary, secondary, tertiary), management structures (facility, district, national etc.), and continuum of care (promotion through to palliation); • disease and population groups: significant causes of disease burdens and main populations affected. Strategy development teams can consider these conceptual frameworks to identify aspects that should be accounted for in a quality measurement framework. A mapping exercise can then take place to assign appropriate measures from illustrative lists and existing national indicator sets to each aspect, identifying any gaps that may have to be filled by newly developed measures. Summary: quality indicators and core measures Actions for the strategy development team Content of the strategy document • Review global and expert illustrative indicator lists • Catalogue and assess available national quality indicators • Define key steps in the development of a national quality measurement framework • Map available and suggested quality measures against framework and plan for development of bespoke measures to fill gaps • Outline of national quality measurement framework • Plan for monitoring, evaluation and accountability • Measures refined by testing a preliminary set and taking actions to fill gaps in measurement capacity 58 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y DEVELOPING AN OPERATIONAL PLAN FOR IMPLEMENTATION National quality strategies can be supplemented with operational plans that detail the practical steps, resources, responsibilities and timeframe for the implementation of the strategy. Development of these will draw upon the same processes used in the eight NQPS elements areas, focusing on how the identified actions will be implemented. Overview and rationale Formulating the policy for quality and then designing a national quality strategy is a complex endeavour. The operational plan defines clear milestones and tasks that must be undertaken, clarifies roles and responsibilities, sets clear timelines, and addresses financial and resource considerations. Each country will decide the appropriate timeframe for the operational plan, often choosing to further classify and plan short-term versus longer-term actions and identifying crucial milestones. An operational plan can significantly aid dissemination and execution of the strategy and ensure the document does not simply “sit on the shelf”. It may also help to translate a national strategy into subnational operational plans to promote ownership across the system, highlighting the need for close linkages between national and subnational plans. While the strategy itself plans to build cohesion across stakeholders in the health system, align quality goals and priorities, and identify key levers to achieve these quality goals, the operational plan goes a level deeper to define explicit tasks, roles, timelines and financial considerations. A template for an operational plan is available in the accompanying tools compendium. When and how should the operational plan be developed? An operational plan is often developed after formal ratification of the policy and strategy document by the structure (directorate, unit or working group) responsible for quality and quality improvement. A country may already have its own process for developing operational plans. Often, these are yearly plans that correspond to a country’s financial planning cycle. At a high level, an operational plan that supports national quality direction should start with the overall aims and goals laid out by the policy and strategy. Elements to consider in the operational plan include (a) where to begin (for example, are there certain tests or pilots in specific geographical locations to begin first?); (b) level of the health system (for example, beginning with national initiatives versus state or local initiatives); and (c) timing and plan for nationwide spread and scale-up. Collaboration and buy-in across all health system levels is important in developing an operational plan. Specific actions taken will be spread across national, regional, district, community and facility levels. What elements should the operational plan include? At a high level, the operational plan should answer the following questions, as they relate to the overall aims and goals of the national quality strategy. • What are the tasks or actions that must be undertaken? • How should tasks or actions be prioritized, if available resources are limited? • Who are the persons who have the responsibility for each of these tasks or actions? • What is the timeline in which these tasks or actions must be completed? • How much and what kind of resources must be provided to complete each task or action? • What specific performance measures should be collected (for example, quarterly) throughout the length of the operational plan to evaluate the success and effectiveness of the plan? Within the operational plan, tasks or actions may be prioritized based on interventions outlined in the quality policy and strategy document and a thorough understanding of the current state of quality and the existing assets to be leveraged. While it can differ by country, in general, an operational plan spans the length of one to two years. 59 P A R T I I . S T R A T E G Y D E V E L O P M E N T INTEGRATING TECHNICAL PROGRAMMES WITH NQPS Any national quality strategy is ultimately focused on achieving better health outcomes and improving health system performance in dimensions of quality such as effectiveness, safety, patient-centredness, timeliness, efficiency and equity. Accomplishing these goals requires policy formulation to create an enabling environment, addressing deficiencies in the delivery system and integrating the improvement and measurement efforts of disease-specific and population- specific health programmes that exist in every country, also known as vertical or technical programmes. A national quality strategy must be comprehensive and inclusive of all populations and health care needs, though priorities will inevitably be identified. Intentionally integrating with technical and disease-specific programmes allows the national strategy to leverage the already existent quality-related strengths and capabilities of technical programmes and ensures that those programmes are not left functioning outside the national strategy. Furthermore, integration of technical programmes may enhance engagement with donor organizations, allow tried-and- tested local solutions to inform the broader strategy, and lead to efficiencies in use of limited resources. For the technical programmes there can also be significant advantages, for example the potential to scale up efforts through a national programme, efficiencies of access to national health infrastructure, and improvement of programme outcomes due to a stronger system. Whether considering long-standing programmes such as maternal and child health, or donor- supported initiatives such as HIV programmes, technical programmes may simultaneously address the best ways to organize and deliver individual health services along with systematically improving and measuring population health. These programmes, especially in low- and middle- income countries, often have basic quality-related capabilities in place, even before national quality strategies have been formally implemented. Examples of those capabilities include guidelines and standards, patient pathways, continuous monitoring of patient outcomes and routine use of quality and safety indicators. Integration of technical programmes is necessarily a two-way process: national quality strategies must account for the activities, assets and learning from existing technical programmes, and existing technical programmes should endeavour to align with national quality processes and priorities. Clearly, there is a potentially wide variation in levels of integration of technical programmes within national quality strategies. Options for integration include the following. • The technical programme is fully subsumed within the national quality strategy. This ensures maximum alignment, but is probably only possible for existing government-led programmes that have a primary focus on quality of care (for example, there may be an existing national effort on maternal and child health quality of care, which could be easily integrated in a systemwide effort with little disruption). • Technical programmes can act as “pathfinders” for national quality strategies. In this scenario, specific technical programmes can be used to begin or trial roll-out of the strategy, to allow for rapid field-testing and scale-up making use of well resourced programmes. In such instances, care should be taken to ensure that the strategy is not dominated by only one technical area and that benefits are systemwide. • National quality strategy and technical programmes can be explicitly linked on a strategic level. In this scenario, technical programmes maintain their operational autonomy, but there is joint strategic planning to ensure efficient use of resources and pursuit of common goals. Technical programmes would be expected to explicitly reference and endorse the national quality strategy in future planning processes. • Existing programmes are acknowledged and plans made for future integration. Given the complexities of integrating multiple programmes, a practical initial step is for the national 60 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y quality strategy to examine and acknowledge relevant technical programmes to ensure there is no duplication of efforts or areas of divergence in aims and activities. Technical programmes would be encouraged to gradually align with the national quality strategy, and the strategy itself could contain explicit activities to plan and operationalize integration. The type of integration may vary between countries and technical programmes, but initial steps that can be taken by the strategy development team include: • identification of relevant technical and vertical programmes as part of the situational analysis and stakeholder mapping; • early engagement of relevant implementing partners, including consultation with technical programmes on how to increase the applicability of the quality strategy, assessment of the capacity of the programmes to support strategy implementation, and discussion of options for integration; • mapping of areas of overlap and divergence between the proposed national quality strategy and the aims and activities of technical programmes; • contribution of quality-related expertise and technical know-how from the technical programme to a newly emerging or still evolving national quality strategy; • integration of data and measurement systems from the technical programme into the national measurement framework and quality data systems; • ensuring cross-learning between quality-related efforts in different technical programmes through strategic oversight provided by a national drive on overall quality; • development of a plan for alignment and integration, including an agreed joint programme of work, consideration of budgetary challenges and opportunities, or a timetable for further consultation. PART ΙΙΙ TOOLS AND RESOURCES 62 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y Background This handbook provides an overview of the background, rationale, and process of efforts to develop national policy and strategy on quality of care, as well as suggested content for documents outlining such policies and strategies. Putting this into action will require more detailed consideration of each element. Moreover, different countries will have different needs, priorities, capabilities, resources, and procedures for policy and strategy development; the support required for each step of the process will necessarily differ. In-depth consideration of each element of the NQPS process may be supported by a number of different means, for example through involvement of external experts or use of further tools and resources. Products that might support teams developing national quality policies and strategies include country case studies, global guidance documents produced by WHO and others, literature reviews, and dedicated tools that can be adapted and used to catalyse discussion and collect data. A number of such resources have been created by WHO, technical organizations, academic institutions, and countries themselves, and many are freely published for use and reference by others. While some may be specific to quality of care, others might be more generic but still relevant to the process, for example tools to perform situational analysis or assess health information systems. This section of the handbook does not present tools and resources for direct use, given that many of these run to numerous pages and are contained in already published documents. Instead, it outlines how tools and resources can be accessed, selected and used to support the NQPS process, and provides an overview of the compendium of tools and resources that is available for use alongside the handbook. The accompanying compendium of tools and resources is a more detailed document with an overview of selected tools and resources that can support the NQPS process. Both the compendium itself and the tools and resources will be accessed through a repository in the WHO Global Learning Laboratory. Finding, selecting and using tools to support the NQPS process While the compendium accompanying this handbook provides selected tools and resources for priority aspects of the NQPS process, and will be added to in future, it is not intended as a com- prehensive list of all relevant products. In many instances, those developing national quality policies and strategies may find it helpful to search for, adapt or develop other tools specific to the needs of their NQPS process, for example those relating to a specific NQPS element or technical area, or those available in local languages. Such an exercise does not necessarily have to be a complicated or methodologically strict process, and can be done relatively quickly, with the aim being to assist the overall process rather than add an unnecessary process burden. Box 18 lists some potential sources of tools and resources. Box 18. Potential sources of tools and resources • NQPS tools and resources compendium • Academic literature • World Health Organization website • Expert technical organizations (website or direct contact) • Academic institutions • Professional bodies • Other health policy or strategy development teams • NQPS documents available in other countries 63 P A R T I I I . T O O L S A N D R E S O U R C E S Suggested steps for identifying supplementary tools are outlined below. 1. Identify NQPS elements requiring more detailed input. As each country will have different priorities within their work on NQPS, they will have differing requirements for further tools. Much of the time, there will be sufficient expertise and experience within policy and strategy development teams or the broader set of stakeholders to perform the various elements outlined in this handbook, but it may become clear early in the policy and strategy development process that certain elements will require more in-depth work. Use of supplementary tools for the NQPS process should only be done where this is additive, as the process need not be overcomplicated. 2. Develop and implement a search strategy. This will require identification of potential sources of existing tools (see Box 18). While some tools will be publicly available online, others may only be found on direct engagement with the organization that owns them. It may be helpful to consider whether similar tools might have been developed locally to support other policy and strategy development processes; for example, many national health strategic plans have been developed after extensive stakeholder consultation and situational analysis, and both the tools and data from these may be available for use. For online searches, unless specifically searching for academic literature, it is usually best to search directly on the websites of the main technical agencies and other relevant institutions, and to undertake broader searches on standard search engines rather than academic databases. Generally, using a focused set of search terms is preferable so that searches do not yield too many results to search through. Features such as Google Advanced Search (https://www.google.co.uk/advanced_search) allow the user to search for specific terms on any given website, for example to look for “situational analysis” on all WHO pages. 3. Selection criteria. If apparently relevant tools are located, these should be assessed to ensure they are fit for purpose and will add value to the NQPS process. Criteria should be decided upon by the local team, but may include reliability of the source, applicability to local setting, and ease of use. Occasionally, there may be an identified need for greater support for a particular element of the NQPS process that is not met by existing available tools and resources. For example, countries may wish to perform an in-depth situational analysis on a key priority area for which there is no existing data collection tool. In this instance, it may be necessary to develop a bespoke tool to support the process. Again, the key consideration here should be whether the effort required is proportionate to the gains for the NQPS process, or whether there is a more appropriate way of supporting the particular element. New tools should always be developed and used with caution, as untested tools may not provide the required support, and indeed can present methodological challenges. More commonly there will be a relevant existing tool that can be adapted for local use. This may involve, for example, translating tools into local languages, or selecting relevant tried and tested survey questions from a more extensive data collection tool. If new or adapted tools are developed as part of the NQPS process in a particular country, owners of these tools are encouraged to share these via the WHO Global Learning Laboratory (GLL) for Quality Universal Health Coverage. When using supplementary tools to support the NQPS process, it is important to first identify the required resources to implement the tool, and to balance this against the expected benefit. The required resources may be in terms of financial cost and time required to implement a tool (for example, short non-generalizable surveys of facilities to catalyse discussion, versus large-scale statistically valid health system surveys), or could relate to the capacities required to implement tools (for example, whether there is the required expertise in engagement of stakeholders and communities). 64 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y Tools and resources compendium Clearly, a number of relevant tools and resources already exist – from WHO, external partners, and countries themselves – and are often freely available to use. However, initial country en- gagement in the WHO NQPS initiative has revealed that there is still an unmet need for tools and resources in some areas of the policy and strategy development process; this may be be- cause such tools do not exist, or are not easily identified and accessed, or are not of sufficient quality to be useful. In light of this, the NQPS handbook links closely with the WHO GLL, which aims to create a safe space to share knowledge, experiences and ideas; to challenge ideas and approaches; and to spark innovation for quality in the context of universal health coverage. Within the GLL, a focussed learning pod on NQPS has been created to facilitate sharing of experiences between countries and serve as a go-to resource for available tools relevant to NQPS. Available on the WHO GLL is a compendium of tools and resources that is a companion document to this hand- book. The compendium provides an overview of tools and resources that have been identified as helpful to support the NQPS process, and the tools identified therein are available either through direct hyperlink from the compendium or on the WHO GLL itself. This compendium comprises tools and resources that have predominantly already been produced and published by WHO and external organizations; these have been supplemented by de novo tools developed to fill critical gaps, as well as country-specific tools and examples. The compendium is not intended as a comprehensive list of all tools and resources that can support the NQPS process, but rather as a pragmatic collection of a number of tools of particular relevance, focusing on meeting country demand. The compendium is envisaged as a living document that will be updated as more tools are identified and developed, and as more countries progress on development of their national quality policies and strategies. Below is a brief overview of the approach taken to develop version 1 of the compendium. 1. A WHO meeting (June 2017) on NQPS involving national quality leads from eight countries allowed a collective examination of desired tools and resources to support NQPS, resulting in initial selection of categories of priority tools and resources designed to reflect those aspects of the NQPS process requiring more detailed input. This was based on a review of the handbook and consultation with the countries participating in the initial phase of the co-development process. 2. Scoping exercises were performed for each priority category. These differed for each category, but generally included definition of search criteria, search of publicly available sources, and liaison with country partners where required. 3. Selection of tools and resources was conducted based on the consensus of the NQPS team, with a focus on added value to the NQPS process and applicability at country level. The identified tools and resources are listed within the compendium under each of the above categories, along with instructions on how to access them and a description of how they can contribute to the NQPS process, as shown in Figure 5. 65 P A R T I I I . T O O L S A N D R E S O U R C E S Figure 5. Tools and resources: sources and relevance to the NQPS process Resource Access (web link or GLL) Institution/ author & year How this tool/resource supports the NQPS process NQPS Situational Analysis Tool Available within the NQPS learning pod on the WHO Global Learning Laboratory for Quality UHC WHO-NQPS Team 2017 Methodology for comprehensive assessment of a country’s national policies in healthcare quality Further engagement with countries and other partners will be maintained to identify and develop tools to bridge important gaps and expand the resources according to country demand. Of note, there was a need identified at the June 2017 meeting for development of further tools and resources to support national quality advocacy efforts and for integration of specific technical areas, and it is envisaged that these and other emerging categories will be addressed in future iterations. Joining the WHO GLL Instructions on how to join the WHO Global Learning Laboratory for Quality Universal Health Coverage, on which the compendium and associated tools can be accessed, are available here: http://www.who.int/servicedeliverysafety/areas/qhc/gll/en/index3.html. Name of tool, resource or example Direct web link, description of how to access, or signposting to WHO Global Learning Laboratory Organization, country or author, plus year created or updated Brief description of the resource and how it can be used to support NQPS process 66 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y GLOSSARY Term Definition Access (to health services) The perceptions and experiences of people as to their ease in reaching health services or health facilities in terms of location, time, and ease of approach (22). Accreditation A formal process by which a recognized body, usually a non- governmental organization, assesses and recognizes that a health care organization meets applicable pre-determined and published standards. Accreditation standards are usually regarded as optimal and achievable, and are designed to encourage continuous improvement efforts within accredited organizations. An accreditation decision about a specific health care organization is made following a periodic on-site evaluation by a team of peer reviewers, typically conducted every two to three years. Accreditation is often a voluntary process in which organizations choose to participate, rather than one required by law and regulation (23). Appraisal Evaluation of the performance of a health worker or trainee health worker against a published standard. Assessment A formal process of evaluation of a process or system, preferably quantitative, but sometimes necessarily qualitative (24). Benchmark (i) A measurement or point of reference at the beginning of an activity which is used for comparison with subsequent measurements of the same variable; (ii) an acceptable standard in evaluation (24). Data Facts and figures as raw material, not analysed (25). Equity in health (i) The absence of systematic or potentially remediable differences in health status, access to health care and health-enhancing environments, and treatment in one or more aspects of health across populations or population groups defined socially, economically, demographically or geographically within and across countries; (ii) a measure of the degree to which health policies are able to distribute well-being fairly (26-29). Evaluation The systematic and objective assessment of the relevance, adequacy, progress, efficiency, effectiveness and impact of a course of actions, in relation to objectives and taking into account the resources and facili- ties that have been deployed (30). Fragmentation (of health services) (i) Coexistence of units, facilities or programmes that are not integrated into the health network (31); (ii) services that do not cover the entire range of promotion, prevention, diagnosis, treatment, rehabilitation and palliative care services; (iii) services at different levels of care that are not coordinated among themselves; (iv) services that do not continue over time; (v) services that do not meet people’s needs (25). Health The state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (25, 32). Health service Any service (i.e. not limited to medical or clinical services) aimed at contributing to improved health or to the diagnosis, treatment and rehabilitation of sick people (30). 67 G L O S S A R Y Health system (i) All the activities whose primary purpose is to promote, restore and/ or maintain health (25); (ii) the people, institutions and resources, arranged together in accordance with established policies, to improve the health of the population they serve, while responding to people’s legitimate expectations and protecting them against the cost of ill-health through a variety of activities whose primary intent is to improve health (31). Health system building blocks An analytical framework used by WHO to describe health systems, disaggregating them into six core components: leadership and governance (stewardship); service delivery; health workforce; health information system; medical products, vaccines and technologies; and health system financing (33). Health system performance (i) The level of achievement of the health system relative to resources (33); (ii) the degree to which a health system carries out its functions (service provision, resource generation, financing and stewardship) to achieve its goals (34). Health systems strengthening (i) The process of identifying and implementing the changes in policy and practice in a country’s health system, so that the country can respond better to its health and health system challenges (35); (ii) any array of initiatives and strategies that improves one or more of the functions of the health system and that leads to better health through improvements in access, coverage, quality, or efficiency (36). Infection prevention and control Infection prevention and control is a scientific approach and practical solution designed to prevent harm caused by infection to patients and health workers (37). Input A quantified amount of a resource put in a process (25). Lever In relation to implementation of a policy or strategy, levers refer to mechanisms that supervisory authorities (at any level of the health system) can use to promote or enforce adherence to the policy or strategy. These often relate to procedures that can reward or sanction individuals or organizations according to their accountability for implementation; for example, legislation to enforce aspects of a policy might be called a lever, as might inclusion of policy adherence measures in health worker supervision or career progression processes. Licensure Licensure is a process by which a governmental authority grants permission to an individual practitioner or health care organization to operate or to engage in an occupation or profession. Licensure regulations are generally established to ensure that an organization or individual meets minimum standards to protect public health and safety. Licensure to individuals is usually granted after some form of examination or proof of education and may be renewed periodically through payment of a fee or proof of continuing education or professional competence. Organizational licensure is granted following an on-site inspection to determine if minimum health and safety standards have been met (25). Monitoring The continuous oversight of an activity to assist in its supervision and to see that it proceeds according to plan. Monitoring involves the specification of methods to measure activity, use of resources, and response to services against agreed criteria (30). 68 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y Operational plan An operational plan focuses on effective management of resources with a short time framework, converting objectives into targets and activities, and arrangements for monitoring implementation and resource usage. Specific meanings include (i) translation of the national strategic plan within a one-year time frame; (ii) translation of the national strategic plan into a subnational plan, e.g. a district plan, usually with a shorter time frame than the national strategic plan; (iii) a subset of a national strategic plan, limited to a particular programme (25). Outcome Those aspects of health that result from the interventions provided by the health system, the facilities and personnel that recommend them and the actions of those who are the targets of the interventions (22). Output The quantity and quality of activities carried out by a programme (25). Ownership The effective leadership and coordination by countries of their development policies, strategies and development actions (25). Patient safety Patient safety is the absence of preventable harm to a patient during the process of health care. The discipline of patient safety is the coordinated efforts to prevent harm, caused by the process of health care itself, from occurring to patients (38). People-centred health services “An approach to care that consciously adopts the perspectives of individuals, families and communities, and sees them as participants as well as beneficiaries of trusted health systems that respond to their needs and preferences in humane and holistic ways. People-centred care requires that people have the education and support they need to make decisions and participate in their own care. It is organized around the health needs and expectations of people rather than diseases.” (39). Performance-based payment, performance-based funding Payment or funding conditional upon taking a measurable action or achieving a predetermined performance target. It may refer to transfer of funds by donors to recipient countries, or to payment of providers or provider organizations for reaching service targets (25, 40). Priority setting The identification, balancing and ranking of priorities by stakeholders (25). Quality assurance All the planned and systematic activities implemented within the quality system, and demonstrated as needed, to provide adequate confidence that an entity will fulfil requirements for quality (41). Quality control Operational techniques and activities that are used to fulfil requirements for quality (41). Quality improvement “An organizational strategy that formally involves the analysis of process and outcomes data and the application of systematic efforts to improve performance” (42). Quality management All activities of the overall management function that determine the quality policy, objectives, and responsibilities, and implement them by means such as quality planning, quality control, and quality improvement within the quality system (41). Quality planning Activities that establish the objectives and requirements for quality and for the application of quality system elements (41). 69 G L O S S A R Y Regulation The imposition of external constraints upon the behaviour of an individual or an organization to force a change from preferred or spontaneous behaviour (25, 43). Resilience The ability of a system, community or society exposed to hazards to resist, absorb, accommodate to and recover from the effects of a hazard in a timely and efficient manner, including through the preservation and restoration of its essential basic structures and functions (44). Situation analysis Analysis of the current status and expected trends in a country’s health and health system. Ideally this includes (i) assessment of current and future health needs and determinants of health; (ii) assessment of expectations and demand for services; (iii) assessment of the health system performance, health sector capacity and health system resources, and the gaps in responding to current and future needs and expectations; and (iv) analysis of stakeholder positions (25, 45). Stakeholder An individual, group or organization that has an interest in the organi- zation and delivery of health care (24). Standard An established, accepted and evidence-based technical specification or basis for comparison (24, 25). Strategy A series of broad lines of action intended to achieve a set of goals and targets set out within a policy or programme (25, 46). Sustainability The potential for sustaining beneficial outcomes for an agreed period at an acceptable level of resource commitment within acceptable organizational and community contingencies (25, 47). Target An intermediate result towards an objective that a programme seeks to achieve, within a specified time frame. A target is more specific than an objective and lends itself more readily to being expressed in quantitative terms (25). Universal health coverage All people and communities can use the promotive, preventive, cura- tive, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship (10). 70 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y REFERENCES 1. Quality of care: a process for making strategic choices in health systems. Geneva: World Health Organization; 2006. 2. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington (DC): National Academies Press; 2001. 3. Improving value in health care: measuring quality. Paris: Organisation for Economic Co- operation and Development; 2010. 4. Donaldson LJ, Donaldson RJ. Essential public health, 2nd edition. Petroc Press; 2000. 5. Miranda S, Olexa GA. Creating a just culture: recalibrating our culture of patient safety. Pennsylvania Nurse. 2013;68(4):4–9. 6. Pronovost PJ, Wachter RM. Progress in patient safety: a glass fuller than it seems. American Journal of Medical Quality. 2014;29(2):165–9. 7. Marx D. Patient safety and the “just culture”: a primer for health care executives. New York: Columbia University; 2001. 8. Everybody’s business – strengthening health systems to improve health outcomes: WHO’s framework for action. Geneva: World Health Organization; 2007. 9. Transforming our world: the 2030 Agenda for Sustainable Development. New York: United Nations; 2015 (https://sustainabledevelopment.un.org/post2015/transformingourworld, accessed 2 February 2018). 10. Health financing for universal coverage. Geneva: World Health Organization (http://www. who.int/health_financing/universal_coverage_definition/en/, accessed 2 February 2018). 11. What is universal health coverage? Geneva: World Health Organization; 2014 (http:// www.who.int/features/qa/universal_health_coverage/en/, accessed 2 February 2018). 12. Strengthening integrated, people-centred health services. Resolution WHA69.24, Sixty- ninth World Health Assembly. Geneva: World Health Organization; 2016. 13. Service delivery and safety: World Health Assembly adopts Framework on Integrated People- centred Health Services. Geneva: World Health Organization; 2016 (http://www.who.int/ servicedeliverysafety/areas/people-centred-care/framework-wha/en/, accessed 2 February 2018). 14. The world health report. Health systems financing: the path to universal coverage. Geneva: World Health Organization; 2010. 15. Donabedian A. Evaluating the quality of medical care. Milbank Memorial Fund Quarterly. 1966;44(3 Suppl):166-206. 16. Das J. The quality of medical care in low-income countries: from providers to markets. PLoS Medicine. 2011;8(4):e1000432. 17. Leatherman S, Sutherland K. The quest for quality in the NHS: a mid-term evaluation of the ten year quality agenda. London: Stationery Office; 2003. 18. Leatherman S, Sutherland K. Designing national quality reforms: a framework for action. International Journal for Quality in Health Care. 2007;19(6):334–40. 19. Leatherman S, Sutherland K. The quest for quality: refining the NHS reforms. London: Nuffield Trust; 2008. 20. Shekelle P, Lim YW, Mattke S, Damberg C. Does public release of performance results improve quality of care? A systematic review. London: Health Foundation; 2008. 21. Donabedian A. Explorations in quality assessment and monitoring, volume I. The definition of quality and approaches to its assessment. Ann Arbour, MI: Health Administration Press; 1980. 71 R E F E R E N C E S 22. Starfield B. Basic concepts in population health and health care. Journal of Epidemiology and Community Health. 2001;55(7):452–4. 23. Rooney AL, van Ostenberg PR. Licensure, accreditation, and certification: approaches to health services quality. Bethesda: United States Agency for International Development; 1999. 24. Last JM, editor. A dictionary of public health. Oxford University Press; 2007. 25. Health systems strengthening glossary. Geneva: World Health Organization (http://www. who.int/healthsystems/hss_glossary/en/, accessed 6 February 2018). 26. Starfield B. Equity in health. Journal of Epidemiology and Community Health. 2002;56:483–4. 27. Dahlgren G, Whitehead M. Levelling up (part 1): a discussion paper on concepts and principles for tackling social inequities in health. In: Studies on social and economic determinants of population health, No. 2. Copenhagen: WHO Regional Office for Europe; 2006. 28. Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health. Geneva: World Health Organization; 2008. 29. La renovaciόn de la atenciόn primaria a la salud en las Américas [Renewal of primary health care in the Americas]. Washington (DC): OPS/OMS; 2007 (http://www2.paho.org/hq/dm- documents/2010/Renovacion_Atencion_Primaria_Salud_Americas-OPS.pdf, accessed 16 October 2017) (in Spanish). 30. Roberts JL. A glossary of technical terms on the economics and finance of health services. Copenhagen: WHO Regional Office for Europe; 1998. 31. Salud en las Américas, volume I. Washington (DC): Pan American Health Organization; 2007. 32. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference. New York: World Health Organization; 1946. 33. The world health report 2000. Health systems: improving performance. Geneva: World Health Organization; 2000. 34. Murray C, Evans D, editors. Health systems performance assessment: debates, methods and empiricism. Geneva: World Health Organization; 2003. 35. WHO Executive Board, 128th session. Health system strengthening: current trends and challenges. Geneva: World Health Organization; 2011. 36. Islam M, editor. Health systems assessment approach: a how-to manual. Submitted to the United States Agency for International Development in collaboration with Health Systems 20/20, Partners for Health Reformplus, Quality Assurance Project, and Rational Pharmaceutical Management Plus; 2007. 37. Clean care is safer care: infection prevention and control. Geneva: World Health Organization (http://www.who.int/infection-prevention/about/ipc/en/, accessed 6 February 2018). 38. Patient safety. Geneva: World Health Organization (http://www.who.int/patientsafety/ about/en/, accessed 6 February 2018). 39. What are integrated people-centred health services? Geneva: World Health Organization (http://www.who.int/servicedeliverysafety/areas/people-centred-care/ipchs-what/en/, accessed 19 February 2018). 40. Eichler R. Can ‘‘pay-for-performance’’ increase utilization by the poor and improve the quality of health services? Washington (DC): Center for Global Development; 2006. 41. Juran JM, Godfrey AB. Juran’s quality handbook, fifth edition. McGraw-Hill; 1999. 42. Evidence-based Practice Center systematic review protocol: closing the quality gap 2010: 72 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y quality improvement interventions to address health disparities. Rockville, MD: Agency for Healthcare Research and Quality; 2012 (https://effectivehealthcare.ahrq.gov/topics/ disparities-quality-improvement/research-protocol, accessed 19 February 2018) 43. Saltman RB. Regulating incentives: the past and future role of the state in health care systems. Social Science and Medicine. 2002;54:1677–84. 44. UNISDR terminology on disaster risk reduction. United Nations International Strategy for Disaster Reduction; 2009. 45. A framework for national health policies, strategies and plans. Geneva: World Health Organization; 2010. 46. Health impact assessment: glossary of terms used. Geneva: World Health Organization (http://www.who.int/hia/about/glos/en/index2.html, accessed 6 February 2018). 47. Understanding the sustainability of health programmes and organizational change. Paper for Victorian Quality Council. La Trobe University, Faculty of Health Sciences; June 2007. World Health Organization 20 Avenue Appia CH-1211 Geneva 27 Switzerland Please visit us at: http://www.who.int/servicedeliverysafety/areas/qhc/nqps/en/ ISBN 978-92-4-156556-1

HANDBOOK FOR NATIONAL QUALITY POLICY AND STRATEGY A practical approach for developing policy and strategy to improve quality of care HANDBOOK FOR NATIONAL QUALITY POLICY AND STRATEGY A practical approach for developing policy and strategy to improve quality of care Co-developed by the World Health Organization and countries pursuing national quality initiatives Handbook for national quality policy and strategy: a practical approach for developing policy and strategy to improve quality of care ISBN 978-92-4-156556-1 © World Health Organization 2018 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc- sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation. Handbook for national quality policy and strategy: a practical approach for developing policy and strategy to improve quality of care. Geneva: World Health Organization; 2018. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/ about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Designed by CommonSense, Greece Printed by the WHO Document Production Services, Geneva, Switzerland 3 CONTENTS Foreword ................................................................................................................... 5 Acknowledgements .................................................................................................... 6 Abbreviations ............................................................................................................ 7 INTRODUCTION .......................................................................................................9 What is a national quality policy and strategy? ...........................................................10 Importance and integration of policy and strategy ......................................................11 Making the case for quality ........................................................................................12 Defining the concept of quality .................................................................................13 A culture of quality ...................................................................................................14 Quality across the health system ...............................................................................15 NQPS within the context of universal health coverage and the SDGs ..........................16 Handbook for national quality policy and strategy .....................................................17 NQPS initiative .........................................................................................................18 PART I. POLICY DEVELOPMENT ............................................................................ 19 Development of a national quality policy ................................................................ 21 1. National health goals and priorities ...................................................................... 21 2. Local definition of quality..................................................................................... 23 3. Stakeholder mapping and engagement .................................................................. 24 4. Situational analysis: state of quality ......................................................................25 5. Governance and organizational structure for quality .............................................. 26 6. Improvement methods and interventions ............................................................... 28 7. Health management information systems and data systems ................................... 30 8. Quality indicators and core measures .................................................................... 30 PART II. STRATEGY DEVELOPMENT ...................................................................... 32 Development of a national quality strategy ............................................................. 34 1. National health goals and priorities ...................................................................... 34 2. Local definition of quality..................................................................................... 36 3. Stakeholder mapping and engagement .................................................................. 37 4. Situational analysis: state of quality ..................................................................... 40 5. Governance and organizational structure for quality .............................................. 42 6. Improvement methods and interventions ................................................................45 7. Health management information systems and data systems ................................... 52 8. Quality indicators and core measures .................................................................... 55 Developing an operational plan for implementation ................................................. 58 Overview and rationale ............................................................................................ 58 When and how should the operational plan be developed? ........................................ 58 What elements should the operational plan include? ................................................. 58 Integrating technical programmes with NQPS .......................................................... 59 4 PART III. TOOLS AND RESOURCES ...................................................................... 61 Background ............................................................................................................. 62 Finding, selecting and using tools to support the NQPS process ................................. 62 Tools and resources compendium ............................................................................. 64 Glossary .............................................................................................................66 References ..........................................................................................................70 Boxes Box 1. Policy and strategy informed by implementation ......................................................11 Box 2. Defining quality health care .....................................................................................13 Box 3. Culture of quality: key features ................................................................................14 Box 4. Water, sanitation and hygiene: a critical foundation for quality across health systems ...16 Box 5. Goals and priorities ................................................................................................ 22 Box 6. Health security and quality: closely linked priorities ................................................. 22 Box 7. Illustrative list of potential stakeholders ................................................................. 25 Box 8. Health care quality: roles and responsibilities of selected stakeholders ..................... 27 Box 9. Basic elements essential for systemwide quality ...................................................... 29 Box 10. Variations in national quality strategies................................................................. 35 Box 11. Case study: defining quality in Sudan .................................................................... 36 Box 12. Community and patient engagement: the Ugandan experience .............................. 39 Box 13. External evaluation, licensing and certification ...................................................... 46 Box 14. Applying the Juran Trilogy to guide selection of interventions ................................ 47 Box 15. Sample key questions to assess current data sources ............................................. 52 Box 16. Potential sources of quality measurement available in many countries ................... 53 Box 17. Ten criteria for assessing quality indicators for a core set ....................................... 56 Box 18. Potential sources of tools and resources ............................................................... 62 Figures Figure 1. Shift from linear models to implementation-informed policy and strategy development .................................................................................................................... 12 Figure 2. Sample organigram for national quality efforts .................................................... 43 Figure 3. Illustrative activities across five levels of hierarchy ............................................... 50 Figure 4. Framework of interventions at each level of hierarchy: Mexico ............................. 51 Figure 5. Tools and resources: sources and relevance to the NQPS process ......................... 65 Tables Table 1. Framing the dimensions of quality ........................................................................ 23 Table 2. Stakeholders and related tasks ............................................................................. 38 Table 3. Illustrative quality interventions .......................................................................... 48 5 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y FOREWORD The Sustainable Development Goals place a clear emphasis on achieving universal health coverage, which means “ensuring that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship”. The WHO Framework on Integrated People-centred Health Services presents a vision for the future in which “all people have access to health services that are provided in a way that responds to their preferences, are coordinated around their needs and are safe, effective, timely, efficient and of an acceptable quality”. The proposed action within the WHO Framework places a clear emphasis on policy levers to enhance quality. The development, refinement and execution of a national quality policy and strategy is a priority for countries as they strive to improve the performance of their health care systems. With the growing momentum towards universal health coverage, there is a corresponding awareness that improved access must be accompanied by focused efforts to improve the quality of health services to achieve the desired improvements in health outcomes. Countries are seeking advice to inform their efforts on national quality policy and strategy. They are taking diverse approaches with multiple entry points for improving quality, and many are also looking to the subnational level as a focus for action. However, the objective remains the same: improvement in quality of health care as a pivotal entry point for health systems strengthening, and ultimately achieving enhanced population health. In recognition of this critical need, the WHO initiative on national quality policy and strategy has four objectives: (a) to raise awareness, knowledge and skills concerning national quality policy and strategy in low- and middle-income countries; (b) to outline key processes for the planning, development and implementation of national quality policy and strategy; (c) to provide support to countries in this arena; and (d) to continue co-development and documentation of processes related to the development and implementation of national quality policies and strategies within a learning laboratory arrangement. This document provides a foundation for this initiative, building on an existing body of work from WHO and others. It provides structure around the subject area, outlines some of the key issues for consideration and presents a starting point for the action that needs to follow. It will continue to be refined through a co-development process involving countries and technical partners, which will also yield a number of complementary resources. This handbook is one output of a larger initiative that seeks to respond to the needs of countries for strategic and practical counsel around national quality policies and strategies. The linkages with wider health policy and planning are central to this approach. The audience for this foundation document is diverse. The primary audience is those responsible for leading the development and implementation of national quality policies and strategies. A much wider set of stakeholders who actively participate in the national process will benefit. Partners at the national, regional and global level that are involved in providing support in quality improvement efforts will also stand to benefit from the content provided. Each country must pursue its own pathway to universal health coverage guided by multiple and complex considerations. A carefully designed national approach to quality can be a pivotal entry point for countries as they work to achieve better health outcomes. 6 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y ACKNOWLEDGEMENTS The WHO Handbook for national quality policy and strategy was produced under the overall direction of Edward Kelley and Shams Syed from the Service Delivery and Safety Department, WHO headquarters, Geneva. The principal writing team consisted of Sheila Leatherman, Shams Syed, Ruben Frescas and Matthew Neilson. Sheila Leatherman provided substantial content to the handbook, given her role as lead adviser to the WHO initiative on national quality policy and strategy. Previous research and publications of Sheila Leatherman and co-authors have contributed throughout all sections of the handbook. Previous work of WHO related to quality and patient safety policy and strategy, both at WHO headquarters and in the WHO regions, has contributed significantly in shaping the handbook. Preparation of the handbook was informed by country examples of development of national quality policy and strategy, many of which are featured in the text. We would like in particular to acknowledge the contribution of a number of countries to the emerging body of knowledge captured in the handbook – Colombia, Ethiopia, Ghana, Indonesia, Liberia, Malawi, Mexico and Sudan. We would also like to acknowledge the work of a range of technical partners, including the International Society for Quality in Health Care, the Institute for Healthcare Improvement, the USAID Applying Science to Strengthen and Improve Systems Project (ASSIST), and HealthQual, which has influenced the field and informed this work. We acknowledge Bruce Agins and Josh Bardfield for their contribution to the section on integrating technical programmes with national quality policy and strategy; Lisa Hirschhorn and Sun Mean Kim for their assistance in the sections on health management information systems, data and measurement; Liana Rosenkrantz Woskie, Anthony Moccia and Ruma Rajbhandari for their work on quality interventions; and Julie Storr, Lopa Basu, Nana Mensah Abrampah, Rhea Bright, Breda Cosgrove and Laura Simpson for review of the handbook. Valuable inputs in the form of contributions, peer reviews and suggestions were provided by Kehinde Balogun, Stephen Balogun, Pierre Barker, Jeffrey Braithwaite, Lucky Chikaura, Susan Davis, Paulina Pacheco Estrello, Raghavendra Guru, Maki Kajiwara, Pierre Claver Kariyo, Manuel Kassaye Sibhatu, Samuel Kidane, Jason Leitch, Garth Manning, Rashad Massoud, Mohamed A. Mohamed, Margaret Montgomery, Zainab Naimy, Edgar Necochea, Wendy Nicklin, Robbie Pearson, Charles Shaw, Sylvia Sax, Sodzi Sodzi-Tettey, David Weakliam and Albert Wu. A first working draft of the handbook was peer-reviewed at a meeting in Geneva, Switzerland, in June 2017 with the following country participants: Hind Babekir Hassan Abdallatif, Philip Kerkula Bemah, Daniel Gebremichael Burssa, Andrew Likaka, German Escobar Morales, Benjamin Nyakutsey, Sebastian Garcia Saisό and Eka Viora. Also attending were the following WHO country and regional experts: Salma Burton, Nino Dal Dayanghirang, Jonas Gonseth-Garcia, Mondher Letaief and Juan Eduardo Tello. The meeting was also attended by the following WHO experts from headquarters: Benedetta Allegranzi, Giorgio Cometto, Neelam Dhingra-Kumar, Bruce Gordon, Ann-Lise Guisett, Heather Harmon, Lauren Hoisl, Dirk Horemans, Sun Mean Kim, Blerta Maliqi, Asiya Odugleh-Kolev, Archana Shah and Satvinder (Vindi) Singh. The development of the document was kindly supported by the Japanese Ministry of Health, Labour and Welfare through a contribution to the World Health Organization. 7 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y ABBREVIATIONS GLL Global Learning Laboratory for Quality Universal Health Coverage HMIS health management information system MDG Millennium Development Goal NQPS national quality policy and strategy OECD Organisation for Economic Co-operation and Development SDG Sustainable Development Goal WASH water, sanitation and hygiene WHO World Health Organization 8 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y The handbook at a glance What is this document? A handbook outlining the case for developing national policy and strategy on quality of health care, the process required to do so, and supporting tools Policy Strategy The policy is based upon an agreed ambition with explicit statement of intention, and becomes the agreed “course of action”. This section describes how to develop a national quality policy, either as a stand-alone document or as part of wider national health policy. The strategy provides a clear roadmap and outlines “how” the policy will come to fruition. Many aspects of the strategy process will take place simultaneously with policy development. This section outlines a structured, multistakeholder, data-driven process. Tools A number of further tools and resources can support the NQPS process. This section describes how to access and select such tools, and introduces an accompanying compendium of tools available on the WHO Global Learning Laboratory for Quality UHC. Operational planning National health priorities Situational analysis Stakeholder mapping & engagement Governance and organizational structure Improvement methods & interventions Quality indicators & core measures Health management information systems & data systems Strategy implementation can be outlined in a detailed operational plan, which defines key tasks, assigns responsibilities, identifies milestones, and considers practical aspects of implementation, such as funding. Integrating technical programmes Countries often have existing quality initiatives focused around specific technical areas (such as HIV or water, sanitation and hygiene) or population groups (such as mothers and children). Successfully integrating these efforts with overarching work on national quality necessitates careful planning. Who is it for? Authorities developing national policies and strategies on quality, stakeholders involved in the process, and external partners supporting ministries of health How should it be used? As a structured approach to support development of national quality policy and strategy, to complement existing national expertise and external support Universal health coverage means all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship. Many countries are making efforts to improve quality of care and institutionalize a culture of quality across their health system. These efforts can be strengthened through the development ofNational Quality Policy and Strategy (NQPS). This handbook provides an overview of eight key elements required to produce such policy and strategy documents, and is presented in three main sections: policy, strategy and tools. Ministry Ministry Ministry Th e ei gh t el em en ts o f N Q PS Government Local definition of quality Committee INTRODUCTION 10 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y Section overview • What is a national quality policy and strategy (NQPS)? • Importance and integration of policy and strategy • Making the case for quality • Defining the concept of quality • A culture of quality • Quality across the health system • NQPS within the context of universal health coverage and the SDGs • How to use this resource Each country is motivated to address the issue of health care quality for various reasons. These include a belief in and commitment to quality health care as a public good; growing awareness of gaps in safe, effective and person-centred care; a drive towards universal health coverage and the understanding that improvements in access without appropriate attention to quality will not lead to the desired population health outcomes; cost pressures and a push for greater efficiency and value for money across the health system; growing recognition of the need to align the performance of public and private health care delivery in fragmented and mixed health markets; an increasing understanding of the critical importance of trusted services for effective preparedness for outbreaks or other complex emergencies; and finally, expectations from the public, media and civil society with a growing public demand for transparency and accountability. Though reasons for national efforts on quality may vary, countries will encounter common issues as they develop or refine their quality-related policies and strategies, and the basic tasks are similar. While it is clear that the ability of countries to provide quality care will be affected by available resources, national efforts to improve quality of care must not be seen as solely the concern of high-income countries or as an issue only to be addressed when access has been expanded. Each domain of quality has clear relevance to any health care system, and while different countries may have the resources to address each to a different degree, there will almost always be a number of low-resource starting points for action. Indeed, as a focus on quality promotes more efficient, effective and integrated services that respond to population need, national efforts to improve quality of care can themselves help any health system to increase the value for money it provides. What is a national quality policy and strategy? A national quality policy and strategy (NQPS) is an organized effort by a country to promote and plan for improved quality of care. It will often be outlined in a document, providing an official, explicit statement of the approach and actions required to enhance the quality of health care across a country’s health system, and needs to be linked closely with the wider national health policy and planning process. Responsibility for the development of such documents is commonly held by the ministry of health, working in close collaboration with a range of policy- makers and implementers. Experiences from countries with national quality policies and strategies have highlighted the benefits of one coherent plan that provides guidance and direction on quality at all levels of the system. However, quality-related policies exist within the context of wider national governance arrangements. The NQPS can help clarify the linkages with national health – and non-health – policies, plans and priorities, highlight the importance of quality-focused processes in realizing overall health priorities, and define lines of accountability to work towards more people-centred health services. 11 I N T R O D U C T I O N Importance and integration of policy and strategy Many countries choose to focus on a national quality strategy; however, there is benefit in also elaborating a national quality policy that secures political buy-in, helps drive the strategy and its implementation, and places national quality efforts within the wider policy environment. While there may be significant overlap in the development process and content, there is a clear distinction between the two: the policy is based upon an agreed ambition with explicit statement of intention and becomes the agreed “course of action”. It may make the case for action and outline broad priorities to be addressed. The strategy provides a clear roadmap and outlines “how” the policy will come to fruition, and may be refined during the longer term of the policy. The “quality strategy” is a bridge that helps a health system accelerate achievement of health goals and priorities, using quality management principles that incorporate quality planning, control and improvement. While this document outlines a process of simultaneous development of policy and strategy, country needs may drive a focus on either policy or strategy. Irrespective, it is important to consider both when making an informed decision. The policy and strategy should of course be thought of in an integrated manner: commonly just one document or, in some cases, complementary and co-dependent documents developed as part of a systemwide effort to improve quality of care. Indeed, it is entirely reasonable to also consider whether the most appropriate mechanism for development and publication of national quality policy, strategy, or both is as part of broader integrated national health planning. There are benefits and disadvantages of both approaches. For example, while integration of quality efforts within national health policy and strategy may bring benefits such as increased political buy-in, integrated implementation efforts, and opportunity for systemwide consideration of quality, stand-alone documents may allow for greater detail, higher profile of quality, and use of different planning and implementation timescales. Whichever approach is used, care should be taken to ensure development of the NQPS is aligned with broader national health planning, whether by fully integrating the development and publication processes or simply aligning the goals, priorities and actions and cross-referencing documents. Policy and strategy may have a particular focus on health care services that are publicly funded or provided, though consideration should be given to how they can impact the full health care system. Working across the full continuum of care, the national direction on quality needs to also include the private sector, including faith-based organizations, and there may be key roles for cross-sectoral organizations such as professional bodies, local governments and academia. Box 1. Policy and strategy informed by implementation Traditionally, policy, strategy and implementation are thought of as a linear process. However, moving to a triangular process (see Figure 1) where implementation experience drives policy and strategy development can build a sense of ownership among those implementing and ensure products are grounded in the realities of service delivery and patient and community experience. In practice, implementation-informed policy and strategy development requires sustained and meaningful engagement with stakeholders across the health system throughout the process, recognizing there need not be an inherent dichotomy between “top-down” and “bottom-up” approaches to improve quality. 12 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y Making the case for quality The process of developing and implementing national policy and strategy on quality of care can itself be a key mechanism for advocating improvements in quality of care, as it can engage and secure buy-in from key stakeholders (notably at national government level), bring the issue to public and professional prominence, and provide an opportunity to demonstrate the value to the health system of such initiatives. However, even to arrive at the point of securing adequate support to start developing national policies and strategies may require intensive efforts. In a resource-constrained environment with competing health priorities, advocacy for a focus on a particular issue can be challenging. Initial steps to lay the groundwork for a national effort on quality may include: • identifying and engaging key decision-makers and policy influencers; • demonstrating potential for impact, for example through evidence, or sharing of case examples from other countries; • involvement of external advocates such as technical agencies and academia; • building support among health care staff and the public, for example through engagement of media, small-scale capacity-building in quality improvement, promoting sharing of learning and generation of evidence, and mobilization of civil society; • securing seed funding for initial efforts to enhance quality, for example from donor agencies or professional bodies, to allow momentum to be built and encourage domestic investment; • seeking opportunities to influence broader health system planning to incorporate a focus on quality, for example during development of national health strategic plans or national health budgeting. It is also important to recognize that most countries will have existing relevant initiatives that can be built upon, and which may help to catalyse a broader initiative on NQPS. Examples of common entry points include existing technical programmes such as HIV or maternal and child health, external evaluation programmes such as accreditation, and subnational or facility-level quality improvement initiatives. Figure 1. Shift from linear models to implementation-informed policy and strategy development 13 I N T R O D U C T I O N Defining the concept of quality To date, there is no single universally accepted definition of “quality”, though there is a commonly shared understanding of basic concepts and defining dimensions (1). Within the global health community, the definition below from the United States Institute of Medicine has been widely used. It establishes the basic goal of positively impacting health outcomes at both the individual and population levels, and emphasizes the central importance of evidence and professional knowledge. By the definition, quality is: The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (2). In addition, the Institute of Medicine lays out six general dimensions, or aims, of quality by stating that care should be safe, effective, patient-centred, timely, efficient, and equitable. This set of dimensions or attributes has also been adopted and adapted in countries outside the United States of America (2). In 2006, the World Health Organization (WHO) similarly defined the basic concepts of quality in stating that care should be effective, efficient, accessible, acceptable, patient-centred, equitable, and safe. Significantly, this definition introduced the dimension of “accessible” as a broader aim than just “timely” (1). Over the last decade the Organisation for Economic Co-operation and Development (OECD) has chosen to highlight three dimensions of quality – effectiveness, safety and patient-centredness – thus bringing domains together. This more concise conceptualization has also influenced thinking in a number of countries (3). More recently, the WHO Framework on Integrated People-centred Health Services has described “high quality care” as “care that is safe, effective, people-centred, timely, efficient, equitable and integrated”. And of course, access to health services underpins all quality efforts, especially in the era of universal health coverage and the drive for equitable population coverage and financial protection. Notably, patient safety has long been seen as an entry point for efforts to improve quality of care, and safe care can be seen as a barometer of the success of basic systems to improve quality. Box 2 summarises a selection of the main components of definitions of quality health care. Box 2. Defining quality health care Quality health care can be defined in many ways but there is growing acknowledgement that quality health services across the world should be: • Effective: providing evidence-based health care services to those who need them. • Safe: avoiding harm to people for whom the care is intended. • People-centred: providing care that responds to individual preferences, needs and values. In addition, in order to realize the benefits of quality health care, health services must be: • Timely: reducing waiting times and sometimes harmful delays for both those who receive and those who give care. • Equitable: providing care that does not vary in quality on account of age, sex, gender, race, ethnicity, geographical location, religion, socioeconomic status, linguistic or political affiliation. • Integrated: providing care that is coordinated across levels and providers and makes available the full range of health services throughout the life course. • Efficient: maximizing the benefit of available resources and avoiding waste. 14 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y Although there is significant convergence now on what the essential dimensions of quality are within the health sector, each country will probably have its own local understanding or definition of quality. The process of defining quality through stakeholder engagement and consensus building is crucial in establishing a shared intention and understanding for the national approach to quality. Recognizing the importance of contextualizing quality is critical, as it will help to further guide the focus and creation of a quality policy and accompanying strategy that responds to local needs. A culture of quality When planning a national effort to improve quality of care, it is useful to consider the importance of developing and institutionalizing a “culture of quality” in organizations and across the health system as a means to sustainable and meaningful change. There is no single definition of what a culture of quality entails, but it has been described as “an organization which creates a working environment which is open and participative, where ideas and good practices are shared, where education and research are valued and where blame is used exceptionally” (4). It is generally understood to mean that, at all levels of a health system, there is an inherent and explicit recognition of the value of efforts to improve the quality of care provided, and such efforts are systematically promoted within an enabling environment that encourages engagement, dialogue, openness and accountability. Some of the features of a health system with an embedded culture of quality are outlined in Box 3. However, culture within organizations and health systems is set and maintained by a complex set of factors, including prevailing wider cultural norms, community expectations, health system leadership, health system structures and networks, and the medico-legal environment. Understandably, effecting change within such cultures may therefore be a slow and challenging process, and may be opposed by those threatened by cultural change. There is a key role for political and health system leadership in defining and promoting a culture of quality, refining the legal environment, and leading by example to embed the required values throughout the system. Stakeholder engagement and situational analysis, as described in more detail in Parts I and II, can be used to help understand the current culture within the system and identify barriers and facilitators for cultural change. Indeed, the whole process of developing and implementing an NQPS can support broader cultural change across the health system, providing an explicit statement of the desired culture and a set of actions that can aid its institutionalization. Box 3. Culture of quality: key features • Leadership for quality at all levels • Openness and transparency • Emphasis on teamwork • Accountability at all levels • Learning embedded in system • Active feedback loops for improvement • Meaningful staff, service user and community engagement • Empowering individuals while recognizing complex systems • Alignment of professional and organizational values • Fostering pride in care • Valuing compassionate care • Coherence of quality efforts with service organization and planning 15 I N T R O D U C T I O N When discussing the intended culture to be supported by the NQPS, it may be worth considering the desired balance between a “no blame” and a “just” culture (5, 6). A “no blame” culture recognizes that errors inevitably occur within a health care system, often due to multiple factors and system failures, and that a response that seeks only to blame the well intentioned will not adequately address system deficiencies. In order to continually identify and address system errors, a “just” culture attempts to promote a safe environment for quality improvement by encouraging identification and correction of systemic failures while still acknowledging personal accountability (7). Personal accountability may be seen to discourage careless or deficient practice, but may also encourage clinicians to practice defensively or fail to report mistakes. These concepts are of course not mutually exclusive; instead, policy-makers should be aware of the impact that differences in culture can have on quality of care across a health system. There are also important considerations for policy and strategy development around how the culture of teams responsible for implementation across the health system can impact its success. Delivering reforms to health care provision that are inclusive, equitable, and promote a culture of improvement requires that clinical and managerial teams responsible for implementation reflect these principles in their own approach and values. Health care systems exist to serve the population, so it is critical that people are at the heart of efforts to institutionalize a culture of quality. Such a culture must embrace and enable meaningful engagement of the communities served by the system, and the system must be fit for purpose to perform this engagement. For example, involving patients, families and communities in the planning, management, delivery and evaluation of health services helps ensure that priorities reflect what matters to them, and introduces a new level of accountability for quality care. Hence, investment in the structures and skills required for engagement can be a powerful means to set and institutionalize a culture of quality within a health system. Quality across the health system While quality of care is predominantly expressed at the level of the interaction between the provider and receiver, it takes place within a much broader, complex health system, and this context should be considered by those planning national efforts to improve quality of care. The WHO health system building blocks (8) are often used by countries to examine the interface of national quality efforts with different parts of the health system within their specific context. This can help to ensure that some of the basic structures and processes that will underpin the policy and strategy are in place, and that their influence on delivery of quality care is accounted for. For example, service delivery in many countries may still be based on traditional hierarchical provider–patient relationships. Reorienting care around the needs, preferences and engagement of the people served by health providers can be a powerful step to institutionalize quality of care. High turnover of the health workforce may provide a challenge to maintenance of institutional quality structures and knowledge, and may itself result from working environments that are not conducive to quality care. Adherence to evidence-based quality standards requires reliable access to essential medicines and commodities; endeavours to enhance quality of service provision thus require examination of supply chains and quality of medicines. Applying a quality lens to health financing reforms can help ensure that in expanding access to services other domains of quality, such as equity and efficiency of service provision, are not compromised. Leadership and governance is critical to the success of NQPS. To avoid such efforts becoming a vertical, stand-alone initiative, strong support for quality is required among existing health system leadership at all levels, which may be aided by building quality improvement capacity among leaders themselves. Alignment between quality policy and strategy and wider health governance is – as stated previously – of paramount importance. 16 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y Box 4. Water, sanitation and hygiene: a critical foundation for quality across health systems Multiple cross-cutting entry points require careful attention when linking quality to health systems. For example, water, sanitation and hygiene (WASH) in health care facilities is a fundamental aspect of strong, resilient health systems. This is especially true in low- and middle-income settings where WASH is often lacking and even absent. As a key component of safe and quality services, WASH improves not only health outcomes and the experience of care, but also staff morale and the efficiency of services. Improving WASH services can immediately address inequity, as such services are often lacking in the facilities serving the most vulnerable communities. For example, in Liberia, WASH in health care facilities is a key component of the national post-Ebola health systems strengthening and quality efforts, involving mentoring, supportive supervision, and monitoring alongside infrastructure improvements. This is critically linked to the core components of infection prevention and control, which are also being implemented in Liberia. Both WASH and infection prevention and control are required to ensure patient and health worker safety, and where their provision is insufficient, community trust in services is likely to be damaged. Given the fundamental role of these key health service capabilities in provision of safe, quality care, assessing and addressing them in the context of national directions on quality is an important step. NQPS within the context of universal health coverage and the SDGs The adoption of the Sustainable Development Goals (SDGs) (9) and the focus on universal health coverage (10, 11) provide a critical entry point for the activation of NQPS in low- and middle-income countries. SDG 3 – “ensure healthy lives and promote well-being for all at all ages” – will drive action at the local and global levels (9) Within this goal, target 3.8 highlights the importance of quality essential health care services. How this is achieved is of course complex, requiring multiple considerations and inputs. However, one important success factor is a governance structure for quality with clearly articulated policies and strategies. Progress towards universal health coverage can be driven by a move towards integrated people- centred health services that can respond effectively to the emerging and varied health challenges of the 21st century. A WHO framework on the subject was approved by all Member States at the World Health Assembly in 2016 (12, 13). One of the five strategic directions provides specific focus on the need to strengthen governance and accountability (12, 13). As part of this strategic direction, there needs to be a strong emphasis on the development of policies and strategies that enhance quality of service delivery at the point of care. This requires careful consideration of how national direction and structure can help support subnational and local services that populations engage with to meet their health care needs. Within the context of achieving the SDGs, the global universal health coverage movement is resulting in many countries considering not only their financial and provider payment structures but also their quality structures as a means of improving health outcomes while also reducing waste and redundancy, thus promoting more efficient use of effective services to meet health sector priorities (14). Indeed, among all countries, but particularly those facing significant resource limitations, there is an urgent need to develop processes and structures for quality that can best utilize the resources available and continuously seek to evaluate and improve upon practices and services provided. Universal health coverage: Ensuring that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship (10) TARGET 3.8 Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all (9). 17 I N T R O D U C T I O N Handbook for national quality policy and strategy This document aims to support the development of NQPS. In particular, it supports the efforts of countries to design, implement, refine and sustain their strategic approach to quality health service delivery. This handbook is not an extensive manual of all actions required to implement a national initiative on quality, but describes the elementary steps to develop NQPS as a foundation. A number of further resources on quality of care are available from WHO and other organizations. Who should use this resource? This handbook is designed to support governments and policy-makers (at the national, state, and provincial levels) who are considering whether and how to develop an NQPS or are currently in the process of developing one. It may also be helpful for technical advisers, donors and other stakeholders supporting governments in areas related to NQPS. While much of this handbook has been designed to support development of NQPS in low- and middle-income countries, which may face particular challenges to improving quality of care, the processes outlined are relevant to any national or subnational authority preparing or reviewing their national efforts on quality of care. How to use this resource This handbook and accompanying compendium of tools provides direction on both the development process and content of national quality policies and strategies, and will facilitate development or refinement of these policies and strategies by policy-makers and practitioners who best know their unique country complexities. Users should see this document as a resource to help inform and structure quality policies and strategies responsive to the specific country needs while building on the guidance from existing literature, lessons from the field and expert consultation. The handbook is not a prescriptive guide, but rather a structured approach that helps ensure that development and implementation are as comprehensive as possible. To help users identify and access information that they may require, the handbook is divided into three colour-coordinated parts, as follows. • Part I focuses on quality policy development. • Part II focuses on linked processes of strategy development. • Part III describes how to access and use supplementary tools to support the NQPS process. There is significant overlap between the processes outlined in parts I and II of the handbook. This is to allow for the fact that not all users of the handbook will be developing both policy and strategy. It is suggested that these sections are read together, so an appropriate process specific to the needs of the user can be developed. Accompanying this handbook is a supplementary document entitled Compendium of tools for national quality policy and strategy, which presents a number of tools developed to support the NQPS process. 18 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y How was this resource developed? The content of this handbook has been developed based on work supporting countries in the development and execution of NQPS, as well as a review of a sampling of over 20 existing quality strategies across low-, middle-, and high-income countries globally. As this field continues to evolve and grow, there will be an increasing need to further refine this document and to build on the cross-country exchange of knowledge and best practices. The work will continue to be informed by partnering with individual countries, WHO regions, and expert partners. NQPS initiative This handbook and compendium of tools forms one part of a wider WHO-led effort to support development of national policies and strategies on quality of care. Recognizing that countries are at different stages in the process of developing and implementing national initiatives to improve quality of care, the NQPS initiative focuses on three main activities, as outlined in the following paragraphs. 1. Co-development of technical resources This activity encompasses the handbook, compendium, and associated tools and resources to support development of national policies and strategies on quality of care. There is a focus on true co-development, recognizing the significant experience and expertise injected into resource development by country authorities that have planned, developed and imple- mented national quality policies and strategies. It is intended that the need for further re- sources will continue to be assessed, and that existing tools and resources will be continually refined based on the experience and needs of country authorities using them. 2. Catalysing national action through technical cooperation To supplement the information provided in the written resources, WHO is coordinating fo- cused technical support to countries at different stages of the policy and strategy develop- ment process. This support aims to build in-country capacity for effective development, im- plementation and monitoring of national quality policies and strategies, as well as allowing future resource development to be informed by country engagement. 3. Learning agenda A number of academic and technical organizations around the world are engaged in sup- porting national quality initiatives. The NQPS initiative aims to engage with these efforts to ensure maximum effectiveness and promote shared learning. NQPS is a key focus of a related WHO initiative, the Global Learning Laboratory (GLL) for Quality Universal Health Cover- age. The GLL links the experiences, expertise, passion and wisdom of people from across the globe, representing multiple disciplines, on important issues relating to quality in the context of universal health coverage. The focus is accelerated global learning informed by local action in recognition of the importance of connecting people to facilitate dynamic, multidi- rectional sharing of knowledge and practice. A focused community on NQPS within the GLL has been created to link up experiences, facilitate knowledge sharing between countries and provide tools and resources to support NQPS. An overview of the GLL is available at http:// www.who.int/servicedeliverysafety/areas/qhc/gll/en/. PART I POLICY DEVELOPMENT 20 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y Section overview: Part I. Policy development Development of a national quality policy: National health goals and priorities Local definition of quality Stakeholder mapping and engagement Situational analysis: state of quality Governance and organizational structure for quality Improvement methods and interventions Health management information systems and data systems Quality indicators and core measures This section focuses on important aspects of the policy development process, with steps to consider when drafting a national quality policy. The factors influencing each country in their policy development process and content will vary widely; thus this section focuses on commonalities. Subsequent sections will further discuss how this policy should be implemented through a more defined strategy and operational plan. How the national quality policy is developed, written and ratified should be decided by each country (or subnational authority) in accordance with their respective governmental structures and taking into consideration their unique context and population needs. In some countries enabling legislation will be needed, for example to establish new governmental or parastatal bodies or to establish new forms of mandatory action (for example, registration and licensing of health professionals) or to define new forms of regulation (provider licensing or accreditation). This may trigger the need for an explicit national quality policy document. In other situations, the implementation of a national quality policy or strategy may be part of the routine five-year health sector plan or an internal ministry of health policy document. In this instance, it would be important to engage early with the department and individuals responsible for this broader national health planning to design a process that incorporates the necessary aspects for quality policy. There are a number of different approaches, but the most common forms would be one or a combination of the following: • quality policy and strategy as part of the formal long-term health sector national policies and plans; • a quality policy document developed as a stand-alone national document, usually within a multistakeholder process and often led or supported by the ministry of health; • a national quality strategy with a detailed action agenda, including a section on essential policy issues; • a national quality statement drawing on existing relevant policies and national health documents; • a constitution or terms of reference for the responsible ministry of health department or national quality body, outlining agreed policy direction; • enabling legislation or regulatory statute to support the national efforts to improve quality of health care. Each of the above options for national quality policy requires similar development processes to ensure policy is responsive to local needs, achievable, and well governed. 21 P A R T I . P O L I C Y D E V E L O P M E N T To take forward policy development, it is important to define and understand the organizational structures of the process. As noted earlier, the ultimate responsibility for such policies usually falls under the ministry of health, but this should be tailored to each country’s ultimate designated governing body. The ministry of health may, however, delegate or establish a task force or committee to author the policy with relevant stakeholder contributions and review. There will probably be a need for relevant consultations to help with technical aspects of policy development on a wide range of issues. Consultation and vetting of the policy development through the help of experts looking critically at the document will be important not only to inform its development, but also to anticipate and help correct its weaknesses and flaws. This is an important process in the development of the policy, and it is recommended that it should undergo various rounds of review before a final version is drafted. These policies will deal with multiple health-related fields and disciplines, each of which may already have existing policies, legislation or technical documents (such as standards) that address certain factors within the quality policy domain. Thoroughly examining and integrating the existing policies, standards and laws where possible may help in the drafting process and may even strengthen other programmes through this process. Existing and relevant policies may be diverse, including, for example, standards in specific technical programmes (maternal and child health, HIV, tuberculosis, etc.) or regulations for health care facilities and requirements for professional licensing. Further discussion of how to integrate technical programmes is presented at the end of Part II of this document. Co-developing a national policy allows national health authorities to identify and maximize quality synergies in systems with limited capacity. Further, the policy-making process can be strengthened by ensuring a strong focus on implementation through involvement of those directly involved in health service delivery in a wide range of technical areas, including those with a focus on certain diseases or population groups. Once the policy has undergone both internal and external expert review in several iterations, it should undergo the formal ratification or approval process customary in the respective country to become an official policy. Steps can be taken proactively to ensure the political support required to enable the completed policy to be ratified. This policy, and the responsible structures outlined within it, should then have the authority to meet the intended goals and guide the development of strategy. However, as mentioned previously, development of both national quality policy and strategy often occur concurrently in an integrated process. Part II will discuss functional tasks to consider when developing a strategy for enacting the policy. DEVELOPMENT OF A NATIONAL QUALITY POLICY The following eight elements can be considered important in developing a national quality policy. These elements will also be reflected in the final policy document itself. This material is based on expert input, field experience and the background analysis conducted for the foundation of the NQPS project, including interviews and review of a sample of national policy and strategy documents examined to identify the common content areas and topics. Attention to these eight elements within the national quality policy also serves as the foundation for developing a national quality strategy, described in detail in Part II, on strategy development. 1. National health goals and priorities Most countries have national health goals and priorities (see Box 5) that help to direct resources to meet the most pressing demands of the population. Where these goals or priorities exist, the national quality policy should aim to align the quality agenda accordingly. It should also be understood that the development of goals and priorities for the quality policy – for example, the traditional focus on maternal and child health – does not mean that other areas not explicitly included are unimportant, but that the selected areas are of pressing concern within the national context. There should be a clear and continuous process to address additional priority areas and goals as necessary to meet the changing needs of the population. 22 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y Box 5. Goals and priorities There is a distinction between goals and priorities, although they are at times used inter- changeably. Goals are usually more general aspirations or targets that set the course for future activities. They should be clear and meet a particular need, and should also be time bound, with a means to assess progress and achievement. In the case of international goals, such as the SDGs and the previous Millennium Development Goals (MDGs), countries may ratify these but add specific country context and ambition. While there are no limits to the number of goals or aims that should be included in the document, most countries generally include a maximum of five goals across a specified period of time. Priorities help direct attention more specifically to a number of critical areas. These areas are usually identified through national health data (for example, on burden of disease), sentinel events, or national research, and may be long-term or emerging priorities (for example, based on anticipated or changing population, health threats, or political and economic environment). National health priorities can be widely defined to include priority clinical conditions (for example, multidrug resistant tuberculosis, cardiovascular disease), populations (for example, women and children, slum dwellers or migrant populations), or targeted geographical regions (for example, rural areas or border regions ). Usually, these goals and priorities are defined by the ministry of health, through the contributions of various technical experts and stakeholders throughout the health sector. When reflecting on what the goals and priorities should be, it is important to consider the needs of the people alongside the capacity of the health system to deliver. This requires a careful balance of need versus resourcing, which becomes a topic for debate when trying to improve quality while also striving for expanded access to care. If the goals and priorities try to tackle too much without being counterbalanced with the resources needed to meet those demands, the policy is set for failure. Conversely, if the goals and priorities are not expansive enough to meet the needs of the people, the benefit of such a policy may not be evident and can lead to stakeholder disappointment, or even mistrust. Therefore, it is important to have a balanced approach to focusing on the priorities and goals that both meet the specified needs of the pop- ulation and acknowledge the realistic capacity of the system to deliver. It is, however, critical to focus on the long term in developing policy; sufficient capacity may not currently exist but it may be possible to reduce the gap through effective policy-making and structured efforts to seek further priority resources and technical support. The accompanying compendium contains a tool to shape thinking on goals and priorities that can help in framing the policy. Box 6. Health security and quality: closely linked priorities Major public health crises, such as outbreaks of highly infectious disease like Ebola virus, are an increasing national health priority for many low- and middle-income countries. While emergency response might prioritize access to services over quality, if those services are not trusted and utilized by communities, are not equipped to safely and effectively manage cases, do not provide adequate protection to their health workers, and cannot maintain routine care during surges of demand, then resources will be inefficiently used and emergency response will be jeopardized. Aligning quality efforts with existing priorities such as health security may help secure political capital and financial resources, bolstering both agendas. 23 P A R T I . P O L I C Y D E V E L O P M E N T Summary: national health goals and priorities Actions for the policy development team Content of the policy document • Identify existing national health sector goals and priorities • Develop and align goals and priorities for quality policy, including review of existing data where applicable • Outline of identified goals and priorities • Explicit reference to existing national health policy and strategic plans 2. Local definition of quality Numerous definitions of quality can be found in the global literature. In development of the national quality policy, it is critical to state the definition of quality that will underpin the national approach in order to ensure a shared understanding and language that is acceptable to local country context. Furthermore, the exercise of developing a local definition of quality in itself is useful to the policy-making process as it can open a dialogue about the reach and importance of quality, elicit what is important to stakeholders and how interventions might be targeted to meet local priorities, and prompt policy-makers to learn more about the meaning of quality and its implications. As highlighted earlier, there are a number of widely used definitions of quality. However, these definitions may leave a fair amount of interpretation open for defining what quality looks like from national, subnational and facility levels. Table 1 offers a structured approach for helping to tailor a definition that meets the contextual needs and aligns with national goals and priorities. Table 1. Framing the dimensions of quality Questions that help to frame the dimensions of quality to local needs, in the context of national goals and priorities Effective Is care appropriate for the health needs of the population and consistent with knowledge and evidence for achieving the best possible health outcomes? Safe Does the delivery of health services utilize the safest means possible and reduce avoidable harm? People-centred Is the experience of care positive through the eyes of patients and families? Is there a sense of trust among communities in the quality of care available? Do patients, families and communities feel empowered as partners in designing and refining the delivery of health services? Timely Are waiting times for treatment acceptable to the population and sufficiently short to avoid unnecessary harm? Equitable Are there barriers to or disparities in factors related to age, sex, gender, race, ethnicity, geographical location, religion, socioeconomic status, linguistic or political affiliation? Integrated Are there gaps in patient care between clinical settings? Do components across the health sector communicate to maintain seamless transition of patient care? Efficient Are resources allocated and used in the best possible manner to achieve outcomes? 24 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y Policy drafters can utilize Table 1 as a check to stimulate thinking on these dimensions for incorporation in the policy document. While countries are encouraged to consider how each of these dimensions can be reflected in the policy and strategy, they may choose to focus on a subset, or to introduce locally agreed dimensions. Indeed, countries are encouraged not to default to use of existing global definitions on quality, but to instead be informed by these and craft a local definition that is owned and championed by their constituents. When available, additional consultation and mutual agreement on the proposed definition should be sought from a multidisciplinary group that may include providers, academics, quality experts, health service managers, community advocates and regulators. Although this definition will provide an essential starting point, throughout the quality journey of a particular country the accepted definition may be revised according to country progress and needs. Summary: local definition of quality Actions for the policy development team Content of the policy document • Identify previously developed or published local definitions of quality and consider content from the introduction section of this handbook • Develop locally owned definition to support development and implementation of the policy and strategy • Consider stakeholder consultation to refine or co-develop definition • Statement of local definition • Reference to original source of local definition or brief description of process of development 3. Stakeholder mapping and engagement Quality of care is a product of the wider health system. By including key stakeholders in the policy development, the comprehensive nature of the factors that influence quality of health services can best be addressed. Indeed, a wide range of stakeholders needs to contribute to the policy development. Given that health care in most countries is viewed as a public good and a right of the people, governments are expected to ensure adequate funding, resourcing and provision of a basic level of services. The government is in many respects the architect of the policy but should be guided and informed by those involved in the management and provision of health services. Careful stakeholder mapping and analysis can ensure the right people are contributing, facilitate effective engagement, and account for the impact of stakeholder power and relationships. Engaging with both public and private sectors is necessary to cover all populations and to stimulate the necessary change in “quality culture” across the health sector. Just as important is the contribution of communities and people who are receiving services – especially vulnerable and marginalized populations and patient groups. The ministry of health will also have to engage across other government ministries, national bodies, local authorities and development partners. A direct benefit of including a wide range of stakeholders is to better tailor the policy to the various users and beneficiaries of the policy, as well as harnessing buy-in. The global health community should be considered in how they are to be engaged and coordinated, particularly in sharing cross-country lessons and providing specific technical assistance. Box 7 lists some potential stakeholders that could be targeted for consultation and for co-development of the policy. Each country will need to carefully consider and select the stakeholders needed to author its respective policy. This list is not comprehensive, but provides some general considerations. The headings and categories within the list may differ by country. 25 P A R T I . P O L I C Y D E V E L O P M E N T Box 7. Illustrative list of potential stakeholders (note: non-exhaustive list) Government health organizations o Ministry of health o Health professional council o Provincial health offices o District offices and hospitals o National data/informatics specialists Health service organizations o Public sector health services o Faith-based health services o Private sector health services o Traditional and complementary health services Professional bodies o Health care professional councils o Specialty societies o Medical academies Line ministries o Finance o Social affairs o Education Cooperating partners o Insurance entities o Financial support o Communications/media support Civil society o Advocates o Health promoters o Delivery programmes and services Communities o Advocates/outreach o Patient societies Source: Adapted from stakeholder mapping tool used in development of Ghana quality strategy. Once a diverse team has been assembled, clear roles need to be defined for lead architects and the core team as well as for others who will support the creation of the policy. The team will collectively have to identify and address important issues and actions focused on strengthening the quality of care being delivered by the health system. These roles and responsibilities are described below in Box 8. Of further note is the critical importance of embedded community engagement approaches that cut across many of the roles and responsibilities described for specific stakeholders. Summary: stakeholder mapping and engagement Actions for the policy development team Content of the policy document • Identify relevant stakeholders • Map stakeholder roles and plan stakeholder involvement in policy development process • Brief outline of stakeholder engagement process • Acknowledgement of contribution of stakeholders 4. Situational analysis: state of quality The situational analysis, which should be country owned and led but may be supplemented by inclusion of outside experts, is further described in Part II. Its importance as part of the policy document is to establish the current “state of quality” in the nation, encompassing relevant priorities, challenges and problems, related programmes and policies, organizational capabilities and capacity, leadership and governance, and related resources. This will serve to define the gaps identified between population needs and the capacity to reliably deliver quality health services. The linkages with national efforts to move towards universal health coverage may be particularly important to describe within this situational analysis. It is helpful to describe both a nation’s historical quality journey and its current state of quality – including strengths and weaknesses. Historical information can date as far back as necessary. For example, one such country document outlined a timeline starting in the 1980s in order to provide an overview of the initial structure of the health system and how it has evolved over the years. 26 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y When considering the historical perspective, it may be useful to identify not only whether there have been previous national efforts to improve quality, but to examine why these have succeeded or failed, and whether there can be any lessons taken from other policy initiatives across the health sector. Where the situational analysis identifies ongoing quality-related initiatives and structures, it may be possible to refine or build on these in the context of the new policy. The situational analysis provides information from multiple data sources – interviews, focus groups, review of relevant documents and analyses of secondary data – to describe the current landscape and clearly identify the performance gaps between what is actual and what is achievable. This step will be key to grounding the policy to address the real challenges that exist at the front line, and to identifying what actions could have the most impact. Knowledge, behaviours, beliefs and attitudes about quality will all be important to understand as the policy and strategy are being developed. The situational analysis also allows careful consideration of key focus areas within quality efforts; for example, some countries have utilized patient safety as an entry point to stimulate national action on quality of care, while others might emphasize effectiveness and people-centredness. Existing technical programmes (for example, disease- specific initiatives or those focused on specific populations such as mothers and newborns) may also provide rich experience and resources that can catalyse a broader national effort and inform systemwide quality of care efforts. Situational analysis can also reveal important intelligence about how best the policy-making process can be navigated, for example by eliciting why previous health policies have succeeded or failed and what current contextual factors may affect success. Tools to support this situational analysis process are described in the accompanying compendium. Summary: situational analysis Actions for the policy development team Content of the policy document • Plan situational analysis process • Collect relevant data from multiple sources on state of quality, contextual factors, and historical quality journey • Multistakeholder analysis of findings to translate into priorities and strategy • Description of methods of situational analysis • Summary of comprehensive findings • Identification of key findings • Statement of priorities and targeted areas of interventions and action 5. Governance and organizational structure for quality Governance, leadership and technical capacity across the health system are all necessary factors for improving quality and should be discussed explicitly. It is important to understand where and how policy will be developed, enacted, implemented and monitored among existing or newly proposed structures, and how this will be affected by the wider political environment. As an initial step, it may be helpful to identify the key authorities, organizations and individuals that will be involved in establishment and implementation of quality policy and strategy at the national level and at subnational and local levels. The governing body or structures will differ from country to country. Early on in the process of developing policy, it is helpful to understand how the policy will progress from the conceptual stage to being fully endorsed and enacted. To begin with, it should be decided what form the policy will take, as discussed earlier in this document. Once that has been determined, the policy development team must identify which individuals or groups should be involved, clarify which people and organizations need to approve the policy, the process through which the policy is officially adopted, and how the policy will interface with existing health system policy and legislation. 27 P A R T I . P O L I C Y D E V E L O P M E N T Box 8 identifies some of the common roles and responsibilities. In a growing number of countries, some form of unit or department with responsibility for quality efforts is in place. This department may or may not have the power to enforce certain policies, but may bear the responsibility to assess and make revisions to the approach or address matters related to gaps identified in quality care. It is important to ensure that policies clearly define the organizational structure, roles and responsibilities of these departments to fully utilize the capacity of the group, and recognize where responsibilities can be shared across the health sector. The role of community engagement and empowerment is a further critical consideration within the context of governance and accountability; for example, it should be determined how patients, health care staff and wider communities can be meaningfully involved in development, implementation and monitoring of the policy and strategy. Box 8. Health care quality: roles and responsibilities of selected stakeholders Clear description of roles and responsibilities is essential to delineate expectations and hold various stakeholders accountable. The policy can help define these roles and responsibilities. Some examples include: Ministry of health Provide leadership and direction of national efforts Quality department or directorate (usually within ministry of health) Support development and implementation of national policy and strategy National coordination committee Monitor and evaluate progress, identify gaps in quality, and coordinate and align inputs of multiple stakeholders to policy and strategy Subnational quality committee / management teams (regional and district) Monitor and evaluate regional- or district-level progress and address quality issues Professional bodies Assist and support training, professional education and setting standards Insurance entity Fund and monitor incentive programmes and integrate measures for quality improvement in payment mechanisms Institutional boards Review institutional quality improvement programmes and initiatives and engage community in improving service delivery Health facility teams Carry out quality care practices and standards, and report the relevant health data for continuous quality improvement Existing disease-specific or population programmes – for example HIV or maternal and child health – may also have well established governance structures. As part of the policy development process, it is useful to map the structures of programmes with particular relevance to ensure alignment. It is of critical importance that consideration be given to the levers available to ensure the policy is implemented as intended. Thus requires identification and development of structures for accountability and enforcement. This can be a complex endeavour, as the degree to which a policy is successfully implemented relies not only on specific measures but also on the culture within the system, how well the policy is received, and the relationships between key stakeholders. At the heart of successful policy implementation are empowered stakeholders across the system, who should be enthusiastic partners with an interest in the success of the policy. In some circumstances, there may be a case for mandatory adherence to standards, with 28 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y remedial action or sanctions for any violation or failure to comply. Various forms of sanctions may affect licensing, accreditation or funding, and there may be recourse to legal mechanisms, including fines or other action through the legal systems. However, the need for, and use of, such mechanisms should be carefully considered within the context of creating a policy environment suitable to the particular circumstances of each country. Proposed governance mechanisms should be agreed upon by all stakeholders, and delegated as necessary to the appropriate responsible agencies. Each country, in consultation with their respective professional bodies, can identify the best mechanisms for policy enforcement. The subsequent strategy development discussed in Part II will help to address the question of governance for quality through a systematic approach. Summary: governance and organizational structure for quality Actions for the policy development team Content of the policy document • Map existing structures for governance across the health system • Identify mechanisms for policy enactment and enforcement • Decide upon governance structure for both policy development and wider quality efforts • Outline of proposed governance structure for national quality efforts, including requirements to implement this • Description of existing and proposed levers for policy enforcement (e.g. legislation, licensing systems) 6. Improvement methods and interventions This section outlines the set of improvement concepts and principles to be considered to achieve the overall goals of the policy. It is often helpful additionally to state assumptions around these improvement interventions as well as the resources required and risk mitigation strategies to be put in place. A short list of actions commonly considered by governments in establishing the national policy and the accompanying strategy is presented in Box 9. These are common elements for implementing successful systemwide quality efforts. They include strong leadership with the ability to set priorities relevant to the needs of the people and foster an environment conducive to addressing those needs. The ability to assess and regulate the delivery of established standards of care is also important, and may encompass both professional and institutional licensure and inspection and external evaluation of providers. While external evaluation programmes such as accreditation are often early entry points for national improvement efforts, the evidence for their impact on quality is variable; it is important to recognize that these approaches should be embedded within a broader structured effort encompassing the required governance structures and a suite of effective interventions that is appropriate for the local context. 29 P A R T I . P O L I C Y D E V E L O P M E N T Box 9. Basic elements essential for systemwide quality o Leadership to set priorities and shape environment for quality o Establishment of standards and targets o Professional and institutional licensure o Inspection and external evaluation o Workforce development and retention o Incentive mechanisms (financial and non-financial) o Measurement, benchmarking and feedback o Large-scale improvement initiatives by target population, clinical condition, etc. o Patient, family and community engagement (including participation, education, choice and feedback) o Transparency with public performance reporting The well known Donabedian model (15) describes three parameters for evaluating quality of care: structure, process and outcome. This can be a useful approach in the policy planning process to conceptualize the wide range of potential improvement methods and interventions and to ensure that the policy considers key determinants of quality. Structure relates to the setting within which care is delivered, for example the health facility and the human and financial resources underpinning it; process relates to the provision of care itself, including all aspects of the transaction between receivers and providers of care; and outcome is the measurable effect on health status, which may be affected by a wide range of factors. Those developing national policy on quality of care should consider how it can incorporate interventions addressing both structure and process, and how the policy will ultimately affect health outcomes. Training and engagement of the workforce may present an opportunity to overcome limitations in capacity. Incentive mechanisms can be used to influence behaviour towards quality processes, but this will also have to be incorporated into more sustainable norms of practice. In places where certain practices and interventions have led to improved quality care, these efforts should be reviewed to assess their potential for scale-up within the country. In this regard, it is important that the evidence generation and learning agenda is promoted as an essential support mechanism for selecting and refining interventions. An important requirement for achieving both scale-up and sustainability is the intentional engagement of people (patients, families and communities). This empowerment will require education and awareness of the importance for both providers and the general public of these concepts, principles and skills. As part of this engagement, the public should be empowered to access and understand performance reporting to hold the health system accountable, and to facilitate the demand for change. An approach to thinking through selection and implementation of discrete quality-related interventions is discussed in Part II on strategy development. Summary: improvement methods and interventions Actions for the policy development team Content of the policy document • Discuss and select broad priority intervention areas • Outline of broad intervention areas to be addressed by policy and strategy • Discussion of justification, assumptions, resources required and risk mitigation strategies 30 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y 7. Health management information systems and data systems Improving quality relies on the presence of clear and accurate performance data. With the development of a national quality policy, there will inevitably be a necessary emphasis on the systems required for measurement and reporting, including the feedback loop in place to stimulate and measure improvement. There are at least five integrated data and analysis capabilities needed to support a comprehensive national quality programme: • a national hierarchical data collection and reporting system; • department of health/ministry of health executive information system and quality database; • clinical decision support and patient recording systems at the front line; • quality monitoring and feedback systems to assess individual performance against standards or targets and comparative benchmarking data; • public and comparative reporting for transparency and accountability. Clearly, countries will be at different stages in development of these capacities. The policy document will provide an outline assessment of the current status of capacity and the intended course of action to build the capabilities required, including how improvements in data capacity should be prioritized. Key items to be provided include a description of existing possible data sources; identification of data gaps; and actions required to develop the necessary data infrastructure to deliver better quality and to monitor and report on performance. A clear policy direction on the need for quality efforts to be integrated with health management and information systems is critical, given the tendency for quality initiatives to run parallel to routine systems in many cases. Summary: health management information systems and data systems Actions for the policy development team Content of the policy document • Map existing data sources and capabilities • Identify gaps in current health information systems related to quality • Propose directions to optimize health information systems for quality • Identify existing health sector policy and plans related to data systems and health information • Brief overview of available health information and data systems • Outline of proposed health information and data systems to support national quality efforts • Explicit reference to integration of quality efforts with health management and information systems 8. Quality indicators and core measures A comprehensive policy will include the aims for routine quality monitoring and feedback of health service providers and managers, as well as the aggregation of data and overall evaluation of what progress is being made against the national goals for priority areas. This requires the identification of a core set of quality indicators with the necessary policies and processes to support multiple purposes, such as feedback to providers; transparency to the public; benchmarking to understand comparative performance and unjustified variations in quality; analysis of cost-effectiveness; and assessment of the effectiveness of discrete quality interventions and the overall national approach to quality. Quality measures are critically important in judging whether quality improvement activities are effective or not. Without measurement, it is impossible to know whether improvement actions are actually producing better quality of care and leading to any significant change in health 31 P A R T I . P O L I C Y D E V E L O P M E N T outcomes. Quality measurement – through the use of standardized indicators – allows health care providers and policy-makers to assess progress across all levels of health care: national, regional, local, facility and individual. This level of information can also support better reporting to the general public to improve transparency and trust, even when results may fall short of targets. Further detail on the process of developing a comprehensive framework for quality measurement is provided in Part II on strategy development. Summary: quality indicators and core measures Actions for the policy development team Content of the policy document • Appraise relevant indicators already collected and reported by the health sector • Set policy direction on the development of the core indicator set (see parts II and III) • Presentation of indicators and justification for selection • Overview of how indicators will be used PART II STRATEGY DEVELOPMENT 33 P A R T I I . S T R A T E G Y D E V E L O P M E N T Section overview: Part II. Strategy development • Development of national quality strategy National health goals and priorities Local definition of quality Stakeholder mapping and engagement Situational analysis: state of quality Governance and organizational structure for quality Improvement methods and interventions Health management information systems and data systems Quality indicators and core measures • Developing an operational plan for implementation • Integrating technical programmes with national quality policy and strategy As previously described, national quality policy and strategy may often be developed simultaneously as part of a national quality programme, and may exist in one integrated document. Further to this, while the strategy outlines the process by which the policy is enacted, a more detailed operational plan is often required. Such a plan outlines the practical aspects of execution of priority actions, including roles, responsibilities and timelines. Further detail is provided at the end of Part II. This section will review some practical components to consider when moving policy into action through the development of a quality strategy. The suggested process and content of the final document mirrors closely the policy development process, and is based on the same eight elements. In addition, development of a national strategy facilitates integration of existing programmes and initiatives within a coherent national quality framework; this may include existing technical programmes (such as those on HIV or maternal and child health). Further detail on how to approach integration is provided at the end of Part II. The strategy should provide a timeframe for the various activities to be launched, with enough time for logistics and support to be put in place to support those initiatives. This will probably include allocating resources, reorganizing agencies or reorienting personnel, broad awareness building and communication, and associated training and workforce development. As mentioned, the strategy may include an operational plan that provides a detailed roadmap for pertinent intermediate steps. Often, in early implementation, some level of organizational change among stakeholders, including the responsible ministry or agency, will be required to comply with policy regulations, and there may also be a need for technical assistance to help stakeholders define the processes that are required logistically for compliance. External consultancy agencies may be sought, or a task force or committee may be established in the interim, prior to the policy taking full effect, to help facilitate the required changes. The objective of this National Strategy is to articulate multiple inter- ventions that have been developed during the past fifteen years, into a single group of coherent actions that lead towards a strengthened and common aim for all health care institutions in this country, public and private, into a new era of quality improvement for the health of the Mexican people through the convergence of all towards an effective universal health coverage. National Quality Strategy of Mexico, 2016 “ ” 34 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y The process of enacting policies may expose unforeseen challenges that necessitate amend- ments to the strategy – although a vetting and consulting period during the development of the strategy should mitigate much of this. Therefore, in the operational plan there should be consideration of how to monitor and troubleshoot early challenges during the implementation phase of a strategy, for example through formal process evaluation or governance measures such as strategy oversight committees. This should be well documented and there should be a channel to feed that information back to the appropriate overseeing agency or individual for prompt attention and correction. DEVELOPMENT OF A NATIONAL QUALITY STRATEGY Despite the many ways countries differ, review of current knowledge and practices has identified similarities from country to country on how to design and operationalize strategies for national quality improvement efforts. Eight elements in the process are outlined here; these are the same eight elements outlined in the policy process in Part I, and many may be performed simultaneously where appropriate. At other times, national quality policy can drive the development of a quality strategy. These elements are described below to help facilitate strategy development, although not all countries will pass through every element, or in the same order. 1. National health goals and priorities A “quality strategy” is a bridge that helps a health system accelerate the achievement of its health goals and priorities, using quality concepts and evidence-based methods and principles that incorporate quality planning, control and improvement. A crucial first step is understanding the country’s existing national health goals and priorities, identifying potential gaps, and proposing any new goals and priorities that should be included in the national quality strategy. The purpose of this exercise is to identify and prioritize national health goals and priorities so that the quality strategy is fully aligned rather than being developed separately in parallel. The quality policy and strategy – and their implementation – should be across the health system, avoiding the risk of creating a vertical quality programme. Linking the strategy to existing goals and priorities also helps the process of buy-in across various stakeholder groups towards the development of a national quality strategy. Existing goals and priorities will inevitably differ among countries, and will be expressed in different formats and levels of detail. While many national health goals and priorities may be explicitly relevant to quality of care provided by health services, a number may have indirect contributions, for example focusing on determinants of health, prevention of risk, and expansion of access to services. Where the existing goals have a clear focus on quality of care, it is helpful to directly draw on these during formation of the strategy; where a quality focus is lacking, it may be necessary to propose and advocate setting of new goals and priorities in national health planning. The national quality strategy may follow the content and structure outlined in an existing policy document, such as a five-year national health plan, and may specify additional relevant health goals with targeted achievement dates. Goals that link to broader global health initiatives (such as the SDGs) or goals linked to major in-country donor programmes may also be included. Sometimes a national health goal may be specifically linked to a sentinel event or public outcry for greater quality in the health care system, for example reduction of maternal mortality or reduction of health care-associated infections. It may be a useful exercise to explore in greater detail the existing national goals and priorities, assessing how they came to be prioritized, what implications they might have for health service provision, and the logical case for how national quality efforts might help to achieve them. While it is always possible to specify new goals and priorities for the national quality strategy, demonstrating clear alignment with previously stated goals can help build political support and ensure integration of quality efforts within wider health system strengthening. Health system budgeting may also be linked to existing national 35 P A R T I I . S T R A T E G Y D E V E L O P M E N T health goals and priorities; it is important to clarify this linkage and assess the implications for funding of the national quality strategy. Setting priorities may be accomplished by various methods, often starting with analysis of the disease burden and avoidable morbidity and mortality. The rationale for this method is to pro- vide a common language that can be well understood and supported by various audiences. How- ever, countries are increasingly moving away from looking at just the disease burden to more proactively defining priorities in terms of population health and well-being. Principles such as more equitable access and universal health coverage may also be statements of priority that shape the quality strategy. The development of priorities and goals for the national quality strategy can be done in a straightforward and transparent manner, taking account of the following. • National goals and priorities will be drawn from the principal national health plan docu- ments and policies. • Additional goals and priorities may emerge from other areas, including the situational analysis, global SDGs and donor programmes. • If the list of goals and priorities exceeds what can reasonably be included in a national quality strategy (that is, numbering more than can be realistically monitored and translated into actionable activities within available resources and timeframe), two pathways can be followed: reduce the list of priorities by applying explicit criteria, or divide the list of priorities into short and long term. • Once a list is established, feedback should be sought from diverse stakeholders before finalization. • Timelines and criteria for future review and revision should be made explicit. Box 10. Variations in national quality strategies Variations do not only occur in the structure of national quality strategies – but also in the emphasis placed on certain areas identified as priorities by countries. This underscores the importance of understanding quality gaps that require attention within strategies. Ethiopia The ultimate aim of the National Health Care Quality Strategy is to consistently ensure and improve the outcomes of clinical care, patient safety, and patient-centredness, while increasing access and equity for all segments of the Ethiopian population, by 2020. Namibia The quality strategy in Namibia aims to provide a framework for implementation of quality management initiatives at all levels of health service delivery through four strategic objectives: (a) improve quality management systems and accountability; (b) ensure client-centred care and empowerment of consumers; (c) improve patient and health worker safety; and (d) improve clinical practice. Goals of national quality strategies may relate to specific dimensions of quality that are priority areas for that country, though many will touch on all or a number of quality dimensions. Selection of goals may also be influenced by current or recent major public health events, for example outbreaks of infectious disease or mass migration, which can impact health service capacity and priorities. Indeed, during the implementation phase of a strategy, such events might prompt revision of goals; this can help align the strategy with emerging critical needs, and should again be done in consultation with key stakeholders. The statement of goals might focus on desired and specific high-level health and health care outcomes, such as “reducing avoidable mortality by x% over five years”. The means by which the 36 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y high-level goal will be reached can be stated, for example through pursuing universal health coverage or addressing health worker shortages. Another type of goal statement might focus on improvement in specific dimensions of quality, such as effectiveness, safety or people- centredness. Advocacy efforts may be required to embed goals and priorities related to quality across the health system and ensure they are reflected in national health planning and budgeting as well as in the dedicated strategy. Summary: national health goals and priorities Actions for the strategy development team Content of the strategy document • Identify existing sources of published or expressed national health goals and priorities • Appraise existing goals for relevance to quality strategy • Consider, as part of situational analysis and strategy planning process, the need for additional goals and priorities • Develop a statement of goals and priorities for the national quality strategy • Statement of national goals and priorities for quality of care • Reference sources of existing national health goals and priorities 2. Local definition of quality It is important to ensure that the strategy reflects the quality definition adopted to anchor activities and processes. These definitions provide the context in which the strategy will function and be evaluated. Although this should already be established in preceding policy, if it does not exist, then it should be strongly considered early in the process of strategy development. Development of a local definition can be an early task for the team developing the strategy and can also be a useful exercise for engagement of key stakeholders in debate about what the local priorities should be (Box 11). Further information on defining and contextualizing quality is found in the equivalent section on local definition of quality in Part I of this handbook, and in the introductory section. Box 11. Case study: defining quality in Sudan “Providing the best possible patient-centred care using available resources and evidence-based practice.” Definition of quality, Sudan Quality Strategy, 2017 In 2016, Sudan began the process of developing a national quality strategy, and invited a wide range of stakeholders to offer input to the strategic planning. Drawing on stakeholder inputs, the strategy development team drafted a local definition setting out what quality would mean in the context of this renewed national effort to improve services. The team selected a definition that is succinct and easily meaningful to a range of stakeholders from politicians to health professionals. It reflects not only the need for effective patient-centred care, but also the imperative to use limited resources wisely. 37 P A R T I I . S T R A T E G Y D E V E L O P M E N T Summary: local definition of quality Actions for the strategy development team Content of the strategy document • Identify existing quality definitions from national health publications or previous quality efforts and consider content from the introduction section of this handbook • As part of strategy planning or stakeholder engagement process, refine and decide upon suitable local definition to guide strategy process. This may have already been done if national quality policy is already developed • Explicit quality definition, and how this will be reflected in the actions set out in the strategy 3. Stakeholder mapping and engagement For the quality strategy to be successful, meaningful stakeholder collaboration and engagement is crucial across the design, implementation and evaluation phases. While the development of the strategy may be driven from a particular lead organization, often a unit or directorate within the ministry of health, it is important to work with a broad set of key stakeholders from across the health care system at the federal, state, community and local levels. Structured engagement will help to build shared understanding as well as mutual ambition and commitment; this can help to identify the resources and assets available to support strategy development and implementation. Engagement for policy and strategy can be performed as part of the same process. Though particular stakeholder groups may vary by country, in general, they consist of at least the following: • government: ministries (health and related non-health, such as finance), quasi-governmental arms-length bodies and key elected officials; • regulators and other external evaluators and standard-setting bodies; • public and private insurance entities and authorities; • professional societies; • providers (community, primary, secondary and tertiary care, traditional medicine providers, public and private sectors); • civil society organizations, large faith-based organizations, patient groups and patients; • nongovernmental organizations and community-based organizations; • payers, funders and donors. In many countries, small-scale (and in some instances large-scale) quality improvement efforts will already be taking place in health facilities and community providers across the health system, sometimes supported by external technical agencies. This front-line expertise in quality improvement is likely to have yielded useful experience on what works locally, and this should be captured within the stakeholder engagement process. Conducting stakeholder mapping or a stakeholder analysis can identify which organizations or individuals might be drivers, catalysts or blockers in relation to a national quality strategy. When deciding which stakeholder groups to actively include, a set of questions can clarify who should be “at the table” to understand the current state of quality, identify salient issues and gaps, and formulate strategy for advancement. Essential questions to consider when identifying key stakeholders include the following. • Who is responsible for quality at each level of the health care system? • Who or what influences quality at each level of the health care system? • What are the critical levers or drivers to achieve better health outcomes and who drives these? 38 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y • What groups will be champions and what groups will be detractors of a national quality strategy? • What are the key organizations responsible for delivering services across the health system? • Which organizations or individuals support the ministry of health in developing strategic plans? These questions help clarify the key actors that should be involved, in what role – such as developer, reviewer, expert consultant or implementer – and at what stages of the process. Table 2 provides some examples of how stakeholders can be identified and the specific tasks that they can either support or lead. Table 2. Stakeholders and related tasks Stakeholder Task(s) Ministry of health • Lead author • Lead directorate for NQPS Other relevant government ministries (such as finance, social affairs, education) • Provide strategic input to strategy development process • Identify related policy issues, finance requirements and legal instruments • Integrate actions with initiatives from other sectors (for example medical training) Health professional councils and specialty societies • Identify improvement interventions • Technical support for situational analysis and external evaluation National health insurance agency • Review the payment implications • Integrate incentives for improvement Provincial, regional, district health management teams • Engage health facilities and integrate management and quality functions • Disseminate action items and technical support for implementation • Monitor and evaluate progress of quality initiatives through effective management processes Faith-based, private, and traditional health providers • Engage the network of faith-based organizations • Disseminate action items and technical support for implementation • Support the district health management team in monitoring and evaluation of progress of quality initiatives Public sector health providers and hospitals • Full engagement in situational analysis • Provide technical guidance and expertise towards improved clinical practices Nongovernmental organizations and development partners • Provide technical support on strategic planning and implementation of quality interventions based on the quality strategy Civil society organizations, community stakeholders • Contribute to situational analysis • Review strategy development process to ensure it is appropriate and meaningful to the public and patients • Contribute to selection of meaningful local indicators 39 P A R T I I . S T R A T E G Y D E V E L O P M E N T How: a process for engaging stakeholders Feedback from the stakeholder groups throughout the process is required to ensure alignment across the health care system. A variety of approaches exist around stakeholder engagement; the most common methods involve stakeholder interviews, meetings, working group development, and soliciting feedback. As a first step, interviews with key stakeholders can help gather input, such as local quality definitions, perceptions and objective data regarding the current state of quality, what an “ideal” state of quality looks like, existing gaps, and ideas on closing these gaps. As the team progresses, groups of stakeholders may be convened to test, refine and finalize various elements of the national quality strategy. The development of specific working groups may also be helpful; for example, people with clinical and measurement expertise could develop a proposed set of quality indicators to be brought to a wider group of stakeholders for review and ratification. Development of national quality strategy often tends to use a top-down approach designed and planned by the government and launched across the health system; it is, however, crucial to involve and engage the front line, utilizing a bottom-up approach, to inform development of the overall strategy in light of the strengths and challenges that exist, and to help direct resources. This is important due to the chasm that often exists between front-line realities and high-level strategic planning. Given the intimate knowledge of practitioners and managers, their input is critical. Implementation-informed strategy requires connecting with providers at the point of care directly, or through their professional associations or societies, and ensuring that the strategy is meaningful and comprehensible to front-line providers. It is their behaviour that will determine the success or failure of the strategy, so securing early buy-in from those providing care can be crucial. However, even with sufficient buy-in, health care providers must be resourced with an enabling environment conducive to the required behaviour change for improvements in care. Stakeholder engagement can help elicit the supporting structures required for such an environment, and the challenges to be overcome in its creation. Box 12. Community and patient engagement: the Ugandan experience Uganda has a long history of national efforts to improve quality of care, having first embarked on a quality improvement programme in the mid-1990s. Throughout these initiatives, patient and community engagement has been increasingly recognized as an essential component. Uganda has established health unit management committees to give community members meaningful input to facility management and oversight of performance, introduced a patient charter outlining the rights of service users, and in the most recent national quality strategy involved civil society and health consumer representation in the task force coordinating development and implementation. Of vital importance is the community and patient perspective, which may be captured from site visits to facilities and engaging in public meetings to capture the voices of patients, families and communities in the process of strategy development (Box 12). Community and patient representatives can also be involved directly in both the policy and strategy development processes and the subsequent implementation and governance arrangements, helping to ensure that efforts are grounded in “what matters” to the people ultimately using the services. However, this process requires careful planning to ensure communities are appropriately engaged and empowered. For example, challenges such as linguistic barriers or low health literacy may have to be overcome to allow effective dialogue during the process. Health services need to be reoriented towards patient needs and preferences, and this can only be achieved through meaningful engagement. Community and patient engagement, while adding a further resource 40 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y requirement to programmes to improve quality of care, allows the community to be used as a key asset in situational analysis, development of appropriate interventions, governance and accountability, and evaluation of success. These perspectives and engagements will empower people, and provide a layer of accountability at the community level. Summary: stakeholder mapping and engagement Actions for the strategy development team Content of the strategy document • Identify key stakeholders from across the health system • Map stakeholder roles and influence on the strategy development • In a collaborative process, assign responsibility to selected stakeholders f or input to relevant aspects of the quality strategy • Plan for active engagement of stakeholders to maximize useful input and minimize barriers to strategy development and implementation • Schedule multistakeholder meetings as required for strategy development (may include writing groups, situational analysis processes, a steering group, and a validation meeting) • Outline of stakeholder engagement process with acknowledgement of stakeholder input • Outline of key stakeholder roles for suggested actions within strategy 4. Situational analysis: state of quality In most cases, the first phase of developing the NQPS includes a well structured and thorough situational analysis of the state of quality in the health care system at the national, state or provincial, local, institutional and community levels. This situational analysis will build a better understanding of the current state of quality, the existing strengths of the health care system to leverage quality improvement, the anticipated barriers and facilitators for the strategy development process, the major challenges and pressing priorities facing the health system, and the current status of important contextual factors such as infrastructure, capacity and political climate. It can be used to guide the approach taken by the team developing and implementing the strategy, and may also be shared with other key stakeholders to facilitate their engagement. Conducting a full situational analysis will probably take several months and combine a number of important activities, including convening stakeholders, holding briefings, desk research of a wide variety of documents (described below), conducting individual interviews and focus groups for information gathering, and writing up summary reports. This range of activities should draw on perspectives and expertise from the national level right down to health care providers on the front line of service delivery. Inclusion of a wide variety of stakeholders, as outlined in the previous section on stakeholder mapping and engagement, is essential for understanding the collective attitudes, experience and aspirations that will be foundational to future efforts. The comprehensive situational analysis will include a review of historical and current information as well as the collection and collation of new data. The following generic information is likely to be important and useful. 41 P A R T I I . S T R A T E G Y D E V E L O P M E N T • Review of all relevant documents. These will include the national health policy and five-year national health plan, which will provide vital information on country priorities, resources and context. The national quality strategy should be fully aligned with and supportive of existing national policies and plans. • Review of quality-related legislation, regulation and statutes. This will provide information about licensing requirements, medication quality and safety control, and inspection of facilities. • Quality-related government and public sector documents. Examples include professional training materials, protocols and guidelines relevant to health care quality. Relevant documents will reside in such settings as the ministry of health or the national health insurance entity and will include information as varied as environmental and medical waste management requirements or patient rights charters. • Performance data about quality from the health care system. Sources will include hospitals, primary care facilities, and outpatient centres and clinics, from which can be obtained routinely collected health management information system (HMIS) data as well as special-purpose data sets. These data will allow for a detailed understanding of the actual performance across the health system in such areas as access, effectiveness, safety, efficiency, equity and patient- centredness. • Technical and vertical programme reports. These will provide useful quality-related data on the appropriateness of processes and health outcomes of specific populations. • Mapping of available resources to support national quality efforts. Relevant resources can be obtained from domestic budgets, local implementation partners, external agencies, and aligned technical programmes. • State of quality survey (described below). While collection and analysis of such a wide range of data might be challenging in some contexts, the process does not always need to be lengthy and resource intensive. In countries where resources for such exercises are limited, it may be possible to use as a starting point existing analyses that have been done for other health system planning needs, for example to inform development of a national health strategic plan. Aspects of the situational analysis can also be combined with other elements of the national quality process, for example using stakeholder engagement processes to collect important data. Support for the situational analysis may be available from other agencies active in quality of care, for example national professional bodies or external technical agencies. The more comprehensive an analysis that can be done, the more the strategy will benefit, but the important point here is that the strategy should be grounded as far as possible in the identified needs of the country and the assets available to tackle these. Even with few resources, such an approach is possible. A number of tools to support this process are outlined in the compendium of tools accompanying this handbook. A questionnaire to conduct semi-structured interviews or elicit written responses can provide important background information, including stakeholder experience, and supplement the information gleaned from the data sources and analyses described above. Through this data collection activity – which will be based on individual and small group interviews (or in some cases written responses) – the team can better understand the attitudes and perspectives of stakeholders based on their experience. The four basic content areas, and their rationale, of the survey on the current state of quality are as follows. • National quality context. To ground the national quality strategy, it is helpful to know the related history, events and initiatives that led to its formation. This consists of understanding what has already been done around quality planning, control and assurance, and improvement, including in relevant disease- or population-specific programmes. Depending on how centralized 42 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y or fragmented the country’s health system is, these initiatives may be coming from a range of different places, for example the private sector, donor funding or local initiatives, and will be influenced by a host of political, economic, demographic and other factors. • Policy and planning. Health care quality in all countries is driven by policy and enacted through some kind of structured planning functions. For example, national priorities are explicitly identified and then determine macro-level resource allocation, affecting clinical delivery of services at the local level. In parallel form, national standard setting can highly influence the appropriateness of clinical decision-making and the safety of the institutions where people seek care. • Regulation, governance and oversight. This is a descriptive analysis of how the formal and informal functions related to leadership, governance and oversight influence quality. It is important to conduct this assessment across all levels of the health system, including national, state or provincial, local, institutional and community levels, ensuring that both the public and private sectors are included. The main elements to consider are the structures and accountabilities for quality, while carefully identifying the strengths and weaknesses of legislative, policy and regulatory factors. • Existing quality measurement and improvement activities. It is important to take stock of current quality-related initiatives taking place across the country at national, state or provincial, local, institutional and community levels. This analysis can lead to an insightful assessment of present capacity and competencies, while identifying “shining lights” as well as gaps. Summary: situational analysis Actions for the strategy development team Content of the strategy document • Select and develop tools for situational analysis process • Identify key stakeholders to be engaged • Collect data on existing activities, health system planning, governance and oversight, contextual factors, and the historical quality journey • In a multistakeholder process, analyse the data to inform selection of priorities, clarification of governance and structures, development of interventions, and practical plans for monitoring and evaluation • Summary of situational analysis process • Headline situational analysis findings 5. Governance and organizational structure for quality There are two governance structures that must be considered. The first will be a governance structure that will create, establish and enforce the national policy direction on quality. The second will be the governance and organizational structure that bears the responsibility of fulfilling the strategy and ensuring its intended purpose. Part I discusses the former, but this section will focus more on the latter. Those who took part in the drafting of the strategy usually have tactical roles in catalysing its implementation. This requires defining clear roles and responsibilities of key named individuals and organizations who will oversee particular aspects of the strategy and will execute it on the ground. 43 P A R T I I . S T R A T E G Y D E V E L O P M E N T The governance of the strategy will also depend on dedicated leadership and management, especially for national-level initiatives that are meant to reach regions, facilities and local communities. Communication flow must have a clear path from central to decentralized end points, and vice versa; clarifying governance structures can ensure that local quality improvement champions and facility teams can meaningfully feed into subnational and national processes. Existing mechanisms for health sector leadership, outreach and communication should facilitate the strategic implementation of the policy to avoid parallel systems. If these channels do not exist, having them written within a strategic plan and then institutionalized is strongly advised. Organigrams are important as a visual tool that helps both internal and external actors understand the process and flow of the governance structure (see the compendium for examples of organigrams) (Figure 2). Figure 2. Sample organigram for national quality efforts Ministry of health Hospital quality committee Community Ql team Hospital quality committee Department Ql team Department Ql team Community Ql team National quality assurance/improvement committee Quality assurance/ improvement/management committee Subnational quality committee Subnational quality committee To help the strategy development team assess both current governance assets and gaps, and to conceptualize the desired structure, it may be helpful to consider the following questions. Who is currently responsible for quality-related functions? This may be addressed during the situational analysis and stakeholder engagement elements of the process, but often there will be a complex or unclear picture. Of note, it may be important to clarify relationships between ministries of health, accreditation or licensing bodies, and 44 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y professional bodies, and what agreements are in place to manage these relationships. It may be helpful to map not just which individuals and organizations are responsible throughout the system, but also what resources and power they have at their disposal to discharge these responsibilities. The strategy can then be used to clarify roles and responsibilities, fill important gaps, plan for adequate resource allocation and outline how the system will work together. Is there an organigram? Organigrams can be a useful tool to map out the processes, accountability and flow of information within a health system. There may be existing organigrams showing how current national quality efforts are organized or how they fit in with the broader health system. As part of the stakeholder engagement process, it may be useful to determine whether there is a common understanding of the quality structures across the system, as different actors may have alternative perspectives. When planning the strategy, it is helpful to agree upon and publish an organigram, and to encourage this exercise to be repeated at subnational and facility levels as a means of clarifying roles and responsibilities. The confirmation of such organigrams can also be used to promote discussion on how each relationship within the structure will function, and whether any measures need to be put in place to strengthen each designated body. Is there clear accountability for quality at all levels of service delivery? This requires consideration of what accountability means at different levels of the health system, how quality of care is being measured to facilitate accountability, and what measures are in place or are feasible for addressing deficiencies in care identified through accountability processes. Addressing this question might reveal the need for the strategy to establish new or strengthen current accountability structures, and can help ensure the strategy is implementable at all levels. It is important to recognize here that accountability is not a unidirectional process, and that in developing the governance structure and processes there is a need to ensure they facilitate both top-down performance management and strengthen bottom-up linkages between quality improvement teams, subnational bodies and national authorities. What are the specific responsibilities of each major body or position? Answering this may again form part of the stakeholder engagement or situational analysis ele- ments of the process. In particular, it may be helpful not only to map the current situation, but also to identify any gaps or challenges in relation to the required roles and responsibilities for the intended core elements of the strategy. Specifically, it will be helpful to examine the roles, mandates, and capabilities of professional societies, councils, and similar official bodies, includ- ing their relationships with the ministry of health, providers, and each other. What resources exist and will be required? Organizational change and strengthening of organizational capacity across the health system may require significant resources. It is useful to determine what resources are currently available to support governance efforts, including within existing budgets of key stakeholders (for example professional bodies), and how resource use can be prioritized if necessary. Is the current legislative environment fit for purpose to support the strategy? Successful operation of the proposed governance structure relies on a supportive legislative environment. This may already exist in the form of specific health sector legislation, statutory responsibilities of professional and regulatory bodies, and established legal precedent on key issues. However, a case may have to be made for revision or strengthening of existing laws or creation of new legal instruments to enable effective strategy implementation. This may be a difficult or protracted process, and indeed may not be an initial priority, but it is important within the strategy development process to consider the impact of the current legislative environment and the potential value of any refinements. 45 P A R T I I . S T R A T E G Y D E V E L O P M E N T How are communities, patient organizations, and community- and faith-based organizations represented within existing health system governance structures? Although governance structures will vary in their composition, one particular group that should be represented is the “community” – the general population or the beneficiaries of the quality strategy. Although support from leadership and government structures is important, the end-users are an essential contributor to the broader process of quality improvement. Having a mechanism for including that voice in the development of the strategy is important, but its presence is equally as important when implementing the strategy and for ensuring accountability. Throughout the proposed governance structure there should be embedded mechanisms for community engagement; this requires dedicated activities to build the capacity of the health system to facilitate engagement. Patient charters may be a tool to help empower the role of patients and families interfacing at the community level. This should be aligned with existing national, regional and local laws and regulations that protect health consumers. Consideration should also be given to systematic inclusion of community representation on national, subnational and facility-level health management bodies, and there should also be a mechanism for assessing feedback from the community level. More detail regarding feedback and monitoring mechanisms will be discussed in subsection 8 below on quality indicators and core measures. Summary: governance and organizational structure for quality Actions for the strategy development team Content of the strategy document • Carefully consider the questions posed above to ensure effective examination of existing and proposed governance and organizational structures for quality • Develop appropriate and practical measures to ensure accountability • Identify levers for enforcement of strategy implementation at different levels of the health system • Specification of governance and accountability arrangements for the strategy, including organigram if appropriate and explicit statement of role of the community 6. Improvement methods and interventions Strategy can be defined as a plan chosen to bring about a desired future for achieving partic- ular goals. Strategic planning will need to identify quality improvement interventions that can address the national priorities and accomplish the explicit quality goals. Selection of quality improvement interventions must be accompanied by an implementation plan that is practical, effective and sustainable. The task of designing and implementing a national strategy can increasingly be guided by a growing evidence base on the impact of discrete and combined interventions. Literature from health service research, clinical medicine and social sciences refers to a large number of inter- ventions that vary widely in underlying assumptions, required resources and the context in which they have been implemented. However, much of the published evidence comes from higher-in- come countries and requires careful consideration based on varying contexts of countries, re- gions, states or provinces, and communities. Unfortunately, evidence is still scant in low- and middle-income countries and is often focused more on the structural aspects of quality, such as stock of medicines, which does not necessarily shed light on quality of medical care (16). There- fore, it is important to understand that this is an iterative and evolving process requiring ongoing assessment of what interventions and levers are working to improve health outcomes while identifying those that do not have positive results or that may even be causing untoward and 46 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y unintended consequences. Even with acknowledged gaps in evidence, it is still possible to use available experience, knowledge and science to identify those interventions most likely to pro- duce improvements in quality. Such an approach emphasizes the value of implementation-based strategy development, in which the strategy can be a dynamic document that incorporates real experience of implementation and previous quality efforts. Local quality improvement cham- pions and facility teams may already be operating within a number of countries, and can be a source of local intelligence on what is likely to work and where the challenges may be in use of certain interventions. Given the often limited evidence on interventions, developing an active learning agenda is a key support function for a national quality programme. Within the strategy, consideration should be given to how evidence can be generated, and how learning can best be captured, documented and shared. Box 13. External evaluation, licensing and certification As governments fund efforts towards universal health coverage, there is increasing demand that the quality of services paid for by public funds should be assessed and assured. External evaluation, such as accreditation, may consist of both self-assessment and external review of performance against standards, and is often an early step in national efforts to improve quality. Licensing describes a government-endorsed regulatory process to grant permission and specify scope for the health care practice of an individual or organization, usually preceding accreditation. Certification provides recognition – from state, private or nongovernmental bodies – for organizations, people, processes or objects that meet defined conditions developed for the certification process. More information is available from International Society for Quality in Health Care (https:// isqua.org). While each country will have different interventions and activities, there are a number of high-level concepts that are relevant across nations’ health care systems and that can help communicate and organize a national strategy. Though others exist, three practical approaches for designing, organizing and delivering national-driven quality intervention are outlined here: • Juran Trilogy: a concept for understanding the “big picture”; • selecting interventions: identifying the purpose, type of action and discrete intervention; • national multi-tiered approach: designing actions at all levels of the health care system. The Juran Trilogy: the big picture A commonly cited concept in health care improvement efforts is the Juran Trilogy. The Juran Trilogy comprises three separate but related approaches that must all be present in a national strategy: quality planning, quality control, and quality improvement.1 This can be a useful structure to conceptualize the different domains that can be addressed when selecting interventions. In the context of health, the Juran Trilogy highlights the need for coherent national planning and policy formulation to set direction, accompanied by operational methods to ensure that the critical processes of health service delivery are designed to work and that the target levels of performance are being achieved and sustained. 1. Definitions of quality planning, quality control and quality improvement are provided in the glossary. 47 P A R T I I . S T R A T E G Y D E V E L O P M E N T This concept can be particularly helpful for nations as they build their quality strategies, recognizing that all three functions – planning, control and improvement – are necessary and complementary. For example, in the development of its national health quality strategy Liberia used the three components of the Juran Trilogy to examine previous and ongoing health sector quality efforts and guide thinking on where to focus resources for identified priorities. While quality improvement has historically often taken precedence in national quality programmes, it is important that methods and interventions address all three imperatives – planning, control and improvement – in a complementary manner. For example, reducing health care-associated infections is not likely to be possible without having the right policies in place (planning), robust infection prevention and control mechanisms properly conducted (control) and appropriate approaches for changing institutional and individual behaviours (improvement). Box 14. Applying the Juran Trilogy to guide selection of interventions Quality planning • How can patient and provider voices be captured in planning quality initiatives? • What new products and policies are required at different health system levels? Quality control • Are there published standards or guidelines? • What systems can be used to promote and assure provider and system performance? Quality improvement • What capacity is there at different health system levels for identifying and correcting deficiencies in performance? Selecting interventions Perhaps the most daunting challenge to safeguarding and improving quality is the judicious selection of “interventions” – the policies, programmes, structures and other actions implemented across all levels of the health care system to impact health outcomes. This is admittedly a difficult task for all countries, for multiple reasons. • The evidence is often hard to interpret regarding the effectiveness and impact of interventions. • Ideologies and beliefs often prevail over evidence, even where it exists. • Expertise may not be readily available for designing specific interventions. • Stakeholders may resist certain actions (such as public reporting of performance data). • Resources may not be available. The universe of interventions to impact quality is large and difficult to fully conceptualize. Organizing these interventions can enhance a common understanding and allow better choices about which of the interdependent interventions to select across all countries and across diverse health systems. We do know there are no “silver bullets” or fail-safe solutions and that a combination of interventions used simultaneously in a complementary and integrated strategy is needed for quality improvement to prevail. A quality improvement intervention is a change process in health care systems, services, or suppliers for the purpose of increasing the likelihood of optimal clinical quality of care measured by positive health outcomes for individuals and populations (Agency for Healthcare Research and Quality) “ ” 48 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y The list of illustrative interventions in Table 3 has been selected for several reasons. The quality- related interventions cited are relevant in a wide variety of countries globally; are commonly considered as options for action; have some evidence to guide selection and use; are intuitively reasonable; and can be implemented at multiple levels, from small primary care clinics to the level of a national programme. That being said, quality interventions need to be examined carefully. The list presented is by no means exhaustive; there are other interventions that could easily have been included. This set of interventions has been selected for their potential impact on quality by reducing harm, improving front-line delivery of health care services, and building systemwide capacity for quality improvement. The illustrative interventions are intended to point to some of the options and possibilities available to the managers, practitioners or policy-makers keen to advance quality of care. The interventions are presented as simply as possible, highlighting the salient issues. However, none is simple to implement, and they should not be viewed in isolation – some of these interventions are interrelated and thus when implemented in combination can have greater impact. As more countries work to improve quality of care, more context-specific evidence for “what works” is expected to emerge, so it is recommended that the latest evidence, experience and contextual knowledge is taken into account when selecting interventions. Table 3. Illustrative quality interventions Intervention Definition and application System environment • Registration and licensing of doctors and other health professionals, and of health organizations, is often considered a key determinant and foundation of a well performing health system. • External evaluation and accreditation is the public recognition, by an external body (public sector, non-profit or for profit), of an organization’s level of performance across a core set of prespecified standards. • Clinical governance is a concept used to improve management, accountability and the provision of quality health care. It incorporates clinical audit; clinical risk management; patient or service user involvement; professional education and development; clinical effectiveness research and development; use of information systems; and institutional clinical governance committees. • Public reporting and comparative benchmarking is a strategy often used to increase transparency and accountability on issues of quality and cost in the health care system by providing consumers, payers, health care organizations and providers with comparative information on performance. • Performance-based financing and contracting is a broad term for the payment of health providers based on some set of performance measures. It is increasingly used as a quality lever. The amount contingent on performance is often a subcomponent of the full payment, which may be based on a range of financing es. • Training and supervision of the workforce are among the most common interventions to improve the quality of health care in low- and middle-income countries. • Medicines regulation to ensure quality-assured, safe and effective medicines, vaccines and medical devices is fundamental to a functioning health system. Regulation, including post-marketing surveillance, is needed to eliminate substandard and falsified medicines based on international norms and standards. 49 P A R T I I . S T R A T E G Y D E V E L O P M E N T Reducing harm • Inspection of institutions for minimum safety standards can be used as a mechanism to ensure there is a baseline capacity and resources to maintain a safe clinical environment. • Safety protocols, such as those for hand hygiene, address many avoidable risks that threaten the well-being of patients and cause suffering and harm. • Safety checklists such as the WHO Surgical Safety Checklist and WHO Trauma Care Checklist can have a positive impact on reducing both clinical complications and mortality. • Adverse event reporting documents an unwanted medical occurrence in a patient resulting from specific health services or during patient medical encounters in a medical care setting. It should be linked to a learning system. Improvement in clinical care • Clinical decision support tools provide knowledge and patient-specific information (automated or paper based) at appropriate times to enhance front-line health care delivery. • Clinical standards, pathways and protocols are tools used to guide evidence-based health care that have been implemented internationally for decades. Clinical pathways are increasingly used to improve care for diverse high-volume conditions. • Clinical audit and feedback is a strategy to improve patient care through tracking adherence to explicit standards and guidelines coupled with provision of actionable feedback on clinical practice. • Morbidity and mortality reviews provide a collaborative learning mechanism and transparent review process for clinicians to examine their practice and identify areas of improvement such as patient outcomes and adverse events without fear of blame. • Collaborative and team-based improvement cycles are a formalized method that brings together multiple teams from hospitals or clinics to work together on improvement around a focused topic area over a fixed period of time. Mutual learning mechanisms across health care organizations are increasingly prominent. Patient, family, and community engagement and empower- ment • Formalized community engagement and empowerment refers to the active and intentional contribution of community members to the health of a community’s population and the performance of the health delivery system. It can function as an additional accountability mechanism. • Health literacy is the capacity to obtain and understand basic health information required to make appropriate health decisions on the part of patients, families and wider communities consistently. It is intimately linked with quality of care. • Shared decision-making is often employed to more appropriately tailor care to patient needs and preferences, with the goal of better patient adherence and minimizing unnecessary future care. • Peer support and expert patient groups link people living with similar clinical conditions in order to share knowledge and experiences. It creates the emotional, social and practical support for improving clinical care. • Patient experience of care has received significant attention as the basis of designing improvements in clinical care. Patient-reported measures are important in themselves; patients who have better experience are more engaged with their care, which may contribute to better outcomes. • Patient self-management tools are technologies and techniques used by patients and families to manage health issues outside formal medical institutions. They are increasingly viewed as a means to improve clinical care. 50 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y National multi-tiered approach to quality Responsibility for the quality of health care services is present at multiple hierarchical levels in every country. Generally, there are at least five levels where activities take place and accountability for quality exists (17-19), though others may be identified depending on the particular setting, for example in countries with significant subregional health system management. In selecting interventions, an exercise can be performed to identify required functions by health system level, helping ensure strategies are comprehensive and locally appropriate. The five levels can be described as follows (Figure 3). • National-level functions include policy formulation, infrastructure building, resourcing and accountability to the public. • At a subnational level (region, province, state) there are usually functions of rationalizing national policy to the contextual needs of a region, as well as macro-management and monitoring of performance. • Communities are often uniquely able to act in the collective interest of the individual patients and citizens by providing voice, performing governance within civil society mech- anisms, and monitoring and assuring accountability. • Institutional entities such as hospitals, clinics and dispensaries are responsible for good governance, competent operations and management to meet the needs of patients, fami- lies and the community. • Individual encounters between the health care worker and the patient are where the care must be effective, safe and people-centred. Some functions may feature across multiple levels, for example the learning agenda, leadership and data management. Figure 3. Illustrative activities across five levels of hierarchy Source: Adapted from Leatherman and Sutherland. • Legislation • National Goal Setting • Regulation and Oversight • Public Performance Reporting • External Evaluation • Accreditation • Targets and Standards • Performance Contracting • Benchmarking • Outreach and Advocacy • Education and Awareness • Provide Input to Health System • Leadership and Governance • Incentives • Traditional QA Functions • IT Decision Support • Performance Contracts • Professional Appraisal • Patient Education • Supervision • Shared Decision Making Regional/ State Community National Institutional Individual 51 P A R T I I . S T R A T E G Y D E V E L O P M E N T Figure 4 shows an example “pyramid” of the levels in a health care system from Mexico’s draft national quality strategy, published in 2016. The framework for interventions can be applied in such a pyramid to understand how specific actions at all five levels create a comprehensive systemwide strategy for quality. Figure 4. Framework of interventions at each level of hierarchy: Mexico • Vice-ministry for integration and development • Directorship for quality and education • National quality steering committee • National center for technology excellence (CENETEC) • National quality award • Regulation for accreditation of schools of medicine • National population satisfaction surveys • Essential actions on patient safety • 9 indexes composed of 33 quality indicators • Monitoring system (INDICAS) • Accrediatation of healthcare facilities • Hospital patient quality and safety committees • Code of ethics for hospitals • Patient satisfaction surveys per unit • Benchmarking of safety culture in units • Pharmacy and therapeutic committee COFAT • Patient satisfaction survey by citizen endorsement groups (Aval Cindadano) • Quality management projects and research in priority diseases • Self-evaluation survey of WHO multimodal strategy and questionnaire of knowledge and perception of hand hygiene • Adverse event registration system • State quality committees • Patients’ rights • Doctors’ rights • Nurses’ rights • Code of ethics for doctors • Code of ethics for nurses • Ql training for healthcare professionals • Management training for top healthcare executives • General practitioner certification • Clinical guidelines • Healthcare algorithms on priority diseases Community National Institutional Individual Regional/State • Citizen endorsement groups • Code of ethics for citizen endorsement groups Summary: interventions for improvement Actions for the strategy development team Content of the strategy document • Plan process of selecting interventions for improvement. This may involve review of current evidence; stakeholder engagement to elicit knowledge of current implementation; and use of approaches such as the Juran Trilogy alongside expert technical input • Map interventions against identified goals and priorities to ensure action is directed towards meeting these • Conduct detailed analysis of illustrative interventions to ensure they are practical and achievable • Identify who is responsible for implementation • Outline of the interventions that have been chosen, and how these address the identified priorities • Detailed description of interventions, including resource requirements, timescales, and responsibility for implementation; this can be further detailed in an operational plan Source: National quality strategy, Mexico, 2016. 52 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y 7. Health management information systems and data systems Health information systems are a necessary component for transformation of health service delivery (20), which is fundamentally the aim of any national quality strategy. Therefore, a robust understanding of data systems is fundamental to the development of a quality strategy. Improving quality is always reliant on the presence of clear and accurate performance measurement data, whether at the level of individual practitioners and providers, or on a broader population level. Thus, the development of a national quality strategy will inevitably entail emphasis on the systems necessary for data collection, measuring and reporting, and the feedback loop in place for improvement. Most countries around the world, including many high-income countries, recognize that their health information systems data sources and metrics are not ideal. Conversely, it is also true that there are always enough data to at least get started. The essential data inputs usually exist in some form and to some degree, but the completeness and accuracy are uneven across geographies and levels of the health care system; for example, hospital data are often better than primary care data. Box 15 provides sample questions that can be applied to assess the current data sources. Box 15. Sample key questions to assess current data sources • What are the current health care data sources (e.g. HMIS, donors)? • What is the accuracy and completeness of the data? • What metrics are being collected within each data source? • What factors need to be considered when using the patient medical records (e.g. availability, accuracy)? • What is the “movement” of data (who is collecting, for what purpose and where is it being reported)? • Is there feedback to facilities and individual providers? • Are there any existing measurement frameworks? • What existing standards of care or protocols have specific metrics accompanied by numerical targets? Feedback and reporting of data are rapidly evolving across the world with increasing public expectations of transparency and accountability regarding health systems. Given the complexity, cost and goodwill at stake in evaluating and reporting performance data, it is critical to establish clear aims and principles, such as (a) primary intended audience (for example, regulators, providers, patients who would be impacted or implicated; (b) intended use (for example, by providers to improve patient care, or for regulators to assess adherence to standards); and (c) data protection (for example, protecting individual providers being disclosed and identified with performance data, while also balancing accountability in the system). Tackling deficits in data, and the complexities of health information systems, can quickly over- whelm those who are responsible for the formulation and implementation of an information system capable of supporting the national quality strategy. Policy-makers and strategists will require significant technical input at this stage. Breaking the task down to manageable pieces can help define strategic action. This involves understanding the current state; mapping out the ideal state; and then developing a plan to bridge the current and ideal future states related to data and measurement throughout the various levels of the health care system. 53 P A R T I I . S T R A T E G Y D E V E L O P M E N T Current state of data and measurement through various levels of health care system The first step is mapping what data are being collected and how they can be accessed and, importantly, made to connect with each other (interoperability) so that quality can be measured across areas. For example, linkages are required between the supply chain, facility-based stock- outs and quality of care delivery. A major potential source of data to monitor quality is the routine HMIS, which may be in the form of an electronic system that can be interrogated to access a range of data across health system levels (for example the widely used DHIS 2). Other routinely collected data to measure and identify gaps for improvement in quality could include data from supervision visits or financial data from insurance. Other useful data sources collected less regularly include standardized surveys measuring facility readiness (for example, service provision assessment, service availability and readiness assessment, service delivery indicators), household surveys of coverage of targeted services or diseases (for example, multiple indicator cluster survey, WASH), or data sources that are more broad (for example, demographic and health surveys). Furthermore, ad hoc data reporting systems that support improvement may exist, for example, local health surveys that explore particular issues in more detail. Box 16 summarizes the various sources of quality measurement that are available in most or all countries. Box 16. Potential sources of quality measurement available in many countries Individual patient medical records (paper or electronic) Routine HMIS Facility surveys: • sampled national standardized survey • routine supervision or monitoring surveys • external evaluation, inspection and accreditation Household surveys Insurance programmes Patient and public questionnaires and online reviews or surveys Medical registries (facility or community) Other routinely collected data, including performance appraisals and supportive supervision There are however areas where data are often missing in existing data sources. These include experiential quality and patient satisfaction; health care worker competence; management, coordination and continuity across care sites; quality in the private sector; and quality of community-delivered care. Work to ensure that these are measured more routinely is an important area for strengthening HMIS as part of an overarching quality strategy. When assessing the current status of data and measurement systems, it is important to consider not only what sources exist, but also how data are being used. For example, at which health system levels are data collated and analysed, and is there feedback into the system to allow modification of behaviours, goals, priorities and measures? It is also important to note whether the various parts of the current system, including individual disease programme data systems, are complementary and compatible, and whether there is a burden on the system from conflicting or duplicative data from different stakeholders. 54 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y Mapping what the “ideal” state would look like There are five basic integrated analytic and reporting capabilities needed to support national quality strategy: • a national hierarchical data collection and reporting system (HMIS); • data sets that reflect the state of quality at the different levels of the health system; • clinical decision support and knowledge management systems for the workforce; • quality monitoring and feedback systems to assess individual performance against standards or targets and comparative benchmarking data; • reporting for transparency and accountability. Strategy development teams, supported by data and information specialists, can identify minimum information system requirements under each of these capabilities, cross-referencing against identified priorities for the strategy. Development of a plan to bridge the current and ideal future states There is no need to wait for the “fix” of flawed information systems and deficiencies in data that are ubiquitous. It is possible to get started on what is available while working within a defined long-term plan for the necessary evolution of data collection and analysis. While existing health information and data systems, however limited, can inform identification of priorities and formation of the strategy, plans can also be put in place, as part of the strategy, for further data system strengthening to meet any gaps between currently available sources and those needed for the ideal state. Clearly, achievement of the ideal state may be a complex and resource-intensive process, so such plans may need to prioritize the development of new systems required to achieve the successful implementation of the quality strategy, and should assess the resources required. Priority may be given to those measures that strengthen existing systems rather than create new processes, and to those that are critical to support other priority interventions outlined in the strategy (for example, performance-based financing requires reliable measurement of provider performance). The major challenge for many countries is too many data of variable quality with gaps in measuring important areas, including provider competence and the patient experience of quality. There is an urgent need to make the data better (data quality) – more accurate, complete, meaningful and actionable. Many countries must also work to better identify and measure critical areas where data are not now being captured while also reducing the burden of data by ceasing collection and measurement where data are not used and are of low priority. Fully appraising existing data and information systems and planning for improvements is likely to require specialist technical support that may be beyond the capability of teams preparing the national quality strategy. In this regard, the role of the strategy is not to provide a detailed plan for improving such systems, but to ensure their importance is clearly recognized and that initial steps are taken to identify and address critical gaps. Summary: health management information systems and data systems Actions for the strategy development team Content of the strategy document • Produce inventory of the current state of data and measurement throughout the various levels of the health care system • Map what the “ideal” state would look like • Develop a plan to bridge the current and ideal future states • Outline of data and information system improvements needed, and timeline for achieving this • Description of how current systems will be used for measuring quality, monitoring provider and professional performance, and supporting decision-making 55 P A R T I I . S T R A T E G Y D E V E L O P M E N T 8. Quality indicators and core measures Translating policy into practice requires that countries identify core measures of quality across the levels of care and dimensions of quality. All countries are currently measuring many components of their health system, often through monitoring and evaluation and routine HMIS, as described in subsection 7 above, and not infrequently through parallel donor-mandated systems. However, there is a growing recognition of the need for harmonization of indicators and systems to create better information to drive policy, decision-making and improvement of health services. To do this effectively will require input and coordination between a number of key stakeholders with a range of skills. These include policy-makers, service delivery managers, the health professions, HMIS/IT with monitoring and evaluation teams, and importantly the broader community of patients and civil society. In addition, there is a growing recognition of the importance of fully including the private sector to ensure that measurement and reporting of quality applies to all populations being served. This section, which should be read in conjunction with subsection 7 above, provides insights on how to define strategic direction on the measurement of quality, examples of quality indicator sets, emerging work on how to maximize data use, and consideration of some areas where more exploration is needed in measuring what matters. Measuring quality of care is a rapidly evolving area; tools and resources will be continuously emerging to increase the utility of data collec- tion, measurement and reporting. A comprehensive quality strategy includes a plan for quality monitoring, feedback and overall evaluation of what progress is being made against the national goals. The objective of national quality indicators is to assess the high-level goals through a set of specific indicators, which can be used to measure the success of the strategy itself and to support efforts at every level of the health care system to pursue actions for improvement. The role of measurement in national quality efforts includes: • monitoring for adherence against standards and guidelines • feedback to providers on quality improvement activities • transparency and accountability to the public • benchmarking to understand comparative performance • strategic or value-based purchasing and contracting • monitoring of the effectiveness of quality interventions. A key task of any national quality strategy is to build measurement and evaluation capability, which requires definition of a national framework of quality indicators. Selection of indicators for such a framework should be based on country priorities, needs and existing data capabilities. The process for framework development will vary between countries. However, a number of important steps are outlined below, which can help with development of such a framework. Review of global and expert illustrative indicators Many countries have struggled to select indicators that can be reliably and efficiently collected, truly reflect the state of quality of care, and are useful in efforts to improve quality of care. To support such efforts, a number of organizations have convened expert groups to propose sets of indicators, including information on how these can be collected and used. It may be useful for national quality strategy development teams to access these illustrative lists to provide direc- tion on how to select indicators that align with the goals and priorities set out in the strategy. Further information on illustrative sets of indicators is available in resources included in the com- pendium. It is likely that further sets of indicators will be developed as part of ongoing global efforts on quality of care. 56 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y Cataloguing and assessing existing quality indicators To ensure best use of existing systems and alignment with current national health priorities, it is important to catalogue and understand the existing quality indicators collected within countries and the data systems within which these indicators are embedded or from which the data are drawn. It is vital to understand whether there is current effective use, meaning that data are collected for valid measurement of an indicator, and whether there is a feedback loop of analysing, reporting, learning and making changes to improve performance. To understand the current state of data systems and quality indicators, the following steps are crucial. 1. Catalogue the various current data sources that can be used for quality indicators. This can include HMIS data sources, donor data, clinical registries, patient surveys and accreditation reports. 2. Clarify what existing frameworks for quality metrics and indicators are currently being used. 3. Within each data source, catalogue specific quality metrics that are currently being collected. 4. Grade the data by assessing their accuracy and completeness. Once the current state of data systems and quality indicators is analysed and assessed, a new or revised framework to correspond with the national quality strategy can be developed. In building a national framework of quality measures, as part of the national quality strategy, it is recommended that existing quality metrics be used to the extent possible in order to best align with current reporting systems and reduce, or minimize, the data burden. To support this process, 10 criteria are presented in Box 17 that can be used to prioritize existing quality indicators or measures for inclusion in a national quality indicator framework. Box 17. Ten criteria for assessing quality indicators for a core set Health priority. Does the indicator measure a specific health priority? Scope of impact. What is the scope of impact in measuring this indicator (e.g. population-size clinical outcomes)? Evidence base. Is there sufficient available and credible evidence for this indicator to be consensual? Defensibility. Is this indicator defensible both from a scientific point of view and from the perspective of what key decision-makers view as important? Feasibility. What is feasible given the data that are already collected; how easy will this be to implement? Accuracy. Are the data collected through this indicator accurate? Actionability. Are clear actions and change in individual, institutional or system behaviours possible from looking at this indicator? Comparability. Can this indicator be compared against a gold standard or with other countries or across regions? Credibility. Is the indicator credible for those who need to take action and those whose performance is being measured and compared? Clarity. Is the indicator described in clear and unambiguous terms? 57 P A R T I I . S T R A T E G Y D E V E L O P M E N T Conceptual frameworks for quality indicator selection To support development of a comprehensive quality measurement framework, there are a number of ways to conceptualize measurement of quality across a health system. These include: • dimensions of quality: for example, those from the definition section in this handbook, or a locally defined set of domains; • Structure/process/outcome: Donabedian’s three areas of structure (including systems), process and outcomes (health and patient experience and satisfaction) (21); • health system organization: including level of care (primary, secondary, tertiary), management structures (facility, district, national etc.), and continuum of care (promotion through to palliation); • disease and population groups: significant causes of disease burdens and main populations affected. Strategy development teams can consider these conceptual frameworks to identify aspects that should be accounted for in a quality measurement framework. A mapping exercise can then take place to assign appropriate measures from illustrative lists and existing national indicator sets to each aspect, identifying any gaps that may have to be filled by newly developed measures. Summary: quality indicators and core measures Actions for the strategy development team Content of the strategy document • Review global and expert illustrative indicator lists • Catalogue and assess available national quality indicators • Define key steps in the development of a national quality measurement framework • Map available and suggested quality measures against framework and plan for development of bespoke measures to fill gaps • Outline of national quality measurement framework • Plan for monitoring, evaluation and accountability • Measures refined by testing a preliminary set and taking actions to fill gaps in measurement capacity 58 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y DEVELOPING AN OPERATIONAL PLAN FOR IMPLEMENTATION National quality strategies can be supplemented with operational plans that detail the practical steps, resources, responsibilities and timeframe for the implementation of the strategy. Development of these will draw upon the same processes used in the eight NQPS elements areas, focusing on how the identified actions will be implemented. Overview and rationale Formulating the policy for quality and then designing a national quality strategy is a complex endeavour. The operational plan defines clear milestones and tasks that must be undertaken, clarifies roles and responsibilities, sets clear timelines, and addresses financial and resource considerations. Each country will decide the appropriate timeframe for the operational plan, often choosing to further classify and plan short-term versus longer-term actions and identifying crucial milestones. An operational plan can significantly aid dissemination and execution of the strategy and ensure the document does not simply “sit on the shelf”. It may also help to translate a national strategy into subnational operational plans to promote ownership across the system, highlighting the need for close linkages between national and subnational plans. While the strategy itself plans to build cohesion across stakeholders in the health system, align quality goals and priorities, and identify key levers to achieve these quality goals, the operational plan goes a level deeper to define explicit tasks, roles, timelines and financial considerations. A template for an operational plan is available in the accompanying tools compendium. When and how should the operational plan be developed? An operational plan is often developed after formal ratification of the policy and strategy document by the structure (directorate, unit or working group) responsible for quality and quality improvement. A country may already have its own process for developing operational plans. Often, these are yearly plans that correspond to a country’s financial planning cycle. At a high level, an operational plan that supports national quality direction should start with the overall aims and goals laid out by the policy and strategy. Elements to consider in the operational plan include (a) where to begin (for example, are there certain tests or pilots in specific geographical locations to begin first?); (b) level of the health system (for example, beginning with national initiatives versus state or local initiatives); and (c) timing and plan for nationwide spread and scale-up. Collaboration and buy-in across all health system levels is important in developing an operational plan. Specific actions taken will be spread across national, regional, district, community and facility levels. What elements should the operational plan include? At a high level, the operational plan should answer the following questions, as they relate to the overall aims and goals of the national quality strategy. • What are the tasks or actions that must be undertaken? • How should tasks or actions be prioritized, if available resources are limited? • Who are the persons who have the responsibility for each of these tasks or actions? • What is the timeline in which these tasks or actions must be completed? • How much and what kind of resources must be provided to complete each task or action? • What specific performance measures should be collected (for example, quarterly) throughout the length of the operational plan to evaluate the success and effectiveness of the plan? Within the operational plan, tasks or actions may be prioritized based on interventions outlined in the quality policy and strategy document and a thorough understanding of the current state of quality and the existing assets to be leveraged. While it can differ by country, in general, an operational plan spans the length of one to two years. 59 P A R T I I . S T R A T E G Y D E V E L O P M E N T INTEGRATING TECHNICAL PROGRAMMES WITH NQPS Any national quality strategy is ultimately focused on achieving better health outcomes and improving health system performance in dimensions of quality such as effectiveness, safety, patient-centredness, timeliness, efficiency and equity. Accomplishing these goals requires policy formulation to create an enabling environment, addressing deficiencies in the delivery system and integrating the improvement and measurement efforts of disease-specific and population- specific health programmes that exist in every country, also known as vertical or technical programmes. A national quality strategy must be comprehensive and inclusive of all populations and health care needs, though priorities will inevitably be identified. Intentionally integrating with technical and disease-specific programmes allows the national strategy to leverage the already existent quality-related strengths and capabilities of technical programmes and ensures that those programmes are not left functioning outside the national strategy. Furthermore, integration of technical programmes may enhance engagement with donor organizations, allow tried-and- tested local solutions to inform the broader strategy, and lead to efficiencies in use of limited resources. For the technical programmes there can also be significant advantages, for example the potential to scale up efforts through a national programme, efficiencies of access to national health infrastructure, and improvement of programme outcomes due to a stronger system. Whether considering long-standing programmes such as maternal and child health, or donor- supported initiatives such as HIV programmes, technical programmes may simultaneously address the best ways to organize and deliver individual health services along with systematically improving and measuring population health. These programmes, especially in low- and middle- income countries, often have basic quality-related capabilities in place, even before national quality strategies have been formally implemented. Examples of those capabilities include guidelines and standards, patient pathways, continuous monitoring of patient outcomes and routine use of quality and safety indicators. Integration of technical programmes is necessarily a two-way process: national quality strategies must account for the activities, assets and learning from existing technical programmes, and existing technical programmes should endeavour to align with national quality processes and priorities. Clearly, there is a potentially wide variation in levels of integration of technical programmes within national quality strategies. Options for integration include the following. • The technical programme is fully subsumed within the national quality strategy. This ensures maximum alignment, but is probably only possible for existing government-led programmes that have a primary focus on quality of care (for example, there may be an existing national effort on maternal and child health quality of care, which could be easily integrated in a systemwide effort with little disruption). • Technical programmes can act as “pathfinders” for national quality strategies. In this scenario, specific technical programmes can be used to begin or trial roll-out of the strategy, to allow for rapid field-testing and scale-up making use of well resourced programmes. In such instances, care should be taken to ensure that the strategy is not dominated by only one technical area and that benefits are systemwide. • National quality strategy and technical programmes can be explicitly linked on a strategic level. In this scenario, technical programmes maintain their operational autonomy, but there is joint strategic planning to ensure efficient use of resources and pursuit of common goals. Technical programmes would be expected to explicitly reference and endorse the national quality strategy in future planning processes. • Existing programmes are acknowledged and plans made for future integration. Given the complexities of integrating multiple programmes, a practical initial step is for the national 60 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y quality strategy to examine and acknowledge relevant technical programmes to ensure there is no duplication of efforts or areas of divergence in aims and activities. Technical programmes would be encouraged to gradually align with the national quality strategy, and the strategy itself could contain explicit activities to plan and operationalize integration. The type of integration may vary between countries and technical programmes, but initial steps that can be taken by the strategy development team include: • identification of relevant technical and vertical programmes as part of the situational analysis and stakeholder mapping; • early engagement of relevant implementing partners, including consultation with technical programmes on how to increase the applicability of the quality strategy, assessment of the capacity of the programmes to support strategy implementation, and discussion of options for integration; • mapping of areas of overlap and divergence between the proposed national quality strategy and the aims and activities of technical programmes; • contribution of quality-related expertise and technical know-how from the technical programme to a newly emerging or still evolving national quality strategy; • integration of data and measurement systems from the technical programme into the national measurement framework and quality data systems; • ensuring cross-learning between quality-related efforts in different technical programmes through strategic oversight provided by a national drive on overall quality; • development of a plan for alignment and integration, including an agreed joint programme of work, consideration of budgetary challenges and opportunities, or a timetable for further consultation. PART ΙΙΙ TOOLS AND RESOURCES 62 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y Background This handbook provides an overview of the background, rationale, and process of efforts to develop national policy and strategy on quality of care, as well as suggested content for documents outlining such policies and strategies. Putting this into action will require more detailed consideration of each element. Moreover, different countries will have different needs, priorities, capabilities, resources, and procedures for policy and strategy development; the support required for each step of the process will necessarily differ. In-depth consideration of each element of the NQPS process may be supported by a number of different means, for example through involvement of external experts or use of further tools and resources. Products that might support teams developing national quality policies and strategies include country case studies, global guidance documents produced by WHO and others, literature reviews, and dedicated tools that can be adapted and used to catalyse discussion and collect data. A number of such resources have been created by WHO, technical organizations, academic institutions, and countries themselves, and many are freely published for use and reference by others. While some may be specific to quality of care, others might be more generic but still relevant to the process, for example tools to perform situational analysis or assess health information systems. This section of the handbook does not present tools and resources for direct use, given that many of these run to numerous pages and are contained in already published documents. Instead, it outlines how tools and resources can be accessed, selected and used to support the NQPS process, and provides an overview of the compendium of tools and resources that is available for use alongside the handbook. The accompanying compendium of tools and resources is a more detailed document with an overview of selected tools and resources that can support the NQPS process. Both the compendium itself and the tools and resources will be accessed through a repository in the WHO Global Learning Laboratory. Finding, selecting and using tools to support the NQPS process While the compendium accompanying this handbook provides selected tools and resources for priority aspects of the NQPS process, and will be added to in future, it is not intended as a com- prehensive list of all relevant products. In many instances, those developing national quality policies and strategies may find it helpful to search for, adapt or develop other tools specific to the needs of their NQPS process, for example those relating to a specific NQPS element or technical area, or those available in local languages. Such an exercise does not necessarily have to be a complicated or methodologically strict process, and can be done relatively quickly, with the aim being to assist the overall process rather than add an unnecessary process burden. Box 18 lists some potential sources of tools and resources. Box 18. Potential sources of tools and resources • NQPS tools and resources compendium • Academic literature • World Health Organization website • Expert technical organizations (website or direct contact) • Academic institutions • Professional bodies • Other health policy or strategy development teams • NQPS documents available in other countries 63 P A R T I I I . T O O L S A N D R E S O U R C E S Suggested steps for identifying supplementary tools are outlined below. 1. Identify NQPS elements requiring more detailed input. As each country will have different priorities within their work on NQPS, they will have differing requirements for further tools. Much of the time, there will be sufficient expertise and experience within policy and strategy development teams or the broader set of stakeholders to perform the various elements outlined in this handbook, but it may become clear early in the policy and strategy development process that certain elements will require more in-depth work. Use of supplementary tools for the NQPS process should only be done where this is additive, as the process need not be overcomplicated. 2. Develop and implement a search strategy. This will require identification of potential sources of existing tools (see Box 18). While some tools will be publicly available online, others may only be found on direct engagement with the organization that owns them. It may be helpful to consider whether similar tools might have been developed locally to support other policy and strategy development processes; for example, many national health strategic plans have been developed after extensive stakeholder consultation and situational analysis, and both the tools and data from these may be available for use. For online searches, unless specifically searching for academic literature, it is usually best to search directly on the websites of the main technical agencies and other relevant institutions, and to undertake broader searches on standard search engines rather than academic databases. Generally, using a focused set of search terms is preferable so that searches do not yield too many results to search through. Features such as Google Advanced Search (https://www.google.co.uk/advanced_search) allow the user to search for specific terms on any given website, for example to look for “situational analysis” on all WHO pages. 3. Selection criteria. If apparently relevant tools are located, these should be assessed to ensure they are fit for purpose and will add value to the NQPS process. Criteria should be decided upon by the local team, but may include reliability of the source, applicability to local setting, and ease of use. Occasionally, there may be an identified need for greater support for a particular element of the NQPS process that is not met by existing available tools and resources. For example, countries may wish to perform an in-depth situational analysis on a key priority area for which there is no existing data collection tool. In this instance, it may be necessary to develop a bespoke tool to support the process. Again, the key consideration here should be whether the effort required is proportionate to the gains for the NQPS process, or whether there is a more appropriate way of supporting the particular element. New tools should always be developed and used with caution, as untested tools may not provide the required support, and indeed can present methodological challenges. More commonly there will be a relevant existing tool that can be adapted for local use. This may involve, for example, translating tools into local languages, or selecting relevant tried and tested survey questions from a more extensive data collection tool. If new or adapted tools are developed as part of the NQPS process in a particular country, owners of these tools are encouraged to share these via the WHO Global Learning Laboratory (GLL) for Quality Universal Health Coverage. When using supplementary tools to support the NQPS process, it is important to first identify the required resources to implement the tool, and to balance this against the expected benefit. The required resources may be in terms of financial cost and time required to implement a tool (for example, short non-generalizable surveys of facilities to catalyse discussion, versus large-scale statistically valid health system surveys), or could relate to the capacities required to implement tools (for example, whether there is the required expertise in engagement of stakeholders and communities). 64 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y Tools and resources compendium Clearly, a number of relevant tools and resources already exist – from WHO, external partners, and countries themselves – and are often freely available to use. However, initial country en- gagement in the WHO NQPS initiative has revealed that there is still an unmet need for tools and resources in some areas of the policy and strategy development process; this may be be- cause such tools do not exist, or are not easily identified and accessed, or are not of sufficient quality to be useful. In light of this, the NQPS handbook links closely with the WHO GLL, which aims to create a safe space to share knowledge, experiences and ideas; to challenge ideas and approaches; and to spark innovation for quality in the context of universal health coverage. Within the GLL, a focussed learning pod on NQPS has been created to facilitate sharing of experiences between countries and serve as a go-to resource for available tools relevant to NQPS. Available on the WHO GLL is a compendium of tools and resources that is a companion document to this hand- book. The compendium provides an overview of tools and resources that have been identified as helpful to support the NQPS process, and the tools identified therein are available either through direct hyperlink from the compendium or on the WHO GLL itself. This compendium comprises tools and resources that have predominantly already been produced and published by WHO and external organizations; these have been supplemented by de novo tools developed to fill critical gaps, as well as country-specific tools and examples. The compendium is not intended as a comprehensive list of all tools and resources that can support the NQPS process, but rather as a pragmatic collection of a number of tools of particular relevance, focusing on meeting country demand. The compendium is envisaged as a living document that will be updated as more tools are identified and developed, and as more countries progress on development of their national quality policies and strategies. Below is a brief overview of the approach taken to develop version 1 of the compendium. 1. A WHO meeting (June 2017) on NQPS involving national quality leads from eight countries allowed a collective examination of desired tools and resources to support NQPS, resulting in initial selection of categories of priority tools and resources designed to reflect those aspects of the NQPS process requiring more detailed input. This was based on a review of the handbook and consultation with the countries participating in the initial phase of the co-development process. 2. Scoping exercises were performed for each priority category. These differed for each category, but generally included definition of search criteria, search of publicly available sources, and liaison with country partners where required. 3. Selection of tools and resources was conducted based on the consensus of the NQPS team, with a focus on added value to the NQPS process and applicability at country level. The identified tools and resources are listed within the compendium under each of the above categories, along with instructions on how to access them and a description of how they can contribute to the NQPS process, as shown in Figure 5. 65 P A R T I I I . T O O L S A N D R E S O U R C E S Figure 5. Tools and resources: sources and relevance to the NQPS process Resource Access (web link or GLL) Institution/ author & year How this tool/resource supports the NQPS process NQPS Situational Analysis Tool Available within the NQPS learning pod on the WHO Global Learning Laboratory for Quality UHC WHO-NQPS Team 2017 Methodology for comprehensive assessment of a country’s national policies in healthcare quality Further engagement with countries and other partners will be maintained to identify and develop tools to bridge important gaps and expand the resources according to country demand. Of note, there was a need identified at the June 2017 meeting for development of further tools and resources to support national quality advocacy efforts and for integration of specific technical areas, and it is envisaged that these and other emerging categories will be addressed in future iterations. Joining the WHO GLL Instructions on how to join the WHO Global Learning Laboratory for Quality Universal Health Coverage, on which the compendium and associated tools can be accessed, are available here: http://www.who.int/servicedeliverysafety/areas/qhc/gll/en/index3.html. Name of tool, resource or example Direct web link, description of how to access, or signposting to WHO Global Learning Laboratory Organization, country or author, plus year created or updated Brief description of the resource and how it can be used to support NQPS process 66 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y GLOSSARY Term Definition Access (to health services) The perceptions and experiences of people as to their ease in reaching health services or health facilities in terms of location, time, and ease of approach (22). Accreditation A formal process by which a recognized body, usually a non- governmental organization, assesses and recognizes that a health care organization meets applicable pre-determined and published standards. Accreditation standards are usually regarded as optimal and achievable, and are designed to encourage continuous improvement efforts within accredited organizations. An accreditation decision about a specific health care organization is made following a periodic on-site evaluation by a team of peer reviewers, typically conducted every two to three years. Accreditation is often a voluntary process in which organizations choose to participate, rather than one required by law and regulation (23). Appraisal Evaluation of the performance of a health worker or trainee health worker against a published standard. Assessment A formal process of evaluation of a process or system, preferably quantitative, but sometimes necessarily qualitative (24). Benchmark (i) A measurement or point of reference at the beginning of an activity which is used for comparison with subsequent measurements of the same variable; (ii) an acceptable standard in evaluation (24). Data Facts and figures as raw material, not analysed (25). Equity in health (i) The absence of systematic or potentially remediable differences in health status, access to health care and health-enhancing environments, and treatment in one or more aspects of health across populations or population groups defined socially, economically, demographically or geographically within and across countries; (ii) a measure of the degree to which health policies are able to distribute well-being fairly (26-29). Evaluation The systematic and objective assessment of the relevance, adequacy, progress, efficiency, effectiveness and impact of a course of actions, in relation to objectives and taking into account the resources and facili- ties that have been deployed (30). Fragmentation (of health services) (i) Coexistence of units, facilities or programmes that are not integrated into the health network (31); (ii) services that do not cover the entire range of promotion, prevention, diagnosis, treatment, rehabilitation and palliative care services; (iii) services at different levels of care that are not coordinated among themselves; (iv) services that do not continue over time; (v) services that do not meet people’s needs (25). Health The state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (25, 32). Health service Any service (i.e. not limited to medical or clinical services) aimed at contributing to improved health or to the diagnosis, treatment and rehabilitation of sick people (30). 67 G L O S S A R Y Health system (i) All the activities whose primary purpose is to promote, restore and/ or maintain health (25); (ii) the people, institutions and resources, arranged together in accordance with established policies, to improve the health of the population they serve, while responding to people’s legitimate expectations and protecting them against the cost of ill-health through a variety of activities whose primary intent is to improve health (31). Health system building blocks An analytical framework used by WHO to describe health systems, disaggregating them into six core components: leadership and governance (stewardship); service delivery; health workforce; health information system; medical products, vaccines and technologies; and health system financing (33). Health system performance (i) The level of achievement of the health system relative to resources (33); (ii) the degree to which a health system carries out its functions (service provision, resource generation, financing and stewardship) to achieve its goals (34). Health systems strengthening (i) The process of identifying and implementing the changes in policy and practice in a country’s health system, so that the country can respond better to its health and health system challenges (35); (ii) any array of initiatives and strategies that improves one or more of the functions of the health system and that leads to better health through improvements in access, coverage, quality, or efficiency (36). Infection prevention and control Infection prevention and control is a scientific approach and practical solution designed to prevent harm caused by infection to patients and health workers (37). Input A quantified amount of a resource put in a process (25). Lever In relation to implementation of a policy or strategy, levers refer to mechanisms that supervisory authorities (at any level of the health system) can use to promote or enforce adherence to the policy or strategy. These often relate to procedures that can reward or sanction individuals or organizations according to their accountability for implementation; for example, legislation to enforce aspects of a policy might be called a lever, as might inclusion of policy adherence measures in health worker supervision or career progression processes. Licensure Licensure is a process by which a governmental authority grants permission to an individual practitioner or health care organization to operate or to engage in an occupation or profession. Licensure regulations are generally established to ensure that an organization or individual meets minimum standards to protect public health and safety. Licensure to individuals is usually granted after some form of examination or proof of education and may be renewed periodically through payment of a fee or proof of continuing education or professional competence. Organizational licensure is granted following an on-site inspection to determine if minimum health and safety standards have been met (25). Monitoring The continuous oversight of an activity to assist in its supervision and to see that it proceeds according to plan. Monitoring involves the specification of methods to measure activity, use of resources, and response to services against agreed criteria (30). 68 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y Operational plan An operational plan focuses on effective management of resources with a short time framework, converting objectives into targets and activities, and arrangements for monitoring implementation and resource usage. Specific meanings include (i) translation of the national strategic plan within a one-year time frame; (ii) translation of the national strategic plan into a subnational plan, e.g. a district plan, usually with a shorter time frame than the national strategic plan; (iii) a subset of a national strategic plan, limited to a particular programme (25). Outcome Those aspects of health that result from the interventions provided by the health system, the facilities and personnel that recommend them and the actions of those who are the targets of the interventions (22). Output The quantity and quality of activities carried out by a programme (25). Ownership The effective leadership and coordination by countries of their development policies, strategies and development actions (25). Patient safety Patient safety is the absence of preventable harm to a patient during the process of health care. The discipline of patient safety is the coordinated efforts to prevent harm, caused by the process of health care itself, from occurring to patients (38). People-centred health services “An approach to care that consciously adopts the perspectives of individuals, families and communities, and sees them as participants as well as beneficiaries of trusted health systems that respond to their needs and preferences in humane and holistic ways. People-centred care requires that people have the education and support they need to make decisions and participate in their own care. It is organized around the health needs and expectations of people rather than diseases.” (39). Performance-based payment, performance-based funding Payment or funding conditional upon taking a measurable action or achieving a predetermined performance target. It may refer to transfer of funds by donors to recipient countries, or to payment of providers or provider organizations for reaching service targets (25, 40). Priority setting The identification, balancing and ranking of priorities by stakeholders (25). Quality assurance All the planned and systematic activities implemented within the quality system, and demonstrated as needed, to provide adequate confidence that an entity will fulfil requirements for quality (41). Quality control Operational techniques and activities that are used to fulfil requirements for quality (41). Quality improvement “An organizational strategy that formally involves the analysis of process and outcomes data and the application of systematic efforts to improve performance” (42). Quality management All activities of the overall management function that determine the quality policy, objectives, and responsibilities, and implement them by means such as quality planning, quality control, and quality improvement within the quality system (41). Quality planning Activities that establish the objectives and requirements for quality and for the application of quality system elements (41). 69 G L O S S A R Y Regulation The imposition of external constraints upon the behaviour of an individual or an organization to force a change from preferred or spontaneous behaviour (25, 43). Resilience The ability of a system, community or society exposed to hazards to resist, absorb, accommodate to and recover from the effects of a hazard in a timely and efficient manner, including through the preservation and restoration of its essential basic structures and functions (44). Situation analysis Analysis of the current status and expected trends in a country’s health and health system. Ideally this includes (i) assessment of current and future health needs and determinants of health; (ii) assessment of expectations and demand for services; (iii) assessment of the health system performance, health sector capacity and health system resources, and the gaps in responding to current and future needs and expectations; and (iv) analysis of stakeholder positions (25, 45). Stakeholder An individual, group or organization that has an interest in the organi- zation and delivery of health care (24). Standard An established, accepted and evidence-based technical specification or basis for comparison (24, 25). Strategy A series of broad lines of action intended to achieve a set of goals and targets set out within a policy or programme (25, 46). Sustainability The potential for sustaining beneficial outcomes for an agreed period at an acceptable level of resource commitment within acceptable organizational and community contingencies (25, 47). Target An intermediate result towards an objective that a programme seeks to achieve, within a specified time frame. A target is more specific than an objective and lends itself more readily to being expressed in quantitative terms (25). Universal health coverage All people and communities can use the promotive, preventive, cura- tive, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship (10). 70 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y REFERENCES 1. Quality of care: a process for making strategic choices in health systems. Geneva: World Health Organization; 2006. 2. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington (DC): National Academies Press; 2001. 3. Improving value in health care: measuring quality. Paris: Organisation for Economic Co- operation and Development; 2010. 4. Donaldson LJ, Donaldson RJ. Essential public health, 2nd edition. Petroc Press; 2000. 5. Miranda S, Olexa GA. Creating a just culture: recalibrating our culture of patient safety. Pennsylvania Nurse. 2013;68(4):4–9. 6. Pronovost PJ, Wachter RM. Progress in patient safety: a glass fuller than it seems. American Journal of Medical Quality. 2014;29(2):165–9. 7. Marx D. Patient safety and the “just culture”: a primer for health care executives. New York: Columbia University; 2001. 8. Everybody’s business – strengthening health systems to improve health outcomes: WHO’s framework for action. Geneva: World Health Organization; 2007. 9. Transforming our world: the 2030 Agenda for Sustainable Development. New York: United Nations; 2015 (https://sustainabledevelopment.un.org/post2015/transformingourworld, accessed 2 February 2018). 10. Health financing for universal coverage. Geneva: World Health Organization (http://www. who.int/health_financing/universal_coverage_definition/en/, accessed 2 February 2018). 11. What is universal health coverage? Geneva: World Health Organization; 2014 (http:// www.who.int/features/qa/universal_health_coverage/en/, accessed 2 February 2018). 12. Strengthening integrated, people-centred health services. Resolution WHA69.24, Sixty- ninth World Health Assembly. Geneva: World Health Organization; 2016. 13. Service delivery and safety: World Health Assembly adopts Framework on Integrated People- centred Health Services. Geneva: World Health Organization; 2016 (http://www.who.int/ servicedeliverysafety/areas/people-centred-care/framework-wha/en/, accessed 2 February 2018). 14. The world health report. Health systems financing: the path to universal coverage. Geneva: World Health Organization; 2010. 15. Donabedian A. Evaluating the quality of medical care. Milbank Memorial Fund Quarterly. 1966;44(3 Suppl):166-206. 16. Das J. The quality of medical care in low-income countries: from providers to markets. PLoS Medicine. 2011;8(4):e1000432. 17. Leatherman S, Sutherland K. The quest for quality in the NHS: a mid-term evaluation of the ten year quality agenda. London: Stationery Office; 2003. 18. Leatherman S, Sutherland K. Designing national quality reforms: a framework for action. International Journal for Quality in Health Care. 2007;19(6):334–40. 19. Leatherman S, Sutherland K. The quest for quality: refining the NHS reforms. London: Nuffield Trust; 2008. 20. Shekelle P, Lim YW, Mattke S, Damberg C. Does public release of performance results improve quality of care? A systematic review. London: Health Foundation; 2008. 21. Donabedian A. Explorations in quality assessment and monitoring, volume I. The definition of quality and approaches to its assessment. Ann Arbour, MI: Health Administration Press; 1980. 71 R E F E R E N C E S 22. Starfield B. Basic concepts in population health and health care. Journal of Epidemiology and Community Health. 2001;55(7):452–4. 23. Rooney AL, van Ostenberg PR. Licensure, accreditation, and certification: approaches to health services quality. Bethesda: United States Agency for International Development; 1999. 24. Last JM, editor. A dictionary of public health. Oxford University Press; 2007. 25. Health systems strengthening glossary. Geneva: World Health Organization (http://www. who.int/healthsystems/hss_glossary/en/, accessed 6 February 2018). 26. Starfield B. Equity in health. Journal of Epidemiology and Community Health. 2002;56:483–4. 27. Dahlgren G, Whitehead M. Levelling up (part 1): a discussion paper on concepts and principles for tackling social inequities in health. In: Studies on social and economic determinants of population health, No. 2. Copenhagen: WHO Regional Office for Europe; 2006. 28. Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health. Geneva: World Health Organization; 2008. 29. La renovaciόn de la atenciόn primaria a la salud en las Américas [Renewal of primary health care in the Americas]. Washington (DC): OPS/OMS; 2007 (http://www2.paho.org/hq/dm- documents/2010/Renovacion_Atencion_Primaria_Salud_Americas-OPS.pdf, accessed 16 October 2017) (in Spanish). 30. Roberts JL. A glossary of technical terms on the economics and finance of health services. Copenhagen: WHO Regional Office for Europe; 1998. 31. Salud en las Américas, volume I. Washington (DC): Pan American Health Organization; 2007. 32. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference. New York: World Health Organization; 1946. 33. The world health report 2000. Health systems: improving performance. Geneva: World Health Organization; 2000. 34. Murray C, Evans D, editors. Health systems performance assessment: debates, methods and empiricism. Geneva: World Health Organization; 2003. 35. WHO Executive Board, 128th session. Health system strengthening: current trends and challenges. Geneva: World Health Organization; 2011. 36. Islam M, editor. Health systems assessment approach: a how-to manual. Submitted to the United States Agency for International Development in collaboration with Health Systems 20/20, Partners for Health Reformplus, Quality Assurance Project, and Rational Pharmaceutical Management Plus; 2007. 37. Clean care is safer care: infection prevention and control. Geneva: World Health Organization (http://www.who.int/infection-prevention/about/ipc/en/, accessed 6 February 2018). 38. Patient safety. Geneva: World Health Organization (http://www.who.int/patientsafety/ about/en/, accessed 6 February 2018). 39. What are integrated people-centred health services? Geneva: World Health Organization (http://www.who.int/servicedeliverysafety/areas/people-centred-care/ipchs-what/en/, accessed 19 February 2018). 40. Eichler R. Can ‘‘pay-for-performance’’ increase utilization by the poor and improve the quality of health services? Washington (DC): Center for Global Development; 2006. 41. Juran JM, Godfrey AB. Juran’s quality handbook, fifth edition. McGraw-Hill; 1999. 42. Evidence-based Practice Center systematic review protocol: closing the quality gap 2010: 72 H A N D B O O K F O R N A T I O N A L Q U A L I T Y P O L I C Y A N D S T R A T E G Y quality improvement interventions to address health disparities. Rockville, MD: Agency for Healthcare Research and Quality; 2012 (https://effectivehealthcare.ahrq.gov/topics/ disparities-quality-improvement/research-protocol, accessed 19 February 2018) 43. Saltman RB. Regulating incentives: the past and future role of the state in health care systems. Social Science and Medicine. 2002;54:1677–84. 44. UNISDR terminology on disaster risk reduction. United Nations International Strategy for Disaster Reduction; 2009. 45. A framework for national health policies, strategies and plans. Geneva: World Health Organization; 2010. 46. Health impact assessment: glossary of terms used. Geneva: World Health Organization (http://www.who.int/hia/about/glos/en/index2.html, accessed 6 February 2018). 47. Understanding the sustainability of health programmes and organizational change. Paper for Victorian Quality Council. La Trobe University, Faculty of Health Sciences; June 2007. World Health Organization 20 Avenue Appia CH-1211 Geneva 27 Switzerland Please visit us at: http://www.who.int/servicedeliverysafety/areas/qhc/nqps/en/ ISBN 978-92-4-156556-1

MANUAL DE POLÍTICAS E ESTRATÉGIAS PARA A QUALIDADE DOS CUIDADOS DE SAÚDE Uma abordagem prática para formular políticas e estratégias destinadas a melhorar a qualidade dos cuidados de saúde MANUAL DE POLÍTICAS E ESTRATÉGIAS PARA A QUALIDADE DOS CUIDADOS DE SAÚDE Uma abordagem prática para formular políticas e estratégias destinadas a melhorar a qualidade dos cuidados de saúde Desenvolvido conjuntamente pela Organização Mundial da Saúde e os países que perseguem iniciativas nacionais para a qualidade Manual de políticas e estratégias para a qualidade dos cuidados de saúde: uma abordagem prática para formular políticas e estratégias destinadas a melhorar a qualidade dos cuidados de saúde [Handbook for national quality policy and strategy: a practical approach for developing policy and strategy to improve quality of care] ISBN 978-92-4-000570-9 (versão electrónica) ISBN 978-92-4-000571-6 (versão impressa) © Organização Mundial da Saúde 2020 Alguns direitos reservados. Este trabalho é disponibilizado sob licença de Creative Commons Attri- bution-NonCommercial-ShareAlike 3.0 IGO (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/ licenses/by-nc-sa/3.0/igo/deed.pt). Nos termos desta licença, é possível copiar, redistribuir e adaptar o trabalho para fins não comerciais, desde que dele se faça a devida menção, como abaixo se indica. Em nenhuma circunstância, deve este trabalho sugerir que a OMS aprova uma determinada organização, produtos ou serviços. O uso do logótipo da OMS não é autorizado. Para adaptação do trabalho, é preciso obter a mesma licença de Creative Commons ou equivalente. Numa tradução deste trabalho, é necessário acrescentar a se- guinte isenção de responsabilidade, juntamente com a citação sugerida: “Esta tradução não foi criada pela Organização Mundial da Saúde (OMS). A OMS não é responsável, nem pelo conteúdo, nem pelo rigor desta tradução. A edição original em inglês será a única autêntica e vinculativa”. Qualquer mediação relacionada com litígios resultantes da licença deverá ser conduzida em confor- midade com o Regulamento de Mediação da Organização Mundial da Propriedade Intelectual. Citação sugerida. Manual de políticas e estratégias para a qualidade dos cuidados de saúde: uma abordagem prática para formular políticas e estratégias destinadas a melhorar a qualidade dos cuida- dos de saúde [Handbook for national quality policy and strategy: a practical approach for developing policy and strategy to improve quality of care]. Genebra: Organização Mundial da Saúde; 2020. Licença: CC BY-NC-SA 3.0 IGO. Dados da catalogação na fonte (CIP). Os dados da CIP estão disponíveis em http://apps.who.int/iris/. Vendas, direitos e licenças. Para comprar as publicações da OMS, ver http://apps.who.int/bookor- ders. Para apresentar pedidos para uso comercial e esclarecer dúvidas sobre direitos e licenças, con- sultar http://www.who.int/about/licensing. Materiais de partes terceiras. Para utilizar materiais desta publicação, tais como quadros, figuras ou imagens, que sejam atribuídos a uma parte terceira, compete ao utilizador determinar se é necessária autorização para esse uso e obter a devida autorização do titular dos direitos de autor. O risco de pedidos de indemnização resultantes de irregularidades pelo uso de componentes da autoria de uma parte terceira é da responsabilidade exclusiva do utilizador. Isenção geral de responsabilidade. As denominações utilizadas nesta publicação e a apresentação do material nela contido não significam, por parte da Organização Mundial da Saúde, nenhum julga- mento sobre o estatuto jurídico ou as autoridades de qualquer país, território, cidade ou zona, nem tampouco sobre a demarcação das suas fronteiras ou limites. As linhas ponteadas e tracejadas nos mapas representam de modo aproximativo fronteiras sobre as quais pode não existir ainda acordo total. A menção de determinadas companhias ou do nome comercial de certos produtos não implica que a Organização Mundial da Saúde os aprove ou recomende, dando-lhes preferência a outros análogos não mencionados. Salvo erros ou omissões, uma letra maiúscula inicial indica que se trata dum pro- duto de marca registado. A OMS tomou todas as precauções razoáveis para verificar a informação contida nesta publicação. No entanto, o material publicado é distribuído sem nenhum tipo de garantia, nem expressa nem implícita. A responsabilidade pela interpretação e utilização deste material recai sobre o leitor. Em nenhum caso se poderá responsabilizar a OMS por qualquer prejuízo resultante da sua utilização. Tradução por Organização Mundial da Saúde, Escritório Regional África. Em caso de discrepância entre a versão em inglês e a versão portuguesa, o texto original em inglês será a versão vinculativa e autêntica. Designed by Revekka Vital / CommonSense, Greece 3 ÍNDICE Prefácio ..................................................................................................................... 5 Agradecimentos ......................................................................................................... 6 Siglas e acrónimos ..................................................................................................... 7 INTRODUÇÃO ..........................................................................................................9 O que são políticas e estratégias nacionais para a qualidade dos cuidados? ..................10 Importância e integração das política e estratégias .....................................................11 Apresentação de argumentos para a qualidade ...........................................................12 Definição do conceito de qualidade ...........................................................................13 Uma cultura da qualidade ..........................................................................................14 A qualidade em todo o sistema de saúde ....................................................................15 PENQ no contexto da cobertura universal de saúde e dos ODS ...................................16 Manual para as políticas e estratégias nacionais para a qualidade dos cuidados ............17 Iniciativa PENQ .........................................................................................................18 PARTE I. FORMULAÇÃO DA POLÍTICA .................................................................... 20 Formulação de uma política nacional para a qualidade ............................................. 22 1. Objectivos e prioridades nacionais de saúde .......................................................... 23 2. Definição local de qualidade ................................................................................. 24 3. Mapeamento e envolvimento das partes interessadas ............................................ 26 4. Análise da situação: o estado da qualidade.............................................................27 5. Estrutura organizacional e de governação para a qualidade .................................... 29 6. Métodos e intervenções para a melhoria ............................................................... 31 7. Sistemas de gestão da informação de saúde e sistemas de dados ............................ 32 8. Indicadores de qualidade e medidas essenciais ....................................................... 33 PARTE II. FORMULAÇÃO DA ESTRATÉGIA .............................................................. 34 Formulação de uma estratégia nacional para a qualidade ......................................... 36 1. Objectivos e prioridades nacionais de saúde .......................................................... 36 2. Definição local de qualidade ................................................................................. 39 3. Mapeamento e envolvimento das partes interessadas ............................................ 39 4. Análise da situação: o estado da qualidade............................................................ 43 5. Estrutura organizacional e de governação para a qualidade .................................... 46 6. Métodos e intervenções para a melhoria ................................................................49 7. Sistemas de gestão da informação de saúde e sistemas de dados ............................ 57 8. Indicadores de qualidade e medidas essenciais ....................................................... 60 Elaboração de um plano operacional para a implementação ..................................... 63 Visão geral e fundamentos ....................................................................................... 63 Quando e como deve ser elaborado o plano operacional? ......................................... 63 Que elementos deverá incluir o plano operacional? ................................................... 64 Integrar programas técnicos com a PENQ ................................................................ 64 4 PARTE III. INSTRUMENTOS E RECURSOS ................................................................. 67 Antecedentes ........................................................................................................... 68 Procura, selecção e utilização dos instrumentos para apoio ao processo de PENQ ...... 68 Compêndio de instrumentos e recursos ..................................................................... 70 Glossário .................................................................................................................. 72 Referências ............................................................................................................... 77 Caixas Caixa 1. Política e estratégia informada pela implementação ...............................................11 Caixa 2. Definição de cuidados de saúde de qualidade .........................................................13 Caixa 3. Cultura da qualidade: principais características .......................................................14 Caixa 4. Água, saneamento e higiene: uma base fundamental para a qualidade em todos os sistemas de saúde ...............................................................................................................16 Caixa 5. Objectivos e prioridades ...................................................................................... 23 Caixa 6. Segurança e qualidade na saúde: prioridades intimamente ligadas .......................... 24 Caixa 7. Lista ilustrativa das potenciais partes interessadas ................................................. 27 Caixa 8. Qualidade dos cuidados de saúde: papéis e responsabilidades das partes interessadas selecionadas .................................................................................................. 29 Caixa 9. Elementos básicos essenciais para a qualidade em todo o sistema ......................... 31 Caixa 10. Variações nas estratégias nacionais para a qualidade ........................................... 38 Caixa 11. Estudo de caso: definição de qualidade no Sudão ................................................ 39 Caixa 12. Envolvimento das comunidades e dos doentes: a experiência do Uganda ............. 42 Caixa 13. Avaliação externa, licenciamento e certificação .................................................. 50 Caixa 14. Aplicação da Trilogia de Juran para orientar a selecção das intervenções .............. 51 Caixa 15. Exemplo de perguntas essenciais para avaliar as actuais fontes de dados .............. 57 Caixa 16. Potenciais fontes de avaliação da qualidade disponíveis em muitos países ............ 58 Caixa 17. Dez critérios para avaliar indicadores de qualidade para um conjunto essencial .... 62 Caixa 18. Potenciais fontes de instrumentos e recursos ...................................................... 69 Figuras Figure 1. Transição de modelos lineares para a formulação de políticas e estratégias informadas pela implementação ........................................................................................ 12 Figura 2. Exemplo de organigrama dos esforços nacionais para a qualidade ........................ 47 Figura 3. Actividades ilustrativas em cinco modelos de hierarquia ....................................... 55 Figura 4. Quadro de intervenções em cada nível da hierarquia: México ................................ 56 Figura 5. Instrumentos e recursos: fontes e relevância para o processo de PENQ ................. 71 Tabelas Tabela 1. Enquadramento das dimensões da qualidade ....................................................... 25 Tabela 2. Partes interessadas e tarefas relacionadas ........................................................... 41 Tabela 3. Exemplos de intervenções para a qualidade ......................................................... 53 5 P R E F Á C I O PREFÁCIO Os Objectivos do Desenvolvimento Sustentável atribuem especial relevo à consecução da co- bertura universal de saúde, que significa “garantir que todas as pessoas e comunidades possam usufruir dos serviços promotores de saúde, preventivos, curativos, de reabilitação e paliativos de que necessitam, com qualidade suficiente para serem eficazes, garantindo, em simultâneo, que o uso desses serviços não colocará o utente em dificuldades financeiras”. O Quadro da OMS sobre Serviços de Saúde Integrados e Centrados nas Pessoas apresenta uma vi- são para o futuro, em que “todas as pessoas terão acesso a serviços de saúde que sejam prestados de forma a dar resposta às suas preferências, estejam coordenados em função das suas necessida- des e sejam seguros, eficazes, oportunos, eficientes e de qualidade aceitável”. As acções propos- tas no Quadro da OMS atribui especial relevo aos incentivos políticos para melhorar a qualidade. A formulação, aperfeiçoamento e execução de uma política e estratégia nacionais para a quali- dade dos cuidados é uma prioridade para os países que lutam para melhorar o desempenho dos seus sistemas de cuidados de saúde. Com a dinâmica crescente no caminho para a cobertura universal de saúde, existe a correspondente consciência de que a melhoria do acesso deve ser acompanhada por esforços orientados no sentido de melhorar a qualidade dos serviços de saú- de, com vista a alcançar os melhores resultados possíveis. Os países estão a procurar aconselhamento para os esforços que estão a desenvolver para a formulação de políticas e estratégias nacionais para a qualidade. Estão a adoptar diversas abor- dagens com vários pontos de acesso para melhorar a qualidade e muitos estão igualmente a considerar o nível subnacional como centro para a sua acção. Contudo, o objectivo permanece o mesmo: melhorar a qualidade dos cuidados de saúde como ponto de acesso central para o reforço dos sistemas de saúde e, consequentemente, conseguir uma melhor saúde para as populações. Reconhecendo esta necessidade crítica, a iniciativa da OMS sobre as políticas e estratégias na- cionais para a qualidade dos cuidados tem quatro objectivos: (a) aumentar a sensibilização, os conhecimentos e as competências no domínio das políticas e estratégias nacionais para a qualidade dos cuidados, nos países de baixos e médios rendimentos; (b) apontar os principais processos para o planeamento, formulação e implementação das políticas e estratégias nacio- nais para a qualidade dos cuidados; (c) prestar apoio aos países nesse domínio; e (d) prosseguir o desenvolvimento conjunto e a documentação dos processos relacionados com a formulação e a implementação das políticas e estratégias nacionais para a qualidade dos cuidados, no seio de um acordo de laboratório de aprendizagem. O presente documento constitui uma base para essa iniciativa, inspirando-se numa série de traba- lhos já existentes da OMS e noutras entidades. Constitui uma estrutura de apoio ao assunto em causa, sublinha algumas das principais questões a considerar e constitui um ponto de partida para as acções que sejam necessárias. Continuará a ser aperfeiçoado, através de um processo de de- senvolvimento conjunto, envolvendo os países e os parceiros técnicos, o que também contribuirá para disponibilizar vários recursos complementares. Este manual é o produto de uma iniciativa mais vasta que procura dar resposta às necessidades que os países sentem de aconselhamento estratégico e prático sobre políticas e estratégias nacionais para a qualidade dos cuidados. A relação com políticas e planos de saúde mais amplos é fundamental para esta abordagem. O público-alvo deste documento de apoio é diversificado. O público primário são os responsá- veis pela liderança da formulação e implementação de políticas e estratégias nacionais para a qualidade dos cuidados. Dele beneficiará igualmente um conjunto mais vasto de partes interes- sadas que participam activamente no processo a nível nacional. Os parceiros dos níveis nacional, regional e mundial que estão envolvidos no apoio aos esforços de melhoria da qualidade tam- bém retirarão proveito do conteúdo apresentado. Cada país deve seguir o seu próprio caminho para a cobertura universal de saúde, orientado por considerações múltiplas e complexas. Uma abordagem nacional para a qualidade cuidadosa- mente elaborada pode constituir um ponto de acesso crucial para os países que trabalham para atingir melhores resultados em saúde. 6 M A N U A L D E P O L Í T I C A S E E S T R A T É G I A S P A R A A Q U A L I D A D E D O S C U I D A D O S D E S A Ú D E AGRADECIMENTOS O Manual da OMS sobre políticas e estratégias nacionais para a qualidade dos cuidados foi ela- borado sob a direcção geral de Edward Kelley e Shams Syed, do Departamento de Prestação de Serviços e Segurança, da Sede da OMS, em Genebra. A equipa de redacção principal foi consti- tuída por Sheila Leatherman, Shams Syed, Ruben Frescas e Matthew Neilson. Sheila Leatherman forneceu conteúdos substanciais para o manual, dadas as suas funções como conselheira principal para a iniciativa da OMS sobre políticas e estratégias nacionais para a qua- lidade dos cuidados. A investigação e publicações anteriores de Sheila Leatherman e co-autores contribuíram para todas as secções do manual. O anterior trabalho da OMS relacionado com a política e estratégia para a qualidade e seguran- ça dos doentes, tanto na Sede como nas Regiões da OMS, contribuiu muito significativamente para a elaboração do manual. A preparação do manual baseou-se nos exemplos dos países em matéria de formulação de polí- ticas e estratégias nacionais para a qualidade dos cuidados, muitos dos quais foram incluídos no texto. Gostaríamos de agradecer em particular a contribuição de vários países para o conjunto de conhecimentos apresentados no manual – Colômbia, Etiópia, Gana, Indonésia, Libéria, Ma- laui, México e Sudão. Gostaríamos igualmente de agradecer o trabalho de alguns parceiros técnicos, incluindo a So- ciedade Internacional para Qualidade dos Cuidados de Saúde (ISQua), o Instituto para a Melho- ria dos Cuidados de Saúde (IHI), o Projecto da USAID para a Aplicação da Ciência no Reforço e Melhoria dos Sistemas (ASSIST), e HealthQual, que influenciou o terreno e contribuiu para este documento. Agradecemos também a Bruce Agins e Josh Bardfield pela sua contribuição para a secção sobre integração de programas técnicos com as políticas e estratégias nacionais para a qualidade dos cuidados; a Lisa Hirschhorn e Sun Mean Kim pela sua contribuição para as secções sobre sistemas de gestão da informação sanitária, dados e medições; a Liana Rosenkrantz Woskie, Anthony Moccia e Ruma Rajbhandari pelo seu trabalho sobre intervenções para a qualidade; e a Julie Storr, Lopa Basu, Nana Mensah Abrampah, Rhea Bright, Breda Cosgrove e Laura Simpson pela revisão do manual. Outras ajudas valiosas, na forma de contributos, revisões de pares e sugestões, foram oferecidas por Kehinde Balogun, Stephen Balogun, Pierre Barker, Jeffrey Braithwaite, Lucky Chikaura, Susan Davis, Paulina Pacheco Estrello, Raghavendra Guru, Maki Kajiwara, Pierre Claver Kariyo, Manuel Kassaye Sibhatu, Samuel Kidane, Jason Leitch, Garth Manning, Rashad Massoud, Mohamed A. Mohamed, Margaret Montgomery, Zainab Naimy, Edgar Necochea, Wendy Nicklin, Robbie Pear- son, Charles Shaw, Sylvia Sax, Sodzi Sodzi-Tettey, David Weakliam e Albert Wu. Uma primeira versão do manual foi revista numa reunião em Genebra, na Suíça, em Junho de 2017, com os seguintes participantes de países: Hind Babekir Hassan Abdallatif, Philip Kerkula Bemah, Daniel Gebremichael Burssa, Andrew Likaka, German Escobar Morales, Benjamin Nyaku- tsey, Sebastian Garcia Saisό e Eka Viora. Estiveram igualmente presentes os seguintes peritos dos países e das Regiões da OMS: Salma Burton, Nino Dal Dayanghirang, Jonas Gonseth-Garcia, Mondher Letaief e Juan Eduardo Tello. Participaram também na reunião os seguintes peritos da Sede da OMS: Benedetta Allegranzi, Giorgio Cometto, Neelam Dhingra-Kumar, Bruce Gordon, Ann-Lise Guisett, Heather Harmon, Lauren Hoisl, Dirk Horemans, Sun Mean Kim, Blerta Maliqi, Asiya Odugleh-Kolev, Archana Shah e Satvinder (Vindi) Singh. A elaboração do documento teve o gentil apoio do Ministério da Saúde, Trabalho e Assistência Social do Japão, através de uma contribuição para a Organização Mundial da Saúde. Finalmente, agradecemos ao escritório regional da OMS para a África, pela tradução deste do- cumento para língua portuguesa e à Escola Nacional de Saúde Pública da Universidade NOVA de Lisboa (ENSP-NOVA) pela importante revisão técnica realizada.  7 S I G L A S E A C R Ó N I M O S SIGLAS E ACRÓNIMOS GLL Laboratório Mundial de Aprendizagem para a Cobertura Universal de Saúde de qualidade OCDE Organização para a Cooperação e Desenvolvimento Económico ODM Objectivo de Desenvolvimento do Milénio ODS Objectivo do Desenvolvimento Sustentável OMS Organização Mundial da Saúde PENQ Políticas e Estratégias Nacionais para a Qualidade dos cuidados SGIS Sistema de Gestão da Informação de Saúde WASH Água, Saneamento e Higiene 8 M A N U A L D E P O L Í T I C A S E E S T R A T É G I A S P A R A A Q U A L I D A D E D O S C U I D A D O S D E S A Ú D E Visão geral do manual O que é este documento? Um manual que apresenta os argumentos para a formulação de políticas e estratégias nacionais para a qualidade dos cuidados de saúde, o processo necessário para o fazer e os instrumentos de apoio Cobertura universal de saúde significa que todas as pessoas e comunidades poderão usufruir dos serviços promotores de saúde, preventivos, curativos, de reabilitação e paliativos de que necessitam, com qualidade suficiente para serem eficazes, garantindo, em simultâneo, que os utentes desses serviços não ficarão expostos a dificuldades financeiras. Muitos países estão a desenvolver esforços para melhorar a qualidade dos cuidados de saúde e institucionalizar uma cultura de qualidade em todo o seu sistema de saúde. Esses esforços podem ser intensificados através da formulação de políticas e estratégias nacionais para a qualidade dos cuidados (PENQ). Este manual apresenta uma visão geral de oito elementos-chave necessários para a elaboração desses documentos de política e estratégia e está estruturado em três secções principais: política, estratégia e instrumentos. A política baseia-se numa ambição partilhada, com declaração explícita de intenções, que se torna no “plano de acção” acordado. Esta secção descreve o modo de formular uma política nacional para a qualidade, quer como documento autónomo, quer como parte de uma política nacional de saúde mais abrangente. A estratégia constitui um roteiro claro e salienta “como” a política poderá ser aproveitada. Muitos aspectos do processo de estratégia terão lugar, simultaneamente, com a formulação da política. Esta secção salienta um processo estruturado, de várias partes interessadas e fundamentado em informação/dados Existem vários outros instrumentos e recursos que podem apoiar o processo das PENQ. Esta secção descreve o modo de lhes aceder e seleccionar, apresentando um compêndio dos instrumentos disponíveis no Laboratório Mundial de Aprendizagem da OMS para uma CUS de qualidade. A implementação da estratégia pode ser indicada num plano operacional pormenorizado, que defina as principais tarefas, atribua responsabilidades, identifique as etapas e considere os aspectos práticos da implementação, tais como o financiamento. Nos países existem muitas vezes iniciativas de qualidade centradas em áreas técnicas específicas (tais como, o VIH, a água, saneamento e higiene) ou grupos populacionais (tais como, mães e crianças). Para integrar com êxito estes esforços, com trabalho abrangente sobre a qualidade a nível nacional, é preciso um planeamento cuidadoso. A quem se destina? Autoridades que formulam políticas e estratégias nacionais para a qualidade dos cuidados, partes interessadas envolvidas no processo e parceiros externos que apoiam os ministérios da saúde Como é que deve ser usado? Como abordagem estruturada para apoiar a formulação das políticas e estratégias nacionais para a qualidade dos cuidados, com vista a complementar os conhecimentos nacionais existentes e o apoio externo Política Estratégia Instrumen- tos Ministério Ministério Ministério Governação Definição local de qualidade Mapeamento e envolvimento das partes interessadas Análise da situação Prioridades nacionais de saúde Métodos e intervenções para a melhoria Sistemas de gestão da informação de saúde e sistemas de dados Indicadores de qualidade e medidas essenciais Governação e estrutura organizacional O s o it o e le m en to s da s PE N Q Seguros? Eficazes? Integrados? Accessíveis? Centrados nas pessoas? Equitativos? Normes Homologation Inspection Personnel Mesures incitatives Benchmarking Mobilisation Planeamento operacional Integração de programas técnicos Comissão INTRODUÇÃO 10 M A N U A L D E P O L Í T I C A S E E S T R A T É G I A S P A R A A Q U A L I D A D E D O S C U I D A D O S D E S A Ú D E Visão geral da secção • O que são políticas e estratégias nacionais para a qualidade dos cuidados (PENQ)? • Importância e integração das políticas e estratégias • Apresentação de argumentos para a qualidade • Definição do conceito de qualidade • Uma cultura da qualidade • Qualidade em todo o sistema de saúde • PENQ no contexto da cobertura universal de saúde e dos ODS • Como usar este recurso Todos os países sentem-se motivados a tratar da questão da qualidade dos cuidados de saúde por várias razões, entre as quais, por: acreditarem que se trata de um bem público, no qual se devem empenhar; terem maior consciência das lacunas existentes em termos de cuidados seguros, eficazes e centrados nas pessoas; pretenderem atingir a cobertura universal de saúde e compreenderem que melhorar o acesso sem a devida atenção à qualidade não lhes permitirá alcançarem os resultados desejados na saúde das populações; estarem cientes da pressão dos custos, sentirem a necessidade de uma maior eficiência e de uma utilização optimizada das verbas em todo o sistema de saúde; reconhecerem, cada vez mais, que é necessário alinhar o desempenho da prestação dos cuidados de saúde a nível público e privado em mercados de saúde mistos e fragmentados; compreenderem melhor a importância fundamental de serviços confiáveis para estarem eficazmente preparados para os surtos de doenças ou outras situações de emergência complexas; e finalmente, por co nhecerem as expectativas das pessoas, da imprensa e da sociedade civil, com uma crescente exigência do público relativamente à transparência e responsabilização. Embora as razões dos esforços nacionais para a obtenção da qualidade possam variar, os países poderão encontrar problemas comuns à medida que formulam ou aperfeiçoam as suas políticas e estratégias relacionadas com a qualidade, sendo as tarefas básicas semelhantes. Embora seja evidente que a capacidade dos países para oferecerem cuidados de qualidade é afec- tada pelos recursos disponíveis, os esforços nacionais para melhorar a qualidade dos cuidados não deve ser considerada apenas como uma preocupação dos países de altos rendimentos ou como um problema que apenas deva ser resolvido quando o acesso tiver sido alargado. Cada domínio da qualidade tem grande relevância para qualquer sistema de cuidados de saúde e, embora diferentes países possam ter os recursos necessários para abordar cada um deles a níveis diferentes, haverá quase sempre alguns pontos de partida com baixos recursos para a acção. Na verdade, enquanto o foco na qualidade promove serviços mais eficientes, eficazes e integrados que dão resposta às necessidades das populações, os esforços nacionais, para melhorar a qualidade dos cuidados, podem ajudar qualquer sistema de saúde a aumentar a eficiência na utilização das verbas. O que são políticas e estratégias nacionais para a qualidade dos cuidados? Políticas e estratégias nacionais para a qualidade dos cuidados (PENQ) são um esforço organiza- do de um país para planear e promover uma melhor qualidade dos cuidados de saúde. Poderão, muitas vezes, ser referidas num documento, como uma declaração oficial e explícita da abor- dagem e das acções necessárias para melhorar a qualidade dos cuidados de saúde em todo o sistema de saúde de um país, e terão de estar intimamente ligadas à política geral de saúde do país e ao processo de planeamento. A responsabilidade pela elaboração desses documentos, normalmente, pertence ao ministério da saúde, em estreita colaboração com diferentes deciso- res políticos e implementadores. As experiências dos países com políticas e estratégias nacionais para a qualidade dos cuidados evidenciaram os benefícios de um plano coerente que forneça orientações sobre a qualidade a todos os níveis do sistema. Contudo, as políticas relacionadas com a qualidade existem no contexto de acordos mais amplos da governação nacional. As PENQ podem ajudar a esclarecer as ligações às políticas, planos e prioridades nacionais no domínio da saúde e outros, salientar a 11 I N T R O D U Ç Ã O importância de processos centrados na qualidade para a concretização das prioridades da saúde, em geral, e definir linhas de responsabilização, para se trabalhar no sentido de ter serviços de saúde mais centrados nas pessoas. Importância e integração das políticas e estratégias Há muitos países que escolheram focar-se numa estratégia nacional de qualidade; no entanto, também é útil elaborar uma política nacional de qualidade que garanta a aceitação política, ajude a desenvolver a estratégia e a sua implementação e integre os esforços nacionais para a qualidade num ambiente político mais vasto. Embora possa haver uma sobreposição significativa entre o processo de elaboração e o conteúdo, a distinção entre os dois é clara: a política baseia-se numa ambição partilhada com declaração explícita de intenções e torna-se no “plano de acção” acordado. Pode apresentar argumentos em prol da acção e indicar as grandes prioridades a abordar. A estratégia apresenta um roteiro claro e indica “como” a política poderá ser aproveitada, podendo ser aperfeiçoada ao longo do período mais alargado de duração da política. A “estratégia de qualidade” é uma ponte que ajuda um sistema de saúde a acelerar a consecução dos objectivos e prioridades da saúde, usando princípios de gestão da qualidade que incorporam o planeamento, o controlo e a melhoria da qualidade. Embora este documento saliente um processo de formulação simultânea de políticas e estratégias, as necessidades de cada país podem orientar a atenção mais para a política ou mais para a estratégia. Apesar disso, é importante ter ambas em consideração, quando se toma uma decisão informada. A política e a estratégia devem, evidentemente, ser consideradas de forma integrada: normalmente, só existirá um documento ou, em alguns casos, documentos complementares e interdependentes elaborados como parte de um esforço de todo o sistema para melhorar a qualidade dos cuidados. Na verdade, é inteiramente razoável ponderar igualmente se o mecanismo mais apropriado para a elaboração e a publicação da política e da estratégia nacionais da qualidade, ou ambas, são parte de um planeamento nacional de saúde integrado mais vasto. Existem vantagens e desvantagens em ambas as abordagens. Por exemplo, enquanto a integração dos esforços para a qualidade no seio da política e da estratégia nacional de saúde pode trazer benefícios, tais como maior receptividade a nível político, esforços de implementação integrados e oportunidades para se considerar a qualidade em todo o sistema, os documentos autónomos poderão permitir maior pormenor, perfil de qualidade mais visível e uso de tempos diferentes para o planeamento e a implementação. Qualquer que seja a abordagem usada, deve-se ter o cuidado de garantir que a formulação de PENQ estará alinhada com os planos nacionais de saúde mais amplos, quer pela integração plena dos processos de formulação e publicação, quer simplesmente alinhando os objectivos, prioridades, acções e documentos de referência cruzada. A política e a estratégia devem dar particular atenção aos serviços que prestam cuidados de saúde e que são financiados ou disponibilizados pelo sector público, embora se deva pensar no modo como elas podem exercer impacto sobre todo o sistema de cuidados de saúde. Trabalhando em todo o ciclo de cuidados, a orientação nacional para a qualidade terá de incluir igualmente o sector privado, incluindo organizações religiosas, podendo atribuir-se papéis importantes a organizações trans-sectoriais, tais como associações de profissionais, governos locais e instituições académicas. Caixa 1. Política e estratégia informada pela implementação Tradicionalmente, política, estratégia e implementação são vistas como um processo linear. Contudo, a passagem para um processo triangular (ver Figura 1), em que a experiência da implementação orienta a formulação da política e da estratégia, poderá suscitar um sentimento de pertença entre os implementadores e assegurar que os produtos se baseiam nas realidades da prestação de serviços e na experiência dos doentes e das comunidades. Na prática, a formulação de políticas e estratégias informadas pela implementação requer um envolvimento sustentado e significativo com as partes interessadas de todo o sistema de saúde durante o processo, reconhecendo que é necessária uma dicotomia inerente entre as abordagens “descendentes” e “ascendentes”, com vista a melhorar a qualidade. 12 M A N U A L D E P O L Í T I C A S E E S T R A T É G I A S P A R A A Q U A L I D A D E D O S C U I D A D O S D E S A Ú D E Apresentação de argumentos para a qualidade O processo de formulação e implementação de políticas e estratégias nacionais para a qualidade dos cuidados pode, em si própria, constituir um mecanismo-chave para defender melhorias na qualidade dos cuidados, pois isso pode suscitar e assegurar a sua adopção pelas principais partes interessadas (nomeadamente, a nível do governo nacional), conferir à questão visibilidade pública e proeminência profissional e constituir uma oportunidade para demonstrar o valor dessas iniciativas ao sistema de saúde. Contudo, mesmo para chegar ao ponto de garantir o apoio adequado para iniciar as políticas e estratégias nacionais será preciso desenvolver esforços intensos. Num ambiente dominado pela contenção de recursos, com outras prioridades de saúde concorrentes, a defesa de uma maior atenção sobre determinada questão poderá ser um desafio importante. Os passos iniciais da preparação do terreno para um esforço nacional visando a qualidade dos cuidados poderão incluir: • identificar e envolver os principais decisores e os influenciadores das políticas; • demonstrar o potencial de impacto, por exemplo, através de evidência ou partilhando exemplos de casos de outros países; • envolvimento de defensores externos, tais como, agências técnicas e instituições académicas; • angariar apoios entre os profissionais de saúde e o público, por exemplo, através do envolvimento da imprensa, formação de capacidades em pequena escala para a melhoria da qualidade, promoção da partilha de aprendizagem e geração de evidência e mobilização da sociedade civil; • garantir fundos de arranque para os esforços iniciais de melhoria da qualidade, por exemplo, de agências doadoras ou associações profissionais, para permitir a criação de uma dinâmica e encorajar o investimento interno; • procurar oportunidades para influenciar o planeamento do sistema de saúde, em geral, a incorporar um foco na qualidade, por exemplo, durante a formulação de planos estratégicos nacionais de saúde ou a preparação de orçamentos nacionais para a saúde. É igualmente importante reconhecer que a maioria dos países terá já iniciativas neste domínio que podem ser fonte de inspiração e que poderão ajudar a catalisar uma iniciativa mais ampla para as PENQ. Exemplos de pontos de acesso comuns incluem os programas técnicos já existentes, tais como o do VIH ou da saúde materna e infantil, programas de avaliação externa, tais como, a acreditação, e iniciativas para a melhoria da qualidade ao nível subnacional ou de unidade de saúde. Figura 1. Mudança do modelo linear para o modelo da formulação de políticas e estratégias informadas pela implementação Experiência de Implementação 13 I N T R O D U Ç Ã O Definição do conceito de qualidade Até à data, não existe uma definição de “qualidade” que seja universalmente aceite, embora haja um entendimento comummente partilhado de conceitos básicos e dimensões da definição (1). No seio da comunidade mundial da saúde, tem sido especialmente usada a definição do Instituto de Medicina dos Estados Unidos da América, que abaixo se apresenta. Esta definição estabelece o objectivo básico de influenciar positivamente os resultados em saúde, tanto a nível individual como da população, realçando a importância central das evidências e dos conhecimentos profissionais. Segundo essa definição, qualidade é: A medida em que os serviços de saúde prestados aos indivíduos e às populações aumentam a probabilidade de se obterem os resultados desejados na saúde e são consistentes com os actuais conhecimentos profissionais (2). Para além disso, o Instituto de Medicina estabelece seis dimensões gerais, ou finalidades, da qualidade, declarando que os cuidados devem ser seguros, eficazes, centrados no doente, oportunos, eficientes e equitativos. Este conjunto de dimensões ou atributos também foi adoptado e adaptado em países fora dos Estados Unidos da América (2). Em 2006, a Organização Mundial da Saúde {OMS) definiu de modo semelhante os conceitos básicos da qualidade, ao declarar que os cuidados devem ser eficazes, eficientes, acessíveis, aceitáveis, centrados no doente, equitativos e seguros. Significativamente, esta definição introduz a dimensão de “acessíveis” como uma finalidade mais alargada do que apenas “oportunos” (1). Durante a última década, a Organização para a Cooperação e Desenvolvimento Económico (OCDE) escolheu salientar três dimensões da qualidade – eficácia, segurança e atenção nos doentes – reunindo assim os domínios. Esta conceptualização mais concisa também influenciou o pensamento em alguns países (3). Mais recentemente, o Quadro da OMS sobre Serviços de Saúde integrados e centrados nas pessoas descreveu “cuidados de alta qualidade” como “cuidados que são seguros, eficazes, centrados nas pessoas, oportunos, eficientes, equitativos e integrados”. E, obviamente, o acesso aos serviços de saúde realça todos os esforços de qualidade, especialmente na era da cobertura universal de saúde e da tendência para a cobertura equitativa e protecção financeira das populações. Curiosamente, a segurança dos doentes é vista, desde há muito, como um ponto de acesso dos esforços para melhorar a qualidade dos cuidados, podendo os cuidados seguros ser encarados como um barómetro do sucesso do sistema básico para melhorar a qualidade. A Caixa 2 resume uma selecção das principais componentes das definições de cuidados de saúde de qualidade. Caixa 2. Definição de cuidados de saúde de qualidade Cuidados de saúde de qualidade podem ser definidos de várias formas, mas é cada vez mais reconhecido que os serviços de saúde de qualidade em todo o mundo devem ser: • Eficazes: prestando cuidados de saúde baseados na evidência a todos aqueles que necessitam. • Seguros: evitando prejudicar as pessoas a quem os cuidados se destinam. • Centrados nas pessoas: prestar cuidados que respondam às preferências, necessidades e valores dos indivíduos. Para além disso, para que os benefícios dos cuidados de saúde de qualidade sejam reais, os serviços de saúde terão de ser: • Oportunos: reduzindo os tempos de espera e, por vezes, demoras prejudiciais, tanto para os que recebem como para os que prestam os cuidados. • Equitativos: prestando cuidados que não variem de qualidade em virtude da idade, sexo, género, raça, etnia, localização geográfica, religião, estatuto socioeconómico, questões linguísticas ou filiação política. • Integrados: prestando cuidados que sejam coordenados em todos os níveis e por todos os prestadores e disponibilizem toda a gama de serviços de saúde ao longo da vida. • Eficientes: maximizando o benefício de recursos disponíveis e evitando o desperdício. 14 M A N U A L D E P O L Í T I C A S E E S T R A T É G I A S P A R A A Q U A L I D A D E D O S C U I D A D O S D E S A Ú D E Embora exista presentemente uma significativa convergência em relação ao que são as dimensões essenciais da qualidade dentro do sector da saúde, cada país terá provavelmente o seu próprio entendimento local ou definição de qualidade. O processo de definir qualidade através do envolvimento das partes interessadas e da formação de consensos é fundamental para estabelecer uma intenção partilhada e um entendimento para a abordagem nacional à qualidade. É essencial reconhecer a importância de contextualizar a qualidade, pois isso ajudará a orientar as atenções e a criar uma política de qualidade e correspondente estratégia que respondam às necessidades locais. A cultura da qualidade Ao planear um esforço nacional para melhorar a qualidade dos cuidados, é útil considerar a importância de desenvolver e institucionalizar uma “cultura da qualidade” nas organizações e em todo o sistema de saúde, como meio para uma mudança sustentável e significativa. Não existe uma definição única do que é uma cultura da qualidade, mas esta tem sido descrita como “uma organização que cria um ambiente de trabalho aberto e participativo, onde as ideias e as boas práticas sejam partilhadas, onde o ensino e a investigação sejam valorizados e onde a culpabilização apenas excepcionalmente seja usada” (4). De modo geral, entende-se que isso significa que, a todos os níveis de um sistema de saúde, existe o reconhecimento inerente e explícito do valor dos esforços desenvolvidos para melhorar a qualidade dos cuidados prestados, sendo esses esforços sistematicamente promovidos dentro de um ambiente favorável que encoraje a participação, o diálogo, a abertura e a responsabilização. Algumas das características de um sistema de saúde com uma cultura de qualidade interiorizada são apresentadas na Caixa 3. Contudo, a cultura nas organizações e sistemas de saúde é criada e mantida por um conjunto complexo de factores, incluindo as normas culturais mais amplas prevalecentes, as expectativas comunitárias, a liderança do sistema de saúde, as estruturas e redes do sistema de saúde e o ambiente legal na área da saúde. Compreensivelmente, efectuar mudanças no seio dessas culturas poderá, por isso, ser um processo lento e desafiante, podendo ter a oposição de quem se sinta ameaçado por essas mudanças culturais. A liderança política e do sistema de saúde tem um papel-chave na definição e promoção de uma cultura da qualidade, adaptando o ambiente legal e dando o exemplo pela integração dos valores requeridos em todo o sistema. O envolvimento das partes interessadas e a análise da situação, como se descreve mais pormenorizadamente nas Partes I e II, podem ajudar a compreender a actual cultura dentro do sistema e a identificar quais as barreiras e os facilitadores da mudança de cultura. Na verdade, todo o processo de formular e implementar PENQ poderá ajudar a uma mudança cultural mais vasta em todo o sistema de saúde, apresentando uma definição explícita da cultura pretendida e um conjunto de acções que possam ajudar à sua institucionalização. Caixa 3. Cultura da qualidade: principais características • Liderança para a qualidade a todos os níveis • Abertura e transparência • Ênfase no trabalho de equipa • Responsabilização a todos os níveis • Ensino integrado no sistema • Circuitos de feedback activos para as melhorias • Profissionais adequados, envolvimento dos utentes dos serviços e das comunidades • Capacitação dos indivíduos, embora reconhecendo a complexidade dos sistemas • Alinhamento dos valores profissionais e organizacionais • Promoção do orgulho em prestar cuidados • Valorização dos cuidados compassivos • Coerência dos esforços, desenvolvidos para a qualidade, com a organização e o planeamento dos serviços 15 I N T R O D U Ç Ã O Ao discutir a cultura para a qual se pretende o apoio das PENQ, talvez valha a pena considerar o equilíbrio desejado entre uma cultura “sem culpados” e uma cultura “justa” (5, 6). Uma cultura “sem culpados” reconhece que há erros que ocorrem inevitavelmente no seio dos sistemas de prestação de cuidados de saúde, frequentemente devido a vários factores e falhas do sistema, e que uma resposta que apenas procure culpar os bem-intencionados não resolverá devidamente as deficiências do sistema. Para identificar e tentar, sistematicamente, corrigir os erros do sistema, uma cultura “justa” tentará promover um ambiente seguro para melhorar a qualidade, encorajando a identificação e correcção das falhas sistémicas, ao mesmo tempo que reconhece responsabilidades pessoais (7). A responsabilização pessoal pode ser encarada como um modo de desencorajar práticas descuidadas ou deficientes, mas poderá também encorajar os clínicos a adoptar uma prática defensiva ou a não reportar os erros. Estes conceitos, evidentemente, não se excluem mutuamente; pelo contrário, os decisores devem estar cientes do impacto que as diferenças de cultura podem exercer sobre a qualidade dos cuidados em todo o sistema de saúde. Existem igualmente importantes considerações sobre a formulação de políticas e estratégias em torno da forma como a cultura das equipas responsáveis pela implementação, em todo o sistema de saúde, pode ter influência sobre o seu sucesso. Fazer reformas na prestação de cuidados de saúde que sejam inclusivas e equitativas e promovam uma cultura de aperfeiçoamento exige que as equipas clínicas e administrativas responsáveis pela implementação façam reflectir esses princípios na sua própria abordagem e valores. Os sistemas de prestação de cuidados de saúde existem para servir as populações e, por isso, é fundamental que as pessoas sejam colocadas no centro dos esforços para institucionalizar uma cultura da qualidade. Essa cultura deve suscitar e possibilitar um envolvimento significativo das comunidades servidas pelo sistema e este deve estar preparado para acolher esse envolvimento. Por exemplo, envolver os doentes, as famílias e as comunidades no planeamento, gestão, prestação e avaliação dos serviços de saúde ajudará a garantir que as prioridades reflectem aquilo que interessa e introduz um novo nível de responsabilidade pelos cuidados de qualidade. Por conseguinte, o investimento nas estruturas e competências necessárias para o referido envolvimento podem ser um meio poderoso de criar e institucionalizar uma cultura de qualidade no seio de um sistema de saúde. Qualidade em todo o sistema de saúde Embora a qualidade dos cuidados seja, sobretudo, expressa ao nível da interacção entre o prestador e o receptor/doente/utente, ela ocorre no seio de um sistema de saúde muito mais amplo e complexo. Esse contexto deve ser tomado em consideração por aqueles que planeiam os esforços nacionais para melhorar a qualidade dos cuidados. Os pilares do sistema de saúde da OMS (8) são frequentemente usados pelos países para examinar o ponto de contacto entre os esforços nacionais para a qualidade e as diferentes partes do sistema de saúde no seu contexto específico. Isso poderá ajudar a garantir que algumas das estruturas e processos básicos, subjacentes à política e estratégia, estão instalados e explicam a sua influência na prestação de cuidados de qualidade. Por exemplo, a prestação de serviços em muitos países pode, ainda, ser baseada nas tradicionais relações hierárquicas entre prestador e doente. Reorientar os cuidados em torno das necessi- dades, preferências e envolvimento das pessoas servidas pelos prestadores de cuidados pode representar um importante passo para institucionalizar a qualidade dos cuidados. Uma frequente rotação da força de trabalho da saúde pode constituir um desafio à manutenção das estruturas e conhecimentos institucionais da qualidade e pode, em si mesma, resultar em ambientes de tra- balho que não são favoráveis à prestação de cuidados de saúde de qualidade. O cumprimento de normas de qualidade baseadas em evidência requer o acesso confiável a medicamentos e produ- tos essenciais; os esforços para melhorar a qualidade da prestação de serviços exigem, por isso, o exame das cadeias de abastecimento e da qualidade dos medicamentos. Aplicar a perspectiva da qualidade às reformas do financiamento da saúde poderá ajudar a que a expansão do acesso aos serviços não comprometa outros domínios da qualidade, tais como a equidade e a eficiência 16 M A N U A L D E P O L Í T I C A S E E S T R A T É G I A S P A R A A Q U A L I D A D E D O S C U I D A D O S D E S A Ú D E da prestação de serviços. A liderança e a governação são cruciais para o êxito das PENQ. Para evitar que esses esforços se tornem numa iniciativa vertical e autónoma, é necessário um forte apoio à qualidade por parte das lideranças existentes no sistema de saúde, a todos os níveis, o que pode ser facilitado construindo capacidades para a melhoria da qualidade entre os próprios líderes. O alinhamento entre políticas e estratégias para a qualidade e a governação da saúde em geral é, como já se afirmou, de primordial importância. Caixa 4. Água, saneamento e higiene: um alicerce fundamental para a qualidade em todo o sistema de saúde Pontos de acesso múltiplos e transversais requerem especial atenção quando se estabelece a ligação entre qualidade e sistemas de saúde. Por exemplo, água, saneamento e higiene (WASH) nas unidades de cuidados de saúde são um aspecto fundamental de sistemas de saúde fortes e resilientes. Isso é especialmente verdade nos países de baixos e médios rendimentos onde o WASH tem falhas ou não existe mesmo. Como componente-chave de serviços seguros e de qualidade, o WASH melhora não apenas os resultados e a experiência na área da saúde, mas eleva também a moral do pessoal e a eficiência dos serviços. Melhorar os serviços WASH pode rapidamente resolver a questão das desigualdades, uma vez que esses serviços muitas vezes não existem nas unidades que servem as comunidades mais vulneráveis. Por exemplo, na Libéria, o WASH nas unidades de cuidados de saúde é uma componente-chave do reforço dos sistemas de saúde nacionais pós-Ébola e dos esforços para a qualidade, envolvendo mentoria, supervisão de apoio e monitorização, ao mesmo tempo que se procedem a melhoramentos nas infra-estruturas. Isto está muito ligado às componentes essenciais da prevenção e controlo das infecções, que também estão a ser implementadas na Libéria. Tanto o WASH como a prevenção e controlo das infecções terão de garantir a segurança do doente e do profissional de saúde. Mas se a sua disponibilidade for insuficiente é provável que a confiança das comunidades nos serviços fique prejudicada. Dado o papel fundamental destas capacidades essenciais dos serviços de saúde para a prestação de cuidados de qualidade, a sua avaliação e abordagem no contexto das orientações nacionais para a qualidade constituem um passo muito importante. PENQ no contexto da cobertura universal de saúde e dos ODS A adopção dos Objectivos do Desenvolvimento Sustentável (ODS) (9) e o foco na cobertura universal de saúde (10, 11) constitui um ponto de acesso importante para a activação das PENQ nos países de baixos e médios rendimentos. O ODS 3 – “garantir vidas saudáveis e promover o bem-estar para todos em todas as idades” – será o motor das acções aos níveis local e mundial (9). Dentro deste objectivo, a meta 3.8 salienta a importância de serviços de prestação de cuidados de saúde essenciais e de qualidade. A forma de o conseguir não é, evidentemente, fácil, exigindo muitas considerações e contributos. Contudo, um importante factor de sucesso é uma estrutura de governação para a qualidade com políticas e estratégias claramente articuladas. Os progressos para a cobertura universal de saúde podem ser impulsionados pela implementa- ção de serviços de saúde integrados e centrados nas pessoas, que possam responder eficazmente aos novos e variados desafios que vão surgindo no século XXI. Um quadro da OMS sobre esta matéria foi aprovado por todos os Estados-Membros na Assembleia Mundial da Saúde em 2016 (12, 13). Uma das cinco orientações estratégicas incide especificamente sobre a necessidade de reforçar a governação e a responsabilização (12, 13). Como parte dessa orientação estratégica, é preciso que exista um forte ênfase na formulação de políticas e estratégias que melhorem a qualidade da prestação de serviços nos pontos de cuidados. Isso exige que seja estudada a forma como as orientações e as estruturas nacionais podem ajudar a apoiar os serviços, a nível subnacional e local, a que as populações recorrem para satisfazer as suas necessidades de saúde. No contexto da consecução dos ODS, o movimento mundial para a cobertura universal de saú- de está a dar frutos em muitos países, considerando não apenas as suas estruturas financeiras e Cobertura universal de saude: Garantir que todas as pessoas e comunidades possam usar os serviços de saude promotores, preventivos, curativos, de reabilitaçao e paliativos de que necessitam, com qualidade suficiente para serem eficazes, garantindo igualmente que a utilizaçao desses serviços nao coloca o utente em dificuldades financeiras (10) 17 I N T R O D U Ç Ã O de pagamento aos prestadores de serviços, mas também as suas estruturas de qualidade como meio de melhorar os resultados em saúde, reduzindo também o desperdício e a redundância e promovendo, desse modo, uma utilização mais eficiente de serviços para o cumprimento das prioridades do sector da saúde (14). De facto, entre todos os países, mas particularmente entre os que se debatem com consideráveis limitações de recursos, existe a necessidade urgente de criar processos e estruturas para a qualidade que possam utilizar da melhor forma os recursos disponíveis e procurar continuamente avaliar e melhorar as práticas e os serviços prestados. Embora grande parte deste manual tenha sido elaborado para apoiar a formulação de PENQ nos países de baixos e médios rendimentos, que possam estar a enfrentar sérios desafios para melhorar a qualidade dos cuidados, os processos indicados são relevantes para qualquer autoridade nacional ou subnacional que esteja a preparar ou rever os seus esforços nacionais para a qualidade dos cuidados. META 3.8 Atingir a cobertura universal de saúde, incluindo protecção contra riscos financeiros, acesso a serviços essenciais de cuidados de saúde de qualidade e acesso a medicamentos e vacinas seguros, eficazes, de qualidade e comportáveis para todos (9). Manual de PENQ: secções coloridas Parte I. Formulação da política Parte II. Formulação da estratégia Parte III. Instrumentos e recursos Manual de políticas e estratégias nacionais para a qualidade dos cuidados O presente documento pretende dar apoio à formulação de PENQ. Em particular, apoia os esforços dos países na elaboração, implementação, aperfeiçoamento e sustentação da sua abordagem estratégica à prestação de serviços de saúde de qualidade. Este manual não é um trabalho exaustivo sobre todas as acções necessárias para implementar uma iniciativa nacional para a qualidade, mas descreve os passos elementares para formular PENQ como ponto de partida. A OMS e outras organizações disponibilizam recursos adicionais sobre a qualidade dos cuidados. Quem deve usar este recurso? Este manual destina-se a ajudar os governos e os decisores políticos (a nível nacional, regional/ estadual e provincial) que estejam a pensar se devem e como devem formular um plano de PENQ ou, para as sitações em que tal plano esteja a ser desenvolvido. Poderá igualmente ser útil para conselheiros técnicos, financiadores e outras partes interessadas, que apoiem os governos, em áreas relacionadas com as PENQ. 18 M A N U A L D E P O L Í T I C A S E E S T R A T É G I A S P A R A A Q U A L I D A D E D O S C U I D A D O S D E S A Ú D E Como usar este recurso Este manual e o compêndio de instrumentos que o acompanha apresentam orientações, tanto para o processo de formulação como sobre o conteúdo das políticas e estratégias nacionais para a qualidade dos cuidados, facilitando a elaboração ou o aperfeiçoamento dessas políticas e estratégias pelos decisores políticos e os praticantes que melhor conhecem as complexidades específicas dos seus países. Os utilizadores devem encarar este documento como um recurso para ajudar a informar e estruturar políticas e estratégias de qualidade que respondam às necessidades específicas dos países, ao mesmo tempo que se inspira nas orientações da literatura já existente, nas lições aprendidas no terreno e nas opiniões dos peritos. O manual não é um guia de receitas, mas antes uma abordagem estruturada que ajuda a garantir que a formulação e a implementação sejam tão abrangentes quanto possível. Para ajudar os utilizadores a identificar e a aceder à informação de que possam necessitar, o manual está dividido em três partes identificadas por cores, como a seguir se indica. • Parte I: incide sobre a formulação de uma política da qualidade. • Parte II: incide sobre os processos relacionados com a formulação da estratégia. • Parte III: descreve o modo de aceder e usar instrumentos suplementares em apoio ao proces- so de formulação das PENQ. Existe uma significativa sobreposição entre os processos descritos nas partes I e II do manual. Isso deve-se ao facto de nem todos os utilizadores do manual estarem a formular políticas e estratégias. Recomenda-se que essas secções sejam lidas em conjunto, para se poder formular um processo apropriado que seja específico para as necessidades do utilizador. Acompanhando o manual, há um documento suplementar intitulado Compêndio de instrumentos para as políticas e estratégias nacionais para a qualidade dos cuidados, que apresenta alguns instrumentos desenvolvidos para ajudar no processo de PENQ. Como foi elaborado este recurso? O conteúdo deste manual foi elaborado com base no trabalho de apoio aos países na formulação e execução das PENQ, assim como na revisão de uma amostra de mais de 20 estratégias da qualidade existentes em países de baixo, médio e alto rendimento em todo o mundo. À medida que este campo continua a evoluir e a crescer, haverá a necessidade de continuar a aperfeiçoar este documento e a aproveitar a troca de conhecimentos e melhores práticas entre os países. O trabalho continuará a basear-se em parcerias com países individuais, as regiões da OMS e parceiros especialistas. Iniciativa PENQ O presente manual e o compêndio de instrumentos são parte de um esforço mais vasto liderado pela OMS para apoiar a formulação de políticas e estratégias nacionais para a qualidade dos cui- dados. Reconhecendo que os países se encontram em diferentes estádios do processo de formula- ção e implementação das iniciativas nacionais para melhorar a qualidade dos cuidados, a iniciativa PENQ incide sobre três actividades principais, conforme se indica nos parágrafos que se seguem. 1. Desenvolvimento conjunto dos recursos técnicos Esta actividade abrange o manual, o compêndio e os instrumentos e recursos a eles associados, para apoiar a formulação das políticas e estratégias nacionais para a qualidade dos cuidados. O trabalho conjunto ocupa um lugar central, reconhecendo a significativa experiência e os conhecimentos técnicos injectados no desenvolvimento de recursos pelas autoridades dos países que planearam, formularam e implementaram políticas e estratégias nacionais para a qualidade dos cuidados. Pretende-se que a necessidade de mais recursos continue a ser avaliada e que os instrumentos e recursos actualmente existentes continuem a ser continuamente aperfeiçoados, com base na experiência e necessidades das autoridades dos países que os usam. 19 I N T R O D U Ç Ã O 2. Catalisar a acção nacional através da cooperação técnica Para complementar a informação fornecida nos recursos escritos, a OMS está a coordenar um apoio técnico orientado aos países que se encontram em diferentes fases da formulação de políticas e estratégias. Esse apoio destina-se a criar capacidade nacional para a eficácia da formulação, implementação e monitorização das políticas e estratégias nacionais para a qualidade dos cuidados, assim como permitir que o futuro desenvolvimento de recursos receba contributos do envolvimento dos países. 3. Agenda de aprendizagem Há um grande número de organizações académicas e técnicas de todo o mundo que participam no apoio às iniciativas nacionais para a qualidade. A iniciativa PENQ pretende articular-se com esses esforços para garantir a máxima eficácia e promover a aprendizagem partilhada. A PENQ é um alvo importante de uma iniciativa da OMS com ela relacionada, o Laboratório Mundial de Aprendizagem (LMA) da Cobertura Universal de Saúde de Qualidade. O LMA combina as experiências, os conhecimentos técnicos, a paixão e a sabedoria das pessoas de todo o mundo, representando múltiplas disciplinas, sobre questões importantes relacionadas com a qualidade no contexto da cobertura universal de saúde. Esse foco acelerou a aprendizagem mundial informada pela acção local como reconhecimento da importância de estabelecer ligação entre as pessoas, para facilitar a partilha dinâmica e multidireccional de conhecimentos e práticas. Foi criada uma comunidade centrada na PENQ, no seio do LMA, para ligar as experiências, facilitar a disseminação de conhecimentos entre os países e disponibilizar instrumentos e recursos de apoio à PENQ. Uma visão geral do LMA está disponível em http://www.who.int/servicedeliverysafety/areas/qhc/gll/en/. PARTE I. FORMULAÇÃO DA POLÍTICA 21 P A R T E I . F O R M U L A Ç Ã O D A P O L Í T I C A Visão geral da secção: Parte I. Formulação da política Formulação de uma política nacional para a qualidade: Objectivos e prioridades nacionais de saúde Definição local de qualidade Mapeamento e envolvimento das partes interessadas Análise da situação: estado da qualidade Estrutura organizacional e governação para a qualidade Métodos e intervenções para a melhoria Sistemas de gestão da informação em saúde e sistemas de dados Indicadores da qualidade e medidas essenciais Esta secção incide sobre aspectos importantes do processo de formulação da política para a qualidade dos cuidados de saúde, com indicação dos passos que devem ser seguidos na formulação de uma política nacional de qualidade. Os factores que influenciam cada país no seu processo de formulação da política e no conteúdo são muito variáveis; por isso, esta secção trata apenas dos aspectos comuns. As secções posteriores tratarão do modo como a política deve ser implementada através de uma estratégia definida e de um plano operacional. Cada país (ou autoridade subnacional) deve decidir de que modo irá formular, redigir e ratificar a política nacional para a qualidade, de acordo com as respectivas estruturas governamentais e tendo em consideração o seu contexto específico e as necessidades das suas populações. Em alguns países, será necessária legislação facilitadora, por exemplo, criar novos órgãos governamentais ou para-estatais ou criar novas formas de acção obrigatória (por exemplo, registo e licenciamento dos profissionais de saúde) ou definir novas formas de regulação (licenciamento ou acreditação dos prestadores). Isso pode implicar a necessidade de um documento explícito de política nacional para a qualidade. Noutras situações, a implementação de uma política ou estratégia nacional para a qualidade pode fazer parte de um plano sectorial quinquenal de rotina ou de um documento interno de política do ministério da saúde. Neste caso, seria importante envolver desde cedo o departamento e as pessoas responsáveis por esse planeamento nacional mais abrangente, para conceber um processo que incorpore os aspectos necessários para a política de qualidade. Existem várias abordagens possíveis, mas as formas mais comuns seriam apenas uma ou a combinação das seguintes abordagens: • política e estratégia para a qualidade como parte das políticas e planos nacionais, oficiais, de longo prazo para o sector da saúde; • um documento sobre a política para a qualidade elaborado como documento nacional autónomo, normalmente no âmbito de um processo de várias partes interessadas e muitas vezes conduzido ou apoiado pelo ministério da saúde; • uma estratégia nacional para a qualidade com uma agenda de acção pormenorizada, incluindo uma secção sobre questões essenciais da política; • uma declaração nacional para a qualidade baseada nas políticas existentes que sejam relevantes e em documentos nacionais sobre saúde; • uma constituição ou termos de referência para o departamento responsável do ministério da saúde ou para o órgão nacional para a qualidade, salientando a orientação acordada para a política; • legislação facilitadora ou estatuto regulador de apoio aos esforços nacionais para a melhoria da qualidade dos cuidados. 22 M A N U A L D E P O L Í T I C A S E E S T R A T É G I A S P A R A A Q U A L I D A D E D O S C U I D A D O S D E S A Ú D E Cada uma das opções acima mencionadas, para uma política nacional da qualidade, requer processos de desenvolvimento semelhantes para assegurar que essa política dê respostas às necessidades locais, que seja exequível e bem governada. Para fazer avançar a formulação da política, é importante definir e compreender as estruturas organizacionais do processo. Como já foi referido, a responsabilidade máxima por essas políticas é do ministério da saúde, mas pode ser atribuída a um órgão directivo designado em cada país. O ministério da saúde pode, no entanto, delegar ou criar um grupo de acção ou uma comissão para elaborar a política, com a contribuição e a revisão das partes relevantes interessadas. Será, provavelmente, necessário consultar peritos que ajudem nos aspectos técnicos da formulação da política numa série de questões. As consultas e o controlo da formulação da política através da ajuda de peritos, que analisem criticamente o documento, será importante não só para informar a sua elaboração, mas também para antecipar e ajudar a corrigir as suas fraquezas e limitações. Trata-se de um processo importante na formulação da política, recomendando-se que seja submetido a várias revisões, antes da redacção da versão final. Estas políticas irão lidar com várias áreas e disciplinas relacionadas com a saúde, cada uma das quais poderá já ter políticas, legislação ou documentos técnicos próprios (tais como, normas) que abordem determinados factores no domínio da política da qualidade. Examinar a fundo e integrar as políticas, normas e leis existentes, sempre que possível, poderá ajudar no processo de redacção e poderá mesmo reforçar outros programas através deste processo. As políticas existentes e relevantes podem ser variadas, incluindo, por exemplo, normas de programas ou regulamentos técnicos específicos (saúde materna e infantil, VIH, tuberculose, etc.) para as unidades de cuidados de saúde e requisitos para o licenciamento de profissionais. No final da Parte II deste documento, apresentam-se outras indicações sobre o modo de integrar os programas técnicos. Assim, elaborar em conjunto uma política nacional permite às autoridades nacionais de saúde identificar e maximizar sinergias de qualidade em sistemas com capacidades limitadas. Por outro lado, o processo de formulação de políticas pode ser reforçado, prestando forte atenção à implementação, através do envolvimento daqueles que estiverem directamente implicados na prestação de serviços de saúde numa grande variedade de áreas técnicas, incluindo aquelas que lidam com determinadas doenças ou grupos populacionais. Após a política ter sido revista por peritos internos e externos em várias ocasiões, deverá ser submetida ao processo formal de ratificação ou aprovação habitual no respectivo país, para poder tornar-se uma política oficial. Podem ser dados passos, proactivamente, no sentido de garantir o apoio político necessário para permitir a ratificação da versão final da política. Esta política, e as estruturas responsáveis nela definidas, passará a ter autoridade para atingir as metas pretendidas e orientar o desenvolvimento da estratégia. Contudo, como já referido, a formulação de políticas e estratégias nacionais para a qualidade dos cuidados decorre muitas vezes em simultâneo num processo integrado. A Parte II discutirá as tarefas funcionais a considerar na formulação de uma estratégia para aplicar a política. FORMULAÇÃO DE UMA POLÍTICA NACIONAL PARA A QUALIDADE Os oito elementos seguintes podem ser considerados importantes na formulação de uma política nacional para a qualidade. Esses elementos serão igualmente reflectidos na versão final do próprio documento da política. Este material baseia-se no contributo de peritos, experiência no terreno e na análise preliminar conduzida para a fundação do projecto de PENQ, incluindo entrevistas e análise de uma amostra de documentos de políticas e estratégias nacionais, para identificar as áreas e tópicos de conteúdos comuns. A atenção a esses oito elementos da política nacional para a qualidade serve igualmente como base para a elaboração de uma estratégia nacional para a qualidade, descrita em pormenor na Parte II, sobre elaboração de estratégias. 23 P A R T E I . F O R M U L A Ç Ã O D A P O L Í T I C A 1. Objectivos e prioridades nacionais na área da saúde A maioria dos países tem objectivos e prioridades nacionais na área da saúde (ver Caixa 5), que ajudam a orientar os recursos no sentido de satisfazer as necessidades mais prementes das populações. Quando existem esses objectivos e prioridades, a política nacional para a qualidade deverá ser alinhada com a agenda da qualidade. É preciso também estar ciente de que a definição de objectivos e prioridades para a política da qualidade – por exemplo, a atenção tradicional à saúde materna e infantil – não significa que outras áreas não explicitamente incluídas não sejam importantes mas, tão só, que as áreas selecionadas são as mais prementes no contexto nacional. Convém que exista um processo claro e contínuo para abordar outras áreas e objectivos prioritários, quando necessário, para satisfazer as necessidades em constante mutação das populações. Caixa 5. Objectivos e prioridades Há uma diferença entre objectivos e prioridades, embora por vezes os termos sejam usados indiferentemente. Objectivos são, normalmente, aspirações ou metas mais gerais que determinam o rumo das futuras actividades. Devem ser claros e satisfazer uma determinada necessidade, devendo igualmente ter um prazo para cumprimento, com um meio de avaliar os progressos e as rea- lizações. No caso de objectivos internacionais, tais como os ODS e os anteriores Objectivos de Desenvolvimento do Milénio (ODM), os países poderão ratificá-los, mas sem esquecer o contexto e a ambição específica do país. Embora não haja limites ao número de objectivos ou finalidades que devem ser incluídos no documento, a maioria dos países geralmente inclui um máximo de cinco objectivos para um determinado período de tempo. As prioridades ajudam a orientar a atenção mais especificamente para algumas áreas críticas. Essas áreas são, normalmente, identificadas através dos dados nacionais sobre a saúde (por exemplo, sobre o fardo das doenças), eventos sentinela ou investigação nacional, e podem ser prioridades de longo prazo ou emergentes (por exemplo, baseadas na população prevista ou em mutação, ameaças à saúde ou ambiente político e económico). As prioridades nacionais de saúde podem ser definidas, em termos gerais, de modo a incluir condições clínicas priori- tárias (por exemplo, tuberculose multirresistente, doenças cardiovasculares), populações (por exemplo, mulheres e crianças, moradores em bairros degradados ou populações migrantes) ou regiões geográficas específicas (por exemplo, zonas rurais ou regiões fronteiriças). Normalmente, estes objectivos e prioridades são definidos pelo ministério da saúde, através das contribuições de vários peritos técnicos e outras partes interessadas de todo o sector da saúde. Ao reflectir sobre que objectivos e prioridades definir, é importante considerar as necessidades das pessoas e, ao mesmo tempo, qual a capacidade do sistema de saúde para desempenhar as suas funções. Para isso, é necessário que exista um cuidadoso equilíbrio das necessidades face aos recursos, o que se torna num tópico para debate, quando se tenta melhorar a qualidade em simultâneo com o esforço para expandir o acesso aos cuidados. Se os objectivos e as prioridades forem demasiado exigentes, sem ter em atenção os recursos necessários para satisfazer essas exigências, a política está destinada ao fracasso. Inversamente, se as finalidades e as prioridades não forem suficientemente ambiciosas para satisfazer as necessidades das pessoas, o benefício dessa política poderá não ser evidente, podendo desiludir as partes interessadas ou mesmo perder a sua confiança. Por conseguinte, torna-se importante usar uma abordagem equilibrada em relação às prioridades e aos objectivos que tanto satisfaçam as necessidades específicas das populações como reconheçam, realisticamente, a capacidade do sistema para funcionar. É, contudo, essencial concentrar-se no longo prazo ao formular a política; no momento, poderá não existir capacidade suficiente, mas será possível colmatar as lacunas através de uma 24 M A N U A L D E P O L Í T I C A S E E S T R A T É G I A S P A R A A Q U A L I D A D E D O S C U I D A D O S D E S A Ú D E formulação de políticas eficazes e de esforços estruturados para procurar outros recursos e apoio técnico para as prioridades. O compêndio, no seu conjunto, contém um instrumento para inspirar a reflexão sobre os objectivos e as prioridades que podem ajudar a estruturar a política. Caixa 6. Segurança e qualidade da saúde: prioridades intimamente ligadas As grandes crises de saúde pública, nomeadamente os surtos de doenças altamente infecciosas, como o vírus Ébola, são cada vez mais uma prioridade nacional de saúde em muitos países de baixo e médio rendimento. Embora a resposta de emergência possa dar prioridade ao acesso aos serviços em detrimento da qualidade, se esses serviços não tiverem a confiança e não forem utilizados pelas comunidades, não estiverem equipados para tratar dos casos com segurança e eficácia, não conferirem uma protecção adequada aos seus profissionais e não conseguirem manter os cuidados de rotina durante os picos de procura, então os recursos serão usados de forma ineficiente, o que colocará em risco a resposta as emergências. Alinhar os esforços para a qualidade com as prioridades existentes, tais como a segurança clínica, pode ajudar a garantir capital político e recursos financeiros, impulsionando ambas as agendas. Resumo: objectivos e prioridades nacionais de saúde Acções para a equipa de formulação da política Conteúdo do documento da política • Identificar os objectivos e as prioridades do sector nacional de saúde • Formular e alinhar os objectivos e as prioridades para uma política de qualidade, incluindo a revisão dos dados existentes, se for esse o caso • Esboço dos objectivos e prioridades identificados • Referência explícita aos planos nacionais existentes de política e estratégias na área da saúde 2. Definição local de qualidade Na literatura mundial, podem encontrar-se numerosas definições de qualidade. Ao formular uma política nacional da qualidade, é fundamental explicitar a definição de qualidade que estará subjacente à abordagem nacional, para assegurar um entendimento comum e uma linguagem que seja aceitável ao contexto local do país. Para além disso, o exercício de formular uma definição local de qualidade é, em si mesmo, útil para o processo de formulação da política, uma vez que poderá iniciar um diálogo sobre o alcance e a importância da qualidade, salientar o que é importante para as partes interessadas e como as intervenções podem ser orientadas para a satisfação das prioridades locais, levando os decisores políticos a aprenderem mais sobre o real significado de qualidade e as suas implicações. Como já foi referido, existem muitas definições de qualidade que são amplamente usadas. Contudo, essas definições poderão ter uma interpretação suficientemente ampla para definir qual a percepção de qualidade numa perspectiva nacional, subnacional e de unidade de saúde. A Tabela 1 apresenta uma abordagem estruturada para ajudar a encontrar uma definição que satisfaça as necessidades contextuais e esteja alinhada com os objectivos e as prioridades nacionais. 25 P A R T E I . F O R M U L A Ç Ã O D A P O L Í T I C A Tabela 1. Enquadrar as dimensões da qualidade Questões que ajudam a enquadrar as dimensões da qualidade nas necessidades locais, no contexto dos objectivos e prioridades nacionais Eficazes Os cuidados são apropriados às necessidades das populações no domínio da saúde e são consistentes com os conhecimentos e a evidência para alcançar os melhores resultados possíveis? Seguros A prestação de serviços de saúde utiliza os meios mais seguros possíveis e reduz os danos evitáveis? Centrados nas pessoas A experiência com os cuidados é positiva aos olhos dos doentes e suas famílias? Existe um sentimento de confiança entre as comunidades no que toca à qualidade de cuidados disponíveis? Os doentes, famílias e comunidades sentem que têm a capacidade, enquanto parceiros, de contribuir para o desenho e aperfeiçoamento da prestação dos serviços de saúde? Oportunos Os tempos de espera para tratamento são aceitáveis para a população e suficientemente curtos para evitar danos desnecessários? Equitativos Existem barreiras ou disparidades em factores relacionados com a idade, sexo, género, etnia, localização geográfica, religião, estatuto socioeconómico, língua ou filiação política? Integrados Existem falhas nos cuidados aos doentes entre as várias unidades clínicas? As componentes do sector da saúde comunicam com vista a manter uma transição dos cuidados aos doentes sem lapsos? Eficientes Os recursos são atribuídos e utilizados da melhor forma possível para atingir os resultados pretendidos? Os redactores da política podem utilizar a Tabela 1 como lista de verificação, para incentivar a reflexão sobre estas dimensões, que deverão ser integradas no documento da política. Embora os países sejam incentivados a considerar o modo como cada uma destas dimensões pode ser reflectida na política e na estratégia, poderão antes optar por concentrar-se num subconjunto ou introduzir dimensões localmente acordadas. Na verdade, os países são encorajados a não usarem, por sistema, as definições de qualidade existentes a nível mundial, mas inspirarem-se nelas para desenhar uma definição local que seja adoptada e defendida pelos seus constituintes. Quando possível, é recomendado consultar-se um grupo multidisciplinar, incluindo prestadores de cuidados, académicos, especialistas, gestores de serviços de saúde, líderes comunitários e reguladores, para se chegar a um acordo mútuo sobre a definição proposta. Embora essa definição constitua um ponto de partida essencial, durante a aplicação desses critérios de qualidade, um determinado país poderá rever a definição aceite, de acordo com os progressos e as necessidades desse país. 26 M A N U A L D E P O L Í T I C A S E E S T R A T É G I A S P A R A A Q U A L I D A D E D O S C U I D A D O S D E S A Ú D E Resumo: definição local de qualidade Acções para a equipa de formulação da política Conteúdo do documento da política • Identificar definições locais de qualidade anteriormente estabelecidas ou publicadas e considerar o conteúdo da secção de introdução deste manual • Elaborar definições locais para apoiar a formulação e a implementação da política e da estratégia • Considerar consultas às partes interessadas para aperfeiçoamento ou elaboração conjunta da definição • Declaração da definição local • Referência à fonte original da definição local ou uma breve descrição do processo de elaboração 3. Mapeamento das partes interessadas e sua participação A qualidade dos cuidados é um produto do sistema de saúde em geral. A participação das principais partes interessadas na formulação da política pode ajudar a abordar a natureza global dos factores que influenciam a qualidade dos serviços de saúde. Na verdade, há várias partes interessadas que terão de contribuir para a formulação da política. Uma vez que os cuidados de saúde na maioria dos países são considerados um bem público e um direito das pessoas, os governos deverão assegurar um financiamento e recursos adequados, bem como a prestação de um nível básico de serviços. Os governos são, em muitos aspectos, os arquitectos das políticas mas têm de ser orientados e informados por aqueles que estão envolvidos na gestão e prestação dos cuidados de saúde. O mapeamento e uma análise cuidada das partes interessadas poderá garantir que o contributo das pessoas certas, facilitar uma participação eficaz e responder pelo impacto do poder e das relações das partes interessadas. O envolvimento com o sector público e privado é necessário para cobrir todas as populações e para incentivar a mudança necessária na “cultura da qualidade” em todo o sector da saúde. Também é igualmente importante a contribuição das comunidades e das pessoas que beneficiam dos serviços – especialmente as populações mais vulneráveis e marginalizadas e dos grupos de doentes. O ministério da saúde terá igualmente de participar com todos os outros ministérios, organismos nacionais, autoridades locais e parceiros do desenvolvimento. Um benefício directo de incluir várias partes interessadas é adaptar melhor a política aos seus diferentes utentes e beneficiários, assim como facilitar a aceitação. É de considerar também o envolvimento e coordenação da comunidade mundial da saúde, particularmente na partilha de lições de outros países e na prestação de assistência técnica específica. A Caixa 7 apresenta uma lista de algumas das potenciais partes interessadas que poderão ser consultadas para a formu- lação conjunta da política. Cada país terá de considerar, atentamente, e seleccionar as partes interessadas necessárias para co-autoras das respectivas políticas. Esta lista não é exaustiva, mas apresenta algumas considerações gerais. Os títulos e as categorias da lista podem diferir de país para país. 27 P A R T E I . F O R M U L A Ç Ã O D A P O L Í T I C A Caixa 7. Lista ilustrativa de potenciais partes interessadas (nota: não exaustiva) Organizações de saúde governamentais o Ministério da Saúde o Conselho profissional de saúde o Gabinetes provinciais de saúde o Gabinetes e hospitais distritais o Especialistas nacionais em dados/informática Organizações de serviços de saúde o Serviços de saúde do sector público o Serviços de saúde religiosos e setor social o Serviços de saúde do sector privado o Serviços de saúde tradicionais e complementares Organismos profissionais o Conselhos profissionais de cuidados de saúde o Associações de especialidades o Academias/Faculdades médicas Outros ministérios o Finanças o Assuntos Sociais o Educação Parceiros da cooperação o Entidades seguradoras o Apoio financeiro o Comunicações/apoio aos media Sociedade civil o Dinamizadores o Promotores da saúde o Programas e serviços de prestação Comunidades o Líderes/proximidade o Associações de doentes Fonte: Adaptada do instrumento de mapeamento de partes interessadas usado na formulação da estratégia do Gana para a qualidade. Uma vez reunida uma equipa diversificada, é preciso definir bem os papéis para os principais atores e para a equipa principal, assim como para outros que possam apoiar a criação da política. A equipa terá de identificar e responder colectivamente a importantes questões e acções centradas no reforço da qualidade dos cuidados que são prestados pelo sistema de saúde. Esses papéis e responsabilidades estão descritos em baixo, na Caixa 8. É igualmente relevante sublinhar a importância fundamental de abordagens integradas de envolvimento comunitário que ultrapassam muitos dos papéis e responsabilidades descritos para as partes interessadas. Resumo: mapeamento e envolvimento de partes interessadas Acções para a equipa de formulação da política Conteúdo do documento da política • Identificar partes interessadas e relevantes • Mapear os papéis das partes interessadas e planear o seu envolvimento no processo de formulação da política • Breve descrição do processo de envolvimento das partes interessadas • Reconhecimento da contribuição das partes interessadas 4. Análise da situação: estado da qualidade A análise da situação, que deve ser adoptada e liderada pelo país, mas pode ser suplementada pela inclusão de peritos externos, é desenvolvida na Parte II. A sua importância como parte do documento da política é estabelecer o actual “estado da qualidade” no país, abrangendo as prioridades, desafios e problemas relevantes, programas e políticas relacionados, aptidões e capacidades organizacionais, liderança e governação, assim como os correspondentes recursos. Isso servirá para definir o fosso identificado entre as necessidades da população e a capacidade de prestar serviços de saúde de qualidade com segurança. A ligação com os esforços nacionais para rumar à cobertura universal de saúde poderá ser particularmente importante de descrever no âmbito desta análise da situação. 28 M A N U A L D E P O L Í T I C A S E E S T R A T É G I A S P A R A A Q U A L I D A D E D O S C U I D A D O S D E S A Ú D E É útil documentar a história do percurso de um país para alcançar a qualidade e o actual estado da qualidade – incluindo os pontos fortes e fracos. A informação histórica poderá recuar tanto quanto necessário. Por exemplo, um desses documentos indicava um prazo iniciado na década de 1980, para apresentar uma visão geral da estrutura inicial do sistema de saúde e o modo como este evoluiu ao longo dos anos. Ao considerar a perspectiva histórica, poderá ser útil identificar não apenas se foram feitos, anteriormente, esforços nacionais para melhorar a qualidade, mas também examinar por que motivo esses esforços foram bem sucedidos ou, porque não resultaram, e se poderão ser retiradas lições de outras iniciativas sobre políticas em todo o sector da saúde. Quando a análise da situação identificar iniciativas e estruturas relacionadas com a qualidade, será possível aperfeiçoá- las ou aproveitá-las no contexto da nova política. A análise da situação fornece informação oriunda de várias fontes de dados – entrevistas, grupos de reflexão, revisão de documentos relevantes e análises de dados secundários – para descrever o panorama actual e identificar claramente as falhas de desempenho entre o que é real e o que é alcançável. Esse passo será essencial para fundamentar a política, enfrentar os desafios reais que existem na linha da frente e para identificar que acções que poderão ter maior impacto. Conhecimentos, comportamentos, crenças e atitudes acerca da qualidade serão importantes para compreender o modo como a política e a estratégia estão a ser formuladas. A análise da situação também permite considerar as principais áreas de foco entre os esforços desenvolvidos para a qualidade; por exemplo, alguns países utilizam a segurança do doente como ponto de entrada para estimular a acção nacional para a qualidade dos cuidados, enquanto outros poderão visar, de preferência, a eficácia e a atenção às pessoas. Os programas técnicos existentes (por exemplo, iniciativas específicas de doenças ou os que visam populações específicas, tais como as mães e os recém-nascidos) poderão também apresentar experiências enriquecedoras e recursos que podem catalisar uma dinâmica nacional mais vasta e informar os esforços de todo o sistema para a melhoria da qualidade dos cuidados. A análise da situação pode igualmente revelar informações importantes acerca do modo de orientar o processo de formulação de uma política, por exemplo, indicando os motivos que levaram ao sucesso ou insucesso de anteriores políticas de saúde e que factores contextuais poderão concorrer para o êxito. Os instrumentos de apoio a este processo de análise da situação são descritos no compêndio anexo. Resumo: análise da situação Acções para a equipa de formulação da política Conteúdo do documento da política • Planear o processo de análise da situação • Recolher dados relevantes de várias fontes sobre o estado da qualidade, factores contextuais e percurso histórico da qualidade • Análise de várias partes interessadas sobre os resultados, para traduzi-los em prioridades e estratégias • Descrição de métodos de análise da situação • Resumo de resultados globais • Identificação dos principais resultados • Declaração de prioridades e áreas visadas das intervenções e acções 29 P A R T E I . F O R M U L A Ç Ã O D A P O L Í T I C A 5. Governação e estrutura organizacional para a qualidade Governação, liderança e capacidade técnica em todo o sistema de saúde são factores necessários para melhorar a qualidade e devem ser explicitamente debatidos. É importante compreender quando e como a política será formulada, aprovada, implementada e monitorizada entre as estruturas existentes ou as novas estruturas propostas e como isso irá ser afectado pelo ambiente político mais geral. Como passo inicial, poderá ser útil identificar as principais autoridades, organizações e indivíduos que estarão envolvidos na criação e implementação da política e estratégia da qualidade a nível nacional e aos níveis subnacional e local. O órgão ou as estruturas directivas serão diferentes de país para país. Mais adiante, durante o processo de formulação da política, é útil compreender como a política evoluirá desde a fase conceptual até à sua integral aprovação e promulgação. Para começar, deve-se decidir que forma a política assumirá, como já foi referido anteriormente neste documento. Uma vez que isso tenha sido determinado, a equipa de formulação da política deverá identificar que indivíduos ou grupos devem ser envolvidos, esclarecer que pessoas e organizações que terão de aprovar a política, o processo da sua adopção oficial e o modo como a política irá interagir com as outras políticas e legislação já existentes no sistema de saúde. A Caixa 8 identifica alguns dos papéis e responsabilidades mais comuns. Caixa 8. Qualidade dos cuidados de saúde: papéis e responsabilidades das partes interessadas seleccionadas A descrição clara dos papéis e responsabilidades é essencial para definir as ações e responsabilizar as partes interessadas. A política pode ajudar a definir esses papéis e responsabilidades. Alguns exemplos são: Ministério da Saúde Liderar e orientar os esforços nacionais Departamento ou Direcção da Qualidade (normalmente, dentro do Ministério da Saúde) Apoiar a formulação e a implementação da política e estratégia nacionais Comissão nacional de coordenação Monitorizar e avaliar os progressos, identificar as falhas na qualidade coordenar e harmonizar os contributos de várias partes interessadas para a política e estratégia Comissão subnacional da qualidade/equipas de gestão (regionais e distritais) Monitorizar e avaliar os progressos alcançados a nível regional ou distrital e abordar questões de qualidade Organismos profissionais Dar assistência e apoio à formação e ensino profissional e estabelecer padrões Entidade seguradora Financiar e monitorizar programas de incentivos e integrar medidas para a melhoria da qualidade nos mecanismos de pagamento Conselhos institucionais Rever os programas e iniciativas de melhoria da qualidade institucional e envolver as comunidades na melhoria da prestação de serviços Equipas das unidades de saúde Aplicar práticas e padrões de qualidade dos cuidados e registar os dados de saúde relevantes para uma melhoria contínua da qualidade Num número cada vez maior de países, existem unidades ou departamentos com responsabilidade pelos esforços para a qualidade. Esses departamentos poderão ou não ter o poder de aplicar certas políticas, mas podem ter a responsabilidade de avaliar e fazer revisões da abordagem ou resolver questões relacionadas com as falhas identificadas ao nível da qualidade dos cuidados. É importante assegurar que as políticas definam claramente a estrutura organizacional, os papéis 30 M A N U A L D E P O L Í T I C A S E E S T R A T É G I A S P A R A A Q U A L I D A D E D O S C U I D A D O S D E S A Ú D E e as responsabilidades desses departamentos, para utilizarem todas as capacidades do grupo e reconhecer quem pode partilhar as responsabilidades em todo o sector da saúde. O papel do envolvimento e capacitação das comunidades é outra consideração importante no contexto da governação e da responsabilização; por exemplo, deve determinar-se o modo como os doentes, os profissionais de saúde e as comunidades em geral poderão ser, significativamente, envolvidas na formulação, implementação e monitorização da política e da estratégia. Os programas específicos de doenças ou de populações já existentes – por exemplo, VIH ou saúde da mãe e da criança – podem também ter estruturas de governação bem estabelecidas. Como parte do processo de formulação da política, é útil mapear as estruturas dos programas com particular relevância para assegurar o alinhamento. É de crucial importância considerar os níveis disponíveis para garantir que a política será implementada tal como pretendido. Isso requer a identificação e o desenvolvimento de estruturas para a responsabilização e a aplicação, o que pode ser uma tarefa complexa, visto que o grau em que uma política é implementada com êxito depende não só de medidas específicas, mas também da cultura no seio do sistema, do bom acolhimento da política e das relações entre as principais partes interessadas. No centro de uma implementação, bem sucedida, da política estão as partes interessadas e capacitadas em todo o sistema, que deverão ser parceiros entusiásticos com interesse no êxito da política. Em algumas circunstâncias, poderá ser necessário uma adesão obrigatória aos padrões, com medidas corretivas ou sanções por qualquer violação ou acto de não conformidade. Há várias formas de sanções que podem afectar o licenciamento, a acreditação ou o financiamento, podendo haver recurso a mecanismos legais, incluindo multas ou outras penalizações previstas no sistema legal. Contudo, a necessidade e o uso desses mecanismos devem ser cuidadosamente considerados no contexto de criar um ambiente para a política que seja adequado às circunstâncias particulares de cada país. Os mecanismos de governação propostos devem ter o acordo de todas as partes interessadas e ser delegados, se necessário, nas agências responsáveis apropriadas. Cada país, em consulta com os seus respectivos órgãos profissionais, poderá identificar os melhores mecanismos para a aplicação da política. A subsequente formulação da estratégia discutida na Parte II ajudará a abordar a questão da governação para a qualidade, através de uma abordagem sistemática. Resumo: governação e estrutura organizacional para a qualidade Acções para a equipa de formulação da política Conteúdo do documento da política • Mapear as estruturas existentes para a governação em todo o sistema de saúde • Identificar mecanismos para a promulgação e aplicação da política • Decidir sobre a estrutura de governação, tanto para a formulação da política como para esforços de qualidade em geral • Esboço de uma proposta de estrutura de governação dos esforços nacionais para a qualidade, incluindo os requisitos para a sua implementação • Descrição dos incentivos existentes e propostos para a aplicação da política (e.g. legislação, sistemas de licenciamento) 31 P A R T E I . F O R M U L A Ç Ã O D A P O L Í T I C A 6. Métodos e intervenções para as melhorias Esta secção apresenta o conjunto de conceitos e princípios de melhoria a considerar para atingir os objetivos gerais da política. Além disso, é muitas vezes útil declarar pressupostos em torno dessas intervenções de melhoria, assim como dos recursos necessários e estratégias de mitigação dos riscos a pôr em prática. Na Caixa 9, apresenta-se uma curta lista de acções, comummente, consideradas pelos governos ao formularem a política nacional e a correspondente estratégia. Estes são elementos comuns para implementar esforços de qualidade bem sucedidos em todo o sistema, incluindo uma forte liderança, com a capacidade para definir prioridades relevantes para as necessidades das pessoas e promover um ambiente que conduza à satisfação dessas necessidades. A capacidade para avaliar e regular a prestação de padrões de cuidados estabelecidos é também muito importante, podendo abranger licenciamentos profissionais e institucionais e a inspecção e avaliação externa dos prestadores. Embora os programas de avaliação externa, como os de acreditação, sejam muitas vezes, os pontos de entrada iniciais para os esforços nacionais de melhoria, as evidências sobre o seu impacto na qualidade são variáveis; é importante reconhecer que estas abordagens devem ser integradas num esforço estruturado mais vasto, que abranja as estruturas de governação necessárias e uma sequência de intervenções eficazes que sejam apropriadas ao contexto local. Caixa 9. Elementos básicos essenciais para a qualidade de todo o sistema o Liderança para estabelecer prioridades e criar um ambiente para a qualidade o Definição de padrões e metas o Licenças profissionais e institucionais o Inspecção e avaliação externa o Desenvolvimento e retenção da força de trabalho o Mecanismos de incentivos (financeiros e não financeiros) o Medição, avaliação comparativa e feedback o Iniciativas da população-alvo sobre melhorias de grande escala, condições clínicas, etc. o Envolvimento dos doentes, famílias e comunidades (incluindo a participação, educação, escolha e o feedback) o Transparência, com relatórios sobre o desempenho público O bem conhecido modelo de Donabedian (15) descreve três parâmetros para avaliar a qualidade dos cuidados: estrutura, processo e resultado. Esta pode ser uma abordagem útil no processo de planeamento da política para conceptualizar a vasta gama de potenciais métodos e intervenções de melhoria e para assegurar que a política considerará os principais determinantes da qualidade. A estrutura está relacionada com o cenário em que os cuidados são dispensados, por exemplo, a unidade de saúde e os recursos humanos e financeiros que lhe estão subjacentes; o processo está relacionado com a própria prestação de cuidados, incluindo todos os aspectos da transacção entre os receptores e os prestadores de cuidados; e o resultado é o efeito mensurável sobre o estado de saúde, que pode ser afectado por uma grande variedade de factores. As pessoas que formulam a política nacional para a qualidade dos cuidados devem considerar o modo como ela poderá incorporar intervenções que aborde m tanto a estrutura como o processo e o modo como a política acabará por afectar os resultados de saúde. A formação e o envolvimento da força de trabalho podem constituir uma oportunidade para ultrapassar as limitações de capacidade. Podem ser usados mecanismos de incentivos para influenciar os comportamentos em relação aos processos de qualidade, mas isso terá igualmente de ser incorporado em normas e práticas mais sustentáveis. Nos locais onde certas práticas e intervenções contribuíram para uma melhoria dos cuidados de saúde, esses esforços devem ser analisados para avaliar o seu potencial para um reforço dentro do país. Nesse sentido, é 32 M A N U A L D E P O L Í T I C A S E E S T R A T É G I A S P A R A A Q U A L I D A D E D O S C U I D A D O S D E S A Ú D E importante que a criação de evidência e a agenda da aprendizagem sejam promovidas como um mecanismo de apoio essencial para seleccionar e aperfeiçoar as intervenções. Um requisito importante para alcançar, tanto o reforço como a sustentabilidade, é o envolvimento intencional das pessoas (doentes, famílias e comunidades). Essa capacitação requer educação e sensibilização para a importância desses conceitos, princípios e capacidades, tanto por parte dos prestadores como do público em geral. Como parte desse envolvimento, o público deve ser capacitado para ter acesso e compreender os relatórios de desempenho, com vista a responsabilizar o sistema de saúde e a facilitar o processo de mudança. Na Parte II, sobre formulação de estratégias, é debatida uma abordagem ao pensamento sobre este tema, através da selecção e implementação de intervenções distintas relacionadas com a qualidade. Resumo: métodos e intervenções para a melhoria Acções para a equipa de formulação da política Conteúdo do documento da política • Discutir e seleccionar áreas abrangentes de intervenção prioritária • Esboço das grandes áreas de intervenção a abordar pela política e pela estratégia • Debate sobre a justificação, pressupostos, recursos necessários e estratégias de mitigação dos riscos 7. Sistemas de gestão da informação de saúde e sistemas de dados A melhoria da qualidade assenta na presença de dados de desempenho claros e rigorosos. Com a formulação de uma política nacional para a qualidade, haverá inevitavelmente uma atenção especial aos sistemas necessários para a avaliação e a notificação, incluindo um circuito de retorno da informação instalado, para estimular e avaliar as melhorias. Existem, pelo menos, cinco capacidades integradas para a análise dos dados que são necessárias para apoiar um programa nacional abrangente sobre a qualidade: • sistema hierárquico de recolha e notificação de dados nacionais; • sistema de informação do departamento da saúde/ministério da saúde e base de dados sobre a qualidade; • apoio às decisões clínicas e sistema de registo com informação sobre os cuidados prestados aos doentes; • sistemas de monitorização da qualidade e de feedback, para avaliar o desempenho individual em função dos padrões ou metas e dados da avaliação comparativa; • relatórios públicos e comparativos para a transparência e responsabilização perante a sociedade. Os países encontram-se claramente em diferentes fases de desenvolvimento no que diz respeito a estas capacidades. O documento da política apresentará um esboço de avaliação do estado actual destas capacidades e das acções necessárias para formar as capacidades requeridas, incluindo o modo de priorizar a informação para melhoria dessas capacidades. Os principais pontos são: uma descrição das eventuais fontes de informação existentes; identificação das lacunas existentes no que diz respeito aos dados; e as acções necessárias para criar a infra- estrutura de informação, com vista a oferecer uma melhor qualidade e a monitorizar e notificar o desempenho. É fundamental que exista uma orientação clara da política sobre a necessidade de esforços para a qualidade a integrar nos sistemas de gestão e informação de saúde, dada a tendência, em muitos casos, para implementar as iniciativas para a qualidade paralelamente aos sistemas existente. 33 P A R T E I . F O R M U L A Ç Ã O D A P O L Í T I C A Resumo: sistemas de gestão da informação de saúde e sistemas de dados Acções para a equipa de formulação da política Conteúdo do documento da política • Mapear as fontes de dados e as capacidades existentes • Identificar lacunas nos actuais sistemas de informação de saúde relacionados com a qualidade • Propor orientações para optimizar os sistemas de informação de saúde relativos à qualidade • Identificar políticas e planos existentes do sector da saúde relacionados com os sistemas de dados e a informação de saúde • Breve descrição dos sistemas de dados e informação de saúde disponíveis • Esboço dos sistemas de dados e informação de saúde propostos em apoio aos esforços nacionais para a qualidade • Referência explícita à integração dos esforços de qualidade nos sistemas de gestão e informação de saúde 8. Indicadores da qualidade e medidas essenciais Uma política abrangente terá de incluir os objectivos de uma monitorização de rotina da qualidade e feedback dos prestadores e dos gestores dos serviços de saúde, assim como a agregação de dados e avaliação global dos progressos que estejam a ser feitos em relação aos objectivos nacionais para as áreas prioritárias. Isso requer a identificação de um conjunto essencial de indicadores da qualidade, com as necessárias políticas e processos de apoio às várias finalidades, tais como: feedback aos prestadores de cuidados; transparência para o público; ponto de referência (benchmarking) para compreender o desempenho comparativo e variações não justificadas da qualidade; análise da relação custo-efetividade; e a avaliação da eficácia de distintas intervenções para a qualidade e a abordagem global para a qualidade, a nível nacional. A avaliação da qualidade é muito importante para se saber se as actividades de melhoria da qualidade são realmente eficazes ou não. Sem uma avaliação, não é possível saber se as acções para a melhoria da qualidade estão realmente a produzir cuidados de melhor qualidade e a gerar uma mudança significativa nos resultados em saúde. A avaliação da qualidade – através do uso de indicadores padrão – permite aos prestadores de cuidados de saúde e aos decisores políticos avaliar os progressos efectuados a todos os níveis dos cuidados de saúde: nacional, regional, local, hospitalar e individual. Este nível de detalhe pode também constituir um apoio para uma melhor informação ao público em geral, de modo a melhorar a transparência e a confiança, mesmo quando os resultados fiquem aquém das metas. Outras informações sobre o processo de preparação de um quadro abrangente de avaliação da qualidade são apresentadas na Parte II, sobre formulação de estratégias. Resumo: indicadores da qualidade e medidas essenciais Acções para a equipa de formulação da política Conteúdo do documento da política • Avaliar os indicadores relevantes já recolhidos e notificados pelo sector da saúde • Definir a orientação da política sobre a elaboração do conjunto de indicadores essenciais (ver as Partes II e III) • Apresentação dos indicadores e justificação da selecção • Visão geral sobre o modo de utilização dos indicadores PARTE II FORMULAÇÃO DA ESTRATÉGIA 35 P A R T E I I . F O R M U L A Ç Ã O D A E S T R A T É G I A Visão geral da secção: Parte II. Formulação da estratégia • Formulação da estratégia nacional para a qualidade Objectivos e prioridades nacionais para a saúde Definição local de qualidade Mapeamento e envolvimento das partes interessadas Análise da situação: estado da qualidade Governação e estrutura organizacional para a qualidade Métodos e intervenções para a melhoria Sistemas de gestão da informação de saúde e sistemas de dados Indicadores da qualidade e medidas essenciais • Elaboração de um plano operacional para a implementação • Integração dos programas técnicos com as políticas e estratégias nacionais para a qualidade dos cuidados Como anteriormente se referiu, as políticas e estratégias nacionais para a qualidade dos cuidados podem, muitas vezes, ser elaboradas em simultâneo como parte de um programa nacional para a qualidade e podem constar de um único documento integrado. Além disso, embora a estratégia realce o processo através do qual a política é promulgada, é muitas vezes necessário um plano operacional mais pormenorizado. Esse plano realça os aspectos práticos da execução das acções prioritárias, incluindo os papéis, as responsabilidades e os calendários. No final da Parte II é fornecida informação mais detalhada a este respeito. Esta secção revê algumas componentes práticas a considerar na transição da teoria para a acção, através da criação de uma estratégia para a qualidade. O processo e o conteúdo sugeridos no documento final espelham bem o processo de formulação da política e baseiam-se nos mesmos oito elementos. Por outro lado, a formulação de uma estratégia nacional facilita a integração dos programas e iniciativas existentes no contexto de um quadro nacional coerente para a qualidade; isso pode incluir programas técnicos já existentes (como os do VIH e saúde materna e infantil). No final da Parte II, apresentam-se mais informações sobre o modo de abordar a referida integração. A estratégia deve apresentar um calendário para as várias actividades a iniciar, com tempo suficiente para a preparação da logística e do apoio a essas iniciativas. Isso poderá incluir a atribuição de recursos, a reorganização das agências ou a reorientação do pessoal, sensibilização geral e comunicação, assim como a devida formação e desenvolvimento da força de trabalho. Como se referiu, a estratégia pode incluir um plano operacional que constitua um roteiro pormenorizado para os passos intermédios que serão pertinentes. Frequentemente, no início da implementação, serão necessárias algumas alterações organizacionais entre as partes interessadas, incluindo o ministério ou agência responsável, para cumprir as normas da política, podendo haver igualmente necessidade de assistência técnica para ajudar as partes interessadas a definirem os processos logísticos necessários para esse cumprimento. Poderá haver recurso a agências de consultoria externas ou pode ser criado um grupo de acção ou uma comissão com carácter provisório, antes de a política entrar em vigor, para ajudar a facilitar as mudanças necessárias. O objectivo desta Estratégia Nacional é integrar as múltiplas intervenções que foram desenvolvidas durante os últimos quinze anos num grupo único de acções coerentes que conduzam a uma finalidade comum e reforçada de todas as instituições de cuidados de saúde neste país, quer sejam públicas ou privadas, numa nova era de melhoria da qualidade para a saúde do povo mexicano, através da convergência de todos para uma efectiva cobertura universal de saúde. Estratégia nacional para a qualidade do México, 2016 “ ” 36 M A N U A L D E P O L Í T I C A S E E S T R A T É G I A S P A R A A Q U A L I D A D E D O S C U I D A D O S D E S A Ú D E O processo de legislar políticas pode revelar desafios que, tendo estado ocultos, exijam alterações à estratégia – embora esta questão possa ser bastante mitigada por um período de verificação e consulta durante a elaboração da estratégia. Por conseguinte, no plano operacional, deve considerar-se o modo de monitorizar e resolver rapidamente os desafios durante a fase de implementação de uma estratégia, por exemplo, através de uma avaliação formal do processo ou medidas de governação, tais como comissões de supervisão da estratégia. Isso deve ser devidamente documentado, devendo existir um canal para enviar essa informação de novo à agência ou pessoa responsável pela supervisão, para que lhe possa ser dada a devida atenção e serem feitas as devidas correções e ajustes. FORMULAÇÃO DE UMA ESTRATÉGIA NACIONAL PARA A QUALIDADE Apesar das muitas diferenças entre os países, a revisão dos actuais conhecimentos e práticas identificou semelhanças entre eles no modo de desenhar e operacionalizar estratégias para os esforços nacionais de melhoria da qualidade. Descrevem-se aqui oito elementos do processo; trata-se dos mesmos oito elementos referidos no processo de formulação da política na Parte I, podendo muitos deles ser executados em simultâneo, quando se justifique. Noutros momentos, a política nacional para a qualidade pode impulsionar a formulação de uma estratégia para a qualidade. Esses elementos são descritos em seguida para ajudar a facilitar a formulação das estratégias, embora nem todos os países passem por todos os elementos, ou não pela mesma ordem. 1. Objectivos e prioridades nacionais da saúde Uma “estratégia da qualidade” é uma ponte que ajuda um sistema de saúde a acelerar a consecução dos seus objectivos e prioridades na área da saúde, usando conceitos de qualidade, métodos e princípios baseados em evidência que incorporem o planeamento, o controlo e a melhoria da qualidade. Um primeiro passo essencial é compreender os objectivos e prioridades nacionais de saúde existentes no país, identificar as potenciais lacunas e propor novos objectivos e prioridades que sejam incluídos na estratégia nacional para a qualidade. A finalidade deste exercício é identificar e hierarquizar objectivos e prioridades nacionais de saúde, para que a estratégia para a qualidade esteja em perfeita harmonia e não seja elaborada separadamente ou em paralelo. A política e estratégia para a qualidade – e a sua implementação – devem ser transversais a todo o sistema de saúde, evitando o risco de se criar um programa vertical para a qualidade. Ligar a estratégia aos objectivos e prioridades existentes também ajuda o processo de adesão de todas as partes interessadas à elaboração da estratégia nacional para a qualidade. Os objectivos e prioridades existentes diferem, inevitavelmente, entre os países e são expressas em diferentes formatos e níveis de pormenor. Embora muitos objectivos e prioridades nacionais da saúde possam ser explicitamente relevantes para a qualidade dos cuidados prestados pelos serviços de saúde, alguns podem ter uma contribuição indirecta, por exemplo, estudando os determinantes da saúde, a prevenção dos riscos e a expansão do acesso aos serviços. Quando os objectivos existentes se centrarem claramente na qualidade dos cuidados, é útil olhar directamente para o seu exemplo durante a elaboração da estratégia; quando não existe um foco na qualidade, poderá ser necessário propor e defender a definição de novos objectivos e prioridades no planeamento nacional da saúde. A estratégia nacional da qualidade pode seguir o conteúdo e a estrutura adoptada num documento de política já existente, como, por exemplo, um plano quinquenal de saúde, podendo especificar outros objectivos de saúde relevantes, com datas de conclusão definidas. Os objectivos ligados a iniciativas mundiais de saúde mais amplas (tais como os ODS) ou os objectivos ligados aos principais programas nacionais de doadores podem também ser incluídos. Por vezes, um objectivo nacional de saúde pode estar especificamente ligado a um evento sentinela ou a uma exigência pública de maior qualidade no sistema de cuidados de saúde, por 37 P A R T E I I . F O R M U L A Ç Ã O D A E S T R A T É G I A exemplo, a redução da mortalidade materna ou a redução de infecções associadas aos cuidados de saúde. Poderá ser um exercício útil explorar com mais pormenor os objectivos e prioridades nacionais existentes, avaliando o modo como foram priorizados, que implicações poderão ter na prestação dos serviços de saúde e o argumento lógico de como os esforços nacionais para a qualidade poderão ajudar a atingi-los. Embora seja sempre possível especificar novos objectivos e prioridades para a estratégia nacional da qualidade, a demonstração de um claro alinhamento com objectivos anteriormente definidos pode ajudar a conquistar apoio político e a assegurar a integração dos esforços para a qualidade no reforço mais amplo do sistema de saúde. A orçamentação do sistema de saúde poderá igualmente estar ligada aos objectivos e prioridades nacionais de saúde existentes; é importante esclarecer essa ligação e avaliar as implicações no financiamento da estratégia nacional para a qualidade. A definição de prioridades pode ser feita através de vários métodos, começando muitas vezes com a análise do fardo/carga das doenças e a morbilidade e mortalidade evitáveis. O fundamento deste método é apresentar uma linguagem comum que possa ser bem compreendida e apoiada por vários públicos. Contudo, os países estão a afastar-se cada vez mais da observação exclusiva do fardo das doenças para uma definição de prioridades mais proactiva em termos de saúde e bem-estar das populações. Princípios como o acesso mais equitativo e a cobertura universal de saúde, podem também ser declarações de prioridades que inspiram a estratégia para a qualidade. A definição de prioridades e objectivos da estratégia nacional para a qualidade pode ser feita de forma linear e transparente, tendo em conta o seguinte: • Os objectivos e prioridades serão retirados dos principais documentos e políticas dos planos nacionais de saúde. • Outros objectivos e prioridades poderão surgir de outras áreas, incluindo a análise da situação, os ODS mundiais e os programas dos doadores. • Se a lista de objectivos e prioridades exceder aquilo que possa ser razoavelmente incluído numa estratégia nacional para a qualidade (isto é, em maior número do que aquilo que poderá ser realisticamente monitorizado e traduzido em actividades exequíveis, no âmbito dos recursos disponíveis e do calendário), podem seguir-se dois caminhos: reduzir a lista de prioridades, aplicando critérios explícitos, ou dividir a lista em prioridades de curto e longo prazo. • Uma vez definida a lista, deverão ouvir-se as reacções das diversas partes interessadas, antes da sua finalização. • Os calendários e os critérios para futura análise e revisão devem ser explícitos. 38 M A N U A L D E P O L Í T I C A S E E S T R A T É G I A S P A R A A Q U A L I D A D E D O S C U I D A D O S D E S A Ú D E Caixa 10. Variações nas estratégias nacionais para a qualidade As variações não ocorrem apenas na estrutura das estratégias nacionais para a qualidade, mas também na ênfase colocado em certas áreas identificadas como prioridades pelos países. Isso sublinha a importância de compreender as falhas de qualidade que requerem atenção no seio das estratégias. Etiópia A finalidade última da Estratégia Nacional para a Qualidade dos Cuidados de Saúde é assegurar e melhorar, sistematicamente, os resultados dos cuidados clínicos, segurança dos doentes e atenção aos doentes, aumentando o acesso e a equidade para todos os segmentos da população etíope, até 2020. Namíbia A estratégia para a qualidade na Namíbia pretende constituir um quadro para a implementação de iniciativas de gestão da qualidade a todos os níveis da prestação de serviços de saúde, através de quatro objectivos estratégicos: (a) melhorar os sistemas de gestão da qualidade e a responsabilização; (b) assegurar os cuidados centrados nos utentes e a capacitação dos consumidores; (c) melhorar a segurança dos doentes e dos profissionais de saúde; e (d) melhorar a prática clínica. Os objectivos das estratégias de um país para a qualidade podem estar relacionados com dimensões específicas da qualidade que sejam áreas prioritárias para esse país, embora muitos possam incluir todas ou apenas algumas dimensões da qualidade. A selecção de objectivos pode também ser influenciada por grandes eventos de saúde pública actuais ou recentes, por exemplo, surtos de doenças infecciosas ou migrações em massa, que podem exercer impacto sobre as capacidades e as prioridades dos serviços de saúde. Na verdade, durante a fase de implementação de uma estratégia, esses eventos podem requerer a revisão dos objectivos; isso pode ajudar a alinhar a estratégia com necessidades críticas emergentes e deve, mais uma vez, ser feito em consulta com as principais partes interessadas. A definição de objectivos pode centrar-se nos resultados pretendidos e específicos dos cuidados de saúde, tais como “reduzir a mortalidade evitável em x% ao longo de cinco anos”. Os meios que permitirão atingir os objectivos deste elevado nível poderão ser declarados, por exemplo, através do caminho para a cobertura universal de saúde ou resolvendo a falta de profissionais de saúde. Outro tipo de declaração de objectivos poderá centrar-se na melhoria das dimensões específicas da qualidade, tais como a eficácia, a segurança ou a atenção às pessoas. Podem ser necessário desenvolver esforços no sentido de integrar os objectivos e prioridades relacionados com a qualidade em todo o sistema de saúde e garantir que eles se reflictam no planeamento e orçamentação nacionais da saúde, assim como na estratégia própria. Resumo: objectivos e prioridades nacionais de saúde Acções para a equipa de formulação da estratégia Conteúdo do documento de estratégia • Identificar as fontes existentes de objectivos e prioridades nacionais de saúde publicadas ou expressas • Avaliar a relevância dos objectivos existentes para a estratégia da qualidade • Considerar, como parte da análise da situação e do processo de planeamento da estratégia, a necessidade de outros objectivos e prioridades • Elaborar uma declaração de objectivos e prioridades para a estratégia nacional da qualidade • Declaração de objectivos e prioridades para a qualidade dos cuidados • Fontes de referência dos objectivos e prioridades nacionais de saúde existentes 39 P A R T E I I . F O R M U L A Ç Ã O D A E S T R A T É G I A 2. Definição local de qualidade É importante assegurar que a estratégia reflicta a definição de qualidade adoptada para interligar as actividades e os processos. Essas definições apresentam o contexto em que a estratégia irá funcionar e ser avaliada. Embora isso deva estar já estabelecido na política anterior, se não existir, deverá ser seriamente considerada no início do processo de formulação da estratégia. A elaboração de uma definição local poderá ser uma das primeiras tarefas para a equipa que formula a estratégia e pode também ser um exercício útil para o envolvimento das principais partes interessadas no debate acerca do que devem ser as prioridades locais (Caixa 11). Outras informações sobre a definição e contextualização da qualidade encontram-se na secção equivalente sobre a definição local de qualidade, na Parte I deste manual e na secção introdutória. Caixa 11. Estudo de caso: definição de qualidade no Sudão “Prestar os melhores cuidados possíveis aos doentes usando os recursos disponíveis e a prática baseada em evidência”. Definição de qualidade, Estratégia do Sudão para a qualidade, 2017 Em 2016, o Sudão iniciou o processo de formulação de uma estratégia nacional para a qualidade e convidou uma grande variedade de partes interessadas, para que oferecessem contributos para o planeamento estratégico. Com base nos contributos das partes interessadas, a equipa de formulação da estratégia redigiu uma definição local, estabelecendo o que a qualidade deveria significar no contexto deste renovado esforço nacional para melhorar os serviços. A equipa selecionou uma definição que é sucinta e facilmente compreendida para uma série de partes interessadas, desde políticos a profissionais de saúde. Essa definição reflecte, não só a necessidade de cuidados eficazes centrados nos doentes, mas também a imperiosa necessidade de usar inteligentemente os recursos limitados disponíveis. Resumo: definição local de qualidade Acções para a equipa de formulação da estratégia Conteúdo do documento da estratégia • Identificar as definições de qualidade existentes a partir de publicações nacionais sobre saúde ou anteriores esforços para a qualidade e considerar o conteúdo da secção de introdução deste manual • Como parte do planeamento da estratégia ou do processo de envolvimento das partes interessadas, aperfeiçoar e decidir sobre uma definição local apropriada que oriente o processo da estratégia. Isso poderá já ter sido feito, se já tiver sido formulada uma política nacional para a qualidade • Definição de qualidade explícita e como ela será reflectida nas acções preconizadas na estratégia 3. Mapeamento e envolvimento das partes interessadas Para que a estratégia para a qualidade seja bem sucedida, é fundamental que exista a colaboração e o envolvimento das principais partes interessadas durante as fases de concepção, implementação e avaliação. Embora a formulação da estratégia possa ser orientada a partir de uma determinada organização de topo, muitas vezes uma unidade ou direcção dentro do ministério da saúde, é importante trabalhar com um conjunto alargado de partes interessadas de todo o sistema de saúde 40 M A N U A L D E P O L Í T I C A S E E S T R A T É G I A S P A R A A Q U A L I D A D E D O S C U I D A D O S D E S A Ú D E aos níveis federal, regional, estadual, comunitário e local. Um envolvimento estruturado ajudará a criar um entendimento comum, assim como ambição e empenho mútuos; isso poderá ajudar a identificar os recursos e activos disponíveis para apoiar a formulação e a implementação da estratégia. O envolvimento na política e estratégia pode ocorrer como parte do mesmo processo. Embora determinados grupos de partes interessadas possam variar de país para país, em geral, eles são, no mínimo, os seguintes: • governo: ministérios (da saúde e não relacionados com a saúde, tais como o das finanças), órgãos para-governamentais independentes e membros eleitos; • reguladores, outros avaliadores externos e organismos de normalização; • entidades e autoridades púbicas e privadas; • associações profissionais; • prestadores de cuidados (cuidados comunitários, primários, secundários e terciários, praticantes tradicionais, sectores público e privado); • organizações da sociedade civil, grandes organizações religiosas, grupos de doentes e doentes e familias; • organizações não governamentais e organizações comunitárias; • contribuintes, financiadores e doadores. Em muitos países, existirão já esforços de melhoria da qualidade de pequena escala (e em alguns casos, de grande escala) nas unidades de saúde e nos prestadores comunitários em todo o sistema de saúde, por vezes com o apoio de agências técnicas externas. Estes peritos, de primeira linha em melhoria da qualidade, já devem ter adquirido provavelmente experiência útil sobre aquilo que funciona a nível local e isso deve ser aproveitado no processo de envolvimento das partes interessadas. Realizar o mapeamento ou uma análise das partes interessadas poderá permitir a identificação das organizações ou indivíduos que poderão ser os condutores, catalisadores ou bloqueadores de uma estratégia nacional para a qualidade. Ao decidir que grupos de partes interessadas devem ser activamente incluídos, há um conjunto de questões que ajudarão a esclarecer quem deverá ser “escolhido” para compreender o actual estado da qualidade, identificar problemas e lacunas visíveis e formular uma estratégia para a melhoria. As perguntas essenciais a considerar na identificação das principais partes interessadas são as seguintes. • Quem é responsável pela qualidade em cada nível do sistema de cuidados de saúde? • Quem ou o que é que influencia a qualidade em cada nível do sistema de cuidados de saúde? • Quais são as principais alavancas ou motores para se atingirem melhores resultados na saúde e quem é responsável por isso? • Que grupos serão dinamizadores e que grupos serão detractores de uma estratégia nacional para a qualidade? • Quais são as principais organizações responsáveis pela prestação de serviços em todo o sistema de saúde? • Que organizações ou indivíduos apoiam o ministério da saúde na elaboração de planos estratégicos? Estas perguntas ajudam a esclarecer quem são os principais actores que devem ser envolvidos e com que papel – autor, revisor, perito consultor ou implementador – e em que fases do processo. 41 P A R T E I I . F O R M U L A Ç Ã O D A E S T R A T É G I A A Tabela 2 apresenta alguns exemplos do modo como as partes interessadas podem ser identificadas e as tarefas específicas que podem apoiar ou liderar. Tabela 2. Partes interessadas e tarefas relacionadas Partes interessadas Tarefa(s) Ministério da Saúde • Autor principal • Direcção-líder da PENQ Outros ministérios governamentais relevantes (Finanças, Assuntos Sociais, Educação) • Fornecer contributos estratégicos para o processo de formulação da estratégia • Identificar questões políticas relacionadas, requisitos financeiros e instrumentos legais • Integrar acções com iniciativas de outros sectores (por exemplo, formação médica) Conselhos profissionais de saúde e associações de especialidades • Identificar intervenções para melhoria • Apoio técnico à análise da situação e avaliação externa Agência nacional de seguros de saúde • Rever as implicações dos pagamentos • Integrar incentivos para a melhoria Equipas provinciais, regionais e distritais de gestão • Envolver as unidades de saúde e integrar as funções de gestão e de qualidade • Divulgar acções individuais e apoio técnico à implementação • Monitorizar e avaliar os progressos das iniciativas para a qualidade, através de processos eficazes de gestão Prestadores de cuidados de saúde religiosos, privados e tradicionais • Envolver a rede de organizações religiosas • Divulgar acções individuais e apoio técnico à implementação • SApoiar a equipa distrital de gestão da saúde na monitorização e avaliação dos progressos das iniciativas para a qualidade Prestadores de cuidados de saúde e hospitais do sector público • Envolvimento total na análise da situação • Prestar orientações e conhecimentos técnicos para melhores práticas clínicas Organizações não governamentais e parceiros do desenvolvimento • Prestar apoio técnico ao planeamento estratégico e à implementação de intervenções para a qualidade com base na estratégia para a qualidade Organizações da sociedade civil, partes interessadas da comunidade • Contribuir para a análise da situação • Rever o processo de formulação da estratégia para garantir que seja apropriado e significativo para o público e para os doentes • Contribuir para a selecção de indicadores locais significativos Como: um processo para envolver as partes interessadas É preciso auscultar as reacções dos grupos de partes interessadas em todo o processo, para assegurar a harmonização em todo o sistema de cuidados de saúde. Existem muitas abordagens em torno do envolvimento das partes interessadas; os métodos mais comuns envolvem entrevistas, reuniões, constituição de grupos de trabalho e pedidos de feedback das partes interessadas. Como primeiro passo, as entrevistas às partes interessadas poderão ajudar a recolher dados, tais como definições locais de qualidade, percepções e dados objectivos relativamente ao actual 42 M A N U A L D E P O L Í T I C A S E E S T R A T É G I A S P A R A A Q U A L I D A D E D O S C U I D A D O S D E S A Ú D E estado da qualidade, qual é o aspecto “ideal” da qualidade, lacunas existentes e ideias para colmatar essas lacunas. À medida que a equipa progride, poderão ser convocados grupos de partes interessadas para testar, aperfeiçoar e finalizar vários elementos da estratégia nacional para a qualidade. A criação de grupos de trabalho específicos poderá ser igualmente útil; por exemplo, as pessoas com conhecimentos clínicos e de avaliação poderão desenvolver uma proposta de conjunto de indicadores da qualidade, que seriam apresentados a um grupo maior de partes interessadas para revisão e ratificação. A formulação da estratégia nacional para a qualidade tende, frequentemente, a usar uma abordagem descendente (top-down) desenhada e planeada pelo governo e lançada em todo o sistema de saúde; é, no entanto, fundamental envolver a linha da frente, utilizando uma abordagem ascendente (bottom-up), para inspirar a formulação da estratégia geral à luz dos pontos fortes e dos desafios que existem e para ajudar a orientar os recursos. Isso é importante, devido ao fosso que muitas vezes existe entre as realidades da linha da frente e o planeamento estratégico feito ao nível superior. O contributo dos clínicos e gestores é essencial, visto que possuem conhecimentos profundos sobres a matéria. Uma estratégia baseada na implementação requer que exista uma ligação com os prestadores directamente no ponto de cuidados ou através das suas associações, assegurando que a estratégia é significativa e compreensível para os prestadores da linha da frente. É o seu comportamento que determinará o sucesso ou insucesso da estratégia e, por isso, é essencial que esta seja adoptada desde o início por parte daqueles que prestam os cuidados. Contudo, mesmo com uma adopção suficiente, os prestadores de cuidados de saúde devem ser recrutados com um ambiente favorável que proporcione a necessária mudança de comportamentos, para que haja melhorias nos cuidados. O envolvimento das partes interessadas pode ajudar a conseguir as estruturas de apoio necessárias para o ambiente referido e a ultrapassar os desafios com a sua criação. Caixa 12. Envolvimento das comunidades e dos doentes: a experiência do Uganda O Uganda tem uma longa história de esforços nacionais para melhorar a qualidade dos cuidados, tendo começado por um programa de melhoria da qualidade em meados da década de 1990. Com essas iniciativas, o envolvimento dos doentes e das comunidades tem sido cada vez mais reconhecido como uma componente essencial. O Uganda criou comissões de gestão das unidades de saúde, para dar aos membros das comunidades um contributo significativo para a gestão das unidades de saúde e a supervisão do seu desempenho, introduziu uma carta do doente apontando os direitos dos utentes dos serviços e, na sua mais recente estratégia nacional para a qualidade, envolveu a sociedade civil e representantes dos utentes dos serviços de saúde no grupo de acção que coordenava a formulação e a implementação. A perspectiva das comunidades e dos doentes é de importância vital, podendo ser testemunhada nas visitas às unidades de saúde e na participação em reuniões públicas, onde se poderá ouvir a opinião dos doentes, famílias e comunidades no processo de formulação da estratégia (Caixa 12). Os representantes das comunidades e dos doentes também poderão ser envolvidos diretamente, tanto nos processos de formulação da política e da estratégia como nos subsequentes acordos de implementação e governação, ajudando a garantir que os esforços se baseiam “naquilo que realmente interessa” às pessoas que, afinal de contas, são os utentes dos serviços. No entanto, este processo exige um planeamento cuidadoso, para assegurar que as comunidades serão devidamee nte capacitadas envolvidas. Por exemplo, desafios como a barreira linguística ou fracos conhecimentos de saúde poderão ter de ser ultrapassados para permitir um diálogo frutífero durante o processo. Os serviços de saúde terão de ser reorientados para as necessidades e preferências dos doentes, o que apenas se poderá conseguir através de um envolvimento real. 43 P A R T E I I . F O R M U L A Ç Ã O D A E S T R A T É G I A O envolvimento das comunidades e dos doentes, embora adicionando mais uma necessidade de recursos para que os programas possam melhorar a qualidade dos cuidados, permite que as comunidades sejam usadas como um activo-chave na análise da situação, criação de intervenções apropriadas, governação e responsabilização e avaliação do êxito. Estas perspectivas e o referido envolvimento capacitam as pessoas e criam um nível de responsabilização nas comunidades. Resumo: mapeamento e envolvimento das partes interessadas Acções para a equipa de formulação da estratégia Conteúdo do documento da estratégia • Identificar as principais partes interessadas de todo o sistema de saúde • Mapear o papel e a influência das partes interessadas na formulação da estratégia • Atribuir responsabilidades a determinadas partes interessadas pelo seu contributo para aspectos relevantes da estratégia para a qualidade • Planear o envolvimento activo das partes interessadas, para maximizar a utilidade do seu contributo e minimizar os obstáculos à formulação e implementação da estratégia • Agendar reuniões com várias partes interessadas, conforme necessário, para a formulação da estratégia (poderão ser incluídos grupos de redactores, processo de análise da situação, um grupo directivo e uma reunião de validação) • Esboço do processo de envolvimento das partes interessadas com reconhecimento do seu contributo • Esboço dos papéis das principais partes interessadas nas acções sugeridas no âmbito da estratégia 4. Análise da situação: estado da qualidade Na maioria dos casos, a primeira fase da formulação de PENQ inclui uma análise da situação aprofundada e bem estruturada do estado da qualidade do sistema de cuidados de saúde, aos níveis nacional, regional, estadual ou provincial, local, institucional e comunitário. Essa análise da situação contribuirá para um melhor entendimento do actual estado da qualidade, dos pontos fortes do sistema de cuidados de saúde para impulsionar a melhoria da qualidade, dos obstáculos previsíveis e dos facilitadores do processo de formulação da estratégia, principais desafios e prioridades mais prementes que se colocam ao sistema de saúde, assim como o actual estado de importantes factores contextuais, tais como as infra-estruturas, as capacidades e o clima político. A análise pode ser usada para orientar a abordagem adoptada pela equipa que está a formular e a implementar a estratégia, podendo igualmente ser partilhada com outras importantes partes interessadas, para facilitar o seu envolvimento. Para realizar uma análise da situação completa, provavelmente, serão necessários vários meses combinando diversas actividades importantes, incluindo a convocação das partes interessadas, a realização de sessões de informação, estudo de vários documentos (abaixo indicados), a realização de entrevistas individuais e grupos de reflexão para recolha de informação e redacção de relatórios sucintos. Esta variedade de actividades deve basear-se em perspectivas e conhecimentos especializados, desde o nível nacional até nível dos profissionais de saúde na primeira linha da prestação de serviços. A inclusão de uma grande variedade de partes interessadas, conforme se indica na secção anterior sobre mapeamento e envolvimento das 44 M A N U A L D E P O L Í T I C A S E E S T R A T É G I A S P A R A A Q U A L I D A D E D O S C U I D A D O S D E S A Ú D E partes interessadas, é essencial para compreender as atitudes colectivas, a experiência e as aspirações que servirão de base a futuros esforços. Uma análise da situação abrangente incluirá uma revisão da informação histórica e presente, assim como a recolha e compilação de novos dados. É provável que a seguinte informação genérica seja importante e útil. • Revisão de todos os documentos relevantes. Entre estes contam-se a política nacional de saúde e o plano quinquenal de saúde dos países, que fornecerá informação vital sobre as prioridades, recursos e contexto do país. A estratégia nacional para a qualidade deve estar integralmente alinhada e apoiar as políticas e planos nacionais já existentes. • Revisão da legislação, regulamentação e estatutos relacionados com a qualidade. Esta revisão fornecerá informação sobre os requisitos para o licenciamento, qualidade dos medicamentos e controlo da segurança, bem como a inspecção das instalações. • Documentos governamentais e do sector público relacionados com a qualidade. Alguns exemplos incluem materiais de formação profissional, protocolos e orientações relevantes para a qualidade dos cuidados de saúde. O ministério da saúde e a entidade nacional de seguros de saúde deverão possuir documentos relevantes com informação tão diversa como os requisitos para o tratamento dos resíduos ambientais hospitalares ou cartas dos direitos dos doentes. • Dados do desempenho sobre a qualidade do sistema de cuidados de saúde. As fontes incluem hospitais, unidades de cuidados primários e centros e clínicas de ambulatório, nos quais se poderão obter os dados do sistema de gestão da informação de saúde (SGIS) que são rotineiramente recolhidos, assim como conjuntos de dados com finalidades especiais. Estes dados permitirão um entendimento mais pormenorizado do real desempenho de todo o sistema de saúde em áreas como o acesso, a eficácia, a segurança, a eficiência, a equidade e a atenção ao doente. • Relatórios dos programas técnicos e verticais. Estes relatórios fornecerão dados úteis relacionados com a qualidade sobre a adequação dos processos e os resultados na saúde de populações específicas. • Mapeamento dos recursos disponíveis para apoiar os esforços nacionais para a qualidade. Há recursos relevantes que podem ser obtidos nos orçamentos nacionais, parceiros locais da implementação, agências externas e programas técnicos alinhados. • Inquérito sobre o estado da qualidade (abaixo descrito). Embora a recolha e análise de tantos dados possa ser problemática em alguns contextos, o processo nem sempre terá de ser longo ou exigir muitos recursos. Nos países em que os recursos para esse exercício são limitados, poderão usar-se, como ponto de partida, análises já existentes que tenham sido feitas para necessidades de planeamento do sistema de saúde, por exemplo, para fundamentar a formulação de um plano estratégico nacional de saúde. Também se podem combinar alguns aspectos da análise da situação com outros elementos do processo nacional para a qualidade, por exemplo, usando os processos de envolvimento das partes interessadas para recolher dados importantes. Além disso, será possível obter apoio para a análise da situação em outros organismos que estejam activos no domínio da qualidade dos cuidados, por exemplo, associações profissionais nacionais ou agências técnicas externas. Quanto mais abrangente for a análise que se faça, mais a estratégia beneficiará, mas o mais importante é que a estratégia seja baseada, tanto quanto possível, nas necessidades do país que tenham sido identificadas e nos activos disponíveis para as satisfazer. Mesmo com poucos recursos, é possível adoptar essa abordagem. No compêndio de instrumentos que acompanha este manual, indicam-se alguns instrumentos de apoio a este processo. Um questionário destinado a entrevistas semi-estruturadas ou a solicitar respostas escritas 45 P A R T E I I . F O R M U L A Ç Ã O D A E S T R A T É G I A poderá fornecer alguma informação básica, incluindo a experiência das partes interessadas, e complementar a informação retirada das fontes de dados e análises atrás mencionadas. Através desta actividade de recolha de dados – que se baseará em entrevistas individuais e a pequenos grupos (ou, em alguns casos, em respostas escritas) – a equipa poderá melhor compreender as atitudes e perspectivas das partes interessadas com base na respectiva experiência. As quatro áreas de conteúdos básicos do inquérito sobre o actual estado da qualidade, e sua fundamentação, são as seguintes. • Contexto nacional da qualidade. Para fundamentar a estratégia nacional para a qualidade, é útil conhecer a respectiva história, eventos e iniciativas que levaram à sua formação. Isso consiste em compreender o que já foi feito no domínio do planeamento, controlo, garantia e melhoria da qualidade, incluindo nos programas específicos de doenças ou populações. Conforme o grau de centralização ou fragmentação do sistema de saúde de um país, estas iniciativas poderão ser oriundas de diversas fontes, por exemplo, sector privado, financiamento dos doadores ou iniciativas locais, e serão influenciadas por vários factores políticos, económicos, demográficos e outros. • Política e planeamento. A qualidade dos cuidados de saúde em todos os países é determinada pela política e representada através de alguns tipos de funções de planeamento estruturadas. Por exemplo, as prioridades nacionais são explicitamente identificadas, determinando, depois, a alocação de recursos a um nível alargado, afectando a prestação de serviços clínicos a nível local. Em paralelo, a definição de normas nacionais pode influenciar muito a adequação da tomada de decisões clínicas e a segurança das instituições onde as pessoas procuram os cuidados. • Regulação, governação e supervisão. Esta é uma análise descritiva de como as funções formais e informais relacionadas com a liderança, governação e supervisão influenciam a qualidade. É importante realizar esta avaliação em todos os níveis do sistema de saúde, incluindo os níveis nacional, estadual ou provincial, local, institucional e comunitário, assegurando a inclusão dos sectores público e privado. Os principais elementos a considerar são as estruturas e as responsabilidades pela qualidade, identificando cuidadosamente os pontos fortes e fracos dos factores legislativos, políticos e reguladores. • Actividades existentes para a avaliação e melhoria da qualidade. É importante inventariar as actuais iniciativas relacionadas com a qualidade que decorrem em todo o país, aos níveis nacional, estadual ou provincial, local, institucional e comunitário. Esta análise pode conduzir a uma avaliação elucidativa das actuais capacidades e competências, identificando os “pontos fortes” e as lacunas. 46 M A N U A L D E P O L Í T I C A S E E S T R A T É G I A S P A R A A Q U A L I D A D E D O S C U I D A D O S D E S A Ú D E Resumo: análise da situação Acções para a equipa de formulação da estratégia Conteúdo do documento da estratégia • Seleccionar e desenvolver instrumentos para o processo de análise da situação • Identificar as principais partes interessadas a envolver • Recolher dados sobre as actividades existentes, planeamento do sistema de saúde, governação e supervisão, factores contextuais e percurso histórico da qualidade • Num processo com várias partes interessadas, analisar os dados necessários para fundamentar a selecção de prioridades, clarificação da governação e estruturas, concepção de intervenções e planos práticos para a monitorização e avaliação • Resumo do processo de análise da situação • Principais resultados da análise da situação 5. Governação e estrutura organizacional para a qualidade Há duas estruturas de governação que terão de ser consideradas. A primeira será uma estrutura de governação que criará, estabelecerá e aplicará a orientação da política nacional para a qualidade. A segunda será a governação e a estrutura organizacional que assume a responsabilidade de cumprir a estratégia e garantir a finalidade pretendida. A Parte I discute a primeira, esta secção concentrar-se-á mais na segunda. As pessoas que participaram na redacção da estratégia têm, normalmente, papéis tácticos na catalisação da sua implementação. Para isso, é preciso definir claramente os papéis e as responsabilidades dos principais indivíduos e organizações designadas que irão supervisionar determinados aspectos da estratégia e a executarão no terreno. A governação da estratégia dependerá igualmente de uma liderança e gestão específicas, especialmente para as iniciativas do nível nacional que pretendem chegar a regiões, unidades e comunidades locais. O fluxo da comunicação deve ter um canal claro, desde os pontos centrais para os descentralizados e vice-versa; a clarificação das estruturas de governação poderá assegurar que os defensores da melhoria da qualidade local e as equipas das unidades poderão contribuir significativamente para os processos subnacionais e nacionais. Os mecanismos existentes para a liderança, proximidade e comunicação do sector da saúde deverão facilitar a implementação estratégica da política, para evitar sistemas paralelos. Se esses canais não existirem, recomenda-se vivamente que eles sejam escritos no âmbito de um plano estratégico e depois institucionalizados. Os organigramas são importantes como instrumento visual que ajuda, tanto os actores internos como externos, a compreenderem o processo e o fluxo da estrutura de governação (ver exemplos de organigramas no compêndio) (Figura 2). 47 P A R T E I I . F O R M U L A Ç Ã O D A E S T R A T É G I A Figurα 2. Exemplo de organigrama dos esforços nacionais para a qualidade Ministério da Saúde Comissão hospitalar para a qualidade Equipa comunitária para a MQ Equipa de departamento para a MQ Equipa de departamento para a MQ Comissão nacional de garantia/melhoria da qualidade Comissão de garantia/ melhoria/gestão da qualidade/ Comissão nacional para a qualidade Comissão subnacional para a qualidade Comissão hospitalar para a qualidade Equipa comunitária para a MQ Para ajudar a equipa de formulação da estratégia a avaliar, tanto os activos como as insuficiências actuais da governação e para conceptualizar a estrutura pretendida, poderá ser útil considerar as seguintes perguntas. Quem é actualmente responsável pelas funções relacionadas com a qualidade? Isto pode ser discutido durante a análise da situação e os elementos do processo de envolvimento das partes interessadas, mas, muitas vezes, o quadro poderá ser complexo e pouco nítido. De notar que pode ser importante esclarecer as relações entre os ministérios da saúde, os organismos de acreditação ou licenciamento e as associações profissionais, e que acordos existem para gerir essas relações. Poderá ser útil mapear, não apenas os indivíduos e as organizações que são responsáveis em todo o sistema, mas também os recursos e os poderes que têm à sua disposição para cumprir essas responsabilidades. A estratégia poderá então ser usada para esclarecer os papéis e as responsabilidades, colmatar lacunas importantes, planear uma alocação apropriada de recursos e definir como o sistema trabalhará em colaboração. Existe um organigrama? Os organigramas podem ser um instrumento útil para mapear os processos, a responsabilidade e o fluxo da informação no seio de um sistema de saúde. Poderão existir organigramas que mostrem o modo como os actuais esforços nacionais para a qualidade estão organizados ou como se enquadram no sistema de saúde em geral. Como parte do processo de envolvimento das 48 M A N U A L D E P O L Í T I C A S E E S T R A T É G I A S P A R A A Q U A L I D A D E D O S C U I D A D O S D E S A Ú D E partes interessadas, poderá ser útil determinar se existe um entendimento comum das estruturas da qualidade em todo o sistema, uma vez que actores diferentes poderão ter perspectivas alternativas. Quando se planeia a estratégia, é útil elaborar e publicar um organigrama e encorajar a repetição desse exercício aos níveis subnacional e de unidade de saúde, como meio de esclarecer os papéis e as responsabilidades. A confirmação desses organigramas pode igualmente ser usada para promover o debate sobre o modo como irá funcionar cada relação dentro da estrutura e se será necessário implementar medidas que reforcem cada órgão designado. Existe uma responsabilização clara pela qualidade a todos os níveis da prestação de serviços? Isto exige saber qual o significado de responsabilização aos diferentes níveis do sistema de saúde, como está a ser avaliada a qualidade dos cuidados para facilitar a responsabilização e que medidas existem ou são exequíveis para resolver as deficiências nos cuidados identificadas através de processos de responsabilização. A resolução desta questão poderá revelar a necessidade de a estratégia criar novas estruturas de responsabilização ou reforçar as já existentes e pode ajudar a assegurar que a estratégia poderá ser implementada a todos os níveis. É importante reconhecer aqui que a responsabilização não é um processo unidirecional e que ao desenvolver a estrutura e os processos de governação é preciso assegurar que eles facilitam a gestão descendente do desempenho e reforçam as ligações ascendentes entre as equipas de melhoria da qualidade, os órgãos subnacionais e as autoridades nacionais. Quais as responsabilidades específicas de cada órgão ou posição? A resposta a esta pergunta pode, mais uma vez, fazer parte dos elementos do processo de envolvimento das partes interessadas ou da análise da situação. Em particular, poderá ser útil não apenas mapear a situação actual, mas também identificar as lacunas ou os desafios em relação aos papéis e responsabilidades necessários para os elementos essenciais da estratégia que se pretendem. Especificamente, será útil examinar os papéis, mandatos e capacidades das associações profissionais, conselhos e órgãos oficiais similares, incluindo as suas relações com o ministério da saúde, os prestadores e entre si. Que recursos existem e serão necessários? A mudança organizacional e o reforço das capacidades organizacionais em todo o sistema de saúde poderá exigir recursos significativos. É útil determinar que recursos estão actualmente disponíveis para apoiar os esforços de governação, incluindo nos orçamentos existentes das principais partes interessadas (por exemplo, associações profissionais), e como poderão ser determinadas as prioridades para a utilização dos recursos, se necessário. O actual ambiente legislativo é adequado à finalidade de apoiar a estratégia? O funcionamento bem sucedido da estrutura de governação proposta depende de um ambiente legislativo favorável. Ele poderá já existir na forma de legislação específica para o sector da saúde, responsabilidades estatutárias dos organismos profissionais e reguladores e precedentes legais estabelecidos sobre questões importantes. Contudo, poderá ser necessário apresentar argumentos para a revisão ou reforço das leis existentes ou a criação de novos instrumentos legais para permitir uma implementação eficaz da estratégia. Este pode ser um processo difícil ou prolongado e, na verdade, poderá não ser uma prioridade inicial, mas é importante, no âmbito do processo de formulação da estratégia, considerar o impacto do actual ambiente legislativo e a potencial mais-valia de qualquer melhoria. Como são representadas as comunidades, as organizações de doentes e as organizações comunitárias e religiosas no seio das estruturas existentes para a governação do sistema de saúde? Embora as estruturas de governação variem na sua composição, um grupo que deveria estar representado é a “comunidade” – a população em geral ou os beneficiários da estratégia para 49 P A R T E I I . F O R M U L A Ç Ã O D A E S T R A T É G I A a qualidade. Embora seja importante ter o apoio das estruturas da liderança e do governo, são os utilizadores finais que contribuem de forma essencial para o processo mais vasto de melhoria da qualidade. É, por isso, importante dispor de um mecanismo que inclua essa voz na formulação da estratégia, mas a sua presença é igualmente importante para a implementação da estratégia e para garantir a responsabilização. Em toda a estrutura de governação proposta deverão existir mecanismos integrados para o envolvimento das comunidades; isso requer actividades específicas de formação das capacidades do sistema de saúde para facilitar o referido envolvimento. As cartas dos direitos dos doentes poderão ser um instrumento útil para ajudar a definir o papel dos doentes e suas famílias que interagem a nível da comunidade. Isso deverá estar alinhado com as leis e regulamentos nacionais, regionais e locais existentes que protegem os utentes dos serviços de saúde. Também deve ser considerada a inclusão sistemática da representação das comunidades nos órgãos de gestão da saúde a nível nacional, subnacional e das unidades de saúde, devendo igualmente existir um mecanismo para avaliar as reacções ao nível da comunidade. Serão apresentadas mais informações relativamente aos mecanismos de feedback e monitorização na subsecção 8 sobre indicadores de qualidade e medidas essenciais. Resumo: estrutura de governação e organizacional para a qualidade Acções para a equipa de formulação da estratégia Conteúdo do documento da estratégia • Considerar atentamente as questões acima colocadas para garantir um exame eficaz das estruturas de governação e organizacionais existentes e das propostas para a qualidade • Conceber medidas apropriadas e práticas para garantir a responsabilização • Identificar as alavancas para garantia da implementação da estratégia a diferentes níveis do sistema de saúde • Especificação de acordos de governação e responsabilização para a estratégia, incluindo um organigrama, se apropriado, e declaração explícita do papel da comunidade 6. Métodos e intervenções para a melhoria A estratégia pode ser definida como um plano escolhido para proporcionar o futuro desejado para a consecução de determinados objectivos. O planeamento estratégico terá de identificar intervenções de melhoria da qualidade que possam dar resposta às prioridades nacionais e atingir os objectivos explícitos da qualidade. A selecção das intervenções para a qualidade deve ser acompanhada de um plano de implementação que seja prático, eficaz e sustentável. A tarefa de conceber e implementar uma estratégia nacional poderá ser cada vez mais orientada por uma crescente base de evidências sobre o impacto de intervenções isoladas e combinadas. A literatura sobre os serviços de saúde, medicina clínica e ciências sociais refere-se a um grande número de intervenções que variam muito no que diz respeito a pressupostos subjacentes, recursos necessários e contexto em que foram implementadas. No entanto, muita da evidência publicada é oriundas de países de rendimentos mais elevados e requerem um estudo atento com base nos diferentes contextos dos países, regiões, estados ou províncias e comunidades. Infelizmente, a evidência ainda é escassa nos países de baixo e médio rendimento e concentram-se, muitas vezes, mais nos aspectos estruturais da qualidade, tais como as reservas de medicamentos, o que não é necessariamente esclarecedor da qualidade dos cuidados médicos (16). Por conseguinte, é importante compreender que se trata de um processo repetitivo e evolutivo que requer uma avaliação contínua das intervenções e instrumentos que estão a contribuir para melhorar os resultados da saúde, identificando em simultâneo os que não apresentaram resultados positivos ou que poderão mesmo estar a ter consequências imprevistas e não desejadas. Mesmo 50 M A N U A L D E P O L Í T I C A S E E S T R A T É G I A S P A R A A Q U A L I D A D E D O S C U I D A D O S D E S A Ú D E com as lacunas reconhecidas na evidência disponivel, ainda é possível usar a experiência, os conhecimentos e a ciência para identificar as intervenções que, provavelmente, irãs produzir melhorias na qualidade. Uma abordagem desse tipo realça o valor da formulação de uma estratégia baseada na implementação, em que a estratégia pode ser um documento dinâmico que incorpore a experiência real em termos de implementação e dos anteriores esforços desenvolvidos para a qualidade. Os dinamizadores locais da melhoria da qualidade e as equipas das unidades poderão estar já a funcionar em alguns países e podem constituir uma fonte de informação local sobre o que eventualmente poderá funcionar e onde se poderão encontrar problemas no uso de certas intervenções. Dada a frequente limitação ao nível da evidência sobre as intervenções, a elaboração de uma agenda de aprendizagem activa é uma importante função de apoio a um programa nacional para a qualidade. No interior da estratégia, deve considerar- se o modo como a evidência pode ser gerada e a melhor forma de compreender, documentar e partilhar a aprendizagem. Caixa 13. Avaliação externa, licenciamento e certificação Uma vez que são os governos que financiam os esforços para a cobertura universal de saúde, é cada vez mais necessário avaliar e garantir a qualidade dos serviços pagos por fundos públicos. A avaliação externa, nomeadamente a acreditação, poderá consistir tanto numa auto-avaliação como na revisão externa do desempenho em função dos padrões existentes, e é, muitas vezes, um primeiro passo dos esforços nacionais para melhorar a qualidade. Licenciamento descreve um processo regulador aprovado pelo governo para conceder permissão e especificar o âmbito da prática dos cuidados de saúde por determinado indivíduo ou organização e que, normalmente, precede a acreditação. A certificação garante o reconhecimento – por parte de órgãos estatais, privados ou não governamentais – de organizações, pessoas, processos ou objectos que cumpram determinadas condições estabelecidas para o processo de certificação. Existe mais informação disponível na Sociedade Internacional para a Qualidade dos Cuidados de Saúde https://isqua.org. Embora cada país exerça diferentes intervenções e actividades, há alguns conceitos que são relevantes em todos os sistemas de cuidados de saúde de diferentes países e que podem ajudar a comunicar e organizar uma estratégia nacional. Embora existam outras, indicam-se aqui três abordagens práticas para conceber, organizar e implementar intervenções para a qualidade conduzidas por vários países: • Trilogia de Juran: um conceito para compreender o “panorama geral”; • Selecção de intervenções: identificar a finalidade, tipo de acção e intervenções isoladas; • Abordagem nacional com vários níveis: conceber acções a todos os níveis do sistema de cuidados de saúde. 51 P A R T E I I . F O R M U L A Ç Ã O D A E S T R A T É G I A A Trilogia de Juran: panorama geral Um conceito frequentemente referido nos esforços para a melhoria dos cuidados de saúde é a Trilogia de Juran. A Trilogia de Juran compreende três abordagens separadas, mas relacionadas, que devem estar presentes numa estratégia nacional: planeamento da qualidade, controlo da qualidade e melhoria da qualidade1. Esta pode ser uma estrutura útil para conceptualizar os diferentes domínios que podem ser considerados ao seleccionar as intervenções. No contexto da saúde, a Trilogia de Juran, sublinha a necessidade de um planeamento e de uma formulação de políticas coerentes a nível nacional para definir o rumo a seguir, acompanhada por métodos operacionais que garantam que os processos críticos da prestação de serviços de saúde são concebidos de modo a funcionar e que as metas de desempenho estão a ser alcançadas e sustentadas. Este conceito pode ser particularmente útil para os países, quando estes formulam as suas estratégias para a qualidade, reconhecendo que essas três funções – planeamento, controlo e melhoria – são necessárias e complementares. Por exemplo, na formulação da sua estratégia nacional de saúde para a qualidade, a Libéria usou as três componentes da Trilogia de Juran para analisar os esforços para a qualidade, anteriores e actuais, do sector da saúde para orientar a reflexão sobre onde centrar os recursos para as prioridades identificadas. Embora a melhoria da qualidade, muitas vezes, tenha beneficiado de precedência nos programas nacionais para a qualidade, é importante que os métodos e as intervenções contemplem os três imperativos – planeamento, controlo e melhoria – de forma complementar. Por exemplo, reduzir as infecções associadas aos cuidados de saúde não será possível, sem ter criado as políticas certas (planeamento), mecanismos robustos de prevenção e controlo das infecções (controlo) e abordagens apropriadas para mudar os comportamentos institucionais e individuais (melhoria). Caixa 14. Aplicar a Trilogia de Juran para orientar a selecção das intervenções Planeamento da qualidade • Como podem ser ouvidas as vozes dos doentes e dos prestadores no planeamento das iniciativas para a qualidade? • Que novos produtos e políticas são necessários nos diferentes níveis do sistema de saúde? Controlo da qualidade • Existem normas ou orientações publicadas? • Que sistemas podem ser usados para promover e assegurar o desempenho do prestador e do sistema? Melhoria da qualidade • Que capacidades existem, nos diferentes níveis do sistema de saúde, para identificar e corrigir as deficiências e fragilidades no desempenho? Selecção de intervenções Talvez o desafio mais exigente para salvaguardar e melhorar a qualidade seja a selecção criteriosa das “intervenções” – políticas, programas, estruturas e outras acções implementadas em todos os níveis do sistema de cuidados de saúde, para exercerem impacto sobre os resultados de saúde. Esta é reconhecida como uma tarefa difícil, para todos os países, por várias razões. • A evidência é , muitas vezes, difícil de interpretar no que diz respeito à eficácia e impacto das intervenções. 1. 52 M A N U A L D E P O L Í T I C A S E E S T R A T É G I A S P A R A A Q U A L I D A D E D O S C U I D A D O S D E S A Ú D E “ ” • A evidência é , muitas vezes, difícil de interpretar no que diz respeito à eficácia e impacto das intervenções. • As ideologias e as crenças muitas vezes prevalecem sobre a evidência científica, mesmo quando estas existem. • Poderão não existir peritos prontamente disponíveis para conceber intervenções específicas. • As partes interessadas poderão criar resistência a certas acções (tais como, a apresentação pública dos dados do desempenho). • Poderão não existir recursos disponíveis. O universo de intervenções que exercem impacto sobre a qualidade é vasto e difícil de conceptualizar integralmente. Organizar estas intervenções poderá facilitar um entendimento comum e permitir melhores escolhas sobre quais as intervenções interdependentes que deverão ser selecionadas em todos os países e em todos os sistemas de saúde. Sabemos que não existem “soluções mágicas”, nem infalíveis, e que é necessário uma combinação de intervenções que possam ser usadas em simultâneo numa estratégia complementar e integrada, para que a melhoria da qualidade prevaleça. Uma intervenção para a melhoria da qualidade é um processo de mudança nos sistemas, serviços ou prestadores de cuidados de saúde, com a finalidade de aumentar a probabilidade de uma qualidade clínica de cuidados avaliada por resultados positivos na saúde dos indivíduos e das populações. (Agência para a Investigação e Qualidade nos Cuidados de Saúde) A lista de intervenções exemplificativas da Tabela 3 foi seleccionada por diferentes razões. As intervenções relacionadas com a qualidade são relevantes numa grande variedade de países em todo o mundo. São normalmente consideradas opções para a acção, têm alguma evidência que podem orientar a sua selecção e utilização e são intuitivamente razoáveis, podendo ser implementadas a vários níveis, desde pequenas clínicas ou unidades de cuidados de saúde primários até ao nível de um programa nacional. Nessa medida, as intervenções para a qualidade terão de ser atentamente examinadas. A lista apresentada não é, de todo, exaustiva; existem outras intervenções que poderiam facilmente ter sido incluídas. Este conjunto de intervenções foi selecionado pelo seu potencial impacto na qualidade, reduzindo os danos, melhorando a prestação de serviços de cuidados de saúde na linha da frente e formando capacidades em todo o sistema para a melhoria da qualidade. As intervenções exemplificativas pretendem apontar algumas das opções e possibilidades disponíveis aos gestores, praticantes ou decisores políticos que pretendam fazer avançar com inicitaivas de melhoria da qualidade dos cuidados. As intervenções são apresentadas com tanta simplicidade quanto possível, sublinhando os problemas mais evidentes. Contudo, nenhuma é simples de implementar e não devem ser vistas isoladamente – algumas destas intervenções estão interrelacionadas e, por isso, quando são implementadas em combinação umas com as outras poderão exercer um maior impacto. À medida que há mais países a trabalhar no sentido de melhorar a qualidade dos cuidados, espera- se que surjam mais evidências e experiencias específicas do contexto sobre “aquilo que funciona” e, por isso, recomenda-se que as últimas evidências, experiências e conhecimentos contextuais sejam tomados em consideração quando se procede à selecção das intervenções. 53 P A R T E I I . F O R M U L A Ç Ã O D A E S T R A T É G I A Tabela 3. Intervenções exemplificativas para a qualidade Intervenção Definição e aplicação Ambiente do sistema • O registo e licenciamento de médicos e outros profissionais, bem como de organizações de saúde é, normalmente, considerado determinante-chave e base de um sistema de saúde com bom desempenho. • A avaliação externa e a acreditação são o reconhecimento público, por um organismo externo (sector público, com ou sem fins lucrativos), do nível de desempenho de uma organização, através de um conjunto essencial de normas e padrões predefinidos. • A governação clínica é um conceito utilizado para melhorar a gestão, responsabilização e prestação de cuidados de saúde de qualidade. Integra a auditoria clínica, gestão do risco clínico, envolvimento do doente ou utente do serviço, formação e evolução profissional, investigação e desenvolvimento da eficácia clínica, utilização de sistemas de informação e comissões institucionais de governação clínica. • A notificação pública e a avaliação comparativa são estratégias utilizadas frequentemente para incrementar a transparência e a responsabilização, em questões de qualidade e custos, nos sistemas de cuidados de saúde, através da disponibilização de informação comparativa sobre desempenho aos consumidores, contribuintes, organizações e prestadores de cuidados de saúde. • Financiamento e contratação baseada no desempenho é uma expressão genérica utilizada para o pagamento dos prestadores de cuidados de saúde com base num determinado conjunto de medidas de desempenho. É cada vez mais utilizado como alavanca da qualidade. O montante dependente do desempenho é muitas vezes uma subcomponente do pagamento integral, podendo basear-se em várias modalidades de financiamento. • A formação e supervisão do pessoal estão entre as intervenções mais comuns para a melhoria da qualidade dos cuidados de saúde nos países de baixo e médio rendimento. • A regulamentação dos medicamentos, para assegurar medicamentos, vacinas e dispositivos médicos com garantia de qualidade, seguros e eficazes é fundamental para um sistema de saúde funcional. A regulamentação, nomeadamente, a vigilância pós-comercialização é necessária afim de eliminar os medicamentos de qualidade inferior e os falsificados, com base nas normas e padrões internacionais. Redução de danos • A inspecção das instituições com vista às normas mínimas de segurança pode ser utilizada enquanto mecanismo para garantir a existência de capacidades de base e recursos para manter um ambiente clínico seguro. • Os protocolos de segurança, como o da higiene das mãos, fazem face a muitos riscos evitáveis que ameaçam o bem-estar dos doentes e causam sofrimento e danos. • As listas de verificação de segurança, nomeadamente as listas de verificação da OMS para a Segurança Cirúrgica e para o Tratamento de Traumatismos, podem ter um impacto positivo na redução, tanto de complicações clínicas como da mortalidade. • A notificação de eventos adversos documenta uma ocorrência clínica indesejada num doente, resultante de serviços de saúde específicos ou durante exames médicos num contexto de cuidados clínicos. Deverá estar relacionada com um sistema de aprendizagem. 54 M A N U A L D E P O L Í T I C A S E E S T R A T É G I A S P A R A A Q U A L I D A D E D O S C U I D A D O S D E S A Ú D E Melhoria dos cuidados clínicos • Os instrumentos de apoio à decisão clínica disponibilizam conhecimentos e informação específica sobre o doente (automatizada ou em papel) em momentos adequados para potenciar a prestação de cuidados de saúde de primeira linha. • As normas, “vias rápidas” e protocolos clínicos são instrumentos utilizados para orientar cuidados de saúde baseados em evidência que há décadas foram implementados a nível internacional. A via rápida clínica (clinical pathway) é cada vez mais utilizada para melhorar os cuidados prestados em diversas patologias com grande afluência de doentes. • A auditoria clínica e feedback é uma estratégia de melhoria dos cuidados ao doente, através da monitorização da adesão a normas e orientações claras, juntamente com o fornecimento de feedback útil e atempado sobre a prática clínica. • A análise da morbilidade e mortalidade constitui um mecanismo de aprendizagem colaborativa, bem como um processo transparente de escrutinío para os médicos analisarem, sem receio de serem culpabilizados, a sua prática e identificarem áreas que careçam de melhoria, tais como os resultados de saúde e os eventos adversos. • Os ciclos de melhoria colaborativa e baseados em equipas constituem um método formalizado que reúne várias equipas de diferentes hospitais ou clínicas para trabalharem em conjunto, visando melhorar determinada área num determinado período de tempo. Os mecanismos de aprendizagem mútua têm um papel cada vez mais preponderante nas organizações de cuidados de saúde. Envolvimen- to e capacita- ção do doente, família e comunidade • O envolvimento e capacitação da comunidade com carácter formal refere-se à contribuição, activa e intencional de membros da comunidade, para a saúde da população de uma comunidade e para o desempenho do sistema de prestação de cuidados de saúde. Pode funcionar como mecanismo adicional de responsabilização. • Literacia em saúde é a capacidade de obter e compreender a informação básica de saúde necessária à tomada de decisões, de forma consistente e adequada, por parte dos doentes, famílias e comunidades mais alargadas. Está intimamente ligada à qualidade dos cuidados de saúde. • A tomada de decisão partilhada é muitas vezes utilizada para ajustar, com maior adequação, os cuidados às necessidades e preferências dos doentes, visando uma melhor adesão do doente, bem como minimizar a prestação de cuidados desnecessários no futuro. • O apoio inter-pares e dos grupos de doentes com doenças específicas estabelecem ligações entre pessoas que vivem em situações clínicas semelhantes, visando a partilha de conhecimentos e experiências. Geram apoio emocional, social e prático para a melhoria dos cuidados clínicos. • A experiência do doente em matéria de cuidados de saúde mereceu uma atenção especial enquanto base do planeamento da melhoria dos cuidados clínicos. As medidas indicadas pelo doente são importantes em si mesmas; os doentes com experiências mais positivas participam mais nos seus cuidados, o que pode contribuir para melhores resultados. • Os instrumentos de auto-tratamento do doente são tecnologias e técnicas utilizadas pelos doentes e pelas famílias para tratar os seus problemas de saúde fora das instituições formais. São cada vez mais vistos como meios de melhorar os cuidados clínicos. 55 P A R T E I I . F O R M U L A Ç Ã O D A E S T R A T É G I A Abordagem nacional para a qualidade em vários níveis A responsabilidade da qualidade dos cuidados de saúde está presente em múltiplos níveis hierárquicos em todos os países. De uma forma geral, existem, pelo menos, cinco níveis em que as actividades se realizam e a responsabilização para a qualidade existe (17-19), apesar de poderem ser identificados outros, conforme o contexto específico, por exemplo em países com uma forte gestão do sistema de saúde sub-regional. Na selecção de intervenções, pode efectuar-se um exercício para identificar as funções necessárias por nível do sistema de saúde, contribuindo para a garantia de que as estratégias são abrangentes e apropriadas a nível local. Os cinco níveis podem ser descritos como se segue (Figura 3). • As funções a nível nacional incluem a formulação de políticas, a construção de infraestru- turas, mobilização de recursos e responsabilização perante o público. • A um nível subnacional (região, província, estado), geralmente existem funções de racionalização da política nacional para as necessidades contextuais de uma região, bem como macrogestão e monitorização do desempenho. • Muitas vezes, as comunidades apenas podem agir no interesse colectivo dos doentes e cidadãos individuais ouvindo as suas opiniões, procedendo à governação no seio dos mecanismos da sociedade civil, bem como monitorizando e garantindo a responsabilização. • As entidades institucionais, nomeadamente, hospitais, clínicas e dispensários, são responsá- veis pela boa governação, operações competentes e gestão para fazer face às necessidades dos doentes, famílias e comunidade. • É nos encontros individuais, entre o prestador dos cuidados de saúde e o doente, que os cuidados têm de ser eficazes, seguros e centrados nas pessoas. Algumas funções podem figurar nos vários níveis, por exemplo na agenda da aprendizagem, na liderança e na gestão dos dados. Figura 3. Actividades exemplificativas nos cinco níveis da hierarquia Fonte: Adaptado de Leatherman e Sutherland. • Legislação • Definição de metas nacionais • Regulamentação e Supervisão • Notificação do Desempenho Público • Avaliação Externa • Acreditação • Metas e Normas • Contrato de Desempenho • Avaliação comparativa • Proximidade e Advocacia/suporte • Educação e Sensibilização • Contribuição para o Sistema de Saúde • Liderança e Governação • Incentivos • Funções Tradicionais da GQ • Apoio às Decisões da TI • Contratos de Desempenho • Avaliação Profissional • Educação do Doente • Supervisão • Tomada de Decisão Partilhada Regional/ Estadual Comunidade Nacional Institucional Individual 56 M A N U A L D E P O L Í T I C A S E E S T R A T É G I A S P A R A A Q U A L I D A D E D O S C U I D A D O S D E S A Ú D E A Figura 4 mostra um exemplo de “pirâmide” de todos os níveis de um sistema de cuidados de saúde do projecto mexicano de estratégia nacional para a qualidade, publicado em 2016. O quadro de intervenções pode ser aplicado numa pirâmide destas para demonstrar de que forma as medidas específicas de cada um dos cinco níveis criam uma estratégia abrangente para a qualidade em todo o sistema. Figura 4. Quadro de intervenções em cada nível da hierarquia: México • Vice-ministério para a integração e desenvolvimento • Direcção para a qualidade e educação • Comissão directiva para a qualidade nacional • Centro nacional de excelência tecnológica (CENETEC) • Prémio nacional de qualidade • Regulamento da acreditação de escolas de medicina • Inquéritos nacionais de satisfação da população • Medidas essenciais sobre segurança do doente • Comissões estaduais para a qualidade Comunidade Nacional Institucional Individual Regional/Estadual • Grupos avalizados de cidadãos • Código deontológico para os grupos avalizados de ciddãos • 9 índices compostos por 33 indicadores de qualidade • Sistema de monitorização (INDICAS) • Acreditação de unidades de cuidados de saúde • Comissões hospitalares para a qualidade e segurança do doente • Código deontológico para os hospitais • Inquéritos de satisfação do doente por unidade • Avaliação comparativa da cultura da segurança nas unidades • Comissão da farmácia e terapêutica (INDICAS) • Inquérito à satisfação do doente por grupos avalizados de cidadãos (Aval Ciudadano) • Projectos de gestão da qualidade e investigação em doenças prioritárias • Inquérito de auto-avaliação da estratégia multimodal da OMS e questionário sobre conhecimentos e percepção da higiene das mãos • Sistema de registo de eventos adversos • Direitos do doente • Direitos do médico • Direitos do enfermeiro • Código deontológico para os médicos • Código deontológico para os enfermeiros • Formação em melhoria da qualidade dos cuidados de saúde • Formação em gestão dos executivos de topo dos cuidados de saúde • Certificado de clínico geral • Orientações clínicas • Algoritmos dos cuidados de saúde e doenças prioritárias Resumo: Intervenções para a melhoria Acções para a equipa de formulação da estratégia Conteúdo do documento estratégico • Planear o processo de selecção das intervenções para a melhoria. Tal pode incluir a análise de evidências actuais, o envolvimento das partes interessadas com vista à obtenção de informação sobre a implementação em curso e a utilização de abordagens como a Trilogia de Juran, juntamente com contributos técnicos especializados • Mapear as intervenções segundo as metas e prioridades identificadas, afim de garantir que as acções são orientadas para a sua consecução • Conduzir uma análise pormenorizada das intervenções exemplificativas para verificar se são práticas e exequíveis • Identificar o responsável pela implementação • Esboço das intervenções escolhidas e da forma como elas irão abordar as prioridades identificadas • Descrição pormenorizada das intervenções, nomeadamente, recursos necessários, prazos e responsabilidade pela implementação; pode ser apresentada com maior pormenor num plano operacional Fonte: Estratégia nacional para a qualidade, México, 2016 57 P A R T E I I . F O R M U L A Ç Ã O D A E S T R A T É G I A 7. Sistemas de gestão da informação de saúde e sistemas de dados Os sistemas de informação de saúde são uma componente necessária da transformação da prestação dos serviços de saúde (20), o que, no fundo, é a principal finalidade da estratégia de qualquer país para a qualidade. Nesse sentido, é fundamental um conhecimento consistente em matéria de sistemas de informação para a formulação de uma estratégia para a qualidade. Melhorar a qualidade depende sempre da existência de dados de medição do desempenho claros e precisos, seja a nível individual de médicos e prestadores de cuidados, seja ao nível mais alargado das populações. Assim, a formulação de uma estratégia nacional para a qualidade implicará inevitavelmente a ênfase em sistemas essenciais para a recolha de informação, medição e reporte, bem como a existência de um circuito de feedback. A maioria dos países de todo o mundo, muitos deles de elevado rendimento, admite que as fontes de informação e as métricas dos seus sistemas de informação de saúde não são os ideais. Em contrapartida, também é verdade que existem sempre dados suficientes para, pelo menos, começar. Existem sempre entradas de dados essenciais, de alguma forma e em certa medida, mas a quantidade, qualidade e rigor desses dados varia de acordo com a região geográfica e o nível do sistema de cuidados de saúde; por exemplo, os dados hospitalares são, geralmente, melhores do que os dados dos cuidados de saúde primários. A Caixa 15 fornece exemplos de perguntas que podem ser utilizadas na avaliação das actuais fontes de informação/dados. Caixa 15. Exemplos de perguntas essenciais à avaliação das actuais fontes de informação/dados • Quais são as actuais fontes de informação/dados dos cuidados de saúde (ex.: SGIS, doadores)? • A informação é fiável e completa? • Que métricas estão a ser recolhidas em cada fonte de informação/dados? • Que factores devem ser considerados quando se utilizam os registos clínicos dos doentes (ex.: disponibilidade, fiabilidade)? • Qual o “movimento” da informação/dados (quem os recolhe, para que efeito e para onde são reportados)? • É dado feedback às unidades e aos prestadores individuais? • Existem quadros para as medições? • Quais as normas de cuidados ou protocolos existentes que têm métricas específicas acompanhadas de metas numéricas? O feedback e o reporte de dados estão a evoluir rapidamente no mundo, com expectativas crescentes de transparência e responsabilização por parte do público relativamente aos sistemas de saúde. Dada a complexidade, os custos e o prestígio em causa, na avaliação e notificação dos dados de desempenho, torna-se fundamental definir finalidades e princípios transparentes, tais como (a) principal público a que se destina (por exemplo, reguladores, prestadores, doentes que seriam afectados ou implicados; (b) utilização pretendida (por exemplo, por prestadores para melhorarem os cuidados prestados aos doentes ou por reguladores para avaliarem o cumprimento das normas) e (c) protecção de dados (por exemplo, proteger os prestadores individuais revelados e identificados pelos dados de desempenho, ponderando igualmente a responsabilização do sistema). Combater a escassez de dados, assim como as complexidades dos sistemas de informação de saúde, pode rapidamente sobrecarregar os responsáveis pela formulação e implementação de um sistema de informação capaz de sustentar a estratégia nacional para a qualidade. Os responsáveis políticos e estratégas irão precisar de um considerável contributo técnico nesta 58 M A N U A L D E P O L Í T I C A S E E S T R A T É G I A S P A R A A Q U A L I D A D E D O S C U I D A D O S D E S A Ú D E fase. Dividir a tarefa em partes que sejam geríveis pode ajudar a definir a acção estratégica. Isto implica compreender a situação actual, identificar o estado ideal e depois elaborar um plano que constitua uma ponte entre o estado actual e o futuro estado ideal, no que respeita aos dados e medições nos vários níveis do sistema de cuidados de saúde. Estado actual dos dados e da medição nos vários níveis do sistema de cuidados de saúde O primeiro passo é identificar que informação está a ser recolhida e de que forma pode ser consultada e, sobretudo, que relação entre si (interoperabilidade), para que a qualidade possa ser medida nas diferentes áreas. Por exemplo, são necessárias ligações entre a cadeia de abastecimento, rupturas de stock a nível das unidades e qualidade da prestação de cuidados de saúde. Uma fonte de informação/dados potencial para a monitorização da qualidade são os SGIS de rotina, possíveis sob a forma de um sistema electrónico que pode ser interrogado para ter acesso a uma diversidade de dados nos diferentes níveis do sistema de saúde (por exemplo, o muito utilizado DHIS 2). Outros dados recolhidos por rotina para aferir e identificar lacunas na melhoria da qualidade podem ser os recolhidos em visitas de supervisão ou a informação/ dados financeiros das seguradoras. Outras fontes de informação/dados úteis recolhidos com menor regularidade incluem inquéritos normalizados para aferir a preparação das unidades (por exemplo, avaliação da prestação de serviços, disponibilidade e avaliação da prontidão do serviço, indicadores da prestação de serviços), inquéritos às famílias acerca da cobertura de serviços ou doenças específicas (por exemplo, inquérito de indicadores múltiplos agregados, WASH) ou fontes de informação/dados mais gerais (por exemplo, inquéritos demográficos e de saúde). Para além disso, podem existir sistemas ad hoc de notificação de dados que contribuam para a melhoria da qualidade, por exemplo, os inquéritos locais sobre saúde, que exploram problemas específicos mais detalhadamente. A Caixa 16 resume as várias fontes de informação/medição da qualidade disponíveis na maioria ou totalidade dos países. Caixa 16. Potenciais fontes de informação/medição da qualidade disponíveis em muitos países Registos médicos individuais dos doentes (em papel ou formato electrónico) SGIS de rotina Inquéritos a nível das unidades: • amostra do inquérito normalizado nacional • inquéritos de rotina de supervisão ou monitorização • avaliação externa, inspecção e acreditação Inquéritos às famílias Programas de seguros Questionários dirigidos ao público e aos doentes e análises ou inquéritos electrónicos Registos médicos (nas unidades ou na comunidade) Outros dados recolhidos por rotina, entre eles, avaliações do desempenho e supervisão de apoio Existem, no entanto, áreas em que é frequente faltarem informações/dados nas fontes actuais. Entre elas, a qualidade da experiência e satisfação do doente, a competência do prestador dos cuidados de saúde, a gestão, coordenação e o seguimento entre os postos de prestação de cuidados, a qualidade no sector privado e a qualidade dos cuidados prestados pela comunidade. Trabalhar para garantir que estas áreas são medidas, de forma sistemática, é importante para fortalecer os SGIS, enquanto parte de uma estratégia abrangente para a qualidade. Ao avaliar o estado actual dos sistemas de informação/dados e de medição, importa considerar não apenas que fontes existem, mas também a forma como os dados estão a ser utilizados. 59 P A R T E I I . F O R M U L A Ç Ã O D A E S T R A T É G I A Por exemplo, a que níveis do sistema de saúde os dados são recolhidos e analisados e se existe feedback para o sistema, de forma a possibilitar a mudança de comportamentos, metas, prioridades e medições. É igualmente importante observar se as diversas partes do actual sistema, incluindo os sistemas de informação/dados de cada programa de doenças, são complementares e compatíveis ou se existe uma sobrecarga do sistema provocada por dados contraditórios ou duplicados das diferentes partes interessadas. Definição do que seria o estado “ideal” São cinco as capacidades básicas integradas, de análise e reporte, necessárias no apoio à estratégia nacional para a qualidade: • um sistema nacional hierárquico de recolha de informação, análise e reporte de dados (SGIS); • conjuntos de dados que espelhem o estado da qualidade nos diferentes níveis do sistema de saúde; • apoio à decisão clínica e sistemas de gestão do conhecimento para os profissionais de saúde; • monitorização da qualidade e sistemas de feedback para avaliar o desempenho individual com base em padrões ou metas e dados comparativos para aferição; • reporte com vista à transparência e à responsabilização. As equipas de formulação das estratégias, apoiadas por especialistas em informação e dados, podem identificar requisitos mínimos do sistema de informação em cada uma destas capacidades, cruzando-os com as prioridades identificadas para a estratégia. Elaboração de um plano que estabeleça uma ponte entre o estado actual e o futuro estado ideal Não é preciso esperar pela “reparação” dos sistemas de informação deficientes ou das omnipresentes falhas dos dados. É possível começar com o que está disponível, ao mesmo tempo que se trabalha num plano concreto de longo prazo para a necessária evolução da recolha de informação e análise de dados. Embora os sistemas de informação e dados de saúde actuais, mesmo que limitados, possam servir de base à identificação de prioridades e à formulação da estratégia, há planos que podem ser criados, enquanto parte dessa estratégia, para que um maior reforço do sistema de dados possa colmatar quaisquer lacunas entre as fontes disponíveis à data e as necessárias para a situação ideal. É óbvio que alcançar o estado ideal pode ser um processo complexo e de utilização intensa de recursos e, por isso, poderá ser necessário que esses planos atribuam prioridade à criação de novos sistemas, que serão úteis para uma implementação bem sucedida da estratégia para a qualidade, devendo igualmente determinar quais os recursos necessários. Podem ser privilegiadas as medidas de reforço dos sistemas existentes, ao invés de criar novos processos, bem como aquelas que são fundamentais para apoiar outras intervenções prioritárias salientadas na estratégia (por exemplo, o financiamento baseado no desempenho requer a medição fiável do desempenho do prestador). O maior desafio para muitos países é a existência de demasiados dados de qualidade variável com lacunas na medição de áreas importantes, entre elas, a competência do prestador e a experiência por parte do doente. É premente a necessidade de melhorar a informação/dados (qualidade da informação/ dados) – mais exactos, completos, substanciais e mobilizáveis. Muitos países têm também de trabalhar no sentido de uma melhor identificação e medição de áreas sensíveis, em que a informação não está à data a ser recolhida, reduzindo simultaneamente a carga de informação, deixando de recolher e analisar aqueles que não são utilizados e têm baixa prioridade. 60 M A N U A L D E P O L Í T I C A S E E S T R A T É G I A S P A R A A Q U A L I D A D E D O S C U I D A D O S D E S A Ú D E A apreciação integral dos sistemas de informação/dados existentes e a planificação das melhorias poderão exigir um apoio técnico especializado que esteja para além da capacidade das equipas de preparação da estratégia nacional para a qualidade. Nesta matéria, o papel da estratégia não é o de apresentar um plano pormenorizado para melhorar esses sistemas, mas sim o de garantir que a sua importância é claramente reconhecida e que são dados os primeiros passos no sentido da identificação e resolução de lacunas importantes. Resumo: sistemas de gestão da informação de saúde e sistemas de dados Acções para a equipa de formulação da estratégia Conteúdo do documento estratégico • Elaborar um inventário do estado actual da informação, dos dados e medição nos vários níveis do sistema dos cuidados de saúde • Definir como seria o estado “ideal” • Elaborar um plano que constitua uma ponte entre o estado actual e o futuro estado ideal • Esboço das melhorias necessárias ao sistema de informação/dados e cronograma para a respectiva concretização • Descrição da forma como os actuais sistemas serão usados na medição da qualidade, na monitorização do desempenho dos prestadores e profissionais e no apoio à tomada de decisão. 8. Indicadores de qualidade e medidas essenciais Transpor uma política para a prática requer que os países identifiquem medidas fundamentais em matéria de qualidade, em todos os níveis dos cuidados de saúde e dimensões da qualidade. Todos os países estão actualmente envolvidos na medição de muitas componentes dos seus sistemas de saúde, muitas vezes através da monitorização e avaliação e dos SGIS de rotina, conforme descrito na subsecção 7 supra, e não raramente através de sistemas paralelos desenvolvidos por doadores. Apesar disso, regista-se um reconhecimento crescente da necessidade de harmonização dos indicadores e sistemas, com vista à criação de melhor informação que oriente as políticas, a tomada de decisão e a melhoria dos serviços de saúde. Fazê-lo de forma eficaz exigirá o contributo e a coordenação entre algumas das principais partes interessadas com várias competências. Entre elas, decisores políticos, gestores da saúde, profissionais de saúde, SGIS/TI com equipas de monitorização e avaliação e, de realçar, a comunidade mais alargada de doentes e sociedade civil. Para além disso, é cada vez mais reconhecida a importância de integrar plenamente o sector privado, como forma de garantir que a medição e reporte da qualidade se aplica a todas as populações servidas. Esta secção, que deverá ser lida em articulação com a subsecção 7, apresenta ideias sobre a forma de definir uma direcção estratégica em matéria de medição da qualidade, exemplos de conjuntos de indicadores de qualidade, trabalhos em curso respeitantes à forma de maximizar a utilização dos dados e ponderação de áreas em que é necessário analisar melhor o que importa medir. A medição da qualidade dos cuidados de saúde é um domínio em rápida evolução; instrumentos e recursos estarão constantemente a surgir para incrementar e melhorar a utilidade da recolha, medição e reporte de dados. Uma estratégia abrangente para a qualidade inclui um plano para a sua monitorização, feedback e avaliação global dos progressos que estão a ser feitos rumo às metas nacionais. O objectivo dos indicadores de qualidade nacionais é avaliar os objectivos, através de um conjunto de indicadores específicos, os quais podem ser utilizados para medir o sucesso da própria estratégia e apoiar os esforços, a todos os níveis do sistema dos cuidados de saúde, com vista a empreender acções que visem a monitorização continua e a melhoria. O papel da medição nos esforços nacionais para a qualidade inclui: 61 P A R T E I I . F O R M U L A Ç Ã O D A E S T R A T É G I A • a monitorização para a adesão mediante normas e orientações • feedback aos prestadores sobre as actividades de melhoria da qualidade • transparência e responsabilização perante o público • ponto de referência para compreender o desempenho comparativo • aquisições e contratos estratégicos ou baseados em valores • monitorização da eficácia das intervenções para a qualidade. Uma tarefa primordial de qualquer estratégia nacional para a qualidade é a criação de capacidades de medição e avaliação, o que requer a definição de um quadro nacional para os indicadores da qualidade. A escolha dos indicadores para esse quadro deverá basear-se nas prioridades, necessidades e capacidade existentes no país para a análise de dados. O processo para a criação do quadro varia de país para país. De qualquer modo, indicam-se em baixo uma série de passos importantes que podem contribuir para a criação desse quadro nacional. Análise de indicadores mundiais e periciais e exemplificativos Muitos países debateram-se com a escolha de um conjunto de indicadores que possam ser fiáveis e eficazmente recolhidos, que reflictam o verdadeiro estado da qualidade dos cuidados de saúde e sejam úteis para monitorizar e melhorar essa qualidade. Para apoiar tais esforços, uma série de organizações reuniu grupos de peritos para sugerirem conjuntos de indicadores, incluindo informação acerca da forma de os recolher e analisar. Aceder a estas listas exemplificativas pode ser útil para as equipas de formulação da estratégia nacional para a qualidade, como forma de definir uma linha de rumo relativamente à escolha de indicadores que estejam alinhados com os objectivos e prioridades estabelecidos na estratégia. Outras informações sobre conjuntos exemplificativos de indicadores encontram-se disponíveis em recursos incluídos no compêndio. É provável que sejam desenvolvidos outros conjuntos de indicadores, como resultado dos esforços mundiais em curso para a qualidade dos cuidados de saúde. Catalogação e avaliação dos indicadores de qualidade existentes Para assegurar a melhor utilização possível dos sistemas existentes e o alinhamento com as actuais prioridades nacionais de saúde, é importante catalogar e compreender os indicadores de qualidade existentes e recolhidos nos países, assim como os sistemas de informação/dados que integram estes indicadores ou a partir dos quais os dados são obtidos. É crucial entender se os dados são efectivamente utilizados, o que significa que eles são recolhidos para a medição válida de um indicador, e se existe um circuito de feedback que possibilite a análise, reporte, aprendizagem e introdução de mudanças que melhorem o desempenho. Para compreender o estado actual dos sistemas de dados e indicadores de qualidade, são fundamentais os passos que se seguem: 1. catalogar as diferentes fontes de informação/dados existentes que podem ser utilizadas para os indicadores de qualidade. Entre elas, as fontes de informação/dados dos SGIS, dados dos doadores, registos clínicos, inquéritos aos doentes e relatórios de acreditação; 2. definir que quadros existentes para as métricas e indicadores de qualidade estão a ser utilizados à data; 3. catalogar, em cada fonte de dados, as métricas de qualidade específicas que estão a ser recolhidas à data; 4. classificar os dados, através da avaliação da sua exactidão e da quantidade e qualidade dos mesmos. Uma vez analisado e avaliado o estado actual dos sistemas de informação/dados e indicadores de qualidade, pode elaborar-se um quadro novo ou revisto que corresponda à estratégia nacional para a qualidade. Ao construir um quadro nacional para medidas de qualidade, enquanto parte da estratégia nacional, recomenda-se que as métricas da qualidade existentes sejam utilizadas tanto 62 M A N U A L D E P O L Í T I C A S E E S T R A T É G I A S P A R A A Q U A L I D A D E D O S C U I D A D O S D E S A Ú D E quanto possível, para o melhor alinhamento possível com os actuais sistemas de notificação e para a redução ou minimização da quantidade de dados. Na Caixa 17, apresentam-se 10 critérios de apoio a este processo, os quais podem ser usados para dar prioridade aos indicadores de qualidade existentes ou para medidas a incluir num quadro nacional de indicadores de qualidade. Caixa 17. Dez critérios para a avaliação de um conjunto essencial de indicadores de qualidade Prioridade de saúde - O indicador mede uma prioridade de saúde específica? Extensão do impacto - Qual a extensão do impacto da medição deste indicador (ex.: resulta- dos clínicos de toda a população)? Base de evidência - Existe evidência credível e suficiente para este indicador ser consensual? Defensibilidade - Este indicador é defensável tanto numa perspectiva científica como naquela que os decisores políticos consideram importante? Exequibilidade - O que é exequível, considerando os dados já recolhidos? Que grau de facili- dade teria a sua implementação? Exactidão - Os dados recolhidos através deste indicador são exactos? Accionabilidade - São possíveis medidas claras e mudanças no comportamento individual, institucional ou sistémico, quando observado este indicador? Comparabilidade - Este indicador pode ser comparado com um padrão ideal ou com outros países, ou entre regiões? Credibilidade - O indicador é credível para aqueles que precisam de tomar medidas e para aqueles cujo desempenho está a ser medido e comparado? Clareza - O indicador é descrito em termos claros e inequívocos? Quadros conceptuais para a selecção dos indicadores de qualidade Para apoiar a criação de um quadro abrangente de medição da qualidade, existem várias formas de conceptualizar essa medição em todo o sistema de saúde. Entre elas: • dimensões da qualidade: por exemplo, as que constam da secção de definições deste manual ou um conjunto de domínios definidos localmente; • estrutura/processo/resultado: as três áreas de Donabedian - estrutura (incluindo os sistemas), processo e resultados (de saúde e da experiência e satisfação do doente) (21); • organização do sistema de saúde: incluindo os níveis dos cuidados de saúde (primários, secundários e terciários), estruturas de gestão (ao nível das unidades, distrital, nacional, etc.) e o ciclo dos cuidados (da promoção da saúde aos cuidados paliativos); • grupos de doenças e populações: causas significativas dos fardos das doenças e principais populações afectadas. As equipas de formulação da estratégia podem ponderar estes quadros conceptuais na identi- ficação dos aspectos que devem ser considerados num quadro de medição da qualidade. Pode, depois, realizar-se um exercício de mapeamento para atribuir a cada componente as medidas adequadas de entre as listas exemplificativas e conjuntos de indicadores nacionais existentes, identificando quaisquer lacunas que tenham de ser colmatadas pelas medidas recém-criadas. 63 P A R T E I I . F O R M U L A Ç Ã O D A E S T R A T É G I A Resumo: indicadores de qualidade e medidas essenciais Acções para a equipa de formulação da estratégia Conteúdo do documento estratégico • Analisar as listas exemplificativas de indicadores definidos por peritos e existentes noutros países • Catalogar e avaliar os indicadores de qualidade nacionais disponíveis • Definir as etapas principais na elaboração de um quadro nacional de medição da qualidade • Mapear as medidas de qualidade disponíveis e sugeridas face ao quadro e planear a criação de medidas específicas para colmatar as lacunas • Esboço do quadro nacional para a medição da qualidade • Plano para a monitorização, avaliação e responsabilização • Medidas aperfeiçoadas, através de teste de um conjunto preliminar e promovendo acções para colmatar as lacunas nas capacidades de medição ELABORAÇÃO DE UM PLANO OPERACIONAL PARA A IMPLEMENTAÇÃO As estratégias nacionais para a qualidade podem ser complementadas com planos operacionais que indiquem exactamente as medidas práticas, os recursos, as responsabilidades e o calendário para a implementação da estratégia. O seu desenvolvimento recorrerá aos mesmos processos utilizados nos domínios dos oito elementos da PENQ, centrando-se na forma como serão implementadas as medidas identificadas. Visão geral e fundamentação Formular a política para a qualidade e depois conceber uma estratégia nacional para a qualidade é uma atividade complexa. O plano operacional define etapas e tarefas precisas que têm de ser empreendidas, clarifica os papéis e as responsabilidades, fixa prazos precisos e atende a considerações de carácter financeiro ou relativas a recursos. Cada país decidirá a calendarização adequada para o plano operacional, optando frequentemente por uma outra classificação e pelo planeamento a curto prazo versus medidas a mais longo prazo e identificando etapas decisivas. Um plano operacional pode ser uma ajuda significativa na divulgação e execução da estratégia e uma garantia de que o documento não é simplesmente “posto na prateleira”. Pode também ajudar a traduzir a estratégia nacional em planos operacionais subnacionais para promover a disseminação para todo o sistema, sublinhando a necessidade de ligações estreitas entre os planos nacionais e subnacionais. Enquanto a estratégia em si visa promover a coesão entre as partes interessadas do sistema de saúde, alinhar metas e prioridades para a qualidade e identificar as principais alavancas para atingir essas metas, o plano operacional age a um nível mais profundo, definindo explicitamente tarefas, papéis, calendários e considerações financeiras. O compêndio de instrumentos anexo contém um modelo de plano operacional. Quando e como deve ser elaborado o plano operacional? Um plano operacional é, normalmente, desenvolvido após a ratificação formal do documento político e estratégico pela estrutura responsável (direcção, unidade ou grupo de trabalho) pela qualidade e melhoria da qualidade. Os países podem ter já o seu próprio processo para a elaboração de planos operacionais. Normalmente, trata-se de um plano anual que corresponde ao ciclo de planeamento financeiro do país. A um nível mais elevado, um plano operacional que apoia a orientação nacional para a qualidade deve começar com os objectivos e metas globais estabelecidos pela política e estratégia. Os elementos a considerar no plano operacional incluem: (a) por onde começar (por exemplo, há que começar por determinados testes ou testes piloto em 64 M A N U A L D E P O L Í T I C A S E E S T R A T É G I A S P A R A A Q U A L I D A D E D O S C U I D A D O S D E S A Ú D E localizações geográficas específicas?); (b) nível do sistema de saúde (por exemplo, começar com iniciativas nacionais versus iniciativas regionais, estaduais, ou locais); e (c) calendarizar e planificar a disseminação e expansão por todo o país. A colaboração e a adesão a todos os níveis do sistema de saúde são decisivas na elaboração de um plano operacional. As acções específicas empreendidas serão difundidas a nível nacional, regional, distrital, das comunidades e das unidades de saúde. Que elementos devem integrar o plano operacional? A um nível mais elevado, o plano operacional deve dar resposta às questões que se seguem, as quais respeitam os objectivos e metas globais da estratégia nacional para a qualidade. • Que tarefas e medidas devem ser implementadas? • Como devem ser estabelecidas as prioridades das tarefas e medidas, caso os recursos disponíveis sejam limitados? • Quem são as pessoas responsáveis por cada uma dessas tarefas e medidas? • Quais os prazos para a conclusão dessas tarefas e medidas? • Que quantidade e tipo de recursos têm de ser disponibilizados para a conclusão de cada uma dessas tarefas ou medidas? • Que medidas de desempenho específicas devem ser recolhidas (por exemplo, trimestralmente) durante todo o plano operacional para avaliar o seu sucesso e efetividade? No âmbito do plano operacional, a prioridade a estabelecer para as tarefas e medidas pode basear-se nas intervenções indicadas no documento da política e estratégia para a qualidade e no profundo conhecimento do estado actual da qualidade, assim como nos activos existentes a que se possa recorrer. Embora possa diferir de país para país, em termos gerais, um plano operacional estende-se por um período de um a dois anos. INTEGRAÇÃO DE PROGRAMAS TÉCNICOS NA PENQ Em última análise, qualquer estratégia nacional para a qualidade centra-se na obtenção de melhores resultados na área da saúde e na melhoria do desempenho do sistema de saúde, em dimensões da qualidade, tais como a eficiência, segurança, atenção no doente, prontidão, efetividade e equidade. A prossecução destes objectivos requer a elaboração de políticas necessárias à criação de um ambiente propício à abordagem de lacunas no sistema de prestação de serviços e à integração dos esforços de melhoria e medição de programas de saúde específicos, para determinadas doenças e/ou populações, que existem em todos os países, também conhecidos por programas verticais ou técnicos. Uma estratégia nacional para a qualidade tem de abranger e incluir todas as populações e necessidades de cuidados de saúde, embora as prioridades sejam inevitavelmente identificadas. Integrar intencionalmente programas técnicos e específicos das doenças permite à estratégia nacional tirar partido dos já existentes pontos fortes e capacidades dos programas técnicos relacionados com a qualidade, garantindo também que esses programas não serão deixados a funcionar fora da estratégia nacional. Para além disso, a integração dos programas técnicos pode reforçar o compromisso com as organizações de doadores, possibilitar soluções locais com provas dadas, que contribuirão para a estratégia mais alargada, e conduzir a ganhos de eficiência na utilização de recursos limitados. Para os programas técnicos também pode haver vantagens significativas, nomeadamente, o potencial para a intensificação de esforços através de um programa nacional, ganhos a nível da eficiência no acesso a infraestruturas nacionais de saúde e melhoria dos resultados do programa, graças a um sistema mais forte. Quer considerando programas de longa data, como o da saúde materna e infantil, quer iniciativas apoiadas por doadores, como os programas do VIH, os programas técnicos podem 65 P A R T E I I . F O R M U L A Ç Ã O D A E S T R A T É G I A simultaneamente abordar as melhores formas de organizar e prestar serviços de saúde individuais e melhorar e medir sistematicamente a saúde da população. Estes programas, sobretudo em países de baixo e médio rendimento, têm muitas vezes instaladas capacidades básicas relacionadas com a qualidade, mesmo antes de as estratégias nacionais para a qualidade terem sido desenvolvidas formalmente. Alguns exemplos dessas capacidades são: orientações e normas, percursos dos doentes, monitorização contínua dos resultados decorrentes da prestação de cuidados aos doentes e utilização de rotina de indicadores de qualidade e segurança. A integração dos programas técnicos é, necessariamente, um processo de dois sentidos: as estratégias nacionais para a qualidade têm de ser responsáveis pelas actividades, activos e aprendizagem dos programas técnicos existentes, enquanto que os programas técnicos existentes devem esforçar-se para se ajustarem aos processos e prioridades nacionais para a qualidade. Existe claramente um grande potencial de variação nos níveis de integração dos programas técnicos nas estratégias nacionais para a qualidade. Entre as opções para a integração, contam- se as seguintes: • O programa técnico é totalmente incorporado na estratégia nacional para a qualidade. Isto garante o máximo alinhamento mas, provavelmente, é apenas possível para os actuais programas geridos pelo governo, cujo principal foco é a qualidade dos cuidados (por exemplo, pode existir um esforço nacional no domínio da saúde materna e infantil, facilmente integrável num esforço ao nível de todo o sistema, sem grandes perturbações). • Os programas técnicos podem funcionar como “guias” para as estratégias nacionais para a qualidade. Neste cenário, os programas técnicos específicos podem ser utilizados no início ou no lançamento experimental da estratégia, para possibilitar ensaios de campo rápidos e a sua expansão, recorrendo a programas equipados com bons recursos. Nestas circunstâncias, há que assegurar que a estratégia não é dominada por uma única área técnica e que os benefícios abarcam todo o sistema. • A estratégia nacional para a qualidade e os programas técnicos podem ser explicitamente ligados ao nível estratégico. Neste cenário, os programas técnicos mantêm a respectiva autonomia operacional, mas existe planeamento estratégico conjunto para garantir a utilização eficaz dos recursos e a persecução de objectivos comuns. Esperar-se-ia dos programas técnicos que referenciassem e subscrevessem, explicitamente, a estratégia nacional para a qualidade em futuros processos de planeamento. • Os programas existentes são reconhecidos e são delineados planos para uma futura integração. Dadas a complexidade da integração de vários programas, um primeiro passo concreto será a estratégia nacional para a qualidade examinar e reconhecer programas técnicos relevantes, para garantir que não existe duplicação de esforços ou domínios de divergência relativamente a objectivos e actividades. Os programas técnicos seriam incentivados a alinhar, gradualmente, com a estratégia nacional para a qualidade e a estratégia poderia ela própria conter actividades concretas para o planeamento e operacionalização da integração. O tipo de integração pode variar de um país para o outro e entre programas técnicos, mas alguns dos possíveis passos iniciais da equipa de formulação da estratégia são os seguintes: • identificação de programas técnicos e verticais importantes, enquanto parte da análise da situação e do mapeamento das partes interessadas; • envolvimento inicial, por parte dos parceiros da implementação relevantes, incluindo consultas com os programas técnicos sobre a forma de incrementar a aplicabilidade da estratégia para a qualidade, avaliação das capacidades dos programas para apoiar a estratégia de implementação e debate acerca das opções de integração; • mapeamento das áreas de sobreposição ou divergência entre a proposta de estratégia nacional para a qualidade e os objectivos e actividades dos programas técnicos; 66 M A N U A L D E P O L Í T I C A S E E S T R A T É G I A S P A R A A Q U A L I D A D E D O S C U I D A D O S D E S A Ú D E • contribuição de conhecimentos especializados e saberes técnicos em matéria de qualidade por parte do programa técnico para uma estratégia nacional para a qualidade recém- emergente ou ainda em evolução; • integração de dados e sistemas de medição do programa técnico no quadro nacional de medição e nos sistemas de dados para a qualidade; • garantia da troca de aprendizagens entre os esforços para a qualidade nos diferentes programas técnicos, através da supervisão estratégica gerada pela motivação nacional para a qualidade global; • elaboração de um plano para o alinhamento e integração, incluindo um programa conjunto de trabalho, análise de desafios e oportunidades orçamentais ou um calendário para novas discussões. PARTE ΙΙΙ INSTRUMENTOS E RECURSOS 68 M A N U A L D E P O L Í T I C A S E E S T R A T É G I A S P A R A A Q U A L I D A D E D O S C U I D A D O S D E S A Ú D E Antecedentes O presente manual oferece um panorâma geral dos antecedentes, fundamentos e processo dos esforços desenvolvidos para formular uma política e estratégia para a qualidade dos cuidados de saúde, assim como sugestões de conteúdo dos documentos que delineiam tais políticas e estratégias. Pôr este processo em marcha carecerá de uma reflexão mais aprofundada de cada elemento. Para além disso, as necessidades, prioridades, capacidades, recursos e procedimentos para a formulação de políticas e estratégias diferem de país para país; será necessariamente diferente o apoio exigido por cada etapa do processo. A análise aprofundada de cada elemento do processo da PENQ pode ser apoiada por uma série de diferentes meios, nomeadamente, através do envolvimento de peritos externos ou da mobilização de outros instrumentos e recursos. Entre os recursos que poderão apoiar as equipas de formulação de políticas e estratégias nacionais para a qualidade contam-se estudos de casos nacionais, documentos com orientações mundiais produzidos pela OMS e outras organizações internacionais, revisões da literatura e instrumentos específicos, que podem ser adaptados e utilizados para recolher dados e desencadear e enriquecer o debate. A OMS, as organizações técnicas, as instituições académicas e os próprios países criaram diversos recursos desta ordem, muitos dos quais são publicados sem restrições de utilização e consulta, ou seja de livre acesso. Embora alguns sejam específicos da qualidade dos cuidados de saúde, outros serão mais genéricos, mas ainda assim importantes para o processo, como é o caso dos instrumentos para efectuar análises da situação ou avaliar os sistemas de informação de saúde. Esta secção do manual não apresenta instrumentos e recursos para utilização directa, dado que muitos destes ocupam inúmeras páginas e constam de documentos já publicados. Em vez disso, destaca-se aqui a forma como os instrumentos e recursos podem ser selecionados, acedidos e utilizados no apoio ao processo da PENQ, apresentando-se um resumo geral do compêndio de instrumentos e recursos, disponível para ser utilizado em conjunto com o manual. O compêndio de instrumentos e recursos anexo é um documento mais pormenorizado com uma panorâmica global dos instrumentos e recursos que podem apoiar o processo da PENQ. O acesso, quer ao próprio compêndio, quer aos instrumentos e recursos, far-se-á através de um repositório no Laboratório Mundial de Aprendizagem da OMS. Encontrar, seleccionar e utilizar instrumentos de apoio ao processo da PENQ Embora o compêndio que acompanha este manual forneça uma selecção de instrumentos e recursos para aspectos prioritários do processo da PENQ, que será ampliada no futuro, ele não pretende apresentar uma lista exaustiva de todos os produtos relevantes. Em muitos casos, as pessoas que estão a formular políticas e estratégias nacionais para a qualidade podem considerá-lo útil para procurar, adaptar ou desenvolver outros instrumentos específicos para as necessidades do processo das suas PENQ, nomeadamente, os que respeitam a um elemento específico ou área técnica da PENQ, ou os que estão disponíveis em línguas locais. Este exercício não tem, necessariamente, de ser um processo complicado ou metodologicamente rigoroso e pode ser feito de forma relativamente rápida, sendo o objectivo acompanhar o processo na sua globalidade, ao invés de acrescentar um fardo desnecessário. A Caixa 18 enumera algumas fontes potenciais de instrumentos e recursos. 69 P A R T E Ι Ι Ι . I N S T R U M E N T O S E R E C U R S O S Caixa 18. Potenciais fontes de instrumentos e recursos • Compêndio de instrumentos e recursos para as PENQ • Literatura académica e científica • Website da Organização Mundial da Saúde • Organizações técnicas especializadas (website ou contacto directo) • Instituições académicas • Organismos profissionais • Outras equipas de formulação de políticas e estratégias para a saúde • Documentos para as PENQ disponíveis noutros países Apontam-se em seguida as etapas sugeridas para a identificação de instrumentos suplementares: 1. Identificar os elementos da PENQ que requerem um contributo mais aprofundado. Dado que cada país terá diferentes prioridades no seu trabalho para a formulação de PENQ, também as suas necessidades em termos de instrumentos adicionais serão diferentes. Muitas vezes, haverá competência e experiência suficientes no seio das equipas de formulação de políticas e estratégias, ou no grupo mais alargado de partes interessadas, para executar os diferentes elementos referidos neste manual, mas poderá tornar-se óbvio, logo no início do processo de formulação de políticas e estratégias, que alguns elementos exigirão um trabalho mais aprofundado. A utilização de instrumentos suplementares para o processo de formulação das PENQ deve ocorrer apenas quando eles forem complementares, uma vez que o processo não deve ser demasiado complexo. 2. Formular e implementar uma estratégia de pesquisa. É algo que exigirá a identificação de potenciais repositórios de instrumentos já existentes (ver Caixa 18). Enquanto alguns deles serão disponibilizados publicamente na Internet, outros serão encontrados apenas no contacto directo com as organizações que os detêm. Pode ser útil verificar se terão sido desenvolvidos instrumentos semelhantes, localmente, para apoiar outros processos de formulação de políticas e estratégias; por exemplo, muitos planos nacionais estratégicos para a saúde foram desenvolvidos após consulta às partes interessadas e análises exaustivas da situação. Nalguns casos, tanto os instrumentos como os resultados podem estar disponíveis e ser utilizados. Em matéria de pesquisas na Internet, a menos que se trate especificamente de pesquisa de literatura académica, é normalmente recomendável pesquisar directamente nas páginas electrónicas das principais agências técnicas e outras instituições de relevo e efectuar pesquisas mais alargadas em motores de busca de referência, em vez de bases de dados académicas. Regra geral, é preferível utilizar um conjunto específico de termos de busca para que a pesquisa não gere demasiados resultados que depois dificultam a seleção e análise. Funcionalidades como a Google Advanced Search (https://www.google.co.uk/advanced_search) permitem ao utilizador pesquisar termos específicos em qualquer website, por exemplo, procurar “análise da situação” em todas as páginas da OMS. 3. Critérios de selecção. Se forem localizados instrumentos importantes, eles devem ser avaliados para garantir que estão à altura da sua finalidade e que serão um valor acrescentado para o processo da PENQ. Os critérios deverão ser decididos pelos grupos locais, mas deverão contemplar a fiabilidade da fonte, aplicabilidade ao contexto local e facilidade de utilização. Por vezes, pode ocorrer uma necessidade identificada de um maior apoio a uma determinada componente do processo da PENQ, não contemplada pelos instrumentos e recursos existentes disponíveis. Por exemplo, os países podem querer levar a cabo uma análise da situação aprofundada, numa área prioritária importante, para a qual não existe um instrumento de recolha de dados. Nestas circunstâncias, pode ser necessário criar um instrumento à medida para apoiar o 70 M A N U A L D E P O L Í T I C A S E E S T R A T É G I A S P A R A A Q U A L I D A D E D O S C U I D A D O S D E S A Ú D E processo. Mais uma vez, a questão fundamental aqui é saber se o esforço exigido é proporcional aos ganhos para o processo da PENQ, ou se existe uma forma mais adequada de apoiar aquela componente específica. Os novos instrumentos devem ser sempre desenvolvidos e utilizados com cautela, já que os instrumentos não ensaiados podem não prestar o devido apoio e até representar desafios de ordem metodológica. Será mais comum existir um instrumento relevante que possa ser adaptado para utilização local. Isto pode envolver, por exemplo, a tradução dos instrumentos para as línguas locais ou a selecção de perguntas de inquérito experimentadas e testadas de um instrumento mais extenso de recolha de dados. Se forem desenvolvidos instrumentos novos ou adaptados, como parte do processo da PENQ num determinado país, os proprietários destes instrumentos são incentivados a partilhá-los através do Laboratório Mundial de Aprendizagem da OMS (LMA) para a Cobertura Universal de Saúde de Qualidade. Ao utilizar instrumentos suplementares de apoio ao processo da PENQ, é importante começar por identificar os recursos necessários à implementação do instrumento e ponderar relativamente ao benefício previsto. Os recursos exigidos podem ser em termos de encargos financeiros e tempo necessário para implementar o instrumento (por exemplo, pequenos inquéritos não generalizáveis das unidades de saúde, para fomentar o debate, versus inquéritos extensos ao sistema de saúde e estatisticamente válidos), ou podem ser relativos às capacidades necessárias para a implementação dos instrumentos (por exemplo, se existem os conhecimentos necessários em matéria de envolvimento das partes interessadas e das comunidades). Compêndio de instrumentos e recursos É evidente que já existe uma série de instrumentos e recursos importantes, da OMS, parceiros externos e dos próprios países, sendo normalmente livre o acesso à sua utilização. Apesar disso, o envolvimento inicial dos países na iniciativa da PENQ da OMS tem mostrado que existe ainda uma necessidade não satisfeita de instrumentos e recursos em algumas áreas do processo de formulação de políticas e estratégias; isto pode dever-se ao facto de que tais instrumentos não existem ou que a sua identificação e acesso não são fáceis, ou não terem qualidade suficiente para serem utilizados. Tendo isto em conta, o manual da PENQ está estreitamente ligado com o LMA da OMS, visando criar um espaço seguro para a partilha de conhecimento, experiências e ideias, questionar opiniões e abordagens e criar inovação para a qualidade no âmbito da cobertura universal de saúde. No contexto do LMA, foi criado um módulo de aprendizagem específico da PENQ para facilitar a partilha de experiências entre países e servir de recurso imediato em matéria de instrumentos relevantes disponíveis para a PENQ. Encontra-se disponível no LMA da OMS um compêndio de instrumentos e recursos, que é um documento de acompanhamento do presente manual. O compêndio fornece uma resenha dos instrumentos e recursos que têm sido identificados como úteis no apoio ao processo da PENQ e os instrumentos nele identificados podem ser acedidos, quer através da hiperligação directa do compêndio, quer no próprio LMA da OMS. Este compêndio engloba instrumentos e recursos que, na sua maioria, já foram produzidos e publicados pela OMS e organizações externas e foram ampliados com instrumentos criados de raiz para colmatar lacunas críticas, bem como com outros instrumentos e exemplos específicos dos países. O compêndio não pretende ser uma lista exaustiva de todos os instrumentos e recursos que podem apoiar o processo da PENQ, mas antes um conjunto prático de uma série de instrumentos de especial importância, destinado a responder às necessidades dos países. O compêndio configura-se como documento vivo a ser actualizado, à medida que mais instrumentos são identificados e desenvolvidos e mais países avançam na formulação das suas políticas e estratégias nacionais para a qualidade. De seguida apresenta-se uma breve panorâmica da abordagem adoptada na criação da versão 1 do compêndio. 71 P A R T E Ι Ι Ι . I N S T R U M E N T O S E R E C U R S O S 1. Uma reunião da OMS (Junho de 2017) sobre a PENQ, envolvendo lideranças nacionais para a qualidade de oito países, permitiu a análise conjunta dos instrumentos e recursos desejáveis para apoiar a PENQ, resultando numa selecção inicial de categorias de instrumentos e recursos prioritários, destinada a reflectir os elementos do processo da PENQ que necessitariam de um contributo mais detalhado. Isto foi feito com base numa análise do manual e em consultas aos países participantes da fase inicial do processo de co-formulação. 2. Foram realizados exercícios de definição do âmbito para cada uma das categorias prioritárias. Os referidos exercícios foram diferentes de categoria para categoria, mas de uma forma geral incluíram a definição de critérios de pesquisa, procura de fontes publicamente disponíveis e articulação com países parceiros, se necessário. 3. A selecção de instrumentos e recursos foi conduzida com base no consenso da equipa da PENQ, com incidência no valor acrescentado para o processo da PENQ e na aplicabilidade a nível dos países. Os instrumentos e recursos identificados estão listados no compêndio relativamente a cada uma das referidas categorias, juntamente com indicações sobre o modo de os consultar e uma descrição da forma como podem contribuir para o processo da PENQ, como mostra a Figura 5. Figura 5. Instrumentos e recursos: fontes e relevância para o processo da PENQ Recurso Acesso (ligação da net ou LMA) Instituição/ autor & ano Forma de apoio ao processo da PENQ deste instrumento/ recurso Instrumento para a análise da situação da PENQ Disponível no módulo de aprendizagem da PENQ no Laboratório Mundial de Aprendizagem da OMS para a CUS de Qualidade Equipa da PENQ da OMS de 2017 Metodologia para a avaliação global das políticas de saúde de determinado país Será mantido um maior envolvimento com os países e outros parceiros com vista à identificação e criação de instrumentos que supram lacunas importantes e expandam os recursos segundo as necessidades do país. De realçar a necessidade, identificada na reunião de Junho de 2017, de desenvolver mais instrumentos e recursos de apoio aos esforços nacionais de defesa em prol da qualidade, bem como de integração de áreas técnicas específicas, prevendo-se que esta e outras categorias emergentes sejam abordadas em futuras interações. Adesão ao LMA da OMS As indicações sobre como aderir ao Laboratório Mundial de Aprendizagem da OMS para a Cobertura Universal de Saúde de Qualidade, no qual se pode aceder ao compêndio e instrumentos associados, estão disponíveis em: http://www.who.int/servicedeliverysafety/areas/qhc/gll/en/ index3.html. Nome do Instrumento, recurso ou exemplo Ligação da net directa, descrição da forma de aceder, ou encaminhamento para o Laboratório Mundial de Aprendizagem da OMS Organização, país ou autor, bem como ano em que foi criado ou actualizado Breve descrição do recurso e da forma como poderá ser utilizado no apoio ao processo da PENQ 72 M A N U A L D E P O L Í T I C A S E E S T R A T É G I A S P A R A A Q U A L I D A D E D O S C U I D A D O S D E S A Ú D E GLOSSÁRIO Termo Definição Acesso (a serviços de saúde) Percepção e experiências das pessoas relativamente à facilidade no acesso aos serviços de saúde ou unidades de saúde em termos de localização, tempo e abordagem (22). Acreditação Processo formal através do qual um organismo de referência, geralmente uma organização não governamental, avalia e reconhece que uma organização de saúde satisfaz normas aplicáveis, pré-determinadas e publicadas. As normas de acreditação são, normalmente, tidas como as melhores e mais exequíveis e são concebidas para incentivar os constantes esforços de melhoria das organizações acreditadas. A decisão de acreditação de uma determinada organização de cuidados de saúde é tomada após uma avaliação periódica, efectuada por um grupo de avaliadores, em geral a cada dois ou três anos. A acreditação é, geralmente, um processo em que as organizações escolhem participar voluntariamente e não por ser exigido por lei ou regulamentos (23). Avaliação do desempenho Apreciação da prestação de um trabalhador ou estagiário, da área da saúde, segundo as normas publicadas. Classificação Processo formal de avaliação de um processo ou sistema, preferencialmente quantitativa, sendo por vezes necessariamente qualitativa (24). Avaliação comparativa (i) Medição ou ponto de referência no início de uma actividade que é utilizada para comparação com medições subsequentes da mesma variável; (ii) padrão aceitável em avaliação (24). Dados Factos e números como matéria-prima, por analisar (25). Equidade na saúde (i) Ausência de diferenças sistemáticas ou potencialmente sanáveis em matéria de estatuto de saúde, acesso aos cuidados de saúde e ambientes favoráveis à saúde e tratamento numa ou mais vertentes da saúde entre as populações ou grupos populacionais definidos socialmente, economicamente, demograficamente ou geograficamente de cada país ou entre países; (ii) medida do grau de capacidade das políticas de saúde distribuírem o bem-estar de forma justa (26-29). Avaliação Apreciação sistemática e objectiva da relevância, adequação, progressos, efetividade, eficiência e impacto de um plano de acção, relativamente aos objectivos e tendo em conta os recursos e as unidades que foram implantadas (30). Fragmentação (dos serviços de saúde) (i) Coexistência de secções, unidades ou programas que não estão integrados na rede de cuidados de saúde (31); (ii) serviços que não cobrem toda a linha de serviços de promoção, prevenção, diagnóstico, tratamento, reabilitação e cuidados paliativos; iii) serviços nos diferentes níveis de cuidados que não estão coordenados entre si; (iv) serviços que não se mantêm com o passar do tempo; (v) serviços que não vão de encontro às necessidades das pessoas (25). 73 G L O S S Á R I O Saúde Estado de total bem-estar físico, mental e social e não meramente a ausência de doença ou enfermidade (25, 32). Serviço de saúde Qualquer serviço (i.e., não apenas serviços médicos ou clínicos) que visa contribuir para a melhoria do estado de saúde ou para o diagnóstico, tratamento e reabilitação de pessoas doentes (30). Sistema de saúde (i) Todas as actvidades cuja função primordial é promover, restabelecer e/ou manter a saúde (25); (ii) pessoas, instituições e recursos, organizados em conjunto de acordo com políticas definidas, para melhorar a saúde da população que servem, respondendo simultaneamente às legítimas expectativas das pessoas e protegendo-as dos custos da saúde precária através de uma série de actividades cuja primeira finalidade é melhorar a saúde (31). Elementos de base do sistema de saúde Quadro analítico utilizado pela OMS para descrever os sistemas de saúde, desagregando-os em seis componentes centrais: liderança e governação (administração), prestação de serviços, pessoal da saúde, sistema de informação de saúde, produtos médicos, vacinas, tecnologias e financiamento do sistema de saúde (33). Desempenho do sistema de saúde (i) Grau de consecução do sistema de saúde em relação aos recursos (33); (ii) grau de cumprimento das funções de um sistema de saúde (provisão de serviços, geração de recursos, financiamento e administração) para atingir os seus objectivos (34). Reforço dos sistemas de saúde (i) Processo de identificação e introdução de mudanças nas políticas e práticas de um sistema de saúde de um país, para que ele possa responder melhor aos desafios de saúde e do próprio sistema (35); (ii) qualquer série de iniciativas e estratégias que promovam uma ou mais funções do sistema de saúde e que conduzam ao melhoramento da saúde através de progressos no acesso, cobertura, qualidade ou eficiência (36). Prevenção e controlo da infecção Abordagem científica e solução prática destinada a prevenir os danos causados por uma infecção na saúde dos doentes e trabalhadores da saúde (37). Contributo Volume quantificado de um recurso investido num processo (25). Alavanca Mecanismos que as autoridades supervisoras (a qualquer nível do sistema de saúde) podem utilizar para promover ou reforçar a adesão a uma política ou estratégia, quando se trata da sua implementação. Normalmente estão relacionadas com os procedimentos que podem recompensar ou sancionar indivíduos ou organizações, de acordo com a sua responsabilidade na implementação; por exemplo, a legislação para fazer cumprir aspectos da política pode ser tida como uma alavanca, como também o pode ser a inclusão de medidas de adesão à política na supervisão dos trabalhadores da saúde ou nos processos de progressão na carreira. 74 M A N U A L D E P O L Í T I C A S E E S T R A T É G I A S P A R A A Q U A L I D A D E D O S C U I D A D O S D E S A Ú D E Qualificação Processo através do qual uma autoridade governamental dá permissão a um profissional individual ou a uma organização de cuidados de saúde para operar ou exercer uma ocupação ou profissão. As disposições para qualificação são normalmente estabelecidas para garantir que uma organização ou individuo cumpre os requisitos mínimos para a protecção da saúde e segurança pública. Geralmente, a qualificação dos indivíduos é atribuída após alguma forma de exame ou prova de frequência escolar e pode ser renovada periodicamente através do pagamento de uma taxa ou certificado de formação contínua ou competência profissional. A qualificação das organizações é conferida após inspecção ao local, afim de determinar se foram observadas as normas mínimas de saúde e segurança (25). Monitorização Acompanhamento permanente de uma actividade para contribuir para a sua supervisão e para verificar se se desenrola conforme planeado. A monitorização envolve a especificação dos métodos de medição da actividade, utilização de recursos e resposta aos serviços segundo critérios acordados (30). Plano operacional Plano centrado na gestão eficaz dos recursos com um quadro a curto prazo, na conversão de objectivos em metas e actividades e nas medidas para a monitorização da implementação e utilização de recursos. Os significados específicos incluem (i) a tradução do plano estratégico nacional no espaço de um ano; (ii) a tradução do plano estratégico nacional num plano subnacional, ex., um plano distrital, normalmente num período de tempo menor do que o do plano estratégico nacional; (iii) um subtipo do plano estratégico nacional, limitado a um determinado programa (25). Resultados Aspectos da saúde que resultam das intervenções disponibilizadas pelo sistema de saúde, as unidades e os funcionários que as recomendaram e as acções dos que são alvo das intervenções (22). Produção Quantidade e qualidade das actividades concretizadas pelo programa (25). Apropriação Liderança e coordenação eficazes por parte dos países relativamente às suas políticas, estratégias e medidas para o desenvolvimento (25). Segurança do doente Ausência de danos passíveis de prevenção causados ao doente durante o processo de cuidados de saúde. A disciplina da segurança do doente é o esforço coordenado para evitar que os danos resultantes do próprio processo da prestação de cuidados ocorram nos doentes. (38). Serviços de saúde centrados nas pessoas “Abordagem aos cuidados de saúde que adopta conscientemente as perspectivas dos indivíduos, das famílias e comunidades e vê-os como participantes e, simultaneamente, beneficiários de sistemas de saúde de confiança que respondem às suas necessidades e preferências de forma humanitária e holística. Os cuidados centrados nas pessoas requerem que lhes seja dada a informação e o apoio de que precisam para tomar decisões e participar nos seus próprios cuidados. Organizam-se em torno das necessidades e expectativas das pessoas em termos de saúde e não das doenças.” (39). 75 G L O S S Á R I O Pagamento baseado no desempenho; financiamento baseado no desempenho Pagamento ou financiamento condicionado à tomada de uma medida mensurável ou ao cumprimento de um objectivo de desempenho pré-determinado. Pode referir-se à transferência de fundos de doadores para países beneficiários ou ao pagamento a prestadores ou organizações de prestadores por atingirem objectivos de serviço (25, 40). Definição de prioridades Identificação, ponderação e classificação de prioridades pelas partes interessadas (25). Garantia da qualidade Todas as actividades planeadas e sistematicamente implementadas no âmbito do sistema de qualidade, e demonstradas quando necessário, para gerar a devida confiança em que uma entidade cumprirá os requisitos de qualidade (41). Controlo da qualidade Técnicas e actividades operacionais utilizadas no cumprimento dos requisitos de qualidade (41). Melhoria da qualidade “Estratégia organizacional que envolve formalmente a análise dos dados do processo e resultados e a aplicação de esforços sistemáticos para melhorar o desempenho” (42). Gestão da qualidade Todas as actividades da função de gestão geral que determinam a política, objectivos e responsabilidades em matéria de qualidade e as implementam através de meios tais como o planeamento da qualidade, o controlo da qualidade e a melhoria da qualidade no âmbito do sistema de qualidade (41). Planeamento da qualidade Actividades que estabelecem os objectivos e requisitos para a qualidade e para a aplicação dos elementos do sistema de qualidade (41). Regulação Imposição de restrições externas sobre a actuação de um indivíduo ou organização para forçar uma mudança da actuação preferida ou espontânea (25, 43). Resiliência Capacidade de um sistema, comunidade ou sociedade expostas a perigos de resistir, assimilar, adaptar-se e recuperar dos seus efeitos de forma rápida e eficiente, nomeadamente através da preservação e recuperação das suas estruturas e funções básicas essenciais (44). Análise da situação Análise do estado actual e tendências previstas na saúde e sistema de saúde de um país. Idealmente, tal inclui (i) avaliação das actuais e futuras necessidades de saúde e determinantes da saúde; (ii) avaliação das expectativas e procura de serviços; (iii) avaliação do desempenho do sistema de saúde, capacidades do sector da saúde e dos recursos do sistema de saúde e ainda das lacunas na resposta às necessidades e expectativas presentes e futuras; e (iv) análise das posições das partes interessadas (25, 45). Parte interessada Indivíduo, grupo ou organismo com interesse na organização e prestação de cuidados de saúde (24). Norma Especificação ou base de comparação técnica estabelecida, aceite e baseada em evidência (24, 25). Estratégia Série de grandes linhas de acção que visa atingir um conjunto de metas e objectivos fixados no âmbito de uma política ou programa (25, 46). 76 M A N U A L D E P O L Í T I C A S E E S T R A T É G I A S P A R A A Q U A L I D A D E D O S C U I D A D O S D E S A Ú D E Sustentabilidade Potencial para manter resultados favoráveis durante um período estipulado a um nível aceitável de compromisso de recursos em contingências organizacionais e comunitárias aceitáveis (25, 47). Meta Resultado intermédio em direcção a um objectivo que um programa visa atingir num prazo específico. Uma meta é mais específica do que um objectivo e presta-se mais facilmente a ser expressa em termos quantitativos (25). Cobertura universal de saúde Todas as pessoas e comunidades podem utilizar os serviços de promoção, prevenção, cura, reabilitação ou paliativos de que precisam no âmbito da saúde, de qualidade suficiente para serem eficazes, garantindo simultaneamente que a utilização destes serviços não expõe o utilizador a dificuldades financeiras (10). 77 R E F E R Ê N C I A S REFERÊNCIAS 1. Quality of care: a process for making strategic choices in health systems. Geneva: World Health Organization; 2006. 2. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington (DC): National Academies Press; 2001. 3. Improving value in health care: measuring quality. Paris: Organisation for Economic Co- operation and Development; 2010. 4. Donaldson LJ, Donaldson RJ. Essential public health, 2nd edition. Petroc Press; 2000. 5. Miranda S, Olexa GA. Creating a just culture: recalibrating our culture of patient safety. Pennsylvania Nurse. 2013;68(4):4–9. 6. Pronovost PJ, Wachter RM. Progress in patient safety: a glass fuller than it seems. American Journal of Medical Quality. 2014;29(2):165–9. 7. Marx D. Patient safety and the “just culture”: a primer for health care executives. New York: Columbia University; 2001. 8. Everybody’s business – strengthening health systems to improve health outcomes: WHO’s framework for action. Geneva: World Health Organization; 2007. 9. Transforming our world: the 2030 Agenda for Sustainable Development. New York: United Nations; 2015 (https://sustainabledevelopment.un.org/post2015/transformingourworld, accessed 2 February 2018). 10. Health financing for universal coverage. Geneva: World Health Organization (http://www. who.int/health_financing/universal_coverage_definition/en/, accessed 2 February 2018). 11. What is universal health coverage? Geneva: World Health Organization; 2014 (http:// www.who.int/features/qa/universal_health_coverage/en/, accessed 2 February 2018). 12. Strengthening integrated, people-centred health services. Resolution WHA69.24, Sixty- ninth World Health Assembly. Geneva: World Health Organization; 2016. 13. Service delivery and safety: World Health Assembly adopts Framework on Integrated People- centred Health Services. Geneva: World Health Organization; 2016 (http://www.who.int/ servicedeliverysafety/areas/people-centred-care/framework-wha/en/, accessed 2 February 2018). 14. The world health report. Health systems financing: the path to universal coverage. Geneva: World Health Organization; 2010. 15. Donabedian A. Evaluating the quality of medical care. Milbank Memorial Fund Quarterly. 1966;44(3 Suppl):166-206. 16. Das J. The quality of medical care in low-income countries: from providers to markets. PLoS Medicine. 2011;8(4):e1000432. 17. Leatherman S, Sutherland K. The quest for quality in the NHS: a mid-term evaluation of the ten year quality agenda. London: Stationery Office; 2003. 18. Leatherman S, Sutherland K. Designing national quality reforms: a framework for action. International Journal for Quality in Health Care. 2007;19(6):334–40. 19. Leatherman S, Sutherland K. The quest for quality: refining the NHS reforms. London: Nuffield Trust; 2008. 20. Shekelle P, Lim YW, Mattke S, Damberg C. Does public release of performance results improve quality of care? A systematic review. London: Health Foundation; 2008. 21. Donabedian A. Explorations in quality assessment and monitoring, volume I. The definition of quality and approaches to its assessment. Ann Arbour, MI: Health Administration Press; 1980. 78 M A N U A L D E P O L Í T I C A S E E S T R A T É G I A S P A R A A Q U A L I D A D E D O S C U I D A D O S D E S A Ú D E 22. Starfield B. Basic concepts in population health and health care. Journal of Epidemiology and Community Health. 2001;55(7):452–4. 23. Rooney AL, van Ostenberg PR. Licensure, accreditation, and certification: approaches to health services quality. Bethesda: United States Agency for International Development; 1999. 24. Last JM, editor. A dictionary of public health. Oxford University Press; 2007. 25. Health systems strengthening glossary. Geneva: World Health Organization (http://www. who.int/healthsystems/hss_glossary/en/, accessed 6 February 2018). 26. Starfield B. Equity in health. Journal of Epidemiology and Community Health. 2002;56:483–4. 27. Dahlgren G, Whitehead M. Levelling up (part 1): a discussion paper on concepts and principles for tackling social inequities in health. In: Studies on social and economic determinants of population health, No. 2. Copenhagen: WHO Regional Office for Europe; 2006. 28. Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health. Geneva: World Health Organization; 2008. 29. La renovaciόn de la atenciόn primaria a la salud en las Américas [Renewal of primary health care in the Americas]. Washington (DC): OPS/OMS; 2007 (http://www2.paho.org/hq/dm- documents/2010/Renovacion_Atencion_Primaria_Salud_Americas-OPS.pdf, accessed 16 October 2017) (in Spanish). 30. Roberts JL. A glossary of technical terms on the economics and finance of health services. Copenhagen: WHO Regional Office for Europe; 1998. 31. Salud en las Américas, volume I. Washington (DC): Pan American Health Organization; 2007. 32. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference. New York: World Health Organization; 1946. 33. The world health report 2000. Health systems: improving performance. Geneva: World Health Organization; 2000. 34. Murray C, Evans D, editors. Health systems performance assessment: debates, methods and empiricism. Geneva: World Health Organization; 2003. 35. WHO Executive Board, 128th session. Health system strengthening: current trends and challenges. Geneva: World Health Organization; 2011. 36. Islam M, editor. Health systems assessment approach: a how-to manual. Submitted to the United States Agency for International Development in collaboration with Health Systems 20/20, Partners for Health Reformplus, Quality Assurance Project, and Rational Pharmaceutical Management Plus; 2007. 37. Clean care is safer care: infection prevention and control. Geneva: World Health Organization (http://www.who.int/infection-prevention/about/ipc/en/, accessed 6 February 2018). 38. Patient safety. Geneva: World Health Organization (http://www.who.int/patientsafety/ about/en/, accessed 6 February 2018). 39. What are integrated people-centred health services? Geneva: World Health Organization (http://www.who.int/servicedeliverysafety/areas/people-centred-care/ipchs-what/en/, accessed 19 February 2018). 40. Eichler R. Can ‘‘pay-for-performance’’ increase utilization by the poor and improve the quality of health services? Washington (DC): Center for Global Development; 2006. 41. Juran JM, Godfrey AB. Juran’s quality handbook, fifth edition. McGraw-Hill; 1999. 42. Evidence-based Practice Center systematic review protocol: closing the quality gap 2010: quality improvement interventions to address health disparities. Rockville, MD: Agency for Healthcare Research and Quality; 2012 (https://effectivehealthcare.ahrq.gov/topics/ disparities-quality-improvement/research-protocol, accessed 19 February 2018) 43. altman RB. Regulating incentives: the past and future role of the state in health care systems. Social Science and Medicine. 2002;54:1677–84. 44. UNISDR terminology on disaster risk reduction. United Nations International Strategy for Disaster Reduction; 2009. 45. A framework for national health policies, strategies and plans. Geneva: World Health Organization; 2010. 46. Health impact assessment: glossary of terms used. Geneva: World Health Organization (http://www.who.int/hia/about/glos/en/index2.html, accessed 6 February 2018). 47. Understanding the sustainability of health programmes and organizational change. Paper for Victorian Quality Council. La Trobe University, Faculty of Health Sciences; June 2007. 79 R E F E R Ê N C I A S World Health Organization 20, Avenue Appia CH-1211 Geneva 27 Switzerland Por favor visite-nos em: http://www.who.int/servicedeliverysafety/areas/qhc/nqps/en/ ISBN 978-92-4-000570-9