WORLD HEALTH ORGANIZATION
ORGANISATION MONDIALE DE LA SANTE
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
REGIONAL COMMITI'EE Forty-fifth session Kuala Lwnpur 19-23 September 1994 Provisional agenda item 15
WPRlRC4SI12
30 July 1994
ORIGINAL: ENGLISH
""'
QUALITY ASSURANCE IN HEALTH SERVICES
The Regional Committee, at its forty-second session, requested the Regional Director to prepare a report on progress in the Region on the use of quality assurance as an integral part of health services. The report was presented the following year to the Regional Committee at its forty-third session. A resolution (WPRlRC43.R7) was adopted requesting the Regional Director to report on the implementation of quality assurance in health services to the Regional Committee at its forty-fifth session. This document reports the progress made by the Region in incorporating quality assurance into the routine activities of health services since the forty-third session of the Regional Committee. It also analyses trends in the development of quality assurance which will form the basis for the future of quality of care. The Committee is requested to review this report and its findings and to consider what further action is needed in this area.
WPR/RC4S/12 page 2
1. BACKGROUND: DISCUSSION AT THE FORTY-THIRD SESSION OF THE REGIONAL COMMI'ITEE
The working document for discussion of this subject by the Regional Committee at its forty-third session in 1992 indicated that "the question for health policy-makers in the 19905 is no longer whether to include quality of carel as an issue in development decisions, but one of how and who will be making these decisions". Quality assurance as a management tool to guide the development of health systems in the Region was described, and the actions of Member States and WHO were outlined. It was noted that the issue of quality had become one of the priority themes when deciding on changes in the health system, although it was not really a new issue to the medical field. For the meaning of quality to be revitalized, health leadership needed to provide a broader vision of the scope of the issues involved. This need was clearly reflected in the second evaluation of the (1) improved equity of access to care; implementation of the Global Strategy for Health for All by the Year 2000 completed in 1991. The most commonly reflected goals for health reform were: (2) mechanisms for containing health service costs; and (3) improved quality in the care that is provided. In 1991, 19 countries and areas explicitly identified an aspect of health-for-all activities related to quality of care. The report concluded that many countries were aware that quality of care was an emerging issue. However, the details of how it could be integrated with other components of health development initiatives were not apparent.
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2. ACTION BY MEMBER STATES
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Resolution WPRlRC43.R7 adopted by the Regional Committee at its forty-third session urged Member States: (1) (2) (3) to incorporate quality assurance in their policies and strategies for achieving health for all; to provide opportunities for health workers to develop skills in implementing quality to share information on their experience in quality assurance in overall health development
assurance techniques; and and in specific service areas. Since 1991, Member States have strengthened the role and place of quality of care in health development policies and strategies. Table 1 shows the comparative status of quality of care
lIn that document (wpRJRC43/10), as well as in this document, the term "quality of c.... " is used in p...ference to "quality assurance" as it indicate. a broader context for the application of quality issues. Quality of care is dermed as the extent to which actual ca ... conforms with agreed criteria for good c.....
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activities in the Region in 1991 and 1994. In 1994,26 of the 3S countries and areas indicated some type of quality of care activity, compared with 19 in 1991.
The scope of activity ranges, from
simply conducting an ad hoc study, project or training on quality of care, to formulation of an explicit policy on quality, to the situation where quality has become an integral part of a national health programme or management system. Table 1. Quality of care activities in the Western Pacific Region in 1991 and 1994
ACTIVlTY Studies/projects and/or training Formulation of policy statements
COUNTRY/AREA
Implementation of quality assurance programme
1991 American Samoa Australia Brunei Darussalam Cambodia China Cook Islands Fiji French Polynesia Guam Hong Kong Japan Kiribati Lao People·s Democratic Republic Macao Malaysia Mariana Islands, Northern Marshall Islands Micronesia, Federated SIaIeS of Naucru New Caledonia New Zealand Niue Palau Papua New Guinea Philippines Republic of Korea
1994 x x -
1991
1994 x x x x x x
1991
1994
x -
x
x
x
-
-
-
x x x -
x x -
-
x
x x
x x
-
-
x x
x
-
-
-
-
-
x -
x
x x -
x x x x
x x
x
x
-
-
-
-
x x
-
x x -
-
-
x
x
-
x
-
Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu VietNam Wallis and Futuna
x
x x x x x x
x
-
-
x x x
-
x
x
-
x
x
-
-
x
x
-
x
x x
x x x x
-
-
x
-
-
-
x
-
-
WPRlRC45/12 page 4
Table 2 shows that there has been a significant increase in the level of planning or action on quality of care matters in the Region.
Table 2,
Comparison of quality of care activities in the
Western Pacific Region in 1991 and 1994
Activity
Total number of countries and areas reporting activities in 1991 1994 22 16 5
Studies, projects and/or training Formulation of policy statements Implementation of quality assurance programme
12 10 5
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The number of countries and areas indicating that they are planning or performing some type of quality of care activity has nearly doubled - from 12 to 22 countries. Much of this increase is in the area of training. There has also been a significant increase (from 10 to 16) in the number of countries and areas indicating that quality of care has been included in a policy statement. Typically, this policy would be expressed as a national health development goal such as "the quality of care to the population will be improved" . Table 2 shows no change in the number of countries and areas reporting that they have adopted a comprehensive programme to implement quality of care. It can be concluded that the Region's ability to institutionalize quality of care is at a very early stage. There is great potential for further growth and development of implementation. Australia, Malaysia, New Zealand, Palau and Singapore continued to develop and strengthen their comprehensive programmes on quality of care. Malaysia was one of the first countries to use quality of care as an indicator of the performance of programme delivery. The evaluation of quality of care is used at all levels as an integral part of management decision-malting. committee chaired by thF Director-Ge~eral
_
This ranges from a national policy-steering
of Health to divisional quality assurance programmes, as
well as hospital-specific,mechanisms. These are supported by a very extensive training programme
WPRlRC45/12 pageS
to ensure that all staff are involved and knowledgeable about quality assurance programmes. Malaysia held its first national quality of care conference in 1993. The conference was used as a forum to further promote the importance of quality of care in Malaysia's health system development. Singapore has also taken a comprehensive management function approach. It has established a senior quality assurance service unit that directs and oversees quality of care activities. Singapore uses many of the same techniques as Malaysia, emphasizing prompt and effective feedback throughout the system. Australia's strategy to promote quality of care fits more pluralistic delivery systems. works mainly through accreditation processes. It
A significant component of an organization's
accreditation is how they handle the issue of quality of care. Efforts are currently being made to address a limitation of this approach which is that it is often difficult for facilities or organizations to compare themselves with others. However, various mechanisms and networking arrangements can be organized to satisfy this need. Accreditation for general practitioners in Australia includes issues of quality of care. Various persons and groups in Australia are also working on the critical issue of preparing clinical practice protocols. In New Zealand, quality is a part of the contract specifications for the purchase of health services. The funding of care has been separated from the provision of services. Through various purchasing arrangements, the Government buys the services it defines as most appropriate to cover the country's needs. -. Consideration of the quality of the service is part of the purchasing agreements, along with the quantity of services to be provided. This innovative approach is of interest to many managers. New Zealand is just beginning to implement this approach and will be gaining more valuable experience in the near future. Palau has started a programmatic approach to implementing standards of care, starting with maternal and child health. detected. These five countries and areas have the most developed methods in the Region for ensuring that quality of care is integral to their management and development systems. Many other countries are moving in similar directions. In Papua New Guinea, quality of care is considered on an equal footing with other matters in all health system decisions. Similarly in Samoa, quality has been accepted as the next issue to be integrated into management decisions. American Samoa is also starting a programmatic approach to quality improvement. The most important feature of this initiative is management's determination to immediately improve upon the performance of the service once a problem has been
WPRlRC4S/12 page 6
Brunei Darussalam has a policy to promote improved quality of health technology. Macao hopes to promote improved quality through health insurance. Vanuatu is working on standard protocols and clinical procedures; these are also being addressed in Viet Nam. The Society of Quality Assurance in Health Care, in the Republic of Korea, had its first national meeting in March 1994. This was a major effort to promote broader-based support for quality assurance These examples illustrate the many approaches taken by activities in the Republic of Korea.
countries and areas to gain more experience in what is the most appropriate approach to develop quality of care improvements on a more comprehensive level.
3. ACTION BY WHO
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Resolution WPRlRC43.R7 also requested the Regional Director: ( I) to cooperate with Member States in devising policies and programmes that promote quality
of care as a central value in public health action; (2) to provide the technical support required for countries to ensure that quality of care is
considered when they deal with issues of equity and financing in health services; (3) to support the training of health personnel in the methods and techniques of quality
assurance; and
(4)
to facilitate the exchange of information among Member States on their experience in
implementing quality assurance programmes.
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3.1
Promoting quality of care Quality of care is being promoted by most of the Region as one of the three principal health
development goals - along with equity and cost containment. This message is an integral part of all WHO's management programme activities. A new initiative to foster exchange of technical information on health reform was recently launched, with a number of regional meetings planned. These meetings will constitute a forum for countries and areas of the Region to share experiences in health development. An outcome of these meetings will be documentation on health reform and various quality of care efforts. This will reinforce the value of the forum and promote the issues discussed. The first meeting was held in Wellington, New Zealand, in May 1994. It will be followed by a South Pacific meeting for small islands in December 1994 and a similar meeting in the northern part of the Region in 1995.
WPRlRC45I12 page 7
3.2
Provision of technical support The number of requests for technical support in quality of care has increased significantly.
Two quality of care national conferences were held, with WHO support, one in Malaysia in 1993, and the second in the Republic of Korea in 1994. Increasing the technical capability of resources and staff from within the Region will continue to be a priority consideration. It is anticipated that collaborating centres on quality of care will be established in the Region in the near future.
3.3
Training The two most significant features of the new emphasis on quality of care are firstly, that care
must be understood in the context of a total system, and secondly, that staff are heavily involved. Previously, quality was associated with medical technology. Now, training of human resources is a vital component in any successful quality of care programme. This is very aptly illustrated in Malaysia, where training is the principal component of the implementation strategy. Training is continuous and highly focused on the operational aspects of quality improvement. The accreditation programme in Australia similarly emphasizes the training component of the quality assurance programme in health facilities. The budgets prepared by countries and areas for use of WHO funds clearly reflect the development of interest in the programme. During the 1992-1993 biennium there was very little mention of collaboration in quality of care. one related to training. training in quality of care. In the 1994-1995 programme budget the topic was raised a number of times, however, only two requests were specific; one for general support and This increased to two general requests, and six quite specific training proposals for 1996-1997. Clearly, many countries and areas now recognize the need for expanded
3.4
Exc:bange of infonnation
Exchange of information is a priority in all WHO's technical programmes in the Region, including quality of care. The methods of application of quality of care are quite varied. It is
consequently extremely important that Member States have access to the full range of resources in this field, and can benefit from others' experiences. Several specific tasks to thoroughly document country experiences on health reform, (which includes quality of care), are currently under way in the Region.
WPRlRC4S/12
pageS
4. FUTURE DEVELOPMENTS
This survey on the development of quality in care in the Region has revealed a number of trends. These will form the basis for future developments in quality of care. There has been a significant increase in the level of awareness and in the number of activities undertaken. In 1994-1995, for example, ten countries and areas made some reference to quality of care in their country budgets even though in many cases it was a very general statement. was to a quite specific need or request. A second trend is the apparent difficulty experienced by countries and areas in articulating a precise development strategy for quality of care improvements. In 1991, five countries and areas had comprehensive quality assurance programmes. national-level programme. In 1994 only the same five had developed a First, exactly what is meant by a With these descriptions as a framework, This situation can be improved. For 1996-1997, 19 countries and areas made reference to quality of care and in most cases the reference
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"quality of care programme" needs to be documented. needs and solutions can be better reviewed and assessed.
4.1
Successful strategies There are at least three distinct approaches to implement a national quality of care
programme.
Review of previous successful health development initiatives shows clearly that This factor will also be
national-level direction and leadership is a key ingredient in success. important for the future of a quality of care initiative. The three approaches use: (1) a central-level
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management
support
function;
(2) accreditation;
and (3) contracting.
In each, the information on quality is as important in
making management decisions as data on quantity and costs. The organization of quality of care information is therefore a support function to management in the same way as any other function such as personnel, budget or logistics. A central-level management support function for quality of care is seen where the national level has considerable responsibility and control over the direct provision of services. This is the situation, for example, in Malaysia and Singapore. It is probably the most effective and efficient approach, however, it depends on having direct control over the management of a significant proportion of the health service operations.
WPRlRC4SI12 page 9
The accreditation and contracting approaches apply where provision of services is either pluralistic or where there is a large private sector. The accreditation method is used where facilities and practitioners must be licensed to carry out their activities, either because of a law or a professional body agreement. Licensing is typically granted after an acceptable accreditation audit has been completed. A section of the audit will review how quality of care is being handled. The assumption is that, when certain standards or procedures of good practice are followed, the desired level of care will be provided. The contracting method gives more direct control over quality outcomes than the
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accreditation option. It has a significant limitation, in that the contractee must have control over a large portion of the funds going to the providers. In New Zealand, for example, which is attempting to apply this option, there is a single payee system for the funding of services. This approach is successful when the contractee and contractor can agree on how to measure qUality. Unfortunately, the technology in this area is not sufficiently advanced. Practitioners or providers in most situations are not able to guarantee a particular level of quality in all of their work. 4.2 Clinical practice protocols In most of the Region, clinical practice protocols need to be developed. This is one of the more significant trends to strengthen and enhance the technical expansion of quality of care. There is a consensus that quality of care programmes will significantly improve once this is done, and technically acceptable measures of outcomes of care are used. The challenge is to fmd acceptable terms and indicators for these measures. With high variability in the outcome of very similar types
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of care, it appears to be difficult to use outcomes as the basis for improvements in quality of care. The current focus is consequently on clinical practice procedures. However, with a more precise understanding of what resources are used and how these resources and skills should be applied to particular clinical conditions, it should be possible to define more precisely what outcome may be anticipated. It is currently expected that the development of clinical practice procedures will
improve the prediction of patient outcomes.
Clinical practice procedures can be used to help
practitioners and to provide guidelines for patient understanding and subsequent satisfaction with their treatment. They can also facilitate control over the cost of care. There are high expectations of potential breakthroughs as a result of such an emphasis on outcomes. It is well known, however, that it is extremely difficult to reach a consensus on acceptable clinical practice for a given
condition. None the less, given the current level of awareness and motivation in the Region, it appears that this is the time for a breakthrough in this area.
WPRlRC45/12 page 10
S. CONCLUSION
Significant progress has been made in the Region in terms of increased awareness that improved quality of care is one of the most important outcomes of ongoing health system reforms. Countries and areas are clearly promoting the need for improved quality of care. and are training staff to work more effectively. For example. there is a wide variety of activities related to making incremental improvements in patient care. large-scale sustainable programme. However. progress has been limited in terms of the number of countries and areas which have been able to institutionalize quality of care into a There are at least three viable approaches to developing As these options mature and are more
sustainable quality of care programmes in the Region.
thoroughly documented. other countries and areas will have a rich learning opportunity to evolve their own comprehensive quality of care systems as appropriate for their own particular circumstances. The next major challenge in quality of care improvements will be the achievement of more consensus on acceptable clinical practices.
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This consensus will enable purchasers and The trend is already for the
providers to agree on what are the expected outcomes of care.
providers of care to be concerned about the outcomes of their services.
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