Publications since last Newsletter

1: Literature and interview summary on quality improvement in healthcare systems of the European Union

The full text of this publication can be found here

Sources of information for literature review

The literature review draws on empirical research, commentaries and theoretical approaches to the analysis of quality improvement strategies in health care. In addition to international and national reports and guidelines on quality, information was sourced from peer-reviewed journals by accessing Medline, Ingenta, Blackwell Synergie, HMIC, ASSIA, and Google search engines. Search commands included combinations of ‘quality’, health services’, ‘health care’, and ‘Europe’. A ten year limit was placed on the search (1994-2004/5), taking account of the rapid reform of health systems across the EU during that period. An expanded search was conducted for specific material (research papers and books) identified from the bibliographies of papers from the initial search. Papers taking a comparative perspective and including EU member states were targeted, taking care to define the status of each state as ‘member’ or ‘accession’ state, at the time of publication. Materials were also provided for
and recommended by experienced partners within the MARQuIS international research team.

More information can be found in the full report

2: Survey among experts on quality improvement in healthcare systems of the European Union

The full text of this publication van be found here

Executive Summary

This survey of national quality improvement policies and strategies in health care systems was completed by 68 key experts in quality improvement across 24 member states. The experts came from a range of professional backgrounds in health care and occupied a variety of roles in policy making, academia and research, health care management, quality societies, quality consultancy, and clinical practice.

The findings from this survey can be summarised as follows:

Differences in national and regional contexts

The data suggests that in many member states, quality improvement policies and strategies are developed both at subnational or regional, and at a national level, and there is considerable variation between regions in some member states, particularly in the different ways that quality is measured and evaluated, in different regional and national government priorities, and in differences in resourcing and support for implementation. These differences mean there is a need for caution both in describing member states’ approaches to quality improvement in healthcare and in making international comparisons.

Quality improvement: a national or international policy issue

The survey suggests that the development of quality improvement policies has taken place primarily within member states, and the most important drivers of policy have been governments, professional organisations such as medical and scientific societies, and media coverage. International influences such as ISQua, and the European Commission and policy development in other member states were reported as having been less important drivers for policy development, suggesting that quality improvement policies and strategies have been predominantly seen as national issues to date.

The dominant role of governments in quality improvement

In this survey national governments emerged as the key players in developing quality improvement policies, setting quality standards and targets, and providing guidance and support to organisations on implementation. Patient and service user organisations were reported as having the least influence on the development of quality improvement policy, even though patient orientation and patient involvement emerged as one of the most important quality improvement priorities for governments.

Although governments were reported as being the key leaders in most aspects of quality improvement, a lack of political leadership and strategic planning in quality improvement was also cited in this survey as a key barrier to progress. It might be argued that concentrating responsibility for quality improvement in government agencies or departments which are also responsible for a wide range of issues such as funding and financing may create some conflicts of interest, and mean that quality improvement policies and strategies receive less attention than they merit.

Common priorities for governments

Respondents identified a number of common priorities for governments for the future development of quality improvement, including a policy focus on patient safety, patient involvement, the development of quality systems, and the evaluation or assessment of quality improvement systems.

Policy documents

In most member states, respondents identified a policy document from government which set out its approach to quality improvement in healthcare (indeed, many respondents identified more than one document). Their content was more likely to cover issues such as systems, structures and targets, and less likely to cover matters such as training, support and resources for quality improvement.

The legal status of quality improvement policies

Having a statutory legal requirement to implement quality improvement strategies for healthcare systems and organisations was reported as being an important incentive for supporting progress in the development of quality improvement initiatives. The implementation and development of quality policies may therefore be at a more advanced stage in member states who have such a legal requirement, and who have had a legal requirement in place for a substantial period of time. The minority of member states who have not yet enacted legislation to require healthcare systems and organisations to put quality improvement policies and strategies in place may wish to consider the experience of those member states which have done so.

Education and training in quality improvement

Education and training in quality improvement emerge in this survey both as important components in the development of quality improvement, and as areas where the lack of provision or effective support is seen as a barrier to progress. Education and training in quality improvement is far from being generally provided either at an undergraduate or postgraduate or continuing professional development level.

Leadership

Research indicates that progress in quality improvement requires strong, engaged and informed professional leadership, but such leadership capacity can only be developed if healthcare professionals have access to and make use of appropriate training and development in healthcare quality improvement, and the survey suggests that such training is often not available in many healthcare organisations.

The mandatory use of quality improvement policies and strategies
Although most member states have some form of legal, statutory requirement for quality improvement in healthcare systems and organisations, the extent to which specific quality improvement systems or approaches are required or mandated varies considerably. The data suggests wide variation in the voluntary and mandatory coverage of different quality improvement policies and strategies across sectors, potentially leading to varying levels of progress and coverage in implementation.

Implementing quality improvement

Although there is a clear commitment to quality improvement at a policy level in most member states, there is considerable scope for progress in making a reality of such policies at the level of healthcare organisations. Even in countries with relatively well established policies on quality improvement, many healthcare organisations lack fundamental components of an effective quality improvement function such as a QI plan for the organisation, an organised programme of QI projects, training and dedicated resources, follow-up and monitoring of quality improvement projects, and monitoring of quality across departments and services.

Information and evaluation

The survey suggests that while there are systems in place for the evaluation of quality improvement, they are largely internal to organisations and data about the progress of quality improvement is not widely shared or available to other stakeholders such as patients and service users. Information from external assessments of quality was reported as being more available to professional organisations, members of the public and service user groups.

While some information on quality improvement is being shared between health care organisations within and between member states, this happens mainly through conferences and workshops, or in reports and documents. Open days, practical guides and toolkits, and special quality events are less frequently used to share information on quality between health care organisations. Exploring more diverse means of disseminating information within and across borders might be valuable.

Information about the quality of health care is not, according to this survey, being routinely or systematically collected by member states who access health services by agreement from another member state. In the 12 member states reporting that they accessed health services in another member state by prior agreement, only one reported having some form of quality evaluation process in place.

Achievements in quality improvement

Respondents descriptions of the achievements of quality improvement were largely focused on the establishment of improvement systems and infrastructure rather than on their impact on healthcare quality.

What facilitates or hinders progress ?

The common factors seen as supporting the implementation of quality improvement were professional involvement and commitment, the provision of training, the existence of a mandatory or legal requirement for quality improvement, and the existence of a QI infrastructure of staff, resources, lead individuals, projects and so on. The main barriers to quality improvement were seen as a lack of funding, an absence of leadership and strategic planning, a lack of incentives, cultural and professional barriers, and a lack of training and support.

The impact of quality improvement on the quality of care and patient outcomes

Overall, the survey suggested that quality improvement policies and strategies were having a marked though variable impact on the quality of care and on patient outcomes. The introduction of clinical guidelines and the use of performance indicators were seen as having had the greatest impact on the quality of care, while patient safety systems like risk management and incident reporting and systems for getting and using patients views were felt to have had rather less direct impact on the quality of care. Some moderate improvements were reported, particularly on the dimensions of staff orientation and patient centredness.

Our findings suggest that the use of clear targets for quality improvement; the provision of resources and support for quality improvement; the existence of a quality improvement “infrastructure” (management arrangements, projects, monitoring and evaluation); and the use of incentives to reward quality improvement are all positively associated with improvements in patient care.

Our survey provides some limited but useful evidence that quality improvement policies and strategies are having an important though moderate impact on the quality of care and on patient outcomes, and points to some of the actions at a policy and system level which seem to be associated with these impacts. While this data must be interpreted with caution, it supports the contention that investing in quality improvement policies and strategies is worthwhile and provides policymakers and other stakeholders with some important indications of “what works”.