the annual quality report a dynamic tool for quality management and accountability

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The Annual Quality Report A dynamic tool for quality management and accountability

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Page 1: The Annual Quality Report A dynamic tool for quality management and accountability

The Annual Quality Report

A dynamic tool for quality management and

accountability

Page 2: The Annual Quality Report A dynamic tool for quality management and accountability

25 November 2005 Final Conference Matra Project

2

Quality System in Health Care National level

Government legislation, regulation Monitoring by HCSA, insurance

companies Certification, accreditation

Institution level Implementation of quality systems Monitoring of quality of services Provision of information to national level

Page 3: The Annual Quality Report A dynamic tool for quality management and accountability

25 November 2005 Final Conference Matra Project

3

Implementation of quality systems in health institutions

Adherence to standards defined by MOH, insurance companies, HCSA

Adherence to standards and systems defined in accreditation/certification

Adherence to clinical practice guidelines (evidence based medicine/nursing)

Achieving maximum patient satisfaction possible

Page 4: The Annual Quality Report A dynamic tool for quality management and accountability

25 November 2005 Final Conference Matra Project

4

Internal monitoring of quality systems Quality committee and quality manager

Multidisciplinary composition Formulate priorities and targets

Joint activity with management and owner Keep track of achievements/constraints

Data collection and analysis Motivate staff showing results

Feedback mechanisms to be developed

Page 5: The Annual Quality Report A dynamic tool for quality management and accountability

25 November 2005 Final Conference Matra Project

5

Accounting to external stakeholders Legal obligation

Indicators formulated by MOH Contractual obligation insurance

companies Accounting to owners

Regional government, municipality Accounting to general public

Patient organisations, patient panels

Page 6: The Annual Quality Report A dynamic tool for quality management and accountability

25 November 2005 Final Conference Matra Project

6

The Annual Quality Report Reflects the vision on the organisation,

its environment and its tasks Is more then a representation of data;

it provides an analysis Is part of a planning and reporting cycle

it reflects on achievements and constraints Is part of a quality system

Defining new goals for coming period

Page 7: The Annual Quality Report A dynamic tool for quality management and accountability

25 November 2005 Final Conference Matra Project

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The Annual Quality ReportContents Mission of the organisation regard to

quality Report over past year

Priorities and plans over past year Resources used (human resources, finances) Activities implemented, e.g. surveys Data on core indicators and analysis Clinical guidelines and protocols in place Education and training provided in organisation

Planning for next year

Page 8: The Annual Quality Report A dynamic tool for quality management and accountability

25 November 2005 Final Conference Matra Project

8

International Experiences Quality reporting hospitals obligatory in

many European countries UK: NHS monitoring system Germany: federal government body monitors

Reports at www.bqs-outcome.de Netherlands and Belgium: quality reports in

legislation, health inspection checks Lessons learned:

Comparison between hospitals: triggers debate

Increased awareness under hospital staffs

Page 9: The Annual Quality Report A dynamic tool for quality management and accountability

25 November 2005 Final Conference Matra Project

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Pilot in Matra project 10 hospitals approached

Hospitals with experience in PATH project Basic format for report provided

Report over first six months 2005 Presentation of reports following this

introduction Proposal to MOH to introduce

mandatory quality reporting for hospitals Putting data on MOH indicators in a context Comprehensive information on activities