The National System of Health Quality Assessment Álvaro Moreira da Silva Board of Direction ERS Porto, 08 May 2014 SINAS

1.Framework for assessing global quality (Hospitals) (Dental Care) Outline

Legal framework ERS have a legal obligation to develop an evaluation system, which aims to assess health care providers in terms of global quality of services The National System of Health Quality Assessment SINAS Inform patients on quality of health care services Encourage continuous improvement in the quality of health care services

SINAS: Assessment model Rating System Voluntary collaboration of health care providers Data are collected in different formats, which result in the classification of each establishment ERS conducts audits of randomly selected establishments, in order to validate the information submitted

Global Quality Assessment  Quality in health care: No consensus on a closed form definition Conceptualizations of quality depend on how broad is the model of care considered (e.g, just medical care or nursing care included?) Health care services includes more than just health care Multidimensional approach needed

SINAS framework  Modularity of the SINAS project: Type of health care provider (“SINAS modules”) Quality dimensions Clinical Excellence Patient Safety Comfort of facilities Patient Focus Patient Satisfaction Registration and licensing Organization and Procedures Patient Safety Comfort of Facilities Patient Satisfaction

Methodologies  Specificities Quality dimensions being assessed are type-of- provider-specific Methodologies for quality assessment are dimension-specific  Technical coherence (same methodologies for similar indicators) Methodologies for performance measurement Methodologies for producing ratings

1 st level of assessment: awarding stars provider complies with all required quality standards ↓ Access to RATING compliance with all required quality standards could not be confirmed ↓ No access to RATING provider did not collaborate with the assessment ↓ No access to RATING Assessment scheme: stars and ratings

2 nd level of assessment: awarding ratings Assessment scheme: stars and ratings quality level III provider with above average performance quality level II provider with average performance quality level I provider with be low average performance insufficient sample sample size was insufficient for statistical inference unreliable data inconsistencies in data were detected not assessed area starting assessement data not supplied

Schedule of assessments and public disclosure  Frequency: twice a year  Communication channel: dedicated website Public disclosure of star and rating coded results  Provider-specific reports With detailed results of performance on each indicator  Transparency: all methodological aspects of the assessments fully described in the website

SINAS implementation  SINAS modules currently implemented Assessment of hospitals Dentists offices and dental care clinics

1.Framework for assessing global quality (Hospitals) (Dental Care) Outline

Implemented Being developed Implemented Quality dimensionsStatus Clinical Excellence Adequacy and Comfort of Facilities Patient Safety Patient Satisfaction Patient Focus

Clinical Excellence  Clinical areas being assessed Orthopaedics, Gynaecology, Obstetrics, Paediatrics, Acute Myocardial Infarction, Stroke, Ambulatory Surgery, Vascular Surgery, Cardiac Surgery, Colon surgery and Intensive Care Units  Clinical indicators Process indicators Outcome indicators  Methodologies For process indicators: no risk adjustment For outcome indicators: risk adjustment model

 Model of performance assessment Assessment based on a check-list covering structural and organisational characteristics of facilities  Issues considered in assessment check-list AdequacyComfort 1. Accessibility5. Hospitalization 2. Maintenance6. Additional areas 3. Self protection measures7. Comfort 4. Risk assessment8. Quality control Hospitais Adequacy and Comfort of Facilities

 Performance indicator: Percentage of items in check-list that are present  Methodology for producing ratings: Clustering: assigning a set of objects into groups so that the objects in the same group are more similar to each other than to those in other groups. Hospitais Adequacy and Comfort of Facilities

 Two perspectives of assessment 1) Ex-ante: patient safety culture 2) Ex-post: indicators (rates) of adverse events incidence  Methodologies Patient safety culture: assessment by check-list → clustering Rates of adverse events: outcome indicators → risk adjustment model Hospitais Patient Safety

 Patient safety culture Commitment of health care organisations to safety at all levels, including structures and facilities, procedures and human resources Assessment with check-list Main background: “Patient Safety Practices” of Agency for Healthcare Research and Quality (AHRQ) “Safe Practices for Better Healthcare 2010” of National Quality Forum (NQF) “International Patient Safety Goals” of Joint Commission International (JCI) Hospitais Patient Safety

 Issues considered in assessment check-list Safety Culture Patients Identification Communication with patients Information to patients Safe use of medications Safe Surgery Checklist Hospitais Patient Safety

 Adverse events indicators Measures that screen for problems that patients experience as a result of exposure to the healthcare system and that are likely amenable to prevention. Main background: Agency for Healthcare Research and Quality (AHRQ) Safety Improvement for Patients In Europe (SImPatIE) OCDE Health Care Quality Indicators Hospitais Patient Safety

 SINAS selection of adverse events indicators Hospitais Patient Safety SSD1 – Death in Low-Mortality DRGs SSD2 – Stage III and IV Decubitus Ulcer SSD3 – Nosocomial Infection (Catheter-Associated Infection) SSD4 – Postoperative Hip Fracture SSD5 – Postoperative Hemorrhage or Hematoma with Re- exploration Required SSD6 – Nosocomial Infection (Postoperative Sepsis) SSD7 – Postoperative Wound Dehiscence SSD8 – Accidental Puncture or Laceration

Hospitais Patient Focus  Aim: Objective assessment of how much are health care organisations centred on patient needs and preferences  Background: Standards of Patient and Family Rights of Joint Commission International (JCI)  Model of performance assessment : Assessment based on a check-list covering structural characteristics, human and physical resources and organisational procedures, that contribute to patient- centred care

 Issues considered in assessment check-list Informed consent Scheduling of services In patient Access to second opinion Religious aid Visits to in-patients Food Training Communication with patients Terminally ill patients Waiting times Post discharge follow up Patient privacy Suggestions, complaints or claims handling Satisfaction Surveys Hospitais Patient Focus

 Aim: Subjective assessment of patient satisfaction with health care services  Types of care to be assessed: Emergency care, inpatient care, ambulatory surgery, outpatient consultations  Model of performance assessment: Survey study Hospitais Patient Satisfaction

Distribution of participants (Ref.30/12/2013) overall results ARS PrivatePublicSocial Providers Norte Centro8225 LVT16305 Alentejo151 Algarve33- Total469026

Hospitais – Clinical Excellence Evolution of participation CollectionPublished Number of Hospitals IncreaseAssessed areas Pilot Project ORTH 1.ª Collection **6375,0%ORTH 2.ª Collection ,8%ORTH; GYN; OBS; PAED 3.ª Collection **7919,7%ORTH; GYN; OBS; PAED 4.ª Collection **857,6% ORTH; GYN; OBS; PAED; AMI; STRO; AMBS 5.ª Collection **850,0% ORTH; GYN; OBS; PAED; AMI; STRO; AMBS 6.ª Collection **861,2% ORTH; GYN; OBS; PAED; AMI; STRO; AMBS 7.ª Collection **10229,1% ORTH; GYN; OBS; PAED; AMI; STRO; AMBS; COLS; CARDS; VASCS; ICU 8.ª Collection **1160,1% ORTH; GYN; OBS; PAED; AMI; STRO; AMBS; COLS; CARDS; VASCS; ICU

Hospitais Ambulatory Surgery Evolution of results

Hospitais Ambulatory Surgery Evolution of the reference values

1.Framework for assessing global quality (Hospitals) (Dental Care) Outline

Implemented Being developed Implemented Quality dimensionsStatus Registration and Licensing Adequacy and Comfort of Facilities Organisation and Procedures Patient Satisfaction Patient Safety

Status of implementation:  First publication of results – August 2013  Provide to population an assessement of 800 dental care providers  Add clinical indicators to the system

N.º of Providers Rating Organisation and Procedures Patient Safety Adequacy and Comfort of Facilities Quality level III331 (53%) 305 (56%) 415 (56%) Quality level II222 (35%) 159 (29%) 258 (35%) Quality level I78 (12%) 84 (15%) 66 (9%) 631 (100%) 548 (100%) 739 (100%)

National System of Health Assessement better care, better outcomes