International Journal for Quality in Health Care 16:91-92 (2004)
© International Society for Quality in Health Care and Oxford University Press 2004; all rights reserved
Book review |
A background for national quality policies in health systems
Charles D. Shaw and Isuf KaloWorld Health Organization, Regional Office for Europe: http://www.who.dk, 2002
WHO Reference no: EUR/02/5037153; 53 pp.
This WHO publication is an excellent resource book on health system quality in Europe. It is in two parts. The first part aims to provide Ministers of Health and other policy makers with background information on common definitions and issues surrounding quality of health systems and health care. The second part offers a framework and principles for a national quality strategy. It contains many examples of current approaches, policies and projects from different countries, containing some 17 tables as well as five annexes. It cites 126 references, including many web sites.
While the book is targeted at WHO member states, its basic premise is almost universally applicable, namely that the growth of technology and information, the demands for transparency and public accountability, and the limits of financial and human resources oblige countries to describe and reform their health system according to internationally recognized standards of structures, process, performance and results. Being able to demonstrate that their quality strategies or policies are based on experience and scientific evidence is an important theme.
Part one provides the context of quality in Europe. It outlines the main reasons given by European Union members and accession states to implement quality assurance strategies, such as unsafe health systems, unacceptable levels of variations in performance and practice, ineffective or inefficient healthcare technologies and delivery, and unaffordable waste.
The elements of a ‘good’ health system detailed here relate to Donabedian’s structure/process/outcome model—the availability of human, financial and technical resources (investment); how the resources are applied (stewardship); and what results are achieved (performance). Not mentioned, but a useful comparison and close match, are the six aims for improvement of the US health system contained in the Institute of Medicine’s 2001 report ‘Crossing the Quality Chasm’: safe, effective, patient-centred, timely, efficient, and equitable.
The authors outline the move in recent years from a top-down quality control model to a continuous quality improvement cycle. However, there is little evidence that regulatory systems have adopted the principles of continuous quality improvement, just as there is also evidence that internal mechanisms have repeatedly failed to ensure safety, efficiency, best practice and public accountability. Even though the methods exist for scientifically evaluating quality improvement programmes in the same way as clinical technologies, this rarely happens. The authors suggest that statutory and voluntary quality systems should be coordinated with national or local government in order to ensure valid standards, reliable assessments, transparency and public accountability. They conclude that a key aim of any national strategy for quality is to identify and develop the common interests and partnerships between governmental and non-governmental contributors.
In relation to this, I note the approach taken in the United Kingdom and New Zealand where the governments are imposing statutory quality systems on health care organizations rather than building on and incorporating existing voluntary accreditation programmes, thereby possibly missing the opportunity to capitalize on the existing commitment to quality of managers, clinicians and other staff. Hopefully, in line with the recommendations in this book, a robust evaluation system of those developments is in place so their efficacy can be determined.
The environment of quality in Europe is described, including the Council of Europe, the European Union and the World Health Organization. While the quality challenges in each country vary, common lessons for quality improvement are outlined.
Part two covers the common elements of intention, organization and activity which national governments show to be important, either by formal publication or by evidence of action. These are presented under four headings: national values and priorities for quality; national organization and structures for quality; methods, techniques and tools for quality development; and resources for quality improvement.
This is a promising framework for developing a national quality strategy. A principle is espoused for each heading. These four principles could serve as positive outcomes or criteria for governments to use in designing and evaluating their national quality strategies or policies. They are accompanied by examples from different countries and some useful definitions.
The principle for methods, techniques and tools includes the concept of recognition and reward for demonstrated quality methods. Part of this is voluntary external quality assessment and improvement programmes being recognized by and consistent with statutory investigation and inspection, and their standards, assessment processes and operations complying with international criteria. ISQua’s ALPHA programme is not referred to here but is relevant as the only system specifically designed for the international evaluation and recognition through certification of health quality standards and through accreditation of health evaluation bodies and training programmes. It is good to see the acknowledgement in this context of the need for such international validation of a country’s evaluation programmes.
A number of external quality assessment mechanisms are described, and health service accreditation is covered in more detail. A set of questions that need to be answered when a national accreditation programme is being set up is included.
Some suggestions on how to implement change and resources needed for quality improvement are included. A pathway for developing a national quality system, based on steps that have been taken in a number of countries, is a useful guide for a country starting out on this process.
The annexes provide a treasure trove of goodies, including a classification of quality concepts and tools and a self-assessment questionnaire to help a country identify existing mechanisms and future opportunities of quality improvements.
The main criticism I have of this book is its lack of a consistent and easy to follow format. It is hard to differentiate major headings from sub-headings, there are no chapters, and there is no numbering system. It would be a more user-friendly tool if all the health strategy development and evaluation components were integrated into a cohesive model. It is a great little book to dip into to get ideas and find references but it has the potential to be an excellent guide for the development of a national health strategy.
The International Society for Quality in Health Care, Mana, New Zealand
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