QUALITY POLICY IN THE HEALTH CARE SYSTEMS OF THE EU ACCESSION CANDIDATES Ursula Fronaschütz, Ursula Püringer

1. QUALITY POLICY IN THE HEALTH CARE SYSTEMS OF THE EU ACCESSION CANDIDATESUrsula Fronaschütz, Ursula Püringer FEDERAL MINISTRY OF SOCIAL SECURITY AND GENERATIONS

2. Presentation contents • Introduction and Background- Ursula Fronaschütz, BMSG • Results of the Austrian study on quality policy in the health care systems of the accession candidate countries (2000) - Ursula Püringer • Quality in Health Care - Experiences from different accession candidate countries - Ursula Püringer and local experts

3. Formal Framework of the Enlargement Process • structured negotiation process • envolvement of authorities at E.U. and national level • based on the acquis communautaire • formal requirement for full memership

4. Informal Framework of the Enlargement Process I • need to know more about each other • E.U. law allows differences • systems in the EU member states • transition systems in the accession candidate countries • development of E.U. health strategy?

5. Informal Framework of the Enlargement Process II • role of international players • role of national players – specific topics of national interest • 1998: Austrian study on quality policy in the health care systems of the EU member states • 2000: Austrian study on quality policy in the health care systems of the accession candidate countries

6. Study titel and authors • Quality policy in the health care systems of the accession candidate countries - Status quo and perspectives • Authors: Ursula Püringer, Brigitt Abbühl and Josef Dézsy

7. Study objectives • Status quo of quality policy in the health care systems of the 12 EU accession candidate countries • Quality assurance in the different health care sectors • Potential and need for cross-national co-operation

8. Study methodology • Countries involved: Bulgaria, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Republic of Cyprus, Romania, Slovak Republic, Slovenia • Sources: questionnaire; personal and/or telephone semi-structured interviews; health care policies, strategies, laws and regulations of the respective country

9. Study results • Historical development: • Quality efforts in the 12 EU candidate countries have to be seen in the light of recent political and economic developments in the region • Health care systems have undergone considerable organisational changes over the last decade

10. Study results • Development of quality policy and introduction of quality assurance measures: • Only recently topic on the health care agenda • Very much oriented towards structural quality issues

11. Study results • Main reasons to implement quality assurance strategies: • Unacceptable variations in performance, practice and outcome • Ineffective or inefficient health care technologies and/or delivery • Customer dissatisfaction

12. Study results • Main reasons to implement quality assurance strategies: • Unequal access to health care services • Waiting lists • High costs to society • Commitment to cost containment

13. Study results • Importance of a national health care quality policy well recognised • Various laws and regulations in place • Often defined responsibilities at the national level (quality task forces, expert committees, national co-ordinator for quality in certain medical fields)

14. Study results • However, these functions are not always vested with the power and resources to sufficiently co-ordinate ongoing quality activities which seems to be a common problem.

15. Study results • Main quality approachesused: • Registration and licensing of physicians and health care institutions • Certification,accreditation, registration of drugs, medical devices and blood products • Development of practice standards/guidelines and audit/peer reviews.

16. Study results • Estonia and many others: regular patients’ satisfaction studies • Latvia: quality policy formulated including a systematic approach along the quality of structure, process and outcome with regard to all health care service delivery. • Poland, Hungary: mechanisms installed to start Health Technology Assessment.

17. Study results • Professional organisations: • Great interest in developing diagnostic and treatmentguidelines to improve day-to-day practice and base doing on scientific (evidence based) decision-making • Diagnostic and treatment guidelines exist nearly everywhere for diseases of public health importance (chronic diseases) and/or the most cost-intensive treatments

18. Study results • Continuous medical education (CME): • High priority to enhance the qualifications of doctors in all medical specialisations • Health insurance companies/institutions: • Crucial role in improving external quality control of the services they purchase.

19. Study results • Hospital level: • Several quality activities take place in all the accession countries • Medical audit, quality circle work, participating in quality awards, patient satisfactionsurveys • Different financing models have been worked out (Hungary 0.1 per cent of total budget of a hospital is dedicated to the establishment and operation of a quality system)

20. Study results • Main hurdles and barriers for a broad implementation of quality assurance in the respective health care systems: • At national level: missing national quality policies, strategies and financing, lack of co-ordination of the various activities

21. Study results • Either, relevant institutions are missing altogether at the national level (quality centres, committees or national co-ordinators) and/or because of the lack of unified quality assessmentcriteria or clinical indicators.

22. Study results • Institutional level: • Resistance of doctors, lack of adequate information systems, additional (mainly administrative) workload • Lack of quality specialists • Having undergone a specialisation as a quality manager does not necessarily guarantee an adequate position within the health care system

23. Study results • Possibilities of a cross-border co-operation in the field of quality assurance in the public health sector are seen positively

24. Study results • In the following areas closer co-operation with the EU would be appreciated: • Quality in hospitals, in particular accreditation and evaluation • Establishment of evidence-based guidelines • Establishment of central medical databases • Establishment of a Health Information System • Telemedicine

25. Study results • In the following areas closer co-operation with the EU would be appreciated: • Management of upcoming challenges concerning electronic health care e.g. chip cards • Establishment of standard data sets for electronic patient records (generic and/or disease specific) • Participation in joint EU projects in the field of quality assurance

26. Study results • In the following areas closer co-operation with the EU would be appreciated: • Participation on workshops, seminars, conferences • Training and education for quality • Collaboration with the EU institutions running similar activities • Co-operation and advice with regard to health care reform

27. Study results • Special emphasis: • Health care quality issues should have a higher priority on the political agenda of the EU • EU-directives should force governments to develop national qualitystrategies and provide the legal framework for organisational change e.g. install quality boards and quality managers within organisations.

28. Study results • Special emphasis: • Support in research, mutual projects, exchange of experiences and quality indicators for international comparisons could be of great help to meet the challenges of the future.

29. Country highlights • Bulgaria: • Situational analysis, priority setting in perinatal care, involvement in quality programme of the WHO • Possibilities studied to develop an own national strategy for quality improvement of health care services based on continuous quality improvement: • focus on the consumer • process development • involvement of all participants in the process of providing health services

30. Country highlights • Bulgaria: • The MoH has established a task force for quality policy. • Up-to-date tools for quality assessment and quality improvement should be introduced in health care facilities (protocols for comparison and evaluation, peer review, medical audit) • Each health care facility should have programmes for quality improvement

31. Country highlights • Estonia: • A Quality Policy for the Estonian Health Care System was prepared during 1996 – 1997 within the framework of the Estonian – Dutch co-operation program ”Quality Improvement of Estonian Health Care, Strengthening Primary Care and Reforming Hospital Network” and introduced to a broader audience in 1997.

32. Country highlights • Estonia: • Development process of the Quality policy: • Working group with representatives of Ministry of Social Affairs (MoSA), University of Tartu, Central Sick Fund, EMA, and Estonian Nurses Association (ENA) prepare draft document of the quality policy

33. Country highlights • Estonia: • Draft document distributed to all Estonian counties and organisations: the EMA andprofessional societies, the Estonian Hospital Association, the ENA, the Estonian County Doctors Association, the Estonian Sick Fund Associations, the Estonian Private Doctors’ Association, the Estonian Disabled People Association, etc. • Based on the received comments amendments made in the quality policy document

34. Country highlights • Estonia: • Since the implementation of a quality policy at the national level requires the co-ordination of activities of various counterparts the quality policy document suggested to set up a ”Centre of Health Care Quality”, which could support and co-ordinate quality projects, quality assurance programs and the development of practice guidelines in the country.

35. Country highlights • Hungary: • Quality assurance related activities at the Division of Health Assurance of the National Health Insurance Fund: • Project for quality assurance in primary health care • Provision of educational materials (CD or floppy disk, general handbook of quality assurance in primary health care and the elaboration of examples related to the chapters of this handbook)

36. Country highlights • Hungary: • Service providers inform the organisers annually about their Quality Statement which contains strategies for providing high-quality services and their quality improvement ideas (process regulation - protocols and guidelines, initiatives for detecting mistakes, eliminating them, and preventing new ones and education plans). Participants submit a summary report on the activities performed in the field of prevention quarterly.

37. Country highlights • Hungary: • Quality survey • Since 1998 annual surveys by questionnaires have been carried out, involving variable numbers of service providers to get a general overview of quality assurance related activities • The surveys provide a comprehensive view on healthcare quality assurance related activities

38. Country highlights • Latvia: • Health Statistics and Medical TechnologyAgency was established 1998 to develop and maintain registers of certified medical professionals, medical services, medical technologies and devices • Quality assurance model based on the typical Donebedian quality criteria of structure, process and outcome has just been elaborated

39. Country highlights • Latvia: • First pillar of the quality assessment scheme: • In 1999 the Agency has started to audit and certify the six groups of health care providers (blood services, medical rehabilitation, dentists, outpatient department, GP practices and hospitals) on the ”Compulsory Requirements for Health Care Organisations” (emphasis on structural quality)

40. Country highlights • Latvia: • For this process the Agency uses its own specialist staff (10 people) and 180 experts from professional organisations • Additionally, the agency has assessed 140 Latvian laboratories according to European standards. 45 of them participate regularly in international interlaboratory comparisons

41. Country highlights • Latvia: • Second pillar of the quality assessment scheme: • voluntary ”Quality assurance system assessment” including the development of diagnostic and treatment guidelines (health care organisations are free to develop themselves together with professional organisations and the Ministry of Welfare) • Competitive advantage with regard to health insurance contractsfor those institutions acting according to it

42. Country highlights • Latvia: • In a third stage, only after implementation of the first two steps of quality assurance, health care services’ outcome can be evaluated. • For the future the agency plans to introduce health technology assessment according to the following scheme:

43. Country highlights

44. Country Highlights • Slovenia: • Medical chamber: very active in initiating and co-ordinating quality projects together with the Ministry of Health and some international co-operations (e.g. NIVEL in a quality circle project) • Peer reviews are performed regularly in hospitals • There is a mandatory medical (internal) audit • National project for the development of quality indicators across all specialist groups

45. Country Highlights • Slovenia: • In 1995 a draft policy on quality in health care was introduced at the WHO Ljubljana conference and published in the national medical journal • This draft has been distributed to the professional associations of each speciality and to all major providers in health care, to the Ministry of Health, the National Insurance Institute, the Association of Consumers and other interested parties

46. Country Highlights • Slovenia: • Positive results from already ongoing quality projects like Oratel, Obsquid and Diabcare had implications for the implementation of the policy • Building on the success of such model projects can encourage providers in other areas of health care to start quality improvement activities and the broad network of already collected data can serve as a model for indicator driven quality improvement

47. Country Highlights • Slovenia: • Many separate laws and regulations define quality assurance in the Slovenian health care system • An expert committee for quality in health care has been set up at the Ministry of Health • A national co-ordinator for quality in general practice has been appointed, however, both functions lack adequate financial support