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The Annual Quality Report. A dynamic tool for quality management and accountability. Quality System in Health Care. National level Government legislation, regulation Monitoring by HCSA, insurance companies Certification, accreditation Institution level Implementation of quality systems
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The Annual Quality Report A dynamic tool for quality management and accountability
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 Final Conference Matra Project
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 Final Conference Matra Project
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 Final Conference Matra Project
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 Final Conference Matra Project
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 Final Conference Matra Project
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 Final Conference Matra Project
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 Final Conference Matra Project
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 Final Conference Matra Project