Qualität im Krankenhaus - internationale Trends -

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1 29. Deutscher Krankenhaustag , Düsseldorf Qualität im Krankenhaus - internationale Trends - Prof. Dr. H.K. Selbmann Institut für Medizinische Informationsverarbeitung der Universität Tübingen

2 Im Umfeld der Krankenhausqualität entstandene Märkte Markt für Unternehmensberater Markt für Anbieter von Zertifikaten Markt für Qualitäts-Informationen Markt für berufliche Qualifizierung Profession: Ärzte, Pflege, Ökonom etc. QM-Modell: Ausbildung zu Assessoren, Auditoren, Visitoren etc. Markt für QM-erfahrenes Personal Märkte für QM oder Zertifizierung unterstützenden Instrumente (IT, Handbücher, Fachliteratur, Leitlinien, Behandlungspfade, Benchmarking etc.) Markt für Forschung (Health Services Research)

3 Treibende Kräfte Patientenautonomie Wettbewerbsfaktor für Anbieter (Alleinstellungsmerkmale) Steuerung der Qualität durch Finanziers und Gesundheitspolitik

4 Council of Europe No. R (97) 17 The Committee of Ministers recommends that the governments of the member states create, where appropriate, policies and structures that support the development and implementation of Quality Improvement Systems, that is, systems for continuously assuring and improving the quality of health care at all levels... e.g. support structures, full use of resources, pre- and postgraduate education, incentives, public accountability, internal evaluation, quality related research, European cooperation

5 Europe for Patients an FP6 SSP Project 2005

6 Aktuelle internationale Schwerpunkte Transparenz - Qualitätsindikatoren - verpflichtendes oder freiwilliges Benchmarking - Qualitätsberichte und Hitlisten - Qualitätszertifikate Patienten-Sicherheit - Leitlinien, Protokolle, Behandlungspfade - Risk Assessment und Management, - Critical Incident Reporting Systems

7 Benchmarking Programs with Quality Indicators ORYX der JCAHO, Part of Accreditation, USA AMI (15), Herzinsuffizienz (4), Pneumonie (12), Op.- Komplikationen (3), Perinatologie (3) IQIP (mit europäischen Partnern), USA stationär (96), ambulant (37), psychiatrisch (42), Langzeitpflege (49) Verein Outcome, CH Output (organis. Bereiche) 4, diagnosen-unabhängig 4, diagnosen-abhängig 7, Patientenzufriedenheit 1 NHS Healthcare Commission, UK key targets 8, clinical focus 10, patient focus 16 (outcome rare) Externe Qualitätssicherung der BQS, D 20 überwiegend operative Bereiche, 169 Qualitätsindikatoren (ca. 50% Outcome) National Quality Measurers Clearinghouse (früher CONQUEST), USA 606 Indikatoren von 34 meist nordamerikanischen Produzenten

8 BAQ: periphere Nervenläsionen nach Karotis-TEA, Bayern 1999

9 Euro Health Consumer Index 2006 Provider Catalogue with Quality Ranking not-so-good Austria, Belgium Czech Rep., Denmark Estonia, Finland Germany, Greece Hungary, Ireland Italy, Latvia Lithuania, Luxemburg Malta, Poland Portugal, Slovakia Slovenia, Spain Sweden so-so Cyprus France Netherlands good United Kingdom (Health Consumer Powerhouse 2006)

10 Stillfreudiges Kh Babyfreundliches Kh Behindertengerechtes Kh Energie sparendes Kh Rauchfreies Kh Tumorzentrum, CCC Brust-, Darm-, Fußzentrum DMP-Krankenhaus Perinatalzentrum QMKD-Zertifikat (Klinische Diabetes Einrichtungen) Schmerzfreies Krankenhaus

11 Die wichtigsten Bewertungs- /Zertifizierungsverfahren in Europa EFQM: EQA, Nationale Preise, Anerkennung, Verpflichtung zur Exzellenz ISO 9001: 2000 (1987) Vornorm für Gesundheitseinrichtungen incl Anleitung( ) USA: JCAHO (1951) CND, AUS, GB, F, I, JCI-A... D: KTQ (2002) Peer Review (Vorbild: Visitatie-Programm, NL, Modelle in D: Pulmonolog., Innere, Neurologie etc.) Selbst- oder Fremdbewertung der Unternehmensqualität bzw. Preisvergabe Zertifizierung des Qualitätssystems Genuin-medizinische Zertifizierung der Gesundheitseinrichtung Fachliche Beratung in Versorgungsfragen

12 Zertifizierungs-/Accreditation Programme in Europe EU 1990 UK HQS und HAP 1994 Finland 1996 Spain F. A. Donabedian 1997 Czech Republic (Stand 2002/2004) Non EU 1998 Poland Switzerland 1999 France, Italy (Lombardia), Latvia, Netherlands 2000 Portugal, UK QI Scotland 2001 Germany, UK RCGP Bulgaria 2002 Denmark, Ireland, Italy (3) Kyrgyzstan 2003 Bosnia (Rep Srpska) 2004 Croatia funded by government Shaw: Accreditation in European Health Care. J Qual Patient Safety 32, 2006,

13 Requirements of Certificates If healthcare facilities want to gain the confidence of patients and financiers by quality certificates, patients and financiers must be able to have confidence in the organisations responsible for the certification procedures and processes. Certification procedures and processes have to be: Valid (if quality is written on the outside, quality must be inside!) Reproducible (independent from evaluation bodies and individual certifiers (auditors, visitors, assessors etc.)

14 International Principles for Healthcare Standards (QM for Content, Indicators and Measurement) Standards contribute to quality and performance improvement in the health organisation and the wider health care system. The scope of standards is patient/client focused and encompasses the management und support infrastructure of that organisation or services. The content of standards is comprehensive and reflects the following dimensions... Standards are planned, formulated and evaluated through a defined process. Standards enable consistent measurement. (März

15 International Accreditation Standards for Healthcare External Evaluation Bodies (QM for the Process of Certification) Governance and strategic directions (6) Organization and management performance (7) z.b. Internal quality management, risk management Human resources management (5) Surveyor/Assessor selection, development and deployment (7) Financial and resource management (2) Information management (4) Survey/Assessment management (7) Accreditation/certification process (6) Standards development (5) Education services (2) met by UK HQS and HAP, France, Ireland (März

16 Aktuelle internationale Schwerpunkte Transparenz - Qualitätsindikatoren - verpflichtendes oder freiwilliges Benchmarking - Qualitätsberichte und Hitlisten - Qualitätszertifikate Patienten-Sicherheit - Leitlinien, Protokolle, Behandlungspfade - Risk Assessment und Management, - Critical Incident Reporting Systems

17 Institute of Medicine, USA 1990: Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. Oft auch Vorlagen für Richtlinien, Protokolle, DMP oder Behandlungspfade

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20 Council of Europe No. R (06) 07 The Committee of Ministers recommends that the governments of the member states ensure that patient safety is the cornerstone of all relevant health policies, in particular policies to improve care. e.g. Patient-safety policy framework, reporting systems of patient-safety incidents (CIRS), complementary sources of information on patient safety, educational programs, reliable and valid indicators for patient-safety (21 from OECD), international co-operation, research on patient safety

21 2007 International Patient Safety Goals (Joint Commission International) Goal: Identify Patients Correctly Requirement 1: Use at least two (2) ways to identify a patient when giving medicines, blood or blood products; taking blood samples and other specimens for clinical testing, or providing any other treatments or procedures. The patient's room number cannot be used to identify the patient. Goal: Improve Effective Communication Requirement 2: Implement a process/procedure for taking verbal or telephone orders, or for the reporting of critical test results that requires a verification "read-back" of the complete order or test result by the person receiving the information. Goal: Improve the Safety of High-alert Medications Requirement 3: Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride >0.9%) from patient care units. Goal: Eliminate Wrong-site, Wrong-patient, Wrong-procedure Surgery Requirement 4: Use a checklist, including a "time-out" just before starting a surgical procedure, to ensure the correct patient, procedure and body part. Requirement 5: Develop a process or checklist to verify that all documents and equipment needed for surgery are on hand and correct and functioning properly before surgery begins. Requirement 6: Mark the precise site where the surgery will be performed. Use a clearly understood mark and involve the patient in doing this. Goal: Reduce the Risk of Health Care acquired Infections Requirement 7: Comply with current published and generally accepted hand hygiene guidelines. Goal: Reduce the Risk of Patient Harm Resulting from Falls Requirement 8: Assess and periodically reassess each patient's risk for falling, including the potential risk associated with the patient's medication regimen, and take action to decrease or eliminate any identified risks.

22 Incident Type N % patient accident ,1 treatment, procedure medication infrastructure access, transfer, discharge clinical assessment documentation Total from April to June ,2 8,6 7,5 7,4 6,1 6,0 100,0 Tab. 4 Reported incident types in acute /general hospitals

23 Aktuelle internationale Schwerpunkte Transparenz - Qualitätsindikatoren - verpflichtendes oder freiwilliges Benchmarking Die Hoffnung ist groß, - Qualitätsberichte und Hitlisten dass diese Aktivitäten -der Qualitätszertifikate und dem Patienten Patienten-Sicherheit tatsächlich nützen. - Leitlinien, Protokolle, Behandlungspfade - Risk Assessment und Management, - Critical Incident Reporting Systems

24 Tübingen auf dem Kopf Herzlichen Dank