National quality improvement policies and strategies in European healthcare systems

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1 Supplement Herbert Simon Institute for Publi Poliy and Management, Manhester Business Shool, Manhester, UK Correspondene to: Professor K Walshe, Harold Hankins Building, Manhester Business Shool, Booth Street West, Manhester M15 6PB, UK; kieran.walshe@mbs.a.uk Aepted 8 Otober 2008 This paper is freely available online under the BMJ Journals unloked sheme, see qsh.bmj.om/info/unloked.dtl i22 National quality improvement poliies and strategies in European healthare systems E Spener, K Walshe ABSTRACT Objetive: This survey provides an overview of the development of poliies and strategies for quality improvement in European healthare systems, by mapping quality improvement poliies and strategies, progress in their implementation, and early indiations of their impat. Study design: A survey of quality improvement poliies and strategies in healthare systems of the European Union was onduted in 2005 for the first phase of the Methods of Assessing Response to Quality Improvement Strategies (MARQuIS) projet. Partiipants: The survey, ompleted by 68 key experts in quality improvement from 24 European Union member states, represents their views and aounts of quality improvement poliies and strategies in their healthare systems. Prinipal findings: There are substantial international and intra-national variations in the development of healthare quality improvement. Legal requirements for quality improvement strategies are an driver of progress, along with the ativities of national governments and professional assoiations and soieties. Patient and servie user organisations appear to have less influene on quality improvement. Wide variation in voluntary and mandatory overage of quality improvement poliies and strategies aross setors an potentially lead to varying levels of progress in implementation. Many healthare organisations lak basi infrastruture for quality improvement. Conlusions: Some onvergene an be observed in poliies on quality improvement in healthare. Nevertheless, the growth of patient mobility aross borders, along with the impliations of free market provisions for the organisation and funding of healthare systems in European Union member states, require poliies for ooperation and learning transfer. The free movement of goods, servies, finane and people within the European Union (EU) has profound impliations for healthare finaning and healthare systems in the 27 member states. 1 The health poliies of individual European member states are beoming more interonneted and interdependent, partiularly beause of the movement of patients and health professionals aross national borders. However, eah member state still has primary responsibility within its own borders for healthare funding, and the provision and monitoring of healthare servies, and the EU has quite limited powers to at in this area. 2 The growing internationalisation of healthare systems in Europe has an bearing on the quality and safety of health servies. 3 While many member states have enated legislation and adopted poliies and strategies at a national level, little is known about the relative progress, ompatibility, and likely interations of these national poliies and strategies, or their likely impliations for EU initiatives. 4 7 We onduted a survey of quality improvement (QI) poliies and strategies in European healthare systems as part of the Methods of Assessing Response to Quality Improvement Strategies (MARQuIS) projet. 8 The study set out to map and desribe the poliies and strategies in use aross the EU, progress made in their implementation, and early indiations of their impat. Our aim was to provide a basis for learning and exhange among member states, and to inform future more detailed empirial studies within MARQuIS at an organisational or hospital level. METHODS A literature review was onduted drawing on omparative empirial researh, ommentaries and theoretial papers, and national or international reports and guidelines on quality in healthare in Europe, published over a 10-year period ( ). 9 We searhed Medline, ASSIA, HMIC and other databases, using as searh terms, various ombinations of quality, health servies, health are and Europe. This literature was used to develop an analyti framework and questionnaire overing six main areas: national environment and ontext, quality poliy goals and values, resoures and support, poliy implementation, information reporting and evaluation, and impat. For the purposes of this survey quality improvement poliies and strategies was an umbrella term used to over a broad range of quality assurane, quality ontrol and quality management approahes to improving healthare servies. We made efforts to define these and other terms used in the questionnaire learly, but reognised that the meaning and interpretation attahed to them by respondents ould vary. We used our own and others ontats and networks, the membership of the International Soiety for Quality in Health Care (ISQua), and web resoures to identify key experts in QI in all 25 member states of the EU, inluding members of international quality soieties and well-established ontats in the field. They ame from a range of healthare bakgrounds inluding aademia and researh, quality soieties, poliy making, quality onsultanies, healthare management and linial pratie. We approahed 174 potential experts in QI by with information about the survey, of whom 103 agreed to omplete the questionnaire; 68 ompleted questionnaires were returned. The Qual Saf Health Care: first published as /qsh on 2 February Downloaded from on 4 Otober 2018 by guest. Proteted by opyright.

2 questionnaire survey was onduted in English, whih may have limited those experts who were able to take part. Quality experts from 24 member states partiipated in the survey, and the numbers of respondents were as follows: Austria (3), Belgium (3) Cyprus (1), Czeh Republi (2), Denmark (3), Estonia (6), Finland (2), Frane (3), Germany (2), Greee (1), Hungary (2), Ireland (2), Italy (5), Lithuania (2), Luxembourg (2), Malta (2), the Netherlands (2), Poland (3), Portugal (3), Slovakia (4), Slovenia (3), Spain (4), Sweden (3) and the UK.(5) The survey took plae between June and November Quantitative data were analysed using SPSS v.10, to produe a range of desriptive and inferential statistis. Qualitative data were subjeted to themati and ategorial analysis. For quantitative data, we onsidered aggregating responses from eah ountry and presenting them at the national level, rather than simply analysing and presenting data for Europe as a whole. However, the numbers of respondents in some individual ountries were too small to permit reliable analysis, and we found that in about half of the ountries there were variations in health poliies and health systems at a subnational (provinial, state or ounty) level whih made national level analyses potentially misleading. Our full report presents some analyses at both levels. 10 In this paper, we mainly present the desriptive results from the survey for Europe as a whole, while using some ountry-level data where it was appropriate to do so, by way of example. RESULTS National environment and ontext The most drivers for the development of poliies and strategies for healthare quality by governments were reported as being the work of professional organisations for example: medial and sientifi soieties; the poliies and priorities of urrent governments; and media overage of quality issues in healthare. Less influene was attributed to patient and servie user organisations, and to international drivers suh as the poliies and initiatives of the European Commission, and the ativities of ISQua (table 1). Quality improvement poliies and strategies in member states an be developed at national governmental level or at a regional level, or from the ombined, oordinated or distintive efforts of national and regional governments. Forty-four per ent of respondents reported the development of quality poliies primarily at the national level, 46% at ombined national and regional levels, and 10% primarily at the regional level. Table 2 offers some examples of eah. Supplement Fifty-five per ent of respondents reported that there was a great deal or a moderate amount of variation in poliies aross regions in their ountry. Some key regional differenes were reported in: approahes to measuring and evaluating quality; priorities aross regions and between national and regional levels; how national poliies were interpreted or implemented at regional level; organisation and implementation of QI; aess to resoures to support QI; professional motivation, training, and ompetene. Quality poliy goals and values Seventy-eight per ent of respondents reported that in their ountry there was a statutory legal requirement for healthare organisations to have QI systems, and suh a requirement was in plae in at least 18 of the 24 member states overed by our survey. Most ommonly (36%), respondents reported that this requirement had been in plae for between 5 and 10 years. Hospital servies and health servies in the publi setor appeared to be the main fous of legal requirements in QI, and they less ommonly applied to long-term and primary are and to the independent or private healthare setor. Respondents were invited to list what they saw as their government s three most priorities for QI within their own healthare systems. The most priorities identified were: development of quality standards and guidelines (18 member states); improving patient safety, orientation, and involvement (16 member states); improving the assessment and evaluation of QI (9 member states); improving information and reporting systems (8 member states); ahieving better value for money (6 member states). Two-thirds of respondents (66%) reported that there was a national poliy doument on QI in healthare produed by government. As table 3 shows, these national poliy douments frequently set out definitions of QI, systems for monitoring and measuring QI, and targets for QI. Rather less frequently they addressed issues suh as the provision of training and support for QI, or the resouring of QI. Qual Saf Health Care: first published as /qsh on 2 February Downloaded from Table 1 The level of importane given to different influenes on the development of quality improvement poliies and strategies (n = 68 respondents) Influenes on the development of quality improvement poliies Very Fairly Not very Not at all Don t know Professional organisations, medial and sientifi soieties 28 (19) 51 (35) 15 (10) 3 (2) 3 (2) Poliies and priorities of the urrent government 54 (37) 21 (14) 15 (10) 7 (5) 3 (2) Media overage of quality issues or problems in healthare 25 (17) 44 (30) 25 (17) 3 (2) 3 (2) National or regional quality task fore or working group 35 (24) 32 (22) 19 (13) 10 (7) 3 (2) Provider organisations, eg, or primary are providers 22 (15) 44 (30) 24 (16) 7 (5) 3 (2) Publi opinion about the quality of healthare 19 (13) 44 (30) 25 (17) 7 (5) 4 (3) Development of quality improvement poliies in other EU 21 (14) 38 (26) 29 (20) 9 (6) 3 (2) ountries Patient and servie user organisations 7 (5) 43 (29) 40 (27) 7 (5) 3 (2) Poliies and initiatives of the European Commission 10 (7) 22 (15) 53 (36) 12 (8) 3 (2) Ativities of the International Soiety for Quality in Health Care 4 (3) 25 (17) 44 (30) 24 (16) 3 (2) i23 on 4 Otober 2018 by guest. 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3 Supplement Table 2 Variation in the lous for development of quality poliies and strategies in government National National and regional Regional Frane Germany UK Luxembourg The Netherlands Spain Hungary Austria Italy Sweden Poliy implementation It was noted earlier that respondents reported that most ountries had some statutory requirement for healthare providers to have systems of QI in plae, partiularly in the publi hospital setor. We identified the six most ommonly used QI systems in our literature searh, and then asked respondents to indiate whether they were mandatory (their use was required) or voluntary (they ould be used if the organisation wanted to do so) in. As table 4 shows, none of these QI systems was widely mandated in the hospital setor, and there was a heavy reliane on voluntary partiipation and implementation. Patient satisfation surveys and performane indiator measures were reported as rather more likely to be mandatory, while areditation and organisational quality or total quality management programmes were muh less so. The six most ommonly used QI systems that we identified in the literature were also used as a framework in subsequent work pakages for the MARQuIS projet. 11 i24 Respondents were also asked about the extent to whih a wide range of measures to support the implementation of QI were present in in their ountry. As table 5 shows, they tended to report that longstanding traditional QI systems suh as ommittees for infetion ontrol, arrangements for equipment maintenane and laboratory quality ontrol proedures were well established. However, the fundamental omponents of a QI programme, inluding an organised system for undertaking QI projets, resoures for QI ativities, regular QI reviews of departments, and training in QI methods were all reported to be muh less ommonly found in. Progress and impat Respondents were invited to reflet and report on the three most ahievements in QI in their healthare system within the past 3 years. The most frequently ited ahievements in QI were: establishing national areditation or quality assurane systems (17 member states); establishing a national soiety for quality in healthare (13 member states); extending patient hoie, patient rights and patient safety (13 member states); improving the training and assessment of professionals (12 member states). These and the wide range of other ahievements reported tended to be onerned with the reation or development of Table 3 The ontent of national quality improvement (QI) poliy douments (n = 45 respondents who reported having aess to a quality improvement poliy doument) Topis in a poliy doument on quality improvement Topi is inluded Topi is not inluded Don t know Systems for monitoring and measuring progress of QI 82 (37) 13 (6) 4 (2) Definition of terms, eg, what is meant by QI 78 (35) 18 (8) 4 (2) Setting national targets for QI 73 (33) 27 (12) 0 Systems for asking patients and the publi for their views on quality in 73 (33) 24 (11) 2 (1) healthare Setting national standards for quality 71 (32) 27 (12) 2 (1) Systems for dealing with adverse events, problems and omplaints 62 (28) 36 (16) 2 (1) from patients Systems for professional regulation and monitoring professional 56 (25) 42 (19) 2 (1) performane Setting standards for professional eduation or training 53 (24) 38 (17) 9 (4) Provision of training or support for healthare organisations on QI 44 (20) 56 (25) 0 Provision of resoures for QI 40 (18) 56 (25) 4 (2) QI, quality improvement. Table 4 The mandatory use of quality improvement poliies and strategies in hospital servies (n = 68 respondents) Quality improvement poliy and strategy in Required in Voluntary in Not appliable/ Don t know Systems for getting the views of patients, eg, satisfation surveys, 50 (34) 43 (29) 7 (5) monitoring omplaints Performane indiators or measures 47 (32) 46 (31) 7 (5) Patient safety systems, eg, inident reporting, risk management 44 (30) 47 (32) 9 (6) Clinial guidelines, pratie guidelines 40 (27) 54 (37) 6 (4) Areditation shemes and programmes 27 (18) 54 (37) 19 (13) Audit, internal assessment of linial standards 25 (17) 63 (43) 12 (8) Organisational quality management programmes, eg, total quality management 22 (15) 66 (45) 12 (8) Qual Saf Health Care: first published as /qsh on 2 February Downloaded from on 4 Otober 2018 by guest. Proteted by opyright.

4 Table 5 The overage of measures to support the implementation of quality improvement (QI) poliies and strategies in the hospital setor (n = 68 respondents) Measure of support systems, proesses and apability in QI, rather than more diretly with the outomes of improvement themselves. Respondents were also asked to report on the main fators whih had ated either as failitators or barriers to the progress of healthare QI; the results are summarised in table 6. Respondents saw the key failitators of progress as professional involvement and training, the existene of a statutory legal requirement for QI, and publi demand or expetations, while the main barriers were a lak of funding, poor politial leadership and strategi planning, and a lak of inentives or motivations for healthare organisations and professionals to engage with QI. DISCUSSION National and international differenes in quality improvement Our survey suggests that there are substantial variations in the development of healthare QI aross the EU, both internationally and within some member states where poliies and strategies are formulated more at a regional than at a national level. These variations make omparisons diffiult, but also In all or most In many In some In a few Committee for infetion ontrol 57 (39) 25 (17) 13 (9) 1 (1) 0 3 (2) Systems for QI in laboratories 38 (26) 38 (26) 12 (8) 4 (3) 0 7 (5) Regular maintenane of linial equipment 40 (27) 32 (22) 9 (6) 10 (7) 1 (1) 7 (5) Committee for QI 21 (14) 31 (21) 18 (12) 24 (16) 3 (2) 4 (3) Reporting systems for quality problems suh as adverse inidents or events 28 (19) 18 (12) 19 (13) 25 (17) 6 (4) 4 (3) Staff training in QI 9 (6) 32 (22) 35 (24) 19 (13) 0 4 (3) Clear responsibilities for linial performane 24 (16) 16 (11) 16 (11) 25 (17) 12 (8) 7 (5) Diretor or leader of QI at a senior level in the organisation 7 (5) 28 (19) 24 (16) 34 (23) 4 (3) 3 (2) A QI plan for the organisation 7 (5) 24 (16) 31 (21) 29 (20) 2 (1) 7 (5) Information systems to provide data on quality of are 9 (6) 19 (13) 22 (15) 35 (24) 9 (6) 6 (4) Regular staff performane reviews 13 (9) 13 (9) 24 (16) 35 (24) 7 (5) 7 (5) Training for leadership in QI 4 (3) 21 (14) 38 (26) 22 (15) 9 (6) 6 (4) Regular internal quality reviews of departments or parts of the organisation 6 (4) 18 (12) 37 (25) 28 (19) 7 (5) 4 (3) An organised programme of QI projets 9 (6) 13 (9) 32 (22) 35 (24) 4 (3) 6 (4) Systemati follow-up and re-auditing of QI projets 4 (3) 9 (6) 22 (15) 44 (30) 15 (10) 6 (4) Dediated finane or budget for QI 4 (3) 6 (4) 19 (13) 49 (33) 15 (10) 7 (5) QI, quality improvement. In none Don t know reate an opportunity for international learning and the exhange of experienes and ideas. While there are some ountries in whih healthare QI has been a governmental poliy onern for up to 20 years or longer, in most it has beome a key onern for poliy makers partiularly in the past 5 10 years. But there are some ountries within Europe where the development of healthare QI is still relatively new, or even embryoni. In broad terms, these findings onur with those of earlier and smaller international surveys in this area. 4 5 Legal frameworks for quality improvement The existene of a statutory legal requirement to implement QI strategies for healthare systems and organisations was reported as being perhaps the most inentive for supporting progress in the development of QI initiatives. The implementation and development of quality poliies may therefore be at a more advaned stage in member states whih have suh a legal requirement, and whih have had a legal requirement in plae for a substantial period of time. The minority of member states who have not yet enated legislation to require healthare Table 6 Fators identified by respondents as failitators or barriers to the progress of healthare quality improvement (QI) Failitators Barriers Supplement Professional involvement, training, and initiatives (16 member states) Under-funding (17 member states) A legal requirement to implement QI (15 member states) Lak of politial leadership and strategi planning (15 member states) Publi demand, expetations and involvement (12 member states) Lak of inentives, onfused inentives, low motivation (12 member states) Quality improvement projets, eg, areditation, liensing, awards, quality assurane, Cultural barriers, eg, professional or bureaurati (11 member states) irles and forums, quality ommittees, improvement entres (10 member states) Politial interest (9 member states) Lak of professional training or eduation (10 member states) Harmonisation of poliy aross the EU, progress in other member states, international Under-staffing, time issues, neglet of staff interests (10 member states) guidelines (7 member states) A national strategy for QI (7 member states) Inadequate management and governane strutures (9 member states) A national soiety for quality (6 member states) Lak of larity in standards, aountability, ontrols, and priorities (5 member states) Finanial inentives to implement QI (6 member states) Weak publi pressure (5 member states) Strong leadership (5 member states) Punitive and negative approahes to monitoring quality or errors (5 member states) Data on linial performane (5 member states) Lak of oordination; networking at organisational, loal, and regional levels (5 member states) Having lear and expliit QI poliies (4 member states) Politial hange and transition (4 member states) Lak of and fear of transpareny (4 member states) Inadequate or unoordinated data on quality (4 member states) i25 Qual Saf Health Care: first published as /qsh on 2 February Downloaded from on 4 Otober 2018 by guest. 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5 Supplement Key messages systems and organisations to put QI poliies and strategies in plae may wish to onsider the experiene of those member states whih have done so. Who drives quality improvement In this survey, national governments emerged as the key players in developing QI poliies, setting quality standards and targets, and providing guidane and support to organisations on implementation. This reflets the major role that national governments play in healthare funding and provision in member states. However, it was notable that patient and servie user organisations were reported as having the least influene on the development of QI poliies. It might be argued that the predominant influene of governments and of the health professions through professional assoiations and soieties means it is more diffiult for patient and user groups to have their voies heard, and to play their part in shaping QI poliies and strategies. This ould mean that those poliies and strategies, and the QI ativities they produe, reflet a professional- and provider-based view of what onstitutes high-quality are. Variable progress in poliy implementation Although most member states have some form of legal, statutory requirement for QI in healthare systems and organisations, and most national governments have issued poliy douments whih set out their poliies and strategies, we found that the extent to whih speifi QI systems or approahes are required or mandated varies onsiderably, and the existene of the basi infrastruture for QI at a hospital level is rather less established than one might expet. The data suggest wide variation in the voluntary and mandatory overage of different QI poliies and strategies aross setors, potentially leading to varying levels of progress and overage in implementation. The basi infrastruture for a viable QI programme is still not present in many healthare organisations. i26 There are substantial international and intra-national variations in the development of healthare quality improvement aross the European Union, but some degree of poliy onvergene is also evident Having a legal requirement for quality improvement strategies is an driver of progress, along with the ativities of national governments and professional assoiations and soieties Patient and servie user organisations appear to be having less influene on driving quality improvement There is wide variation in the voluntary and mandatory overage of quality improvement poliies and strategies aross setors, potentially leading to varying levels of progress in implementation The basi infrastruture for quality improvement is still not present in many healthare organisations The growth of patient mobility aross borders, along with the impliations of free market provisions for the organisation and funding of healthare systems in European Union member states, reate a need for a degree of ooperation and learning transfer at a poliy level Impat The survey provides some limited evidene of the early impat of national quality poliies and strategies, although those ahievements were often desribed by respondents in terms of the development of apaity and apability for QI in healthare systems, rather than with diret examples or evidene of improved quality. It appears that there are signifiant barriers to progressing QI, partiularly onerned with funding, leadership, and inentives for both organisations and individuals. Overall, the survey results suggest that healthare QI has made at least some progress in most ountries of the EU, and that in some states there are now quite omprehensive and robust quality assessment and improvement mehanisms in plae. Limitations Some limitations of our study have already been noted. The small numbers of respondents overall, and their varying levels of knowledge and experiene about sometimes omplex poliies at a national or subnational level, all suggest that aution should be exerised in interpreting these results, and partiularly in making any ountry-level omparisons. However, later phases of the MARQuIS projet in whih we undertook surveys at the hospital level and onduted a programme of hospital visits afforded some opportunities for verifiation through triangulation, and broadly served to onfirm and support these findings. CONCLUSION Poliies on quality improvement in healthare have largely developed at a national level in EU member states, and have been driven by largely national onerns. Nevertheless, we observed some degree of poliy onvergene in areas suh as the widespread adoption of legal or statutory requirements for healthare organisations to put quality improvement systems in plae, the development of speifi mehanisms suh as areditation programmes, and the reent poliy priority aorded to patient safety in many member states. However, it seems unlikely that suh natural onvergene will produe oordinated or integrated quality systems in healthare at a European level, unless the ends of oordination and integration are more proatively pursued. 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