George Boulton
Topics Covered
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What is quality?
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Quality myths
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Financing to achieve policy aims
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Linking quality to a capitation system
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Joined-up implementation issues
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Quality Conference 2008
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Quality in Health Care
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“It may seem a strange principle to enunciate as the very
first requirement in a hospital that it should do the sick no
harm” – Florence Nightingale (1859)
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“Conformance to requirements” - TQM definition – Philip
Crosby ‘Quality Without Tears (1984)
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“Doing the right things, right” - J. A. Muir Gray
‘Evidence-based Healthcare’ (1997)
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Donabedian (1966) advocated the assessment of quality
through 3 approaches: Structure, process and outcome
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Defining Quality in Health Care
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Robert Maxwell Kings Fund, London (1984) identified
6 dimensions of quality:
ACCESS:
Geographical convenience, waiting time for appointment,
hours of business, transport etc?
EQUITY:
Opportunity of access for equal need regardless racial,
cultural and social factors
RELEVANCE TO NEED: Over provision, gaps in services etc.
SOCIAL ACCEPTABILITY: Is the way in which the service is provided
acceptable to the population served?
EFFICIENCY: Are the services delivered as efficiently as possible within
the resources available?
EFFECTIVENESS: Do the services provided attain the intended benefits in
for the heath of the population served?
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Quality Conference 2008
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Quality Myths
Quality is separate from efficiency. Not so, quality is
inextricably linked to efficiency e.g. TQM and DIRFT
 Patients don’t understand quality. Not so, access to
knowledge changing the doctor/patient relationship – the
‘intelligent’ patient
 Quality is a `soft`, subjective issue. Not so, quality is as
measurable as finance or activity
 Quality is a system. Not so, it is a corporate culture, a mind
set, a sub-routine as driving a car
 Quality in health care is `accreditation`, `TQM`, `EBM`, `ISO
9001`, medical audit etc. Not so, these systems and
approaches help develop and sustain a ‘quality’ culture.
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Quality Conference 2008
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Quality Sustaining Systems
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Law and regulation
Accreditation
Visiting and inspection
Licensing & re-licensing of professionals
Professional codes and standards
TQM (based on prevention and DIRFT)
CQI/Quality Assurance
Evidence-based health care
Medical Practice variation (MPV)
Contracting
Care pathways, clinical guidelines, clinical protocols, clinical
algorithms
Patient surveys
Complaints systems
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Quality Conference 2008
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Quality Sustaining Systems
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Research and development
Health Technology Assessment (HTA)
Clinical governance
Clinical /medical/organizational audit
Patient-centered planning
Performance indicator systems
Risk management systems
ISO 9000, 9001,9002 etc.
Benchmarking
League tables
Star ratings – linked to accreditation
Continuous professional education and development
Contracting
Resource allocation and reward systems
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Quality Conference 2008
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Policy Outcomes for Primary
Health Care?
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Improved community/population health status
Reduced avoidable (amenable) mortality
Improved quality of life for the chronically ill and
disabled
Morbidity compression related to the elderly
Higher volume and levels of cases resolved in
primary health care
High levels of uptake (population-based) of PHC
and preventive services
Increased patient satisfaction
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Quality Conference 2008
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Quality and its Link to Resource
Allocation & Reward Systems
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Capitation – a fixed sum per person paid in
advance (usually 1 year) to a health care entity
(e.g. DZ) for the provision of contracted health
care services to an eligible person.
Capitation should be ‘risk adjusted’ for:
Population age structure
Gender structure
Health need differences (crude or standardised
mortality rates
- Poverty/social deprivation
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Quality Conference 2008
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Capitation Reimbursement Systems
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Capitation can operate at two levels:
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As a resource allocation formula to
communities, hospitals or to PHC facilities
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As part of the reward system to individual
physicians and teams
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Quality Conference 2008
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Capitation Weaknesses
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Capitation alone can produce low efficiency and
effectiveness
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It is often used in conjunction with complimentary and
inter related financing streams:
- Incentives for high quality or good practice
- Rewards for high levels of performance
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A typical resource allocation/reimbursement mechanism
using capitation will often involve :
Capitation + Incentive + Performance (85:15, 75:25, 60:40)
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Quality Conference 2008
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Joined-up Quality Strategy
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How to link quality initiatives, approaches and
systems to the resource allocation system?
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A major quality initiative in Serbia is the Book of
Rules on Health Care Quality Indictors
Linkage can be achieved through:
Developments in the contracting process to
include quality systems, processes and targets
- Use of the incentive and performance
components of the resource allocation system
- Use of the reward system
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Quality Conference 2008
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What Should the Financing System Support?
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The development of the ‘Gatekeeper’ role
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The integration of care (referral systems, care pathways,
clinical networks, clinical protocols, care algorithms etc.)
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Increased focus on health promotion and primary and
secondary prevention systems
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Emphasis on early identification, management and control
of chronic disease and illness
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Continuous quality improvement and innovation
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Quality Conference 2008
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What Should the Financing System Support?
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Increased focus on health maintenance and quality of life
issues for the long term chronically sick
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Evidence-based practice (appropriate antibiotic use, call
and recall screening etc.) Compliance with best practice
guidelines/protocols
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Increased levels of community/patient satisfaction with
PHC
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Efficiency and effectiveness in service delivery
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Quality Conference 2008
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Finance-linked Performance
Examples
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New Zealand is currently in the process of
implementing capitation payment system and
divides the incentive and performance
components into:
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Clinical performance issues
Process/capacity performance issues
Financial performance issues
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Examples : Clinical
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Proportion of children fully vaccinated by x age
from target population
Proportion of cervical smears in accordance with
protocol from target population
Breast screening undertaken in accordance with
protocol from target population
Inhaled corticosteroids – average inhaled doses
Ratio of metformin to sulphonylurea prescriptions
Investigation of thyroid function (TSH v T4)
Ratio ESR to CRP test ordering
Flu vaccinations for +65 from target population
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Quality Conference 2008
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Examples : Process/capacity
Number/proportion of patients registered from catchment
 Number/proportion of cases resolved in PHC
 Emergency admissions to hospital for chronic conditions
 Number of new patients attending for a new episode of
treatment
 Waiting times for treatment and in facilities against targets
 Rate of blood pressure checking for over 40s compared to
target population
 Patient satisfaction (as measured by survey)
 Introduction of audit systems
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Examples : Financial Performance
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Compliance of activities, outputs to planned
Compliance of expenditure to budget
Pharmaceutical expenditure in comparison
with benchmarks
Laboratory expenditure in comparison with
benchmarks
Antibiotic prescribing patterns (1st gen/3rd gen)
Proportion of prescriptions expressed on a
generic basis
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Quality Conference 2008
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OECD Quality Indicators for Health
Promotion, Prevention, PHC (HTP No. 16)
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Practical Implementation Issues
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The urgent need for a population data base (registration) at DZ
level to help shift from a curative to a preventive service
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How to link existing quality assurance system (book of rules of
Health Care Quality Indicators) to the financing system to avoid
duplication of effort?
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Convert averages to targets (top 25 percentile performance), rates of
screening to target populations etc.
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Beware over complicated, non-transparent formulae and incentive
arrangements that can be self-defeating
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Need for financial flexibility and incentives at DZ level to promote
and stimulate innovation and continuous quality improvement?
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