Strengthening quality governance in the hospital system and creating a quality culture

The Turkish Government has already set up initiatives for accrediting public hospitals and licensing health professionals, as described in Chapter 1. Having achieved significant level of productivity, emphasis should now move to strengthening quality governance in the hospital system as a whole, with the goal of aligning quality culture and clinical outcome in the public, university and private hospital. This is especially important in light of the trends observed in the previous sections - growth in activity and spending, particularly in the private hospital sector, as well as unequal growth across regions - warranting attention in three main areas:

  • • the establishment of system-wide quality obligations, as a necessary counterpart of granting licensure to practice and SSI funding
  • • the development of quality monitoring systems across the public and private sector
  • • the encouragement of a safety and quality improvement culture.

System-wide quality of care initiatives should be developed

Turkey is in the process of moving towards a governance model whereby the government takes responsibility for assuring quality and safety of health services, rather than the operational running of health services and activities. It is important that services offered by private hospitals be included as part of this process. Experience from other OECD countries suggests that the government has a role to play in providing a framework for system-wide quality governance and create an even playing field across different hospital sectors. For example:

  • • In Australia, the Commission on Safety and Quality in Health Care has developed the National Safety and Quality Health Service Standards (NSQHS Standards), which were implemented nationally from the first of January 2013. Under the new accreditation model, state and territory health departments have agreed that public and private hospitals are required to be accredited to the NSQHS Standards. Further, some states and territories require that additional health service organisations be accredited to the NSQHS Standards. Each hospital selects an approved accrediting agency (agencies accredited by an internationally recognised body) and works with the Commission to ensure the consistent application of the NSQHS Standards. The accreditation cycle ranges from three to four years, and the frequency and style of the mid-cycle assessment, periodic review or surveillance audit vary between agencies. The accrediting agency will provide data on accreditation outcomes to state and territory health departments and to the Commission, which will use this information to report to Health Ministers on the safety and quality of health service organisations across Australia.
  • • In England, the Care Quality Commission (CQC), an independent statutory body established in 2009, is responsible for hospital accreditation and standards, including both regulation and inspection. Hospitals are required to register with the CQC, which reviews all (NHS and private) hospitals in England to verify that national standards of safety, patient centeredness, and care effectiveness are met. The findings of such reviews are shared with the public, and the public is encouraged to share their experience or report concerns to the CQC. The role is similar to the tasks of the Joint Commission in the United States, and the standards are in line with those of the Joint Commission. Many private hospitals also apply for voluntary accreditation to demonstrate quality of care.
  • • In France, the accreditation of all health-care organisations, whether public or private, has been mandatory since 1996. The law insists on external evaluation against standards, incorporating practice guidelines and external recognition. Accreditation focuses specifically on safety issues related to care and is managed by an independent national agency. Financing is ensured partly by the government and partly by the hospitals. The results of the accreditation are communicated to the public and the Regional Hospitalisation Agencies (RHA). In 2004, the government created the Haute Autorite de Sante (HAS), an independent body with financial autonomy in charge of providing information to the public, and responsible for providing health authorities with information needed to make decisions on the reimbursement of medical products and services.
  • • In the United States, the Joint Commission, an independent, not-for- profit organisation, has accredited public and private hospitals for more than 60 years. Approximately 82% of the US hospitals are currently accredited by the Joint Commission. Joint Commission standards focus on organisational quality and the safety of the environment in which care is provided. A Joint Commission accreditation is a condition for licensure and the Medicaid reimbursement in many states. The Commission’s inspections results are made available to the public on the Quality Check Website. Findings from the Joint Commission inspections and accreditation procedures were released in an annual report on quality and safety in 2011, listing hospitals and their performance. Hospitals are subject to a three-year accreditation cycle. Other health-care accreditation organisations also operate in United States.

In 2008 the Turkish Government introduced licensing requirements for private hospitals to ensure quality, and also capped supplementary fees charged by hospitals to patients. A system of standards has been developed to assess the quality of hospital services, which applies to private hospitals, too. In addition to expanding the scope of such government standards, which at the moment focus mainly on structural and process indicators, Turkey could consider strengthening other forms of accreditation of hospitals, inspired by ISQua. This is already happening, in a limited way, as some private hospitals seek voluntary third-party accreditation from the Joint Commission International Accreditation System or Hospital ISO Certification as a way to attract international patients, but could be further encouraged. Accreditation incentivises hospitals to review their care and compare it to international standards, so that compliance with the standards encourages quality improvement of the hospital. Another important area would be to specify minimum staff qualifications and profiles, safety standards and other minimum standards to be met across the public and private sector.

Strengthening monitoring of quality of care across the public and private sectors

The collection and reporting of quality indicators helps to monitor safety and effectiveness of care and contributes to efforts to reduce medical errors and unnecessary treatment. Data infrastructure and monitoring of quality of care in Turkish hospitals could be further strengthened and the underpinning data infrastructure developed across the public and private sector. Chapter 1 already describes the impressive improvement in the data infrastructure for public hospital services at the Ministry of Health level. A quality indicator programme has also developed in the public sector. While private hospitals claim that they collect already some quality indicators, these are not known to the Ministry of Health, or necessarily to patients.

It would seem desirable to strengthen current government efforts at developing quality indicators by extending them to all Turkish hospital sectors, and encouraging reporting by private hospitals on their quality measurement efforts. Nevertheless, Turkish authorities should resist the temptation of imposing top-down requirements onto hospitals. Rather, this process would need to occur as part of the broader reform agenda to support greater hospital transparency and accountability. Individual hospitals should be offered timely feedback on the data submitted, as well as the possibility of monitoring where they appear versus their peers, and thereby identify areas for improvement.

Eventually, this might also support informed decision-making if clinical quality indicators are made available to the public. Some studies suggest that patient satisfaction for inpatient settings is higher than in the equivalent public sector hospitals (Taner and Antony, 2006; Tengilimoglu et al., 1999; Yildiz and Erdogmus, 2004). However, while service and responsiveness (e.g., privacy, communication between the patient and hospital personnel, security, conform and hotel service) are an important dimension of quality, a main concern for patients in making should be that they receive the safest and more effective clinical care quality.

Other OECD countries have initiatives or have arm’s length organisations tasked with reporting on quality indicators in the hospital sector, including private hospitals. These have in some cases been associated with policies to encourage competition by improving information available to consumers and encouraging patient choice. Turkey could look at some of the steps taken in other OECD countries for inspiration. For example:

  • • In Australia, the Institute of Health and Welfare National Hospital Performance Statistics collects 15 indicators for public and private hospital performance which are annually reported, including, for example, accreditation status, emergency department waiting times, adverse events and length of hospital stay. In addition, the Australian Council on Healthcare Standards (an independent organisation providing accreditation of health services), has developed 300 hospital indicators in specific clinical areas, with comparative reports in different clinical areas provided by voluntarily participating hospitals (ACHR, 2008).
  • • In England, the Care Quality Commission reports the health-care performance ratings of Acute and Specialist care trusts on an annual basis. Indicators reported include, for example, waiting times (for emergency admissions, waiting less than two weeks for all cancers); hospital cleanliness, time spent in emergency departments, as well as ten clinic indicators and 16 indicators focused on the patient. The Commission also collects data from independent acute services on range of indicators such as serious injury, returns to theatre, unplanned transfer of patients, unplanned re-admissions, surgical site infections and staphylococcus bacteraemia. In addition, the National Centre for Health Outcome Development (NCHOD), publishes comparative reports including clinical quality indicators for services provided by an NHS health-care service.
  • • In France, national indicators for measuring the quality and safety of hospitals are a component of the hospital accreditation system implemented in 1996, and, since 2009, it has been mandatory for all private and public hospitals to report indicators publicly. The Haute Autorite de Sante (HAS) establishes an annual list of indicators to be reported and the conditions in which all hospitals should make the information public. Although quality indicators are intended to be used for inter-hospital comparison and benchmarking, they are mainly used to achieve compliance with external regulations and standards. Clinical uses of quality indicators are currently being developed, particularly in specialties concerned with measuring quality of care and as part of initiatives such as practice assessment and improvement programmes. The use of indicators for inter-hospital comparisons is underdeveloped at present and mainly takes the form of informal initiatives or reliance on existing professional networks as intermediaries. Public authorities and professional networks are gradually incorporating indicators into their tools and initiatives and the national indicators are beginning to play a part in a global policy of public reporting on hospital performance (HAS, 2011, 2013).
  • • In the United States, the Agency for Healthcare Research and Quality at the US Department of Health and Human Services provides research on safety and quality of health care. The Agency has developed patient safety and quality indicators based on hospital inpatient administrative data to measure health-care performance in several clinical areas, including inpatient care and patient safety. The Agency aims to promote quality improvement and a quality of care culture across the hospital sector, both public and private.

A broader issue is the philosophy or approach underlying quality assurance in Turkey’s hospital sector. The focus of hospital quality monitoring should move from one of control and penalising bad performers, to one of better encouraging continuous improvement. Clinicians and hospital managers should be encouraged to change practice towards better and safer care. Turkey’s creation of Hospital Unions and balanced scorecards of positive and negative performance indicators will go some way towards this. Other ways encourage a culture of continuous quality improvement would be:

  • • educational measures
  • • data collection and disclosure requirements with feedback on performance provided back to hospitals and hospital clinicians
  • • the celebration of good practices or encouragement of hospital/clinician “champion roles”
  • • encouragement of self-assessment tools.

The experience of other OECD countries could guide Turkish authorities in their efforts.

For example, a study on hospital improvement strategies in the United States suggests key factors that have contributed to the creation of a culture of quality improvement (Silow-Carroll et al., 2007). First, often in a response to a crisis management satiation, hospitals have implemented organisational changes, such as such the establishment of multidisciplinary teams that address deficiencies, quality-related committees, policies to encourage staff to express concerns, and encouragement of clinical or nursing champions who take a lead in developing protocols. These structural changes helped to develop a process of systematic problem-identification and problem-solving, which in turn helped the set-up of new treatment protocols and practices. These letters included, for example, the development of clinical guidelines and protocols, department-specific quality plans with well-defined goals, better educational material on issues such as error reduction, hand-washing and infection prevention, and investment in information technology to reduce medication errors and improve data collection.

Nurses, because of their key role as caregivers and therefore their influence on the quality of the treatment provided, have also been demonstrated to play a pivotal role in driving a quality improvement culture. The American Nurses Credentialing Center, a body of the American Nurses Association, has developed the Magnet Recognition Programme, which recognises those organisations that collect nursing-sensitive quality indicators and are able to benchmark data against national or regional databases. Other requirements focus on encouragement of nurses to express concerns and the establishment of a nursing council, for example. The purpose is therefore to help identifying practices that deliver quality, and facilitate the dissemination of good practices (Draper et al., 2008).

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