A in health care services - who.int

1 WHO/EIP/ health ORGANIZATIONGENEVAQ uality andaccreditationin health careservicesA global reviewQuality and accreditation in health care services : a global review resultedfrom a study conducted by the International Society for Quality in HealthCare (ISQua) under contract to the World health Organization. The first ofthis report s three parts describes structures and activities at national andinternational levels around the world to promote quality in health second part catalogues quality concepts and tools in local use in variouscountries. The third part outlines initiatives in health service accreditationand analyses the operation of functioning national programmes aroundthe world. The appendices include recommendations of major internationalbodies and meetings on quality and Information for PolicyDepartment of health Service Provision (OSD)World health Organization1211 Geneva 27 AND accreditation IN health CARE services : A GLOBAL REVIEWWHO/EIP/ and accreditationin health care servicesA GLOBAL REVIEWE vidence and Information for PolicyDepartment of health Service ProvisionWORLD health ORGANIZATIONG eneva2003 World health Organization 2003 All rights reserved.

2 Publications of the World health Organization can be obtained from Marketing and Dissemination, World HealthOrganization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: for permission to reproduce or translate WHO publications whether for sale or for noncommercial distribution shouldbe addressed to Publications, at the above address (fax: +41 22 791 4806; email: designations employed and the presentation of the material in this publication do not imply the expression of any opinion what-soever on the part of the World health Organization concerning the legal status of any country, territory, city or area or of its author-ities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for whichthere may not yet be full mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended bythe World health Organization in preference to others of a similar nature that are not mentioned.))

3 Errors and omissions excepted, thenames of proprietary products are distinguished by initial capital World health Organization does not warrant that the information contained in this publication is complete and correct and shallnot be liable for any damages incurred as a result of its by minimum graphicsTypeset in Hong KongPrinted in MaltaContentsiiiAcknowledgementsixForewo rdxiPrefacexiiiSection 1. International and national structures and activities for improving health care1 Summary3 Background3 Sources3 Purpose and scope of Section 14 Methods4 Specific elements4 Sources used4 International structures and activities6 Intergovernmental organizations6 International funding organizations15 International nongovernmental organizations18 Other international resources20 National structures and activities24 Published national strategies24 National reviews27 National structures for quality29 National quality initiatives32 National resources35 Discussion39 Policy40 Structure and management42 Quality tools and methods42 Resources42 Conclusion44 References44 Section 2.

4 Quality concepts and tools51 Summary53 Management concepts53 Standards and measurements53 Implementing change53 Resources for quality improvement54 Purpose and scope of Section 254 Methods54 Specific elements54 Sources used55 Quality concepts56 Quality management systems56 External assessment58 Quality tools62 Population and community62 Consumers, users and clients64 Staff welfare65 Staff competence68 Clinical practice69 Service delivery76 Risk, health and safety78 Resource management81 Communications82 Implementing change83 Policy85 Organization85 Project methods85 Change management86 Involving the public88 Resources for quality improvement89 References90 Section 3. health service accreditation programmes103 Summary105 Sources105 Findings105 Purpose and scope of Section 3105 Methods106 Sources used106 Data collection and management106 health service accreditation : summaries by country107 Argentina107 Armenia107 Australia107 Austria107 Belgium107 Bermuda108 Bhutan108 Bosnia and Herzegovina108 Brazil108 Canada108 Colombia108 Czech Republic108 Denmark108 Dominican Republic108 Ecuador109 Estonia109 Finland109 France109 Germany109 Hungary109 India109 Indonesia109 Ireland110 Italy110 Japan110 Kyrgyzstan110ivQUALITY AND accreditation IN health CARE services .

5 A GLOBAL REVIEWL ithuania110 Luxembourg111 Malaysia111 Mongolia111 Morocco111 Netherlands111 New Zealand111 Philippines111 Poland111 Portugal111 Republic of Korea112 Singapore112 Slovak Republic112 South Africa112 Spain112 Switzerland112 Thailand112 Turkey113 United Kingdom113 United States of America113 Zambia113 Survey findings and analysis113 Distribution of responses114 Legal framework115 Relationship to government115 Year of origin116 Programme coverage117 Public access to standards118 Revision of standards119 Country of inspiration120 Site visits120 Public access to reports121 Survey activity121 Surveyor activity122 Expenditure and costs123 Income125 Reflections125 Completeness of the review125 Accuracy125 Observations126 References127 AppendicesAppendix to Member States on quality assurance, WHO Regional Committee for Europe, 1988131 Appendix of the WHO Working Group on Quality Assurance in health Care, Kiel, 1988134 Appendix of the International Consultation on Quality Assurance in District health Systems, Pyongyang, 1992135 Appendix of the Hospital Advisory Group, 1994137 Appendix of the WHO Working Group on Quality Assurance, Geneva, 1994142 CONTENTSvAppendix of the pre-ISQua Meeting on Quality Assurance Methodologies in Developing Countries, St Johns, 1995144 Appendix of the Committee of Ministers of the Council of Europe, 1997146 Appendix of the WHO/ISQua Workshop on Quality Improvement for Middle and Low Income Countries, Dublin, 2000149 Appendix of the WHO Anglophone Intercountry Meeting, Kampala, 2000150 Appendix Questions for a national quality strategy in developing countries151 Appendix National societies for quality (organizations known to ISQua)

6 153 Appendix of quality concepts and tools154 Appendix survey form156 Appendix programmes158 Appendix , ACHS162 Appendix , AGPAL163 Appendix , QIC165 Appendix and Herzegovina166 Appendix Colombia170 Appendix Czech Republic172 Appendix Finland173 Appendix France174 Appendix Germany175 Appendix Indonesia177 Appendix Ireland178 Appendix Italy179 Appendix Japan181 Appendix Malaysia182 Appendix Mongolia184 Appendix Netherlands185 Appendix New Zealand186 Appendix Poland188 Appendix Portugal189 Appendix Slovak Republic190 Appendix South Africa191 Appendix Spain192 Appendix Switzerland194 Appendix Thailand196 Appendix United Kingdom, HQS197 Appendix United Kingdom, HAP199 Appendix United Kingdom, CSB200 Appendix United States of America201 Appendix Zambia202 Appendix Abbreviations and acronyms203 Index205viQUALITY AND accreditation IN health CARE services .

7 A GLOBAL REVIEWT ablesTable Quality assurance review meetings for developing countries, 1993 20007 Table WHO publications on quality since 19908 Table WHO Regional Offices8 Table WHO African Region meetings on quality improvement9 Table WHO Eastern Mediterranean Region workshop reports and publications10 Table WHO European Region workshop reports and publications12 Table WHO South-East Asia Region selected workshop reports and publications13 Table Quality-related research projects of the European Union14 Table Selected World Bank quality improvement projects16 Table International nongovernmental organizations18 Table ISQua international conferences19 Table Principal Cochrane web sites20 Table IHI/BMJ Forum meetings21 Table Examples of QAP projects22 Table Selected international journals related to quality23 Table Selected major quality awards and industrial quality organizations24 Table Examples of legislation for quality in health care25 Table Examples of national policies for

8 Quality in health care26 Table Examples of recent reports and national reviews on quality27 Table Examples of national quality policy groups or councils29 Table Examples of national executive agencies30 Table Selected national societies for quality in health care31 Table Examples of government quality initiatives33 Table Selected government guides to quality34 Table Examples of data systems for quality in health care34 Table Selected seminal studies of adverse events35 Table Examples of recent national accreditation programmes36 Table Examples of reference centres for clinical guidelines and healthtechnology assessment37 Table Examples of national quality training programmes and conferences39 Table Examples of journals of national societies39 Table Uses of population-based indicators63 Table Satisfaction surveys66 Table health status measures67 Table Guidelines and technology assessment: selected Internet sources72 Table Examples of clinical audit73 Table Development of clinical indicators74 Table Clinical indicator programmes74 Table Research studies of adverse patient events in hospital75 Table Routine monitoring of adverse events75 Table Standardizing mechanisms76 Table WHO discussions on standards for laboratory medicine77 Table International guidelines for clinical laboratories77 Table Occasional assessment projects78 Table External calibration of sphygmomanometers, Brazil78 Table Quality in radiology departments79 Table External quality assurance of clinical laboratories79 Table External peer review79 Table Selected public enquiries80 CONTENTSviiTable Costing health services82 Table Quality of clinical records84 Table Quality of data84 Table health care informatics.

9 Selected Internet sources84 Table Coronary artery bypass surgery, Brazil, 199588 Table Consumer participation in health : selected Internet sources89 Table Costs of quality improvement90 Table Countries responding, by WHO Region and result114 Table Countries reporting more than one national programme114 Table Distribution of legislation for national accreditation115 Table National legislation related to accreditation115 Table Relationship to government116 Table Commencement of operations116 Table Duration of development phase117 Table Programme coverage118 Table Public access to standards118 Table Year of approval of current standards119 Table External influences on the development of standards120 Table Survey days per site visit120 Table Survey team members per site visit121 Table Public access to full reports of individual surveys121 Table Main sources of income125 FiguresFigure Growth of operational programmes, 1958 2001117 Figure Public charges for standards.

10 US$119 Figure Standard revisions since first survey120 Figure Full surveys completed in 1999 (except AGPAL)122 Figure Trained surveyors, by programme, 1999122 Figure Surveys and surveyors, 1999123 Figure New surveyors as percentage of total, 1999123 Figure Programme expenditure, 1999, US$124 Figure Survey fees for a 100-bed hospital, US$124 BoxesBox National quality policy: summary of recommendations41 Box Intercountry facilitation: summary of recommendations42 Box Structure and management: summary of recommendations43 Box Resources: summary of recommendations43 Box Criteria for evaluating Internet health information89viiiQUALITY AND accreditation IN health CARE services : A GLOBAL REVIEWA cknowledgementsixThis report resulted from a study conducted by the International Society for Qualityin health Care (ISQua), represented by their Chief Executive Officer, Ms Lee Tregloan,under contract to the World health Organization. The principal investigator of thestudy and author of this report was Dr Charles Shaw.