The following is a guest post to the Leadership Blog by Pedro Delgado, Executive Director (IHI)
The recent National Meeting of Quality in Health organized by the Superintendence in Chile and attended by over 1,000 professionals tried to answer a simple question…is there a better way to regulate healthcare while improving service delivery and outcomes? Increasingly, those involved in accreditation are interested in the methods that are commonly used for Quality Improvement.
The meeting’s theme ‘from accreditation to quality management in healthcare, new strategies, new challenges’ generated many new ideas and perspectives, and the visit made me reflect on the great opportunity for convergence between the fields of Quality Assurance and Quality Improvement.
The Chilean Minister of Health kicked off the event, highlighting the importance of expanding the scope of conditions covered by the Regime of Explicit Health Guarantees. The “Regime” - also known as Plan AUGE - now includes clinical guidelines for 80 conditions – ranked by frequency, seriousness, and cost of treatment - and has been operationalized through an explicit sub-set of enforcement mechanisms relating to access, quality, opportunity, and redress. A publicly available National Registry of Individual Healthcare Providers that will provide patients the opportunity to check whether their provider is legally entitled to render healthcare services in Chile was also announced. AUGE is being linked to the Registry, as the Ministry made it mandatory for anyone receiving care for any of the 80 conditions to be treated by a registered professional. Through accreditation, attention is also being directed at regulating institutions: it will be mandatory for all providing institutions in Chile to be accredited by July 1, 2015. All of these efforts fall broadly into the category of quality assurance which includes all those planned or systematic actions necessary to provide adequate confidence that a product or service will satisfy given needs.
The Chilean efforts are commendable. The country is serious about ensuring regulation of institutions, providers and health care content for their 17 million citizens. Regulatory actions focused on quality assurance are important pieces in the quest for quality for all in healthcare, and governments have a duty to ensure that the health system is well regulated. However, there is much to be done. Accreditation schemes in Latin American countries such as Colombia, Brazil and Chile show variable levels of adherence, participation and the percentage of institutions accredited nationally tends to be low. In addition, the evidence is weak for the effectiveness of accreditation alone to improve health outcomes.
Regulation alone is not enough to close the gaps or chasms that exist in the region around timeliness, safety, effectiveness, efficiency, person centeredness and equity. So let’s consider adding to assurance efforts quality improvement, defined by Batalden and Davidoff as the ‘combined and unceasing efforts of everyone—healthcare professionals, patients and their families, researchers, payers, planners and educators—to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development’; . And let’s use Langley et al’s ideas to illustrate some basic principles to maximize the results of improvement efforts:
Knowing why you need to improve (focused aim)
Having a feedback mechanism (data for learning and action action) to tell you if improvements are occurring and learn
Developing effective ideas for changes that will result in improvement
Testing and adapting changes before attempting to implement
Knowing when and how to make changes sustainable through effective implementation to integrate the changes in the system of interest
Chile is a great example of the possibilities of the assurance plus improvement paradigm. If we took any of the AUGE conditions (diabetes, or depression, or stroke), its a plus to have access to accredited professionals with access to evidence based guidelines, working in accredited institutions. However, is this enough to achieve better outcomes, beyond AUGE’s aim to ensure these are perceived as rights (guarantees) for the citizens on Chile? We know from examples such as the Mid-Staffordshire NHS Foundation Trust in England that regulation alone is not enough, and that regulatory targets alone may in fact be a perverse incentive that results in poor outcomes. Even if Chile were to succeed in its ambitious aims around regulation of institutions, providers and practices, would the country achieve its ultimate aim of better outcomes, better experience of care and more affordable care? Given the limitations of a purely regulatory approach, could the bold Chilean vision be enhanced by a supplemental approach?
While Chile continues to build a strong regulatory platform, their efforts could be magnified by:
Equipping all health professionals (from management to front line clinical and other staff) with basic safety and quality improvement skills to focus on the implementation side of the great tools provided by programs such as AUGE;
Helping clinical and managerial teams to develop clear outcomes driven aims, that they measure in real time and review frequently (weekly or monthly), to learn and continuously improve towards their achievements;
Equipping all healthcare students (nursing, medicine, pharmacy, and others) with basic safety and quality improvement and the opportunity to implement them during their training years, so when they finally become health care providers they have practice and experience in applying these skills;
Making measurement of facility and provider performance transparent to the public, so they are free to choose and most importantly, able to support improvement by taking an active role in their interaction with professionals and self-care;
Promoting an environment where shared learning and collaboration (coo-petition, not competition) is the rule, and not the exception.
Of course governments are not alone in the pursuit of what is best for a population; as Batalden and Davidoff stated in their definition, the ‘combined and unceasing efforts of everyone’ will be needed to move from an assurance frame, to an assurance plus improvement position not only in Chile, but throughout Latin America.