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The National System of Health Quality Assessment
Álvaro Moreira da SilvaBoard of Direction ERS
Porto, 08 May 2014
SINAS
1. Framework for assessing global quality
2. SINAS@Hospitais (Hospitals)
3. SINAS@Saúde.Oral (Dental Care)
Outline
Legal framework
ERS have a legal obligation to develop an evaluation system, which aims to assess health care providers in terms of global quality of services
The National System of Health Quality Assessment SINAS
Inform patients on quality of health care services
Encourage continuous improvement in the quality of health care services
SINAS: Assessment model
Rating System
Voluntary collaboration of health care providers
Data are collected in different formats, which result in the classification of each establishment
ERS conducts audits of randomly selected establishments, in order to validate the information submitted
Global Quality Assessment
Quality in health care:
No consensus on a closed form definition
Conceptualizations of quality depend on how broad is the model of care
considered (e.g, just medical care or nursing care included?)
Health care services includes more than just health care
Multidimensional approach needed
SINAS framework
Modularity of the SINAS project:
Type of health care provider (“SINAS modules”)
Quality dimensions
SINAS@Hospitais
Clinical Excellence
Patient Safety
Comfort of facilities
Patient Focus
Patient Satisfaction
SINAS@Saúde.Oral
Registration and licensing
Organization and Procedures
Patient Safety
Comfort of Facilities
Patient Satisfaction
Methodologies
Specificities
Quality dimensions being assessed are type-of-
provider-specific
Methodologies for quality assessment are
dimension-specific
Technical coherence (same methodologies for
similar indicators)
Methodologies for performance measurement
Methodologies for producing ratings
1st level of assessment: awarding stars
provider complies with all required quality
standards
↓
Access to RATING
compliance with all required quality standards could not be
confirmed
↓
No access to RATING
provider did not collaborate with the
assessment
↓
No access to RATING
Assessment scheme: stars and ratings
2nd level of assessment: awarding ratings
Assessment scheme: stars and ratings
quality level IIIprovider with above
average performance
quality level IIprovider with average
performance
quality level Iprovider with be low average performance
insufficient samplesample size was insufficient for
statistical inference
unreliable datainconsistencies in data were
detected
not assessed area starting assessement
data not supplied
Schedule of assessments and public disclosure
Frequency: twice a year
Communication channel: dedicated website
www.websinas.com
Public disclosure of star and rating coded results
Provider-specific reportsWith detailed results of performance on each
indicator
Transparency: all methodological aspects of the
assessments fully described in the website
SINAS implementation
SINAS modules currently implemented
SINAS@Hospitais
Assessment of hospitals
SINAS@Saúde.Oral
Dentists offices and dental care clinics
1. Framework for assessing global quality
2. SINAS@Hospitais (Hospitals)
3. SINAS@Saúde.Oral (Dental Care)
Outline
Implemented
Implemented
Being developed
Implemented
Implemented
Quality dimensions Status
Clinical Excellence
Adequacy and Comfort of Facilities
Patient Safety
Patient Satisfaction
Patient Focus
SINAS@Hospitais
SINAS@Hospitais
Clinical Excellence
Clinical areas being assessed
Orthopaedics, Gynaecology, Obstetrics, Paediatrics, Acute Myocardial
Infarction, Stroke, Ambulatory Surgery, Vascular Surgery, Cardiac Surgery,
Colon surgery and Intensive Care Units
Clinical indicators
Process indicators
Outcome indicators
Methodologies
For process indicators: no risk adjustment
For outcome indicators: risk adjustment model
Model of performance assessment Assessment based on a check-list covering structural
and organisational characteristics of facilities
Issues considered in assessment check-list
Adequacy Comfort
1. Accessibility 5. Hospitalization
2. Maintenance 6. Additional areas
3. Self protection measures 7. Comfort
4. Risk assessment 8. Quality control
SINAS @ Hospitais
Adequacy and Comfort of Facilities
Performance indicator:
Percentage of items in check-list that are present
Methodology for producing ratings:
Clustering: assigning a set of objects into groups so that the objects in the
same group are more similar to each other than to those in other groups.
SINAS @ Hospitais
Adequacy and Comfort of Facilities
Two perspectives of assessment
1) Ex-ante: patient safety culture
2) Ex-post: indicators (rates) of adverse events incidence
Methodologies
Patient safety culture: assessment by check-list →
clustering
Rates of adverse events: outcome indicators → risk
adjustment model
SINAS @ Hospitais
Patient Safety
Patient safety culture
Commitment of health care organisations to safety at all levels, including structures and facilities, procedures and human resources
Assessment with check-list
Main background:
• “Patient Safety Practices” of Agency for Healthcare Research and Quality (AHRQ)
• “Safe Practices for Better Healthcare 2010” of National Quality Forum (NQF)
• “International Patient Safety Goals” of Joint Commission International (JCI)
SINAS @ Hospitais
Patient Safety
Issues considered in assessment check-list
Safety Culture
Patients Identification
Communication with patients
Information to patients
Safe use of medications
Safe Surgery Checklist
SINAS @ Hospitais
Patient Safety
Adverse events indicators
Measures that screen for problems that patients experience as a result of exposure to the healthcare system and that are likely amenable to prevention.
Main background:
• Agency for Healthcare Research and Quality (AHRQ)
• Safety Improvement for Patients In Europe (SImPatIE)
• OCDE Health Care Quality Indicators
SINAS @ Hospitais
Patient Safety
SINAS selection of adverse events indicators
SINAS @ Hospitais
Patient Safety
SSD1 – Death in Low-Mortality DRGs
SSD2 – Stage III and IV Decubitus Ulcer
SSD3 – Nosocomial Infection (Catheter-Associated Infection)
SSD4 – Postoperative Hip Fracture
SSD5 – Postoperative Hemorrhage or Hematoma with Re-exploration Required
SSD6 – Nosocomial Infection (Postoperative Sepsis)
SSD7 – Postoperative Wound Dehiscence
SSD8 – Accidental Puncture or Laceration
SINAS @ Hospitais
Patient Focus
Aim: Objective assessment of how much are health care organisations
centred on patient needs and preferences
Background: Standards of Patient and Family Rights of Joint Commission
International (JCI)
Model of performance assessment : Assessment based on a check-list covering structural
characteristics, human and physical resources and organisational procedures, that contribute to patient-centred care
Issues considered in assessment check-list Informed consent Scheduling of services In patient Access to second opinion Religious aid Visits to in-patients Food Training Communication with patients Terminally ill patients Waiting times Post discharge follow up Patient privacy Suggestions, complaints or claims handling Satisfaction Surveys
SINAS @ Hospitais
Patient Focus
Aim:
Subjective assessment of patient satisfaction with health care
services
Types of care to be assessed:
Emergency care, inpatient care, ambulatory surgery,
outpatient consultations
Model of performance assessment:
Survey study
SINAS @ Hospitais
Patient Satisfaction
Distribution of participants(Ref.30/12/2013)
SINAS@Hospitais: overall results
ARSPrivate Public Social
Providers Providers Providers
Norte 18 30 15
Centro 8 22 5
LVT 16 30 5
Alentejo 1 5 1
Algarve 3 3 -
Total 46 90 26
SINAS @ Hospitais – Clinical Excellence
Evolution of participation
Collection PublishedNumber of Hospitals
Increase Assessed areas
Pilot Project15-12-2009 36 - ORTH
1.ª Collection 22-09-2010** 63 75,0% ORTH
2.ª Collection 28-01-2011 66 4,8% ORTH; GYN; OBS; PAED
3.ª Collection 11-07-2011** 79 19,7% ORTH; GYN; OBS; PAED
4.ª Collection 28-11-2011** 85 7,6%ORTH; GYN; OBS; PAED; AMI; STRO;
AMBS
5.ª Collection 04-08-2012** 85 0,0%ORTH; GYN; OBS; PAED; AMI; STRO;
AMBS
6.ª Collection 15-11-2012** 86 1,2%ORTH; GYN; OBS; PAED; AMI; STRO;
AMBS
7.ª Collection 23-04-2013** 102 29,1%ORTH; GYN; OBS; PAED; AMI; STRO; AMBS; COLS; CARDS; VASCS; ICU
8.ª Collection 30-12-2013** 116 0,1%ORTH; GYN; OBS; PAED; AMI; STRO; AMBS; COLS; CARDS; VASCS; ICU
SINAS @ Hospitais
Ambulatory SurgeryEvolution of results
SINAS @ Hospitais
Ambulatory Surgery
Evolution of the reference values
1. Framework for assessing global quality
2. SINAS@Hospitais (Hospitals)
3. SINAS@Saúde.Oral (Dental Care)
Outline
Implemented
Implemented
Being developed
Implemented
Implemented
Quality dimensions Status
Registration and Licensing
Adequacy and Comfort of Facilities
Organisation and Procedures
Patient Satisfaction
Patient Safety
SINAS@Saúde.Oral
Status of implementation:
First publication of results – August 2013
Provide to population an assessement of 800 dental care providers
Add clinical indicators to the system
SINAS@Saúde.Oral
N.º of Providers
RatingOrganisation and
ProceduresPatient Safety
Adequacy and Comfort of Facilities
Quality level III 331 (53%) 305 (56%) 415 (56%)
Quality level II 222 (35%) 159 (29%) 258 (35%)
Quality level I 78 (12%) 84 (15%) 66 (9%)
631 (100%) 548 (100%) 739 (100%)
SINAS@Saúde.Oral
