WP6 Questionnaire. Part 3 Data analysis - PaSQ > Home Questionnaire... · 2014-01-09 · 6 1. INTRODUCTION This report describes the analysis of part 3 of the WP6 Questionnaire 1:

WP6 Questionnaire. Part 3 Data analysis

WP6. EU collaboration for Healthcare Quality Management Systems December 2013

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INDEX 0. EXECUTIVE SUMMARY ....................................................................................................................................... 4

1. INTRODUCTION ..................................................................................................................................................... 6

2. GOAL ........................................................................................................................................................................... 6

3. METHODS ................................................................................................................................................................. 7

3.1. QUESTIONNAIRE ............................................................................................................................... 7

3.1.1 Description of Good Organisational Practices ...................................................................... 7

3.1.2 Identification of GOPs available to be shared ....................................................................... 8

3.1.3 Identification of perceived needs .............................................................................................. 8

3.2. POPULATION ....................................................................................................................................... 8

3.3. DATA COLLECTION .......................................................................................................................... 8

3.4. DATA ANALYSIS ................................................................................................................................. 9

4. RESULTS .................................................................................................................................................................... 9

4.1. INFORMATION COLLECTED ......................................................................................................... 9

4.1.1. Number of GOPs collected ........................................................................................................... 9

4.1.2. Member States and organisations sharing the GOP ........................................................ 10

4.1.3. Classification of the organisations sharing the GOPs ..................................................... 13

4.2. ANALYSIS OF GOOD ORGANISATIONAL PRACTICES ....................................................... 15

4.2.1. Topics covered by the Good Organisational Practices ................................................... 15

4.2.1.1 GOPs by topic................................................................................................................................ 15

4.2.1.2 GOPs by topic and Member State ......................................................................................... 16

4.2.1.3 GOPs by topic by Stakeholders, Nations and Regions ................................................. 18

4.2.2. Quality dimensions affected by the GOPs submitted ..................................................... 20

4.2.3. Implementation level ................................................................................................................... 21

4.2.3.1. GOPs implementation level ................................................................................................... 21

4.2.3.2. Implementation level and GOP topic ................................................................................. 22

4.2.4. Implementation barriers ............................................................................................................ 23

4.2.4.1. Implementation barriers found ........................................................................................... 23

4.2.4.2 Implementation barriers for different GOP topics ....................................................... 24

4.3. ANALYSIS TO PREPARE THE EXCHANGE MECHANISM: WILLINGNESS TO SHARE

KNOWLEDGE VERSUS LEARNING INTEREST ............................................................................... 26

4.3.1. Learning interest ........................................................................................................................... 26

4.3.2. GOP submitted versus learning interest .............................................................................. 27

4.4. CLASSIFICATION OF THE GOPs BASED ON SELECTION CRITERIA ........................... 28

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4.4.1. Detailed scores from the 2 independent assessors ......................................................... 30

4.4.2. Identification of discrepancies................................................................................................. 32

4.4.3. Final scores ...................................................................................................................................... 33

4.5. DESCRIPTION OF EACH GOOD ORGANISATIONAL PRACTICE .................................... 38

ANNEXES ...................................................................................................................................................................... 263

Annex 1: Part 3 Good organisational practices: implementation, sharing and learning.....

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Annex 2: Good Organisational Practices (GOP) ......................................................................... 267

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0. EXECUTIVE SUMMARY Introduction and goal:

This report is focused on the analysis of part 3 of the WP6 questionnaire "Quality Management systems in member states and Exchange of Good Organisational Practice”. The goal of part 3 of the WP6 questionnaire was to collect information about the most relevant transferable Good Organisational Practices (GOP) to be shared by EU Member States and the perceived needs of EU Members for learning from Transferable Good Organisational Practices through the Exchange Mechanism. This information was needed in order to prepare the exchange mechanism in future steps of this project. Good Organisational Practices were defined as “Plans, strategies or programs at national or regional level (encompassing structure and process) oriented to improve the quality of healthcare that can be useful for other healthcare systems (states or regions)”. Methods: A semi-structured questionnaire with 18 questions that guided the description of each Good Organisational Practice was filled out on-line by Member States, Regions and EU Stakeholders, aiming to collect as many relevant Good Organisational Practices as possible. Data was collected from November 9, 2012 to March 15, 2013. Data was reviewed for invalid and duplicated records and descriptive analysis was performed with Access and SPSS software. Good organisational practices were classified based on four criteria in order to facilitate additional information to prioritize the different practices for the Exchange Mechanism: 1- GOP relationship with the perceived needs of other Member States, Regions or EU Stakeholders, 2- Positive results obtained after the implementation of the GOP, 3- Level of difficulty or resources needed to implement the GOP in other Member States, Regions or EU Stakeholders and 4- Novelty. Scores for each GOP are included in the report. Results: 1- Transferable Good Organisational Practices (GOP) to be shared: This report includes 118 Good Organisational Practices submitted by Member States as well as EU Stakeholders and Regions. The 118 GOP included in this report have been provided by organisations from 20 EU Member States (MS). MS contribution varies widely from 1 GOP (Belgium, Croatia, Denmark, Finland, Germany and Poland) to 56 GOPs from Spain followed by Ireland with 12 GOPs and United Kingdom with 9 GOPs. Therefore, almost 50% of the total number of GOPs has been submitted by the same Member State. The most common types of organisations providing GOPs were Regional Authorities of Health, Ministries of Health and Healthcare Quality Agencies.

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Regarding the level at which Good Organisational Practices information has been provided, 61 GOPs have been submitted by National organisations, 38 by Regional bodies and 18 by Stakeholders. GOPs were classified in 18 categories based on the type of activity or topic covered by the GOP: Quality improvement project was the most popular topic covered by Good Organisational Practices, with 18 GOPs submitted (15% of the total), followed by Accreditation (12.7%), Clinical guidelines or pathways (10%) and Incident reporting and learning system (8.5%). Most MS shared GOPs covering different topics (for example, 14 Topics covered by the 56 GOPs from Spain, 7 topics covered by the 12 GOPs from Ireland, 7 topics covered by the 9 GOPs from UK), showing that Member States are working on different areas related to quality improvement and patient safety. Since the goal was to collect Good Organisational Practices oriented to improve the quality of healthcare, respondents were questioned about the quality dimensions affected by the GOPs. Most respondents considered that their GOPs affected several or even all the 5 quality dimensions explored, with effectiveness being the dimension most affected (by more than 80% of the total number of GOPs submitted). The questionnaire explored whether respondents had found barriers when implementing the good organisational practice. Over 60% of the respondents reported that they had found some barriers during the implementation phase. Resistance to change, lack of motivation from staff, funding, budget or resources constraints and lack of time from staff / extra work needed are the barriers most frequently cited. Implementation barriers were found in most of the GOP from some topics, such as incident reporting and learning system (90%) or patient safety system (87.5%) whereas barriers were rarely found in GOPs from other topics such as audit system and patient complaint mechanism (0%) or inspection (33%). Regarding the implementation level, 64 of the 118 GOPs included in this analysis were implemented at national level (55%), 43 GOPs were implemented at regional level (36.4%) and 11 were implemented only at local level (9.3%). 2- Perceived needs of EU Members for learning from Transferable Good Organisational

Practices Respondents were invited to select the topics for which they would be wishing to learn good organisational practices. They selected 365 topics in total. Accreditation captured the highest interest, with 48 survey respondents willing to learn about this topic. Other areas of high interest were patient safety system, incident reporting and learning system, quality indicators and clinical guidelines or pathways. Respondents submitted 118 GOP, and they stated 365 times that they would be interested in learning about Good Organisational Practices (which means that the learning interest is over 3 times higher than the GOPs available). For every single topic explored, the learning interest was higher than the good organisational practices submitted. Conclusion: The information collected regarding the 118 GOPs submitted and the perceived needs of Member States for learning from Transferable Good Organisational Practices will be a useful basis to organize Exchange Mechanisms in further steps of this project.

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1. INTRODUCTION This report describes the analysis of part 3 of the WP6 Questionnaire 1: "Quality Management systems in member states and Exchange of Good Organisational Practice”. PaSQ WP6 is specifically focused on activities, methods, and procedures that are developed, organised and implemented at national or regional level, even though they can affect individual organisations. The preliminary design of the questionnaire was developed according to WP6 framework and definitions and discussed with WP6 associated partners (AP), whose suggestions where collected and integrated through several rounds of consultation in September and October 2012. The final version was prepared for the on-line survey thanks to WP2 technical support. A pilot test was carried out by 4 partners (France, Ireland, Norway and Poland) at the end of October 2012 and the final adjustments for the on-line survey were performed during the first week of November 2012. Data collection began on November 12th 2012 and finished on March 15th 2013. The aim of this online survey was to collect information about: The Quality Management Systems in EU Member States, according to PaSQ WP6 framework (Parts 1 and 2) The most relevant Transferable Good Organizational Practices to be shared by EU Member States through Exchange Mechanisms in PaSQ (Part 3) Perceived needs of EU Members for learning from Transferable Good Organizational Practices through the Exchange Mechanisms (Part 3) Parts 1 and 2 of the questionnaire are analyzed in another independent report. 2. GOAL

As previously mentioned the goal of part 3 of the WP6 questionnaire was to collect information about: 1. The most relevant Transferable Good Organisational Practices (GOP) to be shared by EU

Member States through Exchange Mechanisms in PaSQ

2. Perceived needs of EU Members for learning from Transferable Good Organisational Practices through the Exchange Mechanisms.

Since the main goal was to obtain the necessary information to prepare the exchange mechanisms, the analysis of the information collected is mainly descriptive, regarding the GOPs that respondents would be willing to share with other Member States. Most of this information, therefore, is suitable for qualitative description but not for statistical analysis.

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After the identification of the Good Organisational Practices that Member States and PaSQ EU Stakeholders would be willing to share, the next step was to assess the GOP using pre-defined criteria in order to facilitate the selection of the GOPs that will be included in the Exchange Mechanism. The assessment of the GOP using pre-defined selection criteria is also included in this document. 3. METHODS

3.1. QUESTIONNAIRE PART3 of the questionnaire, focused on Good Organisational Practices, had three sub-parts: 1.1 – Description of Good Organisational Practices 1.2 – Identification of Good Organisational Practices available to be shared 1.3 – Learning interest from others' Good Organisational Practices The contents of each of these three parts are described below. The entire part 3 of WP6 questionnaire 1 is included in annex 1. 3.1.1 Description of Good Organisational Practices Part 1.1 contained 18 questions that guided the description of each Good Organisational Practice: - Two multiple choice questions with pre-defined answers, where respondents could select

one or several answers. - One yes/ no question. - Fifteen open questions, where respondents could include free descriptive text. The length

of the text in the responses was limited. The summary of the items included in part 1.1 is included in the following table:

Table 1: Good Organisational Practice Description Items

- Organisation that will be sharing the GOP

- Title of the GOP

- Does the GOP impact in any of the following quality dimensions? (multiple choice)

- Indicate the level where this practice has been implemented. (multiple choice)

- Clinical setting where it has been implemented

- Describe GOP objectives

- Describe GOP target population

- Describe GOP methodology

- Timeframe for proper implementation (based on experience)

- Please describe the implementation tools related to this GOP that are available

- Describe the implementation cost (based on experience).

- Method used to measure the results

- Results obtained (data)

- Analysis of the results

http://www.pasq.eu/Partners/PaSQPartners/EUStakeholders.aspx

http://www.pasq.eu/Partners/PaSQPartners/EUStakeholders.aspx

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- Did you find implementation barriers? (yes/no)

- Please describe

- Describe the strategies used to overcome the barriers (If needed)

- Other information about the GOP that you would like to add

3.1.2 Identification of GOPs available to be shared In order to arrange the Exchange Mechanisms and collaboration networks in the EU regarding Healthcare Quality Management Systems, part 1.2 collected information regarding GOP that Member States and Stakeholders would be willing to share.

Table 2: GOPs available to be shared

Would you be willing to share examples of these Exchange Mechanisms with other member states?

3.1.3 Identification of perceived needs Finally, 1.3 explored the topics that respondents would be interested in learning from other parties.

Table 3: Perceived needs Please indicate for what activities you would be interested to learn from the experiences and examples of others?

3.2. POPULATION

Population approached to fill out the questionnaire fell into the following three groups: Member States, Regions and EU Stakeholders. The aim of WP 6 was to collect as many relevant Good Organisational Practices as possible, to be able to better organize the Exchange Mechanisms. Therefore, no specific sample has been set. 3.3. DATA COLLECTION

Data was collected using the “wiki” on-line platform that hosts all PASQ questionnaires from November 9, 2012 to March 15, 2013. - The National Contact Points (NCP) organized the process to fill in the survey in their

countries, according to their healthcare system, structure and features. NCPs also shared the questionnaire with their Regions, which also had to fill it in online.

- EU Stakeholders were invited to complete Part 3 of the questionnaire, being a complementary source of information related to Good Organisational Practices.

- The NCPs had the opportunity to review online the information provided by their Regions, and Stakeholders.

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Periodic reminders were sent by the European Patients Forum to the NCPs during this timeframe. Completeness and quality of the data were reviewed during the data gathering process and additional information was requested to the NCPs if needed. The data collected were reviewed by the National Contact Points (NCP) from March 18 to March 25th, 2013. The database used for the analysis was closed for data collection and modifications on March 26th, at 9:00 AM. National Contact Points and Stakeholders have been able to make changes and introduce information about new GOPs after that date, but these GOPs are not included in this analysis.

3.4. DATA ANALYSIS

Data were stored on the wiki platform in Access software. Both Access software and SPSS were used for the statistical analysis. Data were reviewed for invalid and duplicated records. Records were considered invalid when no information or only non-legible information was included. Both invalid and duplicated registries were excluded from the database prior to the analysis. Completeness and quality of GOP descriptions were not used as criteria to exclude any registry. Data were analyzed and displayed depending on the type of variables and answer scales that are offered: - For the multiple choice questions with pre-defined answers, descriptive analysis was

performed including the count of each possible answer and percentages and the results are graphically displayed as a bar chart.

- The yes/ no question was analyzed with frequencies and percentages and the results are graphically displayed as a pie chart.

- The open questions, where respondents can include free descriptive text, are presented as a description with qualitative analysis, trying to identify the most common topics covered.

4. RESULTS

4.1. INFORMATION COLLECTED 4.1.1. Number of GOPs collected A total number of 128 registries were entered into the Part 3 of WP6 questionnaire database. During the data validation process 10 registries were excluded because they were duplicated or invalid. Annex 2 identifies all the registries included in the Access database, indicating those that were eliminated during the data validation process.

This report includes 118 Good Organisational Practices provided by National Contact Points as well as EU Stakeholders and Regions

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4.1.2. Member States and organisations sharing the GOP The following table summarizes and classifies the organisations sharing Good Organisational Practices. Information has been classified by country, level at which information has been provided (national, regional or stakeholder), name of the organisation sharing the GOP and number of GOPs shared by each organisation.

Table 4: Organisations sharing the GOP

Questionnaire GOP

Country Perspec. Organisation1 Organisation providing

description Nº of GOP

Austria Stakeholder Austrian Dental Chamber 3

Stakeholder Austrian Institute for Quality in Healthcare

1

Belgium National

Federal Public Service Health, Food Chain Safety, and Environment

Federal Public Service of Health, Food Chain Safety and Environment (FPS)

1

Croatia Stakeholder Agency - HALMED 1

Cyprus Stakeholder

Medical Physics Department Nicosia General Hospital

1

Nicosia General Hospital 3

Denmark National Ministry of Health The National Agency for Patients' Rights and Complaints

1

Estonia National Estonian Health Insurance Fund

Estonian Health Insurance Fund 2

Finland National THL Hospitals 1

France National HAS

DGOS (Ministere des affaires sociales et de la santé), french health ministry

1

HAS 1

Germany National German Agency for Quality in Medicine (AQuMed)

Agency for Quality in Medicine (AQuMed)

1

Hungary National

GYEMSZI Semmelweis University Health Services Management Training Centre

2

Hungarian National Blood Transfusion Service

Hungarian National Blood Transfusion Service

1

Office of tha Chief Medical Officer

National Center for Epidemiology 1

Ireland National Health Information and Quality Authority

Health Information and Quality Authority (the Authority)

2

Health Service Executive 4

Health Service Executive & State Claims Agency

2

1 Name of the organisation (National or Regional) that has filled out all parts of WP6 questionnaire

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Mental Health Commission 1

Nursing and Midwifery Board of Ireland

1

The Pharmaceutical Society of Ireland (PSI)

2

Italy National Agenzia Nazionale per i Servizi Sanitari Regionali

Agenas 1

Italian Ministry of Health 3

Netherlands National NIVEL

CBO 2

Dutch Government 1

HKZ: Harmonization of Qualityjudgement in Healthcare

1

The Netherlands Institute for Accreditation in Healthcare (NIAZ)

1

Various hospitals involved in the GOP

1

Poland National NCQA National Center for Quality Assessment in Healthcare (NCQA)

1

Romania

Stakeholder The National Commission for Accreditation

1

National National School of Public Health and Management

National Commission of Hospitals Accreditation Romania

1

Slovakia National Ministry of Health Ministry of Health 2

Slovenia National Ministrstvo za zdravje

Ministry of health 2

Slovenian Antimicrobial Susceptibility Testing Committee (SKUOPZ)

1

Spain

Stakeholder

Instituto Universitario Avedis Donabedian

1

Hospital 12 de Octubre (Madrid) 1

SOCIEDAD ESPANOLA DE CALIDAD ASISTENCIAL (SECA)

1

National Ministry of Health, Social Services and Equality

Instituto Aragonés de Ciencias de la Salud

1

Ministry of Health, Social Services and Equality (MSSSI)

8

Ministry of Health, Social Services and Equality (MSSSI) and Centro Superior de Investigación en Salud Pública (CSISP-FISABIO)

1

Ministry of Health, Social Services and Equality (MSSSI) and Avedis Donabedian Institute (FAD)

1

Ministry of Health, Social Services and Equality (MSSSI) and Institute for Safe Medication Practices - ISMP Spain

3

Regional Andalusian Regional Ministry of Health and Social Welfare

Andalusian Agency for Healthcare Quality

5

Andalusian Healh Services Inspection

2

12

Andalusian Health Service 4

Andalusian Regional Ministry of Health and Social Welfare

10

Andalucian School of Public Health 1

Aragón Healthcare Service

Aragón Healthcare Service 4

Cantabrian Health Service

Cantabrian Health Service 1

Asturias Health Service The Consejeria of Sanidad (Regional Health Authority)

1

Galician Health Service Galician Health Service - SERGAS 6

Department of Health in Castilla y León

Castilla y León Department of Health

2

Madrid Health Service Madrid Health Service 3

Sweden National The National Board of Health and Welfare

The National Board of Health and Welfare

2

United Kingdom

National

BDA British Dental Association 1

Department Of Health/ Government

Sheffield Teaching Hospitals Foundation Trust

1

Shelford Group: University College London NHS Hospitals Foundation Trust

1

University College London NHS Hospitals Foundation Trust

4

Regional

Healthcare Quality Improvement Partnership

Healthcare Quality Improvement Partnership

1

Welsh Government Welsh Government 1

Total number of Good Organisational Practices (GOP) 118

The 118 GOP included in this report have been provided by organisations from 20 European countries. Member States contribution varies widely from 1 GOP (Belgium, Croatia, Denmark, Finland, Germany and Poland) to 56 GOP from Spain followed by Ireland with 12 GOPs and United Kingdom with 9 GOPs. Therefore, almost 50% of the total number of GOPs have been submitted by the same Member State. Regarding the level at which Good Organisational Practices information has been provided (national, regional or stakeholder), 61 GOPs have been submitted by National organisations, 38 by Regional bodies and 13 by Stakeholders.

Stakeholders 13

National 64

Regions 41

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4.1.3. Classification of the organisations sharing the GOPs The 61 organisations that provided Good Organisational Practices have been classified by type. Table 5 includes the list of organisations and the classification.

Table 5: Classification of the organisations sharing the GOPs Country Organisation sharing the GOPs Type of organisation

Austria Austrian Dental Chamber

Professional Association or Society

Austrian Institute for Quality in Healthcare Healthcare Quality Agency

Belgium Federal Public Service of Health, Food Chain Safety and Environment (FPS)

Ministry of Health

Croatia Agency – HALMED National Agency

Cyprus

Medical Physics Department Nicsia General Hospital

Healthcare Provider

Nicosia General Hospital Healthcare Provider

Denmark The National Agency for Patients' Rights and Complaints

National Agency

Estonia Estonian Health Insurance Fund Ministry of Health

Finland Hospitals Healthcare Provider

France

DGOS (Ministere des affaires sociales et de la santé), french health ministry

Ministry of Health

HAS Health Care Quality Agency

Germany Agency for Quality in Medicine (AQuMed) Healthcare Quality Agency

Hungary

Hungarian National Blood Transfusion Service National Agency

National Center for Epidemiology University or Research Agency

Semmelweis University Health Services Management Training Centre

University or Research Agency

Ireland

Health Information and Quality Authority (the Authority)

Healthcare Quality Agency

Health Service Executive (HSE) Healthcare Provider

Health Service Executive & State Claims Agency Healthcare Provider & National agency

Mental Health Commission Healthcare Quality Agency

Nursing and Midwifery Board of Ireland Professional Association or Society

The Pharmaceutical Society of Ireland (PSI) Professional Association or Society

Italy Agenas Healthcare Quality Agency

Italian Ministry of Health Ministry of Health

Netherlands

CBO Healthcare Quality Agency

Dutch Goverment Ministry of Health

HKZ: Harmonization of Qualityjudgement in Healthcare



Accreditation Body

Various hospitals involved in the GOP Healthcare Provider

Poland National Center for Quality Assessment in Healthcare (NCQA)


Romania The National Commission for Accreditation Accreditation Body

Slovakia Ministry of Health Ministry of Health

14

Slovenia Ministry of health Ministry of Health

Slovenian Antimicrobial Susceptibility Testing Committee (SKUOPZ)

University or Research Agency

Spain

Andalusian Agency for Healthcare Quality Regional Authority of Health

Andalusian Health Service Regional Authority of Health

Andalusian Regional Ministry of Health and Social Welfare

Regional Authority of Health

Cantabrian Health Service Regional Authority of Health

Castilla y León Department of Health Regional Authority of Health

Galician Health Service – SERGAS Regional Authority of Health

Hospital 12 de Octubre (Madrid). Division of Neonatology

Healthcare Provider

Instituto Aragonés de Ciencias de la Salud University or Research Agency

Instituto Universitario Avedis Donabedian Healthcare Quality Agency

Madrid Health Service Regional Authority of Health

Ministry of Health, Social Services and Equality (MSSSI)

Ministry of Health

Ministry of Health, Social Services and Equality (MSSSI) and Centro Superior de Investigación en Salud Pública (CSISP-FISABIO)

Ministry of Health

Ministry of Health, Social Services and Equality (MSSSI) and Avedis Donabedian Institute (FAD)

Ministry of Health

Ministry of Health, Social Services and Equality (MSSSI) andInstitute for Safe Medication Practices - ISMP Spain

Ministry of Health

Servicio Aragonés de Salud (SALUD) Aragón Healthcare Service

Regional Authority of Health

SOCIEDAD ESPANOLA DE CALIDAD ASISTENCIAL (SECA)

Professional Association or Society

The Andalusian School of Public Health University or Research Agency

Regional Health Authority– Asturias Regional Authority of Health

Sweden The National Board of Health and Welfare Ministry of Health

United Kingdom

British Dental Association Professional Association or Society

Healthcare Quality Improvement Partnership Healthcare Quality Agency

Sheffield Teaching Hospitals Foundation Trust Healthcare Provider

Shelford Group: University College London NHS Hospitals Foundation Trust

Healthcare Provider

University College London NHS Hospitals Foundation Trust

Healthcare Provider

Welsh Government Regional Authority of Health

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The following table summarizes the types of organisations that provided GOP:

Table 6: Types of organisations providing GOP Type of organisation No. GOP

Accreditation Body 3 Healthcare Provider 17 Healthcare Provider & National Agency 2 Healthcare Quality Agency 13 Ministry of Health 27 National Agency 3 Professional Association or Society 8 Regional Authority of Health 39 University or Research Agency 6

TOTAL 118

Most organisations providing GOPs were Regional Authorities of Health (39) and Ministries of Health (27) (accounting each group for 55.9% of the total). The third biggest group was Healthcare Quality Agencies (17), accounting for 15.3% of the total. 4.2. ANALYSIS OF GOOD ORGANISATIONAL PRACTICES 4.2.1. Topics covered by the Good Organisational Practices 4.2.1.1 GOPs by topic In order to know the type of activity or topic covered by the GOP, a pre-defined classification of 18 categories was included in the questionnaire.

Figure 1: Topics covered by the GOP

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Eighteen different topics are covered by the GOPs submitted. Quality improvement project was the most popular topic covered by Good Organisational Practices, with 18 GOPs submitted (15% of the total), followed by 15 GOPs related to Accreditation (12.7%), 12 GOPs related to Clinical guidelines or pathways (10%) and 10 GOPs focused on Incident reporting and learning system (8.5%). On the other side, there is only one GOP related to Professional licensing and another one related to Peer review. Two GOPs cover the topic of Center licensing. 4.2.1.2 GOPs by topic and Member State The Good Organisational Practices provided by Member States are classified by topic in order to explore if Member States were willing to share GOPs related to the same topic or they were willing to cover several areas. The classification is shown in table 7:

Table 7: GOPs submitted by Member States classified by Topic

Country Topic N % of Country GOPs

covered by each topic

Austria

Patient complaint mechanism 1 25.0% Patient surveys 1 25.0% Quality improvement project 1 25.0% Quality indicators 1 25.0% TOTAL 4 100.0%

Belgium Patient Safety system 1 100.0% TOTAL 1 100.0%

Croatia Professional licensing 1 100.0% TOTAL 1 100.0%

Cyprus

Clinical guidelines or pathways 1 25.0% Patient empowerment 1 25.0% Patient Safety system 1 25.0% Professional learning program on quality and safety

1 25.0%

TOTAL 4 100.0%

Denmark Incident reporting and learning system 1 100.0% TOTAL 1 100.0%

Estonia Patient surveys 1 50.0% Quality indicators 1 50.0% TOTAL 2 100.0%

Finland Professional learning program on quality and safety

1 100.0%

TOTAL 1 100.0%

France Accreditation 1 50.0% Quality improvement project 1 50.0% TOTAL 2 100.0%

Germany Clinical guidelines or pathways 1 100.0% TOTAL 1 100.0%

Hungary

Audit system 1 25.0% Incident reporting and learning system 1 25.0% Professional learning program on quality and safety

1 25.0%

Quality indicators 1 25.0% TOTAL 4 100.0%

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Ireland

Centre licensing 1 8.,3% Clinical guidelines or pathways 3 25.0% Inspection 1 8.3% Patient involvement 3 25.0% Professional learning program on quality and safety

2 16.7%

Quality improvement project 1 8.3% Quality management system 1 8.3% TOTAL 12 100.0%

Italy

Clinical risk management 1 25.0% Incident reporting and learning system 1 25.0% Patient Safety system 1 25.0% Professional learning program on quality and safety

1 25.0%

TOTAL 4 100.0%

Netherlands

Accreditation 2 33.3% Audit system 1 16.7% Clinical guidelines or pathways 1 16.7% Patient complaint mechanism 1 16.7% Patient Safety system 1 16.7% TOTAL 6 100.0%

Poland Accreditation 1 100.0% TOTAL 1 100.0%

Romania Accreditation 2 100.0% TOTAL 2 100.0%

Slovakia Patient complaint mechanism 1 50.0% Quality indicators 1 50.0% TOTAL 2 100.0%

Slovenia Accreditation 1 33.3% Clinical risk management 2 66.7% TOTAL 3 100.0%

Spain

Accreditation 8 14.3% Centre licensing 1 1.8% Clinical guidelines or pathways 6 10.1% Clinical risk management 4 7.4% Incident reporting and learning system 6 10.1% Inspection 2 3.6% Patient empowerment 3 5.4% Patient involvement 2 3.6% Patient Safety system 4 7.4% Peer review 1 1.8% Professional learning program on quality and safety

3 5.4%

Quality improvement project 13 23.1% Quality indicators 2 3.6% Quality management system 1 1.8% TOTAL 56 100.0%

Sweden Patient empowerment 1 50.0% Patient involvement 1 50.0% TOTAL 2 100.0%

United Kingdom

Audit system 1 11.1% Clinical risk management 2 22.2% Incident reporting and learning system 1 11.1% Patient involvement 1 11.1% Patient surveys 1 11.1%

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Quality improvement project 2 22.2% Quality management system 1 11.1% TOTAL 9 100.0%

We can see in the table that, except for Romania that submitted two GOPs focused on accreditation, most of the MS shared GOPs covering different topics (for example, 14 topics covered by the 56 GOPs from Spain, 7 topics covered by the 12 GOPs from Ireland, 7 topics covered by the 9 GOPs from UK, 5 topics covered by the 6 GOPs from Netherlands), showing that Member States are working on different areas related to quality improvement and patient safety. 4.2.1.3 GOPs by topic by Stakeholders, Nations and Regions GOP topics have been classified based on the type of organisation that provided the information (national, regional or stakeholder). The classification is shown in table 8:

Table 8: GOP’s topic classified by type of organisation Topic Organisation type N %

Accreditation National 8 53.3% Regional 6 40.0% Stakeholder 1 6.7%

TOTAL 15 100.0%

Audit system National 2 66.7% Regional 1 33.3%

TOTAL 3 100.0%

Centre licensing National 1 50.0% Regional 1 50.0%

TOTAL 2 100.0%

Clinical guidelines or pathways National 7 58.3% Regional 3 25.0% Stakeholder 2 16.7%

TOTAL 12 100.0%

Clinical risk management National 5 55.6% Regional 4 44.4%

TOTAL 9 100.0%

Incident reporting and learning system National 6 60.0% Regional 4 40.0%

TOTAL 10 100.0%

Inspection National 1 33.3% Regional 2 66.7%

TOTAL 3 100.0%

Patient complaint mechanism National 2 66.7% Stakeholder 1 33.3%

TOTAL 3 100.0%

Patient empowerment National 2 40.0% Regional 2 40.0% Stakeholder 1 20.0%

TOTAL 5 100.0%

Patient involvement National 5 71.4% Regional 1 14.3% Stakeholder 1 14.3%

TOTAL 7 100.0%

Patient Safety system National 6 75.0% Regional 1 12.5%

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Stakeholder 1 12.5% TOTAL 8 100.0%

Patient surveys National 2 66.7% Stakeholder 1 33.3%

TOTAL 3 100.0% Peer review Regional 1 6.7% TOTAL 1 100.0%

Professional learning program on quality and safety

National 6 66.7% Regional 2 22.2% Stakeholder 1 11.1%

TOTAL 9 100.0% Professional licensing Stakeholder 1 6.7% TOTAL 1 100.0%

Quality improvement Project National 7 38.9% Regional 10 55.6% Stakeholder 1 5.6%

TOTAL 18 100.0%

Quality indicators National 3 50.0% Regional 1 16.7% Stakeholder 2 33.3%

TOTAL 6 100.0%

Quality management system National 1 33.3% Regional 2 66.7%

TOTAL 3 100.0%

We can see in the table that half of the GOP topics have been covered by organisations representing both Member States at National and Regional levels and European Stakeholders.

20

4.2.2. Quality dimensions affected by the GOPs submitted Good Organisational Practices to be included in the Exchange Mechanism had to affect at least one of the Quality Dimensions covered by the project. Respondents had to identify which of the five quality criteria were affected by the GOP, taking into account that 1 GOP could affect several (or all) quality dimensions. Figure 2 identifies the number of GOPs that have been considered to affect each of the 5 quality dimensions covered in this project.

Figure 2: Quality dimensions affected by the GOPs

The figure shows that most respondents considered that their GOPs affected several or even all the quality dimensions, effectiveness being the dimension most affected (by more than 80% of the total number of GOPs submitted). Even equity and acceptability, the dimensions considered less affected, are both affected by over half of the GOPs (both were ticked for 56% of the GOPs).

96

82

75

67

67

0 20 40 60 80 100 120

Effective

Efficient

Accessible

Acceptable

Equitable

Nº of GOPs affecting each quality dimension

118

21

4.2.3. Implementation level 4.2.3.1. GOPs implementation level The goal of this questionnaire was to identify Good Organisational Practices, meaning “Plans, strategies or programs at national or regional level (encompassing structure and process) oriented to improve the quality of healthcare that can be useful for other healthcare systems (states or regions)”. The questionnaire explored at what level the GOPs had been implemented. Respondents should indicate if the GOP had been implemented at national, regional or local level. Several responses could be selected if the GOP was implemented at more than one level. For example a national government could develop any given patient safety system (GOP submitted by a national organisation) to be implemented by the regional departments of health (implementation level, therefore, would be national and regional). To analyze the information regarding GOP implementation level, the responses were grouped onto the higher level: - The category “national level” includes practices that have been included only at national

level, and the practices that have been included at national and also at any other level (regional, local or both).

- The category “regional level” includes practices that have been included only at regional level, and also the practices that have been included at both regional and local levels.

- The category “local level” only includes practices implemented at this specific level, which have been promoted at national or regional level.

The graphic below shows distribution by implementation level.

Figure 3: GOP implementation levels

As shown on the graphic, 64 of the 118 GOPs included on this analysis were implemented at national level (55%); 43 GOPs were implemented at regional level (36.4%) and 11 were implemented only at local level (9.3%).

22

4.2.3.2. Implementation level and GOP topic GOPs have been classified by topic and implementation level to further explore if any specific topic tends to be implemented at a higher or lower level, based on the information collected by the questionnaire.

Table 9: GOPs Submitted by Member State classified by Topic GOP Topic Implementation level N %

Accreditation National 9 60.0% Regional 6 40.0%

TOTAL 15 100.0% Audit system National 3 100.0% TOTAL 3 100.0%

Centre licensing National 1 50.0% Regional 1 50.0%

TOTAL 2 100.0%

Clinical guidelines or pathways National 8 66.7% Regional 3 25.0% Local 1 8.3%

TOTAL 12 100.0%

Clinical risk management National 3 33.3% Regional 4 44.4% Local 2 22.2%

TOTAL 9 100.0%

Incident reporting and learning system National 5 50.0% Regional 4 40.0% Local 1 10.0%

TOTAL 10 100.0%

Inspection National 1 33.3% Regional 2 66.7%

TOTAL 3 100.0% Patient complaint mechanism National 3 100.0% TOTAL 3 100.0%

Patient empowerment National 2 40.0% Regional 2 40.0% Local 1 20.0%

TOTAL 5 100.0%

Patient involvement Regional 5 71.4% Local 2 28.6%

TOTAL 7 100.0%

Patient Safety system National 6 75.0% Regional 2 25.0%

TOTAL 8 100.0%

Patient surveys National 2 66.7% Local 1 33.3%

TOTAL 3 100.0% Peer review Regional 1 100.0% TOTAL 1 100.0%


National 5 62.5% Regional 3 37.5% Local 1 12.5%

TOTAL 8 100.0% Professional licensing National 1 100.0% TOTAL 1 100.0% Quality improvement project National 6 33.3%

23

Regional 10 55.6% Local 2 11.1%

TOTAL 18 100.0%

Quality indicators National 4 66.7% Regional 2 33.3%

TOTAL 6 100.0%

Quality management system National 1 33.3% Regional 2 66.7%

TOTAL 3 100.0%

Most GOPs, regardless of the topic, have been implemented at national level more often than at other levels. The exceptions are GOPs related to patient involvement, that have not been implemented at national level, quality improvement project (55% of them implemented at regional level, 33% at national and 11% at local) and clinical risk management (44% implemented at regional level, 33% at national and 22% at local). Four of the topics covered have been implemented only at one level: the GOPs submitted related to audit system, patient complaint mechanism and professional licensing have been implemented only at national level, while the only GOP submitted related to peer review was implemented at regional level. When reviewing this information is important to keep in mind the small number of GOPs submitted related to these topics. 4.2.4. Implementation barriers 4.2.4.1. Implementation barriers found The questionnaire explored whether respondents had found barriers when implementing the good organisational practice. Over 60% of the respondents reported that they had found some barriers during the implementation phase. Seventy-two respondents filled out the question regarding implementation barriers. Seven answers were not included in the analysis because respondents shared other additional information but not really barriers, or because the information was not understandable. The 65 remaining responses were classified by categories, with some of them being classified in more than one category because they involved several barriers. The barriers that most impacted on the GOPs submitted were:

Resistance to change or lack of motivation from staff – impacted on 19 GOPs Funding, budget or resources constraints - impacted on 15 GOPs Lack of time from staff, extra work needed to implement the GOP – impacted on 11

GOPs Lack of knowledge, expertise or training for staff -impacted on 11 GOPs Lack of safety culture, fear of punishment - impacted on 10 GOPs Limitations due to the design or the methods of the strategy – impacted on 10 GOPs Lack of access or knowledge to technical, electronic equipment – impacted on 8 GOPs Lack of leadership commitment, involvement or participation -impacted on 4 GOPs Coordination, communication, consensus and management – impacted on 3 GOPs No value added visibility – impacted on 3 GOPs Political or legal barriers – impacted on 3 GOPs Results not measured – impacted on 3 GOPs

24

Poor clinical documentation -impacted ons2 GOPs As shown in the list above, resistance to change or lack of motivation from staff, funding, budget or resources constraints and lack of time from staff / extra work needed are the barriers most frequently cited related to the implementation of Good Organisational Practices. If we add barriers related to similar topics we identify that barriers related to staff attitude or awareness (resistance to change or lack of motivation from staff + lack of safety culture, fear of punishment) impacted on 29 GOPs. Barriers related to resource constraints, either funding (funding, budget or resources constraints) or human resources availability (lack of time from staff, extra work needed to implement the GOP) impacted on 26 GOPs. It would be very interesting to explore any possible correlation between different types of barriers. For example, it would be interesting to explore whether resistance to change or lack of motivation from staff, the most common barrier identified, is influenced by other barriers like lack of funding, lack of leadership commitment or no value added visibility, among others. The type of data collected and the study design, however, do not allow this type of analysis. 4.2.4.2 Implementation barriers for different GOP topics An analysis was performed in order to identify whether the implementation of some kinds of Good Organisational Practices found more barriers than other kinds of GOPs. The following table presents the percentage of respondents that found implementation barriers aggregated by the different types of GOPs

Table 10: Implementation barriers by topic*

Topic Total No. of GOPs

Implementation barriers found

% of GOP with implementation

barriers

Accreditation 15 9 60.,0%

Clinical guidelines or pathways 12 7 58.,3%

Clinical risk management 9 7 77.8%

Incident reporting and learning system 10 9 90.,0%

Patient empowerment 5 4 80.,0%

Patient involvement 7 4 57.,1%

Patient Safety system 8 7 87.,5%


9 2 22.,2%

Quality improvement project 18 7 38.8%

Quality indicators 6 4 66.6%

*The table only includes topic categories with more than 5 GOPs that had data about implementation barriers

Some topics found implementation barriers in most of the GOP submitted, such as incident reporting and learning system (90%) or patient safety system (87.5%) whereas other topics rarely found barriers such as audit system and patient complaint mechanism (0%) or inspection (33%).

25

A classification of the responses was performed in order to identify the main implementation barriers for the categories that had sufficient data. The following table presents the most frequent implementation barriers for each topic:

Table 11: Main implementation barriers by topic*

Topic Main Implementation barriers

Accreditation - Design / methods of the strategy (3) - Resistance to change / lack of motivation (2) - Lack of knowledge, expertise / Training (Staff) (2)

Clinical guidelines or pathways − Lack of knowledge, expertise / Training (Staff) (3) − Resistance to change / lack of motivation (2) − Funding /Budget / resources barriers (2)

Clinical risk management − Lack of time / extra work (Staff) (2) − Funding /Budget / resources barriers (2)

Incident reporting and learning system

− Safety Culture / fear to punishment (4) − Lack of time / extra work (Staff) (3) − Resistance to change / lack of motivation (3)

Patient empowerment − Lack of knowledge, expertise / Training (Staff) (1) − Lack of technical / electronic equipment, access or

knowledge (1) − Design / methods of the strategy (1)

Patient involvement − Resistance to change / lack of motivation (1) − Coordination, communication, consensus and

management (1)

Patient Safety system − Resistance to change / lack of motivation (2) − Lack of time / extra work (Staff) (2) − Results not measured (2)


− Funding /Budget / resources barriers (1) − Design / methods of the strategy (1)

Quality improvement project − Resistance to change / lack of motivation (3) − Lack of knowledge, expertise / Training (Staff) (2) − Lack of time / extra work (Staff) (2) − Funding /Budget / resources barriers (2)

Quality indicators − Lack of knowledge, expertise / Training (Staff) (1) − Lack of time / extra work (Staff) (1) − Resistance to change / lack of motivation (1) − Safety Culture / fear to punishment (1)

*The table only includes topic categories with more than 5 GOPs that had data about implementation barriers

Even when the numbers are too small to obtain any conclusion, data show that, not surprisingly, the main barriers for incident reporting and learning system in the sample of GOPs submitted are related to healthcare professionals' lack of safety culture and reluctance to change, while other topics such as accreditation are more affected by the design or the methods chosen as well as staff resistance to change or lack of motivation. Funding, budgeting or resources affect many kinds of projects.

26

4.3. ANALYSIS TO PREPARE THE EXCHANGE MECHANISM: WILLINGNESS TO SHARE KNOWLEDGE VERSUS LEARNING INTEREST

In order to prepare the Exchange Mechanism, the number of MSs willing to share knowledge about each of the topics and the number of MSs expressing interest to learn more about them were calculated. 4.3.1. Learning interest The identification of learning interest followed the same structure, where respondents were invited to select the topics for which they would be wishing to learn good organisational practices. The results are presented in the following figure.

Figure 4: Learning interest by topic

The NCPs selected 365 topics in total. Accreditation captured the highest interest, with 48 MSs willing to learn about this topic. Other areas of high interest were patient safety system, incident reporting and learning system, quality indicators and clinical guidelines or pathways. On the other side, the results also reflect that most respondents were less interested to learn about topics such as peer review, center licensing and professional licensing.

48

26

26

25

25

23

23

23

22

21

19

19

18

12

11

9

8

7

0

0 5 10 15 20 25 30 35 40 45 50

Accreditation

Patient Safety system

Incident reporting and learning system

Quality indicators

Clinical guidelines or pathways

Patient involvement

Quality improvement project

Audit system

Patient empowerment

Clinical risk management

Patient surveys

Quality management system


Inspection

Patient complaint mechanism

Professional licensing

Centre licensing

Peer review

Other

27

4.3.2. GOP submitted versus learning interest From a practical point of view, in order to prepare the Exchange Mechanism, two concepts have been compared by the topic (table 12): the GOP submitted (and therefore available for knowledge sharing) and those wishing to learn.

Table 12: Learning interest versus GOP submitted

Topic Nº

GOPs submitted Nº

wishing to learn

Accreditation 15 48

Patient complaint mechanism 3 11

Patient empowerment 5 22

Patient involvement 7 23

Patient Safety system 8 26

Patient surveys 3 19

Peer review 1 7

Professional licensing 1 9

Professional learning program on quality and safety 9 18

Quality improvement project 18 23

Quality indicators 7 25

Audit system 3 23

Quality management system 3 19

Centre licensing 2 8

Clinical guidelines or pathways 12 25

Clinical risk management 8 21

Incident reporting and learning system 10 26

Inspection 3 12

TOTAL 118 365

Respondents submitted 118 GOP and they stated that they would be interested to learn about Good Organisational Practices 365 times (which mean that the learning interest is more than 3 times higher than the GOPs available). For every single topic explored, the learning interest was higher than the good organisational practices submitted. For some topics, there are over 4 times more people interested in learning than respondents that have submitted GOPs: professional licensing (9 people wishing to learn for each GOP submitted), peer review (7), quality management systems (6.33), patient surveys (6.33) and patient empowerment (4.40). On the other hand, for some topics the proportion between the number of respondents wishing to learn and the GOP submitted is more balanced: quality improvement project (1.77 people wishing to learn for each GOP submitted), professional learning program on quality and safety (2), incident reporting and learning system (2.60), clinical risk management (2.63). This information could be useful in order to select the exchange mechanism method for each type of GOP. For example, information and discussion meetings don’t have any limitation in the number of participants recommended and workshops are recommended for 8 to 15 participants. Both methods could be selected for topics such as professional licensing and peer

28

review, because based on the available information at least 7 to 9 people are wishing to learn for each of GOP submitted. 4.4. CLASSIFICATION OF THE GOPs BASED ON SELECTION CRITERIA

Good organisational practices have been classified based on four criteria (previously validated by the AP) in order to facilitate additional information to prioritize the different practices for the Exchange Mechanisms. The score is provided by the following selection criteria (already agreed with the partners in previous phases of the project), to facilitate the GOP quality depiction and the MS choice for the EM:

1. GOP relationship with the perceived needs of other MSs, Regions or European stakeholders

2. Positive results obtained after the implementation of the GOP 3. Level of difficulty or resources needed to implement the GOP in other MSs, Regions or

European stakeholders 4. Novelty: number of MSs, Regions or European stakeholders that have already

implemented a similar GOP 5. “NR” (Not rated) was used when there was not enough information to rate any given

criterion. The score of each GOP according to the selection criteria was given by two different assessors who have reviewed the GOP without knowing their origin. National Contact Points did not participate in this scoring process. Selection criteria scores are based on a 1 to 4 scale, 4 being the highest possible score

Score Needs Results Transferability Novelty

4

Identified as a perceived need by 26 or more Member States, Regions or European stakeholders

There is objective data available from an evaluation performed pre and post implementation (or intervention vs. control) of the GOP that proves an improvement in at least 1 of the dimensions of quality.

Can be easily implemented in a different MS or region, without main modifications of the methods and tools. Implementation tools are available and ready to be shared with other MSs, regions or European stakeholders, so no major resources needed for the adaptation to implement it in a different country.

No other MS neither region is known to have a similar practice, based on available information from questionnaire 1 and published literature /information.

3

Identified as a perceived need by 23 to 25

Some data available that indicates a positive impact after the implementation of the practice, but only based on case studies, the design of the study is weak or the GOP not implemented long enough to have definitive conclusions.

Some modifications should be made in the methods and / or implementation tools of the GOP in order to implement it in a different MS or region, due to its specificity. Implementation tools are available but need adaptation, so minimum resources (person days, equipment, etc) are needed to implement it in a different country).

Few (<3) MSs and regions have a similar practice, as identified in questionnaire 1 or published literature / information.

29

2

Identified as a perceived need by 13 to 22

The GOP seems to be producing positive results, based on subjective perceptions and opinions of different stakeholders.

The GOP is very specific and mayor modifications would be needed in order to implement it in other MS or region, and / or the implementation tools are difficult to share. Moderate resources (person days, equipment, etc) are needed to implement it in a different country).

Some (>3 < 6) MSs and regions have a similar practice, as identified in questionnaire 1 or published literature / information.

1

Identified as a perceived need by 12 or less

There is no data available about the results.

The GOP is very specific for the MS or region and it seems impossible to implement it in other MSs or regions. Implementation tools are not available or require considerable resources (person days, equipment, etc) to implement it in a different country).

Most MSs and regions already have a similar practice, as identified in questionnaire 1 or published literature / information.

NR Not enough information to rate this item

Not enough information to rate this item



30

4.4.1. Detailed scores from the 2 independent assessors Two professionals from WP6 independently scored each GOP. Detailed results are provided on the table below:

GOP ID

Assessor 1 Assessor 2 < 2 points difference

Needs Results Transfe-rability

Novelty TOTAL Needs Results Transfe-rability

Novelty TOTAL

2 3 NR NR NR NR 3 NR NR NR NR 0

3 2 1 4 2 9 2 1 4 3 10 -1

4 3 4 3 3 13 3 4 2 4 13 0

8 4 4 3 3 14 4 4 3 3 14 0

22 4 4 3 3 14 4 3 3 3 13 1

23 4 4 3 2 13 4 3 3 1 11 2

24 2 2 4 3 11 2 2 4 2 10 1

25 3 1 4 3 11 3 2 4 3 12 -1

26 2 2 2 3 9 2 2 2 2 8 1

27 4 3 4 2 13 4 3 3 2 12 1

28 3 3 3 3 12 3 2 3 3 11 1

31 3 2 3 2 10 3 3 3 1 10 0

32 1 2 3 3 9 1 2 3 3 9 0

35 3 4 3 3 13 3 4 4 2 13 0

36 3 1 3 2 9 3 1 4 1 9 0

37 3 1 3 3 10 3 2 3 2 10 0

38 2 1 3 2 8 2 1 4 2 9 -1

40 3 1 1 1 6 3 NR NR NR 3 3

41 4 2 3 2 11 4 2 3 1 10 1

42 4 2 3 3 12 4 2 3 3 12 0

43 4 2 3 2 11 4 2 3 1 10 1

44 3 1 3 2 9 3 1 2 1 7 2

45 2 4 3 2 11 2 3 3 1 9 2

46 3 4 3 4 14 3 4 4 3 14 0

47 2 1 3 2 8 2 2 4 2 10 -2

48 2 1 3 2 8 2 1 3 1 7 1

49 4 3 3 2 12 4 3 3 1 11 1

50 4 2 3 2 11 4 3 4 1 12 -1

51 4 4 3 2 11 4 1 4 1 10 3

52 3 1 2 2 8 3 1 4 1 9 -1

53 3 1 2 2 8 3 1 2 1 7 1

54 4 4 3 2 13 4 3 3 1 11 2

55 2 2 3 2 9 2 1 3 1 7 2

56 3 4 4 3 14 3 3 4 2 12 2

57 4 2 2 2 10 4 3 3 1 11 -1

58 1 1 1 2 5 1 1 2 1 5 0

59 3 1 3 2 9 3 1 4 1 9 0

60 2 1 3 2 8 2 1 3 1 7 1

61 4 3 3 2 12 4 3 4 1 12 0

62 4 3 3 2 12 4 3 4 1 12 0

63 4 3 3 2 12 4 3 4 2 13 -1

64 3 3 3 2 11 3 3 4 1 11 0

65 3 4 3 2 12 3 4 4 1 12 0

68 4 3 3 2 12 4 3 4 2 13 -1

69 2 1 3 2 8 2 1 3 2 8 0

70 2 3 3 2 10 2 3 3 1 9 1

71 2 3 3 2 10 2 3 3 2 10 0

72 4 4 3 2 13 4 3 3 1 11 2

31

GOP ID Assessor 1 Assessor 2

< 2 points difference



Novelty TOTAL

73 2 4 3 2 11 2 3 3 2 10 1

74 3 2 3 2 10 3 2 2 1 8 2

75 3 4 3 2 12 3 4 3 1 11 1

76 3 3 3 2 11 3 3 3 1 10 1

77 4 2 3 2 11 4 2 4 1 11 0

78 4 3 3 3 13 4 3 3 4 14 -1

79 2 2 3 2 9 2 2 2 2 8 1

80 1 2 3 3 9 1 2 2 3 8 1

81 1 2 3 3 9 1 1 2 3 7 2

82 3 1 2 3 9 3 1 2 3 9 0

83 4 1 4 3 12 4 1 4 2 11 1

84 4 2 3 2 11 4 3 4 1 12 -1

85 2 2 3 2 9 2 4 4 1 11 -2

86 2 2 2 2 8 2 1 2 1 6 2

87 4 4 3 2 13 4 4 4 2 14 -1

88 2 2 2 2 8 2 1 2 1 6 2

89 2 1 2 2 7 2 1 2 1 6 1

90 2 2 3 2 9 2 3 3 2 10 -1

91 3 3 3 2 11 3 3 3 2 11 0

92 1 3 3 3 10 1 4 3 3 11 -1

93 4 1 2 2 9 4 1 3 1 9 0

94 1 2 1 2 6 1 3 2 1 7 -1

95 2 2 3 2 9 2 1 3 2 8 1

96 3 2 2 2 9 3 3 2 2 10 -1

97 3 4 4 3 14 3 4 3 4 14 0

98 3 1 2 2 8 3 1 2 2 8 0

99 1 2 3 2 8 1 2 2 1 6 2

100 3 1 3 3 10 3 1 3 3 10 0

101 3 1 2 3 9 3 1 2 3 9 0

102 1 3 3 2 9 1 3 2 1 7 2

103 3 3 2 2 10 3 3 3 2 11 -1

104 2 2 3 2 9 2 4 3 2 11 -2

105 3 2 4 3 12 3 3 4 3 13 -1

106 3 1 2 2 8 3 1 3 1 8 0

107 2 1 3 2 8 2 1 3 1 7 1

108 4 2 3 3 12 4 2 3 2 11 1

109 4 3 3 2 12 4 3 3 1 11 1

110 4 2 3 2 11 4 2 3 1 10 1

111 1 2 3 2 8 1 3 4 1 9 -1

112 3 2 3 2 10 3 2 2 1 8 2

114 3 2 2 2 9 3 3 2 1 9 0

115 1 2 2 2 7 1 2 3 2 8 -1

116 3 2 2 2 9 3 3 2 2 10 -1

117 2 1 1 2 6 2 1 2 1 6 0

118 2 2 2 2 8 2 2 2 1 7 1

119 2 1 2 2 7 2 1 3 1 7 0

120 3 1 2 2 8 3 1 3 1 8 0

121 4 3 2 3 12 4 3 2 3 12 0






127 3 2 2 2 9 3 3 2 1 9 0

32

GOP ID Assessor 1 Assessor 2

< 2 points difference



Novelty TOTAL

130 3 1 2 2 8 3 1 2 1 7 1

131 3 1 3 2 9 3 1 2 1 7 2

132 2 2 2 2 8 2 3 3 1 9 -1

133 1 4 3 2 10 1 4 2 NR 7 3

134 1 2 3 2 8 1 3 3 1 8 0

135 1 2 3 2 8 1 3 3 1 8 0

136 3 2 2 2 9 3 3 2 1 9 0

137 4 4 3 2 13 4 4 4 1 13 0

138 2 4 2 2 10 2 4 2 2 10 0

139 3 2 3 2 10 3 1 4 1 9 1

140 4 2 3 2 11 4 3 3 1 11 0

141 4 1 3 2 10 4 1 3 1 9 1

142 3 1 3 2 9 3 1 3 1 8 1

143 2 1 3 2 8 2 1 3 2 8 0

144 1 1 2 2 6 1 1 3 2 7 -1

145 4 1 1 2 8 4 1 1 1 7 1

4.4.2. Identification of discrepancies The independent scores from the two surveyors had more than 2 points difference only in 3 out of the 118 GOPS analyzed:

40 3 1 1 1 6 3 NR NR NR 3 3

51 4 4 3 2 11 4 1 4 1 10 3

133 1 4 3 2 10 1 4 2 NR 7 3

After a detailed analysis of these 3 GOPs, it was clearly identified that: - Two of the discrepancies (GOP40 and GOP133) were due to the lack of information

provided in the description of the GOP: one assessor had scored it with the lowest possible score due to the lack of information and the other assessor that considered it NR due to the same reason. Both GOPs were changed to NR.

- The score related to “results” provided by one assessor to the third GOP (GOP51) was changed after a second review of the information.

The final scores for these 3 GOPs were:

40 3 NR NR NR 3 3 NR NR NR 3 0

51 4 2 3 2 11 4 1 4 1 10 1

133 1 4 3 NR 8 1 4 2 NR 7 1

GOP ID Assessor 1 Assessor 2 < 2 points

difference?



Novelty TOTAL

GOP ID Assessor 1 Assessor 2 < 2 points

difference?



Novelty TOTAL

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4.4.3. Final scores

Nº ID Title of GOP

Selection criteria scores


Novelty

1 2 National Clinical Audits and Clinical Outcome Review Programs

3

2 3 Quality Delivery Plan for Wales 2 1 4 3.5

3 4 Department of Geriatric medicine at Sheffield - Oobeya (Big Room)

3 4 2.5 3.5

4 8 Bacteriemia zero Programme 4 4 3 3

5 22 Pneumonia Zero (NZ) Programme 4 3.5 3 3

6 23 Hand Hygiene Program for the Spanish National Health System (NHS)

4 3.5 3 2

7 24 Working with patients for patients; Developing patient education tools for arthroplasty and surgical pathways.

2 2 4 3

8 25 Real time patient feedback 3 1.5 4 3.5

9 26 Ward to Board Risk Register Capture and Assurance Framework process.

2 2 2 2

10 27 Adoption and Implementation of DatixWeb Electronic Incident Reporting System

4 3 3.5 3

11 28 Testing interventions to reduce urology patient readmissions

3 2.5 3 3

12 31 Development. implementation and monitoring of Common protocol for a healthcare response to Gender Violence. 2005-2012

3 2.5 3 2

13 32

"Methodology for the identification, collection and dissemination of Good Practices in health performance against the Gender Violence (GPVAW) in the Spanish National Health System (NHS)"

1 2 3 3

14 35

Improvement of health and social services organizations combining consensus processes for indicator development with methods of external assessment

3 4 3,5 2,5

15 36 GUIASALUD. Clinical Guidelines Program for the National Health System

3 1 3.5 2

16 37 Spanish National Health System Net of Agencies for the Evaluation of Technologies and Services

3 1.5 3 2.5

17 38 Patient Empowerment/"Your guide to safer care" 2 1 3.5 2.5

18 40 Patient involvement by the patient safety act 2010:659.The Hälso och Sjukvardslagen 1982:763

3 NR NR NR

19 41 Accreditation of teaching hospitals: audit 4 2 3 2

20 42 Accreditation of Reference centres 4 2 3 3

21 43 Accreditation program for hospitals. 4 2 3 2

22 44 Development and Implementation of Integrated Care Pathways

3 1 2.5 2

23 45 National Health System Training Program on Patient Safety

2 3.5 3 2

24 46 Medication Safety Self Assessment for Hospitals 3 4 3.5 3

25 47 Psychological support for the patients admitted in the ICU and their families. Full time psychologist in the ICU of NGH

2 1.5 3.5 2.5

34

Nº ID Title of GOP



Novelty

26 48 Clinical Trainer Educator Nurse 2 1 3 2

27 49 Patient Safety Reporting and Learning System (SINASP)

4 3 3 2

28 50 Report and learning system on medication errors 4 2.5 3.5 2

29 51 Patient safety during interventional procedures in Cardiology.

4 1.5 3.5 2

30 52 Monitoring the consumption of antimicrobilas in hospital care in Slovenia

3 1 3 1.5

31 53 Cooperation between scientific societies to develop guidelines for clinical practice and clinical management

3 1 2 1.5

32 54 Patient Safety Improvement by operating a reporting and learning system

4 3.5 3 2

33 55 Development of an e-learning training program in patient safety

2 1.5 3 2

34 56 NIDCAP (Newborn Individualized Developmental Care and Assessment Program)

3 3.5 4 3

35 57 PATIENT SAFETY MANAGEMENT AND ICPS IN BELGIAN HOSPITALS

4 2.5 2.5 1.5

36 58 Complaint mechanism 1 1 1.5 1

37 59 Healthcare quality indicators 3 1 3.5 2

38 60 Nationwide standardised cross-sectional patient satisfaction survey in Austria

2 1 3 2

39 61 Quality Management System of the Sterilization Units in SALUD Hospitals

4 3 3.5 2

40 62 Quality Management System of the SALUD Laboratories

4 3 3.5 2

41 63 Quality Management System of SALUD Primary Healthcare Teams

4 3 3.5 2.5

42 64 "Support to Initiatives on Quality Improvement" Program

3 3 3.5 2

43 65 1.National Nosocomial Surveillance System (NNSR) 2.National Hand Hygiene Campaign

3 4 3.5 2

44 68 Sentinel Events Monitoring System 4 3 3.5 2.5

45 69 Ministry of Health Recommendations 2 1 3 2.5

46 70 Professional Training on Quality and Patient Safety

2 3 3 2

47 71 Implantation of Standard UNE 179003 on Risk Management for Patient Safety. Health Services.

2 3 3 2.5

48 72 Implementation of a Patient Safety Reporting and Learning System in Galician hospitals

4 3.5 3 2

49 73 Training patients and caregivers in health education by means of the Galician School in Public Health for Citizens

2 3.5 3 2.5

50 74 Patient Advisory Council 3 2 2.5 2

51 75 Integral care strategy for patients with pain 3 4 3 2

52 76 Patient safety audits 3 3 3 2

53 77 Online tool to manage the whole safety incidents life cycle, as well as to disseminate the improvement actions.

4 2 3.5 2

35

Nº ID Title of GOP



Novelty

54 78 The Italian National Observatory on Good Practices for Patient Safety

4 3 3 3.5

55 79 RIU-T: Approach of a national health strategy to vulnerable contexts and populations

2 2 2.5 2.5

56 80 Telematic Continuity of care in frail and / or vulnerable patients

1 2 2.5 3

57 81 Telematic Continuity of care in palliative care patients

1 1.5 2.5 3

58 82 Health Care Plan for Caregivers in the Andalusian Health Service: “ + Care Card” (“Tarjeta + Cuidados)

3 1 2 2.5

59 83 Quality of mobile applications on health: distinctive and certification

4 1 4 3

60 84 Introducing accreditation in Slovenian health care institutions

4 2.5 3.5 2

61 85 Decreasing of filed complaints 2 3 3.5 2

62 86 Decreasing of estimated complaints 2 1.5 2 1.5

63 87 ACCREDITATION PROGRAMME FOR ANDALUSIAN PUBLIC HEALTH SYSTEM CENTRES AND UNITS

4 4 3.5 2.5

64 88 Directors of clinical units training in pecuniary responsibility for compensation

2 1.5 2 1.5

65 89 Training Programme in emergencies directed towards residents at the time of their integration into the healthcare centres

2 1 2 1.5

66 90 Organisation and working strategy of national antimicrobial susceptibility testing committee in small country

2 2.5 3 2.5

67 91 Advanced practice nurse attending patients with Advanced Chronic Kidney Disease (ACKD)

3 3 3 2.5

68 92 PROFESSIONAL SKILLS ACCREDITATION PROGRAMME FOR THE ANDALUSIAN PUBLIC HEALTH SYSTEM

1 3.5 3 3

69 93 Hospital accreditation program at national level developed by the National Commission for Hospital Accreditation;

4 1 2.5 1.5

70 94 Stakeholder engagement regarding the registration and inspection of designated centres for older persons.

1 2.5 1.5 1

71 95 School of Patients 2 1.5 3 2.5

72 96 Implementation of The Seasonal Influenza Vaccination Scheme in Retail Pharmacy Businesses.

3 2.5 2 2

73 97 The National Early Warning Score (NEWS) 3 4 3.5 4

74 98 Organisation. implementation and evaluation of National Falls and Bone Health Strategy 2013-2015

3 1 2 2

75 99 Pharmacy Inspection Process 1 2 2.5 2

76 100 National Healthcare Charter ‘You and Your Health Service’

3 1 3 3

77 101 Patient participation in professional regulation 3 1 2 2.5

36

Nº ID Title of GOP



Novelty

78 102 Creation and Organization of a network Biobank in Andalusian Public Health Service (APHS)

1 3 2.5 2

79 103 Stakeholder engagement in the development of the National Standards for Safer Better Healthcare.

3 3 2.5 2

80 104 National Mental Health Services Collaborative (NMHSC)

2 3 3 2.5

81 105 Open disclosure following adverse events in healthcare.

3 2.5 4 3.5

82 106 Institutional Program for the Optimization of Antimicrobial Treatment (PRIOAM)

3 1 2.5 1.5

83 107 National Decontamination Programme for management of reprocessable invasive medical devices (RIMD)

2 1 3 2

84 108 Health Websites Accreditation Programme (HWAP)

4 2 3 2.5

85 109 Risk management through an incident reporting system without damage

4 3 3 2

86 110 Reporting and Learning System. 4 2 3 2

87 111 Self-evaluation and improvement under the EFQM model

1 2.5 3.5 2

88 112 PCAI: Programa Clinico de antecion Interdisciplinar: Clinical program for the interdisciplinar care

3 2 2.5 2

89 114 Accredited program for continuing education (CE) for dentists

3 2.5 2 1.5

90 115 Arbitration body for patient complaints 1 2 2.5 2

91 116 Program for Quality Assurance 3 2.5 2 2

92 117 Patient questionnaire 2 1 1.5 1

93 118 Patient Safety Toolbox Talks 2 2 2 1.5

94 119 Patient safety e-learning 2 1 2.5 1.5

95 120 Self audit system and practice 3 1 2.5 1.5

96 121 National Patient Safety Program (in Dutch: VMS Veiligheidsprogramma)

4 3 2 2.5

97 122 The Netherlands Institute for Accreditation in Healthcare (NIAZ)

4 NR NR NR

98 123 HKZ 4 NR NR NR

99 124 DiliGuide 3 NR NR NR

100 125 Patient complaint legislation 1 NR NR NR

101 126 Stepwise visitation 3 NR NR NR

102 127

Advanced Nurse Competence: Protocolized monitoring individualized drug treatment (Collaborative Prescription) by nurses in the Andalusian Public Health System

3 2.5 2 1.5

103 130 INTEGRATED CARE Process Management 3 1 2 1.5

104 131 Advance Nurse Practice in Case Management of patients with complex chronic diseases and high care needs

3 1 2.5 2

105 132 On-line training program in patient safety 2 2.5 2.5 1.5

106 133 Health Care Professionals' (HCP) licensing 1 4 2.5 NR

37

Nº ID Title of GOP



Novelty

107 134

Inspection protocols for verification of compliance with the quality requirements to the Centers for procurement, processing, storage, distribution and implantation of human tissues and cells.

1 2.5 3 2

108 135 Inspection protocols for verification of compliance with the quality requirements for centers and transfusion services.

1 2.5 3 2

109 136 IMPLEMENTATION OF PERCEIVED QUALITY COMMITTEES in hospitals in the Madrid Health Service

3 2.5 2 1.5

110 137 HAND HYGIENE IMPROVEMENT IN HEALTH CENTERS OF MADRID COMMUNITY

4 4 3.5 2

111 138 Implementation of Environmental Management Systems in accordance with the UNE EN ISO 14001:2004, hospitals Madrid Health Service.

2 4 2 2

112 139 National Disease Management Guidelines Programme (NDMG-Programme)

3 1.5 3.5 2

113 140 "Reporting and learning system for patient safety, called SiNASP”.

4 2.5 3 2

114 141 Accreditation of hospitals 4 1 3 2

115 142 Feedback report to hospitals 3 1 3 2

116 143 Web accessible environment to analyze patient satisfaction survey results and make a comparisons

2 1 3 2.5

117 144 Quality of drug management in hospitals 1 1 2.5 2

118 145 Accréditation des professionnels de santé. Certification Scheme for Doctors

4 1 1 1

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4.5. DESCRIPTION OF EACH GOOD ORGANISATIONAL PRACTICE

The description of the 118 Good Organisational Practices submitted by Member States, Regions and Stakeholders through part 3 of the WP6 questionnaire is included in the following pages. The description of the GOPs is presented with the content and format provided by respondents, without additions or corrections by the research team. The completeness and quality of the description of the different GOPs, therefore, is variable. Nevertheless, the information meets the goal of this report, which was having the necessary information to prepare the Exchange Mechanisms. A more detailed description of the selected Good Organisational Practices will be provided through the different Exchange Mechanisms to be implemented in the next steps of the project. Each GOP has been assigned a correlative number (from 1 to 118) other than the unique GOP ID that was automatically assigned by the database and which is also included in order to facilitate the identification of the GOP in future steps. The description of each GOP includes the following contents:

Good Organisational Practice NAME

GOP Information:

GOP Number - GOP ID

Organisation sharing the GOP

Member state

Topic

GOP Description:

IMPLEMENTATION LEVEL:

CLINICAL SETTING:

OBJECTIVES:

POPULATION:

METHODS:

Methodology

Timeframe implementation

Implementation tools available

Implementation cost

RESULTS:

Method used to measure the results

Results

Analysis of the results

IMPLEMENTATION BARRIERS:

Did you find implementation barriers?

Please describe implementation barriers:

Describe the strategies used to overcome the barriers (If needed)

OTHER INFORMATION:

Other information about the GOP that you would like to add

39

National Clinical Audits and Clinical Outcome Review Programmes

GOP Information:

GOP Number: 1 - GOP ID: 2

Organisation sharing the GOP Healthcare Quality Improvement Partnership

Member state United Kingdom

Topic Audit system

GOP Description:

IMPLEMENTATION LEVEL: National, Regional

CLINICAL SETTING: All hospitals in England and Wales

OBJECTIVES: focus on clinical outcomes; provides meaningful data and feedback to give clinicians the information to stimulate quality improvement; publish information about quality of care to make more health data available to patients

POPULATION: Different for each audit see website: www.hqip.org.uk

METHODS:

Methodology see website www.hqip.org.uk

Timeframe implementation see website www.hqip.org.uk

Implementation tools available see website www.hqip.org.uk

Implementation cost see website www.hqip.org.uk

RESULTS:

Method used to measure the results see website www.hqip.org.uk

Results see website www.hqip.org.uk

Analysis of the results see website www.hqip.org.uk


Did you find implementation barriers? No



OTHER INFORMATION:


40

Quality Delivery Plan for Wales

GOP Information:

GOP NUMBER: 2 - GOP ID: 3

Organisation sharing the GOP Welsh Government


Topic Quality management system

GOP Description:

IMPLEMENTATION LEVEL: Regional

CLINICAL SETTING: NHS Wales organisations

OBJECTIVES: Ensuring both quality improvement and quality assurance

POPULATION: NHS Wales organisations

METHODS:

Methodology Improve the quality of care by: improving patient and user exprience; meeting the care needs of Welsh speakers; providing clinically effective care through the use of findings from National Clinical Ausdits and Clinical Outcome Review Programmes and research and innovation; using new technologies to improve access and quality of care; securing system-wide, sustainable qualtiy and safety improvement through the use of the 1000 Lives Plus quality improvement methodology; strategic oversight and direction provided by the National Quality and Safety Forum.

Timeframe implementation The Quality Delivery Plan is a five year plan to develop the vision for NHS Wales in 'Together for Health'. See website: http://wales.gov.uk/topics/health/publications/health/reports/together/?lang=en

Implementation tools available Quality and Outcomes Framework Clinical Governance self assessment tool for GP practices; Delivery plans for cancer, cardiac, diabetes, stroke, mental health, primary and community and unscheduled care; Plans to include population outcome indicators; a key set of metrics for routine monitoring;

Implementation cost The plan builds on the foundations of Doing Well, Doing Better - Standards for Health Serivces in Wales, the 1000 Lives Campaign and Programme, Putting Things Right and the Annual Quality Framework. Implementation costs are not expected to feature.

RESULTS:

Method used to measure the results Quality and outcomes framework and service specific plans which will include population outcome indicators.

Results: 2012/12 is a transition year as the new approach is introduced. Results not available yet.

Analysis of the results Results not available.





41

OTHER INFORMATION:

Other information about the GOP that you would like to add See link: http://wales.gov.uk/topics/health/publications/health/strategies/excellence/;jsessionid=5B31E1FDC1A3AC6059B4740842611665?lang=en

42

Test, design and launch a transformed model of acute comprehensive geriatric assessment with Toyota methodology (Oobeya)- Sheffield Frailty Unit.

GOP Information:


Organisation sharing the GOP Sheffield Teaching Hospitals Foundation Trust


Topic Quality improvement project

GOP Description:

IMPLEMENTATION LEVEL: Local

CLINICAL SETTING: Geriatric & Stroke Medicine

OBJECTIVES: High quality model of acute hospital geriatric care focussing on efficiency

POPULATION: All geriatric patients within the city of Sheffield

METHODS:

Methodology IHI Model for Improvement – using PDSA cycles to test change

Timeframe implementation Over eighteen months and still implementing further redesign

Implementation tools available Use of IHI Model for Improvement PDSA cycles Measurement for improvement

Implementation cost Mainly staffing costs – time to meet and redesign over the period. Quality improvement expertise from a central Service Improvement team was also prioritised to support the clinical team to undertake this work.

RESULTS:

Method used to measure the results Reduced bed occupancy by over 60 beds 34% increase in discharge by day 0 or 1.

Results13% reduction in raw mortality

Analysis of the results 16% reduction in readmission





OTHER INFORMATION:

Other information about the GOP that you would like to add The improvements we have achieved cannot simply be copied by other organisations but there is a wealth of learning and ideas that could be translated into the local context. We are already receiving many requests for more information on our work from across the UK and beyond. The potential benefits are: Efficiency - lower bed usage Safety – reduced mortality Timeliness – less ‘waste’ of waiting in hospital Equity – achieving a more easily accessed NHS for frail older patients Effectiveness – correct care being delivered in the right place, at the right time so readmission is reduced

43

This work has been presented at a series of local, national and international meetings. We would be happy to provide additional information on this work.

44

Bacteriemia zero Programme

GOP Information:


Organisation sharing the GOP Ministry of Health, Social Services and Equality, Spain

Member state Spain

Topic Patient Safety system

GOP Description:

IMPLEMENTATION LEVEL: National, Regional, Local

CLINICAL SETTING: Intensive Care Units (ICU)

OBJECTIVES: • Reduction of Catheter- related bloodstream infection (CRBSI) <4 CRBSIs per 1000 central venous catheter (CVC) days • To promote PS culture in the ICU • To promote the implementation of patient safety evidence based practices in the ICU POPULATION: All patients admitted to the participating ICUs All adult ICUs from the 17 Health Regions from the Spanish NHS are invited to participate

METHODS:

Methodology Based in the keystone-project lead by Pronovost in USA Prospective cohort study design including three phases: • Plannificaction: adaptation of materials, organization, selection of coordinators at regional and hospital level, engagement of ICUs, baseline data collection. April-Dec-2008 • Implementation: project adaptation to the ICU. Jan-March-2009 • Intervention: April-2009 to Dec 2012 up today The programme includes two types of intervention 1.STOP-CRBSI (evidenced-based-procedures): • Hand hygiene • full-barrier-precautions during the insertion • cleaning-skin with chlorhexiding • avoiding femoral-site • removing unnecessary catheters • proper catheter maintenance 2.PATIENT SAFETY INTERVENTION Professional-perception of PS-culture (Spanish version of the Hospital Survey on Patient Safety) • PS training • Learning from errors • Alliance with managers Programme organization • National-coordination team: SEMICYUC, SMoH, WHO • Regional-coordination-team: regional-representative, MD&nurse-intensivist and preventivist • Local-coordination-team: MD&nurse in each participant ICU Coordinated and supervised operations at every unit, and across units in the health region was stated. Data registered are reviewed by SEMICYUC every 3 month to control information errors • ENVIN-HELICS data based: http://hws.vhebron.net/envin-helics (National Surveillance Program of ICU-Acquired Infection) • Registry of safety indicators: http://hws.vhebron.net/bacteriemia-zero/ (referring to: chlorhexidine skin antisepsis, check-list for catheter insertion, central-line cart, daily goals,

45

learning from errors, and safety rounds) • Web-learning-platform provided by WHO: http://ezcollab.who.int/ Definitions: European surveillance program for nosocomial infections

Timeframe implementation 18 months (including translation-adaptation of the material) to show a reduction rate of 50%

Implementation tools available -Online course (including STOP-CRBSI and PS module) • Posters and video • Spanish version of the Hospital Survey on Patient Safety • Specific tools: Daily goals; Checklist; Walk rounds; Learning from errors framework • Support documents (protocol, guides)

Implementation cost Funds for Health Regions: 1.942.650,72 € Technical management: 341.178 € 11 Project Meetings: 62.578,68 € On line platform and database: 7.505 €

RESULTS:

Method used to measure the results -Method used to measure the results The local team registers monthly the number of patients, patient-days, and catheter-days (patients with one or more central venous catheter: CVC) at each ICU. Variables: • CRBSI, patient’s age and gender, APACHE II score, length of ICU stay, mortality, ICU and hospital characteristics, and length of follow up

Results220 ICU participating (variation over time) More than 15.000 professionals trained online 80% of ICU participate in the programme CRBSI was reduced from 4, 9 episodes per 1000 catheter-days to 2, 8 in 2010, 2,6 in 2011 and 2,2 in 2012 (global mean per year) (p<0.001). The adjusted incidence rate of bacteremia was > 50% risk reduction. • During 2009-2012, 265 death were avoided as well as 35.376 stay-days • Savings for the NHS: 109.771.728 € (3.103 €/ICU-stay-days during 2010) during 2009-2012 period

Analysis of the results Quantitative: • The number of CRBSI, catheter-days, and incidence rates were expressed as medians and interquartile ranges (25th-75th percentile) and mean incident rates. Generalized linear mixed regression models with a Poisson distribution (18) to calculate the incidence rates, incidence rate ratio (IRR), and 95% confidence intervals (CI), was used • Data about scores changes in the perception questionnaire not available yet Qualitative: • Interviews and focus groups were performed to analysed the perception of professionals (data under analysis)


Did you find implementation barriers? Yes

Please describe implementation barriers: .Resistance to accept the project and the needed tools, mainly the PS interventions • Some budget did not reach the ICU participants • Resources restrictions

Describe the strategies used to overcome the barriers (If needed).Continuous contact between coordinator teams • Two meetings every year to present the results (aggregated and by HR), problems detected and improvement proposals • Adaptation of tools if needed (“daily goals”,etc)

46

• Letters to the hospital managers to support the project • Promoting leadership.

OTHER INFORMATION:

Other information about the GOP that you would like to add http://www.seguridaddelpaciente.es/index.php/lang-es/proyectos/financiacion-estudios/proyecto-bacteriemia-zero.html http://hws.vhebron.net/bacteriemia-zero/bzero.asp http://www.who.int/patientsafety/implementation/bsi/bacteriemia_zero/en/index.html • Mercedes Palomar, M.D., Ph.D, Francisco Álvarez-Lerma, M.D., Ph.D., Alba Riera, RN., María Teresa Díaz RN (†), Ferrán Torres, M.D., Ph.D., Yolanda Agra M.D. Ph.D, Itziar Larizgoitia, M.D., M.P.H., Ph.D., Christine A. Goeschel, Sc.D., M.P.A, M.P.S., R.N., Peter J. Pronovost, M.D., Ph.D., on behalf of the Bacteremia Zero Working Group. Impact of a National Multimodal Intervention to Prevent Catheter-Related Bloodstream Infection in the ICU: The Spanish Experience. (Critical Care Med, in press)

47

Pneumonia Zero (NZ) Programme

GOP Information:


Organisation sharing the GOP Ministry of Health, Social Services and Equality (MSSSI)

Member state Spain


GOP Description:


CLINICAL SETTING: Intensive care units (ICUs)

OBJECTIVES: -Main objective: to decrease the national mean incidence density rate (ID) of ventilator associated pneumonia-(VAP) to <9 cases per 1.000 ventilator-days, which means to decrease the rate by 40% in comparison with the mean 2000-2008 rate and by 25% in comparison with the mean 2009-2010 rate. • Secondary objectives: • Promote and improve patient safety culture in NHS ICUs. • Sustain and strengthen the net of ICUs implementing evidence based effective safe practices POPULATION: All patients admitted to the participating ICUs All adult ICUs from the 17 Health Regions from the Spanish NHS are invited to participate

METHODS:

Methodology -Phases: 1.Information and training of healthcare workers on VAP prevention: centralized for ICU team leaders and local sessions and on-line course for all ICU staff. 2. - Dissemination and implementation of the care bundle: joint sessions with medical and nursing staff 3. - Analysis and evaluation: monthly data collection in a common on-line platform; monthly ICU sessions for evaluation and feedback. Every 3 months, identification and discussion of detected weaknesses and setting of objectives for improvement. • Content of the NZ bundle: 2 complementary sets of practices • STOP VAP includes 7 basic compulsory practices and 3 specific highly recommended practices to prevent VAP • A comprehensive safety plan (PSI): seeks to promote and strengthen patient safety culture in the ICUs daily work • Programme organization: • National-coordination team: Scientific societies of intensive care doctors and nurses (SEMICYUC and SEEIUC); MSSSI • Regional-coordination-team: as decided by each Region • Local-coordination-team: MD & nurse in each participant ICU (approved by the hospital management).

Timeframe implementation Final analysis of results after 21 months is being carried out. In the first 12 months of implementation preliminary positive results have already been shown.

Implementation tools available -On line training tools • Posters • Spanish version of the Hospital Survey on Patient Safety • Specific tools: Walk rounds; Learning from errors framework and survey; daily goals; on line risk factors registration form • Support documents (protocol, evidence report, technical guidelines for STOP VAP clinical practices)

48

Implementation cost Funds for Health Regions: 279,099 € Technical management: 90,000 €

RESULTS:

Method used to measure the results ID rate: VAP /1000 ventilator-days The local ICU team monthly registers the global ICU risk factors, including ICU patient-days and ventilator days. When a patient develops VAP a new register is open with information from the patient and the infection according to the ENVIN-HELICS (National ICU Infection Surveillance Study) system: http://hws.vhebron.net/envin-helics/

Results239 ICUs from all Health Regions have provided data to the programme and 76.2% of them have participated for more than 12 months. Preliminary results: in the first 12 months of the program the national ID rate has dropped from 9.4 to 6.9 Around 18,000 professionals have received online training. Analysis of the results The longer the participation in the programme, the lower ID The estimated impact after the registration of 500,000 ventilator days: 2,330 fewer pneumonias 280 fewer deaths 43,305 fewer hospital stays (143.000.000 € savings for the NHS)



Please describe implementation barriers: .Resistance to accept the project and the needed tools, mainly the PS interventions • Some budget did not reach the ICU participants • Resources restrictions

Describe the strategies used to overcome the barriers (If needed).Continuous contact between coordinator teams • Two meetings every year to present the results (aggregated and by HR), problems detected and improvement proposals • Adaptation of tools if needed (“daily goals”,etc) • Letters to the hospital managers to support the project • Promoting leadership.

OTHER INFORMATION:

Other information about the GOP that you would like to add Link to the NZ platform: http://hws.vhebron.net/neumonia-zero/Nzero.asp

49

Hand Hygiene Program for the Spanish National Health System (NHS)

GOP Information:



Member state Spain


GOP Description:


CLINICAL SETTING: Hospitals and Primary Healthcare

OBJECTIVES: General Objectives: 1. - To improve healthcare professionals' and patients/visitors' hand hygiene (HH) in order to reduce healthcare associated infections in the NHS. 2. - To promote WHO HH multimodal strategy in the NHS. Specific Objectives: 1. - To promote specific actions with Health Regions (HR) in order to: • Agree on common basic activities. • Identify and select indicators and evaluation tools that can be implemented at different levels • Improve professionals' HH education and training 2. - To provide HR information on WHO initiatives and resources

POPULATION: Healthcare professionals of the NHS Patients and citizens

METHODS:

Methodology 1. - Establish a coordination group at national level formed by MSSSI and HR technical representatives 2. - Establish an organizational structure for the NHS with different functions: MSSSI, NHS coordination group, regional coordination groups, healthcare professionals in charge of the HH program at local level 3. - To provide with support tools:

WHO guidelines and materials in Spanish; evidence on HH; tools for education and training

On-line platform for group work (e-room): sharing of resources, knowledge and experience; discussions...

Follow-up meetings Specific HH area in the Patient Safety Web Training workshops and resources

4. - Decentralized funds for HH promotion in HR

Timeframe implementation 1 year to set up the coordination team and develop an action plan

Implementation tools available -e-Room (internal platform for group communication and work) • Specific site in patient safety web • WHO multimodal HH strategy tools in Spanish • On line course • Promotional videos • Posters and gadgets • Hand Hygiene Self-Assessment Framework (Spanish version) specific platform where

50

successive self-comparisons and aggregated analysis for the different Regions can be performed • Tools developed by Regions

Implementation cost From 2006 to 2011, 4,200,000 € have been provided to the Health Regions for the HH program

RESULTS:

Method used to measure the results Indicators based on WHO recommendations which are annually collected by the Health Regions since 2009: 1.% Hospital rooms with alcohol-based hand-rub 2.% Intensive care units with alcohol-based hand-rub at the point of care 3.%Primary healthcare centres with alcohol-based hand-rub 4.% Hospitals with HH training 5.% Primary Care Centres with HH training 6. Hospital consumption of alcohol based hand-rub (litres/1000 patients-day) 7.%Hospital beds with alcohol-based hand-rub at the point of care 8.%Hospitals performing observation of WHO 5 moments for HH 9.%Hospitals performing self evaluation with WHO framework 10. % Hospitals with HH training on the five moments.

Results-PARTICIPATION (No. of Health Regions): Ind.1: 13(2009); 17(2010); 18(2011) Ind.2: 14(2009); 17(2010); not-evaluated(2011) Ind.3: 14(2009); 17(2010); 15(2011) Ind.4: 16(2009); 18(2010); 18(2011) Ind.5: 12(2009); 16(2010); 14(2011) Ind.6: 14(2009); 14(2010); 17(2011) Ind.7: 12(2009); 12(2010); 14(2011) Ind.8: 9(2009); 15(2010); 17(2011) Ind.9: 14(2010); 12(2011) Ind.10: 13(2009); 16(2010); 15(2011) • RESULTS: Ind.1: 50,73%(2009); 63,78%(2010); 85,49%(2011) Ind.2: 80,80%(2009); 90,43%(2010) Ind.3: 60.04%(2009); 63,43%(2010); 63,60%(2011) Ind.4: 73,02%(2009); 81,25%(2010); 90,10%(2011) Ind.5: not available(2009); 61,22%(2010); 52,44%(2011) Ind.6: 15,21‰(2009); 14,9‰(2010); 13,35‰(2011) Ind.7: 26,47%(2009); 52,58%(2010); 47,20%(2011) Ind.8: 41,35%(2009); 67,33%(2010); 60,60%(2011) Ind.9: 42,50%(2010); 47,70%(2011) Ind.10: 57.58%(2009); 69,08%(2010); 82,60%(2011)

Analysis of the results -Gradual increase of the Health Regions' capacity to provide data for the indicators from hospitals, which points at a steady consolidation of the program. This is less clear in Primary Healthcare • Hospital consumption of alcohol based hand-rub is not increasing, but the variability among Regions has decreased, which indicates an improvement in those Regions which had worse results. • Training and self-evaluation is increasing and even though the %hospitals performing observation is lower, the total number has increased.



51

Please describe implementation barriers: High variability among the Health Regions support and investment in the program

Describe the strategies used to overcome the barriers (If needed)-Coordination between the MSSSI and the HR in order to set up joint objectives and to obtain information at a national level. • To invest effort on networking and resource sharing to be more efficient and motivate campaign leaders

OTHER INFORMATION:

Other information about the GOP that you would like to add Web site: http://www.seguridaddelpaciente.es/index.php/lang-es/proyectos/financiacion-estudios/programa-higiene-manos.html

52

Working with patients for patients; Developing patient education tools for arthroplasty and surgical pathways.

GOP Information:


Organisation sharing the GOP Shelford Group: University College London NHS Hospitals Foundation Trust


Topic Clinical risk management

GOP Description:


CLINICAL SETTING: UCLH Trauma & Orthopaedic Unit and surgical pre-assessment service.

OBJECTIVES: 1.Meet patient information needs 2.Engage patients in their care before, during and after their arthroplasty surgery 3.Promote self management 4.Manage patients expectations about their surgical pathway 5.Develop an arthroplasty education group session 6.Develop arthroplasty and surgical information booklets 7.Develop a patient education film

POPULATION: The arthroplasty information booklets and the patient education group session were specifically developed for patients on the elective hip and knee arthroplasty surgical pathways and their families. The patient education film and “top tips” leaflet were developed to provide general information any patients having surgery at UCLH and their families.

METHODS:

Methodology We collected qualitative data with the following methods: 1.Documentary sources: National and international web search for booklets, patient education sessions, and information films on arthroplasty and surgical pathways 2.Visit and contact UK hospitals that had implemented arthroplasty enhance recovery pathways 3.1:1 interviews with patients that had experience of the UCLH arthroplasty pathways 4.1:1 interviews with patients about to go on an arthroplasty surgical pathway 5.Staff feedback on current patient information and suggestions on future developments. 6.Engage local musculoskeletal patient groups ARMA (arthritis and musculoskeletal alliance) to gain additional perspectives on patient experience and recommendations on education tool development. 7.Engage UCLH patient governors for their input on the arthroplasty patient education, session, information booklets and education film. During the period of developing the education tools we:

1.Engaged all stakeholders 2.Collaborated with the UCLH patient information department 3.Collaborated with the UCLH communication service 4.Presented the education tools to local and divisional clinical governance groups

Timeframe implementation The project in its entirety took 18 months with different completion dates. This included a scoping period of three months. The patient education film took 9 months to film, edit and release. The leaflets and patient education group took

53

approximately 2 months to finalise following the scoping period.

Implementation tools available The GOP was co-ordinated by two part-time clinical project leads (0.75 WTE) that were employed to implement the surgical enhance recovery pathways at UCLH. The posts were under the leadership of the Trust’s service transformation programme the Quality, Efficiency and Productivity Programme. Tools included: • Stakeholders analysis • Project planning • Documentation data analysis, including written and visual • Observation • Intervi • Focus groups ews

Implementation cost The investment for the education tools was gained through a regional award and UCLH special trustees and was approximately L15,000. The investment for the time of the two part time project leads was part of the larger enhance recovery implementation programme and funded internally. Additional resources have been minimal.

RESULTS:

Method used to measure the results Methods used to measure GOP results: 1.Patient and public feedback in group settings and 1:1 2.Staff feedback in group settings and 1:1

Results Results of the GOP: 1.Arthroplasty information booklets 2.Arthroplasty patient education session (joint school) 3.Patient information film for patients having surgery at UCLH 4.“Top tips” leaflet helping patients prepare for surgery

Analysis of the results Analysis of results: Patient and staff feedback on developments has been positive and encouraging. Patients feel re-assured that they know what to expect. Patient feedback from the arthroplasty education session: “You don’t realise how daunting coming into hospital and having surgery is; sitting in the group, I saw other patients and I felt that I was not the only person going through this, and I felt re-assured. When I came in to hospital and recognised some of the patients that were in the group it gave me courage as I knew I was not alone”.



Please describe implementation barriers: There were no significant barriers to implementing the education tools. The only barrier was coordinating people, times and locations for meetings and this was overcome with forward planning and project management.

Describe the strategies used to overcome the barriers (If needed)The only barrier was coordinating people, times and locations for meetings and this was overcome with forward planning and project management.

OTHER INFORMATION:

Other information about the GOP that you would like to add In 2010, we set out to identify all parts of the elective care pathway that could be developed across institutional boundaries to support better preparation and recovery of patients. The majority of enhance recovery elements need patient collaboration and it was crucial we

54

worked with patients to develop advice and information that would help them prepare for their surgery and recovery afterwards. The initial work started with the aim to develop the arthroplasty pathway information and patient education session (joint school) but as the work with patients and staff evolved common themes emerged. We identified that the information patients and staff found useful for a surgical admission was knowing the practical side of the process rather than the exact detail or the surgical procedure. Through this work we made the decision to develop a general information leaflet and patient education film to support patients having surgery at UCLH.

55

Real time patient feedback

GOP Information:


Organisation sharing the GOP University College London NHS Hospitals Foundation Trust


Topic Patient involvement

GOP Description:


CLINICAL SETTING: Inpatient, outpatient & maternity areas

OBJECTIVES: To get timely feedback from patients about their experience of care. This can be accessed by clinical staff and managers.

POPULATION: Patients accessing NHS funded care at UCLH.

METHODS:

Methodology Online patient surveys using iPad or web-based questionnaires. Patients are asked to complete the survey at the point of, or within 48 hours of, discharge.

Timeframe implementation At least 12 months.

Implementation tools available The system (Optimum Meridian) is the tool used. It is a web based system for creating surveys, collecting responses and analysing data. Instant data reporting. Unlimited flexibility in relation to survey make up and design.

Implementation cost • Hosted solution circa L20k p.a. • Data collection; iPad circa L250 • per iPad p.a. + initial hardware cost • Project management circa L50k

RESULTS:

Method used to measure the results Implementation continues to develop as more areas and surveys come on line. Key results include: • over 5000 patients have responded in 6 months • overall scores are good, but much higher visibility of areas where performance needs to improve • evidence that being able to trend performance over time has led to improvements

Results- results “dashboard” available to frontline leaders: feedback specific to their area in real time.

Analysis of the results results “dashboard” available to frontline leaders: feedback specific to their area in real time.



Please describe implementation barriers: • Asking staff to hand data collection device to patients is an additional task for them – not always high on their priority list. • Take up is highly dependent on clinical leadership. If the nurse in charge of the ward is interested it will happen. If not, it is very difficult to progress

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Describe the strategies used to overcome the barriers (If needed) Strategies • Managed by director chaired steering group • Communication – via email, local intranet and a wide range of forums (nursing, management and patient) • All clinical leaders have access to results and are encouraged to review them • Backing of key members of the executive team • Project personnel available to support frontline areas. • Engaging teams in design and development of surveys • Supporting documents – “how to”, FAQs, posters for displaying results locally • Monthly status report – number of returns/performance scores. • Using results in local & organisation performance/quality meetings

OTHER INFORMATION:

Other information about the GOP that you would like to add • There is no dispute about the value of getting feedback from patients. • The use of electronic/online data collection is however not as widely spread through the NHS as one might expect. • This system has proven its value in terms of providing detailed and real time feedback to managers and staff. As the online report section is updated as soon as the patient completes a survey, managers have access to the very latest results. This is powerful in that not only can they see what is being said about their area straightaway, but that they can take action to rectify it. • We have seen improvements in a number of key patient experience metrics since implementation (e.g. finding a member of staff to talk to about worries and fears). Firstly, because we have been able to identify the issue and put some actions in place to address it and also because we can track outcomes to see if the actions are being effective.

57

Ward to Board Risk Register Capture and Assurance Framework process.

GOP Information:





GOP Description:


CLINICAL SETTING: UCLH is a Large Acute NHS Foundation Trust located across 8 main hospital sites with 19 clinical divisions. There are 3 Clinical Boards with significant devolved authority, who oversee the day to day operations of divisions. 7000 staff provides a wide range of both acute and specialist services.

OBJECTIVES: The objectives are as follows: i.To ensure risks are effectively captured, managed and mitigated in an open and fair culture. ii.To sustain a risk management process that instils accountability at Divisional and corporate level through the allocation of Board Risk leads.

POPULATION: Risks are captured through two inter-connected processes; the risk register and the Assurance Framework. Risk register: Local managers are required to undertake operational, financial and clinical risk identification. It is the responsibility of the Board and Divisional Management Teams to undertake the strategic analysis of all identified risks.

METHODS:

Methodology The Chief Executive has overall responsibility for risk management at UCLH. Designated ‘Risk Leads’ covering Divisions have specific roles as the focal point and local champion for risk management development. They work collaboratively with the Risk Management Team in the Governance department to ensure that local intelligence around risk is assessed and communicated appropriately throughout the organisation. Risk registers are populated through Datix which enable the Governance department to have visibility of trust wide risks. These registers are then extracted (dependent on severity and current score) and populated into a quarterly risk report for discussion, scrutiny and debate at the Risk Co-ordination Board. This also provides an opportunity for cross-divisional learning and trend analysis trust wide. Following this, key risks / issues / assurance can be provided to the Board. There will be cases when risks identified at the tactical, operational or project level will be significant to UCLH. Such risk will be escalated to the appropriate level through the Trust’s line management processes. The Board sets the risk appetite of UCLH and the system for enabling risk control and contingency decisions.

Timeframe implementation Divisions had previously managed and populated their own risk registers. The transfer to a centrally held software system (including training) took approximately six months (not including technical requirements). It is important to mention that a positive risk appetite / culture was already in place

Implementation tools available The system adopted to achieve the aims of corporate risk visibility was Datix. The risk register roll out project was delivered subsequent to the Datix incident reporting project completion. Thus there was little change management / engagement requirement needed.

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A Datix administrator was key to the roll out of the project to ensure training was available as well as governance expertise. Tools available included one to one training, e learning, induction training, and latterly drop in clinics Implementation cost Aside from the individual costs for inputting information within divisions and resource time required from the governance team for advice & monitoring. Costs can be related to the following: • Datix administrator (band 5/6) covering all Datix management and training functions. Cost of risk register Datix module (this cost is Trust specific).

RESULTS:

Method used to measure the results The new electronic risk register has been populated by all Clinical Boards and Divisions. Corporate functions are also represented. Results There has been significant improvement in overall awareness and understanding of the key aspects and functions of risk registers

Analysis of the results Interrogation of the register will show clear evidence that risks have been identified, reviewed and mitigated in a timely manner, previously the flow of risks could potentially remain stagnant due to the type of corporate monitoring that was in place.



Please describe implementation barriers: The key barrier related to the acceptance of change in relation to populating an IT based system from a simple excel sheet.

Describe the strategies used to overcome the barriers (If needed)Fortunately all employees had previously been exposed to a similar Datix system (incidents) which assisted in the mitigation of evasion behaviour.

OTHER INFORMATION:

Other information about the GOP that you would like to add We have been recognised in our work by being identified as a good practice demonstration site for Datix, co-ordinating visits from as far afield as Saudi Arabia and neighbouring Trusts.

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Adoption and Implementation of DatixWeb Electronic Incident Reporting System

GOP Information:




Topic Incident reporting and learning system

GOP Description:


CLINICAL SETTING: UCLH is a Large Acute NHS Foundation Trust located across 7 Main hospital sites with 19 clinical divisions. There are 3 Clinical Boards with significant devolved authority, who oversee the day to day operations of divisions. 7000 staff and provides a wide range of both acute and specialist services.

OBJECTIVES: The aims were to facilitate greater reporting, improved distribution of incident related intelligence at all management levels whilst also enabling greater localised learning and ownership of patient safety issues. The Trust replaced implemented an incident reporting system with an online electronic solution accessible to all staff.

POPULATION: Incident Reporting is a process applicable to all staff, therefore the system had to be carefully designed to combine ease of use, alongside all information analysis requirements for scrutiny and learning purposes. A project group was established to ensure that the system was created with both of these elements in mind.

METHODS:

Methodology Key methodology around electronic incident reporting includes:- • Genuine engagement from those involved (including software company and staff) • demonstrable willingness to flex plans based on feedback • an ability to clearly describe the "future state" and benefits • action to address gaps between current and future state. The running themes in terms of system implementation were to communicate / educate / change and challenge systems / manage welfare and expectations In summary the system and its initial implementation project was given high visibility throughout the Trust. The Project Group were given regular updates from the Project team, and championed the concept of the DatixWeb system to make people across the Trust aware of the impending changes and their benefits. Trust wide emails were sent to inform staff of go live dates, posters were created to advertise this and distributed across sites, and a story was run on Insight. Staff were kept informed of developments at every potential stage. Following the implementation of the system, further training and information sessions continue to be delivered by the Datix Administrator as part of audit days and staff inductions.

Timeframe implementation The implementation followed eighteen months of careful planning and preparation, to ensure that induction and training were undertaken by all staff who would be using the system from the first day it was put into effect. The main project, from start up to go-live date took approximately 9 months. (see below) Implementation tools available The Trust developed two e-learning packages based on Datango software which proved to be very successful. This e-learning enabled the rapid trust-wide implementation of the system from a single date, as opposed to any phased roll out. Of the two training packages, one focused solely on the reporting process which all staff had to complete whilst the other addressed the incident review process for all identified handlers. The training packages incorporated screenshots.

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Implementation cost Main costs related to the creation of additional IT Infrastructure (server set up and system installation), project Management and the software purchasing/licensing. Some cost savings were made by the development and appointment of in-house Datix software experts The project was delivered within budget and to agreed timescale.

RESULTS:

Method used to measure the results Based on other experiences, it was identified that for most Trusts incident reporting levels decreased upon initial implementation as people adjusted to change. However, at UCLH, incident reporting dramatically increased as staff embraced online reporting. This acceptance of the new system was statistically apparent, as the number of incidents reported within the first 6 months doubled, compared to the same time the previous year. This increase in reporting has continued to rise significantly in the two years since implementation.

Results Following implementation the number of Incident Handlers was increased to cope with this higher reporting, further distributing local ownership and risk awareness. More specialised forms have been created since initial roll-out, as more people have become aware of the functionality of the system and understood its capabilities. Local real time incident reporting has enabled Incident Handlers and managers to address incidents and any issues raised more quickly and easily, identifying immediate serious incidents, resulting in improved patient safety.

Analysis of the results The risk management team identifies patient trends and forwards reports to specific divisional groups in the Trust. Monthly risk reports are sent out to the divisions that enable the managers to drill down and create their own reports - such as the Falls Group or Tissue Viability nurses. Reports are also sent to the Patient Safety Steering Risk Committee and the Executive Board. The trust has also seen encouraging decreases in the number of catastrophic/major incidents as a proportion of overall reporting rates. Although this cannot be directly attributed to the software, it is likely to played a significant part.



Please describe implementation barriers: YES – Some Incident Handler and location data required to populate the database was delayed, as some divisions struggled to understand what information to provide within the agreed timescales. After go live, some divisions complained that their location setup didn’t reflect the way they classified their areas, which needed additional work and resources to amend classifications to better reflect such locations.

Describe the strategies used to overcome the barriers (If needed)Significant challenges revolved around the engagement and involvement of the Tust’s ICT provider, with specific process requirements relating to upgrades/system changes sometimes proving difficult. Key links and relationships were created to help ease these difficulties, though some IT requirements remained time consuming.

OTHER INFORMATION:

Other information about the GOP that you would like to add None

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Testing interventions to reduce urology patient readmissions

GOP Information:





GOP Description:


CLINICAL SETTING: The clinical setting was a urology surgery ward. Ward staff and specialist nurses were involved in testing interventions from the State-wide Action to Reduce Re-hospitalizations (STAAR) initiative to reduce readmissions.

OBJECTIVES: Patient non-compliance with taking their medications causes preventable readmissions which lead to poor patient experience and increased length of stay. The objectives of the GOP were to develop, PDSA test and implement quality improvement interventions to reduce Urology patient readmission rates using a 90 day rapid improvement cycle approach.

POPULATION: Urology surgery patients

METHODS:

Methodology Baseline data on 30 day urology readmission rates was collected. This showed that the rate of urology surgery admissions was over twice the Trust average (i.e. 15% compared to a Trust average of ~6%). Patient interviews and case note review of urology surgery readmissions were carried out. Length of stay and cost of readmissions were calculated. This showed that the average length of stay for a readmitted urology surgery patient was 2 days. It was estimated that over 9 months there had been a loss of income of around L174,000 from the urology surgery readmissions. Case note review identified sixty-five preventable readmissions from April 1st 2011 to January 31st 2012. Figure 1 shows that the majority of patients were readmitted out of hours. To reduce readmission rates amongst urology surgery patients, the following prototypes were developed and PDSA tested: • Patient information traffic light sheets for cystoscopy, bladder reconstruction and tine line neuromodulation patients. • A single point of access telephone number which patients could call to discuss post-discharge concerns or issues. • A teach back medication protocol combined with a post-discharge survey, medication reminder chart and 48 hour teach back follow up to check patient understanding of their medications post-discharge.

Timeframe implementation The work was carried out using a 90 day rapid improvement cycle approach. Further work has been carried out since the completion of the 90 day rapid improvement cycle to spread the quality improvement interventions across the ward.

Implementation tools available Copies of the prototype patient information traffic light sheets and the teach back protocol are available on request.

Implementation cost The cost of backfilling the Charge Nurse who led the work for 2 days per week was around L9,000.00

RESULTS:

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Method used to measure the results Urology patient readmission rate data was collated (Figure 2). ‘Tracking data’ on patients involved in PDSA testing was also collected to identify whether each patient had been readmitted within 30 days of discharge. Results showed that three out of twenty-nine patients were readmitted (10%). Results PDSA feedback showed: • Patient information traffic light sheets make post discharge information and guidance simple. Patient feedback was unanimously positive. Patients reported that they had never had post-discharge information presented to them in such a simple and accessible format before • A single point of access telephone number ensures patients have access to urology expertise ‘out of hours.’ A log book of calls made to ward staff using the single point of access telephone number has proven that the system not only prevents readmissions but also acts as an early warning system to identify patients suffering serious complications.

Analysis of the results Using teach back for medications pre-discharge and 48 hours post discharge gives staff confidence that patients and carers have understood their medications. The interventions have improved both patient experience and post-discharge understanding of medications.



Please describe implementation barriers: Our plan to engage community care partners in the improvement was not achieved. Originally, we planned to engage community nurses in using teach back to check patient and carer understanding of their medications after the patient had been discharged from hospital.

Describe the strategies used to overcome the barriers (If needed)However, we were unable to translate the links we made with community care providers into discernible action. Future work on teach back would benefit from harnessing the engagement of community care providers.

OTHER INFORMATION:

Other information about the GOP that you would like to add Copies of the traffic light patient information sheet for cystoscopy patients and the teach back medication protocol available on request. Further information on the work we have carried out in this area is available by contacting Dr Jane Carthey at [email protected]

63

Development, implementation and monitoring of Common protocol for a healthcare response to Gender Violence.

2005-2012

GOP Information:


Organisation sharing the GOP Ministry of Health, Social Services and Equality

Member state Spain

Topic Clinical guidelines or pathways

GOP Description:


CLINICAL SETTING: Basically in Primary Care (PC), but they have also made progress in Specialized (hospitals)

OBJECTIVES: Its main target is to provide healthcare professionals with homogeneous action guidelines when faced with cases of violence specifically directed against women, covering both: care and follow-up as well as prevention and early detection.

POPULATION: Healthcare professionals in primary and specialized care. Specially useful for PC professionals, as it is at this level that contact with victims of gender violence is more immediate and direct. Healthcare managers:it provides a model of organization to plan and act on health care in cases of gender-based violence.

METHODS:

Methodology ORGANIZATION: The National Health System Interterritorial Council agreed to create a Commission Against Gender Violence, presided by the Healthcare Secretary General and formed by the Public Health, Quality an Innovation Directorate General, representatives of each Autonomous Community, the Equality Policies General Secretariat, and the Women’s Institute, The Observatory on Women’s Health assuming its Secretary ship. This Commission held their first meeting in November, 2004. In the Commission have established expert working groups to go planning different actions (adequacy of information systems, elaboration of epidemiological indicators, quality criteria for training, evaluation of performances, ethical and legal aspects) PROCESS: The Protocol has been made after reviewed international scientific evidence and the protocols of action health in the Autonomous Communities (AC. regional governments). The document is the result of the discussion and consensus in the bosom of a working group composed of professionals of the AC and experts in health and gender-based violence. The document brings together general concepts and guidelines for healthcare action (signs and symptoms of suspicion, plans of action based on the status of women) and coordination with other sectors (justice, forces and bodies of security, social services, etc.).

Timeframe implementation First 4 years(2005-2009):phase of dissemination/awareness-raising and training of professionals as well as the preparation of systems of health information (at least in PC). Awareness and training is continue. The following 5 years:begin to measure impacts and outcomes in clinical practice (studies at the regional level)

Implementation tools available • Common Protocol for the National Health System (NHS) and Protocols of the Autonomous Communities (AC) edited or revised with the release of the Common Protocol. • The Commission Against Gender Violence (GV) of the NHS Interterritorial Council, coordinating all actions

64

• 5 working groups of the Commission to go tracking implementation • Annual Reports monitoring proceedings (indicators of epidemiological GV cases detected and registered in health services and training processes)

Implementation cost 2005-2009:reviews (scientific evidence of tools; analysis of legislation, policies, programs and initiatives, systematization and collection of indicators) (approx. 150,000€). 2009-2010. Grant Programs Annually to health services of regional Governments (total sum both years 7.250.000€) 2011-2012. Only budget dedicated to the civil servant employees involved

RESULTS:

Method used to measure the results 1. Epidemiological indicators (from medical history or part of injury) See at: http://www.msc.es/organizacion/sns/planCalidadSNS/pdf/equidad/A4ViolIndicadoresIng.pdf 2. Training for Professionals Indicators and Quality Criteria See at: http://www.msc.es/organizacion/sns/planCalidadSNS/pdf/equidad/A4ViolCriteriosIng.pdf 3. Also, forms or templates to collect them, are available in the Annual Reports. See at: http://www.msssi.gob.es/organizacion/sns/planCalidadSNS/ivg2011Intro.htm Pages 108-146

Results CASES DETECTED AND REGISTERED: In 2011, the NHS has detected and informed 9614 battered women of 14 years and older from the AC through grievous bodily harm as information source (91.6 per 100,000). 6083 women abused in those same ages have been cases communicated by the AC from the Medical History as source of information (70 per 100,000). PROFESSIONALS TRAINING: In 2011, 13966 professionals who participated in 573 training activities that occupied a total of 5577 hours have formed. They were accredited within the formation, 79% (452). It highlights the increase of training in Emergency services.

Analysis of the results PC almost quadruplicates term means the detection of cases made from SC. Physical abuse the most frequent. Speclevel detects increased frequency of sexual abuse. Current partner/ex-partner as alleged primary aggressor. Women battered by their partners or ex-partner high occur in young groups (20 to 39 years). In absolute number, women are mostly Spanish, but rates are higher in women of economic immigration. Difficulties to detect cases in pregnant women. Students most come to training in professional women's health services although teaching teams highlight the predominance of medical men. Nursing has more concern for prevention and care of gender violence



Please describe implementation barriers: EPIDEMIOLOGICAL INDICATORS Actual incidence difficult to assess without a study to correct duplication between sources and levels of care. Lack of homogeneity in the codification of detected cases (PC/SC Information Systems) It is necessary to train health professionals to register and obtain GV epidemiological indicators and in specific programs designed for collection. Assessment and monitoring of quality in care. Management of the user interface (PC/SC/Emergency)

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TRAINING Training on gender-based violence not included in pre-grades. Ministry should promote its inclusion. Training materials on-line are needed. We only have absolute data from trained professionals, not of the scope of the training. Describe the strategies used to overcome the barriers (If needed)Training in prevention and early detection in gender violence in medicine and nursing internal resident (MIR and EIR in Spain) can be an opportunity, when they finish their gender violence training, they could develop clinical sessions in centres where they do their practices. Working in collaboration with the autonomous communities and other General addresses of the Ministry (health information management professional) for obtaining common denominators for calculating rates of coverage (target population) of trained professionals

OTHER INFORMATION:

Other information about the GOP that you would like to add All information: • the source and design of the Common Protocol, review in 2012, to adapt it to the contexts of increasing vulnerability • The follow-up reports, design of indicators, etc. is available in Spanish and English on the website of the Ministry: http://www.msssi.gob.es/organizacion/sns/planCalidadSNS/e02_t03_Comision.htm • Research studies on screening tools and others can be located at: http://www.msssi.gob.es/organizacion/sns/planCalidadSNS/e02_t03.htm We attach the forms (data collection sheet) designed for the collection of Epidemiological indicators: http://www.msc.es/organizacion/sns/planCalidadSNS/pdf/equidad/informeViolenciaGenero2009/genderViolence2009Report.pdf (pages 99-124)

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"Methodology for the identification, collection and dissemination of Good Practices in health performance against the Gender Violence (GPVAW) in the Spanish National

Health System (NHS)

GOP Information:



Member state Spain

Topic Other

GOP Description:


CLINICAL SETTING: Basically in Primary Care (PC), but they have also made progress in Specialized (hospitals)

OBJECTIVES: 1. Establish a standardized process for the identification/collection/dissemination of GPVAW within NHS. 2a.Improve quality-of-care of women suffering GV (and their dependants) 2b.Motivate professionals/ health services for GPVAW. 2c/d.Facilitate mutual learning and transfer of GPVAW within NHS 2f.Contribute to NHS sustainability by improving effectiveness/efficiency in GV 2g.Development of 1/2004 Organic Law (Integral-protection-measures-against-gender-violence)

POPULATION: • Professional health management and decision makers • Responsible for the health information systems • Professionals in primary and specialty care services • Women's associations General Population

METHODS:

Methodology ORGANIZATION: the Observatory Women's Health (OWH), as technical secretariat of the Commission Against Gender Violence of the NHS has drafted a proposal for: • Definition of GPVAW • Quality criteria (14 criteria) • Tools for assessment or evaluation of the candidate experiences for good practice that allow to check the 14 criteria (check-list) • Method to organize the collection of experiences and referral to the evaluation group of actions for their assessment and subsequent presentation of finally selected experiences to the plenary of the Commission. PROCESS: Every official representative of the 17 Autonomous Communities (AC) in the Commission is the focal point for forwarding to the Observatory their GP candidate experience documentation. The Observatory send the documentation to the Actions Evaluation Group (Evaluator Group), composed of another AC and expert institutions in scientific knowledge about GV and health policies, in addition to representatives of the Spanish Government Delegation for Gender Violence. The Evaluator Group grades and proposes to Commission the list of experiences presented and selected as GP at the end of year. Finally, the Interterritorial Council approves her subsequent proposition. GP selected have been included in the website of the Ministry, namely in the online search

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engine located (including google-maps).

Timeframe implementation Pilot study completed during 2012: • First quarter: agree methodological process and tools • Second quarter: collect experiences from AC healthcare services • Third quarter: experiences evaluated by Evaluator Team • Fourth quarter: selected experiences submitted to plenary of the Commission. Finally submitted to Interterritorial Council for final approval. First half 2013: online search engine implementation (Ministry-website)- freely available. • During 2013:second call to identify new experiences.

Implementation tools available • Process-methodology: procedure documentation standardized in all its phases • Template to describe the experience (annex I) and instructions sheet (annex II) • Check-list for qualitative self-evaluation of experience presented (Annex III) • Check-list for assessment and evaluation used by the Evaluator Group to qualify and select the experience as GP (annex IV). • Standard model of evaluation Report where the evaluation group has made the final score and the proposal as GPVAW, including improvement measures regardless of the outcome • Outcome of the pilot study report, standard model • Virtual workspace for the Evaluator Group to exchange documentation and expose their evaluation reports. (E-room) • Audio conferencing working group.

Implementation cost • Budget dedicated to 18 civil servants from different institutions • Travel costs for 1 day meeting for 18 representatives in the Committee • Cost of connections for 4 Audio Conferences (Evaluator Group) • Cost of E-room (virtual tool to working Group): contract of purchase and maintenance is responsibility of the Ministry.

RESULTS:

Method used to measure the results • For the final score of each GP we used a check-list. The evaluator group used it to qualify and select the experience as GP (annex IV). • A listing for the inventoried collection of experiences from piloting 2012. • Design and development of online search engine, in order to incorporate it into the web of the Ministry.

Results13 experiences have been presented for the whole of the 17 Autonomous Communities in this first call

Analysis of the results More than half of experiences selected as GP is comprised in the strategic lines of: • Adaptation of the health information systems for the collection of epidemiological indicators of gender-based violence • Training of professionals of the health services in the area of gender-based violence The selected experiences correspond to all the strategic lines raised (see General Annex to this questionnaire) except at the specific line of sanitary attention to daughters and sons of women who suffer GV



Please describe implementation barriers: Barriers have not been found, but we suggest some points of improvement.

Describe the strategies used to overcome the barriers (If needed)The most important is that

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annex IV (check-list to evaluate) is going to be improved and modified before its use in the collection of 2013, as observed by using this tool, which is a little biased toward experiences of direct intervention with the target population, the type of experiences with women suffering GV either the awareness and training interventions. However if it experiences related with health information systems or general methodologies of process, it is necessary to improve it to match the final score according to the degree of partial compliance with each criteria.

OTHER INFORMATION:

Other information about the GOP that you would like to add They are appended (only in Spanish, still not have proceeded to translation) the forms designed as: • Experience data sheet.(Annex I) • Instruction sheet for completing the sheet (annex II) • Check-list for qualitative self-evaluation of experience presented by the responsible project team candidate. (Annex III) • Evaluation and assessment Check-list. (Annex IV). Used by the Evaluator Group to qualify and select the experience as GP CONTACT: ROSA Ma LÓPEZ RODRÍGUEZ Programmes Coordinator Observatory Women's Health Directorate-General of Public Health, Quality and Innovation Ministry of Health, Social Affairs and Equality [email protected] Phone number: 34/ 915964075 Fax: 34/91.596.11.35

69

Improvement of health and social services organizations combining consensus processes for indicator development with methods of external assessment

GOP Information:


Organisation sharing the GOP Instituto Universitario Avedis Donabedian

Member state Spain

Topic Quality indicators

GOP Description:

IMPLEMENTATION LEVEL: Regional, Local

CLINICAL SETTING: We applied our methodology in 25 projects covering seven different health/social care sectors: Assisted living facilities, elderly health care (nursing homes, convalescence and palliative care), care for people with drug abuse problems, mental health, abused woman, mental incapacity and physical handicapped people. Total of 684 centres from 3 regions in Spain.

OBJECTIVES: Improvement the quality of care provided by health and social services organizations using consensus indicators for the external assessment of health and social services.

POPULATION: All patients that receive services in the organizations involved in the project.

METHODS:

Methodology Our methodology follows a four-step approach: 1. stakeholder involvement and creating an enabling environment, 2. using standardized consensus methods for indicator development, 3. using rigorous external evaluation methods to assess results and 4. developing and implementing quality improvement initiatives.

Timeframe implementation The first phases of the project (development of indicators, external assessment and development of improvement plans) can take around 1 and a half and 2 years. The implementation of the improvement plan varies, but it usually covers a 2 – 3 year period.

Implementation tools available • Description of the methodology • Several indicator sets (for all the clinical settings previously named) • Training materials for external evaluators • Software to introduce results of external evaluations Please note that all these materials are in Spanish.

Implementation cost Development of indicators: • 15 - 20 working days of QI expert • 6 – 8 days of 5 to 10 experts from the field. External assessment: • 3 days per organization Implementing QI initiatives. • 5 to 10 working days of QI expert • Field staff: varies depending on the goals

RESULTS:


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The set of indicators developed by consensus is used in order to measure the results in two different steps of the project:

1) at the beginning, to establish the baseline and to identify opportunities for improvement and 2) after a 2- 3 year period working on the implementation of results.

Data is collected by external evaluators, specifically trained for this project. Results For the overall performance assessment we observe in all four sectors major improvements ranging from 8.9% to 65.6% (difference in average compliance on the set of indicators between baseline assessment and the reassessment after 2 -3 years)

Analysis of the results Results show improvement in all organizations involved in the project, but the improvement is higher for organizations with a lower baseline score. This is positive because it means that the project promotes both improvement and homogeneization of services.



Please describe implementation barriers: • Some experiences only included the baseline assessment, due to lack of funding for the reassessment • Political changes that imply a change in priorities could be a challenge for this kind of 2 – 3 years long projects

Describe the strategies used to overcome the barriers (If needed)The project involves developing a set of indicators that is also useful internally as a basis for quality improvement, in case the second reassessment was not possible due to lack of funding or strategic / political changes.

OTHER INFORMATION:

Other information about the GOP that you would like to add The methodology for this GOP has been published in a peer review international journal in English, what could help sharing the information with other MS: Hilarion P, Sunol R, Groene O, Vallejo P, Herrera E, Saura RM. Making performance indicators work: the experience of using consensus indicators for external assessment of health and social services at regional level in Spain. Health Policy 2009 Apr;90(1):94-103 The method is not limited to the settings where it has already been implanted, it could also be implemented in any healthcare and social care setting, both at local, regional and national level.

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GUIASALUD. Clinical Guidelines Program for the National Health System

GOP Information:


Organisation sharing the GOP Instituto Aragonés de Ciencias de la Salud

Member state Spain


GOP Description:

IMPLEMENTATION LEVEL: National

CLINICAL SETTING: Not apply

OBJECTIVES: GuíaSalud Project was set up in 2003 by the Spanish NHS Inter Territorial Board. Objectives: • To promote the development, adaptation or update of clinical guidelines (CGL) based on the best available scientific evidence, using a homogeneus and contrasted methodology. • To spread the clinical guidelines in the NHS POPULATION: Regional Health Services Healthcare professionals

METHODS:

Methodology CGL development includes 3 different processes: 1.CGL elaboration: • Define the questions • Establish explicit and systematic criteria to evaluate scientific evidence • Formulate recommendations according to the level of evidence, taking into account also other aspects that must be considered • List the recommendations in a stepwise fashion, clearly distinguishing those based on scientific evidence from those founded by experts’ consensus. 2.CGL update Update begins when new evidence is found through monitoring or when the deadline determined for update is over. Then update process steps begin (bibliographic search, critical reading, synthesis of evidence, elaboration of recommendations, CGL edition). 3.CGL implementation includes: • Premises for CGL implementation • The relevance of context for CGL implementation • Identification of barriers and facilitators • CGL implementation strategies. How to facilitate change • Implementation evaluation

Timeframe implementation Not included

Implementation tools available • Elaboration manual • Update manual • Implementation manual

Implementation cost The program has an annual budget. In 2012 the budget was 750.000 €

RESULTS:

Method used to measure the results Number of CGL developed

Results25

Analysis of the results Not included

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OTHER INFORMATION:

Other information about the GOP that you would like to add Methodological tools: http://portal.guiasalud.es/emanuales/elaboracion/index.html http://portal.guiasalud.es/emanuales/actualizacion/documentos/manual_actualizacion.pdf http://portal.guiasalud.es/emanuales/implementacion/documentos/Manual_Implementacion.pdf

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Spanish National Health System Net of Agencies for the Evaluation of Technologies and Services

GOP Information:



Member state Spain


GOP Description:


CLINICAL SETTING: No applies

OBJECTIVES: General objective: to facilitate decission making on inclusion, financing terms or desinvesting and appropriate use of healthcare technologies by their global implementation through the regional healthcare services so as to promote equity and sustainability in the national health system (NHS) Specific objectives:

1.NHS Health Services offer. 2.Knowledge and evidence transfer for decison making. 3.Common methodology framework. 4.Resources and methodological tools sharing. 5.Shared Training programs 6.Health technology evaluation common culture.

POPULATION: Regional Healthcare Services

METHODS:

Methodology The Management Committee, constituted by all members of the net, is in charge of:

• Presenting the national authorities a joint and previously agreed position regarding research on health and healthcare services. • Managing the development of reports on evaluation of health technologies in a coordinated way.

Timeframe implementation 18 months from its creation till the technical documents with the methodological framework were available

Implementation tools available • The Technical Secretariate, performed by the Deputy Directorate on Quality and Cohesion from the Ministry of Health, Social Services and Equality. • The Technical Committee makes the net working procedures, guarantees a common methodology for the quality of reports evaluation and development, and reviews and approves the reports entrusted to the net, safeguarding their quality.

Implementation cost Specific funds in the annual national budget to support those health technologies evaluation activities that the Net has predetermined. In 2012, 4.000.000 €.

RESULTS:

Method used to measure the results The Management Committee meetings and methodological documents developed by consensus.

Results Technical documents: • Reports application form • Report typology and format • Common procedure for external review management: Application and Declaration of interest

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• Common working procedures (Methodological manual)

Analysis of the results Not included





OTHER INFORMATION:

Other information about the GOP that you would like to add Reports developed by the Agencies are available on this platform: http://aunets.isciii.es/web/guest/home

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Patient Empowerment/"Your guide to safer care"

GOP Information:


Organisation sharing the GOP The National Board of Health and Welfare

Member state Sweden

Topic Patient empowerment

GOP Description:


CLINICAL SETTING: All patients have the possibility to reach eighter from their caregivers or from the web site.

OBJECTIVES: The maingoal is to involved the patient and their relatives in their care to make the care more safer.

POPULATION: All patients.

METHODS:

Methodology The recommendation is built on GRADE and packaged to the patients about how to meet their caregiver and to create an active role for the patient.

Timeframe implementation To reach different kind of patient population, this product is now avaible both in print and in web site and different kind of languages and different kind of dissabilities.

Implementation tools available See above

Implementation cost About 10 miljon SEK.

RESULTS:

Method used to measure the results Statistical and qualitative methods.

Results For example know a days people/patients know that stop smoking is very important before surgery.

Analysis of the results Under development.



Please describe implementation barriers: The caregivers is not always interested to involve the patients and their relatives in care.

Describe the strategies used to overcome the barriers (If needed)The patients rights are described by the law.

OTHER INFORMATION:

Other information about the GOP that you would like to add No

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Patient involvment by the patient safety act 2010:659.The Hälso och Sjukvardslagen 1982:763

GOP Information:


Organisation sharing the GOP The National Board of Health and Welfare

Member state Sweden


GOP Description:


CLINICAL SETTING: Not relevant

OBJECTIVES: Rights for the patients.

POPULATION: All patients

METHODS:

Methodology Not relevant

Timeframe implementation Not relevant

Implementation tools available The documents are avaible both at print and at the web site. Further on at caregivers.

Implementation cost Not relevant.

RESULTS:

Method used to measure the results For example supervision and patient surveys.

Results Not relevant.

Analysis of the results The caregivers must continued the work to involved the patients.



Please describe implementation barriers: An holistic perspective is not implemented in the care all over Sweden yet.

Describe the strategies used to overcome the barriers (If needed)Not relevant.

OTHER INFORMATION:

Other information about the GOP that you would like to add Without concordance no compliance !!

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Accreditation of teaching hospitals: audit

GOP Information:



Member state Spain

Topic Accreditation

GOP Description:


CLINICAL SETTING: Teaching hospitals

OBJECTIVES: General objective: to guarantee that hospitals participating in health sciences specialized education develop their teaching according to the regulation that frames this activity and as it is established in the teaching program from each speciality Specific objectives:

1.Develop quality management systems in teaching hospitals. 2.Guarantee a common methodological framework for teaching hospitals evaluation and accreditation. 3.Create a culture of hospital evaluation

POPULATION: 150 hospitals that are certified as teaching centres for specialized education in health sciences.

METHODS:

Methodology The MSSSI Unit for Accreditation and Audit, supported by evaluators from the Regions, has developed evaluation criteria and procedure manuals according to the Spanish legislative framework and the subsequently developed regulation for the specialized education in health sciences. Each year an evaluation plan is carried out, including teaching hospitals audits and documentary assessment. Once the centre has been evaluated after documentary review or audit, a proposal for an improvement and accreditation plan is prepared and presented to the Accreditation Committee, made up by representatives of the different health sciences specialties National Boards, the members of which are expert clinicians.

Timeframe implementation 2 years

Implementation tools available • MSSSI Unit for Accreditation and Audit • Evaluation teams linked to the Regions. • Evaluation criteria and technical proceedings. • Teaching program • Accreditation Committee • Annual satisfaction survey for health sciences interns

Implementation cost No specific funds are available. 1000 € per audit are estimated, excluding human resources.

RESULTS:

Method used to measure the results See below

Results • Common evaluation procedures: technical proceedings (Manual) • Audit report template

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• Audit report (per hospital). • Improvement plan (per hospital). • Interns satisfaction report (annual and per hospital) • Proposal of accreditation (per hospital) Analysis of the results An evaluation procedure of the healthcare teaching structure related to the specialized education on health sciences in Spain has been developed and implemented. This procedure makes it possible for hospitals to be reaccreditated as teaching centres.





OTHER INFORMATION:


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Accreditation of Reference centres It is incumbent on the MSSSI the accreditation of hospital units as national reference

centres. This means that patients can move to hospitals from different Health Regions to get assistance when a very qualified healthcare team is required to perform highly

complex procedures.

GOP Information:



Member state Spain

Topic Accreditation

GOP Description:


CLINICAL SETTING: Neurology and neurosurgery, ophthalmology, oncology, plastic surgery, cardiovascular surgery.

OBJECTIVES: General objective: to guarantee that hospitals providing these procedures and activities fulfil the technical requirements. Specific objectives:

• To guarantee a common methodological quality framework for evaluation and accreditation of Reference units and centres. • To create an evaluation culture in hospitals.

POPULATION: 50 hospitals that have applied for accreditation of reference units for those procedures (around 50) for which technical requirements have already been approved.

METHODS:

Methodology The MSSSI Unit for Accreditation and Audit has developed accreditation criteria and procedure manuals according to the Spanish legislative framework and the subsequently developed regulation for the appointment of reference centers, units and services. Each year an evaluation plan is carried out, including the audit of those units that have applied to be appointed as national reference center for any of the procedures approved by the NHS Inter-territorial Board. Once the centre has been audited, an Accreditation Report is prepared and presented to the Reference Centers, Services and Units Appointment Committee, made up by experts and representatives of the Health Regions.


Implementation tools available • MSSSI Unit for Accreditation and Audit • Audit teams • Assessment criteria and technical proceedings • Appointment Committee

Implementation cost No specific funds are available. 1000 € per audit are estimated, excluding human resources

RESULTS:

Method used to measure the results See below

Results • Common evaluation procedures: technical proceedings (Manual). • Audit/Accreditation report template • Audit report (per centre)

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• Accreditation report (per centre)

Analysis of the results An evaluation procedure of the healthcare structure related to those reference procedures with approved technical requirements and prioritized by the Health Regions has been developed and implemented. This procedure makes it possible for hospital units to be accreditated as national reference centres.





OTHER INFORMATION:


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Accreditation program for hospitals.

GOP Information:


Organisation sharing the GOP National Center for Quality Assessment in Healthcare (NCQA)

Member state Poland

Topic Accreditation

GOP Description:


CLINICAL SETTING: hospital care level

OBJECTIVES: To improve quality and safety of hospital care in Poland.

POPULATION: Patients, hospital management, healthacare professionals.

METHODS:

Methodology • offering educational training for hospitals which entered the process • conducting accreditation survey • providing the accreditation report indicating the area for improvement;

Timeframe implementation It took us about 3 years to introduce and implement the national level accreditation program. For a hospital it takes at least one year to adjust hospital performance to the accreditation standards requirements.

Implementation tools available • accreditation standards • accreditation procedure • training and retraining of surveyors • educational activities for hospitals and staff

Implementation cost It would be difficult to estimate implementation costs as accreditation department is just one of the few other ones at NCQA and we have a single budget for overall functioning.

RESULTS:

Method used to measure the results - level of compliance to accreditation standards

Results • implementation of surgical safety checklist • appropriate antibiotic prophylaxis • monitoring of HCAIs • introduction of R&L systems for ADEs • patient surveys

Analysis of the results • feedback is provided to hospitals during the consecutive accreditation surveys; • discussion with quality teams and hospital leaders during hospital visits



Please describe implementation barriers: resistance to change of healthcare professionals (especially doctors) lack of the requirement to analyse own clinical practice

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Describe the strategies used to overcome the barriers (If needed)education and training for hospitals

OTHER INFORMATION:


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Development and Implementation of Integrated Care Pathways

GOP Information:


Organisation sharing the GOP Nicosia General Hospital

Member state Cyprus


GOP Description:


CLINICAL SETTING: Several Clinics/ Departments of Nicosia General Hospital. Will be rolled out to the other hospitals soon

OBJECTIVES: • enhance communication between Health Care Workers and patients • set treatment goals, schedule diagnostic tests at the time of admission • schedule a detailed discharge program • avoid mistakes • facilitate teaching and training of new personnel • cost efficiency of health care delivery • ensure application of evidence based medicine by all

POPULATION: Our target is to map 60% of all patient admissions with integrated care pathways

METHODS:

Methodology A team consisting of doctors nurses and members of the board of the hospital has been established and trained. Data were retrieved from the IT system of the hospital, using ICD-10 coding, to find the top diagnosis for hospital admissions across all departments of the hospital. Before developing a pathway the routine of the department is reviewed and compared to evidence based medicine. Then a discussion is carried out between the team members and head doctors and nurses of the department. A draft pathway is developed and piloted on the ward for a week. Then the final pathway is developed.The pathway incorporates a detailed plan for the patient including diagnostic tests, blood tests, medication, nutrition, nurses, anaesthetists, physiotherapy and other interventions, temperature and blood pressure charts, fluid intake and output, nurses and doctors reports.The care pathway finally is put in the patient's records.

Timeframe implementation It is an ongoing procedure

Implementation tools available Power point presentation and education material available

Implementation cost Salary of a nurse

RESULTS:

Method used to measure the results A booklet including information on clinical skills and competences is given to all newcomers Self assessment questionnaires are given to the HCW before and after training, and areas for improvement are identified the results are measured through the annual reports regarding • infections • decubitus ulcers • patient falls • VAP etc

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Results As mentioned above

Analysis of the results The indicators as mentioned above for the quality of care and patient safety





OTHER INFORMATION:


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National Health System Training Program on Patient Safety

GOP Information:



Member state Spain

Topic Professional learning program on quality and safety

GOP Description:


CLINICAL SETTING: Specialized and Primary Healthcare, Health Regions Patient Safety central services

OBJECTIVES: • To promote culture and knowledge in patient safety in the National Health System • To prevent, detect, analyze and minimize adverse events • To disseminate evidence and safe clinical practices

POPULATION: Clinicians, local and regional quality and risk management teams, healthcare services managers

METHODS:

Methodology • Multifaceted approach: face-to-face sessions and workshops; on-line courses (supervised and self-guided) and tutorials; on-line multimedia resources • Contents: epidemiology and adverse events prevention; risk management; evidence based medicine; communication and effective team work; safe practices • Different levels: basic courses (at regional level and national level: risk management tools and patient safety basic concepts); on-line risk management courses; master degree; specific courses (hand hygiene, BZ (CLABSI prevention bundle), NZ (VAP prevention bundle), report and learning system (SiNASP) users and managers) • Specific funding to HR for basic courses and MSSSI development of more specialized courses oriented to training of risk managers and multiplicators • On-line resources and tools can be used by HR for their own training programs implementation

Timeframe implementation Gradual implementation: basic courses (from 2005); risk management courses (from 2006); master degree (from 2007)

Implementation tools available • Tutorials (Basic PS concepts; risk management tools; Hand-hygiene; medication safety): http://www.seguridaddelpaciente.es/index.php/formacion/tutoriales.html?phpMyAdmin=mvRY-xVABNPM34i7Fnm%2C23Wrlq5 • On-line resources on EBM: http://www.seguridaddelpaciente.es/index.php/lang-es/formacion/recursos-en-linea.html • Risk management projects database: http://www.seguridaddelpaciente.es/index.php/formacion/proyectos-seguridad-paciente.html?phpMyAdmin=mvRY-xVABNPM34i7Fnm%2C23Wrlq5

Implementation cost Online risk managements courses (Platform, 23 editions, projects database):635,000 € Master (5 editions): 598,000 €

RESULTS:

Method used to measure the results Number of professionals trained

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Satisfaction Number of editions Impact

Results • Master in Patient Safety (2007-2012): 4 editions, 120 professionals (68% MD; 23% Nur; 9% Others); 120 final projects; high satisfaction • Risk management (on-line course 2006-2011)): 20 editions (18 Spain/PAHO/WHO and 2 EUNETPAS); 1,081 professionals; 300 projects; High satisfaction • Hand hygiene: 101 multiplicators trained in 2009-2010 and 9,400 professionals have completed the on-line tutorial provided by the MSSSI in the last 14 months. Data from regional and local training is not available • BZ: >17,000 professionals trained in 2009-2011 (10% MD, 57% N, 30% NA, 3% others) • NZ: 7.910 professionals in 2011 (11% MD, 60% N, 28% NA,1% others)

Analysis of the results • The Teaching programme facilitates continuous learning in PS and provides trained leaders (managers and clinicians) in all HR with the capability to promote safe clinical practices and PS strategies at local and regional level • The methodology facilitates the high participation and involvement in PS strategy • The programme depends on policy determination and funding allocation





OTHER INFORMATION:

Other information about the GOP that you would like to add All information and resources can be found in: http://www.seguridaddelpaciente.es/

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Medication Safety Self Assesment for Hospitals

GOP Information:


Organisation sharing the GOP Ministry of Health, Social Services and Equality (MSSSI) Institute for Safe Medication Practices - ISMP Spain

Member state Spain


GOP Description:


CLINICAL SETTING: Hospitals

OBJECTIVES: 1.To provide hospitals with a self-assessment tool to identify those areas of the medication use system with the greatest opportunities for improvement 2.To encourage continuous self-assessment by hospitals and to facilitate comparison of each hospital’s data with data from the aggregate of the other participating hospitals

POPULATION: Hospitals quality and safety units/commissions and pharmacists

METHODS:

Methodology The self-assessment tool is a Spanish adaptation of the Medication Safety Self-Assessment (MSSA) for hospitals originally designed by the Institute for Safe Medication Practices in USA. It includes 232 assessment items, which reflect specific practices or measures designed to prevent medication errors. The assessment tool is structured into 10 sections which represent the key elements that determine the safety of the medication use system. These key elements include one or more core characteristics up to a maximum of 20. The tool is accessible through an on-line platform. Any hospital from the NHS can apply for a code and a password and access the tool and perform the self assessment. The tool provides the hospital with different statistical analysis from all the items and elements included in the questionnaire. The hospital's data are included in a database and this facilitates comparison with the aggregated data from all the hospitals that have performed the self-assessment. The hospital can also compare its own data with previous self-assessments.

Timeframe implementation Tool adaptation and on-line implementation: 1 year Self-assessment: 3 team sessions around 1-2 hours long are recommended

Implementation tools available On-line tool Questionnaire to download Definitions Instructions Frequently asked questions

Implementation cost Adaptation and design: 45,000 € Maintenance: minor Baseline and follow-up study: 66,000 €

RESULTS:

Method used to measure the results National Health System baseline study in 2007 (105 hospitals) and follow-up study in 2011 (165 hospitals, 82 having participated in the 2007

88

study)

Results A comparison of the progress between the 2011 and 2007 studies show that the greatest relative increases were obtained for core characteristics 18-17-4-and-15, which refer to medication error detection and analysis by professionals (84.5%), development of an error reduction program (49.4%), communication of drug orders and other drug information (46.6%) and continued safety training (46.3%), respectively. Significantly higher values for the whole survey were found for the hospitals that had taken the survey in 2007 (7.3% absolute difference). Statistically significant differences were found in all the core characteristics, except in characteristics 3, 10, 12, 14 and 17

Analysis of the results The degree of implantation of safe medication practices in Spanish hospitals has increased (20 percentage points; a 25% relative increase). Increase was more pronounced in those hospitals that also participated in the 2007 evaluation (an increase of 13.3 percentage points; 33.3% in relative terms), in which improvement was seen in safe medication practices in all types of hospitals and in the 20 core characteristics. These hospitals also obtained better results in the 2011 evaluation than those hospitals that only participated in this most recent evaluation, achieving 7.3 more percentage points. All of the above supports the notion of using the self-assessment survey as a proactive tool for improving medication use safety.





OTHER INFORMATION:

Other information about the GOP that you would like to add Link to self-assessment tool: http://farmacia.flagsolutions.net/cake/

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Psychological support for the patients admitted in the ICU and their families: Full time psychologist in the ICU of NGH

GOP Information:


Organisation sharing the GOP Nicosia General Hospital – Intensive Care Forum

Member state Cyprus


GOP Description:


CLINICAL SETTING: The practice has been implemented in the Intensive Care Unit of Nicosia General hospital

OBJECTIVES: • Improvement of the health care quality • Improvement of the communication between health care personnel and patients • Improvement of the communication between health care personnel and patients’ families • Patients are more compliant to the therapy • Decrease the prevalence of stress and depression levels among patients and their families • Increase of patients’ and relatives’ satisfaction

POPULATION: ICU patients and their families

METHODS:

Methodology The role of the psychologist in the ICU 1.Daily present in the ICU and at the morning round of the doctors 2.Introduction of the psychologist to the families by the medical personnel 3.Recommendation for a psychological session Psycho-social evaluation 1.Demographics 2.Socio-economic Status 3.Anxiety Inventory Psychological Support 1.Brief Integrative Psychotherapy 2.Crisis Intervention 3.Psycho-education 4.Communication Skills education

Timeframe implementation Immediate implementation

Implementation tools available N/A

Implementation cost One FTE Psychologist

RESULTS:

Method used to measure the results Data from each interview/session are stored and analysed comparing several factors.

Results Not yet analysed and published. But there has been improvement in several fields. Better communication among patients, families and the health care professionals. Decrease of stress and anxiety levels of the relatives. Patient and families satisfaction level increased regarding the care of the ICU. There has been a decrease of conflicts between families and

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personnel

Analysis of the results Not yet analysed





OTHER INFORMATION:

Other information about the GOP that you would like to add The above service has been implemented in the Intensive Care Unit of NGH for 3 years. The services of the psychologist are provided by a non profitable organisation, the Intensive Care Forum.

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Clinical Trainer Educator Nurse

GOP Information:


Organisation sharing the GOP Nicosia General Hospital – Intensive Care Unit

Member state Cyprus


GOP Description:


CLINICAL SETTING: Intensive Care Unit Nicosia General Hospital

OBJECTIVES: TRAINING OF PERSONNEL IN ICU REGARDING PATIENT SAFETY AND QUALITY OF HEALTHCARE ISSUES • Continuous education of nurses • education of new staff • training on new equipment or consumables • theoretical trainig based on real needs according to everyday practice.(ie indicators of the ICU as number of infections, are reviewed and training is carried out accordingly)

POPULATION: Personnel of ICU in Nicosia General Hospital

METHODS:

Methodology Training is carried out in different ways • organisation of lectures and seminars for all workers of the ICU • bed side training • one to one training according to weaknesses identified • training on new equipment, machinery or consumables • through the interactive web based platform that has been implemented in the ICU units of Nicosia and Limassol Hospitals, The University of Crete Greece and the Open University of Cyprus

Timeframe implementation This is an on going procedure

Implementation tools available all teaching material is available

Implementation cost -cost of one FTE nurse

RESULTS:

Method used to measure the results A booklet for Clinical Knowledge and Competences is given to all health care workers on the ICU • self assessment questionnaires • through the annual reports and measurement of indicators: • infections • rates of VAP • rates of catheter related blood streem infections • decubitus ulcers • patient falls etc Results data of the annual report of the hospital comparison of the data and estimation of trends

Analysis of the results not yet available


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OTHER INFORMATION:


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Patient Safety Reporting and Learning System (SINASP)

GOP Information:


Organisation sharing the GOP Ministry of Health, Social Services and Equality (MSSSI) Avedis Donabedian Institute (FAD)

Member state Spain


GOP Description:


CLINICAL SETTING: Hospitals (piloting in Primary Care)

OBJECTIVES: 1.To improve Patient Safety through the analysis of healthcare incidents and adverse events 2.To promote changes in the system necessary to prevent the repetition of these incidents in the future 3.To learn from healthcare incidents: incident notification analysis and identification of new hazards, trends, risk factors and contributing factors

POPULATION: Healthcare professionals Risk management units National and regional patient safety managers and administrators

METHODS:

Methodology 1.Process: 2007-2012 • Phase 1: • Bibliographic review and visits to other countries' experiences (UK-DK) • Experts consultation: 18 Health Regions-HR representatives and 12 patient safety experts • Focus groups with patients' associations representatives • Healthcare professionals consultation: 59 representatives from 53 scientific societies • Definition of basic principles for the system • Phase 2: • Questionnaire design (based on WHO framework, systems already implemented in 3 other countries and 4 HR and specific Spanish medication error reporting system) and on-line platform development • Pilot test at hospital level (2 hospitals from 2HR) • Pilot test at HR level (32 hospitals from 2 HR) • Phase 3: • Gradual implementation in other HR • Pilot test in Primary Care 2.System attributes: • Voluntary, non-punishable, confidential • Anonymous notification (or initially identified and unidentified post-analysis) • Analysis oriented to local learning and improvement • System-oriented analysis 3.System structure and information/analysis flow: Local healthcare professional: incident notification Local safety unit: analysis, action and feedback at local level Regional unit: local support and regional analysis and feedback National coordination: technical support and global analysis 4.Implementation process (hospital level): structured and guided process including: Face-to-face instruction and training to trainers

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Local cascade training Work circuits definition Project launch Start of reporting and technical support

Timeframe implementation 3-6 months for local implementation

Implementation tools available On-line platform Guide for implementation Training materials for local sessions On-line course System manager guide User guide Letter for hospital executives Commitment form for Health Region authorities and for hospital management Root cause analysis tools and real examples

Implementation cost Design and pilot: 210,000 € Technical support (2009-2012): 359,638.50 € Health Regions dissemination: 40,800 €

RESULTS:

Method used to measure the results At NHS level, global monitoring indicators: Volume of reporting (no of incidents at national/regional,etc) Characteristics of reporting (by professional, by risk, etc) Management of reporting (time needed;actions initiated..) Analysis of reporting (Cause-root analysis, group meetings..) Feedback performed (by Web and email, newsletters,etc)

Results System implemented in 5 Health Regions: 66 hospitals 2,952 notifications received in 2011; 8,239 in 2012 28,750 healthcare professionals trained till the end of 2012

Analysis of the results SiNASP has been gradually implemented and the results obtained (local implementation, reports, analysis, feedback) also follow a gradual process. High variability which mainly depends on regional support and local leadership. More than 50% of reporters identify themselves, which shows no worry about punitive actions around the reporting system although no legal protection exists in Spain for reporters. Feedback reports elaborated and disseminated at local level are increasing, as well as case discussion sessions.



Please describe implementation barriers: • Human resources, time and support provided to the hospitals by Health Regions is variable and this circumstances highly affect local implementation. • Local changes in hospital management and patient safety responsibilities also jeopardized the project in some cases • The lack of legal protection for reporters.

Describe the strategies used to overcome the barriers (If needed) Direct contact with Health Regions authorities in charge of patient safety Direct technical support to the hospitals

OTHER INFORMATION:


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Link to SiNASP web: https://www.sinasp.es/

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Report and learning system on medication errors

GOP Information:


Organisation sharing the GOP Ministry of Health, Social Services and Equality (MSSSI) Institute for Safe Medication Practices ISMP-Spain

Member state Spain


GOP Description:


CLINICAL SETTING: All. The system collects information from events taken place in any clinical setting OBJECTIVES: 1. Analyze, classify and assess medication errors reported by any healthcare professional 2. Identify the patient safety problems associated to these medication errors, elaborate technical proposals to prevent them and support their implementation.

POPULATION: All healthcare professionals, Pharmaceutical companies, Pharmacists associations, Spanish Agency of Medicines and Medical Devices

METHODS:

Methodology • ISMP Spain receives notifications on medication errors from different sources: on-line form, e-mail, ordinary mail, phone call, specific local (hospitals and primary care) learning and report system on medication errors, regional report system from Andalucía (since 2010), national patient safety report and learning system -SiNASP- (since 2012). • These notifications are classified and analyzed according to the Spanish classification for medication errors and taking into account: severity, medicines involved, error types and processes, causes and contributing factors. Once analyzed, all information coming from other sources is stored in the same database implemented for the local-national report and learning system. • Based on the analysis, recommendations and reports are elaborated and addressed to the Spanish Agency of Medicines and Medical Devices, the Pharmaceutical companies or the Pharmacists associations. Also specific alerts and bulletins are prepared and disseminated for all healthcare professionals and the public.

Timeframe implementation One year

Implementation tools available ISMP web Local report and learning system on medication errors

Implementation cost Around 30,000 € per year to mantain the Web page and Newsletters and expert collaboration

RESULTS:

Method used to measure the results Annual report including the number of analysis carried out, the alerts and bulletins disseminated and the actions known to have been implemented or initiated by the pharmaceutical industry or the national Agency.

Results Around 850 notifications are analyzed each year. The number of bulletins and alerts disseminated depends on the results of the analysis (usually 2 bulletins/year).

Analysis of the results The results obtained have allowed to change the presentation of some medications and to establish national recommendations.


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OTHER INFORMATION:

Other information about the GOP that you would like to add LInk to ISMP Spain web: http://www.ismp-espana.org/

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Patient safety during interventional procedures in Cardiology.

GOP Information:


Organisation sharing the GOP Medical Physics Department Nicsia General Hospital

Member state Cyprus


GOP Description:


CLINICAL SETTING: Interventional procedures in Cardiology

OBJECTIVES: To apply the radiation protection principle ALARA and enhance patient radiation safety for patients undergoing interventional procedures in cardiology.

POPULATION: Patients subject to interventional procedures in Cardiology.

METHODS:

Methodology Radiological exposure data for each patient are extracted from individual Electronic Dose Report . Data analysis based on exposure condition?. (Physician, Details of Intervention). Comparison of results with relevant internationally established references. Recommendations to Departments for control and minimisation of patient dose.

Timeframe implementation • Preparatory stage for procedure establishment (research and development): 1 MONTH • Data validation : 1 DAY • Data Collection : 3 MONTHS • Analysis of results: 2 WEEKS • Feedback of results (preparation for presenting results and arranging departmental management liaison) :3 WEEKS Repeat loop for re-evaluation of patient dose: Infinite

Implementation tools available • Electronic Dose Reporting capability from ionizing radiation modality (Angiography system) • Power Point Presentations • SPSS Statistics

Implementation cost 10000-15000 Euros for both hospitals including human resources.

RESULTS:

Method used to measure the results The indicators used to assess the GOP are: a) Average Total Accumulated Dose Area Product per patient per procedure (Average Total DAP) b)Average Total Fluoroscopy Time per patient per procedure (Average Total FT). c) Average Entrance Surface Dose at International Reference Point (Average ESD at IRP). A set of 100 patients dosimetric data are collected from each hospital. (10% confidence interval with a population of 1200 patients/year at 95% confidence level.)

Results For PCI (including CA) procedures: (Average Total DAP): 186 Gy.cm2 (Average Total FT) : 24,2 mins (Average ESD at IRP):3464 mGy Dosimetric indices are also available per physician For purely diagnostic (CA) procedures:

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(Average Total DAP): 63 Gy.cm2 (Average Total FT) : 9,5 mins (Average ESD at IRP):1000 mGy Dosimetric indices are also available per physician Analysis of the results Results are higher than international references. Strong correllation of excessive fluoroscopy time with doses.



Please describe implementation barriers: Yes. Availability of Medical Personnel and correct conditions to explain the impact of these results on patients and the safety implications.

Describe the strategies used to overcome the barriers (If needed)Involve the hospital administration and communicate the risks using opticoacoustical aids from international organizations (e,g data and pictures of over-irradiated patients).

OTHER INFORMATION:


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Monitoring the consumption of antimicrobilas in hospital care in Slovenia

GOP Information:


Organisation sharing the GOP Ministry of health

Member state Slovenia

Topic Clinical Risk Management

GOP Description:


CLINICAL SETTING: In all types of Slovenian hospitals in the following wards: - surgery, internal medicine, gynaecology, paediatric,Intensive care units (ICU)

OBJECTIVES: The objective of GOP is to collect comparable and realiable data on antibiotic use. Since 2001 100% of hospitals are providing data. The goal is that every hospital pharmacist can see his own data and compare "his" hospital antibiotic use with the average of hospitals of same type and size.

POPULATION: Clinical farmacists

METHODS:

Methodology Under regulations from 2011 evry hospital is now obliged to monitor the consumption of antimicribials; this has become a quality indicator in hospital care.The data from the hospital as a whole and from the 5 wards are collected by the end of january for the past year.National data on ambulatory care and hospital crae are also publicly available from www.si-map.org

Timeframe implementation 6 - 12 months

Implementation tools available Hospital pharmacists receive data and present them at meetings (making management familiar with data, education of physicians).

Implementation cost Zero 16.000 EUR for IT

RESULTS:

Method used to measure the results The data from hospitals are analysed by the National Antimicrobial Committee.

Results Members of the Committee will susequently audit the appropriateness of antimicrobial use. Every hospital should be audited within the next 5 years. The differece and percentage change compared to the previous year are also provided.

Analysis of the results The data from hospitals are analysed by the National Antimicrobial Committee.



Please describe implementation barriers: Non cooperation of hospital pharmacists, non cooperation/ignorance on the management part or from the physicians Describe the strategies used to overcome the barriers (If needed) Motivation, contiuous education on usefulness of the GOP.

OTHER INFORMATION:

Other information about the GOP that you would like to add Hospitals are the epicentre of development of bacterial resistance and the data on consumption of antimicrobials provide the basis for immproving antibiotic prescribing,

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evaluating trends, interventions, benchmarking and correlation between antibiotic consumption and resistance.

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Cooperation between scientific societies to develop guidelines for clinical practice and clinical management

GOP Information:


Organisation sharing the GOP SOCIEDAD ESPANOLA DE CALIDAD ASISTENCIAL (SECA) Spanish Society of Healthcare Quality Contact: Pilar Astier [email protected]

Member state Spain


GOP Description:


CLINICAL SETTING: Methodological support from SECA to other scientific societies for the design of clinical practice guidelines

OBJECTIVES: To provide the methodology and healthcare quality tools during the design of clinical practice guidelines, healthcare processes and indicators of therapeutic evaluation from other scientific societies that work in the healthcare area.

POPULATION: Scientific societies working in healthcare

METHODS:

Methodology Three specific areas of work: 1.Collaboration on the methodology of design and evaluation of the care process for patients with melanoma. In cooperation with the Spanish interdisciplinary melanoma group. 2.Collaboration on the methodology of design and evaluation of indicators of pharmaceutical care for HIV patients. In cooperation with the Spanish Society of Hospital Pharmacy and the GeSIDA group from the Spanish Society of Internal Medicine 3.Development of a set of indicators of clinical effectiveness for Primary and Specialized Healthcare Timeframe implementation Each project has taken around one year since the signature of the agreement until the final monograph publication

Implementation tools available To show SECA's members competency in the design and evaluation of clinical practice guidelines and healthcare processes to other scientific societies in the healthcare area. To begin cooperation agreements for particular pathologies or sets of indicators.

Implementation cost Each project is sponsored by an institution that establishes the funding available. Human resources and time allocated are adjusted to it and so is the scope of the recommendations.

RESULTS:

Method used to measure the results 1.To verify the execution of the agreement 2.To publish a monograph and to disseminate it to the members and professionals related to the healthcare area dealt with.

Results Since the first two monographs (melanoma and HIV) have just been published there is no data yet on their initial impact

Analysis of the results Field results not available yet. Nor are the barriers




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OTHER INFORMATION:

Other information about the GOP that you would like to add Skin cancer patients' expectations: http://www.calidadasistencial.es/images/gestion/biblioteca/348.pdf Care process for skin cancer patients: http://www.calidadasistencial.es/images/gestion/biblioteca/350.pdf Indicators of pharmacotherapy in HIV patients: http://www.calidadasistencial.es/images/gestion/biblioteca/349.pdf The document on indicators of clinical effectiveness for Primary and Specialized Healthcare is under development. It has been elaborated by expert consensus during the V SECA Meeting of Primary and Specialized Healthcare Quality Coordinators, held on May 23rd 2012 in Zaragoza.

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Patient Safety Improvement by operating a reporting and learning system

GOP Information:


Organisation sharing the GOP Semmelweis University Health Services Management Training Centre

Member state Hungary


GOP Description:


CLINICAL SETTING: We receive reports from 5-10% of hospitals, but there are more institutes which use the report sheets without reporting to us. The regular forums on patient safety are attended by representatives from 30-40% of all hospitals.

OBJECTIVES: Improving patients’ and workers’ safety • patient safety related researches, exploring and distributing existing practices • operating a reporting system (NEVES) and forming a recommendation (NEKED) to support root cause analysis of adverse events and organizational learning • developing recommendation to support AE prevention • distribute recommendations to providers • improve organizational culture POPULATION: Reporting system: front-line staff, quality managers, healthcare workers with managerial duties Forum: quality managers, healthcare workers with managerial duties, both in primary and secondary care, representatives of patient associations, patient rights representatives, front-line staff

METHODS:

Methodology Operating a complex patient safety program Reporting system: voluntary, anonymous. Reports are submitted on a pre-defined structured online form, in various topics, and are sent to the system operators (independent experts on PS data analysis). The questionnaire aims to explore the underlying causes of AE-s. Their development is performed by experts on the given area of healthcare. The selection process of events is the following: • frequent enough • the result of well identified processes • processes are responsibilities of more people (to avoid unwillingness to report) • possible to reduce the occurrence of events by intervening into the processes The reportable events are adverse events, incidents or activities holding great risk. Data analysis is performed partly by the reporting institute when they receive the aggregated data of their reports. The other part is immediate, supported by default statistical analyses. The institutes receive results automatically both in written and graphic form. Every institute is able to see the aggregated anonymous results, and statistics of their own reports. Patient safety forums: bimonthly events, aiming to distribute knowledge on patient safety, gather initiatives and exchange experiences. They start with keynote speech, followed by active discussion with the participants, who may share their experiences on the selected issue.

Timeframe implementation 1 year

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Implementation tools available • Online form • Software for data analysis and national comparison • Case studies to support implementation and interpretation of results • All presentations of all forums are available and organised by topic

Implementation cost oftware development: 3.000.000 HUF IT tools 1.000.000 HUF HR: 15 expert days/data collection sheet methodology of analysis and feedback: 15 expert day/ data sheet

RESULTS:

Method used to measure the results Number of institutions/ reports/ participants

Results Analysis of results is performed on institute level. A survey was performed to assess opinions on the program. (Results in the next field) Analysis of the results 83% of participants stated that their approach have changed due to the program. In 89% of the institutes, participants discuss what they have learnt. 63% of respondents stated that they have changed some practices in their institutions. (based on 62 responses)



Please describe implementation barriers: • willingness to report changes • difficult to implement changes • late feedback • organizational culture (fear of consequences) • management not committed • not enough knowledge to analyse results (statistics, root cause analysis) • data used for wrong purposes (e.g. comparing different units)

Describe the strategies used to overcome the barriers (If needed)Involving management, changing organizational culture through the forums. There were opportunities for the institutional management to get acquainted with the importance of the program and the managerial duties and opportunities. The presentation pointed out the importance of patient safety, showed the logic of our reporting system, the purpose and methodology of the root cause analysis, the possible conclusions, and the work of the Patient safety forums altogether.

OTHER INFORMATION:

Other information about the GOP that you would like to add Get in touch with the institutional management, their involvement is necessary. Our experiences suggest that convincing is a successful method. The maintenance of the program requires immediate feedback to the reporters, because this is the base of a quality improvement strategy. If the feedback is late or nonexistent, the willingness to report decreases. After introducing the immediate feedback, the increase in willingness to report was perceptible. Institutions should be helped throughout their activity in the program (reporting, data analysis, RCA, appropriate methodologies). The forums aim to support this; the necessary knowledge on methodology is included in the presentations.

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Development of an e-learning training program in patient safety

GOP Information:


Organisation sharing the GOP Semmelweis University Health Services Management Training Centre



GOP Description:


CLINICAL SETTING: Hospitals, ambulatory care settings

OBJECTIVES: The participants should be able to recognise and manage the risks occurring during healthcare. They should know and apply the known best practices to improve patient safety and be familiar with the proper way of handling the occurred patient safety incidents and be able to draw the conclusions of them

POPULATION: Front-line physicians and other healthcare workers, quality managers and their colleagues Graduate students in the field of healthcare Residents Hospital workers, physicians, nurses, pharmacists participating in training programs

METHODS:

Methodology Structure of the e-learning program The e-learning program contains 9 modules, each with 5-10 lessons. Each lesson takes 60 minutes to complete; the necessary time to finish a module is between 10 and 15 hours. At the end of every lesson there are exercises and self-check questions to help learning and understanding. To complete a module, students must write a test which covers all topics in the specific module. It is required to answer 85% of the questions correctly. Learning process: The lessons follow each other sequentially, it is possible to navigate backwards, but in order to unlock the next module students must complete the end of module test successfully. Appearance: • Slideshows, with detailed explanations and recommended literature. If possible, hyperlinks were inserted to reach the articles more easily. • A constantly available glossary • For each person who is interested in completing the training, we offer individual registration, with which they are allowed to read the lectures and complete the exercises and end of module tests. • In order to unlock a new module, students must finish the previous one successfully. The WHO patient safety curriculum guide multi-professional edition was used during development.


Implementation tools available • Complete course material available on e-learning platform (open access) • on-line test exams

Implementation cost Software-ready version: 3.000.000 HUF (90 hrs) 3 experts days/lesson, designing: 2 hours/lesson

RESULTS:

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Method used to measure the results Number of participants/ successful exams

Results83 registered participants Successful exams Used for the training for the standard developers in the Hungarian accreditaion program

Analysis of the results no data



Please describe implementation barriers: The e learning course is in Hunagarian.

Describe the strategies used to overcome the barriers (If needed)translating the material to English

OTHER INFORMATION:


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NIDCAP (Newborn Individualized Developmental Care and Assessment Program)

GOP Information:


Organisation sharing the GOP Hospital 12 de Octubre (Madrid). Division of Neonatology

Member state Spain


GOP Description:


CLINICAL SETTING: Division of Neonatology at the "12 de Octubre" Hospital. It involves doctors, nurses, auxiliary nurses and families from inpatient newborns. At national level specific training is being delivered in order to have certified healthcare professionals with capacity to spread the practice. More than 40 training courses have already been delivered throughout Spain.

OBJECTIVES: • To provide a suitable environment for the premature baby/the ill newborn and their family that makes it possible a physiological and emotional development similar to the intrauterine one. • To provide the Neonatology patient a type of care that makes it possible not only the recovery from his pathology but also a suitable and comprehensive development. • To favour the emotional link between the parents and the newborn while the parents recover their role of caregivers.

POPULATION: • Premature babies and their families • Ill newborns and their families

METHODS:

Methodology • Training and certification of at least 10% of healthcare professionals (doctors and nurses) working in the unit. Each professional's training takes around 15 months. Then at least one of the professionals trained must be certified as trainer (the trainer's training takes around 2 years) All the process takes around 5 years. • In the meantime, the trainers (in our case one from the Boston center and another from Argentina) come to our unit 8 times and successive APRA evaluations are carried out in order to check the environmental changes recommended (light, noise, handling protocol, family care, pain treatment, unit open 24 hours to parents... and the most important: the ability to observe and understand the baby's signals in order to adapt care to its needs.

Timeframe implementation 5 years are required to achieve the centre's NIDCAP certification after the NIDCAP International Federation's evaluation, since it is necessary to certify 10% professionals, to change attitudes and to make structural adjustments.

Implementation tools available • Specific training and evaluation guidelines • External assessments and audits throughout the implementation process • Patients and professionals' satisfaction survey

Implementation cost -Each professional's certification costs like a master's degree (5000 €). Total cost of training around 60,000 €Environmental changes: around 200,000 € (doors, window shades, refurbishment in waiting rooms and parents rooms, armchairs, floor changes, lightning...)

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RESULTS:

Method used to measure the results Surveys, unit performance indicators, mortality, length of stay

Results We haven't finished collecting 2012 information yet (there are still inpatients born in 2012) but the 2011 data on survival of newborns under 1500g was excellent (93%) and the length of stay decreased. The professionals' satisfaction survey has been carried out. The results have been published. The level of satisfaction is very high and there is a clear improvement in the perceived quality. A pilot of the parents' survey has been performed (very high level of satisfaction) and we are about to carry out the definitive one.

Analysis of the results We cannot assure that NIDCAP is the only reason for the improvement but since its implementation results are increasingly better. We are going to carry out a longitudinal study comparing the results after two years in a cohort of NIDCAP newborns and another cohort without NIDCAP. We will mainly study the emotional adjustment and behavioural disorder. This study is under design.



Please describe implementation barriers: To change attitudes is complex. An analysis of barriers has been performed (submitted for publication) and the most important was coordination and communication between different groups of professionals (doctors, nurses, auxiliary nurses) and the perception that more professionals are needed.

Describe the strategies used to overcome the barriers (If needed) To intensify training and meetings between different groups of professionals; to open new communication channels, to use electronic media to improve communication; to create groups and nets.

OTHER INFORMATION:

Other information about the GOP that you would like to add Mosqueda R, et al, Staff perceptions on Newborn Individualized Developmental Care and Assessment Program (NIDCAP) during its implementation in two Spanish neonatal units, Early Hum Dev (2012), doi:10.1016/j.earlhumdev.2012.07.013

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PATIENT SAFETY MANAGEMENT AND ICPS IN BELGIAN HOSPITALS

GOP Information:


Organisation sharing the GOP Federal Public Service of Health, Food Chain Safety and Environment (FPS

Member state Belgium


GOP Description:


CLINICAL SETTING: Participatory hospitals: Acute, psychiatric and long term care institutions.

OBJECTIVES: Implementing a reporting and learning system for (near-) incidents, to start analyzing (near-) incidents using Root Cause Analysis and to classify these incidents in order to enhance patient safety management.

POPULATION: Participatory hospitals

METHODS:

Methodology • The development or description of an incident and near-incident reporting and lessons

learned system; • Analysing five different incidents or near-incidents according to a retrospective analysis

method and giving a description of the proposed improvement actions and formulated recommendations;

• Classifying these five analysed incidents according to the International Classification for Patient Safety (taxonomy) of the WHO, using and encoding at least the classes: type and characteristics of the incident and consequences for patient and organization (minimal dataset);

• Adding a blank copy of all reporting forms used in the institution

Timeframe implementation Started in 2008, on-going project, hospitals will have to continue reporting incidents and analyse them to enhance patient safety.

Implementation tools available XML export format, criteria, workshops and PowerPoint Presentations

Implementation cost Depending on each hospital own year budget.

RESULTS:

Method used to measure the results Quantitative and qualitative methods.

Results In 2011 94% of the hospitals had a notification and learning system up and running. Not all the hospitals yet fully comply with the defined minimal dataset from the taxonomy. The XML-export model was integrated in the reporting and learning system by 62% of the hospitals.

Analysis of the results Analysis of the yearly reports allows the follow-up of the elaboration and implementation of the notification and learning system.



Please describe implementation barriers: Cost for small hospitals/institutions and reports not evaluated.

Describe the strategies used to overcome the barriers (If needed)The FPS organizes on-going education (workshops for caregivers as well as for information technologists) and support by

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means of a web based helpdesk www.forum.icps-belgium.be in order to discuss the problems and find solutions.

OTHER INFORMATION:

Other information about the GOP that you would like to add I couldn't upload documentation.

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Complaint mechanism

GOP Information:


Organisation sharing the GOP Complaint mechanism is given by law. Exactly describe procedure, which has patient to follow when complaining healthcare or services related to healthcare. Procedure define also competent authorities at each step of complaining.

Member state Slovakia

Topic Patient complaint mechanism

GOP Description:


CLINICAL SETTING: Available for all kinds of healthcare and services and/or other decisions related to healthcare

OBJECTIVES: Establish clear rules and reponsibilities in process of complaints

POPULATION: Patients receiving healthcare

METHODS:

Methodology Not applicable

Timeframe implementation Implemented

Implementation tools available Law on Healthcare Insurance Companies and Surveillance over Health Care

Implementation cost Not applicable

RESULTS:

Method used to measure the results Annual reports of Healthcare Surveillence Authority on complaints

Results National data available on the levele of Healthcare Surveillence Authority on complaints. Healthcare providers have their own statistics on complaints, those data are not centrally available.

Analysis of the results Provided throug annual report of Healthcare Surveillence Authority





OTHER INFORMATION:


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Healthcare quality indicators

GOP Information:


Organisation sharing the GOP Ministry of Health

Member state Slovakia


GOP Description:


CLINICAL SETTING: Selected areas of hospital and out-patient healthcare

OBJECTIVES: Provide healthcare insurance organizations and public with data on healthcare outputs and/or outcomes achieved by individual healtcare providers or organisations.

POPULATION: Healthcare providers in selected area of healtcare. Examples: Re-admissions for the same diagnose in period of 30 days Number of preventive examinations performed by primary care physician

METHODS:

Methodology Source of data is data set provided by healthcare organization to insurance funds

Timeframe implementation Implemented

Implementation tools available NA

Implementation cost Not known/quantification is difficult

RESULTS:

Method used to measure the results Al healthcare providers in country receive evaluation based on outcome/output in certain parameter. Healthcare providers are segmented in performance clusters.

Results Annual results divided by indicator - healtcare provider-insurance fund

Analysis of the results Provided by healthcare insurance funds, published on the web



Please describe implementation barriers: Difficult interpretation by patient community Complicated process to introduce new indicator Significant amount of work to measure indicators for healthcare insurance funds


OTHER INFORMATION:


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Nationwide standardised cross-sectional patient satisfaction survey in Austria

GOP Information:


Organisation sharing the GOP Austrian Institute for Quality in Healthcare

Member state Austria

Topic Patient surveys

GOP Description:



OBJECTIVES: Objective The objective of the project was the development of a nationwide standardised patient questionnaire for the measurement of quality of care and furthermore the derivation of potentials for improvement.

POPULATION: Patients in hospitals

METHODS:

Methodology Methods The whole project started with a national and international literature research to include relevant and already established patient questionnaires. Based on this research a concept was designed that described research questions, methods and timeframe of the project. The following development process of the questionnaire was divided into different steps. To follow the demand of a cross-sectional approach while also gaining data within the sectors it was decided to develop two kinds of questions. Basic questions (these questions can be used in each sector of health system) on the one hand and specific questions (they focus on selected conditions within the different health care sectors) on the other. Following the innovative cross-sectional approach it was essential to concentrate on issues such as transitions between the different sectors of the health system and patient information. Because of the complexity of the whole project it was decided to start the development with a focus on the hospital sector.


Implementation tools available Questionnaire on Patient Satisfaction related to Quality of Care

Implementation cost If you use the already developed questionnaire, the costs for implementation should be around one € per questionnaire.

RESULTS:

Method used to measure the results Due to political open points of discussion, the implementation in all Austrian hospitals had to be postponed. So the results have not been measured so far. Results After the literature research it was pointed out that the cross-sectional and nationwide approach of the project was unique in this form as there is less experience in cross-sectional patient satisfaction surveys. Furthermore the focus on processes of care is innovative as most of the established patient satisfaction questionnaires mainly concentrate on structural topics such as accommodation, food and so on. The feedback of the stakeholders showed that there is much demand for such a questionnaire.

Analysis of the results The cross-sectional national survey has provided new and interesting data which points out specific problems between and within the sectors in the health system. The questionnaire provided data related to the following seven dimensions: overall

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satisfaction, staff, information, care within the hospital, transition processes and coordination. In the future it is planned to give regular feedback to the participating institutions, containing benchmarking charts and interpretations. Long-term aim is to contribute to better patient satisfaction within and especially at transitions between the different sectors in our health system.



Please describe implementation barriers: In the political discussions, Austrian stakeholders insisted that the survey should not only be performed in hospitals, but also for patients of GPs etc. The legal and logistical questions as to how this should be done have not been decided yet.

Describe the strategies used to overcome the barriers (If needed)We are in the process of developing a questionnaire for the outpatient sector as well.

OTHER INFORMATION:

Other information about the GOP that you would like to add The pilot survey started in November 2009 in nine departments of six different hospitals. The pilot survey was finished in January 2010. It could not be implemented on a regular basis because of political discussions, but should be implemented in all hospital by next year.

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Quality Management System of the Sterilization Units in SALUD Hospitals

GOP Information:


Organisation sharing the GOP Servicio Aragonés de Salud (SALUD) Aragón Healthcare Service

Member state Spain

Topic Accreditation

GOP Description:


CLINICAL SETTING: It has been institutionally implemented since 2007 in the Sterilization Units from all (9) SALUD acute care hospitals OBJECTIVES: To sustain a quality management system which guarantees that all sterilization units use proper procedures, provide right maintenance to the equipment, offer continuous training to their workers and comply with the legal requirements, and thus play their role in the prevention of adverse events and respond to the needs and expectations from their "clients", mainly the surgery units

POPULATION: In-patients for whose care sterilized material is used

METHODS:

Methodology ISO 9001 based Quality Management System, externally certified: Process map development Definition of objectives and indicators Documentation of procedures and technical instructions Continuous improvement (monitoring of indicators, detection of incidents, management of non-compliances, corrective and preventive actions) Internal audits, system review and external audits

Timeframe implementation Around 12 months

Implementation tools available Training Work teams

Implementation cost • Design and implementation phase (around 12 months): cost of external consulting • Regular maintenance after implementation: own resources • Cost of annual external audits

RESULTS:

Method used to measure the results Objectives and indicators follow-up Annual system review Annual internal audits Annual external audits by certification bodies

Results No non-compliances identified in the last external audit. The SALUD sterilization units opened 62 non-compliances after the internal audit. The most frequent were found in the process of material preparation and sterilization The number of incidents collected in the different processes varies from 99 to 368 per year depending on the unit. The highest refer to the processes of reception and sterilization. Clients highly appreciate the communication with the units and the proper conditions of the material received. The worst valued factor is the time of delivery

Analysis of the results Besides each unit's specific proposals, it has been agreed to continue with the project of optimization, management and traceability of surgical equipment. To implement a new procedure for equipment management, to approve the review of the

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procedure for non-compliances and to establish some work groups requested by our clients: expiration of sterilized material and controls. Also to develop SALUD 2012 Training Plan. Objectives/indicators for 2012: • To improve the sterilization process achieving invalid cycles <3.5% • Satisfaction >90% • Training >92% • To comply with reception requirements >96,5%



Please describe implementation barriers: • Professionals' difficulty to assimilate ISO languaje • To achieve rigorous documentary registration

Describe the strategies used to overcome the barriers (If needed) • Information and Training on ISO • Simplification of Documentary System • Quality Coordinators help • Support to professionals

OTHER INFORMATION:


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Quality Management System of the SALUD Laboratories

GOP Information:



Member state Spain

Topic Accreditation

GOP Description:


CLINICAL SETTING: It has been institutionally implemented since 2009 in the Laboratories from all (9) but one SALUD acute care hospitals. Technical areas implemented: Biochemistry, Pathology, Microbiology, Haematology, Toxicology and Immunology. It is gradually expanded.

OBJECTIVES: To sustain a quality management system which guarantees the technical competency of all SALUD laboratories' workers and also that proper procedures are used, right maintenance to the equipment is provided, continuous training is offered to workers and the compliance with the legal requirements, and thus SALUD laboratories play their role in the prevention of adverse events and respond to the needs and expectations from their "clients".

POPULATION: People requiring an analytical determination or sample taking

METHODS:

Methodology ISO 15189 based Quality Management System, externally certified by ENAC: Process map development Internal controls Intercomparative exercises Definition of objectives and indicators Documentation of procedures and technical instructions Continuous improvement (monitoring of indicators, detection of incidents, management of non-compliances, corrective and preventive actions) Internal audits, system review and external audits

Timeframe implementation Around 18 months. It varies depending on the number of hospitals, number of laboratories and number of assays certified.


Implementation cost -Design and implementation phase (around 18 months): cost of external consulting • First three years: internal audits were carried out with the support of external consulting. Now with the labs' own resources • Regular maintenance after implementation: own resources • Cost of annual external audits by ENAC (National Accreditation Body)

RESULTS:

Method used to measure the results Objectives and indicators follow-up Annual system review Annual internal audits Annual external audits

Results3 non-compliances and 43 observations were identified in the last external audit. The SALUD labs opened 86 non-compliances after the internal audit. The most frequent were related to equipment breakdowns/maintenance/calibration and documentation. All clinical labs perform internal controls of their processes and take part in intercomparative

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exercises. In 2012, 3,939 incidents were identified in the different processes. The higher numbers were associated with test request forms, non-received samples and haemolysed samples. Most incidents take place during the pre-analytic phase. Analysis of the results Besides each lab's specific proposals, it has been agreed: • to plan actions related to the evaluation of the intercomparative exercises • to go on with the labs' own professionals performing the internal audits • to review the non-compliance template • to offer the course "Internal auditors ISO 15189" • to develop a consensus study of indicators for each technical area • To establish objectives for several areas: % transport cool-boxes with acceptable temperature registers % haemolysed samples % correctly identified samples Accomplishment of internal and external quality control % timely delivered reports



Please describe implementation barriers: Professionals' difficulty to assimilate ISO languaje To achieve rigorous documentary registration

Describe the strategies used to overcome the barriers (If needed)-Information and Training on ISO • Simplification of Documentary System • Quality Coordinators help • Support to professionals

OTHER INFORMATION:


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Quality Management System of SALUD Primary Healthcare Teams

GOP Information:



Member state Spain

Topic Accreditation

GOP Description:


CLINICAL SETTING: It has been institutionally implemented since 2010 in SALUD Primary Healthcare Teams (PHT). Initially with 9 teams and right now 36 have been certified and the goal is to get to 125.

OBJECTIVES: To sustain a quality management system which guarantees that PHT use proper procedures, provide right maintenance to the equipment, offer continuous training to healthcare workers and comply with the legal requirements, and thus play their role in the prevention of adverse events and respond to the needs and expectations from their "clients", mainly the population of their health zone

POPULATION: General population (children/adults/aged people). In rural health zones mainly aged people.

METHODS:

Methodology ISO 9001 based Quality Management System, externally certified: Process map development Definition of objectives and indicators Documentation of procedures and technical instructions Continuous improvement (monitoring of indicators, detection of incidents, management of non-compliances, corrective and preventive actions) Internal audits, system review and external audits

Timeframe implementation Around 12 months


Implementation cost -Design and implementation phase (around 12 months): cost of external consulting • Regular maintenance after implementation: self resources • Cost of annual external audits by certification bodies

RESULTS:

Method used to measure the results Objectives and indicators follow-up Annual system review Annual internal audits Annual external audits

Results7 minor non-compliances were identified in the last external audit. The 36 PHT opened 167 non-compliances after the internal audit. The most frequent were associated with documentation and maintenance of equipment. The number of incidents collected in the different processes was 729. The higher numbers are related to structure, equipment and net connection in rural areas. Improvement areas detected: care of patients with diabetes, with tobacco addiction and with cardiovascular risk

Analysis of the results Besides each PHT's specific proposals, it has been agreed: to urge PHT to

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encourage Health Councils activity, to go on with the implementation of the verification and calibration of equipment, to use the detected incidents, complaints and non-compliances as a quality improvement tool and to introduce the analysis of objectives and indicators in a systematic way in the regular communication meetings. Moreover, the SALUD Quality Unit is entrusted to create a work group to analyze new indicators for the Primary Healthcare Management Contract



Please describe implementation barriers: Professionals' difficulty to assimilate ISO language To achieve rigorous documentary registration

Describe the strategies used to overcome the barriers (If needed)-Information and Training on ISO • Simplification of Documentary System • Quality Coordinators help • Support to professionals

OTHER INFORMATION:


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"Support to Initiatives on Quality Improvement" Program

GOP Information:



Member state Spain


GOP Description:


CLINICAL SETTING: Since 2000 the Program has encouraged the participation of SALUD professionals from all healthcare settings (primary healthcare teams, general hospitals, mental health, long term care...)

OBJECTIVES: • To promote quality improvement activities in SALUD • To facilitate the exchange of experiences • To create a sustainable structure that bolsters the development of new quality improvement initiatives • To favour the promotion of new quality improvement methodologies and knowledge in SALUD

POPULATION: Patients and professionals from Aragón Healthcare System

METHODS:

Methodology 1. Annual Call for quality improvement projects submitted by teams of professionals. 2. Selection of those projects that are accepted for the annual program 3. Selected projects may rely on the support of the Quality Units and can get some funding. 4. Once the project has been carried out a report has to be elaborated and presented to the

Direction in order to be evaluated to receive official recognition of the work performed. 5. The projects can be presented during the annual SALUD Quality Workshops.

Timeframe implementation For guidance only, once three annual calls have been carried out with satisfactory results, the program is considered to be implemented

Implementation tools available Broad dissemination Simplicity in the administrative procedures for the presentation of proposals

Implementation cost • Time dedicated to proposals organization and selection • Project funding can change depending on the annual budget, but in our experience this factor has not been essential for the success of the implementation

RESULTS:

Method used to measure the results Annual evaluation of the number of projects received, healthcare area they refer to, geographical origin…. Specific studies performed in 2007 and 2012 Results In the period 200-2011 2,235 projects were selected: 80% related to assistance, 20% related to management/organization/administration Main issues: • ISO quality management systems • Evidence based guidelines, protocols, procedures… • Organizational/administrative processes • Patient Safety

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• Patient & family information/communication • Healthcare coordination, handover • Professionals training • Chronic diseases Healthcare professionals appreciate the program. More than 75% consider the results of their projects have been highly positive. Improvements they have put forward: • To guarantee the funding allocated • To strengthen the support of the quality coordination team • To introduce new incentives to motivate the professionals

Analysis of the results The Support Program is highly appreciated by healthcare professionals and has become a good tool to establish a “quality culture” in the organization. Nonetheless it is necessary to improve the evaluation of the results achieved by the projects developed.



Please describe implementation barriers: Our rigid administrative procedures for funding management

Describe the strategies used to overcome the barriers (If needed)Budget management decentralization to Healthcare Areas

OTHER INFORMATION:


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1.National Nosocomial Surveillance System (NNSR) 2.National Hand Hygiene Campaign

GOP Information:


Organisation sharing the GOP National Center for Epidemiology



GOP Description:


CLINICAL SETTING: 1.hosptal setting 2. health care workers

OBJECTIVES: 1. Creation of a national reference database for nosocomial infections and to facilitate

feedback of results so that participating hospitals can compare their rates with national aggregated data and use that as a benchmark to measure their own performance.

2. Improvong hnd hygiene practice

POPULATION: 1. hopsital patients 2. health care workers

METHODS:

Methodology 1. NNSR is a standardized web-based system based on Centers for Disease Control and Prevention (CDC) National Nosocomial Infection Surveillance System (NNIS) and National Healthcare Safety Network NHS definitions and methodology. It has the following components: surgical site infection (SSI), adult and neonatal intensive care unit (ICU) device associated infections, hospital-wide bloodstream infections, hospital-wide infections caused by MDROs and nosocomial outbreak reports. 2. WHO multimodal hand haygiene improvement strategy


Implementation tools available education, free software, feedback of results

Implementation cost na

RESULTS:

Method used to measure the results Yearly SSI cumulative incidences by surgical procedure and trends were determined. Yearly median catheter associated bloodstream infection (CABSI)rate and trend analyisi. reduction of CVC-BSI rates between 2005 and 2008 was 45% and proved to be significant.

Results The trend analysis of the SSI cumulative incidence showed a significant decreasing trend (p<0.05) for hip and knee prosthesis interventions between 2005 and 2010. Significant eduction of CABSI rates between 2005 and 2010. Analysis of the results aggregated cumulative incidence (crude percentage of surgical intervention resulting in a SSI) and confidence interval by surgical procedure, trend analysis Catheter associated bloodstream infection/1000 catheter day per hospital and yearly median rate


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OTHER INFORMATION:


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Sentinel Events Monitoring System

GOP Information:


Organisation sharing the GOP Italian Ministry of Health

Member state Italy


GOP Description:



OBJECTIVES: To monitor Sentinel Events occurred inside the hospitals To have a Data Base containing a classification of sentinel events, to collect information about different kinds of SE and contributing factors. Also action plans to improve patient safety

POPULATION: All the patient receiving a health care services

METHODS:

Methodology Italian MoH defined a list of 16 different sentinel events to correctly classify them. When an adverse event occurs the Hospital fills out a specific form and sends it to the Region. The region check it and sends to the MoH trough a dedicated information flow. The MoH has the Data Base of all the SE. The MoH after the validation inserts it inside the Data Base. Up to now the System has 16 different categories and we published a Recommendation for some of these sentinel events, but our intent is to have a Recommendation for each of these SE to avoid or reduce the risk for the patients. This is a voluntary system of signalling. We publish periodically a Report available on Ministry of Health web side (www.salute.gov.it)

Timeframe implementation We start this activity during 2005 in a experimental way , and it was formalized by law in 2008, but is still improving

Implementation tools available It is important to have an agreement between Government and Regions, share and disseminate the information with the stakeholders

Implementation cost The implementation required an information flow nation wide, it was about 300.000 Euro for National Health System, to create the platform, the software and the training for the health care workers

RESULTS:

Method used to measure the results An increasing number of voluntary signalling means a great interest in this field, and the use of it.

Results Our data base contains about 1500 SE validated The most frequent event is Patient Fall 22,26%, the second is Patient Suicide 15,67%.

Analysis of the results ---



Please describe implementation barriers: Sometime the health facility fill out the first form but the region doesn’t complete the procedure, and the System doesn’t insert the new event in the Data Base. There is a cultural barrier for the health professional to report a SE due to legal effects.

Describe the strategies used to overcome the barriers (If needed)In the Italian Health care System, according to the regions, there is a Clinical Risk Manager in every hospital .

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Also there are training courses about patient safety and risk management avilble at national, regional an local level.

OTHER INFORMATION:

Other information about the GOP that you would like to add This system gives the possibility to know the areas needing more attention, it springs up the real problems, and the need of elaborate and disseminate Recommendations, Guide Lines, policy requirements and Best Practices.

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Ministry of Health Recommendations

GOP Information:



Member state Italy


GOP Description:


CLINICAL SETTING: Hospital

OBJECTIVES: Give information and organizative actions to reduce SE occurrence

POPULATION: Healthcare workers, patients, managers and other stakeolders

METHODS:

Methodology 14 Recommendation have been published, based on sentinel events occurred or on the basis of international experiences. They are drawn up by Working group,reviewed by scientific societies, National and Regional Agencies. They are available on MoH web site (www.salute.gov.it) List of MoH Recommendations: • Preventing errors during anticancer drug therapy • Preventing patient falls in health facilities • Preventing therapy errors using drugs “Look-alike/sound-alike” • Death or severe injury due to malfunctioning of the transport system iside or outside hospital Recommendation for the prevention of bisphosphonate associated osteonecrosis of the jaw/ mandibular bone • Recommendation for the prevention of adverse events consequent to malfunctioning of medical devices and electromedical instruments • Recommendation to prevent acts of violence against healthcare workers • Recommendation for the prevention of death, coma or severe bodily harm originating from an error in pharmacological therapy • Recommendation for the prevention of maternal death correlated to childbirth and/or labour • Recommendation for the prevention of a transfusional reaction due to ABO incompatibility • Recommendation for suicide prevention of hospital patients • Recommendation for the correct identification of patients, surgical site and procedure • Recommendation to prevent the retention of gauze, instruments or other material in a surgical site • Recommendation for the correct use of concentrated solution containing Potassium Cloride –KCL- and other concentrated solutions containing Potassium

Timeframe implementation It depends on the Recommendation. Some of them are easy to implement, it is up to each Health Facilities to implement the Recommendations and it depends on their priorities Implementation tools available There is a monitoring system to verify the Recommendations implementation. The Data Base is managed by Agenas. Other tools for the implementation are training programs, workshops and meetings

Implementation cost The cost of Monitoring System for the Recommendations Implementation is about 200.000 Euro.

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The implementation of each recommendation depends on the health organization and on the type of recommendation.

RESULTS:

Method used to measure the results We have in place a Monitoring System for the Recommendations Implementation

Results We have data for each Recommendation about the implementation inside the healthcare organizations, these data are available on Monitoring System.

Analysis of the results ---



Please describe implementation barriers: Cultural Barriers and Economical barriers. Also other priorities previous defined and lack of commitment


OTHER INFORMATION:


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Professional Training on Quality and Patient Safety

GOP Information:



Member state Italy


GOP Description:


CLINICAL SETTING: All heath care professionals of the National Health care Service working in all clinical setting

OBJECTIVES: Give all the health care professionals e-learning courses in order to provide tools methodology to face and improve quality and patient safety. These courses are free and accredited.

POPULATION: All healthcare workers

METHODS:

Methodology For these courses different kinds of methodologies are used such as: e-learning, classroom training and with tutor. These courses are provided by MoH in partnership with professional organization of medical doctors, pharmacists and nurses.

Timeframe implementation Each course last one year. Since 2008 until now we organized 10 courses, some are closed and some are still on going.

Implementation tools available The implementation tools are specific handbooks for each course, the web platform, the satisfaction questionnaires an the evaluation questionnaires

Implementation cost These courses are free for users. For the Organization (MoH) the cost is about 600,000 Euro for all courses.

RESULTS:

Method used to measure the results The methods used to measure the results are the number of professionals passing the final test, and the number of training credits provided

Results We obtained an important feedback from all heath care professionals reaching about 400.000 people passed, and about 5millons of credits provided Analysis of the results We have a data base which consent us to define and distinguish how many medical doctors, pharmacists and nurses, by provinces, age , gender, health care facilities. This data base consent to know the strengths and weakness for each course.





OTHER INFORMATION:


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Implantation of Standard UNE 179003 on Risk Management for Patient Safety. Health Services.

GOP Information:


Organisation sharing the GOP Galician Health Service

Member state Spain


GOP Description:


CLINICAL SETTING: Hospitals belonging to the Galician Health Service

OBJECTIVES: • Identify and evaluate risks and decrease/eliminate dangers which patients could face in the health system. • Reduce incidents and Adverse Events due to health care. • Manage risks in a proactive manner. • Generate greater confidence in the health system. • Obtain better clinical and financial results.

POPULATION: All patients covered by the Galician Health Service and their relatives. All health professionals in the Galician Health Service who work in hospitals. All hospital management teams in the Galician Health Service

METHODS:

Methodology Training health professionals in order to improve the patient safety culture and train health professionals in the use of tools for managing risks. High management leadership on Risk Management for Patient Safety. Create a multidisciplinary work group. Establish a Risk Management policy approved by hospital management. Define the scope of the Risk Management System. Define criteria for risk evaluation which are to be approved by hospital management. Lay down the goals which will be approved by hospital Management. Lay down the resources and internal communication systems. (Notification system, bulletins) and external systems which are necessary for the correct functioning of the Risk Management System. Lay down and document the procedures for identifying, analyzing, and processing risks in order to eliminate them or, if this was not possible, control and minimize its impact on patients. Draw up a risk map. Develop, approve and maintain those Documents and Records which are necessary for the correct functioning and verification of the Risk Management System. Risk Management System Guidebook. Introduce the Risk Management System in the hospital/service/department. Audit the correct functioning of the Risk Management System. (Internal audits and external audit for certification). Continuous Improvement of the Risk Management System.

Timeframe implementation 1 year in a health care service.

Implementation tools available Standard UNE 179003:2010 Health Services. Risk Management for Patient Safety. AENOR. FMEA Root Cause Analysis

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Risk prioritization Incident Notification Systems (SiNASP) Guidebook for Severe Adverse Events Management and Sentinel Events in the Galician Health Service. (IHI based) Document control procedure, record control and audits in different services. Risk Management System Manual of different services. Risk map of different services.

Implementation cost Cost of the external audit for certification. Travel costs and expenses of internal auditors. Work group meetings are time consuming. In some cases, treatment actions need to be implemented which also lead to additional

resources which lead to additional costs which must be approved by hospital management

RESULTS:

Method used to measure the results Internal and external Audit of the Risk Management System.

Results Certified services: Dialysis in Hospital Barbanza; Oncology-Hematology in the Santiago

Integrated Management Area; Hospitalization, Intensive Care Unit and Blood Bank in Povisa Hospital.

The following Units have passed Stage 1 of external certification: Laboratory in Hospital Barbanza; Hospitalization Oncology-Hematology in the Lugo Hospital.

All services now have a risk map, Incident Notification System, records and indicators which translates into greater information on Adverse Events which have decreased considerably since Risk Management System implementation. Health professionals and patients are more aware of patient safety

Analysis of the results Health professionals’ evaluation of the Risk Management System was very positive: not

does it only improve patient safety, based on facts and data, but also health professionals’ safety as well.

Health professionals revise all operational procedures in their service and identify critical points and potential risks, during the health care procedure. They discover risks of which they were not aware of up until that moment and practices which allow patient safety improvement and thus improvement in quality of care.

Multidisciplinary participation is fundamental, including patient participation.



Please describe implementation barriers: • Health professionals’ resistance to change. • Health professionals’ lack of time in order to set up a work schedule for developing a Risk Management System. Many hours of dedication are necessary. • Health professionals’ lack of knowledge and training in risk management for patient safety.

Describe the strategies used to overcome the barriers (If needed) • Training health professionals. • Training patients and general public by means of the Galician School in Public Health for Citizens. • The Management and Galician Health Service’s acknowledgement of the work health professionals have put forth. • Multidisciplinary teams provide feedback of results of work done which acts as motivation by means of bulletins, indicator monitoring, etc.

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• Certified services act as educators in risk management courses, forums and scientific meetings, offering their experiences. Participation as external auditors in audits which take place in other services

OTHER INFORMATION:

Other information about the GOP that you would like to add As opposed to other quality management systems which health professionals do not perceive as proximate or clearly related with their work, the Risk Management System is valued in a positive way as they feel that this represents changes in the way of doing things, based on data as a result of their work, which they identify and must put forth in their healthcare duties. This does not only improve patient safety but also their own safety when carrying out their responsibilities. They note and verify the outcomes of their duties, what works well and what is not “safe”. The have feedback information on their efforts in this field. The implementation of a Risk Management System takes up a lot of health professionals’ time and effort, but they perceive the outcomes. The implementation of Standard UNE 179003 Risk Management System implies having implemented the requirements of Standard ISO 9001. Reference: Standard UNE 179003:2010. AENOR

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Implementation of a Patient Safety Reporting and Learning System in Galician hospitals

GOP Information:


Organisation sharing the GOP GALICIAN HEALTH SERVICE (SERGAS)

Member state Spain


GOP Description:


CLINICAL SETTING: All hospitals in the Galician region

OBJECTIVES: Implement an electronic system of voluntary, non-punitive reporting of adverse events, directed at gaining knowledge in order to improve safety. Standardize and strengthen structures to manage a reporting system and implement improvements (Safety Cores) in all our hospitals. Reinforce safety.

POPULATION: All 15 hospitals in the Galician Health Service

METHODS:

Methodology • Develop a computer program. In our case, we used a system which the Spanish Ministry of Health had offered us. • Training reporters. This was structured in two stages. First stage: Train those personas who were to become managers and responsible for further training. Second stage: training all healthcare professionals. • Training regional managers and hospital managers. • Design and develop a procedure dealing with the reporting. • Reporters begin reporting. • Planning and developing improvement plans. • Managers monitor reporting indicators.. • Methodological support in order to apply root cause analysis. • Develop feedback reports for health professionals. • Divulge benchmarking reports.

Timeframe implementation 1 year for an organization of our size.

Implementation tools available • The computer program, which includes tools for reporting, managing and elaborating follow-up reports. • Training material for those reporting professionals, both electronic and on paper. • Training material for region managers and local managers (hospital) • Models for monitoring training and implementation. • Recommendation guidebook for managing serious adverse events.

Implementation cost In our case, this project was sponsored by the Spanish Health Ministry. In terms of training and implementation: one health professional for one year.

RESULTS:

Method used to measure the results Automatic monitoring of the 14 most important indicators in all hospitals, both monthly and yearly. These indicators register and compare number of reportings per health professional, the characteristics (number of reportings considered very serious with regards to the total); quick reply and efficiency of the system managers (number of group meetings, reportings processed in less than a month); hospital management’s

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commitment with the system (number of information and results sessions, number of improvement actions taken on, number of feedback reports…)

Results Between 2011 and 2012, 2.711 reportings took place (1007 in 2011 and 1904 in 2012).

87% resulted in improvement actions. Medication and identification errors were the main fields where reporting took place.

47% of those who reported identified themselves voluntarily. A sum of 244 group meetings and 92 results presentation sessions took place, to “learn

from one’s mistakes”. 4 manager meeting took place to interchange experiences and there was an anual

benchmarking conference with hospital directors. In its second year, all hospitals exceeded the goal that was set out in the hospital

management contracts.

Analysis of the results During 2011, we focused on training and system implementation in all Galician hospitals. In 2012 we maintained and perfected the system with an important improvement as to level of reporting.



Please describe implementation barriers: 1)Big differences in terms of safety in different hospitals. 2)Insufficient committment on behalf of hospital management initially. 3)Fear of possible punitive measures and/or legal repercussions.

Describe the strategies used to overcome the barriers (If needed) Multidisciplinary intensive training focused on many professionals., specific reinforcement

in those hospitals which needed it most; meetings with managers from different hospitals and setting forth best practices.

Include Hospital directors in Security Cores and training seminar. Awareness and information meetings between the project managing and hospital directors

in their own hospital. Include an indicator dealing with the use of this system in management contracts between

the Galician Health Service and hospitals. Benchmarking conferences. Information and clarifications as to the program’s functioning; possibility of reporting

anonymously; no personal information about patients nor health professionals in the reporting procedure.

OTHER INFORMATION:

Other information about the GOP that you would like to add 1.The use of an incident reporting system is a powerful tool for gaining knowledge and improvement in patient safety matters and is beneficial for the whole organization. 2.It allows us to understand, analyze and gain knowledge of incidents, adverse events and risky situations that take place in hospitals and which health professionals detect. 3.It acts as a guidebook for improvement and adverse event prevention. 4.Encourages team work and sets forth improvement initiatives. It also decreases variability and is thus beneficial for all citizens. 5. Since there is one data base for reporting all incidents, we can learn about specific problems that hospitals have in terms of patient safety and thus establish improvement actions in order to solve these problems. 6.Those health professionals that work more closely with patients are able to report situations, that would otherwise never have seen the light, so those in charge can solve them.

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Training patients and caregivers in health education by means of the Galician School in Public Health for Citizens

GOP Information:


Organisation sharing the GOP Galician Health Service - SERGAS

Member state Spain


GOP Description:


CLINICAL SETTING: In the Galician Health Service to give free access to classroom activities to all citizens of the region and online activities to all internet users.

OBJECTIVES: Provide training in care and self-care to patients and citizens, improve care for chronic patients, prevention, health literacy and participation.

POPULATION: Patients, family members, caregivers and the general public.

METHODS:

Methodology The patients and citizens needs are identified by means of representatives of Citizen Participation Groups as well as those which the Organization and its members detect. They identify the needs of patients / citizens through their representatives in the organs of participation and also detected by the organization and its members. The annual calendar of activities is elaborated based on these needs.

Timeframe implementation Six months

Implementation tools available New communication and information technologies are used to manage activities through a website www.sergas.es/escolasaude . Teaching teams are comprised of healthcare professionals of the Galician Health System as well as patients and citizens who act as trainers. Activities take place in the School’s classrooms and/or in a decentralized fashion, in different municipalities in the region.

Implementation cost The cost of implementation and annual maintenance varies depending on the number of activities. On average cost is approximately € 80,000 per year.

RESULTS:

Method used to measure the results The evaluation of the activities are done through satisfaction surveys, specific evaluation questionnaires, teacher evaluation forms, knowledge assessment questionnaires before and after the activity as well as the comments and suggestions that come through the site. Results Results for January 2010-December 2012: • Number of students 8940 • Total hours of activity: 1328 • Number of workshops held: 352 • Number of Forums "Ask the Expert": 40 • Number of "Dialogues with patients': 29 • Number of attendees Dialogues: 949 • % Of correct answers which increased once the activity concluded 23% • Overall satisfaction with the activity: very satisfied: 87% • Applicability of learning-High or Very High: 88.6% • Qualification of teachers on a scale of 0 to 10: 9.2 • Number of visits to the website: 181.228

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Analysis of the results • The initiative proved satisfactory to patients' associations who expressed their appreciation for all the information, enabling them to improve their work and to have better knowledge of their disease. • Every year there is greater demand for activities and patient organizations ask for “on demand” activities by means of website. Students rate the experience as very necessary as it allows them to contact other associations. • This project has received several national awards



Please describe implementation barriers: Problems arising from the use of website since there are still many people who do not have internet access. Many chronic patients and elderly people have little or no experience as far as new technologies goes.

Describe the strategies used to overcome the barriers (If needed) • The participation of Patient Organizations has been crucial to facilitate accessibility, information and communication with patients. • Using formative activities through website has improved patients’ and citizens’ communication abilities via web. • The use of new tools such as Twitter allows us to reach remote municipalities.

OTHER INFORMATION:

Other information about the GOP that you would like to add The training activities are related to themes such as: Training trainers. Chronic and emerging diseases. Caring for the caregiver. Gender violence prevention. Patient safety. Patient involvement. Healthy Lifestyles. Using ICT. Galician Health Service resources, circuits and functioning. Other main activities: Forums "Ask the Expert", where through an online forum, those interested can ask the expert any question that has to do with the theme being discussed. "Dialogue with Patients" this initiative meets the needs of patient organizations as to improvement in the health services field. Recommendation guides are developed and are discussed with healthcare professionals in order to implement and put forth improvement actions. So far two guidebooks have been elaborated: "Recommendations when informing parents over Down Syndrome" and "Healthcare recommendation for patients with autism spectrum disorder.” The School’s website also serves as a platform of information and support to patient organizations, with their own web space where they can receive notices and share experiences and knowledge

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Patient Advisory Council

GOP Information:



Member state Spain


GOP Description:


CLINICAL SETTING: Set forth in the Galician Health Service. Made up of all patient organizations in the region who were willing to participate.

OBJECTIVES: The Patient Advisory Council’s goal is to help improve patient safety and acts as a structure for increasing quality in health services, by encouraging participation and offering patients the necessary information in order to make their own decisions.

POPULATION: Founding members: Director of the Galician Health Service, Director of Health Care Director of Public Health and Innovation Director of the Galician School in Health Administration Director of the Galician School in Public Health for Citizens Members: Representatives of 72 Galician patient organizations

METHODS:

Methodology It meets twice a year and its objective is to move forward in patient safety; increase quality in health services by means of encouraging involvement and offering patients the necessary information in order that they may make their own decisions.

Timeframe implementation Three months

Implementation tools available This council was created by means of a decree from the Galician Health Service. (Decree 60/2010 of 26 January).

Implementation cost Cost of sign language interpreters present in the meetings.

RESULTS:

Method used to measure the results • The results are evaluated according to the number of meetings held, members who attended and proposals which were established. • The patient organizations’ involvement in work groups and activities of the Galician School in Public Health for Citizens. Results Meetings held: 4 Proposals: 257 formative activities They are trained as trainers and then participate as teachers in workshops aimed at chronic patients. They validate patient satisfaction surveys. They validate surveys based on learning needs. They participate in SERGAS Quality and Safety Congress and as speakers in the Galician Congress on Pain and others. They designate members who will represent patient organizations in the Galician Commission on the Strategy Against Pain.

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Analysis of the results Patient involvement in formative activities, providing information on care and self-care, was evaluated with an average score of 8.8, on a scale from 1-10. Other regions have requested information on the Patient Advisory Council and as far as we know, some of these regions are constituting similar councils.





OTHER INFORMATION:

Other information about the GOP that you would like to add Duties of the Patient Advisory Council: • Advise on formative needs of patient organizations. • Advise on the Galician School in Public Health’s programs and propose new activities. • Participate in the School’s formative programs and in forums. • Review and advise on material, documents and audiovisual instruments having to do with the Galician School in Public Health for Citizens and aimed at patients. . • Review and advise the Galician Health Service on information guides aimed at patients. • Advise on existing information about patient safety. • Participate in programs, discussion groups and work groups in order to improve care guides for chronic patients. • Participate in new hospital staff admittance programs in order to inform them on their needs and expectations. • Advise on the design of new hospitals and primary care centers in order to improve accessibility.

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Integral care strategy for patients with pain

GOP Information:



Member state Spain


GOP Description:


CLINICAL SETTING: All healthcare centers in the Galician Health Service

OBJECTIVES: Improve the patient with pain approach in the Galician Health Service in order to achieve optimal pain management for all Galician citizens, thus obtaining “pain free” hospitals. Improve quality of life of people with pain and their relatives.

POPULATION: All patients which receive healthcare assistance in the Galician Health Service. All healthcare professionals in the Galician Health Service.

METHODS:

Methodology 2010: Galician Health Minister’s Institutional Declaration during the Global Day Against Pain. Background study in the Galician Health Service. Collaboration with scientific societies and experts who deal with pain care. Bibliographical revision and insight on what is happening in other countries. Design, publication and distribution of scales and other material. Pain as a fifth vital sign is implemented in all public hospitals. Pain is registered in the vital signs chart and in the GACELA Management of Care Application 2010-2011. This objective is included in the management contract which is signed by all hospital directors. 50% of all in-patients must have a pain evaluation register in their vital signs chart. Quarterly monitoring and feedback with benchmarking information in hospitals. 2012: The Galician Commission on the Strategy Against Pain is constituted in 2012 made up of a multidisciplinary group with patient involvement. Hospital study of children with pain in 2012. Systematization of chronic non cancer pain care procedure in primary care (multidisciplinary work group with patient involvement) in 2012 and implementation in 2013. Training plan for healthcare professionals and for patients by means of the Galician School in Public Health for Citizens. Design and elaboration of the “Patient as pain expert” 2012-2013.

Timeframe implementation Evaluation of pain as a fifth vital sign: 1 year All other actions are continuous and PDCA is necessary.

Implementation tools available Legal text of Pain Commission constitution. Care to patients with pain procedures. Pain evaluation scales: VAS, numerical scale, facial pain evaluation scale… Electronic medical record and register of pain in the vital signs chart and in the GACELA Management of Care Application. Formative actions. Galician School in Public Health - Website Other materials: rulers, posters, booklets

Implementation cost Costs of training health professionals. Adaptation of computer program GACELA to record pain as a fifth vital sign and characteristics

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of pain.

RESULTS:

Method used to measure the results Availability of pain care procedures which have been approved by hospital management. Training records of healthcare professionals and patients. Qualitative and Quantitative audit of implementation. Records of pain evaluation as fifth vital sign in GACELA and other Special Records. Quarterly monitoring, to make sure that at least 50% of inpatients have a pain evaluation register in their vital signs chart. Quarterly monitoring and feedback with benchmarking information between centers. Results Pain as a fifth vital sign register in inpatients in the Galician Health Service in 2011 (14 hospitals): 71.235 patients (32.3% of all inpatients) and in 2012: 152.997 patients (69.8% of all inpatients). Pain Commission was created. The pain as a fifth vital sign procedure was implemented in all 14 public hospitals. Documentation of the Chronic Non Cancer Pain Care Procedure was concluded and systematized. Formative program of classroom and online activities for health professionals and patients dealing with pain. Analysis of the results Quarterly monitoring which includes sending information based on comparative data to hospital managers, quality departments and healthcare professionals. All centers use systematized procedures with Galician Health Service consensus, which guarantees optimal care. The project’s success is based on patient and citizen involvement.



Please describe implementation barriers: Healthcare professionals’ opposition to change. Poor knowledge of information technology makes registering more difficult. The healthcare professionals’ lack of training in the pain care field.

Describe the strategies used to overcome the barriers (If needed)Training in pain care and gaining knowledge of the GACELA management of care application in order to record pain evaluation. Including pain evaluation in the hospital management contracts.

OTHER INFORMATION:

Other information about the GOP that you would like to add Patients, patient organizations and the general public have evaluated the strategy in a positive way, allowing them to participate in all levels of their health management. Health professionals have evaluated the implementation as a necessity and are satisfied with the work that all are taking on: individuals, scientific societies, professional associations. Healthcare professionals are satisfied with the informational feedback on actions and achievements which are taking place which allows them to note how the outcomes are a result of their efforts.

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Patient safety audits

GOP Information:



Member state Spain


GOP Description:


CLINICAL SETTING: Hospital sector – 100% of all hospitals belonging to the Galician Health Service

OBJECTIVES: • Acknowledge the degree of compliance with 25 indicators dealing with patient safety projects. • Identify strong points and improvement areas of each hospital in order to apply the necessary measures. • Share experiences with other health quality leaders by participating in the audits as observers. • Compare and share results with the rest of hospitals.

POPULATION: All hospitals in the Galician Health Service; a total of 15 hospitals.

METHODS:

Methodology • Planning an external audit. A total of 25 indicators were chosen, dealing with patient safety. Of these, 15 indicators which involved leadership aspects, strategy, internal communication and procedures; 10 direct observational indicators in care units which involved patient identification, safe use of ClK, fall prevention and pressure ulcers, using Patient Safety Reporting and Learning System, pain management, revision and maintenance of crash carts and expiry control of drugs and perishable goods in care units. • Sending documentation to centers. • Elaboration of a schedule involving the interchange of quality leaders as audit observers. • The audit and revision of the documentation that was claimed. Visits to the care units for direct observation and conclusions meeting with hospital’s management staff. • Elaboration of the final report, including degree of accomplishment and improvement recommendations. • Benchmarking conference where results are presented and compared with the rest of hospitals in an anonymous fashion. Timeframe implementation • Planning: 2 weeks • Visits: 6 hours (in large hospitals this timeframe was insufficient). Two five hour periods are recommended for large hospitals. • Elaboration and closing report: 1 or 2 working days per hospital.

Implementation tools available • Form with indicators regarding evaluation criteria. • Final report and results form.

Implementation cost • A doctor and a nurse in the Quality Department of the Galician Health Ministry were responsible for organizing and undertaking this audit in all 15 hospitals during a two month period.

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• Two health quality leaders which were present in each audit.

RESULTS:

Method used to measure the results All audits followed the same evaluation system, where two expert auditors in patient safety, analyzed all the data and evaluated all observational criteria in the care units, by means of material verification, interviews with health professionals and medical records revision. Results Average accomplishment of all 25 indicators in the 15 hospitals was 64%. Some indicators involving documented safety procedures such as safe use of ClK, Patient Identification, traceability of blood products or correct pain management were close to reaching 100%. Averages over 90% were reached in some indicators involving training in patient safety and the existence of communication channels on adverse events. As to the 10 observational indicators, average accomplishment was of 56%. Best results were achieved in patient identification and as to the use of VAS scale for pain management.

Analysis of the results 1.The evaluation of the degree of implementation of the different safety projects in hospitals of the Galician Health Service is a very strong knowledge and motivation tool. 2.Those aspects which are monitored and where institutional rules exist, achieve a satisfactory degree of accomplishment (patient identification, pain, Patient Safety Reporting and Learning System, ClK, etc.) 3.The audits allow us to detect those areas which are up for improvement in all hospitals and where an institutional approach would be beneficial (correct use of medication, expiry control, etc.)



Please describe implementation barriers: 1.There are important differences in safety culture from one hospital to another. In some hospitals, obtaining the documentation and its revision proved to be more complicated than in others. 2.Some medical directors were reluctant to attend the audit meetings because they felt that these audits were intended for nursing staff. 3.The time aspect and the distance to and from hospitals are aspects that should be kept in mind if this practice is to be implemented. 4.Those quality leaders who had attended audits in other hospitals as observers had advantage over those who had not.

Describe the strategies used to overcome the barriers (If needed) 1.Send information/documentation beforehand, detailing the evidence required. Before the visit, reconfirm date, time and documentation requested, with quality leaders. 2.Audit team made up of a doctor and a nurse. In the initial documentation we specified that at least one person from the medical director´s office should be present. If this was not so, his or her presence was requested before beginning the audit. 3.Adapt planning. 4.Guarantee that quality leaders may participate as observers only after having their own hospital audited, in order to avoid being bias when comparing hospitals

OTHER INFORMATION:

Other information about the GOP that you would like to add 1.This is not the first audit hospitals have had to face. We have been working directly and in a coordinated way with hospital quality leaders in terms of patient safety projects for the last four years, thus we are constantly in touch with them and there is a high degree of mutual trust and understanding. 2.Continuous improvement is the main approach and so these methods are considered very

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useful sources of information for hospitals. 3.The fact that Quality leaders from other hospitals act as observers in the audits, guarantees transparency and is a source of mutual knowledge. 4.The presentation of a global report with results from all hospitals within a benchmarking session for all hospital management, proves to be a strong source of motivation for improvement.

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Online tool to manage the whole safety incidents life cycle, as well as to diseminate the improvement actions.

GOP Information:


Organisation sharing the GOP Andalusian Agency for Healthcare Quality

Member state Spain


GOP Description:


CLINICAL SETTING: Primary care, hospitals, emergency teams.

OBJECTIVES: "Management of the whole safety incidents life cycle. Promotion of the implementation of improvement actions to prevent new incidents and to share them with other centers/units working on the system. To offer a tool that allows the healthcare centers/units to manage their incidents locally."

POPULATION: Universal. Aimed at healthcare professionals as well as citizens.

METHODS:

Methodology Literature review. Development of the incidents reporting module, based on the International Classification

for Patient Safety, open to healthcare professionals and patients, and with two different forms available, an extended one and its reduced version.

Development of the management module, where every incident linked to a healthcare center/unit can be managed by the center/unit designated responsible, evaluating the risk level, analyzing the incident and establishing improvement areas, which can be shared with other users in the system.

Review of the tool in collaboration with patient safety experts and improvement of the tool.

Timeframe implementation Two months, including the translation of the tool to a different language.

Implementation tools available Comprehensive reporting and learning system, composed by two different modules: one for reporting the incidents and getting statistical reviews, and a second one for managing the reported incidents, only accessible for a responsible person for every healthcare center/unit registered in the system. When new incident is reported, linked to the center/unit where it happened, the responsible person in system receives notification message. Then, the incident can be analyzed in the managing module, where improvement areas can be defined and assigned to a person in charge, and the detected improvement areas can be shared with other centers/units registered in the system

Implementation cost Minimum cost. No special training is required to handle the tool and no software acquisition is needed.

RESULTS:

Method used to measure the results In order to measure the level of development of the project the following variables have been used: number of healthcare centers/units registered in the application and number of reported incidents.

Results386 healthcare centers/units registered into the system (12 of them are from outside Andalusia and even outside Spain) 2049 notifications reported to the system (1845 from healthcare professionals and 204 from citizens) since 2009.

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Analysis of the results Of the total amount of reported incidents , 135 have been or are being managed through this tool and 94 of them have been already solved. 243 improvement actions have been collected, 218 of which have been shared with other users of the system. The area from where more incidents have been reported is primary care, mainly incidents involving the care process or the clinical procedure, followed by drug-related incidents, in the case of incidents reported by healthcare professionals. Regarding the notifications from citizens, those related to the healthcare (diagnosis, treatment, surgery, diagnostic tests) and medication are the most common.



Please describe implementation barriers: Reluctance of healthcare professionals to report due to the fear of retaliation and, mainly, due to time constraints.

Describe the strategies used to overcome the barriers (If needed)We are working currently on the readjustment of the reporting forms, to make them simpler, more intuitive and shorter, so less effort is needed form the user. On the other hand, one mobile app version of the system is planned, pursuing the same improvements and providing the system with new possibilities that enrich the reporting (e.g. geolocation)

OTHER INFORMATION:

Other information about the GOP that you would like to add The system is able to connect with other reporting systems, either national or international.

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The Italian National Observatory on Good Practices for Patient Safety

GOP Information:


Organisation sharing the GOP Agenas

Member state Italy


GOP Description:


CLINICAL SETTING: ---

OBJECTIVES: The overall objective of the Observatory is to improve patient safety through a cyclic model for collecting, classifying, disseminating and transferring patient improvement experiences. A web-based archive has been created for sharing good practices within a community network of professionals and organizations with the aim of exchanging experiences and knowhow

POPULATION: Regions, Professionals, Health Organizations, Citizens

METHODS:

Methodology The methodological approach is based on the following steps: Identification and Collection of the experiences, classification, dissemination and transferring of the safe practices. In order to promote Regional monitoring and interregional transferring of the good practices, a bottom up action is being carried out based on Regional/interregional workshops.

Timeframe implementation 12 months (if based on institutional mandate, as in the experience herein reported ) Implementation tools available An annual call for good practices launched by Agenas addressed to Regions, Healthcare organizations and professionals A (web) form for the SCP description based on the SQUIRE guidelines (www.squire-statement.org) A computer-based tool (included in SCP description form) for supporting professionals in calculating the costs of the practice implementation A web system for good practices submission and collecton A web searchable database available on Agenas website. The practices’ descriptions are searchable by Title; Region; Kind of intervention (e.g., data collection, patient involvement); Adverse Event; Range of cost. Peer review program and inter-regional workshops for promoting safe practices transferring

Implementation cost For the system set up: 1 public official full time for 12 months, 1 public official (manager) part time for 12 months, 1 computer expert full time for 6 months. Total about € 30.000 For the annual call for good practice: 1 assistant part time for 5 months; 1 computer expert part time for 3 months: Total about € 15.000 For dissemination activities About € 50.000 (in 4 years)

RESULTS:

Method used to measure the results N° of Regions participating in the call for good practices N° of total submitted practices N° of submitted practices for Region N° of submitted safe practices (based on Agenas classification)

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N° of submitted potential safe practices (based on Agenas classification) N° of submitted initiative (based on Agenas classification) N° of health care organizations participating in the call for good practice N° of professionals participating in the call for good practice N° of access at the Observatory web pages N° of transferred safe practices

Results Active participation of all the Italian Regions (21/21) 1549 experiences submitted(2008-2012) of which: 250 healthcare organizations and 430 professionals registered in the system (only in the

period 2010 -2012) 12.148 people visited the Observatory web page (in the period June 30th 2010- May 31th

2012) Since 2010, a field for writing an abstract for citizens has been added to the reporting form. The abstract is aimed at communicating with non-professionals, in a way that is understandable, the meaning of the improvement intervention, thus establishing conditions of trust and transparency. Analysis of the results Since 2008 an average of 300 a year are reported to the Observatory Most practices have been submitted by Local Health Units (40%) and by Public Hospital (25%) About 40% of the submitted practices concerns “change planning and implementation”; 24% of the practices refers to “Tools for measurement and data gathering”; 4% falls in “Patient feedback tools”; 21% are “Multi-method tools”; (21% falls in the “Other” category) 1,000 visits to the Observatory website (on average) per month with a peak of about 3,000 visits in the months from October to November (in correspondence with the Italian National Conference on Patient Safety)





OTHER INFORMATION:

Other information about the GOP that you would like to add The experience started in 2008 based on a State –Regions Agreement by which the Italian National model of governance of patient safety was settled. The Ministry of Health supported the Observatory by financing the system set and start up. The Observatory on good practice for patient safety has been designed and implemented to be: a strategy for continuous improvement of quality and safety of care (by promoting transfer of safe practices) a regional and national web archive of patient safety improvement interventions a network of health professionals who share knowledge and experiences a tool that facilitates transfer of experience a source of information for the citizen It has been designed and implemented on principles and tools shared among Agenas, Ministry of Health, Regions, Health Organizations, Professionals (who are periodically asked to give their feedback)

149

RIU-T: Approach of a national health strategy to vulnerable contexts and populations

GOP Information:


Organisation sharing the GOP Ministry of Health, Social Services and Equality (MSSSI) and Centro Superior de Investigación en Salud Pública (CSISP-FISABIO)

Member state Spain


GOP Description:


CLINICAL SETTING: Community Health, Primary Healthcare Services, Sexual and Reproductive Healthcare and Public Health Preventive Programs OBJECTIVES: • To qualify community leaders to perform actions oriented to attain accessibility and proper use of healthcare services in vulnerable contexts and populations • To involve healthcare professionals in this education action process • To develop tools for the transfer to other contexts • To create a national net of experiences

POPULATION: Spanish native –including Romani- population and migrant people (mainly from Morocco, Rumania and Latin America) living in vulnerable contexts; districts with high unemployment levels, school failure, urban fragility and cultural/physical distance from healthcare services and their professionals

METHODS:

Methodology • Political, executive and technical support has to be obtained • 3 professionals drive the process and create a cross-sectoral net of professionals who select the community members (12 women and 3 men) according to their leadership profile and their belonging to different cultural groups of the district. • The leaders participate in a learning process as health agents. In this process professionals are involved and visits to different community services (primary healthcare, sexual and reproductive healthcare, public health, hospital -mainly emergency and mother&child areas) are included. • The group of health agents carries out different kind of activities: individual, for groups (workshops on self-care, access and use of services, use of medicines...), in the community or dissemination. They receive some economic incentive for their commitment. • Process and results are evaluated using quantitative and qualitative methodology • Education-action process takes 150 hours during 9 months. Cycles follow one another in a continuous way.

Timeframe implementation 2-4 years depending on the previous support for program development We consider the program has been implemented if at least two cycles of selection, education action and evaluation have taken place

Implementation tools available • Checklist with 21 criteria to select the district where to begin the program • List of abilities and responsibilities for each professional involved in the implementation • Education bundle for professionals to learn how to implement the education action model: • Leaders selection method • Action plan document • Training methods

150

• Types of activities • Evaluation

Implementation cost • Human resources: 90,000 €/year. • Incentives for health agents: 18,000 €/year • Evaluation studies: 12,000 €/year • Overheads: 6,000 €/year • Total: 126,000 €/year

RESULTS:

Method used to measure the results • Qualitatively analysed personal and group interviews to community leaders about their perceived changes. • Community leaders' social nets analysis using UCINET and SPSS programs • Group interview to professionals from the community services about their perceived changes after program implementation • Indicators on the socio-demographic profile of districts and towns and on the use of services

Results • The program started in 2008 and takes places in 3 towns, covering around 100,000 people: Algemesí (4 editions), Alzira (2 editions) and Sueca (1 edition). • 39 agents (33 female and 6 male) have been qualified and they have reached 1,723 people. • Knowledge change, access to services and preventive programs and a higher trust in professionals have been identified. • In each town maps of health assets have been developed and a net of 35-40 professionals agreeing with the health agents' perceived changes has been constituted

Analysis of the results RIU has shown to be useful to get people belonging to different cultural groups from these contexts be qualified as health agents and have positive influence in the access to and use of services and programs. This process also generates changes in the professionals and the organisation and achieves that proper information circulates thus providing an approach between healthcare services (mainly primary healthcare and sexual & reproductive health) and the population. Professionals -although they do not incorporate community work in a continuous way- get closer to vulnerable people and contexts, feel satisfied and mutual confidence increases



Please describe implementation barriers: -Lack of coordination between healthcare levels and other sectors (social, education and the third sector) • Professionals' lack of skills and abilities for community work • Professionals' belief that changes in these contexts are difficult and unlikely • Lack of resources to guarantee the sustainability of the intervention and the evaluation • Difficult access to healthcare indicators. Disaggregation at district level is complex. • Needs in these contexts exceed the answers that can be provided from the program

Describe the strategies used to overcome the barriers (If needed) • The creation of the Program's cross-sectoral net and the work performed mean a significant step towards coordination and qualification for joint work between healthcare professionals and those from other sectors. • The elaboration of an education bundle to increase professionals' qualification and make it possible to spread the experience to other districts. • Professionals are sensitized in the health assets model which complements the problems and needs centred model. • Cross-database is enabled in order to facilitate disaggregation of district data and indicators.

151

OTHER INFORMATION:

Other information about the GOP that you would like to add RIU has been initially carried-out in Valencia Region. In the framework of the National Sexual and Reproductive Health Strategy, several tools have-been-designed in 2010-2011 in order to transfer the program to other Spanish Regions. Although RIU has-been-developed in vulnerable contexts, this experience can also help to increase participation/mutual-commitment/joint-production of population's/professionals'/organization's actions oriented to equity-in-access-and-use-of health-services-and-programs regardless of the subject and the people they are aimed at. An added value is that RIU links intervention to participatory research, and thus obtains innovative products that can be transferred to quality improvement in the Health System such as the participatory analysis of health, the map of assets and the participatory evaluation. Paredes-Carbonell JJ et al. Projecte RIU: Un riu de cultures, un riu de salut. Una propuesta de intervención en salud en entornos vulnerables. Comunidad. 2011; 13: 34-7 Comisión para Reducir las Desigualdades Sociales en Salud en Espana. Avanzando hacia la equidad. Propuesta de políticas e intervenciones para reducir las desigualdades sociales en salud en Espana. Madrid: MSPS; 2010. Paredes-Carbonell J et al. Herramientas de transferencia de un modelo de buena práctica para desarrollar la Estrategia de Salud Sexual y Reproductiva en Población Vulnerable en el Sistema Nacional de Salud. Valencia: CSISP, 2010 (Report for MSSSI) Paredes-Carbonell JJ et al. Desarrollo de un programa de formación-acción para aproximar la Estrategia de Salud Sexual y Reproductiva a entornos de elevada vulnerabilidad. Valencia: CSISP, 2011 (Report for MSSSI)

152

Telematic Continuity of care in frail and / or vulnerable patients

GOP Information:


Organisation sharing the GOP Andalusian Regional Ministry of Health and Social Welfare

Member state Spain

Topic Other

GOP Description:


CLINICAL SETTING: Primary Care (Health Centers) Hospital Care (inpatient units)

OBJECTIVES: 1. To Ensure continuity of care and patient safety 2. To Improve accessibility 3. To Improve the effective management with the treatment: pharmacological, care / self-care, control of risk detected. 4. To Optimize the use of resources and services 5. To ensure quality of care and patient satisfaction and carers

POPULATION: There are groups of people in which the discontinuity of care is particularly unfavorable, as fragile patients are. To the introduction of this service, the fragility variables has been limited in: age, polypharmacy, comorbidity, absence of competent carers and basic activities daily life dependence

METHODS:

Methodology Tracking Protocols Using: Nurses who monitor phone, have: Diagnoses algorithms • early detection Therapeutic OAlgoritmos * • preventing problems • early intervention • referrals to family nurses • referrals Coordinating Center of Emergency • Standardized language NANDA-NIC-NOC The monitoring team is made up of one tele-operator located in “Salud Responde” (Andalusian Health System call center) for call forwarding to nurse team. It offers medical reference for any inquiries by the team nurse in emergency coordination center in each province. Education and training of nursing staff for telephone follow-discharge Information and training of nurses Andalusian Heatlh System Service Centers for recruitment of patients and the web application use.

Timeframe implementation 1year

Implementation tools available 1. Web application for monitoring telephone from Andalusian Health System call center: “Salud Responde” 2. Design of Monitoring Protocols for discharged patients in home setting 3. Training the care team for continuity of care 4. Communication and information Plan for Health System Professionals

153

Implementation cost Design and implementation of web application: 12.000 euros Web Application support: From 8.000-10.000 euros/ year Call Center Reference Team and Service: 1 tele-operator and 3 nurses + support services. 90.900 euros/ year

RESULTS:

Method used to measure the results Exploiting database available (from the web application for continuity of care) System claims in the Andalusian Health System

Results 1. Improve accessibility to professional reference for ensure continuity of care and ensure patient safety 2. Optimize the efficiency of health resources by automating and delegating protocolized actions to the telephone following team • Reduce the use of emergency services • Decrease hospital readmissions 3. Satisfaction of patients and caregivers 4. Satisfaction of the professionals involved: tele- continuity of care team, hospital equipment reference and primary care centers.

Analysis of the results The positive results of effectiveness, efficiency, guarantee patient safety and improving accessibility and equity in care, have led to the use of this service to ensure continuity of care to other patient groups (ex : palliative care needs)



Please describe implementation barriers: The greatest difficulty in its Implementation has been the identification and recruitment of people with Increased susceptibility to benefit from this service due to the resistance in some hospitals in the network to provide discharge in weekends, bank holidays or eve to patients under the conditions of fragility described.

Describe the strategies used to overcome the barriers (If needed)Communication plan to address health centers on the success of the service and the patient and family satisfaction.

OTHER INFORMATION:

Other information about the GOP that you would like to add Telecare service in the Andalusian Public Health System ensure continuity of care for frail or vulnerable patients discharged from Hospital inpatient units at weekends and holiday eves, by telephone follow-up interventions. The service is provided by a team of nurses with specific training in discharge telephone follow When the patient's situation meets these characteristics of fragility or vulnerability, the referring nurse activated phone continuity of care during the patient's stay in hospital service, whether patient high-end occur weeks holidays or eve. Activation occurs during discharge planning, To do this, the nurse concerning the patient in the hospital enters relevant information to the home monitoring in a web application where this information can be accessed by telecare equipment These teams maintain a proactive telephone contact before 24 hours after discharge and are available for patient or carer in resolving queries and connecting with other resources. After the weekend or holiday, the continuity of care is solved by the care teams (doctor-nurse) of primary care centers. These professionals access the application to view the information on the monitoring carried out by teams of telecare

154

Telematic Continuity of care in palliative care patients

GOP Information:



Member state Spain

Topic Other

GOP Description:


CLINICAL SETTING: Primary Care (Home Environment) Hospital Care (inpatient units)

OBJECTIVES: To Ensure continuity of care and patient safety prevention and relief of suffering effective management of treatment, self-care, control of risk detected and early emergency intervention To Improve accessibility To Improve the. To Optimize the use of resources and services To ensure quality of care and patient satisfaction and carers

POPULATION: Palliative patients and caregivers

METHODS:

Methodology Tracking Protocols Using: Nurses who monitor phone, have: Diagnoses algorithms • early detection Therapeutic algorithms* • preventing problems • early intervention • referrals to family nurses • referrals Coordinating Center of Emergency • Standardized language NANDA-NIC-NOC The monitoring team is made up of one tele-operator located in “Salud Responde” (Andalusian Health System call center) for call forwarding to nurse team. It offers medical reference for any inquiries by the team nurse in emergency in a coordination center in each province. Education and training of nursing staff for telephone follow-discharge Information and training of nurses Andalusian Heatlh System Service Centers for recruitment of patients and the web application use.


Implementation tools available 1. Web application for monitoring telephone from Andalusian Health System call center: “Salud Responde” 2. Design of Monitoring Protocols for discharged patients in home setting 3. Training the care team for continuity of care 4. Communication and information Plan for Health System Professionals

Implementation cost Design and implementation of web application Web Application support Call Center Reference Team and Service Comunication Plan and Training

155

Total Cost 145.000 euros

RESULTS:

Method used to measure the results Exploiting database available (from the web application for continuity of care)

Results 1. Improve accessibility to professional reference for ensure continuity of care and ensure patient safety 2. Optimize the efficiency of health resources by automating and delegating protocolized actions to the telephone following team 3. Satisfaction of patients and caregivers 4. Satisfaction of the professionals involved: tele- continuity of care team, hospital equipment reference and primary care centers

Analysis of the results The positive results of effectiveness, efficiency, guarantee patient safety and improving accessibility and equity in care, have led to the use of this service to ensure continuity of care to other patient groups (ex : palliative care needs)



Please describe implementation barriers: This service continues its implementation process this year so when this phase ends we will analyze the results that have been obtained to redirect subsequent developments


OTHER INFORMATION:

Other information about the GOP that you would like to add Telecare service in the Andalusian Public Health System ensure continuity of care for palliative care patients by the development of a web application to implement a program for monitoring and allowing the access to patients in need of palliative care and caregivers, favoring quality palliative care. This initiative is part of the right to die with dignity guaranteed by the Statute of Andalusia for citizens Through the Andalusian Health System call center service (“Salud Responde”)and in coordination with professionals, the Ministry of Health offers a 24 hours service with personalized monitoring and ongoing patients who are in the final phase of life. The service is provided by a team of nurses with specific training in discharge telephone follow. This service is based in these three points: a. The reagent Health Council on overview reasonable doubt. It is not necessary to be included in the platform. b. Inclusion of terminal patients discharged from inpatient units.in telecare service c. - Maintain the continuity of care of the terminal patients at home, in discontinuity of care periods: evenings, nights, holidays, weekends .....

156

Health Care Plan for Caregivers in the Andalusian Health Service: “ + Care Card” (“Tarjeta + Cuidados)

GOP Information:



Member state Spain


GOP Description:


CLINICAL SETTING: 1. Caregivers of patients with high level of functional dependence and / or cognitive impairment (Barthel <60/Pfeiffer> = 5), palliative care or dementia. 2. Take care for 10 hours or more a day. 3. Not receive financial remuneration for caregiving

OBJECTIVES: 1.To establish positive mesure for disabled persons caregivers ensuring large differential access to professional services in the Andalusian Health Service. 2. To conduct a comprehensive care (assessment and specific care plan) and response to care needs for all caregivers captured as cardholders of the + care card

POPULATION: 1. Caregivers of patients with high level of functional dependence and / or cognitive impairment (Barthel <60/Pfeiffer> = 5), palliative care or dementia. 2. Take care for 10 hours or more a day. 3. Not receive financial remuneration for caregiving

METHODS:

Methodology 1. Inclusion of carers as a target population of the Andalusian Health Service, susceptible own specific services 2. Protocol health care for caregivers. Implementation strategy: • Designe the process of implementation and monitoring of measures to develop health care for caregivers in each center of the SSPA • Attract caregivers in community health centers and their profile detection from hospital by nurses who have been referring to the patient and caregivers at hospital. • Use the Web environment, in hospital and community level centers, for the identification of Caregivers • Establishe of benchmark coordination: the case managers nurses at hospital and in the community. • Communication plan and working with the different services

Timeframe implementation <one year.

Implementation tools available • Plan for dissemination among professionals and between patient associations. • ID Card + care identified with every caregiver • Identify the nurse case manager as a leader in the collection and allocation of the Card. • Implementation of affirmative action in the geriatric and socio and helth field

Implementation cost “Card + CARE” inssuance” (150.000 cards) Design and implementation of web application Web Application support

157

Nursing training to implement the services Communication Plan with Managers and different professionals involved Total cost: 157.200 euros* • Facilities to rest and others needs at hospitals are not included in this document

RESULTS:

Method used to measure the results To measure results METHOD: SSPA Information Systems (Diabaco). Audits to health centres to check the measures implemented. Surveys of user satisfaction

Results In Andalucia there are 65,675 carers in Great dependents. 9803 men and 55,872 women.

Analysis of the results In all SSPA centers has implemented affirmative action to carers: stop shop for managing appointments, preferential treatment, accompanying the patient circuit ..... Caregiver at hospitals: Facilities to rest and others needs such as: food, hygiene



Please describe implementation barriers: • Deficiencies in physical structures, primarily in Hospital, to promote the single and the rest areas of the caregiver.

Describe the strategies used to overcome the barriers (If needed) • Involvement of Managers and Outreach Campaign to professionals

OTHER INFORMATION:

Other information about the GOP that you would like to add Caregivers, because of the situation of the people who care and care requirements, are in a special overload situation. For them, The Card “+ Care” Programme starts and this card was assigned according to criteria of patient dependency and overload situation of the caregiver, . The caregiver cardholder may receive a number of positive measures, in areas related to differential access to professionals and management procedures, with greater accessibility and agility. Such as: Preferential access to consultations, and generally to all health center services. The “+ Care Card” service promotes the unique act in administrative management, or supply of materials necessary for the care, improve health care at home, and also other measures are established in case of hospitalization As well as a set of interventions that are conducted specifically from health centres professionals with these people who care. The activities or interventions are related to their own care “bio-psycho-social health” (Ex: workshops for their own care and psycho load decrease, offer rehabilitation and physiotherapy…) and care of the person in their charge. These measures are implemented at both, in community care (Primary Care health center) and in the hospital setting

158

Quality of mobile applications on health: distinctive and certification

GOP Information:


Organisation sharing the GOP Andalusian Agency for Healthcare Quality Andalusian Regional Ministry of Health and Social Welfare

Member state Spain

Topic Accreditation

GOP Description:


CLINICAL SETTING: N/A OBJECTIVES: To distinguish those mobile applications on health that implement the necessary measures to fulfill a serie of recommendations for quality and safety, so they can be used by citizens reliably and minimizing risks.

POPULATION: Universal. It is aimet at anyone responsible for mobile applications on health.

METHODS:

Methodology Literature review. Design of recommendations for the design, use and assessment of mobile applications on

health, in collaboration with a group of experts. Design and development of an online application for the development of self-assessment

and assessment of mobile applications on health. Elaboration of recommendations, improvement actions and best practices from the

analysis of the results of the assessment process. Distinctive award.

Timeframe implementation undefined

Implementation tools available Comprehensive management system for assessment of mobile applications on health, consisting of two modules, one for self-assessment and other one for assessment, accessible through username and password for each mobile application responsible and for assessors. When a new application is received, the self-assessment phase of the mobile application starts. The application responsible finds there guidelines to fulfill the self-assessment process, from minimum requirements that the application must meet.The responsible of the application can access to a Help section, contact an advisor and access to a communication zone.

Implementation cost Minimum cost. No special training is required to handle the tool and no software acquisition is needed.

RESULTS:

Method used to measure the results No results yet. It is being implemented.

Results No results yet. It is being implemented.

Analysis of the results No results yet. It is being implemented.



Please describe implementation barriers: Reluctance of mobile applications on health developers to go through an assessment process.

159

Describe the strategies used to overcome the barriers (If needed)We are working currently on raising awareness among designers of mobile applications on health about the advantages of creating quality applications aimed at your target audience and fulfilling minimum standards.

OTHER INFORMATION:


160

Introducing accreditation in Slovenian health care institutions

GOP Information:


Organisation sharing the GOP Ministry of health


Topic Accreditation

GOP Description:


CLINICAL SETTING: Hospitals (general and specialized), primary care nstitutions

OBJECTIVES: To introduce and support the process of achieving international accreditation certificate

POPULATION: Top management

METHODS:

Methodology Ministry of health (MOH) cerated a working group to develop a national approach towards accreditation. The experts in the working group decided not to develp our own standards but rather to encourage the accreditation based on international accreditation standards.In this way we achieved the accreditation of severa health care institutions in a relatively short time.

Timeframe implementation 6 months for setting the policy and several years for hospital accreditation, according to the level of preparedness of each hospital

Implementation tools available MOH has issued a policy document on how to approach accreditation process. National Health care insurance institute (the payer of health care services) included a

financial dis-incentive in the annual agreeent with health care organizations which stimulates accreditation.

Implementation cost The costs of MOH related to the drafting of the policy document are estimated to be few hundred Euros. The cost of accreditation by internationally recognized organizations are determined through negotiations with involved parties. The MOH co - financed the first accreditation survey in several hospitals to accumulative cost of 85.000 Eur.

RESULTS:

Method used to measure the results The MOH has asked the hospitals to report to the ministry the activities connected to accreditation and when certificates are obtained.

Results As of February, 27 th there are 9 accredited hospitals out of 29. A further 18 hospitals or primary health care institutions are preparing for accreditation.

Analysis of the results Survey reports have been analysed by the MOH. The most frequent non-conformities have been recognized and presented to the hospital management.



Please describe implementation barriers: Fianacial obstacles


OTHER INFORMATION:


161

Decreasing of filed complaints

GOP Information:


Organisation sharing the GOP Andalusian Health Service

Member state Spain


GOP Description:


CLINICAL SETTING: All healthcare settings (primary care, hospital, ambulatory, etc.)

OBJECTIVES: To avoid exceeding a certain number of complaints per year in every healthcare setting.

POPULATION: All the Public Healthcare Services users

METHODS:

Methodology We began with this indicator in 2010, gathering all the healthcare settings of the Andalusian Health Service. An average of the filed complaints per type of setting was calculated. This average is the number of complaints which might not be exceed.


Implementation tools available Tools: • Improvement of health professionals’ verbal communication with the users. • Feedback of the resolved estimated complaints in order to avoid those incidents repeats again, sending copies of the resolutions to the directors of those implicated clinical units.

Implementation cost Not quantified.

RESULTS:

Method used to measure the results Number of complaints per year

Results Achievement of the objective in the most healthcare settings. This has involved a decreasing of the whole number of complaints.

Analysis of the results Two factors have been essential to achieve the goals: • The fact that this indicator is included within the objectives of clinical units. • The fact that implicated professionals in every single complaint know its resolution so they can avoid it happens again.





OTHER INFORMATION:


162

Decreasing of estimated complaints

GOP Information:



Member state Spain


GOP Description:


CLINICAL SETTING: All healthcare settings (primary care, hospital, ambulatory, etc.)

OBJECTIVES: To decrease the number of monetary complaints. It will indicate an improvement in patient safety and, therefore, a better healthcare quality.

POPULATION: All the Public Healthcare Services users

METHODS:

Methodology With the clinical documentation completed and the director’s report of the implicated clinical unit, an opinion by the physician of the Risk and Assurance Service must be done. This opinion report will conclude whether the monetary complainted performance might be estimated or not. This GOP is based on the previous GOP about the filed complaints so it is necessary to link both training programs addressed to the Directors of those types of Clinical Units with more probabilities of complaints. Hence, it is important that the Directors understand the importance of a good verbal communication with the users, as well as the need of filling in the clinical records appropriately (expressing everything done with the patient) and making a correct report. These reports are very important and useful in order to defend the complaint health care.

Timeframe implementation It depends on every Clinical Unit. In some cases it was immediately after the training Implementation tools available Tools: • Improvement of health professionals’ verbal communication with the users. • Feedback of the resolved estimated complaints in order to avoid those incidents repeats again, sending copies of the resolutions to the directors of those implicated clinical units.


RESULTS:

Method used to measure the results Number of resolved estimated complaints per year.

Results Decreasing of the rates of resolved estimated complaints per year.

Analysis of the results To achieve these objectives, it is essential that implicated professionals in every complaints know directly its resolutions, in order to avoid it will happen again. Similarly, those professionals must receive the training program described above.



Please describe implementation barriers: Inadequately filled in clinical records. They don’t reflect everything done with the patient, as well as those Director’s reports which are not useful for an appropriated medical opinion fulfillment.

Describe the strategies used to overcome the barriers (If needed)Contacting directly with the implicated professional to inform them about the importance of their report and clarifying their doubts in its making.

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OTHER INFORMATION:


164

ACCREDITATION PROGRAMME FOR ANDALUSIAN PUBLIC HEALTH SYSTEM CENTRES AND UNITS

GOP Information:



Member state Spain

Topic Accreditation

GOP Description:


CLINICAL SETTING: Primary Healthcare, Specialized Healthcare, Emergency. Public and private scope.

OBJECTIVES: To give a public express recognition of the healthcare centres quality. To drive continuous improvement processes in the Health System. The accreditation is conceived as a tool. It is not the aim.

POPULATION: Primary healthcare units and centres. Specialized healthcare units and centres. Haemodialysis units. Emergency centres. Clinical laboratories. Pharmacy offices. Early child care centres. Diagnostic Imaging centres. Blood transfusion centres. Orthopaedic aids shop. Clinical Nutrition and Dietetics units. Healthcare centres without admission

METHODS:

Methodology The self-assessment is very important in the accreditation model. The continuous improvement is based on people and organizations potential. In the self-assessment phase, professionals identify their current position, determine what they want to achieve and plan how to get it. Self-assessment generates an agreement and shared improvement space where professionals, managers and citizens act. (1) The accreditation model departs from standards with which health centres advance towards their citizen services improvement and the development of tools for the management of the quality improvement. Standards are distributed in the following quality dimensions: Person, Health System centre, Organization of activities focused on person (patient safety included), Professionals, Support Processes and Results. From our view of the quality, standards constitute a system in continuous evolution. Citizen contributes with their needs and their expectations. The accreditation is progressive. It has three levels: advanced, optimal and excellent and it is effective for five years.

Timeframe implementation With the developed methodology and the assistance of ME jora C, an application which support the process, accreditation manuals can be generated to test them in 12 months approximately.

Implementation tools available

165

12 Accreditation Manuals for Healthcare Centres and Units. (3) ME jora C, a web-based computer application where the accreditation process (Application,

Self-Assessment, Assessment and Monitoring) is developed

Implementation cost 1 Standards Manual elaboration: 5.000 €. ME jora C application Licensed: 60.000 € ME jora C applicationTranslation: 65.000 € 4 Assessors Training: 40.000 € Certification Process per unit: 4.500 €

RESULTS:

Method used to measure the results Descriptive analysis, validated satisfaction barometer, measurement of units’ performance.

Results More than 650 healthcare centres in the accreditation process, 556 processes finished. (4) Units which have completed the accreditation process consider it adapted to the reality, flattering in the decision making and useful to plan the continuous improvement. It is demonstrated in a statistically significant way that accredited centres reach better results than those centres which have not initiated their accreditation process.

Analysis of the results According to the methodology, results confirm that the accreditation programme impulse the healthcare centre continuous improvement, obtaining better results once the accreditation process has begun.





OTHER INFORMATION:

Other information about the GOP that you would like to add This Accreditation Programme is based on the self-assesment as an environment of reflection about continuous improvement. It is accredited by ENAC (National Entity of Accreditation) and their assessors training is accredited by ISQUA (International Society for Quality in Health Care). ACSA Accreditation Model has been recognised by the Portuguese Ministry of Health as an official accreditation model in Portugal. More Information: 1.Almuedo-Paz A, Núnez-García D, Reyes-Alcázar V and Torres-Olivera A. The ACSA Accreditation Model: Self-Assessment as a Quality Improvement Tool. In: Mehmet Savsar editor. Quality Assurance and Management.InTech 2012. p. 289-314. 2.http://www.juntadeandalucia.es/agenciadecalidadsanitaria/programas de acreditacion/centros/centro y unidades fases/ 3.http://www.juntadeandalucia.es/agenciadecalidadsanitaria/programas de acreditacion/centros/programas de acreditacion/ 4.http://www.juntadeandalucia.es/agenciadecalidadsanitaria/resultados_de_acreditacion/centros_y_unidades_sanitarias/datos_de_actividad.html

166

Directors of clinical units training in pecuniary responsibility for compensation

GOP Information:



Member state Spain


GOP Description:


CLINICAL SETTING: Those types of healthcare settings with more probabilities of receiving complaints

OBJECTIVES: • To provide recommendations on making their pecuniary responsibility for compensation reports. • To insist in the need of expressing in their clinical records everything they have done with the patients. • To encourage a constructive feedback that allows to promote initiative, confidence and collaborative work in order to improve health care quality.

POPULATION: Those types of healthcare settings with more probabilities of receiving complaints

METHODS:

Methodology Classroom training for Directors of clinical units putted into groups regarding their specializations. Professionals from the Risks and Assurance Service will impart the training, containing both theoretical and practical contents. This training program will be a necessary bridge to achieve the other GOP regarding filed complaints and estimated complaints.

Timeframe implementation The content of the training program was prepared in 3 months. The length of the training program in each group is about 6 hour. Most of the assistant professionals introduce what they had learnt.

Implementation tools available Tools: • Theoretical and practical content based on real complaints.


RESULTS:

Method used to measure the results Number of complaints both estimated and filed ones, per year.

Results • Improvement of the clinical records quality. • Improvement of the Directors’ reports quality in order to respond the complaints. • Decreasing of the number of filed complaints. • Decreasing of the number of estimated complaints.

Analysis of the results The achievement of the proposed objectives and reciprocal open communication channel with the clinical units directors deserve to continue planning more training sessions.



Please describe implementation barriers: Inadequately filled in clinical records. They don’t reflect everything done with the patient, as well as those Director’s reports which are not

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useful for an appropriated medical opinion fulfillment.

Describe the strategies used to overcome the barriers (If needed)Contacting directly with the implicated professional to inform them about the importance of their report and clarifying their doubts in its making.

OTHER INFORMATION:


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Training Programme in emergencies directed towards residents at the time of their integration into the healthcare centres

GOP Information:


Organisation sharing the GOP Regional Ministry of Health and Social Welfare

Member state Spain


GOP Description:


CLINICAL SETTING: Public Healthcare Centres Emergency Rooms where residents are trained.

OBJECTIVES: To train residents in clinical reasoning abilities, management of the most frequent diseases in emergencies, knowledge of feedback loops, tests and teamwork.

POPULATION: Doctors who are integrated in Andalusian public healthcare centres to be trained as specialists during four or five years and have shifts in emergency rooms at least in the first year of their residency.

METHODS:

Methodology Healthcare Centres identify prevalent processes in emergencies and determine those questions related to the attention given to patients which can be important for the residents training. A specific training programme is defined and developed in this context and based on previous years’ experience. This programme is given by emergency room professionals. This improves their relationship with residents and, therefore, the teamwork.

Timeframe implementation As this model integrates residents once a year, this GOP has to be habitually introduced and developed when residents begin their training in the healthcare centre.

Implementation tools available Online platform for the residents training management in the Andalusian Public Health System: www.portaleir.es

Implementation cost The implementation doesn’t have an additional cost because it is a training programme given by healthcare centres professionals in their ordinary workday.

RESULTS:

Method used to measure the results The Regional Ministry of Health and Social Welfare is developing a model for measuring training programmes transfer and impact. Up to now, a specific method for measuring results is not available although the survey filled in by residents each year shows the high satisfaction index of this programme.

Results no data

Analysis of the results No data





OTHER INFORMATION:


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Organisation and working strategy of national antimicrobial susceptibility testing committee in small country

GOP Information:


Organización sarín te GOP Slovenian Antimicrobial Susceptibility Testing Committee (SKUOPZ), i.e. ”Slovenska komisija za ugotavljanje občutljivosti za protimikrobna zdravila – SKUOPZ



GOP Description:


CLINICAL SETTING: In clinical microbiology laboratories and public health institutes, results of antimicrobial resistance surveillance are freely available online

OBJECTIVES: Describe GOP objectives 1. Coordination and improvement of methods for antimicrobial susceptibility testing (AST) 2. Nationwide surveillance of antimicrobial resistance with publication of results accessible to all (Internet) 3. SKUOPZ members provide national data for international surveillance of antimicrobial resistance (e.g. for EARS-Net Slovenia)

POPULATION: Target population for AST methods: all clinical laboratories. Target population for results of antimicrobial resistance surveillance (AMRS): all physicians

METHODS:

Methodology Slovenian Antimicrobial Susceptibility Testing Committee (SKUOPZ) has members from all accredited clinical microbiology laboratories and national institute for public health – at meetings of SKUOPZ goals are determined and converted to detailed plans. Plans are implemented by appointed members of SKUOPZ and appointed working groups (members from laboratories involved in SKUOPZ).


Implementation tools available Establishment of national antimicrobial committee in suitable organizational structure with goals and funding. Appointment of members (human resources). Organizational structure of committee and working groups settled

Implementation cost In our model, costs are covered by member organisations (work for national goals, travel expenses for meetings, web-site). Impossible to estimate, no experience.

RESULTS:

Method used to measure the results 1. Are AST methods nationally coordinated and implemented? 2. Are national results of AMRS published? 3. Are data for international surveillance provided?

Results 1. Coordinated implementation of yearly CLSI (Clinical and Laboratory standards Institute) changes and some new tests for AST. Some internal documents for transition from CLSI to EUCAST prepared. 2. Two publications, both accessible on Internet. 3. Data for EARS-Net provided

Analysis of the results 1. Useful documents used in laboratories in practice.

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2. National AMRS results (many bacterial species) accessible on Internet in national language. 3. Data used by EARS-Net



Please describe implementation barriers: Yes: insufficient financial and human resources

Describe the strategies used to overcome the barriers (If needed)Trying to find additional financial resources to ensure effective operation of the SKUOPZ

OTHER INFORMATION:


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Advanced practice nurse attending patients with Advanced Chronic Kidney Disease (ACKD)

GOP Information:


Organisation sharing the GOP Andalusian Public Health System

Member state Spain


GOP Description:


CLINICAL SETTING: Primary and hospital care

OBJECTIVES: Enhancing patients’ empowerment to allow them to make decisions about different types of renal replacement or conservative therapy; Enhancing self-care and patients’ autonomy; improving quality of life of patients with Advanced Chronic Kidney Disease (ACKD).

POPULATION: Patients with Advanced Chronic Kidney Disease (ACKD) (IV-V) with renal replacement or conservative therapy and their cares.

METHODS:

Methodology Definition of target population, objectives, and service portfolio of ACKD nurses. Definition of competencies profile. Design and development of training plans. Dissemination and strategy of establishment plan. Definition of results and quality criterias.


Implementation tools available Tools: Protocol of advanced practice nurse attending patients with ACKD edited by Department of

Care Strategies - Andalusian Regional Ministry of Health and Social Welfare. Training plan. Dissemination and establishment strategy. Competencies accreditacion manual (in process).

Implementation cost Design and digital publication of protocols: 1500 euros. Accreditated training activities for 20 nurses: 3000 euros. Accreditation process of advanced competency: 0 euros for Andalusian Public Health System workers. Adaptation of Digital clinical history and information systems for recording and monitoring: between 8000 and 10000 euros

RESULTS:

Method used to measure the results Training monitoring data (Training and Professional Developement Service of Andalusian Health Service) Andalusian Agency for Health Care Quality information system for accreditation of advanced competency

Results A total of 11 nurses of 6 hospitals of the Andalusian Health Service were trained. During 2011 a total of 283 patients were attended. At 31st December, 224 of them are still active (31 with conservative therapy). 33 started dialysis during 2011 and y 27 died. 65.2% of patients who decided on technique chose hemodialysis (HD) and 34 % Peritoneal dialysis (PD)

Analysis of the results Analysis after the first year of implementation 2010 - 2011:

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Peritoneal dialysis grew up compared to hemodialysis in our region in 2011, in 166 new patients. This increase verified fundamentally in centers related with the strategy development (from 8.3% in 2010 to 12.7% in 2011 for hemodialysis). It allowed a saving 420000 euros for the Andalusian Health Service (~14500€ for patient/year). The development of protocol of advanced practice nurse attending patients with ACKD, permitted an increase of house peritoneal dialysis, the transplant from living donor previous to dialysis and conservative therapy.



Please describe implementation barriers: Now we are extending the practice to other hospitals of the Andalusian Health Service

Describe the strategies used to overcome the barriers (If needed)Review and monitoring of implementation and reorientation indicators with managers of hospital centers to provide continuity to advanced practice development.

OTHER INFORMATION:

Other information about the GOP that you would like to add Advanced practice attending Advanced Chronic Kidney Disease is provided by a nurse who have received formal training and developed specific competencies to give cares to patients with Advanced Chronic Kidney Disease in 4 y 5 level. The nurse provides comprehensive cares, personalized and with an optimum quality level to pepole with Advanced Chronic Kidney Disease and their cares, guarantying to cover every need and expectative of patients and their cares. The nurse informs adequately patients and their cares about the replacement therapy, encouraging patients’ decision making choosing freely between the different types of therapies, promoting patients’ participation managing them, inciting continuity between different care levels and performing a rational use of the resources.

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PROFESSIONAL SKILLS ACCREDITATION PROGRAMME FOR THE ANDALUSIAN PUBLIC HEALTH SYSTEM

GOP Information:



Member state Spain

Topic Peer review

GOP Description:


CLINICAL SETTING: Primary Healthcare, Specialized Healthcare, Emergency.

OBJECTIVES: To recognize the achievements of professionals in their real and daily practice. To promote professional development and continuous improvement.

POPULATION: Healthcare professionals of 74 disciplines: doctors and nurses who work in Primary healthcare, specialized healthcare and emergencies, Physiotherapists, Occupational Therapists, Geneticists, Specialists in Clinical Tests, Microbiologists, Anatomopathologists, Pharmacists who work in Primary healthcare and specialized healthcare, Neurophysiologist and Nutritionists.

METHODS:

Methodology Based on a portfolio methodology, since 2005, ACSA has developed an accreditation model focused on the recognition of the achievements reached by professionals in their practice. The model pretends to contribute to the attention given to patients’ continuous improvement and it is an instrument for the continuous professional development. It is voluntary, based on the self-assesment done by professionals in their real everyday practice and progressive with three accreditation levels: advanced, expert and excellent. It has been developed by scientific societies and Healthcare management representatives. 74 Professional skills accreditation manuals have been defined (2), one for each discipline. They are based on the following quality dimensions: User rights, Complete healthcare assistance (patient safety included), The Professional (teamwork, professional development, research and teaching), Efficient use of resources, Outcome orientation in the Professional Development Results. Two assessors who belong to the same discipline and who have achieved the excellent level accreditation evaluate the professional. The Accreditation is effective for five years.

Timeframe implementation With the developed methodology and the assistance of ME jora P, an application which support the process, accreditation maps can be generated to test them in 12 months approximately

Implementation tools available 78 Professional Skills Accreditation Manuals, one for each discipline. (3) ME jora P, a web-based computer application where the accreditation process (Application, Self-Assessment, Monitoring and Assessment) is developed.

Implementation cost Elaboration of 1 Skills Manual: 5.000 €. ME jora P application Licensed: 100.000 € ME jora P application Translation: 80.000 € 4 Assessors Training: 40.000 € Certification Process per professional: 700 €

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RESULTS:

Method used to measure the results Descriptive analysis, validated satisfaction barometer, reliability and validity analysis, measurement of profesionals’ performance.

Results More than 20.000 professionals have initiated the accreditation process, 8.845 have finished it. The perceived utility in the continuous professional development is demonstrated (“self-learning and reflection thanks to exercise”, “maintenance and improvement of competence”, “maintenance and improvement of result”). Accreditation Programme reliability and validity is demonstrated. It is demonstrated in a statistically significant way that professionals who have initiated their accreditation process reach better results than those professionals who have not initiated their accreditation process. It is demonstrated in a statistically significant way that accredited professionals reach better results than non-accredited professionals.

Analysis of the results According to portfolio methodology, results confirm that the programme is useful for continuous professional development and it promotes continuous improvement in their work reaching better achievements when they initiate the accreditation process.





OTHER INFORMATION:

Other information about the GOP that you would like to add This Professional Skills Accreditation Programme is based on the self-assesment as an environment of reflection about continuous improvement. Peer review contributes to the remarkable acceptance of the accreditation model by professionals and it promotes continuous professional development as the Accreditation Council for Continuing Medical Education indicates. (4) This programme has obtained three national prizes given by important media and specialized consultant. 1.http://www.juntadeandalucia.es/agenciadecalidadsanitaria/system/galleries/download/acsa/Programas_Acreditacion/pcp_es.pdf 2.http://www.juntadeandalucia.es/agenciadecalidadsanitaria/programas_de_acreditacion/profesionales/herr_apoyo_comp_prof/competencias_profesionales_herr_apoyo.html 3.http://www.juntadeandalucia.es/agenciadecalidadsanitaria/resultados_de_acreditacion/competencias_profesionales/situacion_actual.html 4.Bellande B, Winicur Z, Cox K. Urgently Needed: A safe place for self-assesment on the path to maintaining competence and improving performance. Adacemic Med. 2010; 85: 16-8.

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Stakeholder engagement regarding the registration and inspection of designated centres for older persons.

GOP Information:


Organisation sharing the GOP Health Information and Quality Authority (the Authority)

Member state Ireland

Topic Centre licensing

GOP Description:


CLINICAL SETTING: Designated centres for older people in Ireland. These include private nursing homes, publicly funded (by the Health Service Executive) and voluntary residential services for older people.

OBJECTIVES: Seminars for providers and persons in charge of designated centres for older people in Ireland. The purpose of these was to provide information and updates on the registration and inspection regulatory process, relevant guidance and to address specific questions or queries raised by providers and persons in charge.

POPULATION: Providers and persons in charge of residential care settings for older people in Ireland. Providers are named on the register as carrying on the business of the residential care setting while the person in charge is named on the register as being in charge of or managing the service.

METHODS:

Methodology The Authority is committed to ongoing and inclusive engagement with its stakeholders. This helps to ensure that the work of the Authority is responsive to the needs of those involved in receiving and delivering services. In October 2012, the Authority hosted three seminars for providers and persons in charge of designated centres for older people. The purpose was to update participants in relation to changes in the regulatory process, to make them aware of new guidance to help them in delivering a safe, high quality service and to address any queries or issues they may have about the work of the Authority. An advisory group comprising of staff from the Authority and provider representatives was convened to ensure that the seminars addressed the topics of most relevance to providers. Participants were encouraged to email in their questions and queries prior to the first seminar and these were addressed at the questions and answers session and other sessions where applicable. A seminar was held in each of the Authority’s regulatory areas – Central, North and South. All presentations and responses to queries were made available on the Authority’s website after the seminars.

Timeframe implementation Approximately twelve weeks elapsed between the initial advisory group meeting and the first seminar taking place. Provider representatives had approximately 6 weeks to revert to their members and ask them for their questions, queries or issues regarding the registration and inspection process.

Implementation tools available Not applicable

Implementation cost The 3 seminars cost about €10,000. The main costs were venue hire as the Authority could not accommodate the size of the groups in its own premises and catering costs as a light lunch was provided for participants at each seminar.

RESULTS:

Method used to measure the results A feedback questionnaire was provided at each seminar for attendees to complete. It was optional for attendees to complete this questionnaire. They were asked about their overall satisfaction with the seminar and with each of the agenda items.

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They were also asked about the seminar relevance and for suggestions about topics which could have been included in the session.

Results Based on data collected when attendees registered their attendance at the seminar on the day over 600 people (n=666) attended the 3 seminars. Overall 74% (n=420) of all designated centres in Ireland were represented at the seminars. The persons in charge were the largest proportion of seminar attendees comprising 48% of total attendees (n=320). Providers comprised 33% of seminar attendees (n=218) while “other” nominess made up 19% (n=123) of attendees. A total of 488 seminar feedback forms were completed.

Analysis of the results Overall, most respondents were satisfied with the seminars with a 3.35 average rating for them (based on a satisfaction rating scale of 1-5 where 1 was lowest and 5 was highest). Satisfaction ratings were in the moderate to high range for all agenda items. Overall, 90% of respondents felt that the seminar was relevant to them. Over one fifth of respondents (22%) said there was another topic which they would have liked to have been included in the seminar. Participants provided a variety of suggestions for topics which could have been included in the seminar.



Please describe implementation barriers: Publicly funded residential care services for older people in Ireland are provided by the Health Service Executive (HSE). The HSE announced a moratorium on travel for its’ staff at the time the seminars were being organised. This could potentially have impacted on the numbers of staff who would have been in a position to attend the seminars.


OTHER INFORMATION:

Other information about the GOP that you would like to add Engaging with service providers at the planning stage for the seminars helped to ensure that the content of the seminars were relevant for providers.This engagement faciliated providers to ask questions and raise queries about the Authority’s work. This is turn provided the Authority with an insight into the issues and topics relating to the registration and inspection of designated centres that service providers were having difficulty with. The seminars facilitated discussion between the Authority and providers about these issues and topics. They also gave providers an opportunity to seek further clarifiaction on an issue if necessary. In addition, the Authority will use the feedback from providers to inform the organisation of future seminars.

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School of Patients

GOP Information:


Organisation sharing the GOP The Andalusian School of Public Health

Member state Spain


GOP Description:


CLINICAL SETTING: Patients with different chronic diseases (diabetes, asthma, breast cancer, COPD, fibromyalgia, heart failure, colon cancer, caregivers, palliative care). These trained patients have trained other patients, reaching more than 15,000 patients, besides all patients reached through social networks.

OBJECTIVES: • To improve patients and users’ knowledge and skills about their chronic disease, quality of life, services use, adherence, and lifestyle habits through educational workshops to pass on this training. • To encourage more active patients and citizens and to make them stewards regarding their illness.

POPULATION: Patients associations, users, patients and patients family are the target population. At first, we have worked with people from the associative field considering that thus there is more chance that the skills and knowledge provided will achieve a more efficient dissemination in the field of their association.

METHODS:

Methodology This initiative is designed as a cascade training strategy and peer-to-peer learning. Patients are trained to train other patients. Trained patients replicate the training to other known patients, or other patients contacted through social networks (Twitter, Facebook, YouTube, blogs, Webs, and virtual classrooms). It is a practical and skills training approach.

Timeframe implementation Three months per each pathology. At first you have to form the initial group of trainer patients and then ensure that this formation extends in cascade through associations or mainly healthcare settings themselves (there are 170 potential clinical units to work with).

Implementation tools available • Several educational materials (guides, presentations, case studies, videos, blogs, digital meetings with professionals) for use in the training. • Model letters of invitation to participate • Model call for training activities programs

Implementation cost 200000 euros.

RESULTS:

Method used to measure the results • Surveys of satisfaction to those who are trained. • Semi-structured interviews with trainer patients.

Results • Results of satisfaction. (satisfaction above 85%) • Qualitative data on expectations and subsequent measurement

Analysis of the results • Satisfaction Surveys: Statistical Analysis. • Semi-structured interviews: Content Analysis.

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• Evaluation studies of the training activity. • Pre-post training questionnaires.



Please describe implementation barriers: Expectation of a greater continuity of the training programs by forming patients • Reluctance to be patients who "are" indeed training instead of health professionals

Describe the strategies used to overcome the barriers (If needed) • Clearly define since the beginning the "rules of the game" • Clarify the benefits of peer-to-peer training and stress that is a complement to the training provided by health professionals • Continuity with social networks, e-mail, blogs, etc. • Patients Congress, as a place of motivation • Regional meetings with patients and professionals

OTHER INFORMATION:


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Implementation of The Seasonal Influenza Vaccination Scheme in Retail Pharmacy Businesses The principles used for the introduction of the seasonal influenza

vaccination programme shall be used to roll out additional extended services within the community pharmacy sector in the future.

GOP Information:


Organisation sharing the GOP The Pharmaceutical Society of Ireland (PSI)



GOP Description:


CLINICAL SETTING: There are over 1700 retail pharmacy businesses (“pharmacies”) in the Republic of Ireland. Pharmacists, who have completed the accredited vaccination training programme and where a private area compliant with PSI Guidance is provided at the pharmacy, may elect to provide influenza vaccination services.

OBJECTIVES: To support and ensure the safe and effective implementation of the seasonal influenza vaccination services in pharmacies throughout the Republic of Ireland.

POPULATION: Pharmacists, who have received the accredited training, are permitted to vaccinate patients over 18 years of age.

METHODS:

Methodology Legislative change was introduced in October 2011 in the Republic of Ireland, permitting pharmacists to administer influenza vaccine and adrenaline injection (in case of anaphylaxis to flu vaccine). The Council of the PSI approved Accreditation Standards for Influenza Vaccination Training Programmes for Pharmacists. The School of Pharmacy at the University of Dublin, Trinity College was designated as the accrediting body. In 2011, a course on influenza vaccination training, provided by Hibernian Healthcare Ltd, was approved by the accrediting body. In 2012, a course of training provided by Boots Retail (Ireland) Ltd. was approved together with the refresher courses of training provided by Hibernian Healthcare Ltd. for the 2012-2013 Winter 'flu season’. (Pharmacists wishing to administer the vaccine undergo an initial training programme, followed by refresher courses on an annual basis.) The training programmes include quality assurance procedures in relation to vaccination technique and the management of anaphylaxis and resuscitation. Approximately 1400 pharmacists received training in 2011 and the vaccination service was implemented in almost 500 pharmacies across Republic of Ireland at that time. The PSI issued guidance in 2011 to assist pharmacists in the provision of the vaccination service. Revised guidance was issued for the 2012-2013 season.

Timeframe implementation In the six month period prior to the implementation of the vaccination scheme, research, development and drafting of guidance and standards for training were finalised. Due to delays in the legislative process, accreditation of training and issuing of Guidance occurred over a very short time frame.

Implementation tools available Review of Systems in other countries eg Canada, Portugal, UK Involvement with HSE, PCRS and Dept of Health Publication of Guidance Meetings with relevant stakeholders IPU. Large pharmacy chains etc, Implementation cost PSI staff involvement in the development of Guidance and Accreditation Standards.

RESULTS:

Method used to measure the results Successful immunization of over 8,000 patients in

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community pharmacy setting.

Results As above - Successful immunization of over 8,000 patients in community pharmacy setting.

Analysis of the results As above - Successful immunization of over 8,000 patients in community pharmacy setting.



Please describe implementation barriers: 1. Some patients did not receive the optimal dose of vaccine required for immunisation due to an error in the training programme. 2. Some Medical Practitioners resisted the involvement of pharmacists in the delivery of influenza vaccination to the public Describe the strategies used to overcome the barriers (If needed) 1. As a result of the reported underdosing of patients by some pharmacists, the PSI established an independent Risk Review Group to advise on the issues surrounding the error and report on the learnings from this issue. 8 recommendations were made by the group and the PSI has directed that learnings from the report are incorporated into future training and by the new Irish Institute of Pharmacy, which will oversee the management and delivery of continuing professional development (CPD) for pharmacists in Ireland. 2. A meeting with the IMO (Irish Medical Organisation) and medical practitioner representatives was held.

OTHER INFORMATION:


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The National Early Warning Score (NEWS) and associated education programme for the early detection and management of patient deterioration. This project is a work stream of the National Acute Medicine Programme, Health Service Executive in association with

key stakeholders including patient representative groups.

GOP Information:


Organisation sharing the GOP Health Service Executive (HSE)



GOP Description:


CLINICAL SETTING: The NEWS and associated eduction programme has been implemented in 83% of acute hospitals in Ireland. The remaining hospitals have commenced training their staff for implementation of the initiative.

OBJECTIVES: The overall aim of the NEWS project was to develop one integrated solution for a NEWS and associated education programme. This initiative promotes the early detection and timely management of deterioration in patients’ condition to improve outcomes for patients, reducing cardiac arrests, unplanned admission to ICU and unexpected death. POPULATION: All adult patients in acute hospitals (excluding obstetric and paediatric patients). Responsibility for implementing the NEWS applies to healthcare professionals, doctors, nursse and allied health professionals in conjunction with NEWS committees / groups in acute hospitals, and managers in hospitals or groups of hospitals.

METHODS:

Methodology A national lead was identified. Multi-disciplinary National Governance / National Clinical Guideline development and Advisory groups were set up. Evidence was gathered to aid in the decision making process. This included: a) A baseline audit of early warning scores and education programmes in use in acute hospitals. nationally. b)A strengths, weaknesses, opportunities, threats analysis and risks identification. c)A systematic search and review of literature. d)A comparative analysis of education programmes e)An economic impact study. Levels of evidence were linked to the recommendations of the project. The NEWS and adapted COMPASS Education Programme were signed off at senior level. International experts were consulted. The programme was updated following the discovery of new evidence on early warning scores – the update also included the early detection and treatment of sepsis and a National Patient Observation Chart. Barriers and enablers for implementation were identified. A National Clinical Guideline was developed. Audit and evaluation recommendations with specific criteria were identified. Programme Launch took place in March 2012. A website was developed. Implementation has progressed in 80% of acute hospitals.

Timeframe implementation Full implementation is planned for the end of 2013 in all acute hospitals in Ireland providing acute care.

Implementation tools available National Contact person provides support.

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Regional and Local contacts identified. Tools: ‘Train the Trainer’ programme. Training in all acute hospitals. An Education Toolkit. Education Facilitators Guide. Education Equipment List. Education Programme Equipment List. Education Programme Evaluation Forms. Training Manual. Interactive CD. Quiz Questions. Powerpoint Presentation for Education Programme Facilitator. Powerpoint Presentation handouts. Case Study Examples. Implementation Resources. Sample Project Plan. National Patient Observation Chart. Deteriorating Patient Flow Chart for display in wards. ISBAR Communication Tool Chart Guide. The issues log on email to allow for feedback. The material may be downloaded free of charge from:http://www.hse.ie/go/nationalearlywarningscore/ Implementation cost Implementation costs were reduced by expert management of staff release to attend the education programme. This was managed locally. All materials were made available on the website. Initial funding of education materials was supported by the Office of Nursing and Midwifery Services Director - €18,000.

RESULTS:

Method used to measure the results Figures were obtained from acute hospital sites on cardiac arrest figures pre and post implementation.

Results Overall preliminary results indicate an average of 30% reduction of cardiac arrests. This is in line with international data (Buist) and (Bellomo).

Analysis of the results Simple statistics were used to provide figures on the cardiac rate before and after implementation of the NEWS. Some caution was expressed as to the attributing this reduction solely to the introduction of the NEWS.



Please describe implementation barriers: The main barrier for implementation as expected was resistance to a change in culture in acute hospitals, from a small number of staff.

Describe the strategies used to overcome the barriers (If needed)Two national conferences organised – international and national speakers. Multi-disciplinary groups in acute hospitals were visited. Key people, acting as champions on sites were identified. Continuous dialogue was maintained with staff. Quarterly audits completed outlining national progress. An ‘issues log’ set up on email, to address queries. Good news stories were communicated. International evidence and updated information was provided. The Health Information and Quality Authority (the healthcare regulator in Ireland) and the

183

Clinical Indemnity Scheme (part of the State Claims Agency) recommend implementation. These strategies has made implementation a much smoother process.

OTHER INFORMATION:

Other information about the GOP that you would like to add Ireland is the first known country to have agreed a NEWS. The National Clinical Guideline for the NEWS is the first clinical guideline to be endorsed by the Minister for Health which was recommended by the National Clinical Effectiveness Committee in the Department of Health. The aim of the Committee is to provide a framework for national endorsement of clinical guidelines and audit to optimise patient care. The NEWS is a significant development in the Irish healthcare context as part of a generational change in how acute hospitals deliver care by standardisation of the assessment of the assessment of acute illness severity, enabling a more timely response using a common language. The project won 3 awards in 2012: The Taoiseach’s (Prime Minister) Award for the Public Service Excellence Awards, The (Biomnis) Health Innovation Award – Patient Safety Category and the Irish Medical Times Award – Excellence in Healthcare Management. The National Patient Observation Chart was awarded a commendation at the UK Society of Acute Medicine Conference in Manchester (Oct 2012). The awards recognise the hard work and commitment of nurses, doctors, allied health professionals and managers committed to promoting patient safety and quality of care.

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Organisation, implementation and evaluation of National Falls and Bone Health Strategy 2013-2015

GOP Information:


Organisation sharing the GOP Health Service Executive (HSE) in collaboration with the State Claims Agency (SCA).



GOP Description:


CLINICAL SETTING: All – acute, community, residential and primary care settings.

OBJECTIVES: It aims to protect bone health throughout life and prevent falls in Ireland’s ageing population.

POPULATION: Persons aged 65 years and older (11%) or 491,168/4,588,252 population (2011 census)

METHODS:

Methodology Change management project methods such as continuous quality improvement (CQI) plan developed in conjunction with existing quality, safety and risk programmes; aligned to existing health reform agenda; integrated into older persons clinical care programme (national change management forum).

Timeframe implementation 3-5 years

Implementation tools available Strategy recognises the need to collaborate with multiple stakeholders to build greater awareness, strengthen cooperation capacities, streamline clinically effective, high quality service delivery, and support innovative mechanisms to achieve safer environments. Using principles of empowering service user self-mangement, early detection of risk, and the availability of preventative interventions, the approach will optimise the opportunity to use innovative assessment and screening mechanisms, guidelines and assistive technologies to deliver seamless services. HSE also commits to participate with pan-European stakeholders in the European Innovation Partnership Framework to share best practices, strengthen monitoring and service improvement measures and to contribute to data registries alignment.

Implementation cost Personnel resources include the National Sponsorship Group; Regional Operational Groups; Clinical Risk Adviser (SCA) and HSE Lead as National Co-ordinators; administration and liaising functions from existing resources; financial resources including operating within current constraints of cost containments, staff reductions and re-orienting existing practices to minimise overall costs of full implementation.

RESULTS:

Method used to measure the results Reductions in a number of indicators such as older persons being treated for falls, hospital admissions secondary to a fall related injury, nursing home admissions secondary to a fall related injury, hip fractures (Mean DRG Cost 2005-2010 €13,346 per patient), ambulance call outs, A&E presentations, rehabilitation admission requirements, home care package requirements, mortality rates secondary to falls & complications, bed days utilised secondary to falls & fractures.

Results Not yet applicable

Analysis of the results Not yet applicable


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Please describe implementation barriers: Apart from the operational context of working within a difficult economic climate, imposing tight resource constraints and a headcount embargo, the key barriers to overcome are: • Resisting the dissipation and fragmentation that the strategy is designed to eliminate as it cascades from national to regional, to local level • Implementing within a transitional governance framework as our health system that is currently undergoing transformation • Shifting to a model of greater client empowerment, increased personal self-management and individual care-pathway co-design • Balancing central co-ordination, regional innovation and personal autonomy.

Describe the strategies used to overcome the barriers (If needed)To overcome these, we will establish co-ordinated national guidelines to operate at all levels of service delivery, establish uniformity across awareness building channels, harmonise capacity development, and support ‘productive interaction’ between informed, activated patients and prepared, pro-active multi-disciplinary practice teams.

OTHER INFORMATION:

Other information about the GOP that you would like to add The key elements that will be progressed on implementation are: • New falls and fractures clinical care pathway / process, involving screening at multiple points of entry, decision algorithms, and assessment mechanisms • New national guidelines to support the new pathway at different entry points • New national standards to support information dissemination falls prevention awareness • Adoption and adaptation of a new ‘Single Assessment Tool’ during the further development of the project • The development of registers including a hip fracture registry within the HIPE database • The encoding of future care pathways on-line tool to provide pathways contexts to users • Connecting existing home-based tele-care systems and services to the falls early ‘at risk’ screening mechanisms • Development of a ‘falls and fractures community of practice’ within the HSELAND web portal to promote practice development • Support bone health promotion in schools

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Pharmacy Inspection Process

GOP Information:


Organisation sharing the GOP The Pharmaceutical Society of Ireland (PSI)


Topic Inspection

GOP Description:


CLINICAL SETTING: There are over 1700 retail pharmacy business (RPBs) (“pharmacies”) in the Republic of Ireland.

OBJECTIVES: The PSI seeks to inspect all RPBs by the end of 2015, to ensure that all pharmacies are compliant with legislation and practice guidelines and are safe and fit to operate pharmacy services to the public

POPULATION: All retail pharmacy businesses in Ireland will be inspected, prioritising inspections in those pharmacies where risk factors have been identified.

METHODS:

Methodology “Specialist Surveyors” carry out a preliminary review of pharmacies, identifying risk factors. This information aids the PSI in risk assessing pharmacies in order to target where inspections should be prioritised. Pharmacies of serious concern are classified as “Category 1 Risk” and an inspector is sent immediately to visit the pharmacy. Lower risk pharmacies are classed as “Category 2 Risk” and scheduled for inspection as soon as practicable. Inspectors of the PSI carry out routine inspections of pharmacies. The inspections seek to review the primary systems of the pharmacy and typically last 1-2 hours. A report is then issued outlining the required actions which must be taken in response to identified issues or concerns within a designated timeline. The PSI have provided a number of tools on the PSI website to help pharmacists improve their practice and to prepare for inspection. These include: Inspection Checklist and podcast Links to Legislation and PSI Guidance Documents Newsletter Updates The PSI has also engaged with the Irish Pharmaceutical Union in relation to difficulties pharmacists had encountered with the inspection process. It is hoped to launch an annual “self-assessment” tool for pharmacists by which pharmacists and pharmacy owners to help encourage regular “self-auditing” within pharmacies.

Timeframe implementation It is hoped to inspect all pharmacies by year end 2015.

Implementation tools available Inspection Software “Case Management System” Personnel Specialist Surveyors (x 2) Authorised Officers ( x 4 full time equivalents)Administrator ( x1) PSI Website as communication tool

Implementation cost The implementation costs are linked to the development of inspection software and staffing.

RESULTS:

Method used to measure the results Specialist Surveyors have visited all pharmacies in the country Specialist Surveyors have visited Category 2 risk pharmacies on a minimum of two occasions

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50% approximately of pharmacies have been visited by Authorised Officers as of 2012 Risk pharmacies have been identified and visited as a matter of priority by Authorised Officers

Results Through the report process, pharmacists are directed to address shortcomings in their practice and rectify all identified issues In some circumstances, legal and disciplinary proceedings have commenced further to inspections. A log of disciplinary and legal actions taken is maintained.

Analysis of the results Further to the development of inspection software, the most common shortcomings observed in pharmacies can be deduced. Education and information is then issued to pharmacists on these matters through the PSI newsletters. This information is also used to inform the Practice of Pharmacy Development Unit and areas where guidance may need to be issued.



Please describe implementation barriers: Recruitment Embargo Delays in the development of inspection software “ Case Management System” Many pharmacies had not been inspected or had been inspected once in the ten years preceding the implementation of The Pharmacy Act 2007. These pharmacies required greater assistance and time from the authorised officers. Legal and disciplinary proceedings were initiated in some cases, which also imposed greater demands on authroised officers and resulted in decreased availability of authorised officers to carry out inspections to annual targets. Describe the strategies used to overcome the barriers (If needed)Ongoing development of computerised systems to expedite inspection process and report writing to free up the availability of authorised officers Review of inspection pro-forma and inspection strategy. Authorised Officers are now seeking to focus inspections on those pharmacy systems which have greatest impact on patient safety Increased focus on assisting pharmacists prepare for inspection in the hope that this will improve compliance across all areas.

OTHER INFORMATION:

Other information about the GOP that you would like to add It is hoped that the introduction of a self-assessment form will act as an additional tool to improve compliance with legislation and practice guidance.

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National Healthcare Charter ‘You and Your Health Service’

GOP Information:


Organisation sharing the GOP Health Service Executive



GOP Description:


CLINICAL SETTING: Acute hospitals and primary care.

OBJECTIVES: To describe what service users can expect when using health services, and what they can do to help to deliver more effective and safe services. To inform and empower service users to actively look after their own health and to influence the quality of healthcare in Ireland.

POPULATION: It applies to all public health and social care services, including community care services and acute hospitals.

METHODS:

Methodology Development of charter It is based on eight principles which underpin high quality, people-centred care. These principles have been identified through a review of national and international patient charters and through wide consultation with the Irish public. Review of evidence Production of resources Dissemination and awareness plan Evaluation plan

Timeframe implementation 2009 to 2014

Implementation tools available Staff guide Information sessions Promotion materials Web support

Implementation cost €50,000

RESULTS:

Method used to measure the results Patient surveys

Results Implementation stage still ongoing, full results not available yet.

Analysis of the results Implementation stage still ongoing, full results not available yet.





OTHER INFORMATION:


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Patient participation in professional regulation

GOP Information:


Organisation sharing the GOP Nursing and Midwifery Board of Ireland



GOP Description:


CLINICAL SETTING: Impact is on all settings where nurses and midwives practice.

OBJECTIVES: To ensure responsive, patient centered professional regulation.

POPULATION: The public.

METHODS:

Methodology Patient and advocate representatives participate in all levels of the professional regulation governance of nurses and midwives in Ireland including Board membership, sub-committee membership and all project and research group.

Timeframe implementation This has been on-going for many years.

Implementation tools available Legislation, policy and research evidence dictates the importance and appropriateness of having the public and patient representatives playing a prominent and fundamental role in professional regulation including setting standards of education and practice.

Implementation cost Cost is limited to members expenses and subsistence.

RESULTS:

Method used to measure the results A survey of the governance experience of Board members was undertaken based on the 2007-2012 Board. Generally results were positive, a copy of the research has been sent forward to the ISQUA conference in Edinburgh this year.

Results As above

Analysis of the results As above



Please describe implementation barriers: Initial concern of some professional representatives regarding the role of the public in professional self-regulation.

Describe the strategies used to overcome the barriers (If needed)The primary strategy used was engagement and participation whereby the patient representatives and nurse representatives collaborate together on most of the project activity undertaken by the regulator and there is a general consensus of the benefit of broad stakeholder engagement. Multi-stakeholder engagement is a facet of most areas of life in Ireland in 2013.

OTHER INFORMATION:

Other information about the GOP that you would like to add The beliefs and values relating to the important role played by patient/advocates in professional regulation of Nurses and midwives includes patient advocates on disciplinary committees and patient advocates on the programme boards of the Education programmes for

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Nurses and midwives in the Higher Education Settings. In this regard patients are involved in the setting of standards for nurse and midwife education, support programme development within the Higher education institutions and are also involved in the development of professional guidance for the professions and the discipline process for nurses and midwives.

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Creation and Organization of a network Biobank in Andalusian Public Health Service (APHS)

GOP Information:


Organisation sharing the GOP Directorade of Quality, Research, Development and Innovation. Scientific Management of Biobank. Andalusian Regional Ministry of Health and Social Welfare.

Member state Spain

Topic Centre licensing

GOP Description:


CLINICAL SETTING: It is a common ethical framework, with a unique organizational structure and a decentralized activity that integrates all blood banks and tissues for therapeutic purposes, as well as research biobanks and other existing units within the Andalusian Public Health System.

OBJECTIVES: • To unify systems of procurement, processing, custody, release of tissue samples and biological substances of human origin, whatever their destination (care, teaching, research or industrial use). • To sort and coordinating the banks and the sample collections of the APHS. • To strength connections and cooperation programs nationally and internationally.

POPULATION: Andalusian Population

METHODS:

Methodology The organizational model will be equipped with three different areas, marked by their expertise and regulatory framework for action: • Blood. Blood derivatives • Tissues, anatomical parts, chemicals and biological samples for clinical use. • Tissues, chemicals and biological samples for research. The organization of the Biobank is developed on the following basis: • Public Control (guarantor to the citizen). • Tendency to autonomy. New management models more agile, integrated within Public Health Administration. • The purpose is self-financing from the billing of costs of production, processing and distribution conservation. • Services to agencies and public and private entities within and outside Andalusia • Ensure the quality, safety and traceability of data and stored samples and procedures associated with the operation of the biobank. • Answering of inquiries or complaints may be addressed to the biobank.

Timeframe implementation Twenty-four months.

Implementation tools available a) Instalaciones and equipment • Biosecurity plan: sample transport logistics, Signage • Preservation and traceability of samples: precoded tubes, printers, freezers • Conditioning spaces • Sample Processing b) Quality management system. It has a strategic plan that includes goals, mission, values and service portfolio in the Biobank network. It will include strategic, operational and support processes. c) Information management system:

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Widespread use of Bio-and tool-Bank and Sacilab-Saciweb Transfering of the Bio-e-Bank tool server Changes in the tool-and Bio-Bank Design of new plans and sample and procedures processing Definition of new activities Defining new units, sources of samples. d) Training and dissemination activities

Implementation cost Although the initial budget for 2012 was € 1776121 in current expenditure and € 640000 in investments by 2012, the Biobank of APHS, far from being a new expense, substantially reduce the current cost, increasing the quality of the process and improving the results.

RESULTS:

Method used to measure the results The approach focuses on the integration and optimization of the various systems responsible of the collection, handling, processing and supply of tissues and biological samples, increasing the process quality and improving the results. Specifically, measures like: Procedure Control Cost control Traceability Control Sample integrity Control

Results a) The integration and streamlining management structures have resulted in annual savings of 300000 euros. b) The unification of systems of procurement, processing, custody of hover substance and tissue samples: 3 million euros of potential savings. c) Unification of information systems: 100000 euros. d) Improving the management model, with measures such as centralized purchasing of consumables, concentration processing activities: 1 million euros per year. e) Introduction of quality criteria in the storage of samples: 1 million euros per year and transport of 300000 euros a year.

Analysis of the results The scope of our project includes all types of products: Blood and derivatives, umbilical cord blood, tissues (including the reproductive one), biologicals, biological samples for research, embryonic cell lines, reprogrammed cells and other precursor and not precursor cell lines. It also affects all processes of procurement, processing and distribution, regardless of origin and destination and the type of processing or preservation applied. All of them will follow the same systematic biohazard control, track and trace, in a common framework of biomonitoring.





OTHER INFORMATION:

Other information about the GOP that you would like to add Despite finding implementation barriers, it has been an opportunity to involve professionals in an integrated quality system. Undoubtedly, it has posed a challenge to coordinate these activities and to structure directing to user needs, and even anticipating them, in order to eliminate inefficiencies. For its part, to involve donor unit of blood, organs and tissues in the project has provided an opportunity to integrate teams. The aim has been to avoid duplication and identify synergies, seek unification of criteria, quality control systems, as well as to connect

193

these units and activities devoted to obtain, maintain and manage samples for clinical units and research centers within the APHS. Donation and conservation units, care teams and research groups provide a service and mutual benefit in a clear example of the exercise of translational medicine.

194

Stakeholder engagement in the development of the National Standards for Safer Better Healthcare.

GOP Information:


Organisation sharing the GOP Health Information and Quality Authority (the Authority)



GOP Description:


CLINICAL SETTING: The National Standards for Safer Better Healthcare have been designed so that they can be implemented in all healthcare services, settings and locations in Ireland.

OBJECTIVES: To engage with all relevant stakeholders in Ireland and internationally while developing the National Standards for Safer Better Healthcare to ensure that they are fit for purpose and describe areas of importance for quality and safety for service users which are amenable to improvement through standards.

POPULATION: All stakeholders with an interest in the development of national healthcare standards including the Department of Health, service providers, service users, the public, regulators in Ireland and other countries among others.

METHODS:

Methodology A consultative approach is at the heart of the Health Information and Quality Authority’s values of fairness and objectivity, openness and accountability, excellence and innovation, and working together. In line with these principles, the Authority convened an Advisory Group to advise it on the development of the National Standards for Safer Better Healthcare, to support consultation and information exchange and advise on further steps. This group was made up of a diverse range of stakeholders, including service user representatives, healthcare professionals and service providers. To inform the development of the National Standards, the Authority conducted a national representative poll in Summer 2010 asking members of the public for their opinion on the important areas of quality and safety in healthcare. The Authority also consulted with other national and international regulatory organisations and hosted and attended a series of meetings with a range of interested parties to present the concepts and background to the National Standards. To facilitate stakeholder engagement and participation in the development of the National Standards, the Authority published a draft version of the National Standards (the Draft Standards) in September 2010 for public consultation. The public consultation ran for six weeks until November 2010.

Timeframe implementation Consultation process - 21 months A total of fourteen Standards Advisory Group Meetings took place between June 2009 and March 2011. A national representative poll took place in July 2010. A national public consultation on the National Standards took place over 6 weeks from September – November 2010.

Implementation tools available For ease of use and to facilitate the widest participation from all possible stakeholders in the consultation process the Draft Standards were produced in a variety of accessible formats including: • Full text A4 version • Easy to read A5 guide • Audio versions (iTune, MP3 and CD-ROM formats) A consultation feedback form was developed in order to assist people to make a written submission. All documents were publicly available in downloadable formats on the Authority’s

195

website. Respondents could also provide general feedback via email, post or telephone. General comments were also invited through the Authority’s Facebook and Twitter webpages.

Implementation cost Around €42,000 Costs included: • Production of the Draft Standards in various formats (including A4 and A5 hard copies and audio versions) • Additional print run of A5 version was required in response to demand • Public opinion poll conducted by market research company on behalf of the Authority

RESULTS:

Method used to measure the results A consultation feedback form was developed in order to assist people to make a written submission on the Draft Standards. This was publicly available in downloadable format on the Authority’s website. A paper copy was also available on request. This form contained specific feedback questions relating to: • Language, layout and design of the standards • Themes in the Draft Standards • Suitability of standards to be used as the basis for licensing of the healthcare system • Applicability of the draft standards to all healthcare settings • Guidance development • Role of standards in ensuring evidence based clinical practice.

Results A total of 216 submissions were received as part of the consultation process. Of the 216 respondents, 172 (80%) completed feedback forms while the remaining 44

(20%) made written submissions without using the form. The majority of respondents (79%) submitted their responses by email, 12% by online survey and 9% by post.

Of the 216 submissions, 162 were made by organisations while 54 were from individuals. These individual submissions were made by service users, the general public and individual healthcare professionals.

Analysis of the results The majority of submissions welcomed the Draft Standards and provided positive, supportive feedback. Respondents said that the language, layout and design of the Draft Standards was clear and easy to follow. The majority of respondents said that the Draft Standards covered all the important quality and safety topics and that they were a good basis for licensing. Respondents thought that the Draft Standards could be applied to all the healthcare settings mentioned but that more specific guidance and detail would be needed for the different services to which they apply. Respondents agreed that the Draft Standards would support evidence-based practice.





OTHER INFORMATION:

Other information about the GOP that you would like to add The level of engagement and interest of service users, the general public, service providers and other stakeholders in the public consultation on the Draft Standards was very encouraging and was very important in informing the finalisation of the National Standards. The Authority undertook a thematic analysis of all submissions received to determine the main feedback from the public consultation. A summary and analysis of these submissions was published as a Statement of Outcomes on the Authority’s website www.hiqa.ie The feedback received was used to inform the finalisation of the National Standards. The National Standards were submitted to the Minister for Health for approval in May 2011 and were launched in June 2012.

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As a result of feedback from the public consultation process, general guidance to complement the National Standards was also developed and published in September 2012. The purpose of the guidance is to facilitate service providers in understanding and adopting the National Standards in the Irish healthcare system and to provide a common understanding and language for service users, service providers and the public as to how the National Standards will apply across all healthcare services.

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National Mental Health Services Collaborative (NMHSC)

GOP Information:


Organisation sharing the GOP Mental Health Commission



GOP Description:


CLINICAL SETTING: There was a diverse set of sites in mental health services, covering inpatient, community, adults, children, urban and rural communities.

OBJECTIVES: To: 1.Implement an evidence approach to care planning 2.involve service users & carers 3.generate key change ideas & utilise data collection tools 4.Fulfil statutory requirements 5.Implement standards - Quality Framework 6.Evaluate the process. 7.Develop & implement a spread strategy

POPULATION: Mental Health Services

METHODS:

Methodology The NMHSC adopted a model of collaborative learning developed by the Institute for Healthcare Improvement (IHI), whose aim is to improve health care by supporting change. The Breakthrough Series is designed to assist organisations create a structure in which interested organisations can learn from each other and from experts in topic areas where they want to make improvements. A Collaborative is as a short-term learning system that brings together a large number of teams to seek improvement in a focused topic area. As far as we are aware this was the first time this methodology has been used within an Irish mental health care setting. The ‘Breakthrough Collaborative Approach’ adopts an inclusive approach that ensures service users, carers, clinicians and health professionals are involved throughout the entire process and the learning component of the collaborative provide opportunities for capacity building in relation to sustaining and spreading innovations in health care.

Timeframe implementation 18 months

Implementation tools available During the course of the collaborative, several datasets were collected by local project groups and shared nationally. Statistics as to the numbers of care plans issued, and the proportions demonstrating service user and/or carer involvement A written questionnaire, completed by service users, administrated with the support of the Irish Advocacy Network. The instrument was developed specifically in consultation with service users and clinical leads. A self-assessment survey of team functioning, completed by local project team members Self-assessment ratings against the “Pillars of Recovery Service Audit Tool”

Implementation cost 400k

RESULTS:

Method used to measure the results Independent Evaluation

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Results An evaluation report presents the findings of an independent evaluation of the National Mental Health Services Collaborative (NMHSC).

Analysis of the results There was strong and influential service user and carer involvement. This evaluation has found that the NMHSC made progress towards its objectives. No unusual features emerged about the Irish context which suggest that an approach differing from the established IHI model would be more likely to succeed; indeed, the importance of closer compliance with the IHI model has emerged more strongly from this experience.



Please describe implementation barriers: The NMHSC was also founded on a series of compromises, in the sense of departures from the IHI Breakthrough model which enabled it to happen at all. These were: The diversity of the sites The use of non-volunteer sites The emphasis on multidisciplinary, rather than medical leadership

Describe the strategies used to overcome the barriers (If needed)Shortened learning set.

OTHER INFORMATION:

Other information about the GOP that you would like to add An evaluation report presents the findings of an independent evaluation of the National Mental Health Services Collaborative (NMHSC).

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Open disclosure following adverse events in healthcare.

GOP Information:


Organisation sharing the GOP Health Service Executive (HSE) and the State Claims Agency (SCA).



GOP Description:


CLINICAL SETTING: Acute hospitals.

OBJECTIVES: The project objective is to provide training and support for doctors and other healthcare professionals to support them in engaging in the open disclosure process with a view to the development of a national guidance document and national policy on Open Disclosure.

POPULATION: Doctors and other healthcare professionals working in acute hospitals in Ireland.

METHODS:

Methodology 1. Project leads were identified in the HSE and SCA. 2. A national project team was established. 3. Two acute pilot sites were identified. 4. Initial Executive Management Board meetings to undertake proposal sign up and

commitment to the project. 5. Awareness session delivery on site. 6. Open disclosure training on site. 7. Follow up meetings with various applicable committees e.g. Quality and Risk / Governance

Committees. 8. Ongoing supports from HSE and SCA project leads.

Timeframe implementation 2 year pilot programme – 2010 – 2012. The pilot ended in October 2012 and the current emphasis is on the development of a national guidance document and policy in relation to Open Disclosure. Work has already commenced with several hospital sites in Ireland and on the national implementation strategy.

Implementation tools available Awareness sessions delivered on site. Open disclosure training delivered on site.

Implementation cost Not known

RESULTS:

Method used to measure the results Internal evaluation: All training and awareness sessions delivered by the national leads were evaluated using a feedback evaluation form addressing specific aspects of both session types. External evaluation: An external healthcare consultant was employed by the SCA to undertake the evaluation of year 1 of the project. It is anticipated that the overall project will be externally evaluated by a recognised leader / body in open disclosure. This is currently being scoped.

Results Feedback regarding the training and awareness sessions delivered. An external evaluation of year 1 of the pilot project was also undertaken.

Analysis of the results • A clear commitment from both pilot sites to implement Open Disclosure

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• A lack of understanding of what is meant by Open Disclosure • Staff support following adverse events need to improve • Leadership paramount • Lack of training • Uncertainty regarding what to disclose • Fear regarding the area of apology



Please describe implementation barriers: • Time constraints for staff to attend sessions • Leadership visibility issues The roll out of Open Disclosure across all healthcare organisations is planned and the learning from the pilot programme will be incorporated into the national implementation strategy regarding same.


OTHER INFORMATION:

Other information about the GOP that you would like to add The Open Disclosure project is more than a pilot, it is also a change management project that requires a significant cultural shift. The roll out of Open Disclosure across all healthcare organisations is planned and the learning from the pilot project will be incorporated into the national implementation strategy regarding same.

201

Institutional Program for the Optimization of Antimicrobial Treatment (PRIOAM)

GOP Information:


Organisation sharing the GOP Directorade of Quality, Research, Development and Innovation Andalusian Regional Ministry of Health and Social Welfare

Member state Spain


GOP Description:


CLINICAL SETTING: Andalusian Public Health System Hospitals

OBJECTIVES: 1. Optimize the use of antimicrobials in the hospital. 2. Reduce mortality of patients with severe infections. 3. Reduce morbidity of patients with severe infections. 4. Reducing bacterial resistance. 5. Reduce economic costs.

POPULATION: program directed towards all antibiotic prescribers of Andalusian Public Health System

METHODS:

Methodology Design and implementation: Step 1: Institutional agreements Step 2: Constitution of a multidisciplinary operations team Step 3: Elaboration of local guidelines Step 4: PRIOAM implementation Step 5: The main activity of the program consists on a training program directed towards all antibiotic prescribers of the center based on counselling interviews Step 6: Improvement of antimicrobial prescription.

Timeframe implementation The program began in January 2011, implementation in 3 years

Implementation tools available Guidelines, training program, PRIOAM advvisors

Implementation cost Not quantificated

RESULTS:

Method used to measure the results Not Available at this time

Results 1006000€ saved in a year in the pilot Hospital

Analysis of the results Not Available at this time





OTHER INFORMATION:


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203

National Decontamination Programme for management of reprocessable invasive medical devices (RIMD)

GOP Information:


Organisation sharing the GOP Health Service Executive - Quality and Patient Safety Directorate



GOP Description:


CLINICAL SETTING: Central Decontamination Units Endoscope Reprocessing Units Central Decontamination Units (dental) Local Decontamination Units (dental)

OBJECTIVES: The objective of the Programme is to ensure that National Standards developed for reprocessing medical devices, are aligned to International best practice, the programme and Standards development provides the assurance that Decontamination Units develop risk assessments and controls to ensure both staff & patient safety. POPULATION: Decontamination personnel, microbiologists, infection prevention and control personnel.

METHODS:

Methodology Specify National Standards for Decontamination of RIMD Support the system to attain the Standards (training/recommended practices) Provide evaluation tools to assess units against the Standard requirements / development of Quality Improvement Plans and performance indicators

Timeframe implementation Continuous process of evaluation

Implementation tools available National Standards for Decontamination of RIMD Supports for the system to attain the Standards (training/recommended practices) Standard requirements / development of Quality Improvement Plans and performance

indicators

Implementation cost Not known

RESULTS:

Method used to measure the results Not yet applicable

Results Not yet applicable

Analysis of the results Not yet applicable





OTHER INFORMATION:

Other information about the GOP that you would like to add Information on the National Decontamination Programme for management of Reprocessable

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invasive medical devices is available at the following link: http://www.hse.ie/eng/about/Who/qualityandpatientsafety/Quality_and_Patient_Safety_Documents/Deccont_RIMD.html

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Health Websites Accreditation Programme (HWAP)

GOP Information:


Organisation sharing the GOP Andalusian Agency for Healthcare Quality (ACSA), Andalusian Regional Ministry of Health and Social Welfare

Member state Spain

Topic Accreditation

GOP Description:


CLINICAL SETTING: Public and private Health Websites

OBJECTIVES: To improve health websites by verifying the web pages reliability in relation to information contents, connectivity and services provided to users.

POPULATION: Websites of: • Public or private providers of health care • Health sector agencies, including intergovernmental, governmental or non-governmental ones • Patient or support groups • Scientific Societies and Professional Associations • Equipment or research on health issues• Others

METHODS:

Methodology The HWAP based continuous improvement on self-assessment. This self-evaluation fosters internal reflection by the certification process responsible on clear HWAP standards and evidences, in order to verify the existence and subsequent implementation on its website standards and evidence collected in the program. The Agency provides a web-based software tool (ME jora W). Created to support the certification process it allows: to access the content of the HWAP, to see examples and references relating to standards and evidence, to facilitate the development of self-assessment and customize the process, and to establish contact with the Agency to resolve doubts. The standards refer to the following dimensions websites quality: User Rights, Information Management, and Health Content and services as part of the System Center Healthcare. The accreditation granted is valid for two years.

Timeframe implementation With the methodology developed and supported by the ME jora W web-based application, it can be piloted in approximately 6 months.

Implementation tools available Accreditation Manual (2) ME jora W web-based application, which is used throughout the application process, self-

assessment, evaluation and monitoring of the accreditation process.

Implementation cost Defining a Standards Manual: 5000 € ME jora W web-based application license: 50000 € Translation of the application ME jora W: 50000 € Evaluator Training: 10000 € Process certification website: 260 €

RESULTS:

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Method used to measure the results Descriptive studies Analysis of users satisfaction

Results total of 86 health websites are in the process of accreditation, with the following distribution: • 19 sites under development, pending acceptance. • 27 sites under self • 3 sites under evaluation • 11 pending stabilization web pages of the first evaluation standards • 26 accredited health websites (3) Users indicate that: • The Accreditation Program promotes continuous improvement • Increases user confidence in the Website (4)

Analysis of the results In a manner consistent with the methodology that includes self-assessment, the results confirm that the program promotes continuous improvement of Health websites





OTHER INFORMATION:

Other information about the GOP that you would like to add The Andalusian Agency for Healthcare Quality (ACSA) was founded in 2002 as part of the strategy promoted by the Ministry of Health of the Government of Andalusia to improve and ensure quality health care for citizens. Hitherto, the Agency has established and implemented its own model of accreditation, and it has designed a series of accreditation programs as tools for continuous improvement and serving security professionals and citizens, as well as establishing a methodology that facilitates its application in practice maximizing their results. Certification of Health Websites responds to Andalusian institutional commitment with the European initiatives to ensure the rights of citizens, and in this sense, this Accreditation Program reflects the spirit of the document of the Commission of the European Communities, "eEurope 2002 . Quality criteria for web sites related to health, from November 29, 2002. " 1.http://www.juntadeandalucia.es/agenciadecalidadsanitaria/programas_de_acreditacion/paginas_web_sanitarias/el_programa_de_acreditacion.html 2.http://www.juntadeandalucia.es/agenciadecalidadsanitaria/programas_de_acreditacion/paginas_web_sanitarias/el_manual_de_acreditacion.html 3.http://www.juntadeandalucia.es/agenciadecalidadsanitaria/resultados_de_acreditacion/paginas_web_sanitarias/situacion_actual.html 4.http://www.juntadeandalucia.es/agenciadecalidadsanitaria/resultados_de_acreditacion/paginas_web_sanitarias/resultados_evaluacion.html

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Risk management through an incident reporting system without damage

GOP Information:


Organisation sharing the GOP Gerencia Regional de Salud de Castilla y León. Department of Health in Castilla y León

Member state Spain


GOP Description:



OBJECTIVES: 1. - Developing safety culture 2. - Promote learning from the mistakes and introduce barriers to prevent recurrence

POPULATION: Hospital professionals

METHODS:

Methodology 1. - Project planning (8 stages) 2. - First stage. Development of tools:

1) SISNOT: general notification system, voluntary, anonymous incident unharmed local management (at the hospital or unit). The system has a structure based on the taxonomy of the WHO. The application is accessible to any professional through the intranet without the use of keys and has four user profiles: notifier, unit manager,hospital manager and manager of best practices regionally. The application supports the entire risk management process (notification, notification management, incident analysis, management and reporting enhancements for feedback) 2) material for the training of managers, 3) training material for professionals units, 4) incident analysis tool (London Protocol)

3. - Second stage. Management training (safety culture, Reason risk theory , incident analysis, management reporting system) 4. - Third phase. Professional Training unit by unit managers (culture of safety and incident reporting with sisnot) 5. - Fourth phase. Implementation. Incident analysis, and prioritization of proposed improvements to be made 6. - Fifth phase. Feedback through periodic meetings in the unit (incidents reported, contributing factors and improvements to be made) 7. - Phase Six. - Project evaluation through indicators (no. notifications,% analyzed,% incidents that result in improvements) and perception study (usefulness and ease of use)

Timeframe implementation Six months

Implementation tools available General notification system, voluntary, anonymous incident unharmed local management (at the hospital or unit)

Implementation cost Working time of managers dedicated to the analysis of incidents

RESULTS:

Method used to measure the results Indicators obtained from the application

Results515 notifications made 42% with high potential damage

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68% of closed generate notifications improvements

Analysis of the results Although only reported incidents don´t have involved damage, 40% would have caused significant damageif they had reached to the affected patient or even another patient. The system is effective for improvement to avoid the repetition of incidents



Please describe implementation barriers: 1. - Fear of medicolegal repercussions 2. - No value added visibility 3. - Time dedicated professionals needed to manage the system

Describe the strategies used to overcome the barriers (If needed)Designing a system without damage incidents Inclusion of feedback as a critical point of the project Using a software project that supports the entire process of risk management Participation as managers of professionals who know how to drive their units and can perform a more agile notifications Using a simple tool for analysis in 10-15 minutes allows the analysis of an incident without damage

OTHER INFORMATION:


209

Reporting and Learning System.

GOP Information:


Organisation sharing the GOP The National Agency for Patients' Rights and Complaints

Member state Denmark


GOP Description:


CLINICAL SETTING: The Act requires frontline personnel to report adverse events, the institution managers to act on the reports, and The National Agency for Patients' Rights and Complaints to communicate experience from the reports.

OBJECTIVES: The purpose of the Reporting and Leaning System is to gather, analyse and communicate knowledge of adverseevents in order to reduce the number of adverse events in the Danish health care system.

POPULATION: The entire health care system.

METHODS:

Methodology The system is designed as a bottom-up process where the majority of the work is locally rooted. The point is that adverse events that are rooted locally should be analysed and corrected locally. This is also thought to have a considerable impact on the development of a safety culture. The analysis and risk assessment of an adverse event are typically performed locally by the head of the department where the adverse event occurred. This is often done in cooperation with the department’s patient safety officer and the hospital’s risk manager, as well as with frontline personnel and representatives from middle management. On the basis of the local analysis the adverse events are reported to the regional and national level to ensure further learning at these levels.

Timeframe implementation Approximately 1.5 years if you start from scratch.

Implementation tools available A web-based system accessible to all.

Implementation cost About 1 million euros in initial costs. This does not include resources for receiving and analyzing reports.

RESULTS:

Method used to measure the results No formal evaluation yet.

Results The Reporting and Learning System have resulted in an increased focus on adverse events and hence patient safety. On this background a number of initiatives about patient safety and quality of care have been initiated locally and regionally. A formal evaluation is planned for end of 2013 / beginning of 2014.

Analysis of the results See above.



Please describe implementation barriers: Only of a technical nature. Health care staff had a great understanding of the value of learning from their own mistakes - and to spread the knowledge to the rest of health care system.


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OTHER INFORMATION:


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Self-evaluation and improvement under the EFQM model

GOP Information:


Organisation sharing the GOP Gerencia Regional de Salud de Castilla y León. Department of Health in Castilla y León

Member state Spain

Topic Other

GOP Description:


CLINICAL SETTING: Managers of hospitals and primary care

OBJECTIVES: 1. - Promote a culture of management based on total quality 2. - Promote self-evaluation using the EFQM periodically as a reference 3. - Introduce improvements that respond to the opportunities for improvement identified

POPULATION: Leaders of hospitals and primary care managers

METHODS:

Methodology 1. - Inclusion as an strategic objective of the Regional Health Service 2. - Project design and tools (development of training material for reviewers, acquisition of Perfil to use software tool for self-evaluation, design guidance for the preparation of the set of documents that could be useful for the evaluation, configuration recommendations of the evaluation team and help guide for self-evaluation with examples of the health sector at the level of sub-criterion) 3. - Collection of centers interested in participating in the project 4. - Identification of the evaluation team and project coordinator at each center 5. - Formation of the evaluation team (EFQM self-evaluation and methodology) 6. - Preparation of material to be used during the evaluation 7. - Individual self-assessment 8. - Consensus and elaboration of self-evaluation report 9. - Prioritization of areas for improvement to develop within 2-3 years

Timeframe implementation Eight months

Implementation tools available Guide for self-evaluation with examples of the health sector

Implementation cost Time evaluation team

RESULTS:

Method used to measure the results Indicators implantation: % Managers starting the project % Managers who perform self-evaluation % Managers who develop improvement plan

Results % Managers starting the project: 90% % Managers who perform self-evaluation:25%(rest under development) % Managers who develop improvement plan: 25% (rest under development)

Analysis of the results The inclusion of self-evaluation as a strategic objective is facilitating the development of a management culture based in EFQM model and implementing improvements that contribute to the sustainability of the health system

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Please describe implementation barriers: 1. - Experience in the model evaluation team 2. - Time devoted to self-evaluation

Describe the strategies used to overcome the barriers (If needed)Training sessions Computer application of the self-help Help guides with examples of health sector Support and advice through collaborative group developed the intranet

OTHER INFORMATION:


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PCAI: Programa Clinico de antecion Interdisciplinar: Clinical program for the interdisciplinar care

GOP Information:


Organisation sharing the GOP The Consejeria of Sanidad (Regional Health Authority)

Member state Spain


GOP Description:


CLINICAL SETTING: Primay health care and specialized care

OBJECTIVES: To provide care with the highest evidence adapted to the conditions of the region

POPULATION: Health care workers ( MD, nurses, psychologists, social workers) and patients

METHODS:

Methodology Fourteen areas susceptible of clinical improvement were indentifies as a result of the Health Care Plan 2004-2007. With the assistance of a quality consultancy 14 groups of well accepted professionals from the public sector were assembled as to develop with an explicit methodology the PCAI. Once the document was approved, the Health Authority demanded the SESPA, the health service of Asturias, to implement the PCAI. For this doing in each one of the health regions (8 in total) a responsible was designated for each PCAI and Committee inter level was created and a Quality Commission inter level. To develop the protocols working groups were assembled. For each PCAI a series quality and performance indicator was defined

Timeframe implementation The project started in 2004 and the implementation started in 2009. This same year a revision of the PCAI was put in place, ending in 2012.

Implementation tools available There were three plans: Operational Plan: Definition of task for each professional involved, and the resources

needed for the implementation, Management Plan: definition of the organizational structure, and knowledge needs; and Communication Plan: to communicate the new work methodology and how to implement it

Implementation cost The project cost were those of the consultancy, the edition of the PCAI. On the other side, the work done by the professinals was not renumerated.

RESULTS:

Method used to measure the results Measurement of results through the indicators that are included in the program contract with the center or unit.

Results There are too many indicators as there are 14 PCAI and too many units. There are five dimensions each one with several indicators: Accessibility and continuity of care; patient centered care; effectivity of care, security and appropriate resource utilization Analysis of the results Every new program contract evaluates the achievements in order to propose new goals and objectives for eacha PCAI and each clinical unit.



Please describe implementation barriers: The organizational inertia, the problems with the coordination inter level, scarcity of resources in some areas and knowledge and skill problems

Describe the strategies used to overcome the barriers (If needed)Education. A new model of organization were primary ans specialized care are integrated was developed.

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OTHER INFORMATION:

Other information about the GOP that you would like to add The process in itself is very interesting as the participation of the professionals in the definition of goals, standards and criteria reinforces the health care system

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Accredited program for continuing education (CE) for dentists

GOP Information:


Organisation sharing the GOP Austrian Dental Chamber



GOP Description:


CLINICAL SETTING: Dental offices in Austria

OBJECTIVES: To guarantee the standard of CE for dentists and to maximise the number of CE diploma

POPULATION: Dentists established in Austria

METHODS:

Methodology 1. All events concerning CE for dentists have to be accreditated by the Chamber. 2. Credit points depneding on the content and time frame of the event are defined. 3. Dentists participating at CE events are reported to the Chamber. 4. - Credit points are registered per dentist by the Chamber. 5. - Dentists who have reached a certain amount of credit points (120 at the moment) get a diploma for CE.

Timeframe implementation ~ one year

Implementation tools available Data base has to be establisked Communication between Chamber and organisers of events has to be secured.

Implementation cost ~ € 100.000 + annual costs of ~ € 50.000 (personnel and technical costs).

RESULTS:

Method used to measure the results Comparison between the situation from before introducing the program and the situation afterwards concerning the number of dentists completing the CE diploma program.

Results Nowadays ~ 50% of dentists have got a diploma for CE compared to ~ 20% before the introduction of the program.

Analysis of the results The program helped to increase the rate of CE diploma among dentists significantly.





OTHER INFORMATION:


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Arbitration body for patient complaints

GOP Information:





GOP Description:



OBJECTIVES: To handle patient complaints and to avoid high costs for patinets and dentists which would arise if civil courts would handle all patient complaints.

POPULATION: Dentists established in Austria and patients treated by them

METHODS:

Methodology 1. - Establish arbitration bodies on regional and national level composed of representatives of dentists and patients. 2. - Patients have the opportunity to yield their complaints directly at the arbitration bodies in their respective region. 3. - Arbitration bodies decide about the complaints. 4. - Patients and dentists are both free to accept the decision. 5. - If either patient or dentist do not accept the decision complaint will be handled by the arbitration body on national level. 6. - Patients and dentists are both free to accept the decision. 7. - If either patient or dentist do not accept the decision civil courts can be appealed.

Timeframe implementation ~ one year

Implementation tools available 1.Nomination of members of arbitration bodies. 2.Internal rules for arbitration bodies have to be defined. 3. - Procedures for the handling of complaints have to be defined.

Implementation cost ~ € 50.000 per year.

RESULTS:

Method used to measure the results Comparison of the number of complaints going to court.

Results Court cases concerning patient complaints could be reduced. ~50% of the cases were decided by the arbitration bodies in favour of the patients, 50% in favour of the dentists involved. Analysis of the results Results show that the arbitration bodies seem to be successful in getting fair decisions.





OTHER INFORMATION:


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218

Program for Quality Assurance

GOP Information:





GOP Description:



OBJECTIVES: To evaluate the quality of dental care

POPULATION: Dentists established in Austria

METHODS:

Methodology 1. - Program defines various indicators concerning the quality of dental care. 2. - Every single dental office has to evaluate their quality by using the indicators. 3. - The results of the evaluation are controlled by the program via random inspections. 4. - Certificates about positive evaluation are issued. 5. - Reevaluation starts every 5 years using the same procedure.

Timeframe implementation ~ 18 month

Implementation tools available 1. - Database has to be established. 2. - Personnel for the inspections and for administration has to be trained. 3. - Scientific input for the definitionof indicators has to be collected (and financed).

Implementation cost ~ € 180.000 for the circle of 5 years

RESULTS:

Method used to measure the results Analysis of the data base

Results~ 95% of dentists got certificates about positive quality evaluation

Analysis of the results Quality of dental care was raised significantly especially concerning structure- and processquality





OTHER INFORMATION:


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Patient questionnaire

GOP Information:


Organisation sharing the GOP British Dental Association



GOP Description:


CLINICAL SETTING: Dental practices

OBJECTIVES: Gauge patient experiences for the purpose of improvement of quality of service

POPULATION: Patients of dental practices

METHODS:

Methodology Provision of patient questionnaires to patients of the dental practice to consider and evaluate general or specific areas of practice.

Timeframe implementation Dental practices will set their own individual timeframes.

Implémentation Tools avalable Patient questionnaire

Implementation cost No information

RESULTS:

Method used to measure the results Evaluation of resulting feedback by dentist and practice team Results Consideration of results will be individual to the dental practice depending on the survey used, and may lead to changes made in aspects of their practice.

Analysis of the results This will take place in individual dental practices



Please describe implementation barriers: One problem could be non-response from patients.

Describe the strategies used to overcome the barriers (If needed)Sending reminders encouraging them to respond by a specific time.

OTHER INFORMATION:

Other information about the GOP that you would like to add n/a

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Patient Safety Toolbox Talks

GOP Information:


Organisation sharing the GOP Health Service Executive - Dublin North East



GOP Description:


CLINICAL SETTING: This initiative is targeted at all clinical settings in both acute and community settings

OBJECTIVES: To identify a practical solution relating to the delivery of patient safety messages within the workplace. To ensure that the solution could be embedded into daily work routine of staff.

POPULATION: This initiative is aimed at all staff working within clinical or care settings, acute and non-acute.

METHODS:

Methodology In developing this initiative relevant subject experts were invited to participate in the development of the talks. The subject experts submitted the talk content, a standardised format was applied and the talks were then returned to subject experts for sign-off.

Timeframe implementation This initiative will be fully implemented regionally by mid 2013. There is interest in also implementing nationally.

Implementation tools available Guidance, training PowerPoint and prompt cards for the safety talks.

Implementation cost 500 copies of the folders inclusive of talks and guidance have cost €11k. This includes 35 talks and it is intended to expand the number of talks in 2013.

RESULTS:

Method used to measure the results Piloted and evaluated using focus groups and a structured questionnaire.

Results Staff found the tool box talks provided sufficient information which was “clear” and presented in a “Step by Step” manner. The main finding was that it helped to reinforce and reminded staff of previous training they had received and it was not conflicting. The managers found the design very good and visually well presented on the handout and that the layout was logical and easy to follow. The principles of safe and correct practice were clearly outlined and that it was easy to interpret the information to suit your target audience.

Analysis of the results The evaluation showed that both staff and managers agreed there was a value in introducing this concept as it was a quick way of keeping staff up to date and appraised. It was noted that the talks were quick and the staff stated they could focus on the presentation without been duly concerned about what work was left which they would have to catch up on. The managers suggested it reinforced standards and could be used as a way of introducing new practices. They suggested that this also assisted to emphasize their role as a manager and leader.





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OTHER INFORMATION:

Other information about the GOP that you would like to add Toolbox talks are short, discussions or presentations (5-10 minutes) designed to be delivered in the work place i.e. at team meetings or huddles. They are designed to be capable of being delivered by line managers to their staff i.e. do not require a subject expert to deliver. They are generally focused on one specific topic which the talk addresses in simple terms. While it need not be about a safety topic, it is not uncommon for safety to be the topic. Toolbox Talks are aimed to provide the opportunity for a line manager to emphasize the importance of a particular patient safety issue or procedure within the workplace, and for staff to ask questions or make constructive comment.

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Patient safety e-learning

GOP Information:


Organisation sharing the GOP Hospitals

Member state Finland


GOP Description:


CLINICAL SETTING: Hospitals and primary health care. OBJECTIVES: For leaders, teams and individuals working in healthcare organisations Patient safety e-learning offer training and skills for effectively managing operative risk and human errors.

POPULATION: All health care professionals

METHODS:

Methodology The e-learning program, comprising ten modules, was launched in 2012 and is estimated to have over 200 000 users in Finland by 2014. The program is a corner stone of the national patient safety strategy. Collaboration with Huperman Oy has generated exceptional and distinctive patient safety training, which emphasises Finnish knowhow in the field of healthcare.

Timeframe implementation 2011 development and make a pilot in some hospitals 2012 - 2014 implementation 2015 measurement

Implementation tools available Together hospitals patient safety professionals and training centres.

Implementation cost 300.000 euros/3 years In hospitlas 1 day/professional (work contribution)

RESULTS:

Method used to measure the results Quantitative

Results All health professionals (100%) has basics at patient safety since beginnig of 2015.

Analysis of the results In national level.





OTHER INFORMATION:

Other information about the GOP that you would like to add www.thl.fi/potilasturvallisuus

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http://www.potilasturvaportti.fi/

Self audit system and practice

GOP Information:


Organisation sharing the GOP Hungarian National Blood Transfusion Service


Topic Clinical audit.

GOP Description:


CLINICAL SETTING: Blood establishments and the transfusion department of hospitals.

OBJECTIVES: The Quality System is based on Good Manufacturing Practice in transfusion services.All activities are involved in the QS e.g. audit. Quality Manuals have been prepared for steps of processing and examinations in blood banks. Audit protocols are issued to control the work at every levels.

POPULATION: staff in different levels

METHODS:

Methodology Since 2003 our service has a systematic, well defined, periodicaly repeated audit system, that has been published in our standards. Each of the auditor prepare a plan for the new year, and at the end of the year they have to finalize their program and send a report into the QA-QC Dept. The detected mistakes or non-conformance event can not be solved by the staff at regional level, the departments of headquaters are responsible for repairing the mechanisms.


Implementation tools available To present some lectures about our audit system. To give a technical manual according to the EU directives, the national regulations and the principles of quality methods. To visit our service to see the details of audit practice (from planning to finalise the report).

Implementation cost Very low.

RESULTS:

Method used to measure the results To prepare indicators.

Results Collection of the non-complaince reports, Measuring of the knowledge of the staff (test), Cost effective process

Analysis of the results Statistical analysis, Risk analysis,





OTHER INFORMATION:


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nothing

National Patient Safety Program (in Dutch: VMS Veiligheidsprogramma)

GOP Information:


Organisation sharing the GOP Various hospitals involved in the GOP

Member state Netherlands


GOP Description:


CLINICAL SETTING: All Dutch hosptials have committed to this national program

OBJECTIVES: To reduce preventable adverse events by 50% after five years of the National Patient Safety Program through the implementation of ten clinical topics and the implementation of a Safety Management System in all Dutch hospitals

POPULATION: All hospitals in the Netherlands and their patients

METHODS:

Methodology For each of the ten themes, information guides were made by experts. The guides contained information on the theme, the goals of the theme, the way to accomplish these goals and structure, process and outcome indicators by means of which to determine the degree of implementation. The guides were published by the office of the national patient safety program. This office spread the guides in Dutch hospitals and they assisted the hospitals in the implementation of the guides by organizing national theme days, providing a call center, etc. All hospital boards committed to the program and the hospitals were stimulated to implement each of the themes and the safety management system. Timeframe implementation Five years was given to the hospitals for proper implementation. Some hospitals needed less time, others required more.

Implementation tools available Theme guides are available, as is a website. NIVEL conducted the evaluation study of the program, for the themes evaluated an evaluation protocol is available.

Implementation cost ?

RESULTS:

Method used to measure the results Method used to measure the results*Checklists and registration forms were used to measure the outcomes of the ten themes. Themes were evaluated by means of observations, interviews or patient record review, whatever method best fitted the theme.

Results Most themes show an improvement, nation wide, however non of the themes achieved the individual theme goal set on a national level. Large differences have been observed among hospitals, whereas some hospitals were close to achieving the theme related goals, others lagged behind.

Analysis of the results longitudinal prospective study Data was analysed on national level, multilevel analysis was used to see whether there had been significant improvement over time.

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Please describe implementation barriers: Overall barriers were: no sense of urgency, not being able to show effects of results within the hospital, discussions about the contents of the themes, lot of registration in addition to patient care, multidisciplinary themes are more difficult to implement, non-competent theme holder and no clear implementation process in which responsibilities and tasks are divided, little support from professionals, medical doctors and/or hospital board, lack of time, resources, ICT, were all mentioned as barriers to implementation. In addition, theme specific barriers were identified.

Describe the strategies used to overcome the barriers (If needed) Planning of and support of the implementation process Competent and knowledgable theme leader and project group with clear tasks and responsibilities Clear goals, for which results can be shown over the course of the implementation process

OTHER INFORMATION:

Other information about the GOP that you would like to add Results on the ten themes will be made public by the end of April 2013

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GOP Information:


Organisation sharing the GOP The Netherlands Institute for Accreditation in Healthcare (NIAZ)


Topic Accreditation

GOP Description:


CLINICAL SETTING: Total Dutch healthcare field

OBJECTIVES: The Netherlands Institute for Accreditation in Healthcare (NIAZ) offers a contribution to the assurance and improvement of the quality of health care, in particular by developing quality standards and by using them in the external evaluation of health care institutions and health care services, resulting in a judgment in the form of an accreditation that gives third parties - health care consumers, health care insurers, collaboration partners, government agencies and society in general - assurance that healthcare is being produced in an adequate and safe way. POPULATION: all Dutch healthcare institutions can apply for accreditation, it is voluntary but there are strong external pressures to have an accredited quality system. Therefore the majority of hospitals have a NIAZ accreditation.

METHODS:

Methodology The NIAZ accreditation process has several distinct features: an internal survey system within the healthcare organisation, a self assessment report, a primary review of this by the survey team, a survey followed by a survey report, the making of an improvement action plan by the surveyed organisation and a follow up check by NIAZ to see whether progress is made. The first step after applying for an accreditation consists of making a self assessment report by the healthcare organisation that is to be surveyed . NIAZ in the mean time puts together a survey team tailored to the organisation that is to be surveyed. This team assesses the self assessment report and decides whether the organisation is ready for having the survey visit performed. Often this stage sees the gathering of more specific information. Or the organisation is advised to work on some organizational aspects before the next steps in the procedure are to be taken. An important demand of NIAZ is that the organisation has an internal survey system. Meaning that each and every department within the organisation must on a regular basis be surveyed by internal surveyors - independent from the department that they survey. NIAZ in its own assessment builds on this internal survey system. When the survey team gives the green light the survey visit is planned. The survey team will then for a number of days investigate the organisation on site. The size of the survey team and the number of days is dependent on the size and complexity of the organisation that is to be surveyed . Varying from 2 surveyors for 2 days for a very small institution to 9 surveyors for 5 days for a large one. In all cases an extensive investigation is carried out. The survey team beforehand makes a random sample of departments and processes that will be scrutinized. During the survey visit other organizational units may be investigated without prior warning. Safety aspects are always an important issue. According to the accreditation agreement the healthcare organisation must give the surveyors free and unlimited access to all places and all information deemed relevant for the assessment proceedings. Of course with due respect for privileged information because of privacy concerns. All staff members that the surveyors will want to interview must cooperate.

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As soon as possible after the survey visit the survey team draws up a draft survey report. This comprises the findings of the team and identifies opportunities for improvement that need to be addressed by the healthcare organisation. This draft is sent to the organisation for factual correction. After this step the report goes to the College for Quality Certificates. This body will judge whether the healthcare organisation qualifies for being granted an accreditation status. If the decision is negative or if the College decides that a postponement of the decision is in order it advises the Executive Board, which is ultimately responsible. An organisation that does not agree with a decision taken by NIAZ may appeal to the College of Appeal. This body also deals with other complaints a surveyed organisation might have. The healthcare organisation makes a mandatory improvement action plan showing what it will do with the suggestions made by NIAZ. About a year after the accreditation decision NIAZ will again visit the organisation with a small survey team in order to assess the progress that is being made.

Timeframe implementation The length of the process of acquiring accreditation depends on the hospital (resources available etc.). Once the hospital has acquired accreditation, the entire cycle repeats itself every 4 years. Implementation tools available NIAZ uses the General Quality Standard for Healthcare Organisations. This is regularly updated and acquires a version number accordingly. On the basis of NIAZ' General Quality Standard for Healthcare Organisations the organisation analyses its organizational set-up (e.g. strategies, policies, procedures, protocols) in order to assess whether it complies with the NIAZ standard. This extensive process usually yields a lot of improvement opportunities, many of which are fairly quickly implemented.

Implementation cost Unknown, it depends on the hospital how much time and manpower they need to invest in the accreditation process.

RESULTS:


Results External evaluations result in a report, that is written by the auditors that involves a judgment about the quality system of the hospital. Regardless of the judgement (positive/negative) it is published on the NIAZ website giving third parties information about whether healthcare is being produced in an adequate and safe way in that particular hospital.

Analysis of the results The auditors write a report based on findings during their visits, the report gives a recommendation about whether the hospital should receive accreditation or not. When there is a negative advice, the report states the aspects that need to be improved before the hospital can apply for accreditation again.


Did you find implementation barriers? The process of accreditation can cost the hospital a lot of time and manpower.



OTHER INFORMATION:


http://en.niaz.nl/niaz-general-quality-standard-healthcare-organisations-2.3

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HKZ

GOP Information:


Organisation sharing the GOP HKZ: Harmonization of Qualityjudgement in Healthcare


Topic Accreditation

GOP Description:


CLINICAL SETTING: 30 subbranches of Care and Welbeing field

OBJECTIVES: HKZ aims to improve qualith in healthcare and wellfare. Norms are being set concerning qualith and safety for over 30 subsectors in the care and welfare field.

POPULATION: Complete care and welfare field

METHODS:

Methodology In 1996 the Harmonization model for external quality judgement was developed, and updated in 2008. This model is based on the Plan-Do-Check-Act cycle of quality improvement. In addition, the Harmonization model identifies five elements that an organization should pay specific attention to, in which certain quality activities have to be performed and that should logically link to one another to achieve continuous quality improvement. These elements are: Organizational policy, Professionals, Development, Physical environment, Purchase, and Documentation and registration. External inspectors judge the implementation of this model and accompanying activities, in case of proper implementation, organizations with a ISO-9000 certificate.

Timeframe implementation This is very much dependent upon the current state of the organization with respect to quality improvement. Whereas some organizations might be ready for external inspectors to evaluate the implementation of the model within months, others might need more than a year.

Implementation tools available The Harmonization of Quality Judgement in Health care organization offers detailed guidelines and insight in the norms that the health care organization will be tested upon in order to qualify for the ISO9000 certificate.

Implementation cost Costs of adapting the health care organization to the norms and harmonization model are dependent upon the current state of the organization with respect to quality improvement. Costs for external inspectors to judge the degree of implementation of the model and the norms costs in a first extensive certification audit are 1000-1200 Euro/inspector. Dependent upon the size of the organization, more or less inspectors and more or less days are needed for this first audit.

RESULTS:

Method used to measure the results During the audits, external inspectors follow the harmonization model and accompanying norms in order to judge the quality of the quality management system. By means of a sample of patient files, and interviews with professionals, it is tested to what extend the norms have been implemented and are being followed. Results In the Netherlands, more than 3000 health care organizations in 30 subsectors already have got the HKZ ISO 9000 certificate. These organizations continuously improve their processes, know the needs and requirements of their customers and work with well trained professionals.

Analysis of the results In 2003, the HKZ Harmonization model was found to be valid (scientific

229

research by Erasmus University Rotterdam).


Did you find implementation barriers? YES

Please describe implementation barriers: For some organizations, the costs might be high. Implementation requires a culture change: processes have to be lived up to

Describe the strategies used to overcome the barriers (If needed) Many organizations ask for external advice, some consultancy firms offer guidance in the implementation of the Harmonization model.

OTHER INFORMATION:


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DiliGuide

GOP Information:


Organisation sharing the GOP CBO CBO is the reference institute, the benchmark in terms of quality of care. As an (inter)national centre for expertise and innovation in the field of quality of care in the Netherlands and Europe, CBO works with a wide range of strategies, taken from both healthcare and other sectors.



GOP Description:


CLINICAL SETTING: total healthcare field

OBJECTIVES: The CBO provides access to their guidelines using the online tool DiliGuide (www.diliguide.nl). Difference with Wikipedia is that updating is performed by professionals who know their field well. Information is updated under the supervision of the scientific associations. E-learning modules are available.

POPULATION: professionals, patients and developers of medical guidelines

METHODS:

Methodology No method is provided, Diliguide is a platform on which guidelines can be searched for, but also can be updated by groups of professionals who are assigned this function. Timeframe implementation Diliguide was developed by CBO, implementation does not cost time for individual organizations or professioals, they can use the information that is provided by Diliguide right away.

Implementation tools available Diliguide is a webbased platform, organizations or professionals need internet access only to search for guidelines. When a professional or group is developing a guideline, an access code is required in order to access the guideline one is working on. Implementation cost No costs are involved to look up guidelines. For CBO, costs are involved to keep the platform up to date.

RESULTS:

Method used to measure the results Results have not been analyzed.

Results Guidelines are readily available for large groups of professionals, but also for patients, free of charge. Groups of professionals who have the tasks to update guidelines on a national level, use the platform to share ideas and versions of the guidelines.

Analysis of the results Results has not been analyzed.





OTHER INFORMATION:

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Patient complaint legislation

GOP Information:


Organisation sharing the GOP Dutch governement



GOP Description:

IMPLEMENTATION LEVEL: National/ obliged by law

CLINICAL SETTING: total care field

OBJECTIVES: The patient complaint legislation health care field is a Dutch law that was implemented in 1995. The law contains the rights of patients and one aspect of this law is the complaining procedure for clients when they want to report a complaint about a health care institution.

POPULATION: all patients / representatives

METHODS:

Methodology This law describes the complaint procedures and in particular the rights of patients when they have a complaint and the procedures that need to be followed by the health care institution and health care inspectorate.

Timeframe implementation The law was implemented in 1995 for all health care organizations.

Implementation tools available The contents of this law are publicly available.

Implementation cost The implementation costs of this law are unknown.

RESULTS:

Method used to measure the results An evaluation study was carried out in 2012 mapping the current status of the implementation of the law, and suggestions for improvements of the law (NIVEL, 2012)

Results Every patient has the right to complain about health care services, and every health care institution must appoint a complaint coordinator.

Analysis of the results The law has been evaluated and suggestions for improvement were made (NIVEL, 2012)


Did you find implementation barriers? None



OTHER INFORMATION:


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Stepwise visitation

GOP Information:


Organisation sharing the GOP CBO


Topic Audit system

GOP Description:


CLINICAL SETTING: total health care field

OBJECTIVES: A visitation is a structured method used to define opportunities for improvement within the circumstances under which colleages execute their work. CBO developed a step wide plan for conducting visitations. Visitation focus on one discipline and the external peer review is carried out by colleagues from other institutions in the same discipline.

POPULATION: clinical, unidisciplinary teams in health care organziations

METHODS:

Methodology Visitation is udes widely in the selection and monitoring of speciallity medical training. However, external peer review has also been developed to focus on clinical practice, professional development and service quality. Visiting teams are mostly clinical and often unidiosciplinary. Standards tend to be derived implicitly from practice guidelines and personal experience. Reports are not available to the public (Shaw, 2000) CBO developed a model for visitationthat is used to guide the visitation process. And CBO offers training for visitation.

Timeframe implementation Dependent upon the size of the organization and the status with respect to quality improvement methods

Implementation tools available training by CBO

Implementation cost Costs of training and time investement.

RESULTS:

Method used to measure the results Quality standards and the CBO model are used to measure the results, results of the visitation are written down in reports that are not publically available.

Results To improve clinical practice, professional development and service quality.

Analysis of the results CBO model and Quality standards are used to guide the visitation.





OTHER INFORMATION:


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Advanced Nurse Competence: Protocolized monitoring individualized drug treatment (Collaborative Prescription) by nurses in the Andalusian Public Health System

GOP Information:



Member state Spain


GOP Description:


CLINICAL SETTING: Primary Care Hospital Care

OBJECTIVES: • To Ensure continuity of care and patient safety • To improve accessibility of patients and / or caregivers • To improve Health Effective management and fulfillment with the therapeutic plan • To encourage a Shared Demand Management • To optimize service times, the use of professional resources and appropriate use of medicines

POPULATION: Chronic patient monitoring in nursing consultation and / or home care with prescribed drug therapy. Collaborative Prescription is based in protocol defined. Protocols allow nurses variations of the treatment prescribed, based on criteria of evidence and proper use of medication

METHODS:

Methodology • Pharmacological Monitoring protocol design • Training and Professional Accreditation • Implementation of the practice in Andalusian Health System Centers (communication plan, adequacy of tools for monitoring: Medical Records-prescribing module ...) • Integration of the practice in the daily life interventions


Implementation tools available Pharmacological Collaborative Monitoring Protocols: • Oral anticoagulation • Diabetes • Cardiovascular Risk (Antihypertensive and Lipid) • Palliative sedation • Chronic Pain (in press) • Communication plan • Medical Records-prescribing module

Implementation cost Design and digital publication of monitoring protocols for collaborative nursing prescription: 6,000 euros Accredited Training (22 Activities for 430 nurses): 30,000 euros Accreditation process to professional advanced competence: , 0 Adapting Digital History and information systems for recording and tracking: 8,000 to 10,000 euros

RESULTS:

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Method used to measure the results Results of the implementation process: • Monitoring data Training • Advanced Competence Accreditation System in the Andalusian Agency for Healthcare Quality (ACSA) Results430 Nurses performed accredited training (22 accredited training) 72 nurses have completed the accreditation process to implement collaborative prescribing.

Analysis of the results These nurses are already serving in consultation with more than 40% of patients that could be followed in collaborative prescribing protocols implemented. According to data obtained by the registration system of integrated care processes, it is estimated that the number of patients eligible for referral for drug monitoring by nurses are approx. 18,000 Chronic patients (January 2012) The review and analysis of results is performed periodically by Management Care Strategy of Andalusia / ACSA Review of the implementation process to improve the accessibility of professional training process and streamline the accreditation to expand the number of accredited



Please describe implementation barriers: Training and accreditation system: need to improve accessibility to training and streamline the accreditation process for advanced competence in collaborative prescribing by nurses • Recording System: Review the Digital prescribing Module in the patient history (Diraya) to improve functions that enable the development and proper monitoring of the practice.

Describe the strategies used to overcome the barriers (If needed)Ongoing review of results by the Andalusian Care Strategy Direction Evaluation of the first phase of implementation and design phase 2 beside the review of: The Implementation and development of the Practice Process: communication plan to the centers, training and accreditation process, monitoring indicators and registration system and data mining.

OTHER INFORMATION:

Other information about the GOP that you would like to add This practice involves the collaboration of nurse practitioners with medical professionals and dentists from the Andalusian Health System in programs of Protocolized monitoring individualized drug treatment (Decree 307/2009) The prescription of medical devices from nurses aims to improve the accessibility and continuity of care for both patients and caregivers, providing comprehensive care, optimizing the time of care and resource use . This practice is based on therapeutic criteria of scientific evidence demonstrated, efficiency and teamwork.

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INTEGRATED CARE Process Management

GOP Information:

GOP NUMB 103 - GOP ID: 130


Member state Spain


GOP Description:


CLINICAL SETTING: Primary care Hospital care

OBJECTIVES: Promoting continuous improvement, with the participation of professionals, with the aim of generating a response to perceived quality citizenship.

POPULATION: Population Andalusian

METHODS:

Methodology Integrated care processes are a tool for quality improvement to facilitate the work of professionals and clinical management. Detailed in the itinerary of the patients, all actions, decisions, activities and tasks that are linked sequentially in your care, care for a specific reason. Its design is based on flow analysis activities, ensuring continuity of care, clinical effectiveness and taking into account patients' preferences.

Timeframe implementation Management strategy for integrated care processes began in Andalusia in 2000. At the moment it is implemented throughout the Community

Implementation tools available • Situation analysis: identify existing problems in order to establish those improvements that are necessary to proper implementation of the activities, to establish the role and training needs of professionals and, if it was necessary, the adequacy of training them, optimizing existing resources, the incorporation of new technologies, etc.. • Degree of priority needs: categorize competing needs, prioritizing by importance, • Define opportunities of improvement and establish a permanent circle of continuous improvement. • Local adaptation: existing conditions • Recording and evaluation systems

Implementation cost The implementation of BP no specific cost, is included in the welfare activities of the professionals They contemplate additional training costs and any resource adequacy.

RESULTS:

Method used to measure the results Coverage per Process Compliance monitoring quality standards defined in each process

Results actually over 60 integrated care processes implemented in Andalusia Expand information later if required

Analysis of the results Expand information later


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OTHER INFORMATION:

Other information about the GOP that you would like to add http://www.juntadeandalucia.es/salud/channels/temas/temas_es/P_3_POLITICAS_Y_ESTRATEGIAS_DE_CALIDAD/P_3_PROCESOS_ASISTENCIALES_INTEGRADOS

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Advance Nurse Practice in Case Management of patients with complex chronic diseases and high care needs

GOP Information:


Organisation sharing the GOP Directorade of Quality, Research, Development and Innovation.

Member state Spain


GOP Description:


CLINICAL SETTING: Primary Care Hospital Care

OBJECTIVES: • To ensure continuity of care and coordination between the different levels (hospital and community care) • To ensure interventions that reduce attendance at hospitals and health centers and readmission rate. • To work in coordination with the social network and community health • To advise on care within care teams

POPULATION: People included in home care program with clinical complexity; hospitalized with health situations of sudden appearance, assuming change in living conditions and family environment, with advanced chronic pathologies, patients in the end of life situation, lack of self care with inadequate support, caregivers of the target population

METHODS:

Methodology • • Definition of Case Management Model in Primary Care and Hospital: Mission, goals, target population, service portfolio ..... • Institutional Dissemination. • Training Plan for Case managers nurses • Program selection and hiring profiles. • Definition of "dashboard" to monitor service outcomes • Adequacy of systems on the Health History • Practice Accreditation by the Healthcare Quality Agency of Andalusia • Integration of this practice in the geriatric field, social and health context


Implementation tools available • Case Management Model Guide published by the Ministry of Health and Welfare. • Requirements for selection of candidates. • Basic courses for Case managers nurses • Professional Accreditation Guide. • Adequacy of Patient Digital History Implementation cost Design guides and its digital publishing: 1,500 euros. Initial training for 96 nurses: 6,000 euros Recruitment: 2.016 million euros (Initial: 96 nurses in Andalusia / 8 million inhabitants) Advanced Practice Accreditation: 0 euros for public health system professionals

238

Adapting Digital History and information systems: 8,000 to 10,000 euros

RESULTS:

Method used to measure the results Annual evaluation and comparative dashboard between centers. Research Study multicenter controlled Quasiexperimental: ENMAD. Professional accreditation level by the ACSA Results • Annual dashboard evaluation and BENCHMARKING intercenter • Research Quasiexperimental, controlled and multicenter Study: ENMAD Study • Professional accreditation level by the Healthcare Quality Agency of Andalusia

Analysis of the results Case Management Service: • Improve patient autonomy for "Immobilized patient" at home and hospital discharges patients. • Improve the activation of service providers. • Decrease overload caregiver • Improve the institutionalization Index in elderly patients • Improve the management of therapeutic plan for patients and caregivers • Reduce the number of readmissions and hospitalizations.



Please describe implementation barriers: Poor return information through the records in digital history

Describe the strategies used to overcome the barriers (If needed)Expert Panel created to discuss registration systems and propose amendments. (In process)

OTHER INFORMATION:

Other information about the GOP that you would like to add The increase in vulnerabilities (old age, chronic illness, comorbidity, frailty ...) forces to design strategies to ensure continuity of care in increasingly fragmented systems. Case management is a collaborative process through which advance practice nurses in the Andalusian Health Service value, plan, implement, coordinate, monitor and evaluate the options and services required to meet the health needs of a person, coordinating communication and available resources to promote results quality and cost-effective. It is a process to identify problems, design an intervention plan and coordinate activities with professionals and families involved. In this process the nurse case manager sails for the patient to achieve the targets set in their care plan, mobilizing the necessary resources and ensuring a comprehensive and continuous care that meets the needs of the patient and caregiver.

239

On-line training program in patient safety

GOP Information:


Organisation sharing the GOP Directorade of Quality, Research, Development and Innovation.

Member state Spain


GOP Description:


CLINICAL SETTING: Primary care, hospital care and EMERGENCIES

OBJECTIVES: Offering an online training program on patient safety common to all healthcare workers in Andalusia.

POPULATION: All healthcare workers in Andalusia

METHODS:

Methodology Development of an online training platform. Development of training contents in patient safety in four levels: Level 1: Health workers (healthcare support workers, social workers, …) Level 2: Professionals healthcare Level 3: Clinical leaderships Level 4: Managers, Chief Excecutives


Implementation tools available Elearning Moodle platform, patient safety materials (videos, slides…)

Implementation cost 300.000 €

RESULTS:

Method used to measure the results Knowledge questionnaire Satisfaction questionnaire

Results 59 Managers 182 Clinical leaders 2087 Healthcare professionals 383 Health support workers Total 2711

Analysis of the results 90% of respondents are very satisfied





OTHER INFORMATION:


240

Health Care Professionals' (HCP) licensing

GOP Information:


Organisation sharing the GOP Agency - HALMED

Member state Croatia

Topic Professional licensing

GOP Description:


CLINICAL SETTING: Complete Health Care sector (for example hospitals, GPs, pharmacies,etc.

OBJECTIVES: -raising awareness of adverse drug reactions (ADR) reporting • establishing good reporting practices among HCPs • motivating HCPs to report ADRs through continuing professional education (CPE) certification system (CPE points)

POPULATION: HCPs

METHODS:

Methodology Awarding HCPs CPE points for ADRs reporting

Timeframe implementation If stakeholders are interested and willing to participate - arround 2 months

Implementation tools available • contracts with professional Chambers • resources to keep track of reporters' credit points

Implementation cost Half administrative person/day

RESULTS:

Method used to measure the results Increase in number and quality of ADR reports

Results Number of ADR reports in Croatia (2005. - 2011.) Year 2005. 2006. 2007. 2008. 2009. 2010. 2011. Medicines 336 579 655 611 776 983 1831 Vaccines 162 194 192 654 389 331 191 Since 2007 Medical Chamber increased the value of credit points from 0,5 to 2 and in 2006 Chamber of Pharmacy started with awarding credits to pharmacists.

Analysis of the results Number of ADRs reported by medical doctors increased significantly and the share of ADR reports from pharmacists increased from 0 % in 2005 to 25 % in 2011.



Please describe implementation barriers: Restriction from the Chamber of Pharmacists in the maximum number of credit points which can be awarded to a single pharmacist per year.

Describe the strategies used to overcome the barriers (If needed)Ongoing negotiations with the Chamber representatives.

OTHER INFORMATION:


241

Inspection protocols for verification of compliance with the quality requirements to the Centers for procurement, processing, storage, distribution and implantation of human

tissues and cells.

GOP Information:


Organisation sharing the GOP Healh Services Inspection Andalusian Regional Ministry of Health and Social Welfare

Member state Spain

Topic Inspection

GOP Description:


CLINICAL SETTING: Establecimientos de tejidos. Centros de obtención e implante de los distintos tejidos a nivel hospitalario

OBJECTIVES: Assess compliance with the requirements and the implementation of quality control measures required by RD 1301/2006, of 10 November on the premises or tissue banks, as well as obtaining Units and implant of cells and tissues of Andalusia. This nationally RD transposes the following directives, including: 2004/23/EC, 2006/86/EC, 2006/17/EC, 2001/20/EC.

POPULATION: Users and practitioners of these types of centers.

METHODS:

Methodology RD 1301/2006, of 10 November, establishes standards of quality and safety for the donation, procurement, testing, processing, preservation, storage and distribution of human tissues and cells. Defines the tissue establishment (ET) as one where activities of processing, storage or distribution of tissue after collection and to use in humans. Center performs the collection and extraction of tissues or cells. And Implant Center, which has been operating as the application of human tissue in humans. Inspections of these centers can be extraordinary or scheduled, initial and periodic breaks, etc.. The RD provides a general inspection and initial full each ET and then every four years, every two years and subject to verification of reinspections rectify anomalies. The methodology used is similar to that of an audit

Timeframe implementation Six months, requires prior training of inspectors

Implementation tools available As tools are used protocols and annexes (with rules and evidence) of the following: • "protocol inspection of tissue establishments", • "inspection protocol for tissue procurement units" and "units calibration certificate tissue implant ". They are designed to assess the activity of the same, in both public and private

Implementation cost Cost of training of inspectors,

RESULTS:

Method used to measure the results After applying the protocol, a report is to be submitted to the center inspected, it may make submissions to it, and also to develop a remedial plan mandatory anomalies detected. Is considered adequate if it meets these conditions: • Meet more than 80% of the applicable requirements in the protocol. • Does not breach any condition affecting critical processes. • From detected some unfulfilled requirements for major deficiencies, but susceptible of

242

correction, it was considered that the adaptation was conditional on the correction, or immediately after the implementation of a remedial plan to short notice, specifying if necessary, reinspection.

Results Were inspected in 2011, 7 tissue establishments and 32 units of production (16) and implant (16) eye tissue existing in 17 public hospitals and one private school. In 2012, 68 units were inspected for obtaining (28) and implant (40) of bone-tendon, located in 30 public hospitals and 9 private hospitals.

Analysis of the results The centers evaluated in 2011 (ET and procurement centers and ocular tissue implant) have obtained favorable inspection reports, considering that these have adaptation, despite having detected unfulfilled requirement, given that comply with a percentage higher than 80% applicable requirements and have not been detected critical deficiencies, and significant deficiencies detected in some center have been rectified immediately. Those evaluated in 2012, have obtained favorable inspection reports, except one center obtaining t. bone implantation and t 5. bone, for deficiencies related to the operating license and traceability.





OTHER INFORMATION:


243

Inspection protocols for verification of compliance with the quality requirements for centers and transfusion services.

GOP Information:


Organisation sharing the GOP Healh Services Inspection Andalusian Regional Ministry of Health and Social Welfare

Member state Spain

Topic Inspection

GOP Description:


CLINICAL SETTING: Regional transfusion centers and area. Hospital transfusion services.

OBJECTIVES: Assess compliance with the requirements and implementation of quality control measures required by RD 1088/2005,: technical requirements and minimum conditions and blood donation centers and transfusion services RD 1343/2007, by establishing standards and specifications for quality system of centers and transfusion services. Incorporates the provisions of Directives 2002/98/EC and 2004/33/EC.

POPULATION: Users and practitioners of these types of centers.

METHODS:

Methodology Transfusion Centre is one where activities are carried out the collection and testing of human blood or blood components, and distribution when intended for transfusion. And transfusion service, to that linked to a transfusion center, and under the responsibility of a medical specialist in hematology and hemotherapy, which stores blood and blood components for transfusion, and where you can perform compatibility testing of blood and components . Royal Decree 1088/2005 establishes the biennial inspection transfusion centers, so that has developed a specific program that includes inspection of compliance with the requirements applicable to such centers, with finding the unambiguous identification and traceability blood components. The methodology used is similar to that of an audit

Timeframe implementation Six months, requires prior training of inspectors

Implementation tools available As tools are used protocols and annexes (with rules and evidence) of the following: "inspection protocol transfusion centers" and "inspection protocol transfusion service." They are designed to assess the activity of the same, in both public and private.

Implementation cost Cost of training of inspectors,

RESULTS:

Method used to measure the results After applying the protocol, a report is to be submitted to the center inspected, it may make submissions to it, and also to develop a remedial plan mandatory anomalies detected. It is considered appropriate if: • Meet more than 80% of the applicable requirements in the protocol. • Does not breach any condition affecting critical processes. • From detected some unfulfilled requirements for major deficiencies, but susceptible of correction, it is considered that the adaptation is contingent on the remedy, immediately or after implementation of a remedial plan to short notice, specifying where appropriate reinspection. Methodology used is similar to an audit

Results We have inspected the seven blood centers in Andalusia, in 2008, 2010 and 2012. In each evaluation, have been reduced by unfulfilled requirements rectify anomalies. Of these, the

244

most important are those derived from failures that affect the organization and operation of the QMS. In addition, we inspected 28 transfusion services of public hospitals and 18 private hospitals, analyzing the traceability of 575 units of blood and blood products in 2008, with follow-up in 83% of 575 units in 2010, up by 93% cases and 650 units in 2012, with follow-up in 94%.

Analysis of the results Overall, transfusion centers evaluated in 2008, 2010 and 2012 have obtained favorable inspection reports, considering that they have adequate, despite detection of unfulfilled requirements since met with a percentage higher than 80% of the applicable requirements and not been found critical deficiencies and significant deficiencies detected in some center have been rectified immediately, or after implantation of a remedial action plan in the very short term, specifying if necessary, reinspection





OTHER INFORMATION:


245

IMPLEMENTATION OF PERCEIVED QUALITY COMMITTEES in hospitals in the Madrid Health Service

GOP Information:


Organisation sharing the GOP Madrid Health Service

Member state Spain


GOP Description:


CLINICAL SETTING: 35 hospitals

OBJECTIVES: OBJECTIVE: To improve the perceived quality of citizens. SPECIFIC OBJECTIVES • Improve customer satisfaction and companions with the process of care received • Raise awareness among employees about the importance of the user's opinion on the quality improvement. • Promote quality culture within the organization, taking into account the user's perspective.

POPULATION: Professional health centers

METHODS:

Methodology 1. - Preparation of a paper on Recommendations for the Implementation of the Committees on Perceived Quality Madrid Health Service which includes guidance on the composition, functions and implementation of the Committees. 2. - Inclusion in the annual program contract hospitals following quality objectives: Constitution Committee (2009) and development of the same lines of action (2010 and beyond). 3. - Annual Celebration Conference on the contribution of Perceived Quality Committees to continuous improvement of hospitals

Timeframe implementation 2009: Constitution of Committees in each of the hospitals 2010: Launch of the Committees (at least 3 meetings) Years 2011 and up to the present: Implementation of at least four courses of action each

year

Implementation tools available Available document Recommendations for the Implementation of the Committees on Perceived Quality Madrid Health Service. Annual Contract objectives Madrid Health Service with each hospital

Implementation cost No one can estimate a direct cost. In terms of resources, requires part-time participation of a multidisciplinary team, which at least has the management team representative, unit quality, patient service, the medical, nursing area and management area among others.

RESULTS:

Method used to measure the results Evaluation through indicators of program contract hospitals and report of each hospital with description of guidelines developed

Results100% of hospitals have formed the Committee. The analysis of the views of users, along with the information provided by the center workers have allowed Perceived Quality Committees lines have driven improvement in areas of: improving information to patients and family formation professional collaboration with the

246

community, etc. In the years 2011 and 2012 were developed respectively: 181 and 176 lines of action. These actions are complemented by monitoring the actions set by the centers as a result of the annual survey of satisfaction of users of the Madrid Health Service. Analysis of the results -The establishment and implementation of the committees in all hospitals, comprising multidisciplinary professionals, has proved an operational tool for improving the perceived quality. It serves as a collection area, debate and analysis of problems related to the quality perceived by users and guests and also to prioritize, identify and propose actions to improve the perceived quality





OTHER INFORMATION:


247

HAND HYGIENE IMPROVEMENT IN HEALTH CENTERS OF MADRID COMMUNITY

GOP Information:



Member state Spain


GOP Description:


CLINICAL SETTING: Primary care (269 Health centers) and 35 hospitals

OBJECTIVES: Improve compliance with hand hygiene through implementing a multimodal strategy following the PDCA improvement cycle and based on leadership, assessment, development of training strategies and constant communication and return information to professionals

POPULATION: The target population of the project were not health professionals and health in contact with patients in health centers of Madrid Health Service primary care and specialty care

METHODS:

Methodology Describe GOP Methodology The six phases established to develop deployment centers were: 1. - Preparation: identifying responsible for hand hygiene in schools, groups and key people. Total: 300 professionals. 2. - Analysis and diagnosis: first observational study of compliance before the intervention (collected 18,197 hand hygiene opportunities), perception questionnaires to managers (total: 600) and professionals (total: 6000) and knowledge (total: 6000). 3 and 4. - Implementation and enforcement: developing awareness and outreach materials (25,000 units), course design with hand hygiene play-learning methodology, with 10 issues each year. 5. - Evaluation Phase: second observational study of hand hygiene compliance intervention (collected 19,496 hand hygiene opportunities) 6. - Learning and improvement: identifying strengths and areas for improvement

Timeframe implementation Years 2010-2012 to complete the 6 stages of development

Implementation tools available • Document deployment strategy for hand hygiene in Madrid Health Service, which includes several tools to support implementation (surveys, outreach materials, etc.) • Online Program Accredited hand hygiene: with 8 units of learning and a practical part with a simulation game.

Implementation cost Project funded by the territorial cohesion funds for 2009 from the Ministry of Health and Social Policy, to support the implementation of the Strategy on Patient Safety National Health System. Total cost: € 175,000

RESULTS:

Method used to measure the results • Study observation before and after the intervention • Analysis of perception surveys and knowledge • Course evaluation reports on-line hand hygiene • Structure and process indicators agreed with the Ministry of Health

Results-

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The observational study of 2011, compared with 2010 study shows that compliance with hand hygiene has increased in the three care levels analyzed. Hospitals: 38.1% (in 2011) and 30.8% (year 2010), primary: 35.8% (in 2011) and 22.2% (year 2010)

In the various editions of the online course of the years 2011 and 2012, has trained more than 6,000 professionals. The surveys measured satisfaction with the tool show that students in a high percentage recommend the course to other professionals and learned it has application in the workplace

Analysis of the results Compliance with hand hygiene has increased in the Madrid after implementing this improvement cycle. We have a comprehensive intervention to motivate and make lifestyle changes to increase compliance, thanks to a methodology and interactive virtual simulation welfare activities as a game is a suitable tool and widely accepted. Changing habits hand hygiene passes have a strategy that integrates multimodal aspects such as leadership, assessment, training and awareness and benchmarking sustainably over time.



Please describe implementation barriers: Low patient safety culture and resistence to change


OTHER INFORMATION:


249

Implementation of Environmental Management Systems in accordance with the UNE EN ISO 14001:2004, hospitals Madrid Health Service.

GOP Information:



Member state Spain


GOP Description:


CLINICAL SETTING: The project was implemented in 36 hospitals of Madrid Health Service, at different levels and service portfolio, which showed great heterogeneity in terms of the stages of implementation of Environmental Management Systems.

OBJECTIVES: The project's objectives are: a) To promote and support the implementation of environmental management systems, b) Promote environmental indicators homogeneous c) Strengthening the activities of the institution its commitment to the environment.

POPULATION: The target population of the project is all professionals of 36 hospitals, as well as users of these facilities as part of our commitment to the environment.

METHODS:

Methodology This project aimed to implement Environmental Management Systems according to the UNE EN ISO 14001:2004, results based on different actions and the information obtained through a questionnaire broad and comprehensive environmental review, aimed at all hospitals Madrid Health Service (year 2011). This provided a situation analysis specific environmental management in these centers, establishing working groups for different stages of development. For each group defined specific actions by providing tools and ongoing technical advice, this has led to progress in the implementation process and the unification of environmental indicators. A common methodology framework was applied to implement Environmental Management System under UNE EN ISO 14001:2004. Formalizing four work groups which involved experts from hospitals (n= 36) from Madrid Health Service, as its implementation stage. We have developed a systematic and demand technical advice as required deployment group and specific work tools. Also institutional support through various reinforcing actions: information, documentation, environmental awareness, and establishment of technical committees, such as those on "Environmental Indicators" and "Environmental Management Technical Committee."

Timeframe implementation The estimated time for the proper implementation of this project, in accordance with established work schedule, is two to three years.

Implementation tools available The main tools available for this project are: databases initial review environmental documentation (rules, procedures, records, instructions, etc. Of environmental management systems) in different media (intranet, paper, electronic); presentations develop training, tabs and records of environmental indicators.

Implementation cost It is estimated the cost of implementation in 2 hours a month of dedication from the management team (environmental management committee), and 8 hours per week by the responsible environmental management.

RESULTS:

Method used to measure the results To measure the results have been considered: a) Compliance with annual targets set by the Madrid Health Service for 36 hospitals. b) The comparison between the baseline as to the stages of implementation of the

250

Environmental Management System and environmental indicators to final status.

Results The results have been: The percentage of certified hospitals in the UNE EN ISO 14001:2004 has increased from

22.86% to 31.43%; 31, 43% of hospitals that were initial stage have advanced stage towards the

implementation of the system, Agreement was reached ten key environmental indicators, unifying its formulation, on initial

variability eighteen formulations for the same indicator, Institutional support actions (intranet corporate, technical committees and creating

environmental awareness) have contributed to the results.

Analysis of the results There is a major step forward in the implementation of environmental management systems. We need to consider the different types of schools, their heterogeneity in the development of environmental management, and lack of human and financial resources. It is essential institutional commitment promoter element of all actions, to display information tools, training, measurement, and monitoring, which should be accessible to schools and eminently practical.



Please describe implementation barriers: • Staff training • Technical qualifications and profile of responsible environmental management.

Describe the strategies used to overcome the barriers (If needed) • Development of training activities in the centers, and availability intranet. • We have developed a technical assistance to all hospitals, providing concrete tools and practical work. • Have been named responsible for environmental management in the 36 hospitals.

OTHER INFORMATION:


251

National Disease Management Guidelines Programme (NDMG-Programme)

GOP Information:


Organisation sharing the GOP Agency for Quality in Medicine (AQuMed)

Member state Germany


GOP Description:


CLINICAL SETTING: NDMGs are to be implemented in ambulatory care, hospitals and longterm care. The settings depend on the individual guideline, however primary care is a major focus as the guidelines target prevalent chronic diseases. The guidelines are meant to be implemented as widely as possible in these facilities; implementation is voluntary. OBJECTIVES: To promote effective delivery of health and disability services within the framework of disease management in Germany, based on best available evidence from research and practice.

POPULATION: Clinicians working in the health care sector (physicians, nurses, therapists), patients and their families, health care adminstrators, general public

METHODS:

Methodology The development and maintenance of the guidelines are coordinated by AquMed in collaboration with the Guidelines Commission of the Association of the Scientific Medical Societies in Germany. The individual guideline groups are further made up of experts from the relevant scientific medical societies, experts representing other professional groups (nurses, pharmacists, physiotherapists etc) and patient representatives. Process steps in the development of an NDMG are: • topic selection and prioritisation • development of the draft guideline and formulation of recommendations according to a standardized methodology • formal consensus process to finalize the guideline’s recommendations • external review of the guideline • finalization of the guideline and online publication • development of a patient version and implementation tools from the guideline • development of quality indicators from the guideline recommendations • dissemination and implementation of the guideline

Timeframe implementation Average timeframe for guideline development: 3,5 years

Implementation tools available For each guideline the following implementation tools are developed: • short version & pocket version • patient version (“patient guideline”) • supplementary tools (e.g. checklists) • quality indicators which are developed from the guideline’s recommendations • software app • CME based on the guideline Implementation cost Duration and costs of NDMG development process: Example: NDMG for Diabetic Neuropathy in Adults Duration of development: 244 weeks

252

Material and staff costs: approx. 195.365 EUR Example: NDMG for Heart Failure Duration of development: 157 weeks Material and staff costs: approx. 138.535 EUR

RESULTS:

Method used to measure the results The most important components of the evaluation process are guideline-based quality indicators. Suitable quality indicators are derived by AquMed from the NDMG recommendations in collaboration with experts. The use of the indicators to evaluate adherence to the guidelines and an improvement of patient outcomes e.g. within Disease Management Programmes or the German nation-wide quality assurance programme (e.g. hospital-benchmarking system) is encouraged. Until now the evaluation of the NDMGs has not been in the direct scope of responsibilities of AquMed but projects to evaluate some of the NDMGs regionally by AquMed are in planning .

Results See below

Analysis of the results Results from the evaluation of ambulatory Disease Management Programs, which integrate the recommendations from NDMGs, have shown positive results in terms of changes in medical outcomes (Stock et al. The Commonwealth Fund 2011;24(1560)). enerally studies have shown that evidence-based clinical guidelines can be effective in improving the process and structure of care. The effects of guidelines on health outcomes have been studied less and data are less convincing (Lugtenberg et al. Qual Saf Health Care 2009;18:385–392)



Please describe implementation barriers: A barrier in the development process is that it is often difficult to reach consensus when formulating recommendations and this can delay the development of a guideline. he development and maintenance of a clinical guideline are resource-intensive (esp. staff costs for the coordinating institution). further barrier to implementation is that there are still scepticism and limited acceptance in the medical community about clinical practice guidelines.

Describe the strategies used to overcome the barriers (If needed)Raising awareness about the importance of guidelines and capacity building in evidence-based medicine.

OTHER INFORMATION:


253

"Reporting and learning system for patient safety, called SiNASP”. There is the acronym of the name in Spanish: Sistema de Notificación y Aprendizaje para la Seguridad del

Paciente.

GOP Information:


Organisation sharing the GOP Cantabrian Health Service

Member state Spain


GOP Description:


CLINICAL SETTING: In Cantabria it has been implemented in all the Hospitals in the Cantabrian Health Service (3 hospitals in total).

OBJECTIVES: The objective of this learning and reporting system is to improve patient safety from the analysis of situations that caused or could have caused damage to patients. The study of these problems is carried out in order to encourage the necessary changes so these problems do not happen again.

POPULATION: All health professionals in our hospitals that identify an incident related to patient safety may report it.

METHODS:

Methodology It is a voluntary reporting system and guarantees the confidentiality of the notifications. The notifiers have the option to remain anonymous or give their details, which are automatically removed from the system a few days later. It is not punitive, since the purpose is for improvement and implementation of corrective actions. Management and notifications analysis is done locally (in each hospital) and not regionally. In each centre there is a SiNASP manager and a security group that is responsible for the analysis and management of notifications.

Timeframe implementation About 3 or 4 months until the system is up and running

Implementation tools available There is an Internet application where notifications are made and managed. We have designed a plan for professional training.

Implementation cost We do not know the cost of implementing in Cantabria, as the necessary tools for the implementation of the GOP were provided by the Ministry of Health, without any cost to the region.

RESULTS:

Method used to measure the results We have a set of indicators to monitor the use and operation of the reporting system

Results From the date of implementation of SiNASP in Cantabria (May 2012), we have managed 144 reported incidents, and in more than 70, we have implemented improvements actions

Analysis of the results Every three months each Hospital issues a report that lists the following information: number of reported incidents and incidents managed; classification of incidents taking into account different variables: the area where the incident occurred, the profession of the notifier, the type and risk of the incident, and contributing factors. At regional level a report is produced with aggregated data and performs benchmarking with other regions that use the same reporting system (SiNASP)



Please describe implementation barriers: The main barrier is a lack of safety awareness which is a cultural problem. Another problem is the fear of legal consequences by professionals.

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Although it has been said that this is a voluntary reporting system and anonymous, and whose purpose is not punitive, but to improve.

Describe the strategies used to overcome the barriers (If needed)Training and information for professionals.

OTHER INFORMATION:


255

Accreditation of hospitals

GOP Information:


Organisation sharing the GOP The National Commission for Accreditation

Member state Romania

Topic Accreditation

GOP Description:


CLINICAL SETTING: hospitals

OBJECTIVES: • to promote safety behaviors and quality within the hospitals’ services; • to induce the governance focused on patient and employee; • to introduce strategic services planning and risk management

POPULATION: Hospital considered as a whole organization, delivering healthcare and hotel services: medical staff and, subsequently, patients.

METHODS:

Methodology The external assessment provided by trained evaluators, based on predefined standards and criteria, using the check lists, direct observation of different services, inquiring after the experience and satisfaction of the patient and staff.

Timeframe implementation Two years for preparation and capacity building; for proper implementation of the accreditation program there is no significant experience yet.

Implementation tools available The evaluation in based on standards and criteria published on the web-site. The evaluators are using written procedures and methodology, a code of behavior, and apply tools and method developed by CoNAS: check-lists, direct observation, satisfaction questionnaires, interviews and patient’s path. The evaluation of each hospital includes three steps.The accreditation is given based on the final report.

Implementation cost Not relevant experience yet.

RESULTS:

Method used to measure the results Part of the hospitals have different degrees of accreditation.

Results Accreditation reports

Analysis of the results Under preparation



Please describe implementation barriers: • lack of experience for all the actors involved; • small culture for quality in services delivery; • different cultural and technical background of each external evaluator may affect the process of evaluation, in different circumstances.

Describe the strategies used to overcome the barriers (If needed) • improve and update the training of the evaluators • create instruments for standardization of the evaluation

OTHER INFORMATION:


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No

Feedback report to hospitals

GOP Information:


Organisation sharing the GOP Estonian Health Insurance Fund

Member state Estonia


GOP Description:


CLINICAL SETTING: active care hospital

OBJECTIVES: To improve hospitals management and quality of care using the data from hospital invoices to health insurance fund.

POPULATION: Active care hospital managers, clinicians, public

METHODS:

Methodology We selected a number of indicators describing different aspects of hospital activity and quality of care and used the data from health insurance database. The invoices are standardized and have information about patient, care provider, and provided services. Services are coded according to the approved list of services and it’s mandatory to hospitals to use it when sending the invoice to the health insurance fund. The results of the analysis are given in hospitals. Additionally are calculated the average of the hospital type (regional, central or general) and all hospitals. Results are presented in figures and in excel tables allowing to make later more detailed analysis.

Timeframe implementation Approximately one to two month, depend on number of indicators used for report

Implementation tools available Unfortunately there is currently not available any tool in English but we will translate this year report after it is published in health insurance fund web pages. We are using the standardized form for the pdf report trying to place one indicator per page with figure and most important information about used data. There is link from every indicator to the excel sheet with initial data and more detailed information if necessary. The average, median values and/or percentage are calculated also comparisons on different levels.

Implementation cost There is no extra costs for data gathering as it is sent by hospitals to get paid for provided services. Indicators, used in report, are negotiated with specialties earlier during the years. The preparations for report publication take approximately 2-3 moths including data query, analysis and descriptions editing as well. No one get extra paid, it is part of ordinary work for health insurance personnel allocating about 30-40% time during this period.

RESULTS:

Method used to measure the results The data is from invoices started from 1th January to 31 December previous year.

Results the report presents 19 process indicators results to 19 hospitals

Analysis of the results Estonian Health Insurance Fund is not giving any evaluation to results in this report, the analysis take place in hospitals and clinician’s associations.



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OTHER INFORMATION:

Other information about the GOP that you would like to add The report and the results of separated indicators are visible on Estonian Health Insurance Fund web page http://www.haigekassa.ee/raviasutusele/kvaliteet/tagasiside The list of indicators: • waiting times - accessibility to selected hospital care in hospital; • LOS and rehospitalisation (some health conditions and surgical procedure); • acute stroke care – CT/MR scan, thrombolytic therapy; • percentage of day surgery in certain procedures; • case mix index; • coding comorbidities; • percentage of c-section; • participation on cervical screening; • percentage of emergency care patients in acute care hospital.

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Web accessible environment to analyze patient satisfaction survey results and make a comparisons

GOP Information:


Organisation sharing the GOP Estonian Health Insurance Fund

Member state Estonia


GOP Description:


CLINICAL SETTING: active care hospital

OBJECTIVES: To motivate and support hospitals provide in- and outpatient satisfaction surveys and make improvements on service quality

POPULATION: Hospital management and clinicians

METHODS:

Methodology We created in cooperation with 6 hospital quality managers questionnaires for in- and outpatient satisfaction surveys and described the methodology for using it. To help hospitals save and analyze data collected during survey we created an IT program accessible by web where hospitals can insert the data from every single questionnaire. The data will be analyzed automatically and the results are presented in different ways depending on hospital needs. Comparison between hospitals can be done in general and by specialized clinical departments. The figures, created by program, can be easily used in power point presentations for example.

Timeframe implementation The final questionnaire was created during several hospital and insurance fund meetings. Creating and testing the program took about 100-150 hours per questionnaire

Implementation tools available Oracle software

Implementation cost Using those questionnaires and program to analyze data are free for hospitals. The costs to the hospital would be arrangement of the survey on a place and payment to person inserting the patient´s answers from paper to program. For creating the program we used Oracle software insurance fund already had for other purposes. Only costs to insurance fund are salary costs to people involved in the program.

RESULTS:

Method used to measure the results Hospitals are agreed the period they provide the survey in hospitals (usually April), but it’s not mandatory to follow. The data can be inserted any time convenient to hospital. The comparison and discussion is usually in September.

Results Most of active care hospitals (13/18) in Estonia are using this program and doing benchmarking.

Analysis of the results It will be the third year six hospitals are already using this program and at least seven are requested from insurance fund the access to the program.



Please describe implementation barriers: The main barrier in the beginning was hospitals´ unwillingness to show their results to other hospitals and to health insurance fund.

Describe the strategies used to overcome the barriers (If needed)Patience and negotiations

OTHER INFORMATION:

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Other information about the GOP that you would like to add Using the same questionnaire to all hospitals in country makes the results comparable and more attractive to clinicians as well. There may be gaps in the scientific study regularity but we believe the main meaning of satisfaction survey is to draw hospitals and clinicians attention to importance of patients’ satisfaction. Also because hospitals do not use more research companies expensive services they are saving lot of money. It would be easy to use this GOP in any country and even between EU member countries. Using this kind of software instead of excel sheets avoid mistakes during the insertion process and makes comparisons and results presentations very easy.

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Quality of drug management in hospitals

GOP Information:


Organisation sharing the GOP DGOS (Ministere des affaires sociales et de la santé), french health ministry

Member state France

Topic Other

GOP Description:


CLINICAL SETTING: All Hospitals (public and private)

OBJECTIVES: Ensure the quality and security of drug use in hospital Prevent drug iatrogenis in hospital

POPULATION: Health Care Professionals and teams Directions of hospitals Patients

METHODS:

Methodology The hospital, patient, health, territory (HPST) law (July 2009) assigns the management of quality and safety of health care to hospitals. The law focusing on the quality of drug management in hospitals (April 2011) recommends to set up a quality management system in each hospital to ensure the quality and security of drug use. In parallel, a reference guide has been developed by DGOS, fundings and information campaigns provided. Contracts have been encouraged between hospitals and health regional agencies. A national inspection programm has been launched in 2012.

Time frame implémentation Two years by law (arete du 6 avril 2011 relatif au management de la qualité de la prise en charge médicamenteuse) and several years to reach full implementation

Implémentation Tools avalable http://www.sante.gouv.fr/qualite-de-la-prise-en-charge-medicamenteuse-du-patient-dans-les-etablissements-de-sante.html

Implementation cost unknown

RESULTS:

Method used to measure the results practices harmonization

Results not available

Analysis of the results not available



Please describe implementation barriers: Reluctancy to change

Describe the strategies used to overcome the barriers (If needed)Support through guides incentive fundings,…

OTHER INFORMATION:

Other information about the GOP that you would like to add no

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Accréditation des professionnels de santé. Certification Scheme for Doctors

GOP Information:


Organisation sharing the GOP HAS

Member state France

Topic Accreditation

GOP Description:


CLINICAL SETTING: Mainly Hospitals

OBJECTIVES: Improve Quality of Care and Patient Safety through reduction of the number and severity of care-related adverse events by recording and analysing near-misses and production and implementation of risk-reduction guidelines.

POPULATION: Health Care Professionals and teams: • Surgeons (including gynaecologist-obstetricians, dental surgeons, ENT specialists, ophthalmologists), anaesthetists, and specialists in intensive care. • Doctors practising an interventional speciality (cardiology, radiology, gastroenterology, pneumology). • Doctors carrying out obstetric ultrasound examinations or involved in intensive care in healthcare organisations (for complete list, see Article D.4135-2, decree of 21 July 2006).

METHODS:

Methodology The risk management scheme is run by “approved bodies””. Each approved body represents a speciality and shares experience with the approved bodies of other specialities. The decree of 21 July 2006 defines the role of the bodies approved by HAS. HAS approves the bodies on the basis of predefined published criteria. The approved bodies run process and assess certification applications from doctors and inform HAS of their opinion on these applications. Their main task is risk management in their speciality: collecting and analysing reports of near-misses with a view to using the information obtained to produce risk-reduction guidelines with HAS. Participation in the scheme has financial advantages. Private doctors should receive a contribution toward their professional civil liability insurance premiums, which will be covered by the French National Health Insurance. Salaried hospital doctors should receive a contribution towards an annual bonus. Doctors’ obligations • Report the near-misses they have had in the healthcare organisations where they work • Implement the guidelines specifically related to the near-misses that they have reported. • Implement the general guidelines and practice improvement measures derived from an analysis of the near-misses in the database, risk studies, and horizon scanning.

Timeframe implementation Several years

Implementation tools available Rex Database

Implementation cost not available

RESULTS:

Method used to measure the results Number of HCPros involved

Results not available

Analysis of the results not available

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Please describe implementation barriers: Motivation of HC pros

Describe the strategies used to overcome the barriers (If needed)Financial incentive via professional insurance premium reduction

OTHER INFORMATION:

Other information about the GOP that you would like to add No

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ANNEXES

Annex 1: Part 3 Good organisational practices: implementation, sharing and learning

Question Answer categories

3.1 Good Organisational Practices (GOPs)

Plans, strategies or programs at national or regional level

(encompassing structure and process) oriented to improve the quality

of healthcare that can be useful for other healthcare systems at

different levels

Examples:

- The organisation and implementation of a program at

national/regional level to increase the patients’ involvement in

quality and safety policies.

- The training program developed at national/regional level to

promote safety culture for healthcare professionals

- The improvement project designed and coordinated at

national/regional level to reduce healthcare associated

infections in hospitals

- A national/ regional accreditation system for primary care

organisationss

- The development, implementation and evaluation process for

a national clinical guideline for normal delivery

This paragraphs will be visible only with the “Mouse over”

function

3.1.1 Are you able to identify specific GOP practices that have been implemented at an institutional level in your member state, in your region or among your members (European stakeholders)?

Yes

No

Under development (IF YES) Please indicate the activities you could provide examples of specific practices that have been implemented at an institutional level in your member state, in your region or among your members (European stakeholders)?

More than one answer is allowed

o Accreditation o Audit system o Center licensing o Clinical guidelines or

pathways o Clinical risk management o Incident reporting and

learning system o Inspection o Patient complaint

mechanism o Patient empowerment o Patient involvement o Patient safety system o Patient surveys o Peer review o Professional licensing o Professional learning

program on quality and safety

o Quality improvement project o Quality indicators o Quality management system

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o Other, being [free text] 3.1.2 For each of the activities chosen above, please indicate whether you would be willing to share GOP in the Exchange Mechanisms with other member states.

o Accreditation: YES / NO o Audit system YES / NO o Center licensing YES / NO o Clinical guidelines or

pathways YES / NO o Clinical risk management

YES / NO o Incident reporting and

learning system YES / NO o Inspection YES / NO o Patient complaint system YES / NO o Patient empowerment YES /

NO o Patient involvement YES /

NO o Patient safety system YES /

NO o Patient surveys YES / NO o Peer review YES / NO o Professional licensing YES /

NO o Professional learning YES /

NO program on quality and safety YES / NO

o Quality improvement project YES / NO

o Quality indicators YES / NO o Quality management system

YES / NO o Self-evaluation system o Other, being [free text]

3.2 Description of the Good Organizational Practice (GOP) you

would be sharing:

The following questions are related to 1 GOP that you will be willing

to share during the Exchange Mechanisms:

GOP 1:

Organization that will be sharing the GOP: Free text (limited to 50 words)

Title of the GOP:

Free text (limited to 50 words)

Does the GOP impact in any of the following quality dimensions?

More than one answer is allowed

(1) effective,

(2) efficient,

(3) accessible,

(4) acceptable,

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(5) equitable

(6) safe

Description of the GOP:

Indicate the level where this practice has been implemented

(more than one can be selected)

(1) National

(2) Regional

(3) Local

Clinical setting where it has been implemented Free text (limited to 50 words)

Describe GOP objectives Free text (limited to 50 words)

Describe GOP target population Free text (limited to 50 words)

Describe GOP Methodology Free text (limited to 200 words)

Timeframe for proper implementation (based on experience) Free text (limited to 50 words)

Please describe the implementation tools related to this GOP that are

available Free text (limited to 100 words)

Describe the implementation cost (based on experience) Free text (limited to 50 words)

Results obtained after the implementation of the GOP:

- Method used to measure the results Free text (limited to 100 words)

- Results obtained (data) Free text (limited to 100 words)

- Analysis of the results Free text (limited to 100 words)

Did you find implementation barriers? Yes / No

- If yes, please describe: Free text (limited to 100 words)

- Describe the strategies used to overcome the barriers (If needed)


Other information about the GOP that you would like to add:


Please attach any relevant documentation about the practice (for example scientific articles and

reports) that could help understanding the practice:

3.3 Please indicate for what activities you would be interested to o Accreditation o Audit system

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learn from the experiences and examples of others? o Center licensing o Clinical guidelines or

pathways o s Clinical risk management o Incident reporting and

learning system o Inspection o Patient complaint council o Patient empowerment o Patient involvement o Patient safety system o Patient surveys o Peer review o Professional licensing o Professional learning

program on quality and safety

o Quality improvement project o Quality indicators o Quality management system o Self-evaluation system o Other, being [free text]

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Annex 2: Good Organisational Practices (GOP)

2.1 Good Organisational Practices included in the analysis:

ID Name Answer

2 Audit system United Kingdom

3 Quality management system United Kingdom

4 Quality improvement project United Kingdom

8 Patient Safety system Spain



24 Clinical risk management United Kingdom

25 Patient involvement United Kingdom

26 Clinical risk management United Kingdom

27 Incident reporting and learning system United Kingdom


31 Clinical guidelines or pathways Spain

32 Quality improvement project Spain

35 Quality indicators Spain



38 Inspection Sweden

40 Patient involvement Sweden

41 Accreditation Spain


43 Accreditation Poland

44 Clinical guidelines or pathways Cyprus

45 Professional learning program on quality and safety Spain


47 Patient empowerment Cyprus

48 Professional learning program on quality and safety Cyprus

49 Incident reporting and learning system Spain


51 Patient Safety system Cyprus

52 Clinical risk management Slovenia


54 Incident reporting and learning system Hungary

55 Professional learning program on quality and safety Hungary

56 Patient involvement Spain

57 Patient Safety system Belgium

58 Patient complaint mechanism Slovakia

59 Quality indicators Slovakia

60 Patient surveys Austria

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ID Name Answer





65 Quality indicators Hungary

68 Incident reporting and learning system Italy

69 Clinical risk management Italy

70 Professional learning program on quality and safety Italy

71 Clinical risk management Spain


73 Patient empowerment Spain

74 Patient involvement Spain


76 Quality indicators Spain


78 Patient Safety system Italy






84 Accreditation Slovenia








92 Peer review Spain

93 Accreditation Romania

94 Centre licensing Ireland


96 Clinical guidelines or pathways Ireland



99 Inspection Ireland

100 Patient involvement Ireland


102 Centre licensing Spain


104 Professional learning program on quality and safety Ireland

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ID Name Answer

105 Quality improvement project Ireland


107 Quality management system Ireland



110 Incident reporting and learning system Denmark



114 Quality improvement project Austria

115 Patient complaint mechanism Austria

116 Quality indicators Austria

117 Patient surveys United Kingdom

118 Professional learning program on quality and safety Ireland

119 Professional learning program on quality and safety Finland

120 Audit system Hungary

121 Patient Safety system Netherlands

122 Accreditation Netherlands

123 Accreditation Netherlands

124 Clinical guidelines or pathways Netherlands

125 Patient complaint mechanism Netherlands

126 Audit system Netherlands





133 Professional licensing Croatia

134 Inspection Spain

135 Inspection Spain



138 Quality management system Spain

139 Clinical guidelines or pathways Germany


141 Accreditation Romania

142 Qualityindicators Estonia

143 Patientsurveys Estonia

144 Quality improvement project France

145 Accreditation France

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2.3 Good Organisational Practices excluded because they were duplicated or invalid:


18 Accreditation Croatia



39 Patient involvement Sweden


67 Clinical guidelines or pathways United Kingdom

113 Patient complaint mechanism Austria

128 Spain

129 Spain