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Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 1
Seminar on QM in German hospitals
08.11.2013 - Dr. Erwig Pinter
Quality assurance in
German hospitalsQM -
Implementation
Oncological Centers &OnkoZert-
Certification Scheme
Mandatory Certifications of German Health Care Providers
QM in Teaching QM in Clinical studies
Quality assurance in German hospitals
Qualität imKrankenhausBeratungsgesellschaft mbH
Dr. Erwig Pinter, QKB
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 3
1. Quality and hospitals in Germany2. Internal quality assurance3. Focus in different Certification Schemes4. External quality assurance5. Risk management6. Quality management in clinical reality7. Transparency and Marketing with Quality8. Assessment of the benefits of QM9. Literature
Topics
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 4
1. Quality and hospitals in Germany
Topics
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 5
Terms according to DIN EN ISO 9000:2005
Definitions
Quality: “degree to which a set of inherent char acteristics fulfils requirements”
Quality management (QM): “coordinated activities to direct and con trol an organization with regard to quality”
Quality management system (QM-System): “management system to direct and control an organization with regard to quality”
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 6
Definition according to § 2 no. 1 Hospital Law: Medical and nursing assistance Diagnosing, healing or relieving of diseases,
suffering or disfunctions or obstetrics Board and Loading of persons
Hospitals in Germany
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 7
TypeService
Stationary
treatment
Pre- and post-
stationary Day Unit
Outpatient
treatment
Admission Treatment Board Loading Connected toStationary
Types of hospital service
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 8
Public Hospitals: Owner is Federal Republic or a Federal State,
Communal Authority or a Social insurance
Charity based Hospitals: Owners are Churches, Social associations
foundations, Associations
Private Hospitals: Owners are private companies, organisations or
persons
Segmentation of hospitals by ownership
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 9
Ownership segments acute hospitals
2017 acute hospitals in
Germany
Source: destatis, 2012
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 10
718 charity based
hospitals698
private hospitals601
public hospitals
0,17 Mio. beds
6,41 Mio. cases/yea
r0,24 Mio.
beds9,1 Mio.
cases/year
0,09 Mio. beds
3 Mio. cases/yea
r
Ownership segments acute hospitals
2017 acute hospitals in
Germany
Source: destatis, 2012
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 11
Segmentation data acute hospitals
< 100 beds
100-199 beds
200-499 beds
> 500 beds
Total number
Number of hospitals 696 443 624 254 2017
Number of inpatient care 0,8 Mio. 2,2 Mio. 12,4 Mio. 8,0 Mio. 18,3 Mio.
Length of stay in days 8,8 8,0 7,6 7,4 7,8
Number of personnel 51 199 466 1666 -
Source: destatis, 2012
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 12
Owners segments prevention/reha hospitals
1212facilities in Germany
Source: destatis, 2012
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 13
321 charity based
659private
232public
0,07 Mio. beds
0,3 Mio. cases/yea
r0,03 Mio.
beds0,4 Mio.
cases/year
0,11 Mio. beds
1,3 Mio. cases/yea
r
Owners segments prevention/reha hospitals
1212facilities in Germany
Source: destatis, 2012
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 14
Segmentation data prevention/reha hospitals
< 50 beds
50-99 beds
100-199 beds
> 200 beds
Total number
Number of hospitals 286 261 355 310 1212
Number of inpatient care 0,8 Mio. 0,19 Mio. 0,6 Mio. 1,05 Mio. 2 Mio.
Length of stay in days 30,3 27,7 25,35 25 25,5
Number of personnel 19 39 82 148 -
Source: destatis, 2012
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 15
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 20110
500
1000
1500
2000
2500
hospitals public
charity based private
Key data
Source: destatis, 2012
Number of German hospitals decreased by 8% between 2000 und 2011
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 16
18,3 Mio. stationary patients
18 Mio. outpatients
83 Mrd. € turnover cost/year= 3,6 Bio. Rubel(3,2 % gross national product)
2017 acute hospitals in total6 Mio.
emergency cases
Population in Germany: 82 Mio.
Key data acute hospitals
Source: DKG 2011 and destatis, 2012
1,1 Mio. professionals
160 tsd. Physicians700 tsd. Nurses, Function service, Medical engineers80 tsd. Administration200 tsd. Others (technicians etc.)
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 17
2. Internal quality assurance
Topics
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 18
Development of QM in Germany
1997-2000: Demonstration project QM
1975: Quality Control: Munich perinatal study
2000: Internal QM,federal governing board for quality assurance
2004: G-BA
2013: - Mandatory certification of rehabilitation hospitals, - quality assurance report with 289 quality indicators, - patients rights law
Increasing requirements for proving and for transparency
2005: Quality assurance report, Alliance Action for patient safety
1989: external quality assurance
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 19
National Association of Statutory Health Insurance Funds
National Association of StatutoryHealth Insurance Physicians
National Association of Statutory Health Insurance Dentists
German Hospital Federation Federal Medical Chamber Council of Nursing
Organisations developing quality assurance
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 20
Social Code Five (SGB V) § 70 SGB V: Quality, Humanity and Economic
Efficiency Health care for the Insured according to the
recognized medical evidence Sufficient, advisable and not exceeding the
extend of necessity According to the professionally required
quality
Legal framework
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 21
Social Code Five (SGB V) Since the year 2000 steadily more specific and
demanding: § 135a SGB V: Requirements for quality assurance
Implementation and further development of an internal QM
Participation in measures for external quality assurance
§ 137 SGB V: Regulations and decisions for QM Federal Joint Committee (G-BA) formulates basic
requirements for an internal QM and defines quality indicators for the legally
requested quality report
Legal framework
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 22
Federal Joint Committee (G-BA) Highest regulating committee of the self governing
authority of the health care partners Regulatory competency Defines services of health professions to be
paid by the health insurance funds QM in the medical care Regulations in quality
management:internal QM, external quality assurance (=quality control), quality report
Common Federal Council
G-BA(Federal Joint Committee)
Health Insurance Funds
Medical Care
Medical
Profess-ions
Dental Surgeo
n
Hospitals
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 23
Mandatory elements of the internal QM according to the Federal Joint Committee (G-BA)
Requirements for an internal QM in Germany
Continuous improvement
Preventing and handling of
failures
Target-orientation and
flexibility
Employee-orientation,
cooperation and participation
Process orientation
Efficiency
Responsibility and leadership
Patient orientation
Elements of the internal
QM
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 24
Federal Joint Committee (G-BA) requirements for the internal QM-System in a hospital
Internal QM
StructureGoverning council or Steering committeeQM-officer for the executive management
ProcessesQM as part of the facility policyPatient orientationResponsibility of the hospital directorateKey processes, Evidence based Medicine with clinical pathways, guidelines, standards
Other requirements
Effectivity and efficiencyCost-Benefit relation
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 25
Working Group of the Scientific Medical Associations (AWMF): Systematically developed (Evidence based
medicine) Describe the Current state of the art and medical
science Ascertain the decision making procedures of
doctors and patients in respect to an adequate medical diagnostic and treatment standard for specific diseases or health problems
Clear recommendations to act based on assessements of the scientific value and usability of study results
AWMF Guidelines
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 26
AWMF: Guidelines are corridors for the medical decisions
and actions Deviations are possible in certain cases, but
reasons have to be stated The workflow according to the scientific guidelines
of the AWMF has to be adapted to the individual applicability in an individual situation according to the parameters indication consultation, preferences participation in decision making
Clinical relevance of the AWMF Guidelines
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 27
AWMF: S1: Recommendations of scientific expert groups S2: Guidelines based on evidence (S2e) or
consensus of a discipline representing committee (S2k)
S3: Guidelines based on evidence as well as on the consensus of a discipline representing committee
Remark: In Germany it is important for the doctors liability
to obey in detail at least the S-3 guidelines (and a must to get some certifications like OnkoZert)
Classifications of AWMF guidelines
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 28
5 stages in the life of a guideline (AWMF)
Evaluation and Planning the Updating
Implementation
Editorial process and Publishing
Development of a guideline
Planning and organisation
Development process of AWMF-guidelines
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 29
ISO KTQ JCI USA OnkoZert
Basics
Requirements DIN EN ISO 9001
Question- Catalogue with 6 categories
JCI- accreditation standards in 14 chapters
OnkoZert Questionnaire with 10 chaptersGerman Cancer Soc.
Certifi-cation
Certification audit Self assessment and conformity assessment
Self assessment, accreditation-survey
Certification audit by team of general QM-auditor and oncological expert
Special
characteristic
s
Structured QM, process orientation, certification of organisational parts of the hospital possible, internationally recognized, yearly control audit, internal audits
Certification of the entire hospital, specific German certification model for health sector
Certification of the entire hospital, from USA, internationally recognised
Oncological centers: comprehensive cancer centers, cancer organ center, cancer entities, cancer based items, certified general internal QM-System as pre-requirement
General and special Certification Schemes
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 30
7. Yearly conformity audits
6. Issuance of the certificate for 3 years
5. Audit stage 2
4. Audit stage 1
3. Certifying organisation defines audit team
2. Formal pre-check of the certification application
1. Select a certifying organisation
ISO-Certification
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 31
Problems in status assessment: no publicly available source about precise certification
numbers since certification in acute hopitals is voluntarily Each certified hospital promotes its own certification Only active KTQ certifications are listed publicly ISO certifications are not released from the certification
organisations Private data sources about hospitals differ in definitions from
the Federal Authority of Statistics
Result: We could evaluate for you the current certification situation only on a reference basis of about ¾ of the 2017 acute hospitals, namely in 1576, but we can offer at least an overall view of conclusions
Certification status in acute hospitals
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 32
Source: DKA, 2012
Owner Certified
Non-certified
Charity 285 345
Public 217 315
Private 127 287
Hospitals 629 947charity based public private
0%10%20%30%40%50%60%70%80%
45% 41%31%
55% 59%69%
Certification status in acute hospitals
certified not certified
Number of non-certified acute hospitals is still predominant Highest portion of certified acute hospitals is in the charity
based owner sector
Certification status in acute hospitals
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 33
Acute hospitals: about 40 % of the acute hospitals in Germany are certified
in General Certification Schemes (status 2012) Many hospitals are additionally
certified in specific disease certification Schemes
Rehabilitation hospitals: Each rehabilitation
hospital is mandatorily required to show its valid certificate
Market share of Certification Schemes
Market Share of Certification Schemes
in German acute hospitals
KTQ ISO0%
10%20%
30%40%
50%60% 52%
48%
Source: DKA, 2012
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 34
Distribution of KTQ and ISO Certifications in owner-sectors:
ISO certification: more frequently at private acute hospital owners
KTQ certification: more frequently in charity based and public acute hospitals charity based public private0%
10%20%30%40%50%60%70%
56% 53%
39%44% 47%
61%
KTQ DIN EN ISO
Certification Schemes in owner sectors
Source: DKA, 2012
Certification distribution
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 35
These three hospitals are certified in Germany according to JCI: Central Military Hospital Koblenz Clinics of Red Cross Berlin Communal Central Hospital Chemnitz
JCI-Certifications
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 36
ISO QM Standards: DIN EN ISO 9000:2005, Quality management
systems- Fundamentals and vocabulary DIN EN ISO 9001:2008, Quality management
systems, Requirements DIN EN 15224:2012, Health care services - Quality
management system
Standards
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 37
ISO KTQ
Basics
Not specific for Health Care.Origins from Industry
3 year periods between conformity assessements
Benefit
Valuable structured approach but not all ISO elements meet the special needs of indiviual patient
Self-assessment is big workload (1/2 year) in the valuable overall evaluation. Implementation of the possible improvements however is separate act
Special
characteristic
s
Some doctors see much formalism not really improving outcome but hindering patient work
If executives are not convinced by QM and their necessary daily support goes to a minimum: the hospital freezes in QM between the 3 yearly self-assessements ->No further organization developement
Critics to General Certifications Schemes
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 38
Preferred is structured QM approach of ISO type but only with special touch to meet the health sectors needs: Development in the health-care sector in understandable
language of the health care professionals Focus on patient orientation Evidence based medicine Risk-management Prevention of defects and non-conformities Usable for all health-care organisations For small and very complex organisations with all necessary
aspects (patient care, medical competence, clinical pathways etc.)
Assessment after 20 years QM experience
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 39
DIN EN 15224:2012 Defines ISO 9001 for the health-care sector Specifically designed for all healthcare services Requirements to the QM-system Will become the main certification standard Language of the health-care sector Emphasizes the process orientation and risk-management Three standards: clinical process, process of science and
process of teaching Combined certification according to DIN EN ISO 9001 is
possible
The prospective Standard in Europe
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 40
Examples for associations of medical doctors German Association of hematology and oncology (DGHO) German diabetes Association (DDG) Association of children hospitals and children departments in
Germany e.V. (GKindD e.V.) German Association of orthopedics and traumatology (DGOU) German association of angiology (DGA)
Example for other associations German Cancer Association (DKG)
Associations emphasizing and influencing QM
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 41
Certificate Association Number of certified facilities
OnkoZert German Cancer Association
Organ-Cancer Centers: 860Oncological Centers: 57Comprehensive Cancer Centers (CCC) 3
DGHO German Association of Hematology and Oncology
Oncological Centers: 40Competence Centers: 3Study Centers: 6
Quality Seal DDG
German Association of Diabetology
For Clinics:Basic recognition: 248Diabetologicum: 48 Podological specialist for treatment of diabetic feet: 79
Special Certification schemes of Associations
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 42
Certificate Association Number of certified facilities
Quality seal for children hospitals
Association of children hospitals and children clinics in Germany
Clinics for Children and adolescent: 280
Centers for vessel diseases
German Asociation of angiology, German Association of vessel surgery, German Association of radiology
Vessel Centers: 66
Nephrological focus clinic
German Association of nephrology
Focus Clinics: 22
Special Certification schemes of Associations
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 43
3. Focusing different Certification Schemes
Topics
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 44
Main chapters of DIN EN ISO 9001:2008:4. Quality management System5. Management Responsibility 6. Resource Management 7. Product realization7.5 Production and Service provision (Patient care)8. Measurement, analysis and improvement
DIN EN ISO 9001:2008
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 45
Categories1. Patient-orientation in Patient Care2. Ensuring employees-orientation3. Safety in Hospital4. Information 5. Hospital management6. Quality management
KTQ – catalogue version 5.0
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 46
Patient oriented Standards International Targets for Patient safety Access to and continuity of treatment Patient and family rights Assessment of Patients Treatment of Patients Anesthesiology und surgical treatment Management and application of medicines Training of patients and of their relatives
JCI – catalogue 4. revision I
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 47
Organisational oriented Standards Quality improvement and Patient safety Prevention and Control of infections Control, Leadership and Management Facility Management and security Qualifications of employees and further
education Communication and Information management
JCI – catalogue 4. revision II
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 48
1. Structure and processes (e.g tumour boards) 2. Organ-specific diagnostics 3. Radiology4. Nuclear medicine5. Surgical Oncology6. Chemotherapy/Internal Oncology7. Radiooncology8. Pathology9. Palliative Care und Hospice service10.Tumour documentation/Outcome quality
OnkoZert - Survey
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 49
Compliance with requirements defined in checklists:
Profile checklist for facilities for the Basic Treatment of severely injured persons
Checklist for a Regional Trauma Center Profile Checklist for a Supraregional Trauma
Center
Requirements: Personnel requirements Facility and equipment requirements Measures for Quality Assurance
Trauma Network - Requirements
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 50
4. External quality assurance
Topics
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 51
Measures for external quality assurance according to the Federal Joint Committee’s requirements: Goal: improvement of the quality and comparability of health care services German-specific Documentation and transmitting of data to the
evaluating institute in regard to defined quality indicators in 30 chapters e.g. obstetrics, transplantation of cardiac pacemaker
Recording and analyzing data across all hospitals in Germany
Some quality indicators are also part of the quality report
External quality assurance
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 52
6. Objective agreement on quality improving measures
5. “Structured dialog” in significant deviations from normal
4. Inform hospitals about results of the analysis
3. The regional authority and the AQUA Institute analyze the data
2. Transmitting the data to the AQUA Institute and regional authority for quality assurance
1. Patient care and documentation
External quality assurance
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 53
1658 hospitals participated 465 quality indicators of 30 chapters 4 Mio. data sets to analyze Results:
In total, the quality of health care in Germany is on a high level
But specific potentials for improvement identified:E.g. Current documentation in the field of liver transplantation has to be strengthened with more parameters
Results of the external quality assurance 2012
Quelle: AQUA Institut, 2013
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 54
Legal obligation for hospitals to publish yearly a quality report
Content, range and data format are defined by the Federal Joint Committee (G-BA)
Part A: information about structure and health care services of the hospital
Part B: information about structure and health care services of specialty departments of the hospital
Information about quality assurance
Quality reports of hospitals
Quality Report
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 55
5. Risk management
Topics
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 56
Risk“the combination of the probability of an event and its consequences”
Risk-management“coordinated activities to direct and con trol an organization with regard to quality”
Clinical risk“negative effects on the patient outcome according to quality requirements in health care“ E.g. wrong treatment, complications
Risk management
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 57
Risk management as part of quality management Avoiding to do the same work twice Efficient resource management Harmonised documentation Transparency of structures Legal security
Risk management
RM
QM
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 58
Risk management processbecomes more and more important for hospitalsin Germany Patients rights law DIN EN 15224:2012 Alliance Action for
patient safety
Risk management
1. Establishing the context of use
6. M
onit
orin
g an
d re
view
2. Risk identification
5. Risk measures
4. Risk evaluation
3. Risk analysis
DIN ISO 31000:2011
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 59
Partners of the Alliance action for patient safety Federal Joint Committee German Federation of Hospitals Health Insurers Charité Berlin Private Hospital Chain
Projects: Action on Patient Safety Action Clean hands! (Hygienic project) Hospital network CIRS Germany Time out procedures
Risk management
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 60
Survey of the Alliance Action for patient safety Deals with the status of implementing a clinical risk
management system in Germany Results: 484 hospitals participated 27% implemented a risk
management system 31% have a strategy for
implementing a system
Risk management
Survey of the Alliance Action, 2012
yes27%
no26%
intention16%
partially31%
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 61
Critical incident reporting system (CIRS) Goal: prevention by collecting information about
critical incidents, learning from failures Factors for success:
No sanctions Voluntary, anonymous, trust Analysis of incidents by experts System-oriented
Mainly based on a program from a medical liability insurer
CIRS
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 62
Realisation of CIRS in German hospitals Survey of the Alliance Action for patient safety
35% have a systematic CIRS
Main risk factors identified yet: Interaction between
departments pharmacotherapy Infections Hygiene
CIRS
no18%
not yet15%
intention19%non-sys-
tematic13%
system-atic CIRS
35%
Survey of the Alliance Action, 2012
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 63
Learning from the aviation CIRS-systems Checklists Certification procedures for medical and nursing
personnel Training Centers Simulator Training Psychological behavior in stress situations Become sensitive to systematic non-conformities Focus on preventive action
Risk management
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 64
Goal: Patient safety and empowerment of patients Codification of court decisions in more than the last
30 years medical liability claims Asserts legally the status of the continuously
extended patients rights and the defined good medical practice in Germany by Courts
Some new requirements: Doctor has to proof information consent
(now it is doctors burden to proof before court. Before it was patients burden)
Requirements regarding documentation: General rule: “What is not documented did not happen”
Patients rights law
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 65
6. Quality management in clinical reality
Topics
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 66
Level of competence
Acute hospital segmentation in treatment/size
Hopitals with main focuses
Regular and basic services
Differentiation and scope of service
spectrum
1000 beds +
400-1000 beds
20-400 beds
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 67
QM-approaches differ due to hospital size and service:We experienced during the 20 years QM realisation in respect to type and extent of QM realisation: Dominating factors in initiatialization and realisation of QM
Basic Services: Individual executive experiences
Main focus Services: Recommendations of associations
Maximal Service: Legal requirements factor
QM implementation approaches differ
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 68
Short way communications and decisions Two possible ways:
QM is responsibility of some individual persons additionally to and together with their actual work or
Special appointed member of management with responibility for Qualitätsmanagement and e.g. risk-management
Important: Priority setting is a must in different QM-projects
QM in regular and basic hospitals
QM
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 69
Central QM reports to executive management withsome special employees for QM
Appointed QM persons (QMB=ISO 5.5.2) in individual clinics with tasks and responsibilities more specifically differentiated
QM in main focus hospitals
QM
B
QM
B
QM
B
Central QM
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 70
Central QM in the top management of the Holding Local QM in the different sites Specialists for the different QM-sectors in the
central QM Central QM responsible for Public relations and
marketing with QM-topics and the further strategic developing of QM as well as of their organisation (think tank).
QM in maximal spectrum hospitals
Top management and central QM
QM
B
QM
B
QM
B
Central QM
QM
B
QM
B
QM
B
Central QM
QM
B
QM
B
QM
B
Central QM
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 71
7. Transparency and Marketing with Quality
Topics
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 72
Hospital navigator4QD-Quality clinics
Top-ranking doctors list Focus
Ranking list of hospitals or of doctors in weekly magazin Focus
Online search for the best suitable hospital on basis of parameters important for patients provided by biggest health insurer
Online portal with open comparative ranking of participating primarily private hospitals
Transparency and Marketing with Quality
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 73
4QD-Quality clinics Initiative of private hospital chains , e.g. Sana, Rhön, Asklepios Voluntary partcipation of hospitals Mutual audits of the participating
clinics Quality indicators:
340 indicators regarding Outcome quality
21 indikators regarding patient safety
10 each regarding patient and practitioner satisfaction
Transparency and Marketing with Quality
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 74
4QD-Quality clinics Search for the suitable hospital according to the speciality
clinics, indications, treatment possibilities and location Online search with certain parameters or with the body picture Patient gets informations about:
Clinic details Quality parameters Quality Certificate Treatment spectrum Main focuses Equipment/Service
Transparency and Marketing with Quality
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 75
Hospital navigator Initiative of the statutory health insurance (AOK) Informations are based on the
Legally requested Quality reports Voluntary informations of the hospitals Results of patient satisfaction surveys of the legal health
insurers (Patient Experience Questionaire)
Anonymised routine data from the datapools of the health insurers
No verification procedure regarding the voluntary informations of the hospitals and the Quality reports
Transparency and Marketing with Quality
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 76
Hospital navigator Comparison of at least two hospitals in:
General informations Recommendations by patients Main focuses of the hospital Personnel Quality Assurance with
routine data Legally required para-
meters of the QA Patient satisfaction
Transparency and Marketing with Quality
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 77
Top-ranking doctors list Focus The weekly magazin “Focus” publishes
periodically ranking lists of specialised doctors and of hospitals based on quality parameters
Quality Indicators: Recommendations of doctor collegues Recommendations of associations of patients Selfassessements of the doctors publications
Written and phone interviews
Transparency and Marketing with Quality
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 78
8. Assessment of the benefits of QM
Topics
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 79
Focus in personnel training in Germany very important Mandatory further education of doctors has to be proven all
five years (via collection of certification points per event) Additional special health personal trainings in QM,
teambuilding, teamwork and communication Most important in practical terms (BÄK/Bundesärztekammer):
QM-qualification by the Federal Medical Association “Curriculum of medical quality management” 200 hours in three parts in one year with examination Target groups:
Medical chief executives, senior physicians and Consultants
QM postgraduate education as success factor
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 80
QM has to be implemented and is to be applied in the entire hospital (S. Pilz et al. 2013)
Deficiences in the implementation (N. Kasper, 2011)
1. Application of the implemented methods and elaborated standards is not successful
2. Monitoring, measuring and act deficiencies in the independent evaluation of the results of QM deficiencies in act to improve
timely the non-conformities
Areas for improvement
Plan
Do
Check
Act
2
1
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 81
Surveys on behalf of the Federal Joint Committee about the perception of the users about the Quality Reports
Patients and doctors underutilize the Quality Reports of the clinics in the clinic selection Patients in majority don‘t even know the Quality Reports
Perception of the hospitals Quality Reports do merely adequate reflect the real
spectrum and quality of the services of a clinic Quality Reports have to be improved in the way of
presentation, detailedness, comprehensibility for lay people, freedom of too narrow legal arrangement
Areas for improvement
M. Geraedts et al. 2010
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 82
Study of the Society of Quality management in Health Care: The role of QM personnel in hospitals Anonymous Online-Survey of QM-employees in
health care 248 participants in Germany:
different owners and sizes of the facilities 77% of the participating facilites had been
certified
Effectivity of QM
S. Pilz et al. 2013
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 83
Results dynamic, developmental QM contributes effectively
by Structuring, establishing tranparency of and
optimizing the internal workflow Minimizing costs and risks Increasing patient safety Assisting the top management
Effectivity of QM
S. Pilz et al. 2013
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 84
Results The crucial success factor: Close cooperation
between QM and Top management Top management of successful facilites typically
requires and accepts the support by QM
Effectivity of QM
wenig er-folgreich
erfolgreich0%
10%20%30%40%50%60%70%
23%
36%
12%
61%
wenig be-deutsambedeutsam
Less important
important
Significance of the cooperation between QM and executives
S. Pilz et al. 2013successful
less successful
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 85
Different possible roles of QM in a hospital:
Effectivity of QM
Sommerhoff 2012
leading
changing
subordinate
preservative Orientation of QM
Posit
ion
of Q
M
Organisational development
Project reserve
Security Force
Control station
- Quality Control- Repair- Management system-administrator
- Quality Control- Moderator in conflicts - Management system-designer
- Change manager - Internal Consultant
- Project manager- Project service
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 86
Certified QM in health sector is becoming more and more mandatorily required by law: QM as safety factor in economically stringent situations Convincing evidence for benfits by QM in outcome and
processes based on our practical experience Medical laboratories have to prove specified capabilitiesCertifications required: Rehabilitation hospitals DentistsMandatorily QM implementation: QM has to be implemented mandatorily by law
in each health service, e.g. practitioners, emergency medical service, psychiatry etc.
Mandatorily required QM
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 87
9. Literature
Topics
Dr. Erwig PinterQKB-Qualität im Krankenhaus Beratungsgesellschaft mbH 88
Homepage Bundesministerium für Gesundheit: http://www.bmg.bund.de/ministerium/english-version.html
Homepage Deutsche Krankenhausgesellschaft:http://www.dkgev.de/dkg.php/cat/257/aid/10696
Homepage G-BA: http://www.english.g-ba.de/ Homepage AWMF: http://www.awmf.org/ Homepage BÄK:
http://www.bundesaerztekammer.de/page.asp?his=4.3569 Homepage Aktionsbündnis Patientensicherheit:
http://www.aktionsbuendnis-patientensicherheit.de/ Homepage GQMG: http://www.gqmg.de/ Homepage AQUA Institut: http://www.aqua-institut.de/
Literature