Introdução à Medicina
Porto
2008/2009
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Authors
Ana Cristina Barbosa Pereira
Ana Rita de Sousa Vieira de Oliveira
André de Jesus Magalhães Vinha
Catarina Castro Vieira
Eduardo Manuel Pinto Ferreira Silva Freitas
João Manuel Dias Ferreira Rebelo
Mariana Almeida Leite Gomes de Oliveira
Nuno Filipe da Silva Ribeiro
Susete Marli Fonseca da Cruz
Vitoriano Penhor José da Costa
Adviser
Prof. Alberto Freitas
Class n.10
Hospital Management Policy and the Quality of Healthcare
Abstract
The quality of health services is considered a serious public health problem, since they
influence a great part of the population.
Performance and quality of healthcare should constitute a fundamental principle
regarding the planning of the process of improvement a better healthcare to patients.
The term “quality” involves all the direct and indirect interventions that have the objective
to avoid a better service. Several methods can be used, according to the type of indicator we
intend to prevent.
“Given the importance of healthcare, it seems inconceivable that we do not have
excellent ways of evaluating how well we are doing. Yet the fact is, we do not.” [1]
Indeed we don’t have a perfect and an effective system to evaluate the hospital’s
performance and management policies. Nowadays, there are some indicators that allow
extracting valuable information and reaching conclusions about healthcare system.
Using those indicators we expect to evaluate and take some conclusions about the
healthcare performance, since 1990, at hospital S. João.
With those data we established several objectives, being the principal one to understand
the relationship between management decisions and quality of healthcare.
To sum up, this kind of evaluation is very important because it can change positively the
management policies which can reflect in the hospital reality, increasing the quality of healthcare
provided to the patients.
Eddy, David M. ‘’Performance measurements: problems and solutions in Health Affairs.
Vol.17. 4, 1998.
[1]
Hospital Management Policy and the Quality of Healthcare
Key-Words
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Healthcare
Management policy
Quality indicators
Patients
Performance measurements
DRGs.
Hospital Management Policy and the Quality of Healthcare
Introduction
Quality is a concept widely used in our days when we want to evaluate a certain aspect.
However, it is considerably difficult to find an universal definition that can be used and
understood by everyone due to its subjectivity. As in all areas of interest, the quality in health is
also a multidimensional concept and it includes not only the notion of clinical quality but also
social, economical, ethical and physical aspects [2]Taking this into account, it is easy to understand
that the global quality of a health system is the average of the values assigned to each of the
dimensions mentioned above.
In spite of the subjectivity of the concept “quality”, it is extremely necessary to establish
terms of comparison in order to analyze the performance of health systems and its evolution, and
thus improve the conditions of health services. Besides, we must not forget the constant search for
healthcare by a more and more aged population, and also by more informed and demanding
people. [3]
Therefore, governments are increasingly introducing performance management systems
to improve the quality and outcomes of healthcare. [4] Even though it is not an easy task, as it is
impossible to find the perfect evaluation system, it must be accomplished with responsibility in
order to develop the best methods. . To do so, many surveys were made to discover which
quality aspects of a hospital performance must be analyzed, not only to improve the quality of
hospital care but also to find out patients and doctors’ opinion about the relevance of the quality
indicators that are included in hospital reports. [5]
The most used classification systems are DRGs (GDHs in portuguese) and, more
specifically, indicators.
Diagnosis Related Groups (DRG’s) is a system of intern patients’ classification in
homogeneous and coherent groups by the point of view of consuming products, built from
diagnosis characteristics and therapeutic profiles. Much like the diagnosis characteristics, also the
expected results of a treatment are similar in different patients of the same DRG. [6]
Every hospital keeps a permanent database about their patients to classify them in
DRG’s, and that information is sent periodically to Instituto de Gestão Informática da Saúde
(IGIF). At IGIF that data is processed for cost calculation in order to make more accurate
budgets. That data constitutes a great value to information production and is organized in
indicators, such as mortality, surgical problems, and many others. [3]
Indicators can be defined as measurement units that allow monitoring and evaluation of
key variables of an organization through comparison with its corresponding internal and external
referential. So, indicators are empirical instruments that allow us to show the theorical dimension
of a key variable. Specifically, healthcare indicators are measurements that reflect relevant
information about different attributes, health dimensions and factors that influence health system
performance. [7] (pdf Rita) With the information given by these instruments, governments can
know how much money was spent and where it was used (normally prices per DRH’s), as well as
understand where it is needed. [8]
Then, there are some indicators that can provide us useful information about the
performance of a hospital, such as mortality, duration of internment, postponed surgeries,
outpatient department episodes, outpatient surgery, childbirth of cesarean operation, principal
diagnosis, and finally surgical proceedings (and complications). All of these will be used as
sources of data in our study.
Hospital Management Policy and the Quality of Healthcare
Mortality is an indicator with dubious quality (death as a result does not necessarily
mean problems in the provided healthcare). However, it has important advantages: the concept
of death is objective and does not allow subjective interpretations and big differences are not
expected in registration of obits in hospitals. [3]
Duration of internment is a kind of production indicator that is chosen because it can be
more easily interpreted and not for being a good controller of the resources. For each DRG are
established minimum and maximum limits of internment, that allow the identification of irregular
situations.
The number of postponed surgeries is an indicator which consists in a retrospective
evaluation of cancellations of scheduled elective and urgent operations, considering the reason
for the adjournment. The reasons are normally related with the lack of medical clearance and
patient preparation, the lack or failure of instruments or patient cancellation.
Outpatient department episodes are inserted in the area of activity and production. In
fact, its main purpose is to calculate the number of outpatient department episodes to estimate
the evolution of the hospital´s performance. Important sources of data to estimate this indicator
are DRGs.
Outpatient surgery compares the number of outpatient surgeries with the number of
programmed surgeries. Typically, in this type of surgeries, the recovery phase is transferred to
the home environment. For this reason, the practice clinic has little opportunity to observe the
patient's post-operative course. If we relate these numbers with the satisfaction of the patient, the
comparison between each method of operation is very important to obtain information about
reasonable measures for improvement.
Childbirth of caesarian operation is expressed by the relation between childbirth of
caesarean surgery and the total number of childbirths. This indicator does not provide
information about the reason for undergoing caesarean section, and includes caesarean sections
that were performed without a clinical indication as well as those that were medically indicated.
Principal diagnosis is a variable that can decisively affect the course of the illness. It
depends on the formation and experience of the doctor, the availability of technological
resources and it also depends on the time of permanence in the hospital. [9] Evaluating the quality
and the results of the diagnosis and converting that data into numbers, we can relate this
indicator with others, such as the time of internment or mortality. It is calculated in percentage or
simply numbers, and it expresses the quality of the data.
Complications related to surgical procedures are powerful indicators. Although some of
them cannot be avoided, a high number of complications after surgery could be associated with
bad clinical practice or deficient health care quality in hospitals.
We can see, by the examples of foreign countries, that the information given by said
indicators is very useful, as well as the performance measurements. For instance, Australia has
introduced a National Quality and Performance System (NQPS) with the purpose of establish a
higher performance, promote best practice, support under performance and sharpen the focus of
healthcare institutions. [4] To accomplish those goals, about 52 indicators (National Performance
Indicators-NPI) are analyzed. These indicators are concerned with governance, prevention and
early intervention access, integration and chronic diseases management.
Hospital Management Policy and the Quality of Healthcare
In the USA, a study was done to evaluate if the 7 operations chosen as a quality
indicator by the Agency for Healthcare Research and Quality were performed frequently
enough to identify hospitals with increased mortality rates.
To do that, a large number of data from different hospitals and from different gaps of
time was used to turn possible the representation of all hospitals in the country.
Analysing the results of this study, we easily understand that for only one operation, the
majority of hospitals exceed the minimum caseload and for the remainder just a small number of
hospitals met the minimum caseload required.
So, using this indicator, we are assuming that one hospital with great results in this 7
surgeries is an excellent hospital but that might not be exactly true, because this hospital could
have this results simply because his activity is very low in this kind of operations. This way,
patients are falsely reassured that they are choosing a safe hospital basing their choice in this
indicator.
The main conclusion of this study was that the policy makers should consider sample size in
selecting the best quality measure for specific procedures, particularly when data is used for
public reporting. Otherwise, they run the risk of mislabelling hospitals and misinforming patients.
With the importance given by the Australian and American authorities, we can confirm the
importance of having regular analyses to improve management’s policies. [10] We can also use
this examples to avoid measurement errors.
In our study during the next months, we will have access to specific information about S.
João’s hospital through a number of quality indicators. The aim of this project is to analyze these
indicators (the ones defined above) and use them to study the evolution of the hospital
healthcare from 1990 to the present year. Besides that, we would like to use the analyzed
information to try to conclude about the current situation of the studied health services and find
out what could be improved in each one in order to supply a better care to patients. Even being
completely conscious of the difficulty of that task, we consider that path an interesting means of
study the subject, and for that reason we want to be sure how viable our ideas are, before
considering new possibilities.
We believe that quality systems should be encouraged in every health institution, and in
this particular case, in Hospital S. João, because they allow not only the population to increase
their knowledge about some of the hospital services and conditions, but also the doctors and the
rest of the hospital workers to have a general idea of the hospital’s situation that otherwise
would not be accessed. With that information taken into account, everyone can make more
informed and consequently more responsible decisions when making choices.
Although we will only study a small quantity of indicators that, by themselves, do not
give a general idea of the performance of the hospital due to its complex organization in many
services (whose majority will not be evaluated in this project), we believe this is an interesting
way of improving our knowledge about healthcare quality systems and understanding the
relevance of indicators and DRGs in the very complex quality evaluation that, in spite of not
being perfect, it is more and more complete as time goes by.
Reinhardt,U: ‘’Quality in comsumer Driven Health Systems’’, International Journal for Health Care. 1998;
10(5)
[2]
Hospital Management Policy and the Quality of Healthcare
Bentes, Margarida; Berardo, Ana; Matias, Alberto: XVII Congresso da União Europeia de Gestores
Hospitalares; 1999.
[3]
Gardner,Karen L; Sibthorpe,Beverly; Longstaff, Duncan. National quality and performance system for
Divisions of General Practice: early reflections on a system under development. 2007
[4]
[5]Geraedts
M, Schwartze D, Molzahn T. Hospital quality reports in Germany: patient and physician
opinion of the reported quality indicators. Germany: BMC Health Serv Res.; 2007 Sep 28; 7-157.
Bentes, Margarida; Gonçalves, Maria da Luz; Tranquada, Suzete; Urbano, João. A utilização dos
DGH’s como instrumento de financiamento hospitalar. Gestão Hospital, 33-42.
[6]
[7] PDF
RITA
[8] Ribeiro,
Nuno. Administração pública. TOC. 2000/08
Uriel, Zanon. Qualidade da assistência médico-hospitalar: conceito e avaliação de indicadores. 2000
Jul-Set RAS _ Vol. 2, Nº 8. Available from: http://www.cqh.org.br/files/ARTIGORAS08.pdf
[9]
National report on health sector performance indicators 2003 [Internet]. Canberra: . Australian Institute
of Health and Welfare; 2004.
[10]
Hospital Management Policy and the Quality of Healthcare
Research Questions and Aims
To provide a better comprehension of the study we are going to embrace in the next
months, we now specify our research questions and aims.
The main question that stands out when facing this subject is what is the relationship
between management decisions and quality of healthcare, how can we use it to improve the
performance of the providers, and in what way do the indicators serve as links between these
two concepts. Besides this research question, we could have a second one, related specifically to
our object of study, Hospital de São João, which is related to the variation of the values of
hospital indicators concerning the adopted management politics and structural changes
introduced in the last 17 years.
To find answers for that questions or to simply reflect about them (due to the complexity
of the subject and lack of time and information to analyze the matter in its full content), we will
use the information previously provided to try to accomplish some objectives. We intend to study
the evolution of each indicator during the past 17 years and compare its values between
themselves in order to investigate possible relationships between them, try to discover in what
way the indicators and its analyses could contribute to the improvement of the hospital quality,
know how viable it is to introduce certain changes in a hospital’s management, taking into
account the practical repercussions that those changes could bring, and evaluate critically the
decisions which can determine changes in the hospital’s management, in order to realize what
could be done to improve the quality of health care and avoid similar problems in the future.
Hospital Management Policy and the Quality of Healthcare
References
Eddy, David M. ‘’Performance measurements: problems and solutions in Health Affairs.
Vol.17. 4, 1998.
[1]
Reinhardt,U: ‘’Quality in comsumer Driven Health Systems’’, International Journal for Health
Care. 1998; 10(5)
[2]
Bentes, Margarida; Berardo, Ana; Matias, Alberto: XVII Congresso da União Europeia de
Gestores Hospitalares; 1999.
[3]
Gardner,Karen L; Sibthorpe,Beverly; Longstaff, Duncan. National quality and performance
system for Divisions of General Practice: early reflections on a system under development. 2007
[4]
[5]Geraedts
M, Schwartze D, Molzahn T. Hospital quality reports in Germany: patient and
physician opinion of the reported quality indicators. Germany: BMC Health Serv Res.; 2007 Sep
28; 7-157.
Bentes, Margarida; Gonçalves, Maria da Luz; Tranquada, Suzete; Urbano, João. A utilização
dos DGH’s como instrumento de financiamento hospitalar. Gestão Hospital, 33-42.
[6]
[7] PDF
RITA
[8] Ribeiro,
Nuno. Administração pública. TOC. 2000/08
Uriel, Zanon. Qualidade da assistência médico-hospitalar: conceito e avaliação de
indicadores.
2000
Jul-Set
RAS
_
Vol.
2,
Nº
8.
Available
from:
http://www.cqh.org.br/files/ARTIGORAS08.pdf
[9]
National report on health sector performance indicators 2003 [Internet]. Canberra: .
Australian Institute of Health and Welfare; 2004.
[10]