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What are the major strategies to ensure quality of care?

  • Australia

    The Council of Australian Governments (COAG) has endorsed the National Healthcare Agreement that provides an overarching strategy for quality care in Australia. The agreement sets out the common objective of Australian governments in providing health care—improving outcomes for all and the sustainability of the system—and the performance indicators and benchmarks on which progress is assessed. It also sets out national-priority policy directions, programs, and areas for reform, such as major chronic diseases and their risk factors. Indicators and benchmarks in the agreement address issues of quality from primary to tertiary care and include disease-specific targets of high priority, as well as general benchmarks.

    The Australian Commission on Safety and Quality in Health Care (ACSQHC) promotes, supports and encourages the implementation of arrangements, programs and initiatives relating to health care safety and quality matters. The ACSQHC has developed health service standards that have been endorsed by health ministers. These standards require hospitals and day procedure services to routinely conduct patient surveys. Meeting these standards is a requirement for accreditation.

    The Australian Bureau of Statistics (ABS), the national government statistical body, also undertakes an annual patient experience survey.

    The ACSQHC has approved nine nongovernment agencies to accredit health service organisations. States license and register private hospitals, legislate on the operation of public hospitals, and work collaboratively through a National Registration and Accreditation Scheme, which registers and facilitates workforce mobility across jurisdictions while maintaining patient protections.

    The Royal Australian College of General Practitioners has developed standards for the accreditation of general practices. The Medicare Benefits Scheme (MBS) includes financial incentives such as the Practice Incentives Program (PIP), and approximately 80 percent of GPs are accredited.

    To be eligible for government subsidies, aged care services must be accredited by the government-owned Australian Aged Care Quality Agency.

    There are a number of disease and device registries. Government-funded registries are housed in universities and nongovernmental organizations, as well as within state governments. ACSQHC has developed a national framework to support good governance of clinical quality registries.

    The former National Health Performance Authority (soon to be replaced by the Australian Institute of Health and Welfare) reports on the comparable performance of local health networks, public and private hospitals, and other key health service providers. The reporting framework was agreed to by the COAG, and includes measures of equity, effectiveness, and efficiency.

    The federal government has regulatory oversight of quarantine, blood supply, pharmaceuticals, and therapeutic goods and appliances. In addition, there are a number of national bodies who promote quality and safety of care through evidence-based clinical guidelines and best-practice advice. They include the National Health and Medical Research Council, Cancer Australia and the National Blood Authority.

  • Canada

    Since 2014, there have been no new national strategies initiated to ensure quality of care, although in the previous decade the Canada Health Accord provided for dedicated federal funding to provinces to achieve common goals in wait times, primary care, and home care. Some provinces have agencies responsible for producing health care system reports and for monitoring system performance, and many quality improvement initiatives take place at the provincial and territorial level. Examples include the Saskatchewan Health Quality Council, Health Quality Ontario, the British Columbia Patient Safety & Quality Council, and the New Brunswick Health Council.

    The use of financial incentives to improve quality is limited. For example, since 2010, Ontario hospitals have been required to develop and report quality improvement plans, and executive compensation has been linked to the achievement of targets set out in these plans.

    The federally funded Canadian Patient Safety Institute promotes best practices and develops strategies, standards, and tools. The Optimal Use Projects program, operated by the Canadian Agency for Drugs and Technologies in Health, provides recommendations (though not formal clinical guidelines) to providers and consumers in order to encourage the appropriate prescribing, purchasing, and use of medications. The Canadian Institute for Health Information produces regular reports on health system performance.

    There is no system of professional revalidation for physicians in Canada, but each province has its own process of ensuring that physicians engage in lifelong learning, such as a requirement that they participate in a continuing education program, and undergo peer review. There is no information available on doctors’ performance. Accreditation Canada—a not-for-profit organization—provides voluntary accreditation services to about 1,200 health care organizations across Canada, including regional health authorities, hospitals, long-term care facilities, and community organizations.

    Few formal disease registries exist, although many provincial cancer care systems maintain some type of patient registry. Provincial cancer registries feed data to the Canadian Cancer Registry, a national administrative survey that tracks cancer incidence. There is no national patient survey, although a standardized acute-care hospital inpatient survey developed by the Canadian Institute for Health Information has been implemented in several provinces. Each province has its own strategies and programs to address chronic disease (see below).

  • China

    The Department of Health Care Quality within the Bureau of Health Politics and Hospital Administration and overseen by the National Health and Family Planning Commission is responsible for quality of care at the national level. The National Health Service Survey is conducted every five years (the latest in 2013), and a report is published after each survey highlighting data on selected quality indicators.

    Hospitals must obtain licenses from local health authorities for hospital accreditation. Physicians get their practice licenses through hospitals, and they have to renew their licenses after a certain period. Several national hospital rankings are available from third parties to, but there are no financial incentives for hospitals to meet quality targets.

    Following release of the “Temporary Directing Principles of Clinical Pathway Management” by the former Ministry of Health in 2009, clinical pathways are now regulated nationally and used in a similar manner as clinical guidelines are in Western countries. Previously, pathways were created at the hospital, rather than national, level.

  • Denmark

    The Danish Healthcare Quality Programme (DDKM), based on accreditation and a set of accreditation standards, was in operation at the hospital level through 2015. It is currently being replaced in hospitals with a new program featuring fewer standards and more emphasis on clinical and local dimensions (due partially to pressure from the medical profession). The DDKM continues to be rolled out in primary and municipal health care.

    Quality data for a number of treatment areas are captured in clinical registries and published online for institutions, but not for individual health providers at the hospital level . General quality and efficiency data are also published regularly in national level reports as a follow-up to national budget agreements between the state and the regions. Patient experiences are collected though biannual national, regional, and local surveys.

    The Danish Health Authority has laid out standard treatment pathways, with priorities including chronic disease prevention and follow-up interventions. Pathways for 34 cancers have been in place since 2008, covering nearly all cancer patients. The authority monitors pathways and the speed at which patients are diagnosed and treated. DDKM standards enforce the use of pathway programs and national clinical guidelines for all major disease types. Regions develop more specific practice guidelines for hospitals and other organizations, based on general national recommendations. There are no explicit national economic incentives tied to quality, but several regions are experimenting with such schemes. In general, regions are obliged to take action in case of poor results, and may fire hospital managers or introduce other measures to support quality improvement. The Danish Health Authority can step in if entire regions fail to live up to standards.

    The Danish Patient Safety Authority was created in 2015 when the former Danish Health and Medicines Authority was split into separate agencies. It receives anonymized reports of accidents and near-accidents that health care professionals at all levels are obliged to submit to regional authorities, which evaluate the incidents. The information is published in an annually updated database, with the intention of fostering learning rather than sanctioning.

  • England

    The Care Quality Commission (CQC) has responsibility for the regulation of all health and adult social care in England. All providers, including institutions, individual partnerships, and sole practitioners, must be registered with the CQC, which monitors performance using nationally set quality standards and investigates individual providers when concerns have been raised (e.g., by patients). It rates hospitals’ inspection results and can close down poorly performing services. New “fundamental standards” for all health and social care came into force in 2015 (Department of Health, 2014a). The monitoring process includes results of national patient experience surveys.

    The National Institute for Health and Clinical Excellence (NICE) develops quality standards covering the most common conditions occurring in primary, secondary, and social care. National strategies have been published for a range of conditions, from cancer to trauma. There are national registries for key disease groups and procedures. Maximum waiting times have been set for cancer treatment, elective treatments, and emergency treatment. A website, National Health Service (NHS) Evidence, provides professionals and patients with up-to-date clinical guidelines. Support is also provided by NHS Quality Improvement, part of NHS England.

    Information on the quality of services at the organization, department, and (for some procedures) physician levels is published on NHS Choices. Results of inspections by the CQC are also publicly accessible. The Quality and Outcomes Framework provides general practices with financial incentives to improve quality. General practices are awarded points (determining part of their remuneration) for keeping a disease registry of patients with certain diseases or conditions and their management and treatment. For hospitals, 2.5 percent of contract value is linked to the achievement of a limited number of quality goals through the Commissioning for Quality and Innovation initiative. In addition, DRG rates for some procedures are linked to best practice.

    All doctors are required by law to have a license to practice from the General Medical Council. Similar requirements apply to all professions working in the health sector. A process of revalidation every five years is being introduced for doctors. Providers of hospital services must also be registered with the CQC.

  • France

    National plans are developed for a number of chronic conditions (e.g., cancer, Alzheimer’s), rare diseases, prevention, and healthy aging, in addition to the 104 targets set by the 2004 Public Health Act. These plans establish governance (e.g., the cancer plan to coordinate research and treatment in cancer and establish guidelines for medical practice and activity thresholds), develop tools, and coordinate existing organizations. All plans emphasize the importance of supporting caregivers and ensuring patients’ quality of life, in addition to enforcing compliance with guidelines and promoting evidence-based practice.

    The National Health Authority publishes an evidence-based basic benefit package for 32 chronic conditions. Further guidance on recommended care pathways covers chronic obstructive pulmonary disease, heart failure, Parkinson’s, and end-stage renal disease.

    Statutory health insurance (SHI) and the Ministry of Health fund “provider networks” in which participating professionals share guidelines and protocols, agree on best practice, and have access to a common patient record. Regional authorities fund telemedicine pilot programs to improve care coordination and access to care for specific conditions (e.g., stroke) or populations (e.g., newborns, the elderly, prisoners). The PAERPA (Personnes Agées en Risque de Perte d’Autonomie) program, established in 2014 in nine pilot regions, is a nationwide endeavor to improve the quality of life and coordination of interventions for the frail elderly.

    For self-employed physicians, certification and revalidation are organized by an independent body approved by the National Health Authority. For hospital physicians, both can be performed as part of the hospital accreditation process.

    To ensure the lifelong quality of their practice, doctors, midwives, nurses, and other professionals must undergo continuous learning activities, which are audited every fourth or fifth year. Optional accreditation exists for a number of high-risk medical specialties (e.g., obstetrics and gynecology, surgery, cardiology). Accredited physicians can claim a deduction on their professional insurance premiums.

    Hospitals must be accredited every four years; criteria and accreditation reports are publicly available on the National Health Authority website ( CompaqH, a national program of performance indicators, also reports results on selected indicators. Quality assurance and risk management in hospitals are monitored nationally by the Ministry of Health, which publishes online technical information, data on hospital activity, and data on control of hospital-acquired infections. Currently, financial rewards or penalties are not linked to public reporting, although they remain a contested issue.

    Information on individual physicians is not available.

  • Germany

    Quality of care is addressed through a range of measures broadly defined by law, and in more detail by the Federal Joint Committee. Structural quality is assured by the requirement that providers have a quality management system, by the stipulation that all physicians continue their medical education, and by health technology assessments for drugs and procedures. However, there is no revalidation requirement for physicians. Hospital accreditation is voluntary.

    All new diagnostic and therapeutic procedures applied in ambulatory care must be positively evaluated in terms of benefits and efficiency before they can be reimbursed by sickness funds. Volume thresholds have been introduced for a number of complex procedures (e.g., transplantations), requiring a minimum number of such procedures for hospitals to be reimbursed. Process and (partly) outcome quality are addressed through the mandatory quality reporting system for the roughly 2,000 acute-care hospitals. The recently passed Hospital Care Structure Reform Act will provide a focus on quality-related hospital accreditation and payment, beginning in 2016.

    Disease management programs are modeled on evidence-based treatment recommendations, with mandatory documentation and quality assurance. Nonbinding clinical guidelines are produced by the Physicians’ Agency for Quality in Medicine and by professional societies.

    All hospitals are required to publish results on selected indicators defined by the Federal Office for Quality Assurance and, until 2015, the AQUA Institute, allowing for hospital comparisons.

    Many institutions and health service providers include complaint management systems as part of their quality management programs; in 2013, such systems were made obligatory for hospitals. At the state level, professional providers’ organizations are urged to establish complaint systems and arbitration boards for the extrajudicial resolution of medical malpractice claims.

    To strengthen quality by law, in addition to the above, government commissioned the Federal Joint Committee in 2015 to establish the Institute for Quality and Transparency in Health Care, replacing the AQUA Institute. The institute will be operational from January 2016, with the task of developing further indicators for quality assurance, which might provide an additional criterion for decisions on hospital planning and payment.

    The Robert Koch Institute, an agency subordinate to the Federal Ministry of Health and responsible for the control of infectious diseases and health reporting, has conducted national patient surveys and published epidemiological, public health, and health care data. Disease registries for specific diseases, such as certain cancers, are usually organized regionally. In August 2013, as part of the National Cancer Plan, the federal government passed a bill that proposes the implementation of a nationwide standardized cancer registry in 2018 to improve the quality of cancer care.

  • India

    Over the years, several regulations have been enacted and authorities created at the state and national level with the aim of protecting patients and improving quality of care. For example, at the state level, the Nursing Home Act and State Drug Controllers ensure quality of care provided by the private sector. A major impetus to establishing patient rights was the inclusion of private medical practice under the Consumer Protection Act in 1986. To ensure quality of care and define standards for health facilities, a number of laws were introduced, including those creating a national accreditation system, the National Accreditation Board for Hospitals, and the Indian Public Health Standards for primary and secondary health care services. In addition, many hospitals undergo accreditation and certification from international bodies such as the Joint Commission International and the International Organization for Standardization.

    The Health Management Information System was launched in 2008 to monitor health programs and provide key inputs for monitoring and policy formulation. Currently, about 633 of 667 districts report data by facility. Large-scale surveys like the National Family Health Survey, the District-Level Household Survey, and the Annual Health Survey are periodically undertaken at the district, state, and national levels. In addition, the Indian Council of Medical Research maintains disease registries for cancer, diabetes, cardiovascular diseases, and other illnesses.

    The 2010 Clinical Establishments (Registration and Regulation) Act calls for prescribing minimum standards for all public and private clinical establishments in the country. The act has already come into force in certain states (e.g., Arunachal Pradesh, Himachal Pradesh, Mizoram and Sikkim) and in all union territories. In addition, facilities shall charge rates as determined by central government in consultation with the state. The act stipulates fines and penalties if provisions are breached by any facility. A national council for clinical establishment will oversee implementation and compliance at the national level. Similar councils at the state and district levels will be established to enforce compliance locally.

    Currently, a shift to one comprehensive approach of quality assurance is envisaged to replace the existing fragmented approach. For public health care facilities, the strategy would ensure that every facility is measured and scored for quality, and certified and incentivized when it achieves a certain minimum score. Quality measures would include clinical quality as well as patient safety, comfort, and satisfaction. In the private sector, voluntary accreditation with certificates like that of National Accreditation Board for Hospitals and National Accreditation Board for Testing and Calibration Laboratories would predominate. For private facilities that are part of a public–private partnership, quality certification would be mandatory either through those boards or through the public system.

    To ensure quality of medical education, a common national entrance exam is being debated. A licentiate exam will be introduced for all medical graduates, with renewal at periodic intervals.

    Although there has been some progress made and new legislation introduced, progress in government regulation has been slow and implementation challenging , and there is no single government authority responsible to ensure quality of care. Although the Clinical Establishments (Registration and Regulation) Act is one of the most important, far-reaching pieces of public health legislation enacted to date, its effective and uniform implementation in each state remains to be seen.

  • Israel

    For over a decade, Israel has had a well-developed system for monitoring the quality of primary care. Comparative quality data for individual health plans has been made public since 2014 (Jaffe, 2012). While the published data relate to the health plans as a whole, the plans have internal data by region, clinic, and individual physician. The plans and their clinicians have made intensive use of this data to bring about substantial improvements in quality.

    The Ministry of Health (MoH) publishes comparative data on the quality of hospital care. This system is much newer than the system for primary care quality and is currently limited to a handful of indicators. However, it is expected to develop rapidly over the coming years.

    The MoH is in the process of launching a national initiative to reduce waiting times for surgical procedures, and there are several initiatives focused on the care of particular diseases, such as dementia. The health plans are increasingly active in implementing programs for the chronically ill, including disease management.

    Hospitals and clinics require a license from the MoH, granted only when basic quality standards are met. Hospitals are also increasingly seeking, and securing, accreditation from Joint Commission International.

    There are biannual surveys of the general population regarding the service level provided by the health plans. The MoH recently launched an annual survey of hospitalized patients. Results are published by institution.

    There are currently no explicit financial incentives for hospitals and health plans to improve quality. However, due to the competitive environment, public dissemination of quality data may be providing an indirect incentive. Consideration is being given to introducing a limited number of pay-for-performance incentives in the years ahead.

    National registries are maintained by the MoH for certain expensive medical devices and for a broad range of diseases and conditions, including: cancer, low birth weight, trauma, and occupational diseases.

    To receive a medical license from the MoH, persons who studied in an Israeli medical school must also successfully complete a one-year internship. Those who studied abroad are usually also required to pass an examination. Specialty recognition requires specialty training in an accredited program and passing an exam. The there are no re-licensure exams for physicians.

  • Italy

    National and regional governments, responsible for upholding quality, ensure that services included in the essential levels of care are provided and waiting times are monitored. Several regions have introduced programs for prioritizing delivery of care on the basis of clinical appropriateness of services prescribed and patient severity. All doctors under contract with the National Health Service must be certified, and all National Health Service staff participate in compulsory continuing education. The National Commission for Accreditation and Quality of Care is responsible for outlining the criteria used to select providers and for evaluating regional accreditation models (including private hospitals), which vary considerably across the system. These models do not usually include periodic reaccreditation.

    Legislation passed during the 1990s covers three main components of quality: input (quality of infrastructure and human resources); process (appropriateness and timeliness of interventions); and outcome (health status and patient satisfaction).

    National legislation requires all public health care providers to issue a “health service chart” with information on service performance, quality indicators, waiting times, quality assurance strategies, and the process for patient complaints. These charts also have been adopted by the private sector for its accreditation process, and must be published annually, although dissemination methods are decided regionally. Most providers issue data through leaflets and the Internet, while nurses and other medical staff are offered financial performance incentives (linked to manager evaluations but not to publicly reported data).

    The National Plan for Clinical Guidelines (Piano Nazionale Linee Guida) has been implemented in recent years and has produced guidelines on topics ranging from cardiology to cancer prevention and from appropriate use of antibiotics to cesarean delivery.

    Some regions have introduced disease management programs, are experimenting with chronic care models (refer to the section on coordination) and maintain registries, mainly for cancer patients and diabetes. No national registries exist. Patient surveys are not used for quality control.

  • Japan

    By law, prefectures are responsible for making health care delivery “visions,” which include detailed plans on cancer, stroke, acute myocardial infarction, diabetes mellitus, psychiatric disease, pediatric, and home care, as well as emergency, prenatal, rural, and disaster medicine. These plans include structural, process, and outcome indicators, as well as strategies for effective and high-quality delivery. Prefectures promote collaboration between providers to achieve them, with or without subsidies as financial incentives.

    Waiting times are generally not monitored by government, although there is cause for concern in some clinical areas, such as palliative care. Although there are structural health care delivery regulations, relatively few apply to process and outcomes.

    Prefectures are in charge of the annual inspection of hospitals. Sanctions include reduced reimbursement rates if staffing per bed falls below a certain ratio. Hospital accreditation, on the other hand, is voluntary and undertaken largely as an improvement exercise; roughly one-third of hospitals are accredited by the Japan Council for Quality Health Care. However, there is no disclosure of names of hospitals that fail the accreditation process. The Ministry of Health, Labor and Welfare organizes and financially supports a voluntary benchmarking project, in which hospitals report quality indicators on their websites.

    In order to practice, physicians are required to obtain a license by passing a national exam, but they are not subject to revalidation. However, specialist societies have introduced revalidation for qualified specialists. Clinical audits are voluntary. Public reporting on performance has been discussed but is not yet implemented.

    Every prefecture has a medical safety support center for handling complaints and promoting safety. Since 2004, advanced academic and public hospitals have been required to report adverse events to the Japan Council for Quality Health Care.

    Disease and medical device registries have been developed on a voluntary basis, possibly to be used for quality improvement in the future. Surveys of hospital patients’ experiences are conducted every three years.

  • The Netherlands

    At the system level, quality is ensured through legislation governing professional performance, quality in health care institutions, patient rights, and health technologies. In 2014, the National Health Care Institute was established to further accelerate the process of quality improvement and evidence-based practice. The Dutch Health Care Inspectorate is responsible for monitoring quality and safety. Most quality assurance is carried out by providers, sometimes in close cooperation with patient and consumer organizations and insurers. There are ongoing experiments with disease management and integrated care programs for the chronically ill.

    In the past few years, many parties have been working on quality registries. Most prominent among these are several cancer registries and surgical and orthopedic (implant) registries. Mechanisms to ensure the quality of care provided by individual professionals include reregistration of specialists contingent upon compulsory continuous medical education; regular on-site peer assessments by professional bodies; and professional clinical guidelines, indicators, and peer review. The main methods used to ensure quality in institutions include accreditation and certification; compulsory and voluntary performance assessment based on indicators; and national quality improvement programs. Furthermore, quality of care is supposed to be enhanced by selective contracting (e.g., volume standards for breast cancer treatment).

    In 2014, a few pay-for-performance pilot programs featuring quality targets were initiated but, as yet, specifics about the programs and effects are unknown. Moreover, in the new GP funding model, part of the old budget is preserved for pay-for-performance projects. Patient experiences are also systematically assessed and, since 2007, a national center has been working with validated measurement instruments in an approach comparable to that of the Consumer Assessment of Healthcare Providers and Systems, in the United States. Although progress has been made, public reporting on quality of care and provider performance is still in its infancy in the Netherlands. To stimulate the transparency movement, the Ministry of Health called 2015 the “year of transparency.”

  • New Zealand

    The aforementioned health and disability commissioner investigates patient complaints, reports directly to Parliament, and has been active in promoting quality and patient safety.

    DHBs are held formally accountable to government for delivering efficient, high-quality care in hospitals, as measured by the achievement of targets across a range of indicators. These include six “health targets,” published quarterly, that aim to stimulate competition among district health boards (DHBs) and are enforced by financial sanctions if not met. In addition, DHB performance with regard to waiting times, access to primary care, and mental health outcomes is publicly disclosed. Also publicly reported are data comparing the performance of primary health organizations (PHOs), including such information as screening rates for chronic diseases. Data on individual doctors’ performance, however, are not routinely made available. As noted above, PHOs and GPs receive performance payments for achieving various targets.

    DHBs and individual GP clinics and networks run various chronic disease management programs. There are national registries for some diseases, including diabetes, cardiovascular disease, and cancers. Since 2014, public hospitals have been required to conduct a nationally standardized survey of a random sample of patients and to submit data to the Health Quality and Safety Commission, which publicizes the findings.

    Certification by the Ministry of Health is mandatory for hospitals, nursing homes, and assisted-living facilities, which must meet published and defined health and disability standards. All practicing health professionals must be certified annually by the relevant registration authority (e.g., for doctors, the Medical Council of New Zealand), which has ongoing responsibility for ensuring professional standards and providing accreditation. Registration authorities supervise individual professionals where appropriate.

    The Health Quality and Safety Commission is intended to increase the focus on quality and coordinate the varied approaches to quality improvement across DHBs, such as those aimed at improving the patient journey, ensuring safer medication management, reducing rates of health care–associated infection, and standardizing national incident reporting. Other initiatives include the ongoing development of the Atlas of Healthcare Variation (an online tool aimed at highlighting variations in the provision and use of services by geographic area); a series of standard quality and safety indicators for DHBs based on routinely collected data; a program for consumer involvement in service design; and advice for DHBs on how to prepare annual “Quality Accounts,” required since 2012–2013. Much like a financial account, Quality Accounts report on how the DHB has approached quality improvement, including descriptions of key initiatives and their results. In 2013, the commission launched a national patient safety campaign, Open for Better Care, focused on reducing the negative consequences associated with falls, surgery, health care–associated infections, and medications.

    The National Health Board is also working on quality improvement in DHBs, with particular emphasis on management systems, clinical services, and patient pathways. “Clinical governance” has been implemented in most DHBs, meaning that management and health professionals are assuming joint accountability for quality, patient safety, and financial performance.

  • Norway

    The national strategy for quality improvement (2005–15) focuses on efficacy, safety, efficiency, patient-centered care, care coordination, and continuity and equality in access to health care (Directorate for Health 2005). National evidence-based guidelines are being developed for a number of diseases. For cancer, there is a disease management program, introducing defined “packages” to be delivered to patients. To improve patient safety, there is a five-year national program (2014–18), as well as a national reporting and learning system for adverse events. There are 47 national clinical registries for specific diseases, as well as 15 national health registries. There is no registry for technical devices, but a statutory duty for hospitals to report adverse events, including those involving technical equipment.

    The Directorate for Health is in charge of the national program for health care quality indicators. The program includes results from national patient experience surveys. No information is gathered or disseminated regarding results or quality of individual health care professionals’ performance. The Registration Authority for Health Personnel licenses and authorizes all health care professionals and can grant full and permanent approval to those meeting educational and professional criteria. There is no system for reevaluation or reauthorization. The authority issues certificates of specialization to medical doctors, in accordance with specific and transparent requirements. Only the specialization for GPs requires recertification. The Norwegian Board of Health carries out audits of all levels of the health system, including the health care workforce.

    Regional health care authorities (RHAs), hospitals, municipal providers and private practitioners are responsible for ensuring the quality of their services. There is no requirement for accreditation or re-accreditation, although some hospitals or hospital departments are accredited.

    A five-year developmental period (2013–17) is under way for quality-based financing of RHAs, based on performance and improvement on a set of indicators—29 indicators in 2014, increased to 33 indicators in 2015—of which patient experiences constitute about 30 percent of the reporting. Quality-based financing constitutes only about 0.5 percent of the total of the RHAs’ budgets.

    The Norwegian Institute of Public Health uses the Norwegian Prescription Database to produce annual reports on prescribing trends, giving national health authorities a statistical base for planning and monitoring the prescribing and use of drugs. Personal information held by the registry is anonymized.

  • Singapore

    Singapore’s Ministry of Health conducts an annual survey to gauge patient satisfaction and expectations regarding public health care institutions. The survey measures satisfaction with waiting times, facilities, and care coordination, among other health system attributes. Results of the 2012 survey show that 77 percent of respondents were satisfied, and that 78 percent of patients would “strongly recommend” or “likely recommend” institutions to others based on their own experience.

    Public and private hospitals, clinics, laboratories, and nursing homes are required to submit applications to the health ministry for operating licenses. Physicians wishing to practice in Singapore must secure a position with a health care institution and register with the Singapore Medical Council, which maintains the official Register of Medical Practitioners. Physicians are required to fulfill continuing medical education requirements administered by the Medical Council. For institutions, prelicensing inspections are conducted to ensure standards.

    Singapore uses a performance measurement and management process to help health care providers assess and benchmark their performance against peers. The National Health System Scorecard uses internationally established performance indicators to compare performance. The Public Acute Hospital Scorecard is used to measure institution-level performance. Its indicators cover clinical quality and patient perspectives. Similar scorecards for providers are being rolled out in primary care facilities and in community hospitals.

    The scorecards define standards of service and key deliverables required of public health care institutions, and institutions are monitored to ensure compliance. The scorecards incorporate internationally accepted indicators and definitions where possible, such as the U.S. Center for Medicare and Medicaid Services’ Joint Commission– aligned measures for acute myocardial infarction and stroke.

    In 2008, Singapore introduced national standards for health care to set priorities for improvement efforts and alignment with planning initiatives. These standards focus on key areas of concern and are intended to promote a culture of continuous quality improvement. The national standards are implemented through the network of Healthcare Performance Offices, each chaired by a senior clinical leader who reports directly to the institution’s chief executive officer or medical board chairman. Resulting quality improvement outputs can then be incorporated into the National Health System Scorecard and the Public Acute Hospital Scorecard for performance analysis and monitoring.

  • Sweden

    County councils are responsible for accrediting health care providers and following up on conditions for accreditation. These activities include assessing whether quality targets—those associated with a pay-for-performance scheme or tied to requirements for continued accreditation—have been achieved. Providers are evaluated based on information from patient registries and national quality registries, surveys related to patient satisfaction, and clinical audits.

    Concern for patient safety has increased during the past decade, and patient safety indicators are compared regionally (see below). Eight priority target areas for preventing adverse events have been specified: health care–associated urinary tract infections; central line infections; surgical site infections; falls and fall injuries; pressure ulcers; malnutrition; medication errors in health care transitions; and drug-related problems.

    The National Board of Health and Social Welfare, together with the National Institute for Public Health and the Dental and Pharmaceutical Benefits Agency, conducts systematic reviews of evidence and develops guidance for establishing priorities in support of disease management programs developed at the county council level. International guidelines and specialists are also central to the development of these local programs. There is a tendency to develop regional guidelines to inform the setting of priorities in order to avoid unnecessary variation in clinical practice. For example, the National Cancer Strategy was established in 2009, and six Regional Cancer Centers (RCCs) were formed in 2011. The RCCs’ role is to contribute to more equitable, safe, and effective cancer care through regional and national collaboration.

    The 90 or so national quality registries are used for monitoring and evaluating quality among providers and for assessing treatment options and clinical practice. Registries contain individualized data on diagnosis, treatment, and treatment outcomes. They are monitored annually by an executive committee, funded by the central government and by county councils, and managed by specialist organizations.

    Since 2006, the government has published annual performance comparisons and rankings of the county councils’ health care services, using data from the national quality registers, the National Health Care Barometer Survey, the National Waiting Time Survey, and the National Patient Surveys. The 2012 publication included 169 indicators, organized into various categories such as prevention, patient satisfaction, waiting times, trust, access, surgical treatment, and drug treatment. Some 50 indicators are shown also for hospitals, but without rankings. Statistics on patient experiences and waiting times in primary care are also made available through the Internet ( to help guide people in their choice of provider.

  • Switzerland

    Providers must be licensed in order to practice medicine, and are required to meet educational and regulatory standards; continuing medical education for doctors is compulsory. Local quality initiatives, often at the provider level, include the development of clinical pathways, medical peer groups, and consensus guidelines. However, there are no explicit financial incentives for providers to meet quality targets.

    The Quality Strategy, approved by the SFC at 2009, takes a broad conceptual approach with different fields of action, including the implementation of a national pilot program by the Swiss Foundation for Patient Security on medication safety in acute-care hospitals, a pilot program to reduce hospital infections, and the publication of quality indicators for acute-care hospitals. Quality-control mechanisms usually do not involve information from registries or patient surveys. Registries are organized by private initiatives or cantons, such as the cantonal cancer registries.

    At the end of 2013, the Swiss Federal Council (SFC) mandated a task force led by the cantons and the Swiss Confederation (the Dialogue on National Health Policy) to work out a national strategy for the prevention of noncommunicable diseases (NCDs) by 2016. The strategy aims to improve the health competence of the population and promote healthy living conditions. The National Health Report discusses the growing number of case management programs for chronic illnesses.

  • United States

    In 2011, the U.S. Department of Health and Human Services released the National Quality Strategy, a component of the Affordable Care Act (ACA) that lays out national aims and priorities to guide local, state, and national quality improvement efforts, supported by an array of partnerships with public and private stakeholders. Current initiatives include efforts to reduce hospital-acquired infections and preventable readmissions.

    The Centers for Medicare and Medicaid Services (CMS) has moved toward increased public reporting of provider performance data in an effort to promote improvement. One such initiative is Hospital Compare, a service that reports on measures of care processes, care outcomes, and patient experience at more than 4,000 hospitals. In additionally, with support from the ACA and such groups as the Open Government Partnership, CMS is making Medicare data available to “qualified entities,” such as health improvement organizations, which are beginning to release data on payments made by Medicare to individual physicians and amounts paid to physicians and hospitals by pharmaceutical and device companies. Release of such information is intended to both increase transparency and improve quality.

    States have developed additional public reporting systems and measures, including some that address ambulatory care. Consumer-led groups, such as Consumers Union and the Leapfrog Group, also report on quality and safety.

    Incentives to reduce avoidable hospital readmissions among Medicare patients were introduced in October 2012, by way of financial penalties. Since the program’s initiation, 20-day readmission rates nationally have declined from 19 percent to less than 18 percent. (16) Incentives to reduce hospital-acquired conditions, by reducing Medicare payments to the lowest-performing hospitals by 1 percent, were also introduced. Recent data show the first-ever decline in rates of hospital-acquired conditions nationally.

    Finally, Medicare, and the majority of private insurance providers, is implementing a variety of pay-for-value programs. Starting in 2013, 1 percent of Medicare payments are redistributed to the highest performers on a composite of cost and quality measures. The program was introduced to physicians in 2015 on a voluntary basis and is expected to become mandatory by 2017. As yet, results are too preliminary to draw conclusions.