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What are the major strategies to ensure quality of care?

  • Australia

    The overarching strategy for ensuring quality of care is captured in the National Healthcare Agreement of the Council of Australian Governments (2012). 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 that of 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 (ACSQH) is the main body responsible for safety and quality improvement in health care. The ACSQH has developed service standards that have been endorsed by health ministers. These include standards for conducting patient surveys, which must be met by hospitals and day surgery centers to ensure accreditation. The Australian Bureau of Statistics, the national government statistical body, also undertakes an annual patient experience survey.

    The Australian Council on Healthcare Standards is the (nongovernment) agency authorized to accredit provider institutions. States license and register private hospitals and the health workforce, legislate on the operation of public hospitals, and work collaboratively through a National Registration and Accreditation Scheme to facilitate workforce mobility across jurisdictions while maintaining patient protections.

    The Royal Australian College of General Practitioners has responsibility for accrediting general practitioners (GPs). The Medicare Benefits Scheme (MBS) includes financial incentives such as the PIP, and approximately 85 percent of GPs are accredited. To be eligible for government subsidies, aged-care services must be accredited by the government-owned Aged Care Standards and Accreditation 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. The ACSQH has developed a national framework to support consistent registries.

    The National Health Performance Authority reports on the comparable performance of Local Hospital Networks (LHNs), public and private hospitals, and other key health service providers. The reporting framework, agreed to by the Council of Australian Governments (COAG), 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 that promote quality and safety of care through evidence-based clinical guidelines and best-practice advice. They include the National Health and Medical Research Council and Cancer Australia.

  • Canada

    Many 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 the territorial level. The use of financial incentives to improve quality is limited. At the physician level, these have had little demonstrable effect on quality to date. Professional revalidation for physicians, including requirements for continuing education and peer review, varies across provinces.

    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 to encourage the appropriate prescribing, purchasing, and use of medications. The Canadian Institute for Health Information produces regular public reports on health system performance, including indicators of hospital and long-term care performance. To date, there is no information available on doctors’ performance. The federally funded Canadian Foundation for Healthcare Improvement works with the provinces and territories to implement performance improvement initiatives, recently, for example, to reduce inappropriate prescribing for seniors in long-term care facilities. Accreditation Canada—a not-for-profit organization—provides noncompulsory accreditation services to about 1,200 health care organizations across Canada, including regional health authorities, hospitals, long-term care facilities, and community organizations.

    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). The provinces’ and territories’ premiers established the Health Care Innovation Work Group in 2012 to improve quality, for example, to promote guidelines for treating heart disease and diabetes and to reduce costs.

  • Switzerland

    Providers must be licensed 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.

    Increasing the quality of care is a priority of the federal strategy Health2020. The strategy includes the implementation of a national network for quality and of national quality programs in fields like medication safety and hospital infections. In 2008, the Swiss Inpatient Quality Indicators were introduced to monitor and evaluate the quality of care provided by acute-care hospitals. In addition, the National Association for Quality Improvement in Hospitals and Clinics (ANQ) publishes quality indicators for hospital inpatient care based on registries or patient surveys. Some registries are the result of private initiatives, while others, such as the cantonal cancer registries, are organized by the cantons themselves.

  • China

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

    To be accredited, hospitals must obtain a license from the local health authority. Physicians get their practice licenses through hospitals; licenses are subject to renewal. Several national rankings of hospitals are published by third parties, although there are no financial incentives for hospitals to meet quality targets. No public information about individual doctors is made available.

    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 the 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 in part 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 made available online for institutions but not for individual health providers at the hospital level. General quality and efficiency data are published regularly in national-level reports as a follow-up to national budget agreements between the state and the regions. Patient experiences are collected through 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 with which patients are diagnosed and treated. DDKM standards enforce the use of pathway programs and national clinical guidelines for all major disease types. The 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 all five regions are experimenting with such schemes. In general, regions are obliged to take action in the event of poor results. The Danish Health Authority can step in if 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.

  • Germany

    Quality of care is addressed through a range of measures broadly defined by law and in more detail by the Federal Joint Committee. As of 2016, the Institute for Quality and Transparency (IQTiG) is responsible for developing instruments for interfacility and intersectoral quality assurance on behalf of the Federal Joint Committee. In addition, the institute develops criteria for evaluating certificates and quality targets and ensures that the published results are comprehensible to the public.

    All hospitals are required to publish findings on selected indicators, as defined by the IQTiG, to enable hospital comparisons. Volume thresholds have been introduced for a number of complex procedures (e.g., transplants), requiring that hospitals perform a minimum number of such procedures to be reimbursed for them. Process and, in part, 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 introduces a focus on quality-related hospital accreditation and payment, beginning in 2016.

    Structural quality is further 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. For instance, all new diagnostic and therapeutic procedures applied in ambulatory care must receive a positive evaluation for benefit and efficiency before they can be reimbursed by sickness funds.

    Although there is no revalidation requirement for physicians, 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.

    The Robert Koch Institute, an agency subordinate to the Federal Ministry of Health and responsible for the control of infectious diseases and for 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.

    Disease management programs (DMPs), implemented in 2002, ensure quality of care for people with chronic illness. DMPs 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 other professional societies.

  • France

    National plans have been developed for treatment of rare diseases and a number of chronic conditions, including cancer and Alzheimer’s, and rare diseases, as well as for prevention and healthy aging. These plans establish governance (for example, 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 (HAS) 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 health ministry fund “provider networks” in which participating professionals share guidelines and protocols, agree on best practices, 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 or populations, like newborns or the elderly. 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 HAS. For hospital physicians, both can be performed as part of the hospital accreditation process.

    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, such as obstetrics, surgery, and 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 HAS 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 health ministry, 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.

  • England

    The Care Quality Commission (CQC) regulates all health and adult social care in England. All providers, including institutions, individual partnerships, and solo 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. The monitoring process includes results of national patient experience surveys.

    The National Institute of 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, 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 (which determine a portion 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, diagnosis-related group (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 also must be registered with the CQC.

  • India

    Over the years, several regulations have been enacted and authorities created at the state and national levels with the aim of protecting patients and improving quality of care. 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, several laws were introduced, including ones creating a national accreditation system for primary and secondary health care services. In addition, many hospitals undergo accreditation and certification from international bodies.

    The Health Management Information System was launched in 2008 to monitor health programs. Currently, about 633 of 667 districts report data by facility. Large-scale surveys 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. It has come into force in certain states and in all union territories except Delhi. In addition, the law requires facilities to charge rates for procedures and services as determined by the central government in consultation with the state. The act stipulates fines and penalties if provisions are breached by any facility. A national council will oversee implementation and compliance at the national level. Similar councils at the state and district levels will be established to enforce compliance locally. This is one of the most important, far-reaching pieces of public health legislation enacted to date. However, it is up to the states to adopt this, by passing suitable resolutions in their respective assemblies. If implemented and enforced well, it could change the supply side of health care in significant ways and go a long way toward meeting the comprehensive approach to quality assurance envisaged in the draft Health Policy for 2015.

    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.

    In recent years, there has been some progress in government regulation to ensure quality. However, the pace has been slow, and implementation is a challenge, in part because there is no single authority responsible for quality assurance. The lack of a coherent approach in this area has raised concerns about the extent to which government can influence the rapidly expanding private sector to adopt ethical and standardized health services.

  • 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. While the published data relate to the health plans as a whole, the plans also maintain internal data on regions, clinics, and individual physicians. The plans and their clinicians have made intensive use of these data to bring about substantial improvements in quality.

    The Ministry of Health (MoH) publishes comparative data on the quality of hospital care. This data system is much newer than the system for primary care quality and is currently limited to a relatively small number of indicators. However, it is expected to develop rapidly over the coming years. In addition, a new effort is under way to develop and implement quality indicators for continuity of care between hospital and community settings.

    The MoH is in the process of launching a national initiative to reduce waiting times for surgical procedures, and there are several other initiatives focused on the care of particular diseases, such as dementia. The ministry also collects and publishes data on individual hospitals’ waiting times for elective procedures. 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 as long as basic quality standards are met. Hospitals are also increasingly seeking, and securing, accreditation from Joint Commission International.

    An independent research institute carries out biannual surveys of the general population regarding the service level provided by the health plans and the level of satisfaction with the health system. The MoH recently launched an annual survey of hospitalized patients, publishing results for individual hospitals.

    There are currently no explicit financial incentives for hospitals and health plans to improve quality. However, owing 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 training in an accredited specialty program and passing an exam. There are no re-licensure exams for physicians.

  • Italy

    Government at both the national and regional levels are responsible for upholding quality and ensuring that services included in the essential levels of care are provided and that 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 have also been adopted by the private sector for its accreditation process and must be published annually, although dissemination methods are decided regionally. Most providers disseminate data through leaflets and the Internet. 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 are maintaining 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 are structural health care delivery regulations, relatively few apply to process and outcomes. Some fees are paid on the conditions that physicians in charge have certification of stipulated trainings.

    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 is voluntary; as of 2015, 26.7 percent of hospitals were accredited by the Japan Council for Quality Health Care, a nonprofit organization. However, there is no disclosure of names of hospitals that fail the accreditation process. Public reporting on performance is not obligatory, but the Ministry of Health, Labor and Welfare (MHLW) organizes and financially promotes a voluntary benchmarking project in which hospitals report quality indicators on their websites.

    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 not been mandatorily conducted but voluntarily.

    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. The council works to improve quality throughout the health system and develops clinical guidelines, although it does not have any regulatory power to penalize poorly performing providers.

    The Japanese Medical Specialty Board, a physician-led nonprofit body, is developing a new framework for standards and requirements of medical specialty certification. The system is to be implemented in the coming years.

    The government promotes the development of disease and medical device registries mostly for research and development. Surveys of hospital patients’ experiences are conducted every three years.

  • 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 population management pilot programs (initiatives that aim to rearrange health services and promote intersectoral collaboration at the regional level to improve population health and quality of care and to control health care costs) featuring quality targets were initiated but, as yet, specifics about the programs’ effects are unknown. Pay-for-performance constitutes a small portion of general practitioner (GP) funding. Patient experiences are also systematically assessed and, since 2007, a national center has been working with approved 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.

  • Norway

    The National Strategy for Quality Improvement in Health and Social Services (2005–2015) focused on efficacy, safety, efficiency, patient-centered care, care coordination, and continuity and equality in access to health care. 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, and a project to implement similar service packages is under way for mental health and addiction treatment. A five-year (2014–2018) national program aims to improve patient safety, and there is a national reporting and learning system for adverse events in hospitals. A total of 54 national clinical registries have been established for specific diseases, in addition to 15 national health registries. There is no registry for technical devices.

    The Directorate for Health is in charge of a national program for health care quality indicators. The program includes results from national patient experience surveys, as well as quality indicators for criteria such as survival rates, infection rates, and waiting times, and also indicators specific to the different medical areas. No information is gathered or disseminated regarding results or quality of individual health care professionals’ performance.

    The Registration Authority for Health Personnel, in the Directorate for Health, 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 of general practitioners (GPs) requires recertification. The Norwegian Board of Health carries out audits of all levels of the health system, including the health care workforce.

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

    A five-year developmental program (2013–2017) is under way for quality-based financing of RHAs, based on performance and improvement as measured by a set of indicators—29 indicators in 2014, 33 indicators in 2015, and 32 in 2016—with patient experiences constituting about 30 percent of the reporting. Quality-based financing amounts to only about 0.5 percent of the total of the RHAs’ budgets. An evaluation in 2015 did not identify particular downsides to this quality-based financing, but did identify improvement areas.

    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 prescription and use of drugs. Personal information held by the registry is anonymized.

  • New Zealand

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

    District health boards (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 DHBs. In addition, DHB performance on waiting times, access to primary care, and mental health outcomes is publicly disclosed. Also publicly reported are performance data on primary health organizations (PHOs), including screening rates for chronic disease. Data on individual doctors’ performance, however, are not routinely made available. As noted above, PHOs and general practitioners (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 “Patient Experience” surveys of randomly selected patients. The Health Quality and Safety Commission publishes the findings.

    Certification by the Ministry of Health is mandatory for hospitals, nursing homes, and assisted-living facilities. 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 Ministry of Health is also working on quality improvement in DHBs. “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.

    The Health Quality and Safety Commission aims to increase the focus on quality and coordinate DHB activities, such as those aimed at improving the patient journey, 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. These Quality Accounts report on how a DHB approaches 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 harm associated with falls, surgery, health care–associated infections, and medications. Since 2015, it has collated routine data in an annual report aimed at providing a “window” on the quality of New Zealand health care.

  • Singapore

    Singapore’s Ministry of Health conducts an annual patient satisfaction survey to gauge patient satisfaction levels and expectations regarding public health care institutions. The survey assesses waiting times, care coordination, and other health service attributes.

    Public and private hospitals, clinics, laboratories, and nursing homes are required to submit applications to the ministry for licensure. 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.

    The National Health System Scorecard uses internationally established indicators to compare performance. The Public Acute Hospital Scorecard measures institution-level performance, and similar scorecards for providers are being rolled out in primary care facilities and community hospitals. Public health care institutions are monitored to ensure compliance with the standards of service and key deliverables defined by the scorecards.

    In 2008, Singapore introduced national standards for health care to set priorities for improvement efforts and promote a culture of continuous quality improvement. The national standards, which focus on ensuring that public institutions provide appropriate care to satisfy patients’ needs, 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.

  • Sweden

    County councils are responsible for ensuring that health care providers deliver services of high quality. Their governance of providers includes assessing whether quality targets—those associated with a pay-for-performance scheme or tied to requirements for accreditation and its continuance—have been achieved. Providers are evaluated based on information from patient registries and national quality registries, surveys related to patient satisfaction, and dialogue meetings between providers and county councils.

    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 complications.

    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. To reduce unnecessary variation in clinical practice, there has been a trend toward development of regional guidelines to inform priority-setting. 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 more than 100 national quality registries are used for monitoring and evaluating quality among providers and for assessing treatment options and clinical practice. Registries store individualized data on diagnosis, treatment, and treatment outcomes. They are funded by the central government and by county councils, managed by specialist organizations, and monitored annually by an executive committee.

    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 2015 publication included 350 indicators, organized into various categories such as prevention, patient satisfaction, waiting times, trust, access, surgical treatment, and drug treatment. Some 100 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.

  • Taiwan

    Major Ministry of Health and Welfare (MoHW) quality-monitoring systems and the offices governing them include:

    • Hospital accreditation and patient safety (Department of Medical Affairs)
    • NHI program administration (National Health Insurance Administration)
    • Communicable disease control (Centers for Disease Control and Prevention)
    • Cancer prevention and control (Health Promotion Administration)

    Major National Health Insurance Administration (NHIA) strategies to ensure quality of care fall into three broad categories:

    1. Payment incentives: A number of programs have specific funding to improve quality, such as extra bonuses for serving patients in remote and mountainous areas or offshore islands (integrated delivery system [IDS] plans) and pay-for-performance schemes for management of chronic conditions, including asthma, diabetes, breast cancer, and schizophrenia.
    2. Claims management and reviews: Because of the massive volume of claims submitted each day, the review process follows two tracks: a fully automated procedural review utilizing profile analysis based on specific medical criteria and a peer review of randomly selected claims.
    3. Information-sharing and transparency: Public reporting systems targeting hospitals and pharmaceuticals (see discussion of PharmaCloud below) are in place to improve quality and reduce waste.

    The NHIA has developed several hundred quality indicators, some intended for pay-for-performance schemes, some for calculating global budgets, and others for public disclosures and claims review. Many of these serve the dual purpose of improving quality and reducing costs. Important national programs for quality assurance and improvement include:

    • Integrated delivery system (IDS) plans (discussed earlier)
    • Pay-for-performance disease-management programs (discussed above)
    • Family Physicians Integrated Care Plan
    • Hospital Patient-Centered Integrated Care Plan for outpatients age 65 and older with two or more chronic conditions
    • Capitation Pilot Project
    • NHI PharmaCloud (see below)
    • My Health Bank (see below)
    • Post-Acute Care Pilot Project for stroke patients
    • Integrated Post-Acute Care program for burn patients
    • Artificial Joints Registry System to improve patient safety, reduce amenable mortality from unsafe artificial joints, and quality of care (launched in 2016).

    Each July, the National Health Insurance (NHI) Committee meets with scholars and experts to review and grade the five sectoral global budgets for their performance on service delivery, quality, public satisfaction, inappropriate use of resources, and other criteria. There are five grades: exceptional, excellent, good, fair, and bad (the last of which has never been assigned). Each sectoral global budget’s funding allocation increase for the following year is based on the grade it receives—a 0.5 percent increase for exceptional, 0.3 percent for excellent, and so on.

  • 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 (see below).

    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. The 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, 30-day readmission rates nationally for conditions subject to penalties have declined from 21 percent to less than 18 percent. 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, with a 17 percent decline over the first three years.

    The U.S. Department of Health and Human Services (HHS) also set a goal of tying 85 percent of all traditional Medicare payments to quality or value by 2016 and 90 percent by 2018 through these programs and others, such as Hospital Value Based Purchasing.