Establishing Quality Markers for Health Assistance

In the last century the concept has been introduced that any citizen has right to the same quality assistance independently of the social and economical conditions. This means obviously an increase of health expenses which grows time by time in relation to the technical development of the health assistance and the increase of life expectancy.

In the next future a large increase of the costs can be expected due to the increasing percentage in the population of aged people and to the extension of assistance to poor countries.

It is therefore important to reduce the health expenses, without diminishing the quality. It must found solutions which help in solving this problem apparently insoluble since the requests increase as well the expectancy from the citizens which are more conscious and more cultured.

From this time also review in relation to the efficiency and justification of expenses begin to appear. The analysis of the utility of some treatments was made. As regard the personnel in nursing the professionalisation process was accompanied by research into the quality of nursing care.

Also if the pressure to analyse the quality and the needs increase it must wait until 1985 in order to found the reports of National health service in which the heath assistance quality is considered as important aspect of health. The development of European Community and the increased mobility inside Europe requires comparable offers in the different countries and stimulate the national service to develop common criteria of evaluation. In 1990 a first approach was represented by Total Quality Management (TQM) project which may be summarised in this scheme:


General	Specific
Quality Control	Clinical/medical audit
Quality Assurance	Standard Setting (BS5750/ISO9000)
Quality Circles	Accreditation
Total Quality Management (TQM)	Evidence Based Medicine
Continuous quality improvement (CQI)	Guidelines and protocols
Risk management	Clinical Effectiveness/outcomes
Benchmarking	New Technology Assessment

This protocol considers the health assistance efficacy, but does not take care of the patients which are the clients. Any quality evaluation needs to consider as first aspect the client satisfaction. Only in 1992 the Patients card was introduced. This first card concerned more the services rather than clinical quality, such as speed in emergency, in analysis performance. The communicative aspects, the transparency of treatment were ignored.

At the same time the evaluation of the outcomes of single departments and of the total structure will start through the audit mechanism.

At the moment 5 models for the quality assessment processes exist: the first was TQM previously described, the second is the extension of the International Organisation for Standardisation rules to the hospitals (ISO 9004). This model was developed initially for the quality management of Industries and later it was adapted also to services like hospitals.


I Phase	Structure identification
II Phase	Analysis of the activities
III Phase	General plan of Quality Assessment
IV Phase	Formation and motivation op personnel
V Phase	Definition of Quality procedures
VI Phase	Procedures, application and control
VII Phase	Quality control
VIII Phase	Quality iter certification

The result will be a manual of the rules to be followed in order to assure the quality of service.

The third program is European Foundation for Quality Management (EFQM) This model provides companies and institutions with the ability to estimate the current level of quality according to general criteria, including the entire personnel (self assessment ) The report indicates the kind of quality and the way in which it is reached. External evaluators are responsible for the analysis and quality diagnosis.

The project Co-operation for Transparency and Quality (KTQ) was developed in1999 for the hospital and intends to develop a hospital-specific certification process which logically integrates the method and the processes of other model. The aim is that the certification shall provide the hospitals with an incentive to prove better quality of their work.

The patient treatment is the most important aspect as well the transparency of the treatments.

A further model was developed: Quality Model hospitals (Krankenhaus, QMK). It intends to develop measurable criteria for the evaluation of quality in order to permit to compare different services.

This last two modes are in the experimental phase and with respect to the previous they take in strong consideration the patients and the stimulation to implement the quality of the structure.

It can be concluded that this aspect becomes more and more important and it may be interesting to go deeply in this subject.

According also to the National Institutes of Health the attention must be focused in seven main areas:

In order to measure these parameters inside a structure the following indicators may be considered:


1. Type and Equipment of the Hospital
• level of care
• number of departments
• personnel structure:	doctors
	nurses
	technical staff
	administration staff
	others
• number of the beds:
• number of patients:	sex
	age
	lenght of stay
	return rate
• infrastructure of environment.	Area, region
• technical equipment	administration
	technical area
	medical area
2. Hospital Services
• number of the operations
• number of diagnostic procedures and treatments
3. Qualifications
• staff	doctors
	nurses
	technical staff
	administration staff
	others
4. Organisation, processes
• different hospital information system (HIS)
• operation theatre organisation
• ward organisation
• duration of treatment and health care procedure
• complications
5. Patient satisfaction with respect to hospitality
• social treatment
• care results
• efficiency
• personal requests
6. Costs, budget and billing
• revenues according to cases, diagnoses, days and so on
• labour costs
7. Complaint management
• number, type and solution of complaints

This preliminary presentation may be used as a suggestion of our future work. It is in fact important: