Effective implementation and quality development in hospitals by strategies,

standards and staff education

Health Promoting Hospitals Conference

Moscow May 2004

Lone de Neergaard, Director of Health Services

Copenhagen Hospital Corporation

About Denmark

• Population 5 mill.

• Size 45.000 square kilometres

• Max. distance north-south/east-west 450 kilometres

Danish Health Care – Main Characteristics

• Health care is a public task• The private sector is very small• 83% is financed through taxes• Hospital care and visits to general practioners and

practising specialists are free of charge• The responsibility is decentralised• Total public and private expenditure is 8,1% of

GNP

H:S 2004

H:S was established Jan 1st 1995 as a network of 7 hospitals. Consists in 2004 of:

• H:S Head Office • 6 hospitals• H:S Pharmacy• Several functions across the hospitals

• No. of beds 4.000 (400 – 1.200)• No. of full time positions 19.200• Total budget 1.4 billion EURO

Metropolitan area before H:S

• 11 hospitals for 1,2 mill. in 100 square km.

• Owned by 4 political authorities

• Duplication of facilities and specialties

• Difficult to deliver good quality health care and good economy.

Hospital Plan H:S 2000Principles• Adapt structure to the needs of the citizens• Common problems to be treated locally• Highly specialized functions to be gathered• Focus on geriatrics, rehabilitation and stroke• The number of surgical units to be reduced• Establishment of an elective surgical centre• Psychiatry (beds and community centers) to be

expanded

H:S Plan 2000 – Major Changes

• 25 departments merged and moved between hospitals

• Most departments moved within hospitals

• 150 building projects

• 1 hospital with 435 beds closed

• Somatic beds reduced from 4.000 to 2.900

• Personnel reduced by approx. 1.700

Implementation 1996-99• According to plan with very few exceptions• Almost according to time schedule• Number of beds reduced more than planned• More cost reductions than planned• Waiting times reduced generally not increased• Benefit:

bigger unitsbetter coordination and cooperationdevelopment

Why did H:S succeed• Good visions, good plan (broad accept)

• Political will

• Administrativ ability and freedom

• Good cooperation

Head Office and Hospital Boards

• Stability

H:S and Accreditation - WhyJuly 1999 – what next?• H:S 2000 fully implemented - Need for a new

vision/goal/plan with focus on soft values• Vision: to improve quality of every patient’s path

from primary sector through hospital to primary sector

• Can accreditation provide the systematic, coherent approach to include all possible initiatives?

February 2000• H:S Political Body: accreditation and evaluation

of specialty specific quality by indicators

H:S and Accreditation - Process

• March 2000: Decision on accreditation

• Nov 2001: Mock survey

• Jan 2002: Accreditation survey

• Jan 2004: Mock survey

• Jan 2005: Accreditation survey

H:S Quality Management

• Accreditation• Patient Safety• Evaluation of specialty specific quality• Goals for H:S

Measured by data from • Patient administrative systems, Medical records’

review, Selfassesment, Indicators, Internal mini surveys, Databases, Patients’ evaluation ….

H:S Quality Organization

• H:S Quality Committee: consists of H:S Board and six Hospital Boards

• (Advisory) Standing Committees: Blood , Infection control, Medication, Nutrition,

• 28 Specialty Advisory Committees• H:S Units for Clinical Quality Patient Safety

H:S Accreditation - Tools

• Strengthen leadership involvement• Translate standards and develop policies,

guidelines, procedures and plans • Develop indicators and follow up• Education – quality improvement and standards• IT support: document handling, selfassesment, e-

learning• Implementation

Process of Preparation

ImplementationDocumentation

CHC

Hospital

Departments

November November February 2000 2001 2002

GuidelinesPolicies

Challenges

• From top-down start to common ownership• Ownership to standards and processes• All-H:S or hospital specific guidelines• Training of in principle all staff• Document handling• The magnitude of implementation• Change of culture: continuous quality

improvement, standards, data, documentation

Specialty Specific Quality - Evaluation

H:S Unit for Clinical Quality coordinates 28 Specialty Advisory Committees in developing:

• Clinical indicators – Focusing on process and outcome– Selected patient groups: high volume, problem prone,

effective intervention– Cooperation with JCI

• Clinical Audit, cooperation with Sweden • 2004: 18 diseases, 15 specialties, 70 departements

H:S Clinical Indicator Report- own unit over time: stability of processes

H:S Clinical Indicator Report- own unit compared to others (level)

Patient Safety and Sentinel Events - A Hospital with a Memory

Aim: Increased safety by change of culture H:S Unit for Patient Safety established 2001Elements:• Education• Confidential reporting and analysing events • Learning and changing procedures, equipment,

packaging…• Surveillance • Change of culture• Risk-management functions at hospitals

Patient Satisfaction Surveys

National level: Survey every 2nd year, hospital level, somatic and psychiatry

H:S level:

• Standardized questions across all departments yearly

• Department specific questions as needed

Achievements - general

Change of culture – focus on• Quality and performance improvement• Leadership • Indicators and data• Documentation• More uniform level of services• More cooperation across hospitals, departments,

specialties and staff groups

Achievements - specific

• Documentation • Hygiene• Medication• Nutrition• Patient information and guidance, informed

consent• Safety• Staff qualifications and yearly appraisals

H:S continues Accreditation

• The overall opinion is that accreditation is a most valuable and effective tool

• A formal evaluation will identify possibilities of improving the process

• H:S Political Board decides March 2002 to continue accreditation with JCIA

H:S Internal Surveyor Education

21 H:S Quality Coordinators had a 2 weeks educational programme conducted by JCI May 2003 in H:S. The benefits are:

• Able to do internal consultations and “mini mock surveys”

• Able to prepare leaders and staff more profoundly and precisely

• H:S has better basis for taking part in the development of accreditation on the national and international level

Copenhagen Fire Brigade Accredited

Copenhagen Fire Brigade, CFB, deliver ambulance services to H:S. As a consequence of the H:S accreditation CFB decided on an accreditation process with JCIA.

• JCIA developed International Standards on Medical Transportation Organizations 2002.

• CFB was accredited March 2003.

National Legislation on Patient Safety 2003

Parliament passed legislation on Patient safety in Hospitals and Primary Sector - unanimously

• National Board of Health to establish reporting system on sentinel events by Jan 2004

• County Councils and H:S to analyse data and report to the above

• Reporting to be anonymous (patient and staff)

Nationwide Accreditation 2006

• Central and local health care authorities decided 2002 to develop an accreditation model in cooperation with an international organization, incorporating specific Danish demands

• To cover all DK in 2006

H:S IT Strategy

• IT a major issue

• IT Strategy for H:S decided 2001 and confirmed December 2003

• Total Investment 2002-6 is 0.6 billion EU

• ”The Clinical Workplace” or ”The Electronic Patient Record” by 2006

• A Medicine Module is being tested now