o
OECD HCQI (health care quality indicator) 프로젝트에서는 보건 시스템 디자인, 보건의료 시스템 성과, 비 보건의료 결정요인, 환자의 건강상태로 구분한 후 효율성과 형평성을 중심으로 평가 하되 보건의료시스템 성과에 서 효과성, 안전성, 반응성/환자 중심성, 접근성, 비용에 대한 평가를 보건 의료 정책의 목표(보건의료 필요)에 대하여 각각 실시함.그림 2. OECD HCQI(Health Care Quality Indicator) 프로젝트 개념적 틀
나. 평가의 목적, 영역
1) 미국
가) National Quality Strategies (NQS)
o
목적 및 핵심 영역¡
Patient Protection and Affordable Care Act (ACA) 제정에 발맞춰 미 국 보건부(Human & Health Services, HHS)는 다음의 세 가지 목적 달 성을 위한 National Quality Strategy (NQS)를 제안하고 국가 단위의 질 향상 활동에 대한 방향을 제시함5).‑ Better Care
‑ Healthy People/Healthy Communities
‑ Affordable Care
그림 3. 미국 NQS의 목적 및 의료질향상을 위한 우선순위
¡
NQS는 목적 달성을 위한 핵심 영역(priorities)으로 다음의 6가지 영역을 제시함.‑ patient safety
‑ effective communication and care coordination
‑ person and family centered care
5) Available URL : http://www.ahrq.gov/workingforquality/priorities.htm
16
-‑ prevention and treatment of leading causes of mortality
‑ health/well-being. reducing harm caused in the delivery of care
Reduce preventable hospital admissions and
readmissions. 23
Reduce the incidence of adverse health care-associated
conditions. 117
Reduce harm from inappropriate or unnecessary care. 36
2
Ensuring that each person and family mem-bersare engaged as partners in their care
In partnership with patients, families, and caregivers-and using a shared decision-making process-develop culturally sensitive and understandable care plans.
5 Improve patient, family, and caregiver experience of care related to quality, safety, and access across settings. 30
Enable patients and their families and caregivers to navigate, coordinate, and manage their care appropriately and effectively.
0
3
Promoting effective communication and
coordination of care
Improve the quality of care transitions and communications across care settings. 37
Improve the quality of life for patients with chronic illness and disability by following a current care plan that anticipates and addresses pain and symptom management, psychosocial needs, and functional status.
44
Establish shared accountability and integration of communities and health care systems to improve quality
Promote cardiovascular health through community interventions that result in improvement of social, economic, and environmental factors.
0 Promote cardiovascular health through interventions that result in adoption of the most healthy lifestyle behaviors across the lifespan.
3 Promote cardiovascular health through receipt of effective clinical preventive services across the lifespan in clinical and community settings.
16
Promote healthy living and well-being through community interventions that result in improvement of social, economic, and environmental factors.
3 Promote healthy living and well-being through interventions that result in adoption of the most important healthy lifestyle behaviors across the lifespan.
9 Promote healthy living and well-being through receipt of effective clinical preventive services across the lifespan in clinical and community settings.
63
Ensure affordable and accessible high-quality health care for people, families, employers, and governments. 19
Support and enable communities to ensure accessible, high-quality care while reducing waste and fraud. 47
표 3. NQF 핵심영역, 목표, 측정 지표수
나) CMS quality strategy 6)
o
CMS (Center for Medicare & Medicaid Services) 의 미션, 비전, 주요 목 표는 다음과 같음.¡
미션: 높은 질의 의료에 대한 접근성을 높이고 낮은 가격으로 건강을 향상 시킬 수 있도록 하여 국가보건의료 시스템의 강화 및 근대화에 힘씀.¡
비젼: 보건의료시스템의 질을 높여 좋은 질의 의료 제공, 의료의 보장성 및 접근성 향상, 건강 상태 향상을 보장함.¡
CMS 주요 목표‑ 좋은 질 및 낮은 가격
‑ 예방 및 인구 보건
‑ 보건의료 범위 확대
‑ 모든 영역의 기관들과의 협력을 통한 의료질 향상
그림 4. CMS Aims, Main Goals
6) CMS quality strategy 2013 – Beyond. November 18, 2013
18
-Goal Objectives Desired outcomes
Goal 1: Make reporting of errors and potential errors
• Increased access to understandable health Information is
and unnecessary care • Healthcare organizations continually assess adverse events in accordance with evidence-based practices
• Healthcare cost reductions are attributable to the reduction of unnecessary, duplicative, and inappropriate care • Improved achievement of patient-centered goals of care is evident
• Disparities of care are eliminated Prevent or minimize
harm in all settings • Hospital-acquired conditions (HACs) and healthcare- associated infections (HAIs) are reduced
• Medication error rates are improved
Goal Objectives Desired outcomes
• Patient and family access to understandable health information is increased
• Disparities of care are eliminated
Ensure all care delivery incorporates patient and caregiver preferences
• Patients are partners at all levels of care
• Care and treatment reflect the patient’s personal values and goals
• Coordination and communication occurs within and across care teams, including patients, families, and caregivers
• Patient and family preferences are central in decision processes and implementation
• Joint development of treatment goals and longitudinal Improve experience of
care for patients, caregivers, and families
• Improved support for integrated care models
• Expanded use of evidence-based services and primary care
• Increased access to understandable health information • Improved promotion of community-clinical partnerships and services aimed at managing and improving care at the community level
Promote patient
self-management • Improved application of self-management practices in our programs
• Improved visibility of self-management
• Improved support for integrated care models
• Increased access to understandable health information • Updated and available information for use by patients
• Improved patient confidence in managing chronic
20
-Goal Objectives Desired outcomes
conditions
• A respectful, trustworthy, transparent healthcare culture Goal 3:
Reduce admissions and
readmissions • Patient self-management and activation efforts result in reduced admission and readmission rates
• Increased health literacy rate
• Survey results demonstrate measurable reduction in deficiencies related to discharge planning and transitions of care
• Evidence-based best practices that promote appropriate discharge planning and care transition are embedded in the routine practice of care across the healthcare continuum • Appropriate interventions prevent development of health conditions that require acute care
• Wasteful expense from avoidable admissions and readmissions is reduced drastically
• All those who provide care in a particular community work in coordination to optimize patient care
Embed best practices to manage transitions to all practice settings
• Integrated, patient-centric discharge tools are used across all practice settings
• Community-based support systems integrated with healthcare delivery (e.g., National Long-term Care Ombudsman’s Resource Centers, senior centers, faith-based organizations, etc.) are developed and employed
• Patient activation efforts/self-management training are a standard part of care
Enable effective healthcare system navigation
• Evidence-based best practices that enable patient activation/self-management are embedded in the routine practice of care (e.g., certified diabetes educators)
• Payer reimbursement is expanded beyond traditional patient education to include chronic disease self-management education programs
• Cross-setting discharge planning tools that include
Goal Objectives Desired outcomes
patient/family goals and preferences are routinely employed Goal 4: prevention are created, sustained, and recognized
• Prevention-focused healthcare and community efforts are available, integrated, and mutually reinforcing
• Persons are supported in making healthy choices related to screening and prevention
• Disparities in the use of screening and prevention services
• Improved cardiovascular health through evidence-based community interventions
• Expanded adoption of healthy lifestyle behaviors across the life span
• Increased access to effective clinical preventive services in clinical and community settings
• Improved care and quality of life for all Americans through the elimination of disparities Decreased rates of heart attacks and strokes
Improve quality of care for patients with multiple chronic conditions (MCCs)
• Individuals are empowered to use self-care management • Providers are equipped with tools, information, and other interventions that address MCC
• Targeted research focused on individuals with MCCs and effective interventions is supported
• Development of quality measures focused on MCC management and care for individuals with MCCs
• Disparities of care are eliminated
22
-Goal Objectives Desired outcomes
providers to share information with primary care providers, and increased sharing of EHR data by primary care providers with BH providers
• Individuals initially identified with a BH condition receive services within 30 days of screening/ identification
• Better availability of evidenced-based practices for individuals with BH conditions
• Reduced admission to inpatient facilities or emergency rooms of individuals with BH conditions (regardless of reason for admission)
Improve perinatal
outcomes • Reduced elective deliveries prior to 39 weeks (by induction or caesarian section)
• Improved appropriateness and timeliness of perinatal care for all pregnant women
• Decreased premature births • Improved inter-conception care Goal 5: Work
• Promote successful interoperability of health IT systems • Improve population health outcomes
• Reduce disparities in health outcomes
• Reduce healthcare costs through better coordination across health sectors
Improve access within communities to best practices of healthy living
• Children and adults have increased access to community-based preventive services
• Evidence-based preventive services are widely shared and adopted by schools, families, and communities
• Schools, families, and communities have the tools for promoting healthy living
• Prevention-focused healthcare and community efforts are available, integrated, and mutually reinforcing
Promote evidence-based community interventions to prevent and treat
• Promote effective diet, exercise or behavioral health habits that can ameliorate or control chronic diseases
Goal Objectives Desired outcomes chronic disease
Increase use of community- based social services support
• Patients are routinely connected to relevant services offered by community organizations
• Improved integration of health infrastructure and social services
Goal 6: Make
c a r e
affordable
Develop and implement payment systems that reward value over
• Outcomes-based payment arrangements link incentives to quality measures determine practice patterns and to identify outliers
• Improved analytic capacity to investigate cost drivers that inform payment model design and policies
• Quality and cost data inform program integrity and fraud investigations Center for Program Integrity and other auditing and review capacities at CMS
24
-2) 영국
가) 보건부(Department of Health) 7)
o
목적(Purpose)¡
국민들이 건강한 상태에서 생활하고 독립적으로 살아갈 수 있도록 도와줌.o
우선 영역(Priorities)¡
예방적, 건강 증진적, 안전적, 효과적인 의료 서비스를 국민들이 경험할 수 있도록 보건과 의료 시스템을 선도함.o
달성 목표(Improvement goals)¡
국민들이 평생 건강하게 잘 살 수 있도록 함.‑ 질병예방, 75세 이상 노인들에대한 치료 향상, 사회적 접근 확대, 통합 적 보건의료서비스 제공, 치매관련 서비스 향상
¡
보건의료의 기준을 높여 모든 사람이 동일한 의료를 받을 수 있도록 보장 함.‑ 의료질 및 보건의료기술 향상, 육체적인 건강뿐만 아니라 정신적 건강 에도 동일하게 집중
¡
보건 의료 시스템이 국민들의 필요에 맞게 작동될 수 있도록 함.‑ 의료의 질을 유지함으로써 장기적인 관점에서의 보건의료 시스템의 지 속가능성 보장, 접근성 및 재정적 지원 보장, 연구 및 혁신과 관련하여 좀더 효율적으로 협력 하고 지원할 수 있도록 보장
7) Department of health. Departmental improvement plan. April 2014.
Goal Priority
preventing people from dying prematurely by improving mortality rates for the big killer diseases, to be the best in Europe through improving prevention, diagnosis and treatment and reducing health inequalities
transforming care outside hospital, focusing on the role of primary care in providing integrated out of hospital care, but also looking at what can be done to improve urgent and emergency care
implementing social care reforms including integrating health and social care, set out in the Care Act 2014
improving treatment and care of people with dementia to be among the best in Europe through early diagnosis, better research and better support
improving the standard of care throughout the system so that quality of care is considered as important as quality of treatment for everyone, through more accountability, better training, expert inspections, improving safety and more attention paid to what patients say and reducing inequalities in outcomes from care
making a step change in the way technology
demonstrating real and meaningful progress towards achieving true ‘parity of esteem’
improving productivity and long term sustainability and ensuring value for money for the taxpayer
contributing to economic growth
developing organisational capability and the resilience of the Department to fulfil its stewardship role for the health and care system
표 5. 영국 보건부의 목표 및 우선사항
26
-나) NHS (National Health Service) 8)
o
미션(Mission)¡
모든 사람에게 높은 질의 의료를 제공함.‑ 높은 질의 의료는 안전하고 효과적이며 긍정적인 환자 경험을 이끌어 낼 수 있어야 함. 현재와 미래의 세대 모두에게 높은 질의 의료를 제공 하기 위해서는 의료 자원이 보장되어 지속가능한 NHS가 되어야 함.
o
비전(Vision)¡
모든 사람들이 그들 자신들의 건강에 대하여 조정력을 가지고 건강하게 오래 살 수 있도록 지속적인 노력을 통하여 더욱 더 향상된 높은 질의 의 료 서비스를 제공함.‑ 모든 사람은 개인을 포함한 지역사회 및 전체 인구 집단을 포함함.
o
목적(Purpose)¡
보건의료 서비스 문화와 환경을 만들고 직원들이 높은 수준의 의료를 제 공할 수 있도록 하며, 귀중한 공공자원들(재원, 인력, 지식, 기술)이 효과 적으로 사용하도록 하여 최상의 결과를 개인, 지역사회에 지금부터 미래의 세대까지 보장함.‑ 보건의료 서비스 문화와 환경(Condition)이란 세계 최상의 고객중심 의 료 제공, 투명성 보장, 현실적인 환자 및 공공의 참여, 임상 리더들에 대 한 권한부여, 근거 중심 결정, 혁신 향상, 파트너쉽을 통한 협력을 말함.
8) http://www.england.nhs.uk/about/our-vision-and-purpose/
그림 5. NHS 미션, 비젼, 목적, 가치
28
-o
NHS Outcomes Framework9)10)에서 의료의 질을 측정하는 구성요소로서 효과성, 환자경험, 안전성의 3가지 사용하였고 5가지 영역을 제시함.¡
조기사망 예방¡
만성질환자의 삶의 질 향상¡
손상 및 불건강 상태에서의 회복¡
의료에 대한 환자의 긍정적 경험 보장¡
안전한 환경에서의 환자 치료 및 예방 가능한 위험으로부터 보호그림 6. Relationship between NHS next stage review heigh quality care for all and NHS outcomes framework.
9) Lord Darzi. The NHS next stage review high quality care for all. 2008 10) Department of Health. The NHS Outcomes Framework 2015/16. 2014
o
조기사망 예방 영역에서는 4개의 목적이 있음.¡
사망 주요 원인으로부터 조기 사망자 수 감소¡
정신질환환자 조기 사망자 수 감소¡
영, 유아 사망자 수 감소¡
학습장애 환자 조기 사망자 수 감소그림 7. 영역1: 조기사망 예방
30
-o
만성질환자의 삶의 질 향상 영역에서는 7개의 목적이 있음.¡
환자의 건강상태 관리 지원¡
만성질환환자의 신체 기능 향상¡
만성질환환자의 입원기간 감축¡
보호자의 삶의 질 향상¡
정신질환자의 삶의 질 향상¡
치매환자의 삶의 질 향상¡
복합성 만성질환자의 삶의 질 향상그림 8. 영역2: 만성질환자의 삶의 질 향상