Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized EXECUTIVE SUMMARY Quality of Care in the External Assessment of Health Sector in Colombia © 2019 The World Bank Group 1818 H Street NW, Washington DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org and www.ifc.org SOME RIGHTS RESERVED This work is a product of the staff of The World Bank and the International Finance Corporation (The World Bank Group). The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the Executive Directors of The World Bank Group or the governments they represent. The World Bank Group does not guarantee the accuracy of the data included in this work. 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Report No: AUS0000853 External Assessment of Quality of Care in the Health Sector in Colombia EXECUTIVE SUMMARY To consult the full report, please visit: https://www.worldbank.org/en/topic/health/publication/external-assessment- of-quality-of-care-in-the-health-sector-in-colombia A doctor visiting a patient with the onset of Dengue Fever at the local hospital. Buga, Colombia. Photo © Pan American Health Organizatio (PAHO) Abbreviations English CPGs Clinical Practice Guidelines DMDS Territorial Entities (municipalities, health districts) EPS Health Promotion Entity (Health Insurance Enterprise) IETS Institute for Health Technology Assessment IFC International Finance Corporation INCAS National Report on Health Care Quality IPS Health Provider Institution LMIC Low- and Middle-Income Country MPS Ministry of Social Protection MSPS Ministry of Health and Social Protection NCD Non-communicable Diseases NQPS National Quality Policy and Strategy OAPES Advisory Office of Planning and Sectoral Studies OECD Organization for Economic Cooperation and Development PAMEC Audit Program for Quality Improvement PDSP 10-Year Public Health Plan PIC Collective Intervention Plan PND National Development Plan PNMCS National Health Quality Improvement Plan PTD Territorial Health Plan QA Quality Assurance QI Quality Improvement RC Contributory Regime REPS Special Registry of Health Care Providers ReTHUS National Registry of Health Human Resources RIPS Register of Individual Health Care Services RS Subsidized Regime SGSSS General System of Social Security in Health SISPRO Integrated Health Information System SOGC Mandatory System of Quality Assurance WHO World Health Organization External Assessment of Quality of Care in the Health Sector in Colombia | Executive Summary 5 View of Bogota from the Mederi Hospital. Photo © by Anais Furia, IFC Executive Summary This report This assessment of quality of care in the health sector in Colombia examines the state of quality of care as well as how well governments strategize, plan and presents measure quality; set standards of care; build capacity for quality improvement in the sector; ensure adequate resources are available and well distributed to findings from an support quality results; hold organizations accountable for quality results; assessment of apply quality policies consistently. This methodology evaluates these eight domains using 49 criteria based on 171 standards. The assessment is based on quality of care in quantitative analytics, key informant interviews, over 30 visits of public and private healthcare facilities, a review of key policy documents and a survey of a sample of the health sector in health insurance companies. The assessment is a joint initiative from the World Bank Colombia, using a and the International Finance Corporation (IFC) and was undertaken for the first time in Colombia. It took place from January to June 2019. novel methodology developed by the World Bank Group to assess the state of quality of care as well as government oversight, promotion and stewardship of quality of care Clinica Marly, Bogota, Colombia. Photo © Anais Furia, IFC External Assessment of Quality of Care in the Health Sector in Colombia | Executive Summary 7 Outstanding Colombia has made important progress in promoting a quality agenda across its health care system, in addition to a successful expansion of Universal Health improvements Coverage. Clear prioritisation of quality and outcomes dates back to 2006 with the creation of the mandatory system for guarantee of quality of care (Sistema in healthcare Obligatorio de Garantia de la Calidad en Salud). Since then, the country has developed coverage have a wealth of strategies and policies aimed at embedding quality governance throughout the health sector, including quality standards for infrastructure and for been realized since clinical practice, provider licensing, inspection and accreditation, and targets for improvement in health outcomes. Colombia now has a detailed list of quality 1993, yet quality indicators as well as a formidable repository of data in its Integrated Health of care remains Information System warehouse (SISPRO), with many indicators made publicly available and disaggregated by health insurance company and healthcare provider. a challenge and Named individuals with official responsibility for quality are in place throughout the health system, working alongside quality committees in most hospitals. As a result of the key to the these efforts, there have been notable improvements in health outcomes. Healthcare sustainability of acquired infections have become less frequent, there have been improvements in patient satisfaction, and waiting times are now comparable to Organization for the health sector in Economic Cooperation and Development (OECD) peers—even if they remain an issue of concern in Colombia. Still, quality of care is largely seen across the sector as the Colombia change agenda required to turn significant investments in the health sector into a more effective, financially sustainable system meeting the demands of patients and citizens. The National Development Plan for the period 2018-2022, approved by the Colombian congress in May 2019 emphasizes the importance of quality of care as the core strategy to improve the financial sustainability of the health sector. Yet, significant concerns persist about improvements in quality of care not meeting investments and expectations in the sector. A landmark study from The Lancet Global Health Commission on High Quality Health Systems (2018) estimates that over 22,000 Colombians die each year due to poor quality of care, with around another 12,000 dying due to poor access to, or utilization of, services. Although Colombia now provides coverage of healthcare services for a greater share of the population than many other OECD countries (94% to 96% since 2010), health outcomes and quality of care continue to be worse than most other OECD countries. Colombia’s maternal mortality rate is higher than all other OECD countries and some 25% higher than that of Mexico, which had the next highest rate. Colombia’s years of life lost due to pneumonia (a relatively easily treatable clinical condition) also exceed almost all other OECD countries, except for Lithuania and Mexico. 8 The World Bank | IFC For several key indicators, results are worse in rural areas, public hospitals and regions with lower income. The proportion of pregnant women with four antenatal visits was 63% in rural areas compared to 73% in urban areas in 2018. Screening mammography rates for women aged 50 to 69 years are lowest in regional departments with lower income. In-hospital mortality rates per 1,000 admitted patients within 72 hours of admission were higher in rural compared to urban facilities (6.22 vs. 1.35 in 2014). The average waiting time for an appointment with a general physician was slightly higher in public compared to private sector facilities (2.9 vs 2.6 days in 2014). This study also found large rural-urban differences in specialist wait times, such as 38.7 vs 7.4 days for a pediatric consultation and 20.1 vs 14.1 days for general surgery (2016). The wealth of policies and institutions at system-level—described throughout A more ambitious this report—shows that there is no shortage of top-down efforts to drive quality gains. This is not always matched, however, by focused and effective bottom- and consistent up activity. In Colombia’s highly decentralised health care system, greater thought now needs to be given on how to support hospitals, primary care clinics and other approach to health care providers to continuously improve quality of care and health outcomes. measuring, This report offers a balanced set of ten recommendations grouped under five themes on how to do that, whilst strengthening drivers of change at system-level to ensure supporting and effective, safe and patient-centred health care for all Colombians. Recommendations were mapped against current priorities of the government of Colombia to improve improving quality at quality of care and discussed extensively with the government of Colombia during the hospital- and clinic- completion of this assessment. level will be key to unlocking the next wave of quality gains in Colombia’s health care system and ensure its financial sustainability External Assessment of Quality of Care in the Health Sector in Colombia | Executive Summary 9 Key Findings From the Quality Assessment of the Health Sector in Colombia (See summary in Table S3) There is ample room to improve quality of care results in the health sector, with large variations in quality found between the public and the private sector, by geography, urban and rural settings, and worst quality affecting the most vulnerable populations. As measured, satisfaction rates are high and waiting times are low compared to OECD countries, however, measures of care effectiveness suggest weaknesses in care processes for Non-Communicable Diseases (NCDs), efficiency indicators suggest over-use of available resources and low availability of integrated care indicators show further weaknesses in quality of care. The national quality strategy needs to be more explicit about targets, plans, activities, roles and responsibilities, and accountability for results. There are few mechanisms to ensure proper alignment and cascading between national quality strategy and strategies of health insurance companies, department level health authorities and healthcare providers. The rich data sources in the government’s integrated information system for the sector are rarely used for quality improvement activities. Information is not fed back to front-line providers who need it the most. Some data collected are not easily accessible and information that is published is mostly out-of-date. Data are released publicly with little context on how to interpret the results or what actions to take for improvement. Capacity for continuous quality improvement is unevenly distributed in the sector yet there is a tremendous amount of energy and enthusiasm for quality improvement in the sector. There are wide variations in the number of healthcare professionals trained in quality between different healthcare providers and health insurance companies. There is a lack of mechanisms for shared learning between peers, and limited information on benchmarks for quality. The accreditation program is rigorous but has very low enrolment. Use of decision-support tools to guide clinical decision making is limited and should be expanded. Mechanisms to verify clinical skills of providers are weak. There is no core standardized curriculum for medical graduates across the country. There are important disparities in human resource distribution, especially in rural and remote parts of the country. 10 The World Bank | IFC The current model of care is fragmented. This is an important barrier to quality care for a country where most of the burden of disease comes from non-communicable diseases requiring care integration and coordination to be effective. There is poor communication between primary care and specialist services. Patients seek care from multiple providers (e.g. primary care, laboratories, specialty care) in different sites, due to the nature of contracting for different services by health insurance companies. This is an impediment to delivering quality care for an increasing number of patients with multiple chronic conditions. Accountability mechanisms need to be strengthened and accountability for care integration is weak and of concern. Although there are examples of incentives for quality in contracts between few health insurance companies and healthcare providers, this mechanism is generally weak. There are only a few examples of financial accountability for quality. Consumers in theory hold health insurance companies accountable for quality, but lack the quality, timely information to do so. Patient screening for Tuberculosis in the CIDEIM Clinic. Cali, Colombia. Photo © Pan American Health Organizatio (PAHO) External Assessment of Quality of Care in the Health Sector in Colombia | Executive Summary 11 Recommendations To improve quality of care in the health sector, action could be taken by government, health insurance companies, local health authorities and care providers to: (1) strengthen capacity for continuous quality improvement in the health sector; (2) strengthen the quality ecosystem in the sector; (3) improve the rigor and use of information on quality to stimulate patient choice and peer learning for healthcare providers; (4) develop and implement an integrated care model to support the management of individuals with complex, chronic health care needs; and (5) improve accountability and contracting mechanisms to incent for quality. All five themes and related 10 recommendations are summarized in Table S1 at the end of this section, which also presents for each recommendation a preliminary assessment of resources requirements, difficulty of execution and potential impact, each rated on a scale of + to +++. We also indicate whether the expected time horizon for achievement of the impact is short-, mid-, or long-term. Finally, we point to the quality dimensions (such as patient safety, care effectiveness or care integration) each recommendation contributes to. These scores are intended to encourage the Ministry of Health and Social Protection of the government of Colombia to consider implementation, risk management and cost effectiveness considerations as they plan for implementation. It is important to note that this report proposes a cohesive package of interventions which are all necessary and important to achieve sustainable change in quality of care in the sector. If these recommendations should be carefully sequenced and planned by the government, the implementation of all ten recommendations over time will be necessary to achieve impact at scale and make a commitment to quality a cornerstone of the financial sustainability of the sector. It is also important to acknowledge that all actors in the sector have a role to play in implementing the recommendations proposed for consideration: table S2 makes the point that not only the government, but also departmental health authorities; health insurance companies; healthcare providers; and patients and citizens all have to be fully engaged and lead the quality revolution that is required to ensure that a high quality health system in Colombia delivers quality results for all Colombians. 12 The World Bank | IFC 1 Strengthen capacity for quality improvement in the health sector An initial and critical step is to invest in training healthcare professionals to augment their capacity for continuous Quality Improvement (QI) at different levels of the system: from the frontline of healthcare services to departmental health authorities to health insurance companies to government level. Launching national quality campaigns for cancer or diabetes would mobilize the sector in the short term and generate support and engagement from healthcare providers and possibly patients if properly engaged. Quality improvement collaboratives and communities of practice could also play an important role to promote shared learning among healthcare providers, territorial health authorities and health insurance companies and would be transformative. It would also be important to develop and implement a suite of clinical decision support tools, which help healthcare providers follow with clinical best practices. 2 Strengthen the quality ecosystem in the health sector The government could consider updating and expanding the scope of the national system of mandatory guarantee for quality of care to strengthen system capacity for quality improvement and enhance the quality culture in the sector. This includes reforming the accreditation process to implement it at scale using a more stepwise approach to accreditation, but also augmenting the current regulatory system with initiatives to engage and empower patients and citizens so that they participate in planning, design and accountability of health care services and demand better quality healthcare. Another priority would be to invest in improving the clinical competence of healthcare professionals before and after graduation, for example by developing a core curriculum for medical doctors and nurses to improve their level of clinical competence. A strategy for reducing regional disparities in supply of health professionals is needed, with an emphasis on expanding health professional education in rural areas, for example through rural education programs, at both the undergraduate and postgraduate (i.e. residency training) levels. External Assessment of Quality of Care in the Health Sector in Colombia | Executive Summary 13 3 Improve the rigor and use of information on quality of care Colombia has a wealth of information on quality of care, but performance indicators are often not timely, not tailored to the needs of specific information users and of uneven reliability. There is limited guidance on how to use information and suggested targets for improvement. As a result, providers are not using information optimally for improvement, and patients are not using it routinely to choose their healthcare insurer or provider. Patient choice of healthcare provider and insurer could be enhanced by providing patients with localized, pertinent, accessible information on quality of care they encounter (e.g. provider star rating system, rankings of providers). For healthcare providers, the next generation of Colombia’s publicly reported quality measurement system should include quality scorecards at every level of the system. Benchmarks for quality results should be developed to allow healthcare providers (e.g. public hospitals) to compare quality results and learn from each other. Colombia should also establish a new generation of quality indicators, particularly for care integration and quality inequities. Finally, the Ministry of Health and Social Protection should consider putting substantial effort in improving data currency (with quarterly to real-time data being the norm), data quality through regular audits and better dissemination strategies for various information users including the public. Develop and implement a primary health care-focused integrated 4 care model to support the management of individuals with complex, chronic health care needs To adapt to the increasing prevalence of non-communicable diseases, action by departmental health authorities, health insurance companies and government is needed to develop and roll out a new integrated care delivery model while strengthening primary health care. Specific options to consider in the design of an integrated model include: using integrated care pathways for chronic diseases; embedding visiting specialists in primary health care settings; interdisciplinary case management for complex patients; use of patient navigators; telemedicine or e-consult systems to provide primary care providers with greater access to specialists; incentives to co-locate different services (e.g. labs, imaging, rehabilitation) to 14 The World Bank | IFC minimize patient travel; use of home monitoring devices with two-way communication with providers; and shared information systems accessible to all members of an interdisciplinary care team. Incentives and innovation in payment systems should promote integration of care around specific medical conditions such as cancer. To achieve it, it is advisable to expand the scope of the High Cost Account program to other chronic conditions like COPD, mental illness, other rheumatic diseases, and multi-morbidities, as well as to index episodic conditions (e.g. myocardial infarction, stroke or appendicitis); and increase the emphasis on outcomes-based accountability and not just process compliance. Scaling up of self-management support (SMS) approaches should also be encouraged for patients with chronic conditions. Improve accountability & contracting mechanisms to incent for 5 quality in the health sector Enhancing patient participation and engagement in local governance and accountability processes is advisable. Patient empowerment and patient engagement is key to design, plan and manage services in a way that is person-centered, better meets the expectations of patients, families and communities and ensures better financial sustainability of the sector. Other potential interventions to augment demand for quality of care include: a national commitment to a quality guarantee; charters of rights for patients; expanding opportunities for recourse, complaints and participation in local governance systems. Accountability mechanisms to hold health insurance companies responsible for the implementation of integrated care models, and improvements in person-centeredness and efficiency of service delivery should be strengthened, through processes such as better licensing and accreditation mechanisms for health insurance companies. Payment and contracting mechanisms between the Ministry and health insurers need to be strengthened. Examples include incentives to prevent patients from developing high-cost conditions such as renal failure, through prevention and good chronic disease management or ex-post risk adjustment mechanisms for high cost patients or targeted groups of patients such as cancer patients, using the mechanism for high cost patients accounts. External Assessment of Quality of Care in the Health Sector in Colombia | Executive Summary 15 Immediate Next Steps and Further Analytical Work Required Short-term recommendations suggested cover the following: Update and expand the scope of the national system of mandatory guarantee for quality of care including clinical competence of healthcare providers and patient engagement and empowerment Implement an incentive regime for quality cancer care and other medical conditions through ex-post adjustment mechanisms for capitation payments (UPC) paid to health insurance companies Develop mechanisms to benchmark quality of healthcare providers and insurance companies such as an observatory of public hospitals or a ranking mechanism for quality of care provided by health insurance companies Strengthen system capacity for continuous quality improvement and learning & launch quality improvement campaigns for specific conditions such as cancer Further analytical work is suggested to better understand variations and drivers of quality of care and develop more targeted strategies and plans to improve quality of care for remote and rural areas and for most vulnerable populations, who are the most affected by poor quality and unsafe care. 16 The World Bank | IFC Local hospital in Buga, Colombia. Photo External Assessment of Quality of Care in the Health Sector in Colombia | Executive © Pan American Summary 17 Health Organizatio (PAHO) Table S1. Recommendations Based on Colombia Assessment Study on Quality of Care Resources Difficulty of Potential Time Horizon required execution Impact for Impact Main quality (Short, Mid or Dimensions Recommendations (+ to +++) (+ to +++) (+ to +++) Long Term) Affected Strengthen capacity for quality improvement in the health sector 1. Strengthen system capacity for continuous ++ ++ +++ Short Term Effectiveness quality improvement (QI) and learning & launch Efficiency national QI campaigns for specific conditions (e.g. cancer) Patient safety Strengthen the quality ecosystem in the health sector 2 Update and expand the scope of the national + ++ ++ Short Term Patient safety system of mandatory guarantee for quality of Effectiveness care Person-centeredness 3. Improve pre-service and continuous education ++ +++ +++ Mid Term Effectiveness for clinicians with a focus on improving clinical Patient safety competence and QI skills, and building rural training capacity Improve the rigour and use of information on quality of care 4. Augment choice of patients by providing them + + ++ Mid Term Person-centeredness with localized, pertinent information on quality Equity 5. Develop transparent mechanisms to benchmark ++ ++ +++ Short Term Effectiveness quality of providers and insurance companies Timeliness Equity 6. Improve data currency and data quality and +++ +++ +++ Mid Term Effectiveness better disseminate quality, timely information to Care integration healthcare providers, insurance companies and the public Timeliness Develop and implement a primary health care focused integrated care model to support management of individuals with complex, chronic health care needs 7. Develop and roll out a new integrated care +++ +++ +++ Long Term Care integration delivery model while strengthening primary Person-centeredness health care Equity 8. Expand the scope of the High Cost Account ++ ++ +++ Short Term Care integration program to other chronic diseases and scale Person-centeredness up self-management support mechanisms for patients with chronic conditions Improve accountability and contracting mechanisms to incent for quality 9 Enhance patient participation and engagement + ++ +++ Mid Term Effectiveness in system planning and accountability processes Care integration Timeliness 10. Strengthen outcomes-focused accountability ++ ++ +++ Mid Term Effectiveness mechanisms through improved regulation, Efficiency payment systems and incentives such as ex- post adjustment mechanisms for capitation Equity payments Person-centeredness + low ++ medium +++ high 18 The World Bank | IFC Table S2. Implications of Recommendations for System Stakeholders: Who is Involved? Patients, citizens Department Health and their level health insurance Healthcare Academic representative Recommendations Government authorities companies providers centers groups Strengthen capacity for quality improvement in the health sector 1. Strengthen system capacity for continuous FS M or P M P M or P I quality improvement (QI) and learning & launch national QI campaigns for specific conditions (e.g. cancer) Strengthen the quality ecosystem in the health sector 2. Update and expand the scope of FSM M P P I I the national system of mandatory guarantee for quality of care 3. Improve pre-service and continuous FS P P P M I education for clinicians with a focus on improving clinical competence and QI skills, and building rural training capacity Improve the rigour and use of information on quality of care 4. Augment choice of patients by FSM P P P I C providing them with localized, pertinent information on quality 5. Develop transparent mechanisms to FSM P P P P I benchmark quality of providers and insurance companies 6. Improve data currency and data quality FSM P P P I I and better disseminate quality, timely information to healthcare providers, insurance companies and the public Develop and implement a primary health care focused integrated care model to support management of individuals with complex, chronic health care needs 7. Develop and roll out a new integrated FS M or P M M or P I P care delivery model while strengthening primary health care 8. Expand the scope of the High Cost FSM P P P I P Account program to other chronic diseases and scale up self-management support mechanisms for patients with chronic conditions Improve accountability and contracting mechanisms to incent for quality 9. Enhance patient & citizen participation FS M M P I P and engagement in system planning and accountability processes 10. Strengthen outcomes-focused FSM P P P I or P I accountability mechanisms through improved regulation, payment systems and incentives such as ex-post adjustment mechanisms for capitation payments F: provide funding or financial incentives M: manage program I: be informed about activity S: set strategic direction, standards, policies P: participate in program or support implementation C: make informed or strategic choices External Assessment of Quality of Care in the Health Sector in Colombia | Executive Summary 19 20 0 20 40 60 80 100 10 0 60 0 20 40 60 90 120 30 30 50 150 Mexico Colombia Latvia Lithuania Lithuania Mexico Mexico Figure S1. Colombia Latvia Slovak Republic Colombia Iceland Poland Hungary Luxembourg Latvia Slovak Republic Chile The World Bank | IFC Turkey Estonia Turkey Estonia Turkey Estonia Poland MATERNAL MORTALITY (2016) Czech Republic United States United Kingdom United States Hungary Chile Czech Republic France Portugal Chile LIFE EXPECTANCY AT BIRTH OECD (2016) Korea Japan Denmark Czech Republic United States Germany Portugal Hungary United Kingdom Slovak Republic Korea Portugal United Kingdom Belgium Slovenia Canada Canada Greece Austria Germany Finland Finland Greece Belgium Greece Netherlands Sweden New Zealand New Zealand Denmark Slovenia Austria Israel Australia Ireland Slovenia Japan Canada Australia Spain Iceland Spain Netherlands Sweden Comparisons of Health Outcomes Across OECD Countries Ireland PNEUMONIA: YEARS LOST, /100,000 POPULATION, AGED 0–69 YEARS OLD OECD (2015) New Zealand Italy Korea Switzerland Norway France Italy Belgium Norway Netherlands Germany Israel France Sweden Australia Norway Poland Luxembourg Luxembourg Switzerland Italy Austria Israel Spain Finland Ireland Switzerland Iceland Denmark Japan Figure S2. Variations in Selected Indicators by Region, Public-Private or Rural-Urban Status WAITING TIMES FOR AN GENERAL MEDICINE APPOINTMENT IN DAYS (2018) La Guajira San Andres Atlantico 4 3 Magdalena 2 Cesar 1 Sucre Norte Cordoba Bolivar de Santander Choco Antioquia Santander Arauca Boyaca Risaralda Caldas Cundinamarca Casanare Bogota Vichada Quindio Tolima Valle Meta Guainia Cauca Huila Guaviare Narino Caqueta Vaupes Putumayo Amazonas WAITING TIMES IN DAYS (2016) 40 38.7 Rural Urban 35 30 25 20.7 20 16.3 15 14.1 10 8.0 7.4 6.4 5 2.7 0 General Gynecologist General Pediatrics physician surgery External Assessment of Quality of Care in the Health Sector in Colombia | Executive Summary 21 Figure S2. (continued) Variations in Selected Indicators by Region, Public-Private or Rural-Urban Status CESAREAN SECTION RATE (2018) 50 46.2 41 40 30 20 10 0 Private Public CESAREAN SECTION RATE (2017) La Guajira San Andres Atlantico 70 65 Magdalena 60 Cesar 55 Sucre 50 Cordoba Bolivar Norte de 45 Santander 40 Choco 35 Antioquia Santander Arauca 30 25 Boyaca 20 Risaralda Caldas Cundinamarca Casanare 15 Bogota Vichada Quindio Tolima Valle Meta Guainia Cauca Huila Guaviare Narino Caqueta Vaupes Putumayo Amazonas Source: based on data from the National Quality of Health Care Observatory 22 The World Bank | IFC Table S3 below presents the detailed results of the findings from the quality results assessment, for eight dimensions of quality of care further described in the report. The scores reflected in the table below correspond to a general scale from 1 to 4, with a score of 1 for minimal or no activity; a score of 2 for <50% of desired activities, elements or results in place ; a score of 3= for >=50% of desired activities, elements or results in place; and finally a score of 4 if implementation is optimal or at benchmark. Table S3. Summary of Results from Quality Assessment Tool Quality Results Quality Improvement Capacity & Activities Patient experience 3 Critical mass of staff expertise in quality management in system 2.5 Effectiveness — prenatal care 2 Formal quality structures and teams exist 4 Effectiveness — care of children 3 Demonstrated use of QI methods (process maps, PDSA 2 cycles, etc.) Effectiveness — infectious diseases 2.5 National campaigns and other methods to share learnings 2 Effectiveness — NCDs 2 Broad participation in a strong accreditation program 2 Safety — hospital care 2 Widespread use of decision support tools 2 Timeliness — specialty services 2 Efficiency — avoidance of waste 2 Equity — maternal/child health 2 Inputs – Staff, Facilities, Equipment, Supplies Integrated 1.5 Physician supply 3 Nursing supply 3 Quality Strategy & Planning Regional variations in supply of health professionals 2 Workforce management capacity 3 National strategy is in force with national goals & priorities 3.5 Availability of drugs 4 Strategy is cascaded to all regions & institutions and 2 different diseases Hospital bed capacity 3 Strategy is actively managed 3 Model of care 2 Strategy has stakeholder mapping & engagement 2 Accountability and Governance Quality Definition, Guidelines and Standards Safe 2.5 Definition of quality exists 4 Effective 2 Clinical practice guidelines exist 4 Patient centered 2 Standards for physical infrastructure exist 4 Timely 3 Standards for supply, distribution of human resources 2 Efficient 2 Planning standards for supply, distribution of health facilities 2 Equitable 2 Integrated 1.5 Quality Measurement & Reporting Data collection system and quality indicators exist 3.5 Policies & Incentives to Support Quality Data quality assurance mechanisms established 2.5 Quality of care is central to Universal Health Coverage policies 4 Strong infrastructure for reporting and disseminating Patient rights legislation and patient empowerment 4 3 data exists Alignment across quality of care policies 2 Strong analytical capacity exists 2 Comprehensiveness of quality of care policies 3 Strong knowledge exchange mechanisms exist 2 Definition of roles and responsibilities for implementation of 2 quality of care policies 24 The World Bank | IFC