Problem: Overprovision of medical services, particularly minor operations, radiological exams and hospital admissions; inconsistent adherence to care standards and guidelines by providers; weak monitoring and evaluation systems resulting in a lack of accountability.
Solution highlights: Clinical audits were implemented to improve adherence to national guidelines through increasing transparency and accountability for service delivery across health care institutions; lengthy discussions with stakeholders and clear communication of the initiative’s aims were essential for establishing sufficient buy-in to begin implementation; establishing data collection and analysis systems was a critical step for improving and optimizing care. Strong data collection, followed up with monitoring and evaluation, was paramount to the initiative’s success; while the initiative was led by the Ministry of Health, regional health authorities played an increasingly important role in supporting auditing processes and providing local oversight of audited institutions as the initiative expanded.
Description of practice
In the early 2010s, negative patient feedback indicated overprovision of health services was occurring across health care institutions. Complaints were concentrated around the unnecessary performance of minor operations and radiological exams, as well as unwarranted hospital admissions. Review of health care utilization data and health insurance reimbursement data confirmed patient reports. Providers’ deviation from standards and clinical guidelines was partly attributed to a lack of monitoring and evaluation.
The Ministry of Health devised a national initiative in conjunction with stakeholders to implement Audits of Compliance with Medical Indication (ACMI) to increase government oversight of health services in alignment with care standards in place. While health care institutions resisted proposed changes during early stakeholder meetings, discussions were eventually successful in gaining their support by explaining the initiative aimed to improve the quality and performance of services, but not impose penalties. With stakeholders on board, a literature review was conducted to identify priority targets and a multidisciplinary expert committee was convened to help plan the initiative, design auditing tools and guide the implementation process. The plan put forward was to conduct annual peer-led audits across medical specialities to improve providers’ adherence to national guidelines. A pilot audit of intensive care units helped refine the initiative’s design prior to scaling up. Audited clinical specialities now also include radiological imaging services and coronary angiography units. Patient records are selected for audit through random sampling and necessary data is collected through an online portal where selected institutions are required to upload requested files. The collected information is then compared with current national guidelines for each service. Once an audit is complete, institutions receive performance results privately from the Ministry of Health and are required to make necessary improvements based on feedback. Required performance improvements are monitored by Provincial Health Directorates through annual reassessment audits. The Ministry of Health is looking to expand the initiative to audit all medical specialties across all care levels. The Ministry is also considering adjustments to the initiative, such as the inclusion of financial incentives for auditors to increase efficiency and public reporting of audit results to increase accountability and stimulate further performance improvements.
Implementation of practice
What stage is the practice currently in?
Fully implemented and scaled up
Who was/is responsible for the implementation of the practice?
The Ministry of Health led the initiative in response to concerns brought forward by the general public and the Social Security Institute. A scientific commission, composed of ministry representatives and experts in proposed audit areas, was established by the Ministry to design and guide the initiative. While the Ministry continues to provide oversight, activities are increasingly devolved to Provincial Health Directorates as the initiative expands. Auditors work on a voluntary basis and are experts in the audited fields. While the Ministry was able to convince auditors working voluntarily “was their civic duty”, financial incentives are being considered to motivate efficiency improvements.
The initiative supports increased attention and adherence to existing protocols and care guidelines. Approximately 50 000 audits across over 1000 health care institutions covering 10 medical specialties have been conducted to date. As a result of increased government oversight, contraindicated service provision is reported to have decreased, cost savings have been reported and care is more readily accessible for patients with indicated medical need.
This case was prepared as part of a larger effort by the WHO Regional Office for Europe and published (2016) in the document, "Lessons from transforming health services delivery: Compendium of initiatives in the WHO European Region".
© Copyright World Health Organization (WHO), 2016
The methodology used for the development of this case is slightly different from the templates used on the IntegratedCare4People web platform, in particular in the analysis of enabling factors and barriers to change.
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- Necvan Tokmac
- Ministry of Health