Measurements for Improved Quality in Healthcare
The two main actors in the Scottish healthcare system are the Scottish Government and NHS Scotland (National Health Service for Scotland). Budget, policies and strategic initiatives are set by the government, while the NHS is responsible for the delivery of care to the population in its region, and held accountable to the Scottish Parliament. Many healthcare functions are delegated from the government to the 14 territorial NHS Boards, which are responsible for planning and delivering all health services to the population in their areas.
The Healthcare Quality Strategy for NHS Scotland, enacted by the Scottish Government in 2010, provides the overarching context for prioritization of policy development and quality improvement efforts within the NHS. The strategy encourages whole system improvement through mutually beneficial partnerships between clinical teams, the people in their care, and other national organizations involved in healthcare delivery. At its core are three quality ambitions:
- Person-centered – mutually beneficial partnerships between patients, their families and those delivering health services, which respect individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision-making.
- Safe – there will be no avoidable injury or harm to people from health care they receive, and an appropriate, clean and safe environment will be provided for the delivery of health care services at all times.
- Effective – the most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated.
Within the NHS, the Information Services Division (ISD), Healthcare Improvement Scotland (HIS) and the Scottish Intercollegiate Guidelines Network (SIGN) drive the national quality improvement work. The ISD and HIS in particular have increased their roles in quality improvement in recent years and also work closely together on measurement, data collection, and analysis.
As for data and measurement, information for tracking and improving healthcare quality is collected across the entire Scottish healthcare system and spread out across several actors. Historically, data collection and registry maintenance has been decentralized and driven by hospitals and clinical networks. Since a couple of years back, however, the ISD has taken over responsibility for running most national registries and audits. The national strategy is to try and link existing records together with added finesse, rather than start new registries. A general note is to not confuse national quality measurements and quality registries. Disease-specific quality registries are few in Scotland, while national measurements of quality are made systematically to improve healthcare.
Four overarching measurement systems are used to track and improve healthcare quality in Scotland today: audits, to evaluate the performance of the 14 NHS health boards; national audits for measuring and improving the quality of healthcare for selected diseases or conditions; specific quality improvement programs, typically coordinated by the HIS, that can drive improvements around a specific topic, and finally the three national disease registries in Scotland. From a public health perspective, these registries are mainly used on a population level to spot patterns and variations, hence leading to initiatives for changes for improving care.
Participation in register work is generally accepted within the Scottish healthcare sector. There is no reimbursement for reporting data to the registers or central institutions and no financial penalties if data are not reported. In contrast to the hospitals, GPs have a much more developed financial incentive to develop quality as part of their reimbursement or pay is based on their own record data which should mirror compliance with certain nationally set guidelines.
Researchers can access most registries hosted by the ISD and other organizations, but sometimes need permission from different Health Boards and the Privacy Advisory Committee, which can complicate the research process. However, projects are under way to try to facilitate access to both primary and secondary care data for researchers.
There is also a general understanding around the importance of having publically available data. The main data that are regularly published in the media and known to the public are standardized mortality ratios (SMRs) and data on waiting times. The inclusion of patients in registers is described as in general accepted by the public, but it is not established whether this refers to limited awareness among patients or whether it is an active choice.