Study On Medicare Quality Control System Of Public General Hospitals In A District Of Shanghai

[Background]On April 6,2009, CPC Central Committee and the State Council jointly promulgated the’Opinions on Deepening Reform of the Medical and Health Care Systems,’setting off a new round of reform in this regard. The opinions also proposed some new requests on the development of medicare quality in public hospitals. Under the background of healthcare reform in China, in terms of medicare quality control system, the health administrative department attaches great importance to the problems of medicare quality management and control, while it is also facing many new problems and new challenges.At present, the medicare quality control system has been basically established. With the further development of the medical reform, all kinds of medicare quality management and control mechanism have been further established, relevant laws and regulations have gradually been perfected, and a variety of medicare quality control projects have been advanced, which show the determination that the government and the health management institutions possess to strengthen quality management and control of medical service. Medical services has transformed from’medical centered’ to’patients oriented’. Medicare quality management also changed to a management model of medicare quality that is based on the theory of Continuous Quality Improvement and Total Quality Management. The promotion of clinical guidelines originating from evidence-based medicine, and the application of single disease quality management and clinical pathway that integrate elements such as clinical guidelines, service management and cost control, etc, put the medicare quality standard higher and make its content more rich.But it still has many problems in terms of medicare quality control system. Effective accountability mechanism, regulatory capacity, communication and coordination mechanism among regulatory departments, and the supportive information technology need to be further improved. Besides, the number of studies on the regional medicare quality control system is still far from adequate. Regional medicare quality lacks a fair, equitable and reliable third party assessment. This study on medicare quality control systems of public general hospitals in A district in Shanghai may help expand the perspectives of study on regional medicare quality control system, promote the development of key process indicators of the quality control of single diseases or clinical pathway, help enrich the regional literature information on medicare quality control system, and provide the basis for the health policy and decision making process, and better meet the practical needs of the medical reform, to meet the needs of practice of health reform.[Objectives]The main purpose of this study is to analyze the status quo of public general hospitals’ medicare quality control system in Shanghai A district, implementation status of single disease quality control and clinical pathways and the relations with quality control and the link between patient safety climate and patients’ satisfaction based on medicare quality management and control theories, thus providing decision-making reference for promoting the continuous quality improvement in public general hospitals of A district, to provide reference for improving the quality of care in public hospitals in Shanghai public general hospitals’medical care control system.[Contents and Methodology]This study is based on the theoretical framework’ structure, process, outcome’ proposed by Avedis. Donabedian, and is to evaluate the medicare quality control system of public general medical institutions.’Structure’ refers to external medicare quality control system and all internal relatively stable characteristics (physical and organizational) in the public general hospital, including the organizational structure of the external quality system, the functions of each organization, coordination implemented among various organizations, human resources, equipment and facilities and the funding situation;’Process’ means what has the quality control staffs in health administrative organizations, supervision organizations, industrial association and hospital internal quality supervision done and the way they’ve completed the work, including system construction, the content of quality control, quality control methods, quality control frequency, internal and external training, results feedback and information disclosure etc.;’Results’reflects evaluation on the implementation results of medicare quality control system based on the quantity of medical services, efficiency, quality, cost, patient satisfaction, single disease quality control norms and clinical pathway compliance evaluation, assessment of hospital staff on Patient Safety Climate, cognition and evaluation of hospital staff on quality control system in the public general hospitals.Methods include:literature review and existing data collection, external institutes questionnaire survey, interviews with key informants, questionnaire survey on public general hospitals, retrospective review on medical record and expert consultation.[Results]1. Health service status in A districtIn year 2012, the basic situation of the general public tertiary hospitals, Northern secondary hospitals, and Southern secondary hospitals in A district are listed as follows:In terms of services number, the average number of outpatient and emergency people were 1,846,800 people,1,255,000 and 1,165,200 person-times, respectively, which rose by 17.38%,17.84% and 29.96% compared with 2010; discharge person-times were 36,800,22,100 and 26,500, an increase of 40.47%, 16.21% and 10.66% respectively over 2010. In terms of service quality, improved cure rates were 97.56%,95.04% and 90.86%; inpatient acute and critically ill patients survival rate were 88.10%,76.79% and 83.45%, respectively, hospital infectious rate were 2.61%,2.36% and 2.54%; In terms of service efficiency:the average hospital length of stay (calculated according to the actual opening of beds) were 8.06 days, 10.93 days and 9.08 days. In terms of medical cost control, cost of discharged patients per times were 16,300 yuan,10,500 yuan and 9837.7 yuan respectively, showing a growth of -3.37%,17.20% and 13.77% compared with 2010.2. Analysis on Public general hospitals external medicare quality control systemsOrganizational system:A district being mainly under the leadership of Healthcare and Family Planning Commission (Medical Affairs).consisted of the District Medical and Health Workers Association (later referred to as "District Guardian Association") that were relying on the expert group and 20 QC teams responsible for external medicare quality control of regional medical institutions. Health Supervision in A District was responsible for various medical institutions at all levels to regulate the quality and safety of health care and clinical applications of medical technology. A district office which is responsible for handling medical malpractice, medical dispute mediation office, petition office and other agencies ran good, and they had positive external regulatory and facilitating effects on health care quality and safety of hospitals.There were 20 district-level quality control group, including 5 management class quality control group,6 clinical departments class quality control group,9 alternative examination and treatment class quality control group, and the number of members in quality control team was from 4 to 14. Among them, those who are 40-59 years old accounted for 85.60%, those with bachelor’s degree or above accounted for 86.67%; Quality control checks made at least twice a year, the average annual internal quality control training were 0-6 times from 2010 to 2012, there were great differences in training person-times (5 to 300 people). A district operating funds in 2012 QC team was 577,600 yuan, of which 432,600 yuan (about 75%) came from government funding.3. Analysis on internal medicare quality control systems in public general hospitalsOrganizational system:General hospitals mostly formed two levels of medicare quality control system (hospital and department level), few is three-level quality control system. Although slight differences in the specific quality control model, there was a medicare quality management committee or office at hospital level and quality control team at the department level.4. Analysis on single disease quality control/clinical pathway implementation statusIn 151 hospitalized pneumonia patients, who lived in tertiary hospitals and northern secondary hospitals got more standard checking than the southern secondary hospitals which meant being more in line with the Ministry of Health pneumonia single disease control requirements. The average length of stay was 12.46 days; the average cost of hospitalization was 8805.27 yuan.In 97 hospitalized patients with acute myocardial infarction, there were significant differences among public tertiary general hospitals, secondary general hospitals in the north and south in the standardization of medical services, and tertiary general hospitals were more normative. The average length of stay was 1.28 days; an average cost of hospitalization was 37,300 yuan.In 145 patients with heart failure,77.44% of hospitalized patients with heart failure completed initial evaluation on left ventricular function within 24 hours; but only 0.83% completed the review of left ventricular function within a week prior to discharge. The average length of stay was 11.58 days; average cost of hospitalization was 12,000 yuanIn 141 cerebral infarction/ischemic stroke patients,5.93% of patients had cerebral infarction thrombolytic therapy (intravenous rt-PA/or urokinase) records; 32.14% had undergone anticoagulant therapy; 85% had aspirin or clopidogrel gray therapy,77.14% had medication within 48 hours; The average length of stay was 14.71 days; average cost of hospitalization was 14,800 yuan.In 137 type 2 diabetes patients,91.24% of the patients ran glycated hemoglobin tests,55.15% of patients did glycated serum protein examination,98.54% of hospitalized patients had at least one complication check,38.69% had more than 7 examinations for complication. The average length of stay was 13.72 days, and the average cost of hospitalization was 10,400 yuan.In 152 acute appendicitis patients, within 24 hours before surgery,22.73% completed the assessment,75.45% did check but not completely. The percentage of rational choice for prophylactic antimicrobial agents, reasonable time, a reasonable time withdrawal accounted for 91.59%,90.99% and 32.71% respectively. The average length of stay was 6.12 days, and an average cost of hospitalization was 6673.88 yuan.In 146 cesarean section patients,42.47% patients and family members asked for the cesarean section, the majority of patients (99.32%) completed the examinations two days before surgery; 62.33% patients used the first-generation cephalosporin antibiotic drugs as a preventive drug. The average length of stay was 7.42 days; the average medical expenses were 7228.40 yuan.We did a comprehensive analysis on single disease medical practice, medical effects, the length of stay and the medical expenses. Medical practice standard rate of seven single diseases was 37.19%. Diabetes has a higher rates as 81.02%, the overall treatment efficiency was 96.33%; acute myocardial infarction has slightly lower efficiency as 82.61%; average length of stay, the longest was cerebral infarction as 14.71 days; average medical expenses, the highest was 37298.22 yuan for acute myocardial infarction, the minimum is 6673.88 yuan for acute appendicitis.We also analyzed influencing factors which impacted single disease medical effects, the length of stay, medical expenses. Standardized treatment affected the length of stay of pneumonia, acute myocardial infarction and cesarean section; the patient’s age affected the average length of stay of pneumonia, heart failure and acute appendicitis; complications and hospital levels also affect the average length of stay of pneumonia and diabetes.The older the patient, the higher hospital ization medical expenses for pneumonia, acute myocardial infarction, cerebral infarction, diabetes, and acute appendicitis; the longer the length of stay of pneumonia, heart failure, cerebral infarction and diabetic patients,the higher hospital ization medical expenses.5. Employees’Patient Safety Climate assessment and analysis.A survey on 1353 employees belonged to the public general hospitals in A district showed the overall assessment score of the hospital patient safety climate was5.15. "Hospitals responsiveness", "department culture", and "superior management commitment to patient safety issues" scored higher (5.86 points,5.85 points and 5.75 points respectively). But the sores of "without fear of blame", "not mind being embarrassed" and "no fear of an adverse outcome score" were lower (2.63 points,4.47 points and 4.74 points respectively).6. Cognition and evaluation on hospital quality control of the staffs1349 medical staffs were surveyed,74.20% had received training in quality control; 79.03% of people believed that quality control departments conducted monthly self-examination,76.72% of people believed that quality control results had relationship with hospital departments bonuses; 85.95% staffs thought that there were QC improvement suggestions; 89.26% of people deemed that hospital quality control could improve the quality of medical care.77.42% staffs were satisfied with medicare quality control system.40% to 47% of the employees thought the number of medicare quality control personnel was insufficient, training inadequate, and information technology degree not high; 20% to 39% of health care employees pointed out many problems such as short of funds in quality control, quality control results and motivation mechanisms not closely linked, low personnel qualifications, imperfect laws and regulations, irrational control scheme and unscientific quality control indicators, etc.[Discussion and Suggestion]1、Internal and external medicare quality control systemHealth administrative department in A district has formed a comparatively complete external medicare quality control system. Public general hospitals in A district has basically formed two levels of quality control system within the hospital: it sets up medicare quality management committee and/or medicare quality management office at the hospital level, and sets up medicare quality control team at the department level. But the overall coordination mechanism of medicare quality control system in the area has not yet established. The mode of medicare quality management and control needs improving. We propose that a unified regional external monitoring system be established and management standard be set up for hospitals, regular quality check of the hospitals and universal coverage be achieved, thus forming a medicare quality control and monitoring system with characteristics of A district. We suggest that the organization and function of hospital quality control system be improved, every employee be included in the medicare quality control system. The information construction of the medicare quality control system should be strengthened, and the real-time track in the process of medical service information system should be improved, which provides the decision-making basis for the disease management and clinical pathway management.2、Single disease quality control and clinical pathwayThere exists discrepancy between doctor’s diagnosis and treatment behavior and national quality control standard for single diseases or requirements of clinical path. We suggest that the training of quality control of single diseases/clinical pathway requirements in A distirct be improved, the guidance and control of the key process be strengthened, to improve the normative medical service, including the use of antimicrobial drug and medical record writing. We also suggest that the corresponding incentive mechanism of implementation of quality control of single disease and clinical pathway should be formulated, and hospitals should be equipped with necessary facilities to improve the diagnosis and treatment capability of secondary hospitals.3、Patient safety climateMedical errors could not be totally avoided. But the measures taken by hospital to avoid and remedy errors are influenced by the culture of the hospital. The study shows that Patient safety climate in the hospitals in A district has some flaws, which is neither conductive to learn from mistakes and avoid similar mistakes happening for other employees, nor favorable to for hospitals to find the systematic reasons of recurring mistakes. The study also shows that the improvement of hospital patient safety climate could improve the medicare quality management, and the patient satisfaction. Appropriate medicare quality and safety management incentive mechanism should be established, error reporting and learning should be encouraged, blind blame and punish should be abandoned and patient safety climate which is favorable to avoid recurring errors should be built. Hospitals should strengthen the training of medicare quality and safety for medical staffs, enhance staff patient safety consciousness, improve the hospital safety climate, and encourage safety behavior for employees.