IMPROVE THE QUALITY OF CARE IN EUROPE A NEED FOR CLARIFYING THE CONCEPTS AND DEFINING THE M
Regional Office for Europe _______________________
EUR/03/5038066
ENGLISH ONLY
UNEDITED
E78873 MEASURING HOSPITAL PERFORMANCE TO IMPROVE THE QUALITY OF CARE IN EUROPE: A NEED FOR CLARIFYING THE CONCEPTS AND
DEFINING THE MAIN
DIMENSIONS
Report on a WHO Workshop Barcelona, Spain, 10-11 January 2003
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ABSTRACT
The World Health Report 2000 stressed that the organization, configuration and delivery of services impact on the performance of the overall health system performance. The current restructuring of health care services among European countries – both Western and Eastern countries – highlights the importance of efficient hospital organization throughout Europe. The development of new common policy orientations, focusing on the demand for accountability and quality improvement strategies, and a growing interest in patient satisfaction assessment, are incentives for developing hospital performance assessment.
A workshop organized in Barcelona by the WHO European Office for Integrated Health Care Services the 10-11 January 2003 discussed conceptual issues, definitions and concepts of hospital performance measurement and practical issues as the principles for designing and developing benchmarking networks dedicated to measure hospital performance and promote the improvement of quality of care.
The following conclusions were reached: need to have generic definitions adapted to the context of this project; definitions of key dimensions of hospital performance promoting a comprehensive model of hospital performance measurement; and recommendations regarding the design of a benchmarking network allowing participants to compare their own performance to peer hospitals through relevant performance indicators.
The group of experts agreed on six key dimensions for assessing hospital performance:
· Clinical effectiveness · Safety
· Patient centredness · Production efficiency · Staff orientation
· Responsive governance
The original papers of the workshop will be available on the website of the WHO European Office for Integrated Health Care Services (http://www.euro.who.int/ihb ).
Keywords
HOSPITALS – standards
QUALITY INDICATORS, HEALTH CARE – standards
QUALITY OF HEALTH CARE DELIVERY OF HEALTH CARE HEALTH POLICY – trends EUROPE
? World Health Organization – 2003
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WHO Regional Office for Europe, Copenhagen
CONTENTS
Page
INTRODUCTION (4)
HOSPITAL PERFORMANCE PROJECT (5)
BACKGROUND (6)
Models of hospital performance assessment (6)
Different dimensions of hospital performance measurement (7)
CONCLUSIONS (8)
Definitions (8)
The key dimensions of hospital performance measurement (9)
Expansion of dimensions and sub-dimensions (10)
RECOMMENDATIONS (11)
REFERENCES (13)
ANNEX 1: SCOPE AND PURPOSE (14)
ANNEX 2: PROGRAMME (16)
ANNEX 3: LIST OF PARTICIPANTS (18)
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Introduction
As discussed in the World Health Report 2000, the organization, configuration and delivery of services impact on the performance of the overall health system (1). This report introduced the concept of stewardship, stating that governments “should ensure that their country’s health care system provides the optimal health services for its population” (2). To achieve this, emphasis should be put on the development of systems monitoring and regulating the performance of health care providers, especially hospital performance, as such systems are still poorly developed throughout Europe (3).
In that perspective, hospitals deserve special attention:
Hospitals are an important part of any health system: they provide complex curative care that, depending on their capacity, acts as a first referral, secondary or last referral level curative care facility; they also provide emergency care for the severely injured or the critically ill; they are centres for the transfer of knowledge and skills; they constitute an essential source of information and power; and they generally spend the major part of national health resources (4).
Hospitals account for the largest share of overall health expenditure, generally between 50% and 70 % of health care expenditure throughout Europe. Common trends during the ten last years in Europe include a major reduction in the number of beds (even though hospital admissions are not decreasing) and shorter lengths of stay.
During this period, the volume of ambulatory care rose (5). Hospitals had to continue to adapt themselves to changes in their internal and external environments in the general context of restructuring systems (6).
The development of new policy orientations, such as the demand for accountability and quality improvement strategies, or a growing interest in patient satisfaction assessment, are also incentives for developing attention to hospital performance assessment. The concept of performance brings together the concepts of quality, efficiency and effectiveness of health care services.
Performance indicators can be used for internal and/or external reasons. Internal reasons are related to the various management functions of the hospital as a health services delivery organization and the indicators are used as management information to monitor, evaluate or improve the functions in the long term (strategy) or short term. External reasons are related to accountability questions asked by other stakeholders such as the financier (either insurer or State), patients/consumers and the public at large.
Many nations have now integrated hospital accreditation programmes into their health care systems. The basic concept of hospital accreditation among nations is similar but in fact is maturing and changing in those countries where the programmes have long been in place. Hospital accreditation has always been about structure, process, and outcome but has focused mostly on the structure and process aspects. It is now the case in the United States, Australia, Canada, Europe and some other countries where the emphasis is increasingly on outcomes. It needs to be recalled, however, that the identification of a bad outcome is an indicator that there is a problem in the process or the structure. For example, in the measurement of post-operative infection, there is absolutely no meaning other than that some aspect of the process or structure lies at the root of the cause.
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Page 5 In order to develop hospital accreditation, health services need to develop close links with allies like health services research, legislators and the media. No least the latter because of the need to transfer complicated scientifically based information to decision makers and to the public (7).
Hospital Performance Project
The strategic orientations of WHO promote a comprehensive approach to measure hospital performance and encompass different dimensions of performance such as responsiveness, evidence based best practices and organization, continuity and integration of health care services and health promotion, focusing on patients’ needs.
The aim of this project is to identify, based on best practices, a framework, key dimensions to measure hospital performance and a set of valid and reliable indicators related to these dimensions, on which they could assess voluntarily.
The aim is not to produce normative indicators, but to enhance the value of comparison to peer hospitals in order to promote the performance of services delivered to the patients in a voluntary process.
Within this context a working group was set up in November 2002, gathering together European and North American experts. The mandate of this working group was to build and validate a flexible and comprehensive model of hospital performance assessment, allowing the implementation of benchmarking networks on hospital performance at the national or international level. Voluntary quality improvement is the overarching purpose of these networks. In the first meeting of the working group several issues were discussed:
a) conceptual issues as definitions of hospital performance assessment;
b) key dimensions and sub-dimensions of hospital performance; and
c) different models of hospital performance. The expected outcome of the workshop was to
agree on a comprehensive and flexible frame for measuring and assessing hospital performance.
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Background
Models of hospital performance assessment
Different models of hospital performance assessment were presented during the meeting and discussed.
The Canadian experience
The balanced scorecard model (Ontario Hospitals Association, OHA) integrates customer, financial, internal business process, learning and growth – but these four dimensions remain separate, not integrated.
The Ontario Hospitals Association has developed a workable framework, which: · is provider driven
· has voluntary participation
· is risk adjusted for fair comparisons
· uses publicly available methodology
· protects medical data and patient confidentiality
· ensures that indicator selection is scientifically valid
· has a range of report levels e.g. public, private, research and internal (8).
Researchers from the University of Montreal developed a second model (9). Based on Parson’s social system theory, each organisation has to:
1. adapt to environment: respond to social values, resource acquisition, community support,
innovation and learning, market presence etc;
2. attain goals: stakeholder satisfaction, effectiveness, efficiency;
3. produce services: productivity, service volume, quality, coordination; and
4. maintain culture and values: consensus, organizational climate, workplace health.
This model addresses the lack of integration between the dimensions of the different models by including the perspective of alignment between the different perspectives. The different kinds of alignment are strategic, resource allocation, tactical, contextual, operational, and legitimization. The good performance of the model will be the result of the capacity of the organization to maintain the alignment between the different dimensions of performance. It is compatible with the European Foundation for Quality Management (EFQM) framework.
The Danish model focuses on the patients′ pathway with three different perspectives: - a clinical perspective: admission, assessment, investigation, evaluation, discharge, follow-up;
- the patient’s perspective: information/communication, coordination, continuity, patients′ rights, patient safety; and
- an organizational perspective: e.g. public information, leadership, human resources, research, education, risk management.
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Page 7 The model developed by French researchers is a simplified version of the model developed by the University of Montreal. This model incorporates three main dimensions (without alignments): achievement of goals (clinical and epidemiological quality), optimum use of resources and ability to adapt to change and innovate. The French experience is not aiming for a single model, merely for a framework to ensure that legitimate dimensions are included and available to participating hospitals.
The experience of the “Quality Indicator Project” (QIP, Maryland, USA)
This multinational project, originated in Maryland 18 years ago, gathers now about 2000 participants from all continents. The driving force of the implementation of the QIP was accountability: the project was dedicated to produce indicators for hospital boards (10). The “Quality Indicator Project” is not based on any specific model, but on epidemiology of performance (not current thinking on health service structure) and the assumption that all measurement is comparative. The project began with acute care but moved to ambulatory, long term, mental health etc. It also now extends to patient safety, including error rates, to provide epidemiology of risk management.
The project is voluntary and confidential; it does not make definitions or rates public and no judgments are made of participating organizations. Individual reports are produced four times a year for all participants. Taking into consideration that all interpretation (or evaluation) is local, local coordinators are designated in the different hospitals participating in the QIP. Peer hospitals are stratified according to 40 characteristics.
Different dimensions of hospital performance measurement
Different dimensions of hospital performance and their classification were discussed. The model used by the Ontario Hospitals Association (balanced scorecard framework) includes 4 main dimensions: financial, patient perspective, clinical utilization, system integration and change. The model developed by the researchers of the University of Montreal encompasses goal attainment, production, adaptation and culture and values (9).
The United Kingdom performance assessment framework developed by the Department of Health to measure each hospital trust in England sets out measures in six main areas: improvement in people’s health; fair access to services; the delivery of effective care; efficiency; the experiences of patients and their carers; and health outcomes (2).
The dimensions of equity and accessibility could be logically included in the dimensions of hospital performance, but it is debatable whether these dimensions are more related to the overall performance of the health care system than to the performance of individual hospitals.
The dimension of patient safety should also be stressed, considering the current interests of WHO.
A first summary of the different dimensions discussed by the experts, oriented to WHO goals, included effectiveness (including prevention and health promotion), patient centeredness, safety, innovation, community responsiveness (both needs and demands) and integration in the overall delivery system.
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Conclusions
Definitions
A preliminary definition of hospital was accepted in the context of this project: “A hospital can be defined as an organized effort to provide a specific set of medical services, usually physically located in one or several buildings, and related to specialized cure (diagnosis and treatment) and care (as opposed to the primary care level) with the input of health professionals, technologies and facilities.” This definition will be further discussed and slightly re-defined during the next workshop. Even if a generic definition of hospitals should be used in the context of this programme, the use of local definitions should complement this approach.
A definition of the term ‘performance’ was also proposed:
“Performance is the achievement of desired goals. High hospital performance should be based on professional competences in application of present knowledge, available technologies and resources; efficiency in the use of resources; minimal risk to the patient;
satisfaction of the patient; health outcomes. Within the health care environment, high hospital performance should further address the responsiveness to community needs and demands, the integration of services in the overall delivery system, and commitment to health promotion. High hospital performance should be assessed in relation to the availability of hospitals’ services to all patients irrespective of physical, cultural, social, demographic and economic barriers”.
This definition will also be further discussed during the next workshop.
I n order to define a relevant strategy to promote the improvement of quality of care through the measurement of hospital performance, it should be admitted that performance is contingent. Indeed, criteria regarding the best or sufficient set of indicators of performance are based on the values and preferences of actors. Consequently, WHO should provide guidance to hospitals through policy orientations that influence the choice of relevant dimensions, sub-dimensions and the selection of reliable indicators.
The difference between performance (value-free) and quality (evaluated, normative) was stressed (11). The experts agreed that performance had no value in it: performance measurement is generic while evaluation is more local. Three elements should be included in the design and development of a performance assessment model: functioning, measurement methods, judgment and evaluation of results (or ‘observations’) of hospitals.
The current definition of the term ‘assessment’, proposed by ISQUA (2002), was discussed:
“Assessment is the process by which the characteristics and needs of clients, groups or situations are evaluated or determined so that they can be addressed. The assessment forms the basis of a plan for services or action.”(12).
A distinction was made between assessment (putting a value on the measurement of performance) and measurement (act of measuring, without putting any value on the ‘observation’). The purpose of this project is to help organizations to understand (internally) and improve their practices rather than to provide accountability (externally). Hence, a distinction is made within this project between hospital performance measurement (building a tool to help hospital measuring their performance) and hospital performance assessment (assessment, or evaluation, is made locally).
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The key dimensions of hospital performance measurement
The different dimensions proposed by the experts of the workshop were discussed. A consensus was found around six key dimensions. (Table 1)
Table 1:Key dimensions of hospital performance as proposed by the group of experts Dimension Including Clinical effectiveness
Technical quality, evidence-based practice and organization, health gain, outcome (individual and population)
Patient centeredness
Responsiveness to patients: client orientation (prompt attention, access to social support, quality basic amenities, choice of provider), patient satisfaction, patient experience (dignity, confidentiality, autonomy, communication)
Production efficiency Resources, financial (financial systems, continuity, wasted resource), staffing ratios, technology
Safety Patients and providers, structure, process
Staff
Health, welfare, satisfaction, development (e.g. turnover, vacancy, absence) Responsive governance
Community orientation (answer to needs and demands), access, continuity, health promotion, equity, adaptation abilities to the evolution of the population’s demands (strategy fit)
The exclusion of potential dimensions should not be interpreted as WHO denial of the importance of specific issues such as workforce health, non-technical quality or teaching and learning. The choice was to focus on patient care in acute care hospitals and to stress on dimensions of performance that hospitals can concretely affect.
Organizational culture was considered as a determinant of hospital performance, and not as a dimension. Nevertheless, relevant indicators dealing with organizational culture could be included in the future frame of hospital performance measurement.
The key dimensions were compared to the different theoretical models of performance in organization theory. It led to the conclusion that the key dimensions selected captured most of the aspects of performance. (Table 2)
Table 2: Link between the key dimensions of hospital performance and the different theoretical models of performance according to the sociology of organizations Dimension Corresponding theoretical model of performance Clinical effectiveness Rationale of professionals
Patient centeredness Rationale of patient experience and patient satisfaction Production efficiency
Internal resources model + resources acquisition model
Safety Fault-driven model Staff Human relations model Responsive governance
Strategic constituencies model + social legitimacy
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Expansion of dimensions and sub-dimensions
The sub-dimensions proposed by the experts of the workshop were discussed in smaller groups.
The discussion concluded that WHO should provide guidance on policy orientations to permit a better choice of sub-dimensions. The sub-dimensions will be further discussed and validated during the next meeting. Nevertheless, a first draft was proposed in order to analyse the relevance and the feasibility of gathering reliable data for selected sub-dimensions. (Table 3)
Table 3: Analysis of dimensions and sub-dimensions of hospital performance: relevance and feasibility (0 star for not
relevant, 3 stars for very relevant; 0 star for not feasible, 3 stars for very feasible)
Dimensions and sub-dimensions Relevance Feasibility
Clinical effectiveness
Re-admission rate x days *** *** Mortality *** * Complication rate *** Appropriateness *** Length of stay disease specific *** *** Quality improvement progress *** ** Evidence based processes *** (*) SF 36 etc. ** Patient centredness
Waiting time (elective surgery) *** * Equity of access *** Patients rights *** * Patients perception *** * Production Efficiency
Length of stay disease specific *** *** Safety
Hospital-acquired infections *** Falls *** * Bed sore *** * Staff orientation
Turnover *** *** Absentee rate *** *** Responsive governance
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Recommendations
1. Benchmarking networks. The frame developed in this project could be applied in a European benchmarking network on hospital performance assessment according to the following principles:
· the participation in the European network designed and coordinated by WHO EURO would be voluntary; · the indicator information is primarily to be used for internal management purposes and all data will be kept confidential; · it is up to the participating hospitals to choose the areas where they want to benchmark each other; · the indicators are not normative; the priority is to foster the comparison of hospital performance and consequently to improve the quality of care provided; and · different baskets of indicators (basic / intermediate / advanced) will be proposed in order
to allow countries with less developed information systems to use the hospital performance database.
In many countries, hospitals have become weary of indicator projects. It is important to build on existing measures and systems, and to identify and assess standards of data quality.
2. Selected indicators should be based as much as possible on data availability. An assessment on country data availability should be made before selecting validated indicators, especially the common content of minimum data sets for patients discharges from hospital and accuracy.
3. A profile of countries concerned by the pilot testing phase (“environmental assessment phase”) should be provided to the participants for the next meeting.
4. Several countries covering different health systems, cultures and levels of development were chosen: Albania, Denmark, France, Georgia, Germany, Lithuania, the Netherlands, Spain and United Kingdom for the piloting phase.
5. Role of coordinators designated for the pilot test. The coordinators designated will have to fulfil the following tasks:
· to select / gather a group of national experts to comment the proposals of the core group of international experts set up by WHO;
· to coordinate and summarize the comments of the national experts; · to be the focal point for assessing the availability of relevant indicators;
· to participate in a first meeting to design a questionnaire for the pilot-test and select limited but representative number of hospitals to pilot test the model of hospital performance (September 2003); · to gather, summarize and analyse the outcomes of the pilot-test at national level. Organize a meeting with representatives from the hospitals involved to discuss the final outcomes of the pilot test (April 2004); and
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· To participate in a second meeting of the project:
a) to discuss the outcomes of the pilot test at national level with the other pilot
countries;
b) to discuss the possibilities and relevance of international comparisons;
c) to establish recommendations on the key issues and the way forward for the core
group of experts.
6. The next workshop will examine the values and policy orientations WHO wants to promote through the selection of the sub-dimensions, will discuss the sub-dimensions of hospital performance, define the terms in use in the context of this project, and consider the method to use for a global review of validated indicators and at least will specify the purpose of the pilot testing phase. It will take place in Barcelona, 21-22 March 2003.
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(1) The World Health Report: 2000: Health systems: improving performance. Geneva,
World Health Organization, 2000.
(2) Healy J, McKee M. Monitoring hospital performance. Euro Observer, Newsletter of the
European Observatory on Health Care Systems, 2000, Vol. 2, 2:1-3
(3) The European Health Report 2002, Copenhagen, WHO Regional Office for Europe,
2003 (European series, No. 97).
(4) A review of determinants of hospital performance: report of the WHO Hospital Advisory
Group Meeting, Geneva, 11-15 April 1994. Geneva, World Health Organization, 1994
(document WHO/SHS/DHS/94.6).
(5) Healy J, McKee M. Hospitals in a changing Europe / edited by Martin McKee and
Judith Healy. Buckingham, Open University Press, 2002 (European Observatory on
Health Care Systems series).
(6) European Health Care Reform: analysis of current strategies. WHO Regional Office for
Europe, 1997 (European series, No. 72).
(7) Appraisal of Investments in Health Infrastructure. Barcelona, WHO European Office for
Integrated Health Care Services, 2000.
(8) Measuring up. Improving health system performance in OECD countries. In:
Proceedings of conference "Measuring up: improving health system performance in
OECD countries, 5-7 Nov. 2001, Ottawa”. Paris, OECD, 2002
(9) Sicotte, C. et al. A conceptual framework for the analysis of health care organizations’
performance.Health Services Management Research, 1998, 11: 24-48.
(10) Kazandjian V. Accountability through measurement: a global healthcare imperative.
Milwaukee, ASQ Quality Press, 2002.
(11) Kazandjian V, Lied T. Healthcare performance measurement: systems design and
evaluation. Milwaukee, ASQ Quality Press, 1999.
(12) https://www.wendangku.net/doc/9d13006099.html,.au
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Annex 1: Scope and purpose
The WHO European Office in Barcelona is organizing a meeting on Hospital Performance from 10-11 January 2003.
The purpose of this first workshop is to discuss different models for hospital performance assessment. The workshop is part of a new WHO initiative to develop a Hospital Quality Improvement Strategy to support Member States in the implementation of Hospital performance assessment strategies and use of key indicators. The project has three main objectives: 1- Collect evidence on the use of hospital performance assessment models to support countries in their implementation.
2- Produce benchmarking tools to allow hospitals from different European countries to compare themselves to peer groups.
3- Build an experts’ network on hospital performance assessment to support country implementation and analyze outcomes.
The work will be done in three stages: definition and analysis of different models currently used in Europe, USA and Canada; piloting of the agreed models, validated by groups of experts in 6 different countries; and, development of guidelines to facilitate country implementation. Participants in the first workshop are experts with experience in performance and quality assessment in the hospital field. It is envisaged that after this first meeting, three working groups will be set up in order to further develop the workshop recommendations. It is expected that the participants will also contribute to one of the three working groups.
The workshop will address the following tasks:
- Definition of model(s) of hospital performance assessment in Europe.
- Glossary of terms used in the model(s) proposed
- Identification of hospital functions in the performance model(s) proposed
- Analysis of advantages and disadvantages of the different models.
- Definition of key criteria to assess hospital performance and selection of indicators (structural, process, outcome).
- Methodological proposals related to the metrology of indicators.
- Classification of acute care hospitals in order to assess hospital performance.
The expected outcomes of the workshop are: (1) to agree on comprehensive and flexible models of hospital performance;. (2) to provide the basis for the development of a framework to describe the different practices in the field of hospital performance and accreditation in Europe. The WHO European Office in Barcelona is organizing a meeting on Hospital Performance from 10-11 January 2003.
The purpose of this first workshop is to discuss different models for hospital performance assessment. The workshop is part of a new WHO initiative to develop a Hospital Quality Improvement Strategy to support Member States in the implementation of Hospital performance assessment strategies and use of key indicators. The project has three main objectives:
1. Collect evidence on the use of hospital performance assessment models to support
countries in their implementation.
2. Produce benchmarking tools to allow hospitals from different European countries to
compare themselves to peer groups.
3. Build an experts’ network on hospital performance assessment to support country
implementation and analyze outcomes.
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Page 15 The work will be done in three stages: definition and analysis of different models currently used in Europe, USA and Canada; piloting of the agreed models, validated by groups of experts in 6 different countries; and, development of guidelines to facilitate country implementation. Participants in the first workshop are experts with experience in performance and quality assessment in the hospital field. It is envisaged that after this first meeting, three working groups will be set up in order to further develop the workshop recommendations. It is expected that the participants will also contribute to one of the three working groups.
The workshop will address the following tasks:
- Definition of model(s) of hospital performance assessment in Europe.
- Glossary of terms used in the model(s) proposed
- Identification of hospital functions in the performance model(s) proposed
- Analysis of advantages and disadvantages of the different models.
- Definition of key criteria to assess hospital performance and selection of indicators (structural, process, outcome).
- Methodological proposals related to the metrology of indicators.
- Classification of acute care hospitals in order to assess hospital performance.
The expected outcomes of the workshop are: (1) to agree on comprehensive and flexible models of hospital performance;. (2) to provide the basis for the development of a framework to describe the different practices in the field of hospital performance and accreditation in Europe.
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Annex 2: Programme
Friday, 10 January 2003
09.00 – 09.15 Opening and introduction of participants
Mila Garcia-Barbero, Head of the Office
09.15 – 09.30 Background and outline of the “Hospital Performance Assessment in Europe” project
Jeremy Veillard
09.30 – 10.00 Discussion
Chair: Mila Garcia-Barbero, Head of the Office
1 - Defining the terms used in the field of hospital performance assessment
10.00 – 10.15 Definitions of the terms in use: Summary of the background papers and proposals
Jeremy Veillard
10.15 – 10.45 Discussion
Chair: Charles Shaw
10.45 – 11.15 COFFEE BREAK
2 - Classifying and defining the different dimensions of hospital performance
assessment
11.45 – 12.10 The different dimensions of Hospital Performance Assessment: Classification proposals
Johann Kjaergaard and Svend Jorgensen
12.10 – 13.00 Discussion
Chair: Niek Klazinga, Netherlands
13.00 – 14.30 Lunch break
3 - Defining the key dimensions of hospital performance assessment
14.30 – 15.30 Working groups
Identification and discussion of the key dimensions of hospital performance assessment
15.30 – 16.00 COFFEE BREAK
16.00 – 16.30 Presentations: conclusions of the working groups
16.30 – 17.00 Discussion
Chair: Vahé Kazandjian
17.00 Wrap-up (Svend Jorgensen) and conclusions from day one (Jeremy Veillard)
17.30 Closure
20.30 DINNER
SATURDAY, 12 JANUARY 2002
4 - Discussing different models of hospital performance assessment (interactions
between the different dimensions)
09.00 – 09.10 Johann Kjaergaard, Denmark: a Danish model
09.10 – 09.20 Discussion
09.20 – 09.40 Fran?ois Champagne, Canada: Two experiences from Canada
09.40 – 09.50 Discussion
09.50 – 10.00 P. Lombrail, France: project of the French Ministry of Health
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10.10 – 10.20 Vahé Kazandjian, USA: the experience of the IQIP and the model in use
10.20 – 10.30 Discussion
10.30 – 11.00 COFFEE BREAK
11.00 – 12.00 Working groups: Identification and discussion of the advantages and drawbacks of the
different models
12.00 – 12.30 Presentations: conclusions of the working groups
12.30 – 13.30 Discussion
Chair: Henner Schellschmidt
Validation of the proposal of model(s) of hospital performance assessment
13.30 – 14.00 Conclusions
Wrap up: Itziar Larizgoitia Jauregui
Ongoing work: Jeremy Veillard
Closure
14.00 LUNCH
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Annex 3: List of participants
Fran?ois Champagne
Professeur titulaire
GRIS et Département d'administration de la santé Université de Montreal
B.P. 6128, succursale Centre-ville
H3C 3J7 Montreal, Quebec
CANADA Telephone: +15143432226
Fax: +15143432207
E-mail: francois.champagne@umontreal.ca
Pilar Gavilán
Responsible for the Projects Unit
Directorate on Organization, Information Systems, Projects and Evaluation (DOSIPA)
Catalan Institute for Health
Gran via de les Corts Catalanes, 587
08007 Barcelona
SPAIN Telephone: +34 93 482 43 33 Fax: +34 93 482 45 27
E-mail: pgavilan@ics.scs.es
Vytenis Kalibatas
Deputy Managing Director Kaunas Medical University Hospital Eiveniu str. 2
LT-3007 Kaunas
LITHUANIA Telephone: +370 37 32 63 23 Fax: +370 37 32 66 01
E-mail: kalibata@kmu.lt
Vahe Kazandjian
President
Center for Performance Sciences (CPS) 6820 Deerpath Road ? Elkridge, MD 21075 UNITED STATES Telephone: +1 410 379 9540
Fax: +1 410 379 9558
E-mail: vkazandjian@https://www.wendangku.net/doc/9d13006099.html,
Johann Kjaergaard
Head of Unit for Clinical Quality Copenhagen Hospital Corporation Bispebjerg Bakke 20C
2400 K?benhavn NV DENMARK Telephone: +45 3531 2852 Fax: +45 3531 6317
E-mail: jk02@bbh.hosp.dk
Niek Klazinga
Department of Social Medicine Academic Medical Center University of Amsterdam Meibergdreef 9
1100 DD Amsterdam NETHERLANDS Telephone: +31 20 5664892 Fax: +31 20 6972316
E-mail: n.s.klazinga@amc.uva.nl
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Pierre Lombrail Director
P?le Information Médicale, d'Evaluation & de Santé Publique (PIMESP)
Centre Hospitalier Universitaire de Nantes. H?pital Saint Jacques. 85, rue Saint Jacques 44 093 Nantes cedex 1 FRANCE Telephone: +33 2 40 84 69 20 Fax: +33 2 40 84 69 21
E-mail: pierre.lombrail@chu-nantes.fr
Ehadu Mersini Chief of the Planning and Medical Programs Sector Hospitals Department Ministry of Health Tirana ALBANIA Telephone: .+ 355 4 364614 Fax: +355 4 364270 E-mail: ehadmers@https://www.wendangku.net/doc/9d13006099.html,
Laura Sampietro-Colom Director
Directorate on Evaluation and Information Systems Catalan Institute for Health
Gran via de les Corts Catalanes, 587 08007 Barcelona SPAIN
Telephone: +34 93 482 42 62 Fax: +34 93 482 45 27
E-mail: lsampietro@ics.scs.es
Irakli Sasania General Director
M. Iashvili Children's Central Hospital 2/6 Ljubljana str. 380059 Tbilisi GEORGIA Telephone: +995 32 377 220 Fax: +995 32 529 034
E-mail: isasania@cch.ge; isasania@gol.ge
Henner Schellschmidt
Wissenschaftliches Institut der AOK Kortrijker Str. 1 53177 Bonn GERMANY Telephone: +49 228 843 135 Fax: +49 228 843 144 E-mail:
henner.schellschmidt@wido.bv.aok.de
Charles Shaw
Director, Audit and Quality CASPE Research
11-13 Cavendish Square W1G 0AN London UNITED KINGDOM Telephone: +44 20 7307 2879 Fax: +44 20 7307 2422 E-mail: cshaw@https://www.wendangku.net/doc/9d13006099.html,
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World Health Organization WHO Headquarters
Itziar Larizgoitia Jauregui Department of Health Service Provision World Health Organization
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SWITZERLAND Telephone: +41 22 791 12133 Fax: + 41 22 791 47 47
E-mail: larizgoitiai@who.int
Regional Office for Europe
Mila Garcia-Barbero
Head of the Office
WHO European Office for Integrated Health Care Services
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SPAIN Telephone: +34932418270 Fax: +34932418271
E-mail: mgb@es.euro.who.int
Oliver Gr?ne
Technical Officer Health Services
WHO European Office for Integrated Health Care Services
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SPAIN Telephone: +34932418270 Fax: +34932418271
E-mail: ogr@es.euro.who.int
Svend Juul J?rgensen
WHO Consultant
WHO European Office for Integrated Health Care Services
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08006 Barcelona
SPAIN Telephone: +34 93 241 82 70 Fax: +34 93 241 82 71
E-mail: sjj@es.euro.who.int
Isuf Kalo
Regional Adviser Regional Office for Europe 8, Scherfigsvej
DK 2100 Copenhagen ? DENMARK Telephone: +45 39 17 12 65 Fax: + 45 39 17 18 64
E-mail: ika@who.dk
Jeremy Veillard
WHO Office for Integrated Health Care Services Marc Aureli, 22-36
08006 Barcelona
SPAIN Telephone: +34 93 241 82 70 Fax: +34 93 241 82 71
E-mail: jveillard@es.euro.who.int
五年级上册成语解释及近义词反义词和造句大全.doc
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关于时间管理的英语作文 manage time
How to manage time Time treats everyone fairly that we all have 24 hours per day. Some of us are capable to make good use of time while some find it hard to do so. Knowing how to manage them is essential in our life. Take myself as an example. When I was still a senior high student, I was fully occupied with my studies. Therefore, I hardly had spare time to have fun or develop my hobbies. But things were changed after I entered university. I got more free time than ever before. But ironically, I found it difficult to adjust this kind of brand-new school life and there was no such thing called time management on my mind. It was not until the second year that I realized I had wasted my whole year doing nothing. I could have taken up a Spanish course. I could have read ten books about the stories of successful people. I could have applied for a part-time job to earn some working experiences. B ut I didn’t spend my time on any of them. I felt guilty whenever I looked back to the moments that I just sat around doing nothing. It’s said that better late than never. At least I had the consciousness that I should stop wasting my time. Making up my mind is the first step for me to learn to manage my time. Next, I wrote a timetable, setting some targets that I had to finish each day. For instance, on Monday, I must read two pieces of news and review all the lessons that I have learnt on that day. By the way, the daily plan that I made was flexible. If there’s something unexpected that I had to finish first, I would reduce the time for resting or delay my target to the next day. Also, I would try to achieve those targets ahead of time that I planed so that I could reserve some more time to relax or do something out of my plan. At the beginning, it’s kind of difficult to s tick to the plan. But as time went by, having a plan for time in advance became a part of my life. At the same time, I gradually became a well-organized person. Now I’ve grasped the time management skill and I’m able to use my time efficiently.
英语演讲稿：未来的工作
英语演讲稿：未来的工作 这篇《英语演讲稿范文：未来的工作》，是特地，希望对大家有所帮助！ 热门演讲推荐：竞聘演讲稿 | 国旗下演讲稿 | 英语演讲稿 | 师德师风演讲稿 | 年会主持词 | 领导致辞 everybody good afternoon:. first of all thank the teacher gave me a story in my own future ideal job. everyone has a dream job. my dream is to bee a boss, own a pany. in order to achieve my dreams, i need to find a good job, to accumulate some experience and wealth, it is the necessary things of course, in the school good achievement and rich knowledge is also very important. good achievement and rich experience can let me work to make the right choice, have more opportunities and achievements. at the same time, munication is very important, because it determines whether my pany has a good future development. so i need to exercise their municative ability. i need to use all of the free time to learn
世界经典哲学类书籍推荐
世界经典哲学类书籍 哲学，是理论化、系统化的世界观，是自然知识、社会知识、思维知识的概括和总结,是世界观和方法论的统一。是社会意识的具体存在和表现形式，是以追求世界的本源、本质、共性或绝对、终极的形而上者为形式，以确立哲学世界观和方法论为内容的社会科学。 《性心理学》 《作为意志和表象的世界》 《理想国》 《西方哲学史》 《自然哲学的数学原理》 《权力意志》 《新工具》 《纯粹理性批判》《文明论概略》 《劝学篇》 《伦理学》 《耶稣传》 《时间简史》 《逻辑哲学论》 《精神现象学》 《物性论》 《感觉的分析》 《精神分析引论》《基督何许人也——基督抹煞论》 《科学的社会功能》《人有人的用处》《科学史》 《人类理智新论》《逻辑学》 《哲学研究》 《新系统及其说明》《道德情操论》 《实践理性批判》《美学》 《判断力批判》 《基督教的本质》《薄伽梵歌》 《伦理学中的形式主义与质料的价值伦理学》《物种起源》 《物理学》《人类的由来》 《人性论》 《人是机器》 《法哲学原理》 《狄德罗哲学选集》 《野性的思维》 《哲学史教程》 《科学与近代世界》 《人类的知识》 《精神分析引论新编》 《自然宗教对话录》 《基督教并不神秘》 《科学中华而不实的 作风》 《一年有半，续一年有 半》 《时间与自由意志》 《哲学辞典》 《历史理性批判文集》 《苏鲁支语录》 《文化科学和自然科 学》 《十六、十七世纪科 学、技术和哲学史》 《科学哲学的兴起》 《灵魂论及其他》 《斯宾诺莎书信集》 《实验心理学史》 《最后的沉思》 《纯粹现象学通论》 《近代心理学历史导 引》 《佛教逻辑》 《神圣人生论》 《逻辑与知识》 《论原因、本原与太 一》 《形而上学导论》 《诗学》 《路标》 《心的概念》 《计算机与人脑》 《十七世纪英格兰的 科学、技术与社会》 《卡布斯教诲录》 《薄伽梵歌论》 《尼各马可伦理学》 《论老年论友谊论责 任》 《实用主义》 《我的哲学的发展》 《拓扑心理学原理》 《在通向语言的途中》 《科学社会学》 《埃克哈特大师文集》 《逻辑大全》 《简论上帝、人及其心 灵健康》 《宗教的本质》 《论灵魂》 《科学的价值》 《内时间意识现象学》 《艺术即经验》 《宗教与科学》 《感觉与可感物》 《行为的结构》 《真理与方法》 《阿维斯塔》 《善的研究》 《人类知识原理》 《伦理学体系》 《科学与方法》 《第一哲学（上下卷）》 《物理学理论的目的 与结构》 《思维方式》 《发生认识论原理》 《爱因斯坦文集》 《伦理学的两个基本问题》 《数理哲学导论 《耶稣传（第一、二卷）》 《美学史》 《原始思维》 《面向思的事情》 《普通认识论》 《莱布尼茨与克拉克论战 书信集》 《对莱布尼茨哲学的批评 性解释》 《物理学和哲学》 《尼采（上下卷）》 《思想录》 《道德原则研究》 《自我的超越性》 《实验医学研究导论》 《巴曼尼得斯篇》 《人类理解论》 《笛卡尔哲学原理》 《人生的亲证》 《认识与谬误》 《哲学史讲演录》 《圣教论》 《哲学作为严格的科学》 《人类知识起源论》 《回忆苏格拉底》 《心的分析》 《任何一种能够作为科学 出现的未来形而上学导论》 《科学与假设》 《宗教经验之种种》 《声音与现象》 《苏格拉底的申辩》 《论个人在历史上的作用 问题》 《论有学识的无知》 《保卫马克思》 《艺术的起源》
悲惨的近义词反义词和造句
悲惨的近义词反义词和造句 导读：悲惨的近义词 悲凉(注释:悲哀凄凉：～激越的琴声。) 悲惨的反义词 幸福(注释:个人由于理想的实现或接近而引起的一种内心满足。追求幸福是人们的普遍愿望，但剥削阶级把个人幸福看得高于一切，并把个人幸福建立在被剥削阶级的痛苦之上。无产阶级则把争取广大人民的幸福和实现全人类的解放看作最大的幸福。认为幸福不仅包括物质生活，也包括精神生活;个人幸福依赖集体幸福，集体幸福高于个人幸福;幸福不仅在于享受，而主要在于劳动和创造。) 悲惨造句 1.一个人要发现卓有成效的真理，需要千百个人在失败的探索和悲惨的错误中毁掉自己的生命。 2.贝多芬的童年尽管如是悲惨，他对这个时代和消磨这时代的地方，永远保持着一种温柔而凄凉的回忆。 3.卖火柴的小女孩在大年夜里冻死了，那情景十分悲惨。 4.他相信，他们每个人背后都有一个悲惨的故事。 5.在那次悲惨的经历之后，我深信自己绝对不是那种可以离家很远的人。 6.在人生的海洋上，最痛快的事是独断独航，但最悲惨的却是回头无岸。 7.人生是艰苦的。对不甘于平庸凡俗的人那是一场无日无夜的斗
争，往往是悲惨的、没有光华的、没有幸福的，在孤独与静寂中展开的斗争。……他们只能依靠自己，可是有时连最强的人都不免于在苦难中蹉跎。罗曼·罗兰 8.伟大的心胸，应该表现出这样的气概用笑脸来迎接悲惨的厄运，用百倍的勇气来应付开始的不幸。鲁迅人在逆境里比在在顺境里更能坚强不屈。遇厄运时比交好运时容易保全身心。 9.要抓紧时间赶快生活，因为一场莫名其妙的疾病，或者一个意外的悲惨事件，都会使生命中断。奥斯特洛夫斯基。 10.在我一生中最悲惨的一个时期，我曾经有过那类的想法：去年夏天在我回到这儿附近的地方时，这想法还缠着我;可是只有她自己的亲自说明才能使我再接受这可怕的想法。 11.他们说一个悲惨的故事是悲剧，但一千个这样的故事就只是一个统计了。 12.不要向诱惑屈服，而浪费时间去阅读别人悲惨的详细新闻。 13.那起悲惨的事件深深地铭刻在我的记忆中。 14.伟大的心胸，应该用笑脸来迎接悲惨的厄运，用百倍的勇气来应付一切的不幸。 15.一个人要发现卓有成效的真理，需要千百万个人在失败的探索和悲惨的错误中毁掉自己的生命。门捷列夫 16.生活需要爱，没有爱，那些受灾的人们生活将永远悲惨;生活需要爱，爱就像调味料，使生活这道菜充满滋味;生活需要爱，爱让生活永远充满光明。
关于坚持的英语演讲稿
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Dear teacher and colleagues: my topic is on “spare time”. It is a huge blessing that we can work 996. Jack Ma said at an Ali's internal communication activity, That means we should work at 9am to 9pm, 6 days a week .I question the entire premise of this piece. but I'm always interested in hearing what successful and especially rich people come up with time .So I finally found out Jack Ma also had said :”i f you don’t put out more time and energy than others ,how can you achieve the success you want? If you do not do 996 when you are young ,when will you ?”I quite agree with the idea that young people should fight for success .But there are a lot of survival activities to do in a day ,I want to focus on how much time they take from us and what can we do with the rest of the time. As all we known ,There are 168 hours in a week .We sleep roughly seven-and-a-half and eight hours a day .so around 56 hours a week . maybe it is slightly different for someone . We do our personal things like eating and bathing and maybe looking after kids -about three hours a day .so around 21 hours a week .And if you are working a full time job ,so 40 hours a week , Oh! Maybe it is impossible for us at