Quality assessment of clinical health care with the programme of quality standard is a method of health management,
through which better efficiency and safety of health outcomes can be achieved. In the period from 2002 to 2004, a
pilot program of quality has been carried out on the Department of Ophthalmology, University Hospital Center in
Zagreb. Seven internal audit teams of hospital commission and teams of hospital departments were evaluating introducing
practice for quality standards every three months. In the period of two years improvement in all standards of
quality has been noticed (expressed in percent of progress towards the ideal result of 100%): personnel 20%, patient
rights 15%, medical equipment 40%, quality of emergency service 60%, implementation of clinical guidelines and criteria
for elective admission 55%, quality of risk prevention 70%, quality of medical records 60%. The two-years-improvement
dynamics of about 46%, first year 24%

Damir Katušić

Ivan Suić

Mirjana Nasić

Pavle Miklić

Rajko Pokupec

Slobodan Galić

Hrčak - Portal of scientific journals of Croatia

Coll. Antropol. 29 (2005) Suppl. 1: 21–24UDC 617.7:006Original scientific paperInternal Quality Audit and Quality Standardsas a Method of Quality Improvement at theDepartment of Ophthalmology, University HospitalMirjana Nasi}1, Rajko Pokupec1, Damir Katu{i}1, Pavle Mikli}2, Ivan Sui}3 and Slobodan Gali}41 University Department of Ophthalmology, Clinical Hospital Center »Rebro«, Zagreb, Croatia2 University Department of Neurosurgery, Clinical Hospital Center »Rebro«, Zagreb, Croatia3 University Department of Ophthalmology, Clinical Hospital »Systers of Mercy«, Zagreb, Croatia4 University Department of Pediatrics, Clinical Hospital Center »Rebro«, Zagreb, CroatiaA B S T R A C TQuality assessment of clinical health care with the programme of quality standard is a method of health manage-ment, through which better efficiency and safety of health outcomes can be achieved. In the period from 2002 to 2004, apilot program of quality has been carried out on the Department of Ophthalmology, University Hospital Center inZagreb. Seven internal audit teams of hospital commission and teams of hospital departments were evaluating intro-ducing practice for quality standards every three months. In the period of two years improvement in all standards ofquality has been noticed (expressed in percent of progress towards the ideal result of 100%): personnel 20%, patientrights 15%, medical equipment 40%, quality of emergency service 60%, implementation of clinical guidelines and crite-ria for elective admission 55%, quality of risk prevention 70%, quality of medical records 60%. The two-years-improve-ment dynamics of about 46%, first year 24%.Key words: ophthalmology, health care reform, standards, quality, guidelines, patient rightsIntroductionIn the 21st century, the World Health Organizationprogram Health for All by the Year 2000 has been modi-fied into a new concept of realistic approach taking dueconsideration of the macropolitical and economic condi-tions of a particular region, with health promotion assummarized in 21 targets considering a moral commit-ment of all participants (providers and users) to providethe best possible result based on the resources avail-able. Target No. 16 refers to »care quality manage-ment«1. The Health reform which started in 1999 inCroatia is a all-including national programme of pre-ventive, primary and secundary health care2. Croatia isa country that has a declared social politics and it stivesto balance the needs of all user in medical sector. Hospi-tals hold traditionally an important place in Croatia.They enjoy the confidence of the population and hold aprestigious position in the society. Although, they oftenspent a huge amounts of the health budget, they havelittle influence on health of population generally. Any-way, everyday fight for the lives of the individuals justi-fies all the necessary investments.In Croatia, about 14 % of the population are hospital-ized for treatment every year. At the same time, there isan inaequate level of computerization, inappropriatepersonnel structure with too high a proportion of non-medical personnel and too low a proportion of high-school medical personnel, and a tendency towards ex-pensive forms of health care. Although the rate of hospi-tal bed occupancy is highthere is high (81%–87%), ex-ceeding the European Union (EU) average by some 15%,the mean lenght of hospital stay indicates it to resultfrom prolonged hospitalisation3. Although Croatia givesabout 9 % of its BNP for health care, these budget (re-garded in absolute values) can hardly satisfy the volumeand requirements for health care of the population ofCroatia nowadays. For a better utilisation, the hospitalsector approached to the whole reorganisation planninga hospital network appropriate to the needs of the num-ber and distribution of population, thus considering newand more functioning models of financing, identificatingprimar investition and organisation in order to reducewaiting lists, improving technology with which it rea-21Received for publication January 11, 2005U:\coll-antropolo\coll-antro-okultni\nasic.vp28. travanj 2005 13:57:22Plate: 1 of 4Color profile: DisabledBlack  150 lpi at 45 degreesches and optimal effect of treatments and investing inhuman resources because of their temporal and quali-fied maximal utilisation4.Methods through which – routine in the developedworld – the quality of clinical praxis is being improvedand controlled, are quality standards and quality indi-cators5. There is a number of definitions of quality, butthe Avedis Donabedian’s is the first basic and funda-mental one. We cite the definition of World Health Or-ganisation: »Quality in health care can be defined ascare or service with characteristics which comply withspecific requirements and which fulfill – with today’s de-gree of knowledge and available resources – expecta-tions for maximal profit and minimal health and wel-fare risks of the patient.«6.Materials and MethodsUniversity Hospital Centre (in further text: KBC)Zagreb founded a committee for improving quality andinternal supervision and hospital quality in 2002. Thecommittee was multidisciplinary consisting of experts ofall clinical professions, lawyers, nurses and medical en-gineers. The committee was established by seven three-member teams consisting of doctors, senior nurses andsecretaries, who worked voluntary. In 29 departments,including the Department of Ophthalmology, a three-member team was established, which implements theprogramme of quality standard, consisting of head ofthe department, coordinating doctor and the head nurse.Using the internal audit method, the team of the hospi-tal quality committee had meetings every three monthswith the team from the ophthalmological department,considering and improving the implementation of theset of standards for quality improving. Annual descrip-tive evaluation for programme imple- mentation wasperformed. Set of written standards for insuring qualityof health care was taken from the accreditation proce-dure programme of two health systems that are of bestquality: Agence Nationale d’Accreditation et d’Evalua-tion en Sante, France (further: ANAES)7 and NHS Ex-ecutive Department of Health, Great Britain8. The teamwork results was measured by assessing each standardon a scale from 0% to 100% (0 – completely unsatisfac-tory through 100% – completely satisfactory). We setour own acceptable standard : score over 70%. We havegraphically showed the dynamics of the progress in thefirst and second year for following categories: personnel,patient rights, medical equipment, quality of emergencyservice, implementation of clinical guidelines and crite-ria for elective admission, quality of risk prevention,quality of medical records9.ResultsFollowing standard groups were implemented inwritten form:I Patients and patient carePatient rights and informed consentAn internal rule book about patient rights, procedureof giving information to patients about rights which be-longing to them, procedure of giving information to pa-tients about their health condition, list of medical proce-dures which require additional acceptance of patientsand methods of getting it, procedure of getting patient’sacceptance for taking part in biomedical researc, proce-dure of archiving valuable items that belong to the pa-tient, procedure for implementation confidement andisolation of the patient, hospital house order.Medical recordsRules which determine the content of medical docu-mentation required in hospitals, rules that insure regularfilling out of medical documentation in hospital, processof keeping medical documentation from being deleted,counterfeiting and access by unauthorised persons, gu-idelines for determining content of routine doctor an-amnesis and routine physical examination, guidelinesfor determining content of routine assessment by thenurse, documentation that confirms gathering informa-tion about the number of patients distributed by diag-nostic codes and procedure codes, documentation thatconfirms the examination of medical documentation andpossible improvement.Patient care organisationPatient admission procedures during planned admis-sion, emergency cases and disasters, procedure of coop-eration with admission office with other departments,procedure of cooperation of emergency service withemergency medical team, list of medicaments, princi-ples of listing medicaments which are not on the list ofprescribed medicaments, procedures of ensuring medi-caments which are being kept in the pharmacy and inthe department, list of medicaments, equipment andmaterial which must be accessable in emergency cases,procedure of getting medicaments in a emergency case,procedures of preparing and using special kinds of nour-ishment, list of medicaments necessary for correct func-tioning of emergency team and procedure for their sup-plement.II. Managing and administration in theservice of patientsManaging in hospital and its activitiesTasks and strategic objectives of the hospital, hospi-tal development plan, documentation containing realand necesarry structure of the hospital, areas of respon-sibility for most important positions of the hospital –posts with special responsibility, organisation scheme,documentation confirming reports of Hospital’s admin-istration about problems dealing with quality, informa-tion about main extern institutions that are connectedto the hospital, the Hospital Statute.M. Na{i} et al.: Quality Standards in Ophthalmology, Coll. Antropol. 29 (2005) Suppl. 1: 21–2422U:\coll-antropolo\coll-antro-okultni\nasic.vp28. travanj 2005 13:57:22Plate: 2 of 4Color profile: DisabledBlack  150 lpi at 45 degreesManaging of personnelGeneral plan of education and professional trainingof the personnel, plans about education of the personneldistributed by departments, requring qualification forspecial posts in the hospital and description of theseposts, documentation confirming periodic implementa-tion of personnel qualification assessment and its pro-fessional activity. Criteria of these assessments, docu-mentation that confirms setting aside funds for edu-cating personnel on designated purpose, documentationconfirming that every employee had no less than oneform of training each year, programme for accomodationof new employees.Managing logisticsProcedure of planned maintenance and ensuring ofall medical instruments, documentation confirming con-trol systematicness of all medical instruments and theirattests, list of errors in the field of civil engineering andplans about decreasing these mistakes, documentationconfirming security system control in case of interrup-tion of water distribution, electric energy and medicalgases, plan about fire prevention, current attest of fireprevention systems, plan about medical waste disposal,record of identification and storage of medical waste dis-posal, reports of utilisation of radioactive products.III. Quality and preventionManaging the quality and risk preventionSpecial prevention programmes and transfusion sa-fetyReports on unpredictable events (anaesthesia, cho-ronography and other invading diagnostic and therapyprocedures), records on the work time spent within ion-ising radiation zones, records of dosimeter control, pro-cedure of preventing and suppressing clinical infectionsof patients and employeesObservation, prevention and control of infection risksDynamic of progress in observed categories showedthat the best progress was achieved in following catego-ries: quality of emergency service, implementation ofclinical guidelines and criteria for elective admission,quality of risk prevention, quality of medical records.(Figure 1). Proffesional activities which are tradition-ally present in Croatian medical educatiional programand close to natural science, while little progress wasachieved in the area of patient rights and personnel pol-itics, multidisciplinary medical categories close to socialsciences.All categories recorded dynamic increase which showsthe acceptance of the programme by medical personnel.Advancement of the category medical equipment is lim-ited by the budget of the hospital.DiscussionThe process of quality improvement in hospitalsthrough quality standards is an activity that has beenon the run for years. In French agency for accreditationonly the preparing of written materials lasted twoyears. One year for preparing process and further twoyears for team education7. In KBC Zagreb there was aquicker achievement of a result because that model hasalready been tested. Overtaking a model of other coun-tries is probably possible to implement when health sys-tems are being organised similarly, have comparablemedical technology and have similar education pro-grammes10. Introducing standards showed a positive at-titude of medical personnel towards the programme andsignificant enthusiasm. Surely, besides administrativesuccess of the team organisation programme and prepa-ration of written material and protocols the real resultof this programme may be measured only by introduc-tion of clinical quality indicators, what requires addi-tional engagement as well as experts from particularfields and development of software which could objec-tively and continuously follow special parts of medicalinterventions and outcome. Slow progress of program-mes like patient rights or managing human resources isa result of facts that these programmes are multidis-ciplinary and require knowledge and experience in thefield of health organisation, philosophy, medical ethics,psychology, law and economy. They are also less compa-rable and it is more difficult to import them because ofdifferent culturological, religious and social environ-ment as well as of society’s degree of democracy11. Forsuch programmes there is support of specialised agen-cies in countries with more developed health manage-ment which don’t exist in Croatia yet12–14. In ophtal-mologic literature of different internet data bases thereare also presented papers that are close to standard ed-ucation programmes at Medical Faculties, like: clinicalguidelines, effectiveness of some diagnostic or therapyprocess, seldom cost-effectiveness analysis, and in thearea of patient rights mostly patient quality of life refer-ring to specific fields of ophthalmic pathology15–18. Suchtrend gives us light that the education programme inquality of health protection in pregraduate, postgradu-M. Na{i} et al.: Quality Standards in Ophthalmology, Coll. Antropol. 29 (2005) Suppl. 1: 21–2423010203040506070801 2 3 4 5 6 7Clinical standards(1=personnel;2=patient rights;3=medicalprevention;7=medical record)Percentageofimprovementyear 2003year 2004Fig. 1. Percentage of improvement of clinical standards duringthe period of the years 2002–2004 at ophthalmology department.U:\coll-antropolo\coll-antro-okultni\nasic.vp28. travanj 2005 13:57:24Plate: 3 of 4Color profile: DisabledBlack  150 lpi at 45 degreesate and also in courses is decisive for implementation ofquality standards in hospitals19–20.ConclusionsThe quality standard implementation programmethrough teams for internal control is a promising instru-ment for the begining of quality standard introductionto the hospitals. The greatest progress was achieved innatural science medical category standards: quality ofemergency service, implementation of clinical guide-liness and criteria for elective admission. Interdisciplin-ary standards; patient rights and personnel policy areless known to hospital’s personnel, are difficult to adoptand understand and therefore need different expert ed-ucation programmes for the whole medical personnel ofthe hospital.R E F E R E N C E S1. WORLD HEALTH ORGANIZATION: Health For All Database.(WHO Regional Office for Europe, Copenhagen, 2001). — 2. MINISTRYOF HEALTH REPUBLIC OF CROATIA: Health Care Reform: Strategyand Plan for the Reform of the Health Care System and Health Insur-ance of the Republic of Croatia. (Ministarstvo Zdravstva Republike Hr-vatske, Zagreb, 2000). — 3. CROATIAN HEALTH INSURANCE: InstituteDatabase. (Hrvatski Zavod za Zdravstveno osiguranje, Zagreb, 2000). —4. WORLD BANK DEPARTMENT FOR CROATIAAND ALBANIA, MI-NISTRY OF HEALTH OF THE REPUBLIC OF CROATIA. Rev. Soc.Pol., 3–4 (2000) 331. — 5. DORAN, I., G. R. BAKER, M. MURRAY, J.BOHNEN, C. ZAHN, S. SIDANI, J. CARRYER, Health Care ManageRev., 27 (2002) 7. — 6. ELDAR, R.: Vrsno}a medicinske skrbi. (Medi-cinska naklada, Zagreb, 2003). — 7. AGENCE NATIONALE D'ACCRÉ-DITATION ET D'ÉVALUATION EN SANTÉ: Accreditation manual forhealth care organizations. (ANAES Service Communication et Diffusion,Paris, 1999). — 8. NATIONAL HEALTH SERVICE: Quality and perfor-mance in the NHS: High level performance indicators. (United KingdomNational Health Service, Finance and performance assessment, London,1999). — 9. KLINI^KI BOLNI^KI CENTAR ZAGREB: Norme kvaliteteza akreditaciju bolnica. (Ured za unutarnji stru~ni nadzor i kontrolukvalitete, KBC Zagreb, Zagreb, 2004). — 10. NA[I], M., S. ORE[KOVI],Croat. Med. J., 43 (2002) 430. — 11. DOWNIE, R. S., K. C. CALMAN:Healthy respect. (Oxford university press, Oxford, 2001). — 12. COMI-TÉ DE COORDINATION DE L'EVALUATION CLINIQUE ET DE LAQUALITÉ AN AQUITANE: Questionnaire SAPHORA-JOB de satisfac-tion au travail dans les établissements de santé. (CCECQA, Pessac,2004) — 13. BRITISH MEDICAL JOURNAL: Clinical evidence concise.(BMJ Publishing Group, London, 2003). — 14. WWW.AZQ.DE: Germanmanual for clinical practice guidelines. (Ärztliches zentrum für qualitätin der medizin, Cologne, 2004). — 15. MEMBRENO, H. J., M. M. BROWN,G. C. SHAIMAS, Ophthalmology, 109 (2002) 2265. — 16. SCHOENFELD,E. R., M. J. GREENE, S. Y. WU, M. C. LESKE, Ophthalmology, 108(2001) 563. — 17. ROSENBAUM, T. J., Semin. Arthrit. Rheumat., 19(1990) 248. — 18. LITWAK, A. B., Clin. Eye Vis. Care, 9 (1999) 149. —19. KOVNER, A. R., Health Care Manage. Rev., 27 (2002) 27. — 20.SHORT, J. C., T. B. PALMER, Health Care Manage. Rev., 27 (2002) 48.M. Nasi}University Department of Ophthalmology, Zagreb Clinical Hospital Center, Ki{pati}eva 12, 10000 Zagreb, Croatiae-mail: mirjana.nasic@zg.htnet.hrINTERNA KONTROLA KVALITETE I STANDARDI KVALITETE KAO METODA UNAPRJE\ENJAKVALITETE NA ZAVODU ZA OFTALMOLOGIJU KLINI^KE BOLNICES A @ E T A KUnaprje|enje kvalitete bolni~ke zdravstvene za{tite putem programa standarda kvalitete je metoda zdravstvenogmenad`menta kojom se posti`e ve}a efikasnost i sigurnost zdravstvenih ishoda. U razdoblju od 2002. do 2004. godinena Klinici za oftalmologiju Klini~kog Bolni~kog Centra Zagreb proveden je pilot program uvo|enja standarda zdrav-stvene kvalitete. Organizirano je sedam timova unutarnje kolegijalne kontrole bolni~kog povjerenstva za unaprje-|enje kvalitete i timovi bolni~kih odjela koji su svaka tri mjeseca evaluirali uvodjenje standarda kvalitete u praksu.Na Klinici za Oftalmologiju u razdoblju od dvije godine rada zabilje`en je napredak u svim standardima kvalitete(izra`eno u postotku napretka prema idealnom rezultatu izra`enom kao 100%): ljudski resursi 20%, prava pacijenata15%, medicinska oprema 40%, kvaliteta hitnog prijema 60%, primjena klini~kih vodi~a i kriteriji za elektivni prijem55%, prevencija rizika 70%, kvaliteta medicinske dokumentacije 60%. U dvogodi{njem razdoblju kvaliteta je pobolj-{ana za 46% od o~ekivanog idealnog rezultata, prve godine 24%.M. Na{i} et al.: Quality Standards in Ophthalmology, Coll. Antropol. 29 (2005) Suppl. 1: 21–2424U:\coll-antropolo\coll-antro-okultni\nasic.vp28. travanj 2005 13:57:25Plate: 4 of 4Color profile: DisabledBlack  150 lpi at 45 degrees

Internal Quality Audit and Quality Standards as a Method of Quality Improvement at the Department of Ophthalmology, University Hospital

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