Quality development

Patients have a right to safe, high-quality treatment. The Confederation’s Quality Strategy (2009) and implementation report (2011) lay the cornerstones for further enhancing quality and patient safety. Efforts are focusing on quality measurement and improvement.

Amendment of the Health Insurance Act (HIA): Improving quality and cost effectiveness

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On 21 June 2019, the Federal Assembly adopted the partial revision of the Health Insurance Act ‘improving quality and cost effectiveness’. This bill envisages the establishment of a federal extra-parliamentary committee for quality, which will be responsible for supporting the Federal Council in promoting quality of healthcare. It also requires healthcare provider associations and insurers to sign nationally-applicable quality agreements, which healthcare providers will be required to comply with. Every four years, the Federal Council will set targets with regard to guaranteeing and promoting quality of healthcare (quality development). A new strategy is being drawn up in order to set these targets.

The amendment of the HIA will enter into force in 2021; the consultation period on the implementing ordinance has just ended.

Quality: why is action needed?

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There are currently shortcomings in patient safety. Various international studies show that on average one in ten patients experiences an adverse event in hospital. These studies only examined incidents that are documented in medical records. They indicate that around half the events could be prevented. If the findings from a study conducted by the Institute of Medicine¹ are extrapolated to Switzerland, the number of deaths would be around 2,000 to 3,000 per year. As yet, no national adverse event study has been conducted in Switzerland.

Halfon, Staines and Burnand² examined around 1,000 medical records in a Swiss hospital. About 12% of the patients who received treatment experienced one or more adverse events, nearly half of which could have been avoided.

In a data analysis of 96 Swiss hospitals³, the infection expert group “Swissnoso” found that 6% of patients had contracted a hospital-acquired infection (nosocomial infection).

A change of thinking is needed throughout the healthcare sector to create a culture of safety in which mistakes are discussed openly. Only when the taboo has been lifted will it be possible to follow other high-risk sectors (e.g. aviation) and learn from mistakes. In a culture of safety, errors or adverse events always lead to improvements in the system, provided that mistakes are always transparently communicated and systematically logged.

Furthermore, patients need to be sensitised to the risks so that they too can contribute to their own safety. Most patients believe hospitals are safe. They often underestimate the potential risks of medical procedures and do not think critically about whether procedures are necessary (e.g. surgery for herniated discs, knee arthroscopies, or chemotherapy at the end of life).

Quality shortfalls cause substantial avoidable costs within the healthcare system. Avoidable events alone may result in 400,000 unnecessary hospital days in Switzerland.

The Federal Act of 18 March 1994 on Health Insurance (HIA) stipulates that hospital planning must be cost-efficient and quality-driven. This requires measurement and accurate interpretation of quality indicators. Doing so also creates the basis for a structured process of improvement by care providers.

¹ Kohn/Corrigan/Donaldson (editors), To err is human: building a safer health system, Institute of Medicine, 2000

² Halfon/Staines/Burnand, Adverse events related to hospital care: a retrospective medical records review in a Swiss hospital, in International Journal for Quality in Health Care, 2017, 1-7

³ Point Prevalence Survey 2017 of healthcare-associated infections and antimicrobial use in Swiss acute care hospitals; Swissnoso, 2018

Who is responsible for quality?

In the relevant legislation, various players are responsible for quality assurance and promotion.

Under the law governing the healthcare system

The Confederation issues rules and requirements for training and education as well as professional practice.
Within this framework the cantons are responsible for granting the relevant licences and approvals to establishments and professionals. Their role is to police and oversee healthcare, while care providers must exercise their profession diligently¹.

¹ E.g. Art. 40 let. a of the Medical Professions Act of 23 June 2006 (MedBG/LPMéd; SR 811.11); cantonal health and hospital care laws

Under the law governing health insurance

The Confederation

The Confederation states the requirements for the approval of care providers, and in particular issues uniform planning criteria for hospitals and other establishments based on quality and cost-effectiveness (Art. 38 and 39 KVG/LAMal).
It sets the threshold for the development, collection of data and publication of information on quality (as per Art. 59a KVG/LAMal in particular).
It sets subsidiary measures for the event that tariff partners fail to meet their obligations in terms of contractual quality assurance as per Articles 59d and 77 of the Ordinance on Compulsory Health Care of 27 June 1995 (KVV/OAMal) or that the cantons fail to meet their obligations in terms of planning the provision of highly specialised medical care (Art. 39 para 2bis KVG/LAMal).

The cantons

The cantons evaluate the quality and cost-effectiveness of the hospitals in the course of their care planning (Art. 39 KVG/LAMal and Art. 58a–58e KVV/OAMal).
They help assure care providers' adherence to binding federal requirements relating to quality assurance measures and quality measurement.

Care providers

Care providers provide effective, appropriate and efficient care and services within the framework of compulsory health insurance (Art. 32 KVG/LAMal).
They implement quality assurance measures in accordance with the requirements set down by the federal and cantonal authorities and in contracts with the insurers (Art. 39, 43 and 58 KVG/LAMal).
They autonomously assure quality for their organisation and take measures to assure and improve the quality of care provision, including initiating and executing measures designed to facilitate learning, such as benchmarking and best practice (Art. 59d and 77 KVV/OAMal), and establishing a culture of safety.
They collect data on the level of quality and provide this information to the Confederation free of charge (Art. 59a KVG/LAMal).

Insurers

Insurers agree with care providers on tariffs and measures to assure the quality and cost-effectiveness of care (Art. 43 KVG/LAMal).
They review whether care providers meet the requirements regarding the quality and cost-effectiveness of care provided under compulsory heath insurance and apply to the cantonal courts of arbitration for sanctions (Art. 56, 59 and 89 KVG/LAMal).

What are the Federal Council’s goals?

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The Confederation has set the target of ensuring that medical service delivery is safe, effective, efficient, patient-centred, timely and equitable. The dimensions of this objective also provide the relevant dimensions for the measurement of quality indicators. The Federal Council wants to achieve structured improvements in quality and patient safety, which will in turn prevent adverse events. To achieve its goals, it is supporting four National Programmes set up to highlight tangible ways of improving diagnosis and treatment that will help care providers comply with best practice. The Swiss Patient Safety Foundation is running the Programmes on behalf of the Swiss government. Once complete the Foundation works with the providers to validate the measures, which are subsequently declared a professional standard.

How is transparency on quality being achieved?

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The Confederation’s task is to provide reliable, target-audience-appropriate information that the various players in the healthcare system can use to identify issues relevant to quality, take decisions and implement measures.

The quality indicators published by the FOPH for acute hospitals (CH-IQI)¹ include numbers of cases (e.g. number of bypass operations or number of heart attacks treated) and mortality rates (e.g. mortality rates for patients who had had heart bypass surgery). These are published annually for each hospital. The FOPH website has a feature for comparing the results of up to five diagnoses or procedures for up to five hospitals. Comparing numbers of cases for a specific procedure or condition reveals which hospitals have the greater experience

The ANQ (Swiss National Association for Quality Development in Hospitals) also publishes quality indicators for acute care hospitals and psychiatric and rehabilitation clinics. They can be found (in German) on the ANQ website.

In collaboration with the competent bodies, quality indicators are currently also being developed for the home nursing and home help organisations (SPITEX) and nursing homes. After successful completion of the pilot phase, the plan is for the Federal Statistical Office (FSO) to gather this data on a routine basis for publication by the FOPH.

One priority for the FOPH is to collect data and publish quality indicators for medical practices (outpatient medical care). The EQUAM foundation (www.equam.org) has developed quality indicators for doctors' practices, but very few practices use them as yet.

Every two years, the Organisation for Economic Co-operation and Development (OECD) publishes a report containing quality and patient safety indicators. This report includes Switzerland².

¹ Link to fact sheet on CH-IQI quality indicators (in German and French)

² Health-at-a-Glance 2017: OECD Indicators; OECD 2017

How is quality being improved?

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Since 2012 the FOPH has funded National Programmes to improve quality and patient safety, implemented by the Swiss Patient Safety Foundation.

1. Safe surgery	The aim is to reduce the number of avoidable adverse events in surgery by systematically following the WHO’s checklist in operating theatres.
2. Drug safety at points of intersection in acute hospitals	The aim is to avoid adverse drug events (mix-ups, omissions and interactions) and false indications by means of systematic medication reconciliation when a patient is admitted to hospital.
3. Safe urinary catheters	The aim is to reduce the incidence of urinary tract infection by reducing the number of days a urinary catheter is used unnecessarily.
4. Drug safety in nursing homes	The aim is to avoid polypharmacy where possible and reduce the prescription of drugs that are potentially dangerous for elderly people.

Current projects

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Swiss National Report on Quality and Safety in Healthcare – Enhancing the Quality and Safety in Swiss Healthcare

In mid-2018 the Federal Office of Public Health (FOPH) commissioned a Swiss National Report on quality and safety in healthcare, depicting the current state of knowledge on quality and patient safety in Swiss healthcare and showing where action is required.

OECD report: System Governance Towards Improved Patient Safety

The OECD report on system governance towards improved patient safety was commissioned by the FOPH. It was originally due to be published to coincide with the Patient Safety Summit in February, but publication was postponed due to the COVID-19 pandemic. It is now to be published on World Patient Safety Day on 17 September.

The report presents a comparative study of governance aimed at improving patient safety in OECD health systems, and the measures implemented. Its main conclusions are the following: there is no ideal patient safety governance model. Health systems need to be considered in their entirety and continuous learning should be stimulated/encouraged following incidents (reacting to harm) but also through risk assessment and management. The basis of safety governance should be what is best for the patient and the focus should be on fostering transparency and mutual trust among health professionals and regulators. Regulations are key to patient safety, and the national structures put in place must provide centralised leadership in this regard. This centralisation ensures all actors are working towards the same goal. Up to now, most systems have focused on acute care; it is time to extend governance to outpatient and long-term care. In terms of healthcare professionals, the safety culture and open communication need to be reinforced to reduce errors and better manage risk. Transparency and openness facilitate the learning process for professionals. Meanwhile, the relationship between patient safety and data privacy needs to be strengthened and developed.