VietnameseDecision No. 7051/QD-BYT dated November 29, 2016 of the Ministry of Health providing the guidance on the pilot establishment of a number of hospital quality indicators
ATTRIBUTE
| Issuing body: | Ministry of Health | Effective date: | Known Please log in to a subscriber account to use this function. Don’t have an account? Register here |
| Official number: | 7051/QD-BYT | Signer: | Nguyen Viet Tien |
| Type: | Decision | Expiry date: | Updating |
| Issuing date: | 29/11/2016 | Effect status: | Known Please log in to a subscriber account to use this function. Don’t have an account? Register here |
| Fields: | Medical - Health |
THE MINISTRY OF HEALTH
Decision No.7051/QD-BYTdated November 29, 2016 of the Ministry of Health providing the guidance on thepilot establishment of a number of hospital quality indicators
Pursuant to the Decree No. 63/2012/ND-CP dated August 31, 2012 by the Government defining the functions, tasks, entitlements and organizational structure of the Ministry of Health;
At the request of the Director ofMedical Service Administration.
DECIDES:
Article 1.To attach the “guidance on pilot establishment of a number of hospital quality indicators” with this Decision.
Article 2.The “guidance on pilot establishment of a number ofhospital quality indicators”applies to both public and private hospitals.
Article 3.Medical Service Administrationshall be the focus point which cooperates with Departments and relevant units guiding and conducting the implementation of the "guidance on pilot establishment of a number of hospital quality indicators” and organizing the assessment and reporting tothe Minister of Health.
Article 4.This decisiontakes effect on the signing date.
Article 5.Chiefsof the Ministry Offices, the Director ofMedical Service Administration, the Ministerial Chief Inspector and Directors of Departments, Directors of hospitals affiliated tothe Ministry of Health, Directors ofthe Department of Healthof provinces and Departments of Health affiliated to Ministries and regulatory bodies and Heads of relevant units shall implement this Decision./.
For the Minister
The Deputy Minister
Nguyen Viet Tien
GUIDANCE
ON PILOT ESTABLISHMENT OF A NUMBER OFHOSPITAL QUALITY INDICATORS
(To attach with the Decision No. 7051/QD-BYTdated November 29, 2016 bythe Minister of Health)
I. GENERAL PROVISIONS
1.Notion:
The set of “hospital quality indicator” is a tool to measure respects of healthcare service quality performed in form of numbers, ratios or rates as the basis for the improvement of quality of healthcare service and the comparison of service quality among hospitals.
2.Principles for establishment of hospital quality indicators
-Hospital quality indicators are established to measure quality properties which are important and suitable for most hospitals.
-Hospital quality indicators are used for measuring structural elements (inputs), the process and the outcomes of the healthcare services.
-Such indicators are calculated through the collection and analysis of data and indicators.
-Selected indicators of shall tightly relevant to the healthcare service quality, thefeasibilityand the value and orient to the improvement ofservice quality.
-The set of hospital quality indicators is the basis for hospitals to select suitable indicators for period assessment depending on their actual capacity and conditions.
3.Domains of healthcare quality
Professional capacity:the assessment of the provision of healthcare services according to medical advices and regulations on technical classification.
Safety:the harm or risk to patients, health workers and the communityduring the provision of healthcare service.
Efficiency:the assessment of the optimal use of available resources for providing nursing services with the lowest charge and the best effect.
Clinical effectiveness:the assessment of whether the provision medical care or services achieves desired outcomes.
Staff-centered indicators:the provision of benefits forhealth workers
Patient-centered indicators:the assessment of the satisfaction of patients regarding non-medical respects, including living facilities and hygiene in hospital wards, employees’ behaviors, etc.
II.LIST OF HOSPITAL QUALITY INDICATORS
Property | Indicator | Component |
Professional capacity | 1.Rate of application of therapeutic technique according to healthcare levels | Process |
2.Rate of surgery of level II or higher level | Process | |
Safety | 3.Rate of wound infection | Outcomes |
4.Rate of hospital-acquired infection (pneumonia) | Outcomes | |
5.Number of serious medical accidents | Outcomes | |
6. Number of seriousnon-medical accidents | Outcomes | |
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Efficiency | 7.Average duration of medical examination | Process |
8.Average duration of hospitalization (applicable to all types of diseases) | Process | |
9.Actual usage of patient beds | Outcomes | |
10.Efficiency of use ofoperating rooms | Process | |
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Effectiveness | 11.Mortality rate and rate of poor prognosis (applicable to all types of diseases) | Outcomes |
12.Rate of referral to higher-level healthcare facilities (applicable to all types of diseases) | Outcomes | |
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Staff-centered indicators | 13.Rate of injuries caused by sharp objects | Process |
14.Rate of HBV inoculation in health workers | Process | |
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Patient-centered indicators | 15.Rate of patients satisfaction of healthcare services | Outcomes |
16.Rate of health workers’ satisfaction | Outcomes |
III.CONTENTS
IndicatorNo. 1 | Rate of application oftherapeutictechnique according to healthcare levels |
Applicableareas | The whole hospital |
Quality property | Professional capacity |
Qualitycomponent | Process |
Reasons | The application of therapeutic technique is an indicator used for assessing the professional capacity of the hospital, a basis for assessing the ability to meet the healthcare demand of citizens of an area as well as a basis for investment in the development of the hospital. |
Calculation method |
|
Numerator | Total number of therapeutic techniques being applied |
Denominator | Total number of therapeutictechniquesaccording to healthcare levels |
Inclusion criteria | Techniques specified in Circular No.43/2013/TT-BYT |
Exclusion criteria | Therapeutic techniques only available in higher level |
Data sources | Medical records, surgery monitoring books |
Data collection and consolidation | Such data are currently collected and consolidated by hospitals. The measurement of such data does not increase burden on the hospitals. |
Data value | High accuracy and reliability |
Reporting frequency | Annually or biannually |
Indicator No. 2 | Rate of surgery of level II or higher level |
Applicable areas | Surgery |
Quality property | Professional capacity |
Quality component | Process |
Reasons | Surgeries of level II or higher level are performed at hospitals of districts. However, very few district-level hospitals can perform level-II surgeries. Such type of surgeries is often performed at central and provincial hospitals. The rate of level-II surgeries facilitates the assessment of professionalconformityand classification so that suitable measures are taken to enhance the capacity of the lower-level hospitals and reduce the load of the higher-level hospitals. |
Calculation method |
|
Numerator | Total number ofsurgeries of level II or higher levelbeingperformed |
Denominator | Total surgeries being performed |
Data sources | Surgery monitoring books, hospitals’statistical reports, hospitals’ inspection records. |
Data collection and consolidation | Such data arecurrentlycollected and consolidated. The measurement of such data does not increase burden on the hospitals. |
Data value | High accuracy and reliabilitybecause: -Surgeries are classified clearly in a list issued bythe Ministry of Health -Information is collected carefully by departments of the hospitals - Allowancesare verified by hospitals and insurance offices before being paid |
Reporting frequency | Annually or biannually |
Indicator No. 3 | Rate of hospital-acquired infection (wound infection) |
Applicable areas | Surgery |
Quality property | Safety |
Quality component | Outcomes |
Reasons | Wound infection is a common post-surgery complication. Wound infection affects the patient s health, lengthens the hospitalization period and increases the treatment cost.The Ministry of Healthshall specify the hospitals subject to investigation, take records of and supervise the hospital-acquired infection, including wound infection |
Calculation method |
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Numerator | Total number of patients suffering wound infection in thereporting period |
Denominator | Total number of patients undergoing surgeries in the reporting period |
Data sources | Medical records, investigations into wound infection |
Data collection and consolidation | Data about wound infection shall be collected depending on regular investigation by infection-controlling staff of the hospitals. Several central hospitals have carried out hospital-acquired infection control. Regarding hospitals which have not conducted hospital-acquired infection surveillance, the collection and consolidation of data shall be carried out by qualified employees and the installed surveillance system. |
Data value | Averageaccuracy and reliability |
Reporting frequency | Quarterly, biannually, every 9 months or annually |
Indicator No. 4 | Rate of hospital-acquired infection (pneumonia) |
Applicable areas | Surgery |
Quality property | Safety |
Quality component | Outcomes |
Reasons | Pneumoniacaused by hospital-acquired infection is a common complication on patients who receive long-term treatment and/or medical ventilation.Pneumoniacaused by hospital-acquired infection affects the patients’ health, lengthens the hospitalization period and increases the treatment cost.The Ministry of Health shall specify the hospitals subject to investigation, take records of and supervise the hospital-acquired infection, including pneumonia. |
Calculation method |
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Numerator | Total number of patients suffering pneumoniacaused by hospital-acquired infectionin the reporting period |
Denominator | Total number of patients receiving medical ventilation or treatment at hospitals for at least 1 month in thereporting period |
Data sources | Medical records, investigations into the hospital-acquired infection (pneumonia) |
Data collection and consolidation | Data abouthospital-acquired infection (pneumonia)shall be collected depending on regular investigation by infection-controlling staff of the hospitals. Hospital-acquired infectioncontrol has been carried out by central hospitals.Regarding hospitals which have not conducted hospital-acquired infection surveillance, the collection and consolidation of data shall be carried out by qualified employees and the installed surveillance system. |
Data value | Average accuracy and reliability |
Reporting frequency | Quarterly, biannually, every 9 months or annually |
Indicator No. 5 | Number of serious medical accidents |
Applicable areas | The whole hospital |
Quality property | Safety |
Quality component | Outcomes |
Reasons | Serious medical accidents are accidents due to professional mistakes or the side effects of the drugs that lead to serious consequence for patients’ health and life (lifelong sequel or death). Though the number of serious accidents is not remarkable, it requestshandlingand preventive measures as soon as possible. |
Calculation method | Number of serious medical accidents -Serious medical accidents due to the use of drugs +Serious medical accidentsdue to side effects of drugs +Serious medical accidentsdue to surgical operations + Serious medical accidentsdue to medical procedures + Serious medical accidents due to blood transfusion + Otherserious medical accidents |
Data sources | Medical records, professional accidents records, medical accident reporting system,minute books of criticism about deaths, discipline-exercising monitoring book. |
Data collection and consolidation | Hospital are collecting and consolidating data aboutaccidents (caused by the use of drugs, side effects of drugs, surgical operations, medical procedures, blood transfusion, etc.).The measurement of such data does not increase burden ondata collection and consolidation. |
Data value | Low accuracy because health workers and the hospitals do not often make records of and reports on medical accidents. However, data in reports on serious medical accidents are highly reliable. |
Reporting frequency | Annually or biannually |
Indicator No. 6 | Number of serious non-medical accidents |
Applicable areas | The whole hospital |
Quality property | Safety |
Quality component | Outcomes |
Reasons | Seriousnon-medical accidents are accidentsnot caused by professional mistakes nor the side effects of drugs thatlead to serious consequence for health and lifeof patients, health workers and the community(lifelong sequel or death). Though the number of serious accidents is not remarkable, it requests handling and preventive measures as soon as possible. |
Calculation method | Number of seriousnon-medical accidents + Suicide + Falling from heights + Kidnapping + Assault, rape, murder + Fire + Leak or loss of materials or highly hazardous waste + Other accidents |
Data sources | Monitoring books, handover books, discipline-exercising monitoring books, inspection dossiers, etc. |
Data collection and consolidation | Though such contents are not included in regular reporting system, data are collected and consolidated because of their seriousness and relevance to regulatory authorities. The measurement of such indicator does not place a remarkable burden on the collection and consolidation of data in the hospitals. |
Data value | Average accuracy, because hospitalsrarely make reports on the accidents no matter how serious they are.However, data on reported accidents have high reliability. |
Reporting frequency | Biannually or annually |
Indicator No. 7 | Average duration of medical examination |
Applicable areas | Consulting room |
Quality property | Efficiency |
Quality component | Process |
Reasons | Patients often complaint about the long duration of medical examinations, especially those conducted at provincial and central hospitals. The duration of medical examination reflects the patient overload as well as the healthcare organization of the hospitals. The measurement of duration of medical examination contributes in the improvement in the patients’ satisfaction and the efficiency of theconsulting room |
Calculation method | Duration of medical examination is the period of time when the patients complete the medical examination procedures from the time of registration of medical examination to the time they receive the diagnoses, prescriptions or instructions from doctors at theconsulting rooms |
Numerator | Totalduration of medical examinationof all patients |
Denominator | Total number of patients receiving medical examination |
Inclusion criteria | Total number of patients registering the medical examination |
Exclusion criteria | Patients failing to comply with the medical examination procedures |
Data sources | Measuring such indicator, it is required that hospitals will collect and consolidate data about time of medical examination Regarding hospitals applyinginformation technologyin the management of outpatient, the time of registration and the finish time of the examination are displayed on computers. For hospitals not recording the time of registration and the finish time of the examination, such information shall be added to the examination registration books or the examination books. |
Data collection and consolidation | If the registration time and finish time of examination are recorded, the burden on the collection and consolidation of data is minor. |
Data value | High accuracy and reliability |
Reporting frequency | Quarterly, biannually, every 9 months or annually |
Indicator No. 8 | Average duration of hospitalization (applicable to all types of diseases) |
Applicable areas | The whole hospital |
Quality property | Efficiency |
Quality component | Process |
Reasons | The increase in the length of hospitalization increases the seriousness of the overload and the treatment cost the patients must pay. The length of hospitalization reflects the efficiency and the suitability of the treatment and healthcare provided by hospitals. |
Calculation method |
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Numerator | Total number of days of inpatient treatment in thereporting period |
Denominator | Total number ofpersons receivinginpatient treatment in the reporting period |
Inclusion criteria | All of patients having the inpatient treatmentrecords |
Exclusion criteria | Patients referred from other hospitals where they have received inpatient treatment; Patients referred to other hospitals where they continue receiving inpatient treatment |
Data sources | Medical records, hospital admission - discharge - referral books, hospitalstatistic reports |
Data collection and consolidation | Such data are currently collected and consolidatedby hospitals. The measurement of such data does not increase burden on the hospitals. |
Data value | High accuracy and reliability |
Reporting frequency | Quarterly, biannually, every 9 months or annually |
Indicator No. 9 | Actual usage of patient beds |
Applicable areas | The whole hospital |
Quality property | Efficiency |
Quality component | Outcomes |
Reasons | The overload of hospitals, especially of central levels, is an imperative issue. Although the actual number of patient beds is higher than the planned one, most hospitals use the planned number to calculate the usage of patient beds. The usage of patient beds calculated according to the actual number of patient beds reflects more accurately the rate of overload and assist the supervision of changes in the operation of a hospital. |
Calculation method |
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Numerator | Total number of days of inpatient treatment in the reporting period |
Denominator | Actual number of patient beds in total multiplying the number of days in thereporting period |
Data sources | Medical records, hospital admission - discharge -referralbooks |
Data collection and consolidation | Such data are currently collected and consolidated by hospitals. The measurement of such data does not increase burden on the hospitals. |
Data value | High accuracy and reliability |
Reporting frequency | Biannually or annually |
Indicator No. 10 | Efficiency of use of operating rooms |
Applicable areas | Surgery |
Quality property | Efficiency |
Quality component | Process |
Reasons | Operating rooms receive the most investment of the hospitals. In several hospitals, the unreasonable organization of operating rooms leads to the overload and the extension of surgery-pending period while in other hospitalsoperating rooms are rarely used. The measurement and improvement of the usage ofoperating rooms contributes in the reduction of load of the hospital and the efficient use of current resources. |
Calculation method |
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Numerator | Total amount of using time ofoperating rooms (depending on the entering and leaving time) in a quarter |
Denominator | The number ofoperating rooms * 8 hours * 5 days/week |
Inclusion criteria | Elective and urgent surgeries |
Exclusion criteria | - |
Data sources | Currently,dataabout using time of operating roomsarenotcollected and consolidated by hospitals.The measurement of such indicator requires the recording of the time the patients enter or leave the operating rooms to the monitoring books or handover books of the operating rooms or the operating monitoring books |
Data collection and consolidation | Ifsuch dataare recorded, the burden on the collection and consolidation of data is minor. |
Data value | High accuracy and reliability |
Reporting frequency | Quarterly, biannually, every 9 months or annually |
Indicator No. 11 | Mortality rate and rate of poor prognosis (applicable to all types of diseases) |
Applicable areas | The whole hospital |
Quality property | Effectiveness |
Quality component | Outcomes |
Reasons | Mortality rate is a common treatment quality indicator. In Vietnam, for most complex cases where patients are predicted to die, their families apply for discharge for resting at home. Nowadays, since the patients may be admitted after receiving inpatient treatment from other hospitals, the comparison of the efficiency and safety in treatment using hospitals’ mortality rate is not very suitable |
Calculation method |
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Numerator | Total number of patients died at the hospital and predicted to die and discharged on request in thereporting period |
Denominator | Total number of persons receiving inpatient treatment in the reporting period |
Inclusion criteria | Allpersons receiving inpatient treatment |
Exclusion criteria | Patientsreferredfrom other hospitals where they have received inpatient treatment; |
Data sources | Medical records, hospital admission - discharge -referralbooks |
Data collection and consolidation | Dataabout mortality and poor prognosisare currently collected and consolidated by hospitals.However, such data includes patients referred from other hospitals.The measurement of such data does not increase burden on data collectionbut requires a minor change in data collection |
Data value | High accuracy and reliability |
Reporting frequency | Quarterly, biannually, every 9 months or annually |
Indicator No. 12 | Rate ofreferral tohigher-level healthcare facilities (applicable to all types of diseases) |
Applicable areas | The whole hospital |
Quality property | Effectiveness |
Quality component | Outcomes |
Reasons | Referral rate is a common treatment quality indicator. In Vietnam, most complex cases are referred to higher-level hospitals because lower-level hospitals do not have sufficient conditions and capacity to apply the required therapeutic techniques andtreatment regimens, etc.Nowadays, since the patientsor their familiesmayapply for discharge to finish the current treatment and receive treatment from higher-level hospitals without decisions of current hospitals, the comparison of the efficiency and safety in treatment usingthe referralrate is not very suitable |
Calculation method |
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Numerator | Total number of patients referred to higher-level hospitals under decisions of current hospital in thereporting period |
Denominator | Total number of persons receiving inpatient treatment in the reporting period |
Inclusion criteria | - |
Exclusion criteria | Patients applying for discharge from hospitals to finish the current treatment and referral to higher-level hospitals without decisions of current hospitals; patients referred to higher-level hospitals for emergency under decisions of current hospitals |
Data sources | Medical records, hospital admission - discharge - referal books |
Data collection and consolidation | Such data are currently collected and consolidated by hospitals. The measurement of such data does not increase burden on data collection |
Accuracy and reliability | Average accuracy and reliability |
Reporting frequency | Quarterly, biannually, every 9 months or annually |
Indicator No. 13 | Ratioof injuries caused by sharp objectsto 1000 persons |
Applicable areas | The whole hospital |
Quality property | Staff’s orientation |
Quality component | Process |
Reasons | Injuries caused by sharp objects is a main reasons ofoccupational diseasestransmitted through bloodstream which is popular in health workers. |
Calculation method |
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Numerator | Total number of health workers suffering injuries caused by sharp objects in thereporting period* 1000 |
Denominator | Total number of health workers |
Data sources | Such data are currently collected and consolidated by hospitals.However, such accidents are often not reported and recorded by health workers. Data sources should be health workers’ occupational health dossiers and medical interview results (made and recorded in periodiccheck-ups which are held every 6 months according to regulations) |
Data collection and consolidation | The collection and consolidation of information about injuries caused by sharp objects will not cause any noticeable burden on hospitals which seriously comply with regulations oncheck-upandoccupational diseasemanagement for employees. |
Accuracy and reliability | Average accuracy and reliability |
Reporting frequency | Biannually or annually |
Indicator No. 14 | Rate of HBV inoculation in health workers |
Applicable areas | The whole hospital |
Quality property | Stafforientation |
Quality component | Process |
Reasons | The Ministry of Healthprescribes that health workers shall have HBV inoculation. However, hospitals do not highly comply with such regulation. |
Calculation method |
|
Numerator | Total number of health worker having 3 doses ofHBV inoculation* 100% |
Denominator | Total number of health workers requested to have HBV inoculation |
Data sources | Health workers’ occupational health dossier Results of medical interview of health workers in each periodic check-ups |
Data collection and consolidation | The measurement of such indicator shall depend on the occupational health survey conducted in the periodic check-ups provided for health workers according to regulations.The collection and consolidation of information about injuries caused by sharp objects will not cause any noticeable burden on hospitalswhichseriously comply with regulations on check-up and occupational disease management for employees. |
Data value | Average accuracy and reliability |
Reporting frequency | Biannually or annually |
Indicator No. 15 | Rate of patients satisfaction of healthcare services |
Applicable areas | The whole hospital |
Quality property | Patients’ satisfaction |
Quality component | Outcomes |
Reasons | Patients’ satisfaction is an important outcome of hospitals. Patients satisfaction is also relevant to the total number of patients coming to hospitals to receive examination and the future usage of patient beds. As prescribed bythe Ministry of Health, hospitals shall regularly conduct the assessment of patients’ satisfaction. Nowadays, many complaints about the behavior of hospitals staff have been received. |
Calculation method |
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Numerator | Total number of patients satisfied with the behavior of health workers * 100 |
Denominator | Total number of patientsinterviewed |
Inclusion criteria | Patients was and beingdischargedfrom the hospital |
Exclusion criteria | Patients receiving inpatient treatment |
Data sources | Surveys on patients satisfaction |
Data collection and consolidation | The measurement of such indicator does not cause any noticeable burden on hospitals which seriously comply with regulations on assessment of patients’ satisfaction |
Data value | Changeable accuracy and reliability, depending on types of samples and questions and the processing of data. The Ministry of Healthshall issue a consistent questionnaire used for all hospitals to reduce the variance in data |
Reporting frequency | Quarterly, biannually, every 9 months or annually |
Indicator No. 16 | Rate of health workers’ satisfaction |
Applicable areas | The whole hospital |
Quality property | Stafforientation |
Quality component | Outcomes |
Reasons | Health workers’ satisfaction is an important outcome of hospitals.Health workers’ satisfaction is also related to their behavior during the provision of healthcare services.As prescribed by the Ministry of Health, hospitals shall regularly conduct the assessment ofhealth workers’ satisfaction. Nowadays, many complaints about the behavior ofhealth workershave been received. |
Calculation method |
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Numerator | Total number of health workers satisfied with their hospitals’ management * 100 |
Denominator | Total number of health workersin the hospital |
Inclusion criteria | All thehealth workers in the hospital |
Data sources | Surveys onhealth workers’ satisfaction |
Data collection and consolidation | The measurement of such indicator does not cause any noticeable burden on hospitals which seriously comply with regulations on assessment ofhealth workers’ satisfaction |
Data value | Changeable accuracy and reliability, depending on types of questions and the processing of data. The Ministry of Health shall issue a consistent questionnaire used for all hospitals to reduce the variance in data |
Reporting frequency | Quarterly, biannually, every 9 months or annually |
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