The Portuguese Experience of Quality Improvement in Health

Dr. Franca explained that the Portuguese National Health Plan (2004-2010) was criticised by WHO in an evaluation in February 2010. They concluded that, "The Plan does not focus sufficiently on the quality and safety of health care services. The monitoring of health care outcomes, medical processes, medical errors and safety in health care services, as well as safety at the workplace, has not been a particular focus of the Plan."

The strategy for 2011-2016 is in the discussion phase and Dr. Franca defines its mission as "to maximise the health gains for population through the alignment and integration of sustainable efforts of all sectors of society, focusing on access, quality, healthy policies and citizenship."

In a first step to dedicated quality improvement, a new department, Quality in Health, was created in 2009 within the General Directorate of Health, Ministry of Health. This was closely followed by a National Strategy for Quality in Health, published June 2009, with seven priority areas: Clinical and organ - isational quality; transparent information to patients; patient safety; qualification and national certification of health units; integrated disease management and innovation; international patient mobility management; and NHS users satisfaction evaluation and management.

Methods to enhance organisational and clinical quality include a new accreditation system in partnership with the Quality Agency from Andalusia, Spain and the development of national quality indicators. Patients and professionals satisfaction assessment is also to be launched. Regarding patient safety, Portugal is collaborating with various European Associations to control HAIs.

So what are the key weaknesses in quality improvement? Franca believes that Portugal shares the same weaknesses as other countries including the general difficulty to compare QI experiences and lack of benchmarking at national and international level. There is also a lack of support from top-level leaders and a lack of evidence about effectiveness and adequacy of QI methods and tools. Other difficulties include sustaining and financing quality systems and programmes and the inconsistency of strategies and leadership of programmes and of methodologies.

The main achievements in quality improvement can be defined as:

• Quality culture spread in NHS 
• Experience on QI techniques and methods; 
• Risk management and adverse events registries on hospitals as good practices; 
• 24 hospitals achieving the goal of accreditation; 
• Local services projects with a pool of trained professionals in QI methodologies; 
• Interest from professionals on QI and in self- development; and 
• Adhesion to projects from care units and professionals.
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Franca believes we can learn from the Portuguese experience and put QI on the top of the Ministry agenda and develop explicit interest and support. Integrate QI programmes with contracting and financing of care and pay for performance initiatives; publicise results on performance and quality of care, and empower patients and their families, with specific focus on chronic diseases. QI should be integrated in undergraduate courses and into strategy design and actions on a national level.