The Danish Healthcare Quality Programme (DDKM)

The Danish Healthcare Quality Programme is a national system intended to support a continuous quality improvement of the Danish healthcare service as a whole. It is a method to generate persistent quality development across the entire healthcare sector in Denmark: providing standards for good quality and methods to measure and control this quality.

The first draft of the programme proposal was presented at a public hearing in the spring of 2003, and in November 2004 an agreement on establishing a new organisation to run the operation and further development of the programme began. The organisation was established as an independent institution headed by a board of directors, from the Ministry of the Interior and Health, the National Board of Health and the Danish Regions as representatives of the hospital owners.

The objectives of the Danish Healthcare Quality Programme are:

• To avoid errors causing loss of lives, quality of life and resources; 
• To ensure that knowledge achieved via research and experience is utilised in all branches of the healthcare sector; 
• To document work performed; 
• To achieve the same high quality across geographical boundaries and sectors; 
• To generate coherence in citizens' pathways across sectors – e.g. in the transition from hospital to local healthcare; 
• To render quality within the healthcare sector more visible; 
• To avoid that all institutions must invent their own quality assurance system; and 
• To strive towards excellence – at all times.
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The Danish Healthcare Quality Assessment Programme aims to include all Danish publicly financed healthcare services and seeks to operate on a cross-sectoral basis. The programme is a result of a collaboration between central government and the regions, thereby covering the public healthcare sector in full. Also, municipalities, private hospitals, and pharmacies have signed agreements to become a part of the programme. 

The programme aims at generating and combining the data already being collected today in the Danish health sector. These data include, among others, the national quality databases, adverse events, the National Indicator Project and the National Patient Satisfaction Surveys. 

There is also an international dimension. This is why the accreditation standards must be approved by the international accreditation programme organisation, ISQua, the International Society for Quality in Healthcare.

Organisation

The establishment of the quality programme made it necessary to establish a new organisation, and therefore The Danish Institute for Quality and Accreditation in Healthcare (IKAS) was created in 2005 to develop, plan and run DDKM. The institute employs approximately 30 people, with the majority being qualified within the areas of medicine and healthcare. IKAS has been selected as one of the organisations, which on a global level, place the standards of good quality in the healthcare sector. Also, the director of IKAS is a member of the Accreditation Council of ISQua. The first version of the DDKM for hospitals was officially accepted by ISQa in September 2008.

Accreditation

The Danish Healthcare Quality Programme is based on the quality method known as accreditation. The basic principle of accreditation is to determine a minimum level of good quality within a number of areas, which are followed up for their level of compliance. The faults and omissions discovered in the process are used as an empirical basis to improve quality. Each hospital and organisation introduce their own new standards and perform evaluations themselves in the process. Prior to the final accreditation, an external survey is conducted by a team of medical professionals who have received hands-on training by IKAS. They evaluate compliance to the standards. Survey and accreditation is repeated every three years. The standards are also revised every three years, and new standards are added, the reason being that accreditation is based on maintenance and development of quality on a continuous basis.

Standards are available:

• For general areas such as medication, patient involvement, resuscitation and inter-sectoral transfer; 
• Within the organisational area, with standards for management, data safety and technology; and 
• For various disease areas such as gastric ulcers and diabetes. 
• In the first generation of the Danish Healthcare Programme IKAS has submitted the following standards (accepted by ISQua): 
• 104 standards for the regional healthcare sector; 
• 50 standards for the local healthcare sector; and 
• 42 standards for pharmacies.

The IT-System TAK

IKAS and DDKM developed a web-based ITsystem, known as TAK, containing all standards that support and facilitate the process from the time of receipt of standards to final accreditation. TAK is developed in collaboration with the regions and users from municipalities and community pharmacies. 

TAK is a national system making it possible for different organisational levels to collaborate on quality development in one system. At national level, guidelines can be attached to a standard. At regional level, action plans can be added for a number of standards. At the individual unit level, the quality coordinator can use the documents. Data are shared; they are passed around and filed in a lot different places. 

TAK is used in all parts of the implementation process – right from the division of accreditation standards and indicators for the institutions to completion of the accreditation report. 

The system comprises all the accreditation standards and makes it possible to divide the standards between those who are going to work with compliance of standards. Furthermore, TAK provides possibilities to follow the process of compliance of standards – and guidelines and action plans can be attached to TAK in both a central and decentralised way.
Thereby, TAK provides an overview of the division of labour in connection with the work with the DDKM and with the results – likewise the system eases the collection of relevant data.

The Danish National Indicator Project (NIP)

The Danish National Indicator Project was established within the Danish Healthcare System in 1999. The project aims to document and develop the quality of healthcare in disease specific areas. It assesses the healthcare system as an organisation instead of focusing on individuals.

The aim of the project is not to find scapegoats but to bring forth the best possible basis for the improvement and development of quality in the healthcare system. It facilitates a dialogue between the healthcare providers, the leaders, the political system and the patients on the basis of evidence based documentation. 

The Danish National Indicator Project measures the quality of care provided by the hospitals to groups of patients with specific medical conditions. The aim is to create awareness in patients, families, doctors, nurses and other healthcare professionals about the extent to which the completion and outcomes of the treatment are up to the standards expected from a well-functioning healthcare service.

From 2000, national quality standards, indicators and prognostic factors have been developed. Quality of care is now measured (in an audit) for eight diseases:

• Acute surgery (bleeding gastroduodenal ulcer and perforated peptic cancer); 
• Chronic Obstructive Pulmonary Disease (COPD); 
• Diabetes; 
• Heart failure; 
• Hip fracture; 
• Lung cancer; 
• Schizophrenia; and 
• Stroke.

The national audits for every disease are carried out once a year, by the multidisciplinary indicator panel for the specific disease, in order to explain the risk-adjusted results and to point out and recommend activities for quality improvements. When the results from NIP are available they are examined by doctors, nurses and other healthcare professionals involved in treating patients. The objective is to find the areas within the courses of treatment where the quality is already adequate as well as the areas in need of improvement.

Implementation: Survey Team

The survey team is a group of specially educated peers, who perform an external survey in an institution. The main task of the team is to carry out an assessment of the observations related to the standards of accreditation, and summarise these in a total valuation of the institution. The survey team must include surveyors from comparable institutions to that being surveyed.

During 2009 and 2010 there has been training for surveyors in Danish hospitals. The courses include a mix of theory and training exercises with a focus on the standards of accreditation, the principles of assessment, communication and interview techniques, ethics, reporting and the process of accreditation. All Danish Hospitals, public as well as private, are currently working with implementation of the first national system of quality, DDKM. By June 2012 all hospitals should finish their accreditation. At this point, 24 Danish pharmacies have been accredited in DDKM and three municipalities will soon follow. 

For further information of the DDKM and the NIP: www.ikas.dk and www.nip.dk