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Se ha realizado una amplia investigación en los últimos 30 años sobre los métodos que sustentan las guías de práctica clínica (CPGs, Clinical Practice Guidelines), incluyendo su desarrollo, actualización, generación de informes, adaptación para fines específicos, implementación y evaluación. Esto ha generado un aumento de términos, herramientas y acrónimos. Con el tiempo, las CGPs se han desplazado de basadas en la opinión a basadas en la evidencia, incluyendo metodologías cada vez más sofisticadas y estrategias de implementación, y por lo cual mantenerse actualizado de la evolución en este campo de investigación puede ser complicado. Este artículo recopila los resultados de una búsqueda exhaustiva de documentos, para proporcionar orientaciones sobre normas, métodos y sistemas descritos en la metodología y aplicación de literatura actual de CPG. Esta guía está dirigida a las personas que trabajan en calidad y seguridad de la atención de salud; y responsables de la puesta en marcha, investigación o la prestación de asistencia sanitaria. Se presenta en un formato que puede ser actualizado a medida que este campo se extienda. Mientras que el desarrollo y la implementación de GPC han atraído una gran actividad e interés internacional, la actualización de GPC, la adopción (con o sin contextualización), la adaptación y la evaluación del impacto, no están tan bien dirigidas. Ao longo dos últimos trinta anos, foram realizadas inúmeras pesquisas sobre os métodos nos quais se baseiam as diretrizes clínicas (DCs), incluindo o seu desenvolvimento, atualização, difusão, adaptação para fins específicos, implementação e avaliação. Essas pesquisas resultaram em um crescente número de termos, ferramentas e acrônimos. Antes baseadas em opinião, com o passar do tempo, as DCs passaram a ser baseadas em evidências científicas, empregando metodologias e estratégias de implementação cada vez mais sofisticadas. Assim, manter-se a par das evoluções neste campo de pesquisa que pode ser desafiador. Este artigo reúne os achados oriundos de buscas feitas em diversos documentos, com o intuito de fornecer um guia descritivo das normas, métodos e sistemas com base na literatura existente sobre metodologias e implementação de DCs. Este guia se destina àqueles que atuam na área de qualidade e segurança do paciente; e também àqueles responsáveis por contratar, pesquisar ou prestar cuidado de saúde. O guia foi construído de forma que possa ser atualizado à medida que o campo se expande. O desenvolvimento e a implementação das DCs vêm atraindo interesses e movimentos internacionais, ao passo que a atualização, adoção (com ou sem contextualização), adaptação e avaliação do impacto das DCs são assuntos bem menos abordados. 过去30年在建构临床诊疗指引(CPGs)的基础方法上有广泛地研究，包含其发展、 更新、报告、为特定目的而量身打造、 实施和评估。这导致了术语、工具和缩写词的数目不断增加。随着时间经过，CPGs从以意见为基础转变为以实证为依据，包括日渐成熟的方法和实施策略，因此与这一领域的研究发展并驾齐驱是具有挑战性的。本文整理了大量的研究结果，以提供一指南来描述目前CPG的方法和执行文献中有报导的标準、方法和系统。本指南的目标对象为维护医疗服务品质及安全的工作者；以及负责委任、研究或提供医疗服务者。当领域扩大时它可以依情况做更新。CPG发展与实施已经吸引了国际间的兴趣和回响，然而CPG的更新、采用(有或无情境化)、适应和影响的评估，则较少被提及。 過去30年在建構臨床診療指引(CPGs)的基礎方法上有廣泛地研究，包含其發展、 更新、報告、為特定目的而量身打造、 實施和評估。這導致了術語、工具和縮寫詞的數目不斷增加。隨著時間經過，CPGs從以意見為基礎轉變為以實證為依據，包括日漸成熟的方法和實施策略，因此與這一領域的研究發展並駕齊驅是具有挑戰性的。本文整理了大量的研究結果，以提供一指南來描述目前CPG的方法和執行文獻中有報導的標準、方法和系統。本指南的目標對象為維護醫療服務品質及安全的工作者；以及負責委任、研究或提供醫療服務者。當領域擴大時它可以依情況做更新。CPG發展與實施已經吸引了國際間的興趣和回響，然而CPG的更新、採用(有或無情境化)、適應和影響的評估，則較少被提及。 Un travail de recherche important a été réalisé au cours des 30 dernières années sur les recommandations de bonne pratique, allant de leurs méthodes d’élaboration et d’actualisation, leur publication, leur développement pour répondre à des besoins spécifiques, à leur mise en œuvre et évaluation. Cela a conduit à la production croissante de terminologies, d’outils et d’acronymes. Avec le temps, les recommandations de bonne pratique sont passées de l’avis d’experts aux données fondées sur la preuve, avec le développement de méthodologies et de stratégies de mise en œuvre de plus en plus sophistiquées, rendant difficile la mission de se tenir à jour dans ce domaine. Cet article s’appuie sur une recherche documentaire approfondie pour proposer un guide qui présente les standards, les méthodes et les systèmes rapportés dans la littérature sur les méthodes d’élaboration et de mise en œuvre des recommandations de bonne pratique. Ce guide est destiné aux professionnels de la qualité et de la sécurité des soins, qu’ils travaillent sur l’accès, la recherche ou la dispensation des soins. Il est présenté dans un format permettant la prise en compte des nouvelles données. L’élaboration et la mise en œuvre des recommandations de bonne pratique ont fait l’objet d’un intérêt et d’une activité importante au niveau international, alors que les thèmes relatifs à l’actualisation, l’adoption (avec ou sans contextualisation), l’adaptation ou l’évaluation de leur impact ont été moins souvent abordées.

Overuse of unnecessary care is widespread around the world. This so-called low-value care provides no benefit for the patient, wastes resources and can cause harm. The concept of low-value care is broad and there are different reasons for care to be of low-value. Hence, different strategies might be necessary to reduce it and awareness of this may help in designing a de-implementation strategy. Based on a literature scan and discussions with experts, we identified three types of low-value care. The type ineffective care is proven ineffective, such as antibiotics for a viral infection. Inefficient care is in essence effective, but is of low-value through inefficient provision or inappropriate intensity, such as chronic benzodiazepine use. Unwanted care is in essence appropriate for the clinical condition it targets, but is low-value since it does not fit the patients' preferences, such as a treatment aimed to cure a patient that prefers palliative care. In this paper, we argue that these three types differ in their most promising strategy for de-implementation and that our typology gives direction in choosing whether to limit, lean or listen. We developed a typology that provides insight in the different reasons for care to be of low-value. We believe that this typology is helpful in designing a tailor-made strategy for reducing low-value care.

The use of information and communication technologies in health and health care could improve healthcare quality in many ways. Today’s evidence base demonstrates the (cost-)effectiveness of online education, self-management support and tele-monitoring in several domains of health and care. While new results gradually provide more evidence for eHealth’s impact on quality issues, now is the time to come to grips with implementation issues. Documented drawbacks such as low acceptance, low adoption or low adherence need our attention today to make the most of eHealth’ potential. Improvement science is beginning to deliver the tools to address these persistent behavioural and cultural issues. The ceHRes Roadmap, for instance, is a plural and pragmatic approach that includes users’ needs. It is now imperative to improve our implementation strategies in order to scale up eHealth technologies. This will accelerate the much needed transformation of our healthcare systems and sustain access, affordability and quality for all in the near future. El uso de información y tecnología de la comunicación en salud y atención sanitaría podría mejorar la calidad de la atención sanitaria de muchas maneras. La base de la evidencia de hoy demuestra la (coste-) efectividad de la educación online, el apoyo en el auto-cuidado y la tele-monitorización, en algunos dominios de la atención sanitaria. Mientras que los nuevos resultados proporcionan gradualmente más evidencia para el impacto de la eSalud en cuestiones de calidad, ahora es el momento enfrentarse con los temas de implementación. Inconvenientes documentados como son la baja aceptación, la baja adopción, o la baja adherencia necesitan nuestra atención hoy para aprovechar al máximo el potencial de la eSalud. La ciencia de la mejora está comenzando a producir herramientas para abordar estos problemas de comportamiento y culturales persistentes. El ceHRes Roadmap, por ejemplo, es un enfoque plural y pragmático que incluye las necesidades de los usuarios. Ahora es imperativo mejorar nuestras estrategias de implementación con el fin de ampliar las tecnologías de eSalud. Esto acelerará la tan necesaria transformación de nuestros sistemas de salud y mantendrá el acceso, la asequibilidad y la calidad para todos en un futuro próximo. O uso de informação e tecnologias de comunicação em saúde poderiam melhorar a qualidade dos cuidados de saúde de muitas maneiras. Hoje em dia a evidência demonstra a (custo-) efetividade da educação online, suporte para a autogestão e monitorização à distância em várias áreas da saúde e dos cuidados. Enquanto novos resultados fornecem, gradualmente, mais evidência para o impacto da eHealth em termos de qualidade é agora tempo de enfrentar os assuntos relativos à sua implementação. Os obstáculos documentados tais como: uma baixa aceitação, baixa adoção ou pouca adesão necessitam agora da nossa atenção de modo a obter o potencial máximo da eHealth. A investigação está a começar a fornecer ferramentas para responder a estes problemas comportamentais e culturais persistentes. A ceHResRoamap, por exemplo, é uma abordagem plural e pragmática que inclui as necessidades dos utilizadores. É agora imperativo melhorar as nossas estratégias de implementação de modo a ampliar as tecnologias de eHealth. Isto irá acelerar a transformação necessária dos sistemas de saúde bem como a sustentabilidade no acesso e melhoria da qualidade num futuro próximo. 在卫生与健康照护中,信息与通讯技术的运用可以在 许多方面改善健康照护质量。 如今,实证显示在许多 健康与照护领域中,在线教育、自我管理支持和远程 监控具(成本)效益。 当有关电子健康对质量影响的议 题逐渐地提出新的实证结果,现在该开始努力处理执 行上的议题。 现今我们应注意文件化的缺点,例如: 低接受度、低采用性、低依附性,以发挥电子健康的 潜力。 改善科学是一开端,以提供工具来解决这些持 续性的行为与文化议题。 例如:ceHRes路线图是一个 涵盖用户需求之多元与务实的方法,为了扩展电子健 康技术,当务之急是改善我们的实施策略。 这将会加 速我们急需转型的健康照护系统,并在不久的未来维 持可近性、可负担性与质量。 在衛生與健康照護中,資訊與通訊技術的運用可以在 許多方面改善健康照護品質。如今,實證顯示在許多 健康與照護領域中,線上教育、自我管理支持和遠程 監控具(成本)效益。當有關電子健康對品質影響的議題 逐漸地提出新的實證結果,現在該開始努力處理執行 上的議題。現今我們應注意文件化的缺點,例如:低 接受度、低採用性、低依附性,以發揮電子健康的潛 力。改善科學是一開端,以提供工具來解決這些持續 性的行為與文化議題。例如:ceHRes路線圖是一個涵 蓋使用者需求之多元與務實的方法,為了擴展電子健 康技術,當務之急是改善我們的實施策略。這將會加 速我們急需轉型的健康照護系統,並在不久的未來維 持可近性、可負擔性與品質。 健康や医療現場でITを利用することで、医療の質を 様々な点から改善させることができる。昨今、健康 や医療の様々な領域において、オンライン教育やセ ルフマネジメント、遠隔モニタリングの有用性が示 されている。e-ヘルスが医療の質に与える影響は 徐々に示されており、今後は実際の導入をどうする かという問題に取り組む必要がある。受容や採択率、 アドヒアランスの低さという欠点から、e-ヘルスの もつ可能性を最大限生かすために注目する必要があ る。医療の改善はこのような根強い行動や文化の問 題に対する手段を与えはじめている。例えばceHRes Roadmapは、ユーザーのニーズを含めた複数の実践 的な手法である。eヘルスを発展させていくために は、われわれの実現戦略を改善させる必要がある。 それにより医療提供体制に求められている変革を促 進し、医療に対するアクセスや手頃な価格、質など を維持することができるだろう。 L’utilisation des technologies de l’information et de la communication dans le domaine de la santé pourrait améliorer la qualité des soins à bien des égards. Les données probantes actuelles démontrent le bon rapport cout/efficacité de l’éducation en ligne, des programmes de soutien à l’autogestion et de la télé-surveillance dans plusieurs domaines de la santé et des soins. Alors que de plus en plus d’études apportent des preuves de l’impact de la cybersanté sur la qualité des soins, il est désormais nécessaire de trouver des solutions aux problèmes de mise en œuvre. Afin de tirer le meilleur parti du potentiel des technologies de cybersanté, il faut prêter attention aux freins à la mise en œuvre tels qu’une faible acceptation, un faible taux d’adoption, ou une faible observance. Les « sciences de l’amélioration continue » commencent à fournir les outils pour répondre aux questions comportementales et culturelles. La feuille de route ceHRes, par exemple, est une approche plurielle et pragmatique qui prend en compte les besoins des utilisateurs. Il est maintenant impératif d’améliorer nos stratégies de mise en œuvre afin de promouvoir les technologies de cybersanté. Cela permettra d’accélérer la transformation nécessaire de nos systèmes de santé et de maintenir l’accès et la qualité des soins pour tous dans un avenir proche.

Most research on health systems examines contemporary problems within one, or at most a few, countries. Breaking with this tradition, we present a series of case studies in a book written by key policymakers, scholars and experts, looking at health systems and their projected successes to 2030. Healthcare Systems: Future Predictions for Global Care includes chapters on 52 individual countries and five regions, covering a total of 152 countries. Synthesised, two key contributions are made in this compendium. First, five trends shaping the future healthcare landscape are analysed: sustainable health systems; the genomics revolution; emerging technologies; global demographics dynamics; and new models of care. Second, nine main themes arise from the chapters: integration of healthcare services; financing, economics and insurance; patient-based care and empowering the patient; universal healthcare; technology and information technology; aging populations; preventative care; accreditation, standards, and policy; and human development, education and training. These five trends and nine themes can be used as a blueprint for change. They can help strengthen the efforts of stakeholders interested in reform, ranging from international bodies such as the World Health Organization, the International Society for Quality in Health Care and the World Bank, through to national bodies such as health departments, quality and safety agencies, non-government organisations (NGO) and other groups with an interest in improving healthcare delivery systems. This compendium offers more than a glimpse into the future of healthcare−it provides a roadmap to help shape thinking about the next generation of caring systems, extrapolated over the next 15 years.

Providing high quality and safe patient care is a challenge in the current rapidly changing and complex health care environment. A variety of independent tools and methodologies contribute to this effort, e.g. regulatory requirements, quality improvement tools and accreditation methodologies. A concern is that each alone will not achieve the tipping point in health care quality that is required. This paper suggests that the methodology and application of accreditation have the potential to be the force to bring these approaches into alignment and ultimately measurably improve the quality of care. 在现今快速变迁及复杂的医疗照护环境下，提供高质量及安全病人照护是一项挑战。多样的独立工具及研究方法努力促成，像是监管要求、质量改善工具及评鉴方法。担忧的是各项独自无法达到健康照护质量所要求的临界点。本篇文章提出研究方法及评鉴的应用有潜力将这些方法标准化，最终显著地改善照护质量。 Proveer una atención de alta calidad y seguridad al paciente es un reto en el actual rápidamente cambiante y complejo entorno de los servicios de salud. Una variedad de herramientas independientes y metodologías contribuyen a este esfuerzo p.ej. requerimientos regulatorios, herramientas de mejora de la calidad y metodologías de acreditación. Una preocupación es que cada una por separado no consiga alcanzar el nivel en la calidad de la atención de salud que se requiere. Este artículo sugiere que la metodología y aplicación de la acreditación tiene el potencial para ser la fuerza que alinee estosenfoquesy, endefinitiva, mejorar de manera cuantificable la calidad de la atención. 在現今快速變遷及複雜的醫療照護環境下，提供高品質及安全病人照護是一項挑戰。多樣的獨立工具及研究方法努力促成，像是監管要求、品質改善工具及評鑑方法。擔憂的是各項獨自無法達到健康照護品質所要求的臨界點。本篇文章提出研究方法及評鑑的應用有潛力將這些方法標準化，最終顯著地改善照護品質。 Prover cuidado de saúde de alTa qualidade e seguro para o paciente é um desafio no ambiente complexo e de mudanças rápidas corrente. Uma variedade de ferramentas e metodologias independentes contribuem nesse sentido, ex. requisitos regulatórios, ferramentas de melhoria da qualidade e metodologias de acreditação. Uma preocupação é que cada uma separadamente não alcançará a mudança necessária na qualidade do cuidado de saúde. Este artigo sugere que a metodologia e aplicação da acreditação têm o potencial de ser a força que faz com que essas abordagens se alinhem e, em última instância, melhorem de modo sensível a qualidade do cuidado. 高品質かつ患者にも安全なケアを提供することは近 年の急速に変化し、複雑性の中にある医療をとりま く環境においては課題となっている。様々な独立し たツールと方法がこの取り組みに貢献している （例：規制上の要件、質の改善ツール、認証評価 法）。懸念すべき点は、それぞれ単独では求められ る医療の質の転換点までは達しないだろうというこ とである。本稿は認証評価の方法と適用はこれらの アプローチを調整して最終的にはケアの質を適度に 改善する可能性を秘めていると提案している。 Dispenser des soins d’un haut niveau de qualité et de sécurité est un défi dans le contexte actuel d’évolution rapide et complexe des soins de santé. Divers outils et méthodes, indépendants les uns des autres, contribuent à cet objectif, parmi lesquels on peut citer les exigences du régulateur, les outils et méthodes d’amélioration de la qualité et l’accréditation. Il est préoccupant de constater que chacune de ces approches, prise isolément, ne suffit pas à atteindre les améliorations attendues. Cet article suggère que la méthodologie et la pratique de l’accréditation permettent de potentialiser les différentes approches et de les aligner pour, en fin de compte, améliorer de façon mesurable la qualité des soins.

There is evidence that practitioners applying quality improvements often adapt the improvement method or the change they are implementing, either unknowingly, or intentionally to fit their service or situation. This has been observed especially in programs seeking to spread or ‘scale up’ an improvement change to other services. Sometimes their adaptations result in improved outcomes, sometimes they do not, and sometimes they do not have data make this assessment or to describe the adaptation. The purpose of this paper is to summarize key points about adaptation and context discussed at the Salzburg Global Seminar in order to help improvers judge when and how to adapt an improvement change. It aims also to encourage more research into such adaptations to develop our understanding of the when, why and how of effective adaptation and to provide more research informed guidance to improvers. The paper gives examples to illustrate key issues in adaptation and to consider more systematic and purposeful adaptation of improvements so as to increase the chances of achieving improvements in different settings for different participants. We describe methods for assessing whether adaptation is necessary or likely to reduce the effectiveness of an improvement intervention, which adaptations might be required, and methods for collecting data to assess whether the adaptations are successful. We also note areas where research is most needed in order to enable more effective scale up of quality improvements changes and wider take up and use of the methods.

During the Salzburg Global Seminar Session 565—‘Better Health Care: How do we learn about improvement?’, participants discussed the need to unpack the ‘black box’ of improvement. The ‘black box’ refers to the fact that when quality improvement interventions are described or evaluated, there is a tendency to assume a simple, linear path between the intervention and the outcomes it yields. It is also assumed that it is enough to evaluate the results without understanding the process of by which the improvement took place. However, quality improvement interventions are complex, nonlinear and evolve in response to local settings. To accurately assess the effectiveness of quality improvement and disseminate the learning, there must be a greater understanding of the complexity of quality improvement work. To remain consistent with the language used in Salzburg, we refer to this as ‘unpacking the black box’ of improvement. To illustrate the complexity of improvement, this article introduces four quality improvement case studies. In unpacking the black box, we present and demonstrate how Cynefin framework from complexity theory can be used to categorize and evaluate quality improvement interventions. Many quality improvement projects are implemented in complex contexts, necessitating an approach defined as ‘probesense-respond’. In this approach, teams experiment, learn and adapt their changes to their local setting. Quality improvement professionals intuitively use the probe-sense-respond approach in their work but document and evaluate their projects using language for ‘simple’ or ‘complicated’ contexts, rather than the ‘complex’ contexts in which they work. As a result, evaluations tend to ask ‘How can we attribute outcomes to the intervention?’, rather than ‘What were the adaptations that took place?’. By unpacking the black box of improvement, improvers can more accurately document and describe their interventions, allowing evaluators to ask the right questions and more adequately evaluate quality improvement interventions.

The lack of specialist nurses in operating theatres is a serious problem. The aim of this study was to describe reasons why specialist nurses in perioperative care chose to leave their workplaces and to describe the process from the thought to the decision. Twenty specialist nurses (i.e. anaesthesia, NA, and operating room nurses) from seven university-and county hospitals in Sweden participated in qualitative individual in-depth interviews. Data were analysed by systematic text condensation. We identified four themes of reasons why specialist nurses quitted their jobs: the head nurses’ betrayal and dismissive attitude, and not feeling needed; inhumane working conditions leading to the negative health effects; not being free to decide about one’s life and family life being more important than work; and, colleagues’diminishing behaviour. Leaving one’s job was described as a process and specialist nurses had thought about it for some time. Two main reasons were described; the head nurse manager’s dismissive attitude and treatment of their employees and colleagues’ mistreatment and colleagues’ diminishing behaviour. Increasing knowledge on the role of the head nurse managers in specialist nurses’ decision making for leaving their workplace, and creating a friendly, non-violent workplace, may give the opportunity for them to take action before it is too late.

Denmark has unique opportunities for quality measurement and benchmarking since Denmark has well-developed health registries and unique patient identifier that allow all registries to include patient-level data and combine data into sophisticated quality performance monitoring. Over decades, Denmark has developed and implemented national quality and patient safety initiatives in the healthcare system in terms of national clinical guidelines, performance and outcome measurement integrated in clinical databases for important diseases and clinical conditions, measurement of patient experiences, reporting of adverse events, national handling of patient complaints, national accreditation and public disclosure of all data on the quality of care. Over the years, Denmark has worked up a progressive and transparent just culture in quality management; the different actors at the different levels of the healthcare system are mutually attentive and responsive in a coordinated effort for quality of the healthcare services. At national, regional, local and hospital level, it is mandatory to participate in the quality initiatives and to use data and results for quality management, quality improvement, transparency in health care and accountability. To further develop the Danish governance model, it is important to expand the model to the primary care sector. Furthermore, a national quality health programme 2015–18 recently launched by the government supports a new development in health care focusing upon delivering high-quality health care—high quality is defined by results of value to the patients. Dinamarca tiene oportunidades únicas para la evaluación de la calidad y el benchmarking ya que dispone de registros de salud bien desarrollados y un sistema de identificación de pacientes único que permiten a todos los registros incluir información a nivel del paciente y combinar información para obtener una monitorización sofisticada del desempeño en calidad. Durante décadas Dinamarca ha desarrollado e implementado iniciativas nacionales de calidad y seguridad del paciente en el sistema sanitario en términos de guías clínicas nacionales, medidas de desempeño y resultado integrados en bases de datos clínicos para enfermedades importantes y condiciones clínicas, medidas de experiencias de pacientes, notificación de eventos adversos, gestión nacional de quejas de pacientes, acreditación nacional y divulgación pública de toda la información sobre calidad asistencial. A lo largo de los años Dinamarca ha desarrollado una cultura progresiva, transparente y justa de gestión de la calidad; diferentes actores en diferentes niveles del sistema sanitario son mutuamente aplicados y receptivos en esfuerzos coordinados de calidad de los servicios sanitarios. A nivel nacional, regional, local y de hospital es obligatorio participar en iniciativas de calidad y usar información y resultados para gestión y mejora de calidad, transparencia de la atención sanitaria y rendición de cuentas. Para seguir desarrollando el modelo de gobernanza danés es importante expandir el modelo al sector de atención primaria. Asimismo un programa nacional de calidad de salud 2015-2018 recientemente impulsado por el gobierno apoya un nuevo desarrollo en la atención sanitaria enfocando en proporcionar atención sanitaria de alta calidad, definiendo alta calidad por los resultados de valor para los pacientes. A Dinamarca conta com oportunidades singulares para a medição e padrão de comparação de qualidade desde que desenvolveu registros de saúde e identificadores únicos por paciente, permitindo que todos os registros incluam dados do paciente, combinando os dados em um sofisticado sistema de monitoramento de desempenho da qualidade. Ao longo de décadas, a Dinamarca desenvolveu e implementou no sistema de saúde iniciativas de qualidade e segurança do paciente de âmbito nacional, em termos de diretrizes clínicas nacionais, medição do desempenho e de resultados integrados em bases de dados clínicos para doenças e condições clínicas importantes, além da aferição da experiência dos pacientes, notificação de eventos adversos, gestão nacional de queixas de pacientes, acreditação de abrangência nacional e divulgação pública de todos os dados sobre a qualidade do cuidado. Ao longo dos anos, a Dinamarca desenvolveu uma cultura progressiva e transparente na gestão da qualidade; os diferentes atores nos diferentes níveis do sistema de saúde se apoiam num esforço conjunto em prol da qualidade dos serviços de saúde. Nas esferas nacional, regional, local e hospitalar, é obrigatória a participação em iniciativas de qualidade e utilização de dados e resultados na gestão da qualidade, melhoria da qualidade, transparência nos cuidados de saúde e responsabilização. Para desenvolver ainda mais o modelo de governança dinamarquês, é importante expandir o modelo para o setor da atenção primária. Além disso, um programa nacional de qualidade 2015-2018, lançado recentemente pelo governo, apoia um novo desenvolvimento na área de cuidados de saúde com foco na prestação de cuidados de saúde de alta qualidade — a alta qualidade é definida por resultados de valor para os pacientes. 自从丹麦发展出可以将病人资料收录及统整于质量绩效监测的登记系统与独特的病人辨识码，丹麦树立了独一无二的质量测量与评价基准。几十年来，丹麦已制定并实施国家医疗质量与临床指针，纳入了重大疾病及临床情况、病人疾病史之评估、不良事件之通报、国际医疗病患意见反馈处理之绩效和成果的评估等多方面的病人安全措施，并将其医疗质量的数据公告。多年来，丹麦已逐步发展出一套渐进式与透明的质量管理公平文化，在医疗系统中不同层级间的不同角色应一起努力合作，维持医疗服务的质量。在国家、 区域、 地方和医院级别为强制性的参与质量倡导，并利用数据及结果来衡量评估质量管理、 质量改进、 健康照护及责任追究的透明度。而为了进一步的发展丹麦管理模型，将其推广至基层部门是很重要的步骤。此外，政府最近支持推出2015-2018年的国家健康质量计划，将健康照护重点着重于提供高质量的健康照护—由病人的结果评值来定义高质量。 自從丹麥發展出可以將病人資料收錄及統整於品質績效監測的登記系統與獨特的病人辨識碼，丹麥樹立了獨一無二的品質測量與評價基準。幾十年來，丹麥已制定並實施國家醫療品質與臨床指標，納入了重大疾病及臨床情況、病人疾病史之評估、不良事件之通報、國際醫療病患意見反饋處理之績效和成果的評估等多方面的病人安全措施，並將其醫療品質的數據公告。多年來，丹麥已逐步發展出一套漸進式與透明的質量管理公平文化，在醫療系統中不同層級間的不同角色應一起努力合作，維持醫療服務的品質。在國家、 區域、 地方和醫院級別為強制性的參與品質倡導，並利用資料及結果來衡量評估品質管理、 品質改進、 健康照護及責任追究的透明度。而為了進一步的發展丹麥管理模型，將其推廣至基層部門是很重要的步驟。此外，政府最近支援推出2015-2018年的國家健康品質計畫，將健康照護重點著重於提供高品質的健康照護—由病人的結果評值來定義高品質。 デンマークは医療の質を評価し、ベンチマーク する上で、独自の優れた条件を備えている。それと いうのも、デンマークではしっかりと整備された複 数の医療レジストリと、患者を一意に識別できるID システムがあり、全てのレジストリが患者レベルの データを含んでいて、データを結合して洗練された 質評価モニタリングのために用いることができるか らである。数十年にわたりデンマークは、医療シス テムにおける医療の質と患者安全についての国家的 イニシアティブを次のような観点から開発し、実行 してきた。その内容は、国の診療ガイドライン、重 要疾患および重要な臨床的状態についての臨床デー タベースに統合されたパフォーマンスとアウトカム の測定、患者経験の測定、有害事象の報告、患者の 苦情への国による取扱い、国の認証および医療の質 に関連するすべてのデータの公表というものであ る。ここ数年、デンマークは医療の質の管理におい て、進歩的で透明性の高い公正な文化が育つよう、 取り組んできた。すなわち、医療システムにおける 多様なレベルの多様なアクターがお互いに協力して 気遣い、反応しあうことで、医療サービスの質が保 たれるのである。国家レベル、地方自治体レベル、 地域レベルおよび病院レベルにおいて、医療の質向 上イニシアティブに参加し、質をマネジメントし、 改善し、医療の透明性を保ち、また説明責任を果た すという目的でデータと結果を利用することは義務 である。デンマーク式のガバナンスモデルをさらに 発展させるためには、このモデルをプライマリケア 部門にも拡大することが重要である。さらには、政 府により近年開始された国家的医療の質向上プログ ラム2015-2018は、より質の高い医療（―質の高さは 患者にとっての価値という結果で定義される）を普 及させることに焦点をあてており、医療に新たな発 展を支えるものである。 Au Danemark, le développement du recueil de données en santé et l’existence d’un identifiant unique du patient favorisent le développement de bases de données cliniques qui permettent l’évaluation de la qualité, le benchmarking, et l’évaluation de la performance. Au fil des décennies, le Danemark a développé et mis en œuvre au plan national des initiatives dans le domaine de la qualité et de la sécurité des soins: élaboration de recommandations de pratique clinique, mesure des résultats et évaluation de la performance pour les principales pathologies grâce à l’exploitation des bases de données, évaluation de l’expérience patient, traitement des plaintes des patients, accréditation, diffusion publique des données relatives à la qualité des soins. Au fil des ans, le Danemark a également développé une culture positive de l’erreur qui engage l’ensemble des acteurs, à tous les niveaux du système de santé, dans une démarche d’amélioration de la qualité. Il leur est en effet obligatoire de participer aux programmes d’amélioration de la qualité et d’utiliser les données et les résultats à des fins de management de la qualité, d’amélioration de la qualité, de transparence et de reddition de comptes. Les futurs développements prendront également en compte le secteur des soins primaires. En outre, le programme national pour la qualité en santé récemment lancé par le gouvernement danois pour la période 2015–2018, encourage de nouveaux projets qui visent à la délivrance de soins de haute qualité, mesurables par les résultats en termes de valeur ajoutée pour le patient.

Quality improvement approaches can strengthen action on a range of global health priorities. Quality improvement efforts are uniquely placed to reorient care delivery systems towards integrated people-centred health services and strengthen health systems to achieve Universal Health Coverage (UHC). This article makes the case for addressing shortfalls of previous agendas by articulating the critical role of quality improvement in the Sustainable Development Goal era. Quality improvement can stimulate convergence between health security and health systems; address global health security priorities through participatory quality improvement approaches; and improve health outcomes at all levels of the health system. Entry points for action include the linkage with antimicrobial resistance and the contentious issue of the health of migrants. The work required includes focussed attention on the continuum of national quality policy formulation, implementation and learning; alongside strengthening the measurement-improvement linkage. Quality improvement plays a key role in strengthening health systems to achieve UHC.