Health insurance: Quality development in Switzerland

The federal government aims to improve the quality of healthcare in a systematic and structured way. The Federal Quality Commission (FQC) plays a key role in achieving this goal.

Where action is needed

In their 2011 country report the OECD and WHO state that more information is needed on results of treatments and morbidity in connection with healthcare provision so that political decision-makers in Switzerland can pinpoint what the major health risks are and which members of the population are most at risk. In addition, insured persons often possess surprisingly little information on the quality of healthcare providers to be able to make good decisions.

Various international studies have shown that on average one in every ten patients admitted to hospital will suffer an adverse event. These studies only looked at cases documented in medical histories. The studies suggest that around half of these incidents are preventable. If the results of the study by the Institute of Medicine (IoM) are extrapolated to Switzerland, this would mean 2,000–3,000 deaths a year. No national studies have been conducted to date on adverse medical events in Switzerland.

The OECD report ‘System Governance Towards Improved Patient Safety’ of 17 September 2020 compares different governance models for improving patient safety in the health systems of various OECD countries and the measures that can be used. The report’s main conclusions are:

• A system-wide approach is needed to improve patient safety
• Leadership and culture play a key role
  
• Governance is crucial to achieving safety goals
  

The national report of November 2019 on enhancing the quality and safety of Swiss healthcare by Charles Vincent and Anthony Staines maps the current state of knowledge on quality and patient safety in the Swiss health system and highlights where action is needed.

Halfon, Staines and Burnand examined some 1,000 medical records in a Swiss hospital in 2017. They found that 12% of patients had experienced an adverse event, and just under half of these cases could have been prevented.

A measurement carried out by the expert group Swissnoso in 2017 showed that across 96 Swiss hospitals, 6% of patients had contracted a hospital infection.  

Legal basis

On 1 April 2020, the amendment to the Federal Act on Health Insurance (HIA) to improve quality and cost effectiveness entered in force.
With the entry into force of the HIA amendment , the Federal Council has the task, every four years, of setting out objectives in terms of safeguarding and promoting quality of healthcare (quality development) (Art. 58 HIA). In this way and by reviewing objective achievement, the Federal Council will take the lead in quality development.

The revised HIA contains new instruments that serve to expand on and implement the Federal Council’s objectives. They are directed at actors at all levels.

• The Federal Council acts as a strategic body. It establishes a Federal Quality Commission (FQC) (Art. 58b HIA).
  
• The associations of healthcare providers and insurers conclude agreements on quality development that are applicable throughout Switzerland (quality agreements; Art. 58a HIA).
  
• Healthcare providers must comply with the quality agreements (Art. 58a para. 6 HIA).
  

Financial framework

The Federal Assembly will approve a multi-year credit containing a maximum amount up to which the Federal Quality Commission can grant compensation under Art. 58d HIA and financial assistance under Art. 58e HIA (Art. 58g HIA).
The costs of operating the Federal Quality Commission and of carrying out its tasks will be split three ways between the federal government, the cantons and insurers (Art. 58f HIA).
A total credit worth CHF 45.2 million was approved for the period 2021–24.

Quality strategy, objectives of the Federal Council and annual objectives of the Federal Quality Commission (FQC)

On 11 March 2022, the Strategy for quality development in health insurance (Quality strategy) was adopted by the Federal Council. It expands on and updates the quality strategy approved by the Federal Council in 2009 and the implementation of that strategy in the report of 25 May 2011. Based on the new quality strategy, the four-year objectives of the Federal Council and the annual objectives of the FQC for quality development are set.

Every four years, the Federal Council sets out objectives with regard to quality development within the scope of compulsory health insurance (Art. 58 HIA).

Every year, at the request of the Federal Quality Commission (FQC), the Federal Council sets out objectives and reviews achievement of these objectives (Art. 58c HIA).

Federal Quality Commission (FQC)

The FQC is an extra-parliamentary expert commission that supports the Federal Council in promoting quality in healthcare within the framework of the HIA. The FQC comprises representatives of healthcare providers, the cantons, insurers, insured persons, patient organisations and members of the science community.

Its tasks include advising stakeholders on coordination, including targeted recommendations on quality development. To achieve the Federal Council’s objectives, the FQC commissions third parties to run national quality development programmes. It can also support national or regional quality development projects.
You’ll find information on the FQC members and details of its remit here.

Quality agreements

The purpose of the quality agreements is to set out consistent and contractually-binding quality improvement measures. The quality agreements are agreements under public law.

The quality agreements regulate at least the following:

• Quality measurement and quality development measures
  
• Cooperation between contracting parties in defining improvement measures
  
• Checking compliance with improvement measures
  
• Publication of quality measurements and improvement measures
  
• Sanctions in the event of violations of the agreement
• Compilation of an annual report on the status of quality development for the attention of the Federal Quality Commission and the Federal Council
  

The Federal Council will approve the quality agreements. If the associations of healthcare providers and insurers cannot settle on a quality agreement, the Federal Council will set out the rules.

Healthcare providers must comply with the quality agreements. Compliance with the rules on quality development will also be a condition attached to coverage of the care they provide under compulsory health insurance.

Qualiy indicators

The quality indicators for Swiss acute care hospitals published by the FOPH (CH-IQI) comprise case numbers (e.g. number of heart bypass operations or number of treated heart attacks) and mortality rates (e.g. how many deaths occur in patients undergoing a heart bypass operation). They are published annually for individual hospitals. You can compare the results for up to five diagnoses/interventions at up to five hospitals on the FOPH website. Comparison of case numbers for a specific intervention or disease shows which hospital has the most experience.

The ANQ (Swiss National Association for Quality Development in Swiss Hospitals) also compiles quality indicators for acute care hospitals, and psychiatric and rehabilitation clinics. These are available on the ANQ website.

Quality indicators are currently being developed in collaboration with the competent associations for Assistance and Care at Home (SPITEX) and care homes. The plan is for the Federal Statistical Office to routinely collect these data once the pilot phase is complete and for the FOPH to publish them.

One of the FOPH’s priorities is the compilation and publication of quality indicators for medical practices (outpatient medical settings). The EQUAM Foundation has developed a set of medical quality indicators for medical practices, but they are currently only used by a very small number of practices.

The Organisation for Economic Cooperation and Development (OECD) publishes a report every two years on healthcare quality indicators, in which Switzerland is also represented.

The task of developing quality indicators is now part of the FQC’s remit. They will continue to be published via the FOPH.

Learning and reporting systems in hospitals

In his answer of 26 May 2019 to the motion 18.4210 Humbel «Protecting learning systems in hospitals in order to avoid errors» the Federal Council referred to a legal opinion. The legal opinion «Berichtsysteme in Spitälern – Rechtsfragen rund um den Schutz von Berichts- und Lernsystemen in Spitälern vor gerichtlichem Zugriff» written by Prof. Th. Gächter and Prof. K. N. Vokinger from the University of Zurich is now available. The FOPH will further examine the matter based on the conclusions drawn in this legal opinion. The legal opinion is only available in German.