World Medical Association, Declaration with Guidelines for Continuous Quality Improvement in Health Care (1997)

Adopted by the 49th World Medical Assembly Hamburg, Germany, November 1997



Preamble
1. The purpose of health care is to prevent, to diagnose or to treat illness and to maintain and to promote the health of the population. The goal of quality review in health care is continuous improvement of the quality of services provided for patients and the population, and of the ways and means of producing these services.
2. The obligation continuously to improve one's professional ability and to evaluate the methods used is included in the ethical codes of physicians. According to them a physician has to maintain and increase his/her knowledge and skills. He/she shall recommend only examinations and treatments that are known to be effective and appropriate according to the state of medical art.

Purpose of the guidelines
3. Physicians and health care institutions have a moral obligation to strive for continuous improvement of services. The purpose of these guidelines is to strengthen this pursuit by means of quality review practices and to create ethical grounds for such review practices, like clinical peer review.

Guidelines

Application of the guidelines
4. Ethical guidelines for continuous quality improvement concern all physicians, institutions providing health care services for patients, and producers of review services.

Obligation for quality review
5. All physicians, other health care professionals (including health administrators) and institutions have to aspire to improvement of their work. Active participation by everyone in clinical audit and in quality review initiatives should be encouraged. Quality review evaluations can be used for independent external audit, and with the aim of accreditation.

Standards for good quality work
6. Those involved in work with patients need to specify the standards necessary for good quality work and for the evaluation of the quality of the work. The resources and skill mix of staff within health care establishments should be adequate to attain the required standards of good quality work
7. Patient data, whether recorded on paper or on computer, has to be written and preserved with care, taking into consideration the obligations for confidentiality. Procedures, decisions and other matters connected with patients need to be recorded in a form which will allow information for measuring specific standards to be available when needed.
8. Health care professionals should have adequate opportunities to maintain and develop their knowledge and skills. Recommendations and clinical guidelines should be easily available for those requiring them. Health care institutions need to create quality systems for their own use and to ensure that instructions concerning such systems are followed.

Recognition of quality review
9. All physicians should continuously evaluate the quality of their work and their level of ability by self-review methods.
10. The quality of health care can be assessed by both internal and external methods. The agencies for both processes have to be widely approved, and the methods used must be generally accepted and based on research or sufficient knowledge.
11. Internal clinical peer review, observation of examination and of treatment methods, comparison with others, observation of the organisation's ability to act and monitoring of the feedback from patients have to be continuous activities undertaken by every service provider.
12. External quality review initiatives, such as external peer review and audit, should be carried out with a frequency corresponding to the evolution of the field and always when there is special reason for it.

Confidentiality of patients records
13. Patient records can be used in quality review. Patients should be made aware of the use of their records in quality review. Their medical records should be kept confidential and anonymised and should not be accessible to inappropriate persons. All reports, photographs, videos and comparative data have to be presented in such a form that the patients involved in a review cannot be identified.

Confidentiality of peer review
14. A precondition for successful peer review is the freedom of institutions and physicians to agree to be reviewed and their commitment to review. It is recommended that informed voluntary consent be obtained from those to be reviewed.
15. The results of a review belong to those subscribing to it. The results can be used for comparisons and general purposes only with the approval of the subscriber and those involved in the review, unless national legislation provides otherwise.
16. A provider of services can inform his/her customers about the results of quality review and use them in marketing his/her services, provided this is allowed by the law.
17. The review of the work of an individual physician is the responsibility of the physician himself/herself and his/her superior physician. Information regarding an individual physician should not be published without the consent of the physician concerned.
18. An external review shall not reveal to others the results of the review, or other information obtained during the review, without the written permission of the subscriber of the review.

Ethics committees
19. Generally approved ethical principles of health care and national codes of medical ethics have to be followed in quality review.
20. If doubts are raised about ethical issues in a review project they should be referred to an ethics committee. However, in general the routine submission of review projects for approval by ethics committees is not necessary.

Competence of the reviewer
21. The reviewer has to be experienced in the field that the review concerns and competent in quality development techniques and in clinical audit methods. When medical care is reviewed, the reviewer must be a physician. The reviewer has to be accepted by those to be reviewed, whenever possible.

Impartiality of the review
22. The chosen reviewer must be as impartial and as independent as possible. He/she has to be well acquainted with the activities of those to be reviewed. The reviewer has to be objective in his/her report. His/her conclusions should be based on a critical evaluation of observations and facts. The reviewer must not allow commercial or competitive matters to influence the content of his/her statement.

Review and supervision by authorities
23. Quality review of health care and continuous quality improvement of services is a part of the activity of every physician and institution. The supervision of professional activities made by health care authorities is a distinct activity and should be kept separate from health care review. The results of a review of physicians can be used for the purposes of supervising authorities only by a separate mutual agreement between the health care authorities and the physicians concerned, unless national legislation provides otherwise.