Presentatie titel

Recognition of Quality Improvement through certification and accreditationNicole Spieker

Healthcare in Africa - a vicious circleAfrican health care systems stuck in a vicious circle of low demand and supply

Access to quality basic health care among the poor is lowDeliveryFinancingDemandSolidarity

Out-of-pocket expenses

Access to health care

Ownership

SupplyQuality and capacity

Efficiency

Availability data

Risk for owners and investors

PatientCatastrophic spendingLow utilizationLowLowDeliveryFinancingDemandSolidarity

Out-of-pocket expenses

Access to health care

OwnershipSupplyQualityEfficiencyAvailability of dataRiskInvestment opportunitiesPatientIncreased willingness to pre-payDecreased financial riskHigherPrepayment (contribution)by users

Investment Fund for Health in Africa

Medical Credit FundDonors / governments (tax)Government(public)Breaking the vicious circle Premium subsidies

Education and marketing

Upgrading and capacity buildingQuality assuranceCertification and accreditationHealth Insurance Fund

Introducing health insurance

TrustHigher

Quality Improvement vs. accreditation programsQuality Assessment

PrequalificationImprovement tool, dedicated tomaking informed decisions onhuman and material capacitybuilding of medical serviceproviders in Africa

Assets, skills, processesInput for initiation of coordinated improvement programImplementation orientedVoluntary or contractual participationSpecialists/peer to peerAccreditation methods

QualificationEvaluation tool dedicated tomeasure current performanceagainst set standards

Predominantly processes

Input for maintenance of improvement program

Observation oriented

Semi-voluntary participation

Professional assessors

Safe & AcceptablePoorGoodExcellent

QualityStructure & Basic Process Standards:Health & SafetyCleanlinessMedicine Procurement

Quality Assurance Standards for licensingLicensure

Process, Systems & Outcomes (Quality Improvement) StandardsClinical Care & Patient Safety (including infection control)Leadership & Governance

Internationally Accredited Accreditation StandardsAccreditationNumbers of StandardsLicensing and Accreditation programmesQuality improvement and accreditationAccreditation is a process in which certification of competency, authority, or credibility is presented.Organizations which certify third parties against official standards are themselves formally accredited ISQua This accreditation process ensures that their certification practices are acceptable: they are competent to test and certify third parties, behave ethically and employ suitable quality assurance.

International accreditation bodies exist:Managerial accreditation such as ISOHealthcare provider specific accreditation:JCI (USA)COHSASA (South Africa)Accreditation CanadaJAS-ANZ (Australia and New Zealand)Etc..Aspects of qualityRelational qualityhow do we address the patient? (e.g. reception, doctor-patient relationship),how does the patient perceive quality ?

Technical qualityprofessional capacity (e.g. skills, education, diplomas)

Functional qualitywhat is helpful for the care received by the patient (e.g. hygiene)

Organizational qualityorganizing work and workflow, governance structure, etc.

77Healthcare quality performanceCan be measured in different dimensions:Assets (equipment, etc.) available?Skills (medical & other) - deficiencies?Processes: how are they arranged within the clinic?Outputs and outcomes of the clinic (individual and public health?)

Can be improved by different interventions:Purchase of assets & suppliesTraining of staff / continuous educationImplementation of (standard operating) proceduresImplementation of safe systems and processesTechnical assistance (local and long distance)External quality control and proficiency testing

8The SafeCare InitiativeThe SafeCare Initiative was started in 2011 through a collaborative of:

PharmAccess International Foundation, the Netherlands The Council for Health Service Accreditation of Southern Africa South AfricaThe Joint Commission International, USA

SafeCare Initiative Mission

Place the issue of safe health care provision on the agenda in resource-restricted settings and create a platform for like-minded organisations and people who wish to provide safe health care despite resource constraints

SafeCare principles (1) Development of innovative and realistic standards for healthcare providers in resource restricted settings.

Development of a step-wise improvement process that can be measured and used by governments, donors, health insurers, (social) investors and loan providers to implement performance-based financing incentives in tandem with healthcare quality improvement (MCF).

11SafeCare principles (2)The standards and stepwise improvement are developed to:

increase efficiencies of healthcare facilities in resource-poor settingsqualify them to negotiate participation in insurance programs (HIF or commercial), attract (MCF) loans and investmentsincrease patient flows and sustainabilityimprove the reputation and transparency of these healthcare facilities12Standards tailored to HC provider categories

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Tertiary (teaching) hospital- providing majority of specialized medical care .Referral hospital providing a broad spectrum of medical carePrimary health center (minimum one MD, nurse and lab technician)Basic health center offering primary health and maternal care(min. one clinical officer)Health shop/nurse driven clinic: advice on basic health care issues6District Hospital (or faith based/private hospital) providing 24 hrs services

International standards, local solutionsQuality is not necessarily high-tech or high cost

SafeCare allows for realistic, practical and achievable solutions in resource restricted settings

SafeCare: phased approachvvPhase 1: selectionSafeCare EssentialsPhase 2: graded recognitionSafeCare standards + toolsPhase 3: accreditationCOHSASA% of standard complianceFull standardscomplianceLocal facilitation & evaluation visitsLocal facilitation/external evaluation visitsCertificate awardedRapid AssessmentSummary of areas covered by hospital standardsPhase 2: graded recognitionAreas covered by SafeCare Primary Health Care Service standards

Use of SafeCare standards and tools in an annual cycle:

assessment baselineupgrading plantechnical assistanceassessment follow-upcertificatesThe evaluative architectureDepartments / ServicesDepartments / Services StandardCriteriaCriteriaCriteriaCriteria StandardPerformance IndicatorOverall Facility / Service Scores StandardCriteriaCriteriaCriteriaCriteria Standard StandardCriteriaCriteriaCriteriaCriteria Standard StandardCriteriaCriteriaCriteriaCriteria StandardPerformance IndicatorPerformance IndicatorPerformance IndicatorThere are four levels of compliance:Compliant [C]* Partially compliant [PC]*Not compliant [NC]*Not applicable [NA] selected based on category of providerSafeCare scoring system (1)Severity ratingPCNCMild7535Moderate6525Serious5515Very serious455Compliant criteria are scored as 100PC and NC scores are weighted according to their severity:EssentialsSafeCare ISafeCare IISafeCare IIISafeCare IVSafeCare VOverall Score=25>=35>=45>=55>=65< 40At most 4 Service ElementsAt most 2 Service Elements>=50All Service Elements>=60At least 1 Service Element>=70At least 2 Service Elements>=80At least 2 Service ElementsRisk Mgmt>=25>=30>=40>=50>=60HR Mgmt=40>=40>=40>=50Lab Services>=30>=40>=40>=40>=50Patient Rights>=30>=40>=40>=40>=50Critical CriteriaAll FCSafeCare scoring system (2)Average Facility scores across five Nigeria Clinics

A deeper look: average scores 5 Nigerian clinics per service element

Scores per service element

Afri-QA: tools for local data collection

AfriDB: server for data storage and analysis

Service elementsWithin 3 hours after submission of data through AfriQA, a TEMP report is available on AfriDBYearly: independent assessment by COHSASAAccreditation:Accreditation levelIntermediate pre-accreditationEntry level pre-accreditationSafe CareCertificatesof Improvement can be awarded, based on measured improvementCompliance to quality standardsThe Essentials (self) assessment and QI guidance100858075AccreditationCOHSASASafe Care recognition letter of entry

Certificates of Improvement

Future: mapping quality (hypothetical)Phase 3: Accreditation by COHSASA

Accreditation of >530 facilities; 297 facilities in South Africa

Impact of QualityQuality

Appropriateness: The right care at the right time for the right patientAccess: willingness to pay, trust, availabilityCost effectiveness: sustainablity of quality improvement

Transparancy: benchmarking and accountibility

SafeCare contributes to TrustPatients : know where to go (branding) increased revenue for private providersHealthcare providers: can get better access to loans, insurers and patientsBanks :can provide loans based on quality plans and can rely on external validationDonors : can allocate their funds to clear opportunities and monitor resultsGovernments: can be provided with a basis for a legal framework to monitor and regulateInsurers: can choose or reward better performing providers

Thank you for your attentionwww.safe-care.org

Chart116122023201261

Y-Values

Sheet1X-ValuesY-Values11364125206235204123611

Chart11163049688351181

Y-Values

Sheet1X-ValuesY-Values1131643054966858345131811

Chart166.18382259756.867628039955.049925175851.233391225746.9935501471

Average of PERFORMANCE_INDICATOR_SCORE

Sheet1Row LabelsFacility ScoresFacilityAverage of PERFORMANCE_INDICATOR_SCOREPHC 1 (Level 4)66PHC 2 (Level 1)57PHC 3 (Level 3)55PHC 4 (Level 1)51PHC 5 (Level 1)47

Chart150.687830687859.779171027447.196759259356.716153885876.317945326354.484559884645.9861.935019841348.030892857149.870833333361.800930372249.2936507937

SE Score

Sheet1SERVICE_ELEMENTSE ScoreDIAGNOSTIC IMAGING SERVICES51FACILITY MANAGEMENT SERVICES60HUMAN RESOURCE MANAGEMENT47IN-PATIENT CARE57LABORATORY SERVICES76MANAGEMENT AND LEADERSHIP54MANAGEMENT OF INFORMATION46MEDICATION MANAGEMENT62OPERATING THEATRE AND ANAESTHETIC SERVICES48PATIENT RIGHTS AND ACCESS TO CARE50PRIMARY HEALTH CARE SERVICES62RISK MANAGEMENT49SUPPORT SERVICES56