Recognition of Quality Improvement
through certification and accreditation
Nicole Spieker
Healthcare in Africa - a vicious circle
•
African health care systems stuck in a vicious circle of low
demand and supply
•
Access to quality basic health care among the poor is low
Demand
Financing
Low
Supply
↓
Solidarity
↓
↑
Quality and
capacity
Out-of-pocket
expenses
↓
Efficiency
↓
Availability data
↑
Risk for owners
and investors
↓
↓
Access to health
care
Ownership
Delivery
Low
Patient
• Catastrophic spending
• Low utilization
Breaking the vicious circle
- Upgrading and capacity
building
- Quality assurance
- Certification and
accreditation
Health Insurance
Fund
- Premium subsidies
- Education and
marketing
- Introducing health
insurance
Donors /
governments (tax)
Demand
↑
Solidarity
↓
Out-of-pocket
expenses
↑
↑
Government
(public)
Financing
Higher
↑
↑
↑
↓
↑
Trust
Access to health
care
Ownership
Prepayment
(contribution)
by users
Higher
Delivery
Patient
↑
Increased willingness to pre-pay
↓
Decreased financial risk
Supply
Quality
Efficiency
Availability of data
Risk
Investment
opportunities
- Investment Fund for
Health in Africa
- Medical Credit Fund
Quality Improvement vs. accreditation programs
Quality Assessment
“Prequalification”
Accreditation methods
“Qualification”
Improvement tool, dedicated to
making informed decisions on
human and material capacity
building of medical service
providers in Africa
Evaluation tool dedicated to
measure current performance
against set standards
–Assets, skills, processes
–Predominantly processes
–Input for initiation of coordinated
improvement program
–Implementation oriented
–Voluntary or contractual
participation
–Specialists/peer to peer
–Input for maintenance of
improvement program
–Observation oriented
–Semi-voluntary participation
–Professional assessors
Process, Systems &
Outcomes (Quality
Improvement) Standards
Clinical Care & Patient Safety
(including infection control)
Leadership & Governance
Quality Assurance
Standards for
licensing
Internationally Accredited
Accreditation Standards
Numbers of Standards
Licensing and Accreditation programmes
Structure & Basic
Process Standards:
Health & Safety
Cleanliness
Medicine
Procurement
Poor
Safe &
Acceptable
Good
Licensure
Accreditation
Quality
Excellent
Quality improvement and accreditation
•
•
•
•
Accreditation 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 ISO
• Healthcare provider specific accreditation:
• JCI (USA)
• COHSASA (South Africa)
• Accreditation Canada
• JAS-ANZ (Australia and New Zealand)
• Etc..
Aspects of quality
 Relational quality
 how do we address the patient? (e.g.
reception, doctor-patient relationship),
 how does the patient perceive quality ?
 Technical quality
 professional capacity (e.g. skills, education, diplomas)
 Functional quality
 what is helpful for the care received by the patient (e.g. hygiene)
 Organizational quality
 organizing work and workflow, governance structure, etc.
Healthcare quality performance
 Can 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 & supplies
Training of staff / continuous education
Implementation of (standard operating) procedures
Implementation of safe systems and processes
Technical assistance (local and long distance)
External quality control and proficiency testing
The SafeCare Initiative
The 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 Africa
The 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).
SafeCare principles (2)
The standards and stepwise improvement are
developed to:
• increase efficiencies of healthcare facilities
in resource-poor settings
• qualify them to negotiate participation in
insurance programs (HIF or commercial),
• attract (MCF) loans and investments
• increase patient flows and sustainability
• improve the reputation and transparency of
these healthcare facilities
Standards tailored to HC provider categories
1
2
3
4
5
6
Tertiary (teaching) hospital- providing majority
of specialized medical care .
Referral hospital providing a broad spectrum
of medical care
District Hospital (or faith based/private
hospital) providing 24 hrs services
Primary 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 issues
International standards, local solutions
“Quality is not
necessarily hightech or high cost”
SafeCare allows for
realistic, practical
and achievable
solutions in
resource restricted
settings
SafeCare: phased approach
Phase 1: selection
SafeCare Essentials
Local facilitation &
evaluation visits
Phase 2: graded recognition
SafeCare standards + tools
Phase 3: accreditation
COHSASA
Local facilitation/external evaluation visits
vv
Rapid
Assessment
% of standard
compliance
Certificate awarded
Full
standards
compliance
Phase 2: graded recognition
Summary of areas covered by hospital standards
Use of SafeCare standards and tools in an annual cycle:
1.
2.
3.
4.
5.
assessment baseline
upgrading plan
technical assistance
assessment follow-up
certificates
Areas covered
by SafeCare
Primary
Health Care
Service
standards
The evaluative architecture
Criteria
Criteria
Standard
Criteria
Standard
Performance
Indicator
Criteria
Departments
/ Services
Criteria
Criteria
Standard
Criteria
Standard
Performance
Indicator
Overall
Facility /
Service
Scores
Criteria
Criteria
Criteria
Standard
Criteria
Performance
Indicator
Standard
Departments
/ Services
Criteria
Criteria
Criteria
Standard
Criteria
Standard
Criteria
Performance
Indicator
SafeCare scoring system (1)
There are four levels of compliance:
1. Compliant
[C]*
2. Partially compliant [PC]*
3. Not compliant
[NC]*
4. Not applicable
[NA] selected based on category of provider
Compliant criteria are scored as 100
PC and NC scores are weighted according to their severity:
Severity rating
PC
NC
Mild
75
35
Moderate
65
25
Serious
55
15
Very serious
45
5
SafeCare scoring system (2)
SafeCare SafeCare SafeCare SafeCare SafeCare
Essentials
I
II
III
IV
V
Overall Score
<25
>=25
>=35
< 40
>=45
>=55
At most 4
Service
Elements
At most 2
Service
Elements
All Service
Elements
>=50
At least 1
Service
Element
>=60
At least 2
Service
Elements
>=70
>=80
Risk Mgmt
HR Mgmt
Lab Services
Patient Rights
Critical
Criteria
>=65
>=25
<=30
>=30
>=30
>=30
>=40
>=40
>=40
>=40
>=40
>=40
>=40
>=50
>=40
>=40
>=40
At least 2
Service
Elements
>=60
>=50
>=50
>=50
All FC
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 elements
Within 3 hours after
submission of data
through AfriQA, a
TEMP report is
available on AfriDB
Yearly: independent assessment by COHSASA
100
Accreditation
COHSASA
85
80
Accreditation:
Accreditation level
Intermediate pre-accreditation
Entry level pre-accreditation
75
Safe Care
Certificates
of
Improvement
can be
awarded,
based on
measured
improvement
Compliance to
quality
standards
Safe Care recognition letter of entry
The Essentials (self) assessment and QI guidance
Certificates of Improvement
Future: mapping quality (hypothetical)
Phase 3: Accreditation by COHSASA
Accreditation of >530
facilities; 297 facilities in
South Africa
Impact of Quality
Appropriateness: The
right care at the right
time for the right
patient
Transparancy:
benchmarking and
accountibility
Access: willingness to
pay, trust, availability
Quality
Cost effectiveness:
sustainablity of quality
improvement
SafeCare contributes to Trust
• Patients : know where to go (branding)  increased
revenue for private providers
• Healthcare providers: can get better access to loans,
insurers and patients
• Banks :can provide loans based on quality plans and can
rely on external validation
• Donors : can allocate their funds to clear opportunities and
monitor results
• Governments: can be provided with a basis for a legal
framework to monitor and regulate
• Insurers: can choose or reward better performing
providers
Thank you for your attention
www.safe-care.org