The Office of Standards Compliance

1
The Office of Standards Compliance National
Department of Health Dr Carol Marshall Chief
Director Office of Standards Compliance Durban,
15 July 2008
2
National Health Act (2004)

• National Health Act Chapter 10 designated Health
  Officers are to inspect all health establishments
  and agencies every 3 years
• Office of Standards Compliance (national)
  certification / recommendations / closure
  (violations)
• Inspectorates of Health Establishments
  (provincial)- monitoring / inspections /
  recommendations
• In addition the OSC must
• Advise the Minister on prescribed standards, both
  general service provision and specifically for
  quality
• Provide leadership and advice on strategies and
  mechanisms to improve quality across the system
• Report to the Minister on system performance
  against standards

3
Definitions of Quality / QA

• Many definitions, many perspectives
• doing the right thing, right, right away
• .. A core set of activities that contribute to
  designing, assessing, monitoring and improving
  the quality of healthcare
• Focus on
• health outcomes
• Patients / customers
• staff

4
Define

• Goals and objectives, targets
• Standards, criteria
• Guidelines, protocols
• Systems, procedures
• Regulations
• Benchmarks
• Evidence-based, results-focused, appropriate

5
Measure

• What
• Patient information (utilisation, outcomes,
  adverse events)
• Customer satisfaction (patients and public
  staff)
• System performance
• Through
• Independent inspection and certification
• Routine DHIS, surveillance, surveys, EPR
• Management/ resource information

6
Improve

• Close the gap identified when measured against
  defined standards
• Outcome result-driven
• Action-focused / rapid results
• Multiple role-players
• Staff development and continuous learning
• Enabling and facilitatory
• Recognition and rewards as primary driver -
  sanctions only when these fail

7
System-level Approaches to Quality Assurance

• Literature review looking for models that
  include
• the range of basic certification / licensing
  (focussed on safety) as well as
  quality-improvement programmes / accreditation
• strengthening government oversight
• federal or semi-federal systems where the
  respective roles of national and sub-national
  levels are spelt out
• using quality / performance in provider
  contracting
• developing countries
• costs and resources

8
Countries and aspects reviewed

• Columbia
• Dominican Republic
• Honduras
• Malaysia
• Mexico
• Turkey
• Australia
• England
• Italy
• Philippines
• Singapore
• Trinidad Tobago

• Type of system
• Authorities responsible
• Length of time in place
• Description/nature of the programme, targets and
  resources
• Reporting, consequences and impact/effectiveness
• Strengths and weaknesses, changes over time

9
Some findings of interest

• Responsible authorities
• Basic licensing and certification programmes
  common in many countries OR currently being
  developed as basis for national quality assurance
  
• Should have national oversight to ensure
  consistent standard of safety across the country
  although quality improvement initiatives (e.g.
  accreditation) may be decentralised .
• Ensure private sector involvement and support in
  design as well as monitoring
• Nature and duration of the programme targets
• Should benchmark hospitals against each other and
  national standards
• Safety initiatives should target business
  processes and quality of care, not just
  compliance with physical standards, staffing and
  equipment
• Safety initiatives should target public and
  private providers
• Ensure desired performance or competence is
  sustained over time

10
Findings (cont)

• Reporting of results
• Compliance of public and private institutions
  with minimum safety standards are usually
  reported in the public domain, accreditation
  results are usually reported privately unless the
  programme is compulsory
• Consequences
• To provide a level playing field, many licensing
  programmes impose similar sanctions on
  non-conforming public and private providers
• Voluntary initiatives require incentives such as
  public recognition, the ability to seek
  contracts, enhanced fees or the right to offer
  internships.
• Impact/effectiveness
• Quality improvement initiatives should be
  supported by stakeholders such as the community
  the institution serves perceptions are an
  important factor in their effectiveness

11
Definition of terms
12
Overall conclusions

• The numerous health reform programmes being
  undertaken globally recognise that basic
  licensing/ certification and accreditation
  programmes have different goals - accreditation
  does not take the place of basic licensing and
  certification
• In spite of an increasing interest in
  accreditation initiatives, basic licensing
  programmes remain a cornerstone of national
  regulatory approaches and stewardship initiatives
  to ensure consistency of safety for patients and
  personnel across providers
• National accreditation programmes are often a
  prerequisite to the introduction of national
  health insurance systems

13
Current work on national standards (Define)

• National Core Standards for Health Facilities in
  South Africa
• 7 domains
• 40 Action areas
• 77 Standards
• Launched by the Minister
• 24 April 2008

14
Rationale for core standards in the public sector

• The situation
• Many initiatives to improve quality and delivery
• Many successes, many challenges
• Multiple vertical programmes and processes
• Poor synergies
• One size fits all responses
• No standardised tool to measure performance
• Perceptions and reality
• Differences emphasised
• Weak incentives

• Our response
• Measuring performance comparable over time and
  across facilities and provinces
• Focus on the basics - patient safety and
  dignity, essential management
• A horizontal systems perspective that integrates
  different initiatives and different health
  programmes
• Clarifying responsibility
• Benchmarking best practice

15
Appraisal against these standards (Measure)

• To establish a baseline of performance against
  core national standards, criteria and indicators,
  in an initial set of 28 hospitals and 4 Community
  Health Centres over a period of 3 months
• Progress to date
• Self appraisal tool and questionnaire developed
  with red and green flags
• Overview teams of best managers have been
  trained to appraise other provinces
• 12 hospitals and 1 CHC concluded
• Reports to the Minister end July
• 24 hospitals and 3 CHCs by 1 August
• TB hospitals early August
• To review the process and methodology prior to
  institutionalisation and scale-up to other
  facilities
• Provincial workshops planned leading up to
  National workshop in September
• Needs wide consultation and inputs into approach
  and content (definition of core, weighting,
  criteria for certification)

16
Quality improvement in the public sector
(Improve)

• To use the results of the appraisal to recognize
  best practice and to guide the development,
  support and monitoring of facility-specific
  Improvement Plans over 6 months
• Process already underway
• Many other public sector initiatives
• Provincial initiatives adverse event reporting,
  complaints systems / patient satisfaction with
  specific projects, IPC
• NGOs especially COHSASA Management consulting
  companies PPPs and PPIs
• Many Strategic programmes and target groups esp.
  MDGs also focus on NCDs
• Clinical guidelines and clinical audit MM
  reviews and National Committees
• MPH in Hospital Management, support for District
  management training
• Clinic supervision, multiple other audit tools
• Hospital Revitalisation
• Some newer initiatives
• National Patient safety and Customer care
  initiatives
• Electronic patient record
• National Health Insurance

17
The future setting up the OSC and the
Inspectorates

• National Health Act requires 3-yearly inspections
  
• Provincial Inspectorates to assess compliance
  against core standards in 1/3 of facilities each
  year will use / transform the current Licensing
  sections
• Office of Standards Compliance to certify
  compliance based on review of provincial reports
  and verification in a sample of facilities
• May issue recommendations for improvement as
  pre-condition for certification
• Private sector
• First steps will be with private hospitals
• Will use more than R158 / 187 will need to be
  annual?
• Need also to consider other providers as phase 2
  GPs, other facilities, etc.
• Clear differentiation between core and
  developmental standards
• Consultation around core standards inspection /
  appraisal methodology and criteria regulations

18
Core and developmental standards

• Focus of core standards is on ensuring basic
  safety and integrity
• essential role of government to protect the
  public
• especially the more vulnerable / disadvantaged
• Public and private sectors
• Non-compliance after due warning, advice and
  follow-up will incur consequences
• Developmental standards - progressive and
  aspirational
• evidence-based and outcome-focused
• clinical care, value-for-money, access and
  equity

19
Long term results

• Making the public sector a preferred provider,
  especially within the paradigm of more affordable
  health care
• Identifying preferred providers in the private
  sector
• Pushing the whole system towards better results
  and better use of financial and human resources

20
Role and inputs from the private sector

• Consultation
• Public private collaboration in relevant
  groupings to work on new paradigms
• Sharing best practices and lessons
• Improving standards and guidelines
• Improving measurement especially of outcomes
• Culture change both sides