Building Public/Private Partnership for Health System Strengthening

1. Building Public/Private Partnership for Health System Strengthening “Thai Experience with Hospital Accreditation” Assoc. Prof. Jiruth Sriratanaban, M.D., Ph.D. Dept. of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University Bali Hyatt Hotel, Sanur, Bali 21-25 June 2010

2. Outline • Thailand’s Health system • Development of Hospital Accreditation (HA) in Thailand • Hospital accreditation as a mechanism to regulate health care system and to promote public-private partnership

3. Thailand Health System

4. Key information • Population: 67 Million • Rural: Urban Pop. = • Top 3 killers: • Health exp. As % of GDP: 3.3-3.5% • Universal coverage: three compulsory public schemes, i.e. CSMBS, SSS and NHSS (UC) • Public: Private exp. on health = 60:40

6. Some of major challenges in quality of health care in Thailand • Inequity due to mal-distribution of health resources • Increasing health care expenditure • Introduction of close-ended paymentmechanisms by the major healthsecurity schemes • Expansions of business health sectorsand the governmental “Medical hub”policies • Increasing trend of patient complaints and lawsuits Threats against quality of health care

7. Outline • Thailand’s Health system • Development of Hospital Accreditation (HA) in Thailand • Hospital accreditation as a mechanism to regulate health care system and to promote public-private partnership

8. Initiated as a research and development project in 1997 under the Health System Research Institute (HSRI) with financial support from WHO, TRF and HSRI of Thailand • 35 pilot public and private hospitals • Adapted Canadian approach (+ External consultant) • Collaboration for Hospital Quality Improvement and Accreditation • Developed into “Institute for Hospital Quality Improvement and Accreditation” under HSRI • Become “Healthcare Accreditation Institute (Public organization)” since 2009

9. Initial goals of the HA program in Thailand Mechanisms to stimulate and facilitate hospitals to improve quality in an organization-wide and systematic manner Accredit the hospital quality Accredit the hospital quality system

10. Quality hospital CQI Accredit Plan Do Hospital Accredit QA/ Standard Act Check RM Quality improvement cycle

11. Structure / Input Process Outcome GOV Governance LED Leadership IC Infection control IM Information / Medical record ETH Patient rights & organizational ethics Patient Outcome GEN 1 Goals & directions GEN 8 Patient care & Service processes GEN 2 Organization & management GEN 3 Human resources GEN 4 management andHUM development GEN 9 Quality programs e.g. RM, QA, CQI GEN 5 Policy & procedures GEN 6 Facilities & ENV environment MEDMedical staff organization NUR Nursing administration GEN 7 Equipment First version of HA Standards Source: Institute of Hospital Quality Improvement and Accreditation, THAILAND

12. Health needs and customers’ expectations Governance and policy directions [1], [2] Professional systems, patient rights and organizational ethics [11], [12], [13], [14], Analysis, measurement and improvement [8], [9] Resource management [3], [4], [5], [6], [7] Patient care process and services [10], [15], [16], [17], [18], [19], [20] Input Output Patients and other customers Health outcomes, Satisfaction Comprehensive version of HA standard framework: Adjustment for 2000-2005 Source: Institute of Hospital Quality Improvement and Accreditation, THAILAND

13. Information and knowledge management PartIV Staff focus Strategic planning Health care Patient and customer Financial Human resources Organization effectiveness Leadership and Social Health Promotion Leadership Results Focus on patients And Patient rights Process management PartI MBNQA/TQA Model Key hospital systems PartII Hospital and Health care services Standards 2006 PartIII Risk, Safety and Quality Professional management Environmental management Infection prevention and control Medical record system Medication system Medical laboratory system Radiological system Work with communities Patient care processes Patient care processes Entry Patient Assessment Planning (Care & Discharge) Care Delivery Patient & Family Empowerment Continuity of Care Source: Institute of Hospital Quality Improvement and Accreditation, THAILAND

14. Important field operations • Selection and training of peer reviewers or surveyors • Supervision and ongoing education of surveyors • Education and consultation about the standards to health care organizations • Pre-survey processes • Development of a standardized evaluation methodology to assess standards performance • On-site surveys (10-15,000 baht per man-day) • Surveyor documentation and scoring • Post-survey analysis of surveyor findings

15. Training programs Manuals, documents, books, websites Support networks Consultations National forums What happen to hospitals? Hospitals improve quality according to standards Hospitals complete HA self-assessment Intensive consultation visit (ICV) Accreditation survey Accreditation decision by HA Board

16. Example of Roadmap to HA: King Chulalongkorn Memorial Hospital 1999 Commitment and common direction Team / Staff / Supporting facilities Pilot new activities / Expand the existing Improve core processes Expand to the whole organization Self assessment and internal survey Fulfill to meet the hospital standards Request for accreditation survey 2002

17. Improvement of patient care processes Patient care teams (PCT) New protocols for informed consent Comprehensive patient assessments Applications of clinical practice guidelines, critical paths, care map Customized self-helped groups and individual health promotion programs Intensive prevention and control for hospital-acquired infection New Discharge planning programs

18. Example of results ... • Average length of stay : Shorter • 28-day readmission rate : Decline • Hospital-acquired infection: Decline • Patient risk incidence : Fewer serious incidence • Patient satisfaction : Higher • Waiting time : Shorter

19. Accredited hospital means … • Organization commitment on quality improvement • Adequacy of health care resources with efficient management • Existence of quality assurance and continuous quality improvement • Existence of mechanisms to promote professional standards and ethics • Service provision that protects patient rights and promotes organization ethical practices • Quality patient care processes

20. Number of HA-accredited andHPH-certified hospitals

21. Outline • Thailand’s Health system • Development of Hospital Accreditation (HA) in Thailand • Hospital accreditation as a mechanism to regulate health care system and to promote public-private partnership

22. Policies on hospital regulations • Licensure system for private providers • Thai Medical Council standards • Quality improvement programs by MOPH • Standards for infrastructure, 3-S program, TQM, ISO • The Social Security Office (1991) • Health Care Facilities Act, B.E. 2542 • The Constitution of the country (1999 onward) • The National Health Security Scheme

23. Hospital accreditationas a regulatory incentive • Improve quality of health care using the optimal set of hospital standards as guidelines • Patient safety and risk management • Evidence-based practice • Continuous learning and improvement • Stimulate and improve integration and management of health services • Strengthen the public’s confidence

24. Beyond regulatory mechanisms… • Hospital accreditation is an education process, not an inspection • Let’s make it together • Bring the professional organizations into the field. • Create opportunities for performance-based incentives

25. Educational processes Web-based and Paper-based Supporting documents External (Accreditation) survey Meetings for experience sharing and training On-site Process benchmarking and consultation Inter-hospital Quality conference

26. Make it together by knowledge sharing: National forum on Hospital Accreditation

27. Professional organizations into the field • Policy formulation • Standard writing • Implementation of clinical practice guidelines • Accreditation decisions and recognition • Linkage to professional training

28. Opportunities forperformance-based incentives • Social Security Scheme endorsement of HA • Special quota of registered beneficiaries for accredited providers • Additional per-head payment for accredited hospitals • National Health Insurance Scheme movement • Financial support for HA consultation programs • Financial bonus for accredited providers • Impacts for national health service systems • Health promoting hospital • Use of evidence-based practice • Disease management programs by NHSO • Humanized health care initiatives

29. Challenges for policy discussion • Is there an opportunity to use a hospital accreditation program to promote public-private partnership? • How can a hospital accreditation program support a system policy on public-private partnership?

30. Conclusions:HA for Public–Private Partnership • Promote standardized requirements for optimal hospital performance • Create environment for partnership • Platform in policy formulation • Public-private co-operation in improving care • Knowledge sharing activities • Ensure quality and strengthen public confidence