Recognition of Quality Improvement through certification and accreditation

1. Recognition of Quality Improvement through certification and accreditation Nicole Spieker

2. 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 Supply Low • Solidarity • Out-of-pocket expenses • Access to health care • Ownership • Quality and capacity • Efficiency • Availability data • Risk for owners and investors Delivery Low Patient • Catastrophic spending • Low utilization

3. Breaking the vicious circle • Health Insurance Fund • Introducing health insurance • Premium subsidies • Education and marketing • Upgrading and capacity building • Quality assurance • Certification and accreditation Donors / governments (tax) Government (public) Demand Supply Financing Higher • Solidarity • Out-of-pocket expenses • Access to health care • Ownership • Quality • Efficiency • Availability of data • Risk • Investment opportunities Trust Delivery Higher Prepayment (contribution) by users Patient • Investment Fund for Health in Africa • Medical Credit Fund • Increased willingness to pre-pay • Decreased financial risk

4. Quality Improvement vs. accreditation programs • Quality Assessment • “Prequalification” • Improvement tool, dedicated to • making informed decisions on • human and material capacity • building of medical service • providers in Africa • Assets, skills, processes • Input for initiation of coordinated improvement program • Implementation oriented • Voluntary or contractual participation • Specialists/peer to peer • Accreditation methods • “Qualification” • Evaluation tool dedicated to • measure current performance • against set standards • Predominantly processes • Input for maintenance of improvement program • Observation oriented • Semi-voluntary participation • Professional assessors

5. Licensing and Accreditation programmes Internationally Accredited Accreditation Standards Process, Systems & Outcomes (Quality Improvement) Standards Clinical Care & Patient Safety (including infection control) Leadership & Governance Excellent Poor Safe & Acceptable Good Numbers of Standards Quality Assurance Standards for licensing Structure & Basic Process Standards: Health & Safety Cleanliness Medicine Procurement Licensure Accreditation Quality

6. 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..

7. 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.

8. 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 improvedby 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

9. 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

10. 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

11. SafeCare principles (1) • Development of innovative and realistic standards for healthcare providers in resource restricted settings. • Development of astep-wise improvement process that canbe 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).

12. 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

13. Standards tailored to HC provider categories 1 Tertiary (teaching) hospital- providing majority of specialized medical care . 2 Referral hospital providing a broad spectrum of medical care 3 District Hospital (or faith based/private hospital) providing 24 hrs services 4 Primary health center (minimum one MD, nurse and lab technician) Basic health center offering primary health and maternal care(min. one clinical officer) 5 6 Health shop/nurse driven clinic: advice on basic health care issues

14. International standards, local solutions “Quality is not necessarily high-tech or high cost” SafeCare allows for realistic, practical and achievable solutions in resource restricted settings

15. SafeCare: phased approach Phase 2: graded recognition SafeCarestandards + tools Phase 1: selection SafeCare Essentials Phase 3: accreditation COHSASA vv Local facilitation & evaluation visits Local facilitation/external evaluation visits % of standard compliance Full standards compliance Rapid Assessment Certificate awarded

16. Summary of areas covered by hospital standards Phase 2: graded recognition Use of SafeCare standards and tools in an annual cycle: assessment baseline upgrading plan technical assistance assessment follow-up certificates Areas covered by SafeCare Primary Health Care Service standards

17. The evaluative architecture Criteria Standard Performance Indicator Criteria Criteria Standard Departments / Services Criteria Criteria Standard Performance Indicator Criteria Criteria Overall Facility / Service Scores Standard Criteria Criteria Standard Performance Indicator Criteria Criteria Standard Departments / Services Criteria Criteria Standard Criteria Performance Indicator Criteria Standard Criteria

18. SafeCare scoring system (1) • There are four levels of compliance: • Compliant [C]* • Partially compliant [PC]* • Not compliant [NC]* • 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:

19. SafeCare scoring system (2)

20. Average Facility scores across five Nigeria Clinics

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

22. Afri-QA: tools for local data collection

23. 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

24. Yearly: independent assessment by COHSASA 100 Accreditation: Accreditation level Intermediate pre-accreditation Entry level pre-accreditation Accreditation COHSASA 85 80 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

25. Certificates of Improvement

26. Future: mapping quality (hypothetical)

27. Phase 3: Accreditation by COHSASA Accreditation of >530 facilities; 297 facilities in South Africa

28. Impact of Quality Access: willingness to pay, trust, availability Appropriateness: The right care at the right time for the right patient Quality Transparancy: benchmarking and accountibility Cost effectiveness: sustainablity of quality improvement

29. 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

30. Thank you for your attention www.safe-care.org