Quality Assurance and Hospital Accreditation

1. Quality AssuranceandHospital Accreditation Assoc.Prof. Jiruth Sriratanaban, M.D., M.B.A., Ph.D. Department of Preventive and Social Medicine Faculty of Medicine, Chulalongkorn University

2. Session Objectives • To review the reasons why external quality assurance of hospitals is needed • To summarize the different external quality assurance methods • To clarify the differences between registration, certification, process-focused EQA, and participatory EQA • To introduce Hospital Accreditation concepts

3. Session Objectives • To summarize the three popular models of hospital accreditation in OECD countries • To explain the costs and limitations of Hospital Accreditation • To stimulate discussion among participants about the potential relevance of accreditation in their own countries and/or what other EQA methods are or could be applied

4. Content • Hospital quality • Ways to assure hospital quality • External quality assurance • Accreditation experiences

5. What is “Quality”? • Product specification and standard • Conformance to requirement • Fitness for use • Zero defect • Customer satisfaction • Ability to satisfy needs

6. Hospital Quality…? • Inputs • Staff, doctors, specialists • Nurses • Medicines • Facilities • Utilities • Equipments • Care environment

7. Hospital Quality…? • Processes • Patient care and support processes • Management and improvement – identifying, learning from, correcting errors • Patient experience (Perceptions) • Waiting times, Information • Responsiveness

8. Responsiveness to expectation • Respect for person (Patient rights) • Preserve dignity of a person • Confidentiality • Autonomy in choice • Client orientation • Prompt attention • Amenities of adequate quality • Access to social support network • Choice of providers Patient Satisfaction

9. Results of care • Health outcomes • Mortality: • Overall vs. Disease-specific • In-hospital vs. 30-day • Crude rate vs. Adjusted rate • Morbidity • Disease outcomes, e.g. Cure rate • Adverse events, e.g. Infection rate • Quality of Life (QOL)

10. High Quality vs. Low Quality Hospitals High-quality hospitals Low-quality hospitals Fewer competent staff Poorer equipped More process errors Poorly managed Long waiting Dissatisfied patients Poor health outcome Poorer financial outlook Less efficient ? Cheaper ? • More competent staff • Better equipped • Fewer process errors • Well managed • Short waiting • Satisfied patients • Better health outcome • Higher revenue/surplus • More efficient ? • More expensive ?

11. Quality ≠ Cost (empirical) Fleming (1989) Cost B F A C E C1 D Q1 Q2 Q3 Quality

12. Some evidence ?Public vs. Private NFP vs. Private FP • Private FP  Higher risk of death [US] (Devereaux, et al., CMAJ 2002) SyR • Public (Gov)  More assets, equipment, more DR; Private FP  proportionally more support staff and fewer medical professionals; No stat diff. in mortality. [Guangdong, China] (Eggleston et al, BMC-HSR 2010) • Public  More near-miss in OB cases [Indo] (Adisasmita et al, BMC Preg Childbirth, 2008) • Private NFP/FP  Better drug supply, responsiveness, and effort; No diff in satisfaction or competence [Ambulatory HC, L&MIC] (Berendes et al, SR, PLoS Med 2011) • Private  Less likely to die, butmore likely to have unsuccessfully completed TB treatment[Setting, L&MIC] (Montagu et al, 2011) MetA

13. Common health system options for assuring hospital quality • Licensure • Quality Certification • External Quality Assurance

14. Licensure • Process by which a government authority grants permission to an individual practitioner or health care organization to operate or to engage in an occupation or profession

15. Licensure • Ensure minimum standards, set at a minimal level to ensure an environment with minimal risk to health and safety • Generally focus on structural aspects: Inputs and Facilities • Rely upon (periodic) inspection

16. Certification • Passing standards (Minimal?) • Require hospital to collect and submit information demonstrating that they meeting standards • Audit or site visit generally required • Specific areas or functions • More likely to include process standards and process measurements

17. ExternalQuality Assurance • Evolve from manufacturing sectors • Objective assessment by external reviewers or auditors • Published standards • Optimal rather than Minimal • Mainly focus on processes • Require hospitals to monitor “results” or “performance”

18. ExternalQuality Assurance • ISO series (International Organization for Standardization) • Generic standards • Process-focused • Management system • Professional evaluators • Examples commonly applied: • ISO-9000, ISO-14000, ISO- 15189

19. ExternalQuality Assurance • Accreditation • Standards specific for health care providers, e.g. hospital • Process-focused • Health issues, e.g. patient safety, health promotion, clinical governance • Management system and CQI • Both professional and peer evaluators • National vs. International

20. ExternalQuality Assurance • Pros / Cons for consideration • Cost, usually involve : Consultation, Improvement, External assessment • Opportunity for Learning • Public appreciation • Accreditation may be less known to the public • Evolving standards over time

21. Experiences with Hospital Accreditation • Mechanisms for recognition of institutional competence • By an independent accrediting body (Usually) • Participation by professional groups • Applying hospital standards for optimal and achievable performance • With emphasis on self assessment and continuous quality improvement • Hospital survey conducted by external peer reviewers • Voluntary participation (Usually)

22. Experiences with Hospital Accreditation • Three common models

23. Experiences with Hospital Accreditation • Voluntary vs. Mandatory Accreditation • Historically all accreditation was voluntary • May be required for participating in public health insurance schemes, e.g. USA • Mandatory? in some countries, e.g. France, (Licensure effect) • Accreditation in middle-income countries • International :ISO, JCI • Grown quickly in SEA: Medical hub, high-end market • National (Grown during 1990s and early 2000s) • Thailand, Malaysia, South Africa • Both, e.g. Thailand

24. Experiences with Hospital Accreditation • Why National Accreditation has failed • Difficult to create : • Political will • Support from national health care purchasers • Multi-year process to develop • Participation from professionals, as well as authorities • Development of standards, surveyors • Hospital improvement • Limited membership will limit value / importance • Maybe expensive • Scale of operation determine cost-benefit between International vs. National programs

25. Costs to Hospitals • JCI: Avg. fee for survey (2010) = US$46,000 [JCI info] – US$ 100,000 [Asian Hospital & Healthcare Management] • A case of one hospital in India = US$600,000 for upgrading • QHA Trent, UK • Zambia: US$10 000 per hospitalto complete the cycle(Advocacy, Programadministration, Education Accreditation activities) • Thailand HA: Survey = 15,000 Baht/man-day (Min. 4 Man-day) • ISO 9000:$10-25K for small/ mid-size companies (3 to 5 man-day audit with avg. cost of $3000 per man-day plus travel expenses.)

26. Accreditation of other health care providers • Health care institutions • Health centers, Clinics • Nursing home, etc. • Health care programs • Managed health care plans • Individual providers • Tried in India, New Jersey USA, etc. But failed

27. Conclusions • EQA is necessary for private (as well as public) hospitals • EQA systems should be broadly applied to both public and private hospitals equally • International accreditation schemes are useful, but too expensive to serve a role for the overall health market • National accreditation programs are extremely useful, but difficult to create • A lead-institution is required, with long-term commitment and political approval or backing, including from large health care purchasers