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

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

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

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

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 Tertiary (teaching) hospital- providing majority of specialized medical care. Referral hospital providing a broad spectrum of medical care 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 6 District Hospital (or faith based/private hospital) providing 24 hrs services

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

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

Summary of areas covered by hospital standards Phase 2: graded recognition Areas covered by SafeCare Primary Health Care Service standards Use of SafeCare standards and tools in an annual cycle: 1.assessment baseline 2.upgrading plan 3.technical assistance 4.assessment follow-up 5.certificates

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

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 SafeCare scoring system (1) Severity ratingPCNC Mild7535 Moderate6525 Serious5515 Very serious455 Compliant criteria are scored as 100 PC and NC scores are weighted according to their severity:

Essentials SafeCare I SafeCare II SafeCare III SafeCare IV SafeCare V Overall Score<25>=25>=35>=45>=55>=65 < 40 At most 4 Service Elements At most 2 Service Elements >=50 All Service Elements >=60 At least 1 Service Element >=70 At least 2 Service Elements >=80 At least 2 Service Elements Risk Mgmt >=25>=30>=40>=50>=60 HR Mgmt <=30>=40 >=50 Lab Services >=30>=40 >=50 Patient Rights >=30>=40 >=50 Critical Criteria All FC SafeCare scoring system (2)

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 Accreditation: Accreditation level Intermediate pre-accreditation Entry level pre-accreditation Safe Care Certificates of Improvement can be awarded, based on measured improvement Compliance to quality standards The Essentials (self) assessment and QI guidance Accreditation COHSASA Safe Care recognition letter of entry

Certificates of Improvement

Future: mapping quality (hypothetical)

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

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

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