Building Public/Private Partnership for Health System Strengthening Thai Experience with Hospital Accreditation “ 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 June 2010

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

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

Groups of hospitalsNumberTotal Public hospitals (2007) :982 MOPH Community hospitals730 MOPH General hospitals70 MOPH Tertiary-care regional hospitals25 MOPH Specialized hospitals in provinces (except BKK)47 Other public hospitals in provinces (except BKK)60 University / Medical-school hospitals10 MOPH Tertiary-care hospitals / specialized institutions in BKK18 Other public hospitals (e.g. Police, Military, BMA, etc.)22 Private hospitals (2006) :344 Private hospitals in BKK102 Private hospitals in provinces (except BKK)242

 Inequity due to mal-distribution of health resources  Increasing health care expenditure  Introduction of close-ended payment mechanisms by the major health security schemes  Expansions of business health sectors and the governmental “Medical hub” policies  Increasing trend of patient complaints and lawsuits Threats against quality of health care

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

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

Mechanisms to stimulate and facilitate hospitals to improve quality in an organization-wide and systematic manner Accredit the hospital quality system Accredit the hospital quality

Plan Do CheckAct Quality hospital Hospital CQI Accredit QA/ Standard RM

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

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

Leadership Strategic planning Focus on patients And Patient rights Staff focus Process management Results Information and knowledge management Key hospital systems 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 Entry Patient Assessment Planning (Care & Discharge) Care Delivery Patient & Family Empowerment Continuity of Care Health care Patient and customer Financial Human resources Organization effectiveness Leadership and Social Health Promotion Hospital and Health care services Standards 2006 Part IV Part III Part II Part I Patient care processes MBNQA/TQA Model

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

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

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

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

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

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

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

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 The Constitution of the country (1999 onward) The National Health Security Scheme

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

 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

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

Hospitals StaffSitesStaffSitesStaffSitesStaffSites Tertiary- care General Community University (teaching) Private Military Mental Total3, , , ,957536

 Policy formulation  Standard writing  Implementation of clinical practice guidelines  Accreditation decisions and recognition  Linkage to professional training

 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

 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?

 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