1. IDEAL HOSPITAL FRAMEWORK: PROVINCIAL VISITS
GAUTENG PROVINCE
14 SEPTEMBER 2018

2. Outline of the Norms and Standards Regulations applicable to Different Categories of Health Establishments

5. Promulgated Norms and Standards
Promulgated on 2 February 2018
Will come into operation 12 months after promulgation, February 2019

6. Chapters / Domains There are seven chapters in the regulations
Chapter 1-definitions,purpose and scope
Five Chapters(from chapter 2-6) in the regulations which will translate to Domains in the Inspection tool
User rights
Clinical governance and clinical care
Clinical support services
Facilities and Infrastructure
Governance and Human Resources
Seventh chapter – General provisions – does not relate to a clinical environment and will therefore not be used to create a domain in the inspection tools

7. Regulation title / Sub-domain
Each regulation is given a title to summarise its content
User Rights, Facilities and Infrastructure
Each Regulation title will be used to create a sub-domain name
User Information, Management of buildings and grounds

8. Promulgated Norms and Standards
User Information:
services, costs, user experiences
Access to Care:
Emergency patients: triage, emergency transport, appropriate care (stabilisation)
Referrals
Health Records:
Records management system including confidentiality
Biographical data
Documentation of care provided
Consent
Discharge report
Clinical Management systems:
Clinical policies/guidelines available and communicated,
Clinical risk management systems
IPC:
Handwashing, isolation, linen, protective equipment and immunizations
Waste management:
Containers available; collection, handling, storage and disposal of waste

9. Promulgated Norms and Standards (cont. 1)
Medicines and medical supplies:
Availability and stock control
Diagnostic services:
Accreditation by regulatory body
Blood Services:
Cold chain maintenance
Hazardous waste management
Adverse blood reaction management
Medical equipment:
Licensing
All required medical equipment available in each unit
Management of buildings and grounds:
Compliance certificates, maintenance plan, emergency access, ventilation
Engineering services:
Electricity, lighting, medical gas, water, sewage system available and functional without interruption
Transport:
Vehicles licensed and maintained
Drivers have valid driver’s licenses

10. Promulgated Norms and Standards (cont. 2)
Security:
Security staff able to respond to incidents, threats and risks
Functional Governance structure with ToRs
HRM:
HRM plan; Performance management, monitor registration of health care professionals
Occupational Health:
Comply with OHS Act
Adverse Events:
Reporting systems in place, documentation and monitoring of events
Waiting times:
Monitoring of waiting times against targets

11. Sequencing
Sequencing of the chapters has been adjusted to reflect the inspection process
User rights
Clinical governance and clinical care
Clinical support services
Governance and Human Resources
Facilities and Infrastructure

12. Inspection Tools being developed for evaluation of compliance with Norms and Standards
Public hospitals – central, tertiary, regional, district
Public CHCs
Public Clinics
TB Hospitals
Mental Health Hospitals
Private Hospitals
Private clinics

13. Structure to retain hierarchy of the national core standards
Domain
Sub Domain
Standard
Criteria
Measures
Structure to retain hierarchy of the national core standards
Domain - an aspect of service delivery where quality or safety can be at risk.
Sub-Domain - further break down the domains into sub-sections or critical areas which combined describe the scope of that domain.
Standards - what is expected to be delivered in terms of quality care; reflect expected situation resulting from implementation of a policy, procedure or system.
Criteria - elements setting out the requirements for measurable and achievable standard compliance.
Measures - the means or evidence for determining whether the criteria have been met; examine aspects that can be seen, heard or felt by the assessors and give reasonable assurance that a standard is met.

14. Structure Of Measurement Tools

15. Regulation heading = Subdomain Sub-regulation = standard statement
SUB-DOMAIN Access to care
Standard 5 (1) The health establishment must ensure that users are attended to in a manner which is consistent with the nature and severity of their health condition,
 Criterion 5.(2)(a) A health establishment must implement a system of triage.
Measures
1. The guideline or standard operating procedure for triaging is available. Doc, E
Explanatory Note: The document implemented must be approved by a relevant national body, such as the Emergency Medical Services of South Africa. Not Applicable: Never
 2. The procedure used for triage is visibly displayed in the triage area. Obs, E
 3. Staff members responsible for triaging have received training on the triage process in the past 12 months. Doc, V
Explanatory Note: In-service training documentation must include attendance registers and evidence of the topics discussed. Not Applicable: Never
 4. Users are triaged in accordance with the documented procedure. PRA, V
Explanatory Note: The user’s triage status should be indicated on the emergency unit health record. Not Applicable: Never
 5. Triaged users are seen within the target time frames. PRA, V
Explanatory Note: The time the user was triaged should be compared with the time the user was seen to evaluated whether the user was seen within the agreed timeframe, as indicated in the triage poster. Not Applicable: Never
Sub-regulation = standard statement
Sub-regulation = criterion statement
Measure statement with methodology and risk rating
Explanatory note to clarify evidence required

16. OHSC Certification Framework

17. Objects of the OHSC
In terms of Section 78 (A) of the Act, the objects of the OHSC are to:
(a) monitor and enforce compliance by health establishments with norms and standards as prescribed by the Minister of Health in relation to the national health system; and
(b) ensure consideration, investigation and disposal of complaints relating to non-compliance with prescribed norms and standards in a procedurally fair, economic and expeditious manner.

18. Compliance Monitoring
The OHSC monitors compliance with the prescribed Norms and Standards through inspections and investigations;
The OHSC also receives incident notifications (Early Warning System) and complaints.

19. Inspections: Types of Inspections
conducted every four (4) years for certification purposes.
Re-inspections where there was identified breaches.
Routine (Planned) Inspections and
Re-Inspection
They are triggered by early warning system (e.g. Media Reports)
There is always a re-inspection to ensure that the breach has been remedied.
Risk based / Unplanned Inspections

20. Inspections Contd…
All inspections conducted by the OHSC are in accordance with the powers outlined in the Act as well as in the Inspection Strategy (e.g. questioning, requesting documents).

21. Inspections Contd…
Where there is identified breach of norms and standards, inspector shall immediately issue a Notice of Compliance to the person in charge of a health establishment;
The final inspection report will determine the status of a health establishment (whether to issue a certificate of compliance or enforce compliance)

22. Required documents to be developed by the Office
Inspection strategy
Code of conduct of inspectors
Procedures
Enforcement policy

23. Certification
All health establishments found to be compliant with the prescribed Norms and Standards shall be issued with a certificate of compliance;
The certificate of compliance issued by the Office shall be valid for a period of four years and is subject to renewal;
Health establishments shall apply for renewal of the certificate of compliance six months before the expiry date;

24. Certification Contd…
Certification/Compliance status for a health establishment which has applied for renewal may be extended for a period not more than one year;
A compliance notice issued against a health establishment suspends the compliance status until the conditions set out in the compliance notice are fulfilled.

25. The OHSC, and the future link to funding (Policy: National Health Insurance for Universal Healthcare Coverage) xx
Monitoring of risk
Services to be provided
OHSC
NHI fund
Service provision
Certification
Contracting
Compliance with standards & norms
Cost / price
Certification of compliance with norms and standards
as a pre-requisite for funding
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26. Current Compliance Status Framework

27. Proposed Compliance Status Framework
Score
Grade
NG&E
Clinical outcomes
Inspection frequency
80% + A
<20%
Excellent
4 Yearly
70-79% B
21-30%
Good
2 Yearly
60-69% C
31-40%
Fair
1 Yearly
<59% D
>41%
Poor
6 months

28. Proposed Compliance Status Framework Contd…
Grade A: which means that no breaches to the norms and standards were identified during an inspection and the cycle for inspection for that health establishment is 4 years;
Grade B: which means that minor breaches of the norms and standards were identified during an inspection and the cycle for inspection for that health establishment is 2 years;
Grade C: which means that moderate breaches of the norms and standards were identified during an inspection and the cycle for inspection for that health establishment is 1 year;
Grade D: which means that major breaches of the norms and standards were identified during an inspection and the cycle for inspection for that health establishment is 6 months and enforcement action should be taken against a health establishment.

29. THANK YOU!!
REA LEBOGA!!