1. 20 & 21 NOVEMBER 2018 Free State Province
NORMS AND STANDARDS COMPLIANCE INSPECTIONS
20 & 21 NOVEMBER 2018
Free State Province

2. OUTLINE VISION & MISSION OF THE OHSC MANDATE OF THE OHSC
APPOINTMENT OF INSPECTORS
TYPES OF INSPECTIONS
INSPECTION PROCESSES & METHODOLOGY
SCORING & RISK RATING
Code of conduct
Reports

3. VISION AND MISSION OF THE OHSC
Safe and Quality Healthcare for all South Africans
MISSION
We act independently, impartially, fairly and fearlessly on behalf of the people of South Africa in guiding, monitoring and enforcing healthcare, safety and quality standards in health establishments

4. MANDATE OF THE OHSC s78. Objects of the Office
The objects of the office are to protect and promote the health and safety of users of health services by:
Monitoring and enforcing compliance by health establishments with prescribed norms and standards.
Ensuring consideration, investigation and disposal of complaints relating to breaches of norms and standards.

5. MANDATE OF THE OHSC continued
This mandate contributes to two distinct but interdependent priority outcomes. These are:
Reductions in avoidable mortality, morbidity and harm within health establishments through reliable and safe health services.
Improvements in the availability, responsiveness and acceptability of health care standards.

6. TYPES OF INSPECTIONS
Routine Inspections: Every health establishment to be inspected according to the National Health Act 61 of 2003 as amended once in four (4) years.
Additional Inspections: Additional Inspections: An inspector may, at any time, subject to section 82(1) of the Act, conduct an additional inspection, provided that he or she has reasonable grounds to believe that ‒
Such an inspection is needed to establish whether non-compliance has been remedied within the health establishment;
The health establishment is contravening the act or any relevant regulations;
There are serious breaches of norms and standards, based on the indicators of risk; or
The ombudsman findings demonstrate that continued exposure to the health care services provided by health establishment may pose a severe risk to users or health care personnel.

7. TYPES OF INSPECTIONS continued
Risk-based Inspections: Triggered by Early Warning System(EWS), targeted for persistent or critical non compliance and Ombudsman findings.

8. Appointment of inspectors
In terms of section 80(2) of the Act an inspector must be a qualified health professional, who is registered with the Allied Health Professions, the Health Professions Council of South Africa, the South African Nursing Council, or the South African Pharmacy Council,
referred to in the
definition of "statutory health professional council" in section 1 of the Act

9. Appointment of inspectors ( Cont.)
The Chief Executive Officer must issue a person who has been appointed as an inspector in
terms of section 80(2) of the Act with a certificate of appointment as an inspector, in
accordance with section 80(3) of the Act, once the person has successfully completed a
minimum training programme approved by the Office.

10. Appointment of inspectors ( Cont.)
The certificate of appointment as an inspector must include, at a minimum, the following information:
(a) The name and surname of the inspector;
a unique identification number supplied by the Office;
(b) the date of issuance;
the address and contact details of the Office;
(c) a form of photographic identification.
The signature of the Chief Executive Officer.

11. Inspection strategy
An annual inspection strategy guide the inspection activities of the
Office.
The annual inspection strategy will be published on the Office’s public website, and include the following:
1. An approach to prioritising, scheduling and conducting inspections; and
2. resources for the implementation of the inspection strategy.

12. Procedure Manual
The Office developed an inspection procedure manual and tools for inspectors to ensure that
Inspections are carried out in a consistent, fair, equitable and transparent manner

13. Code of conduct
Code of conduct for inspectors as in section 80(2) of the Act states that A copy of the code of conduct for inspectors referred to in sub-regulation (1), must be signed by all the inspectors prior to the commencement of their duties and will be publish in Government Gazette.

14. Inspection Process
An inspector must, before commencing with an inspection contemplated in
section 82 of the Act, issue a notice of inspection to the health establishment.
The notice of inspection should include, at least, the following information:
(a) the purpose of the inspection;
(b)the date of the inspection;
(c) the estimated duration;
(d)The number of authorised personnel expected to take part in the inspection;
(e)The contact details of the inspector primarily responsible for the inspection

15. Inspection Process
The responsibilities of the health establishment. During an inspection, the health establishment must make available the necessary staff,
resources and space to allow inspectors to complete the inspection in a timely and
expeditious manner.
(3) An inspector may question any user, occupant, health care personnel or any person on the
premises of a health establishment about any information that is relevant to the inspection,
or require the person in charge to produce any document, record or material for inspection.
(4) The person in charge may provide the inspector with any relevant information, documents,
records, objects or materials for the inspector's consideration during the inspection visit.

16. Inspection Process
An inspector must prepare an inspection plan, which sets out a clear approach to carrying
Out the inspection for each health establishment to be inspected.
The inspection plan referred to in sub-regulation (4) must be appended to the Notice of Inspection referred to in sub-regulation 13.

17. INSPECTION PROCESSES & METHODOLOGY
Inspections methods include:
Observation
Documents review
Patient record analysis
Patient and staff interviews
Evidence is collected for both compliant and non compliant measures.

18. SCORING & RISK RATING SCORING CUT OFFS Compliant = 1 Non compliant = 0
Not Applicable (N/A) needs substantive evidence
No partial compliance
Any Extreme measure failed in will result in over all non compliance of the HE

19. Proposed Compliance Status Framework
Score
Grade
Risk Rating
Outcome
Inspection frequency
80% + A
<20%
Good
4 Yearly
70-79% B
21-30%
Satisfactory
2 Yearly
60-69% C
31-40%
Fair
1 Yearly
<59% D
>41%
Poor
6 -12 months

20. Types of Health Establishment
PUBLIC HOSPITALS
PUBLIC CLINICS AND CHCS
PRIVATE HOSPITALS AND CLINICS

21. FUNCTIONAL AREAS

22. Functional areas – Hospital
Clinical services
Non Clinical services
Management
Inpatient services
Out patient services
CEO/ Hospital Manager
Clinical Management Group
Infection control
Medical ward x 3
Surgical ward x 3
Maternity ward
Paediatric ward x 3
Newborns
Neonatal ICU TB
Isolation room
HIV/AIDS
Intensive care or high care units x 4
Operating theatre x4
Procedure room
Psychiatric ward:
– Acute ward
– Child and adolescent unit
– Forensic Obervation unit
– Long term ward
– State patient unit
Antenatal clinic
Oral health
Overnight/short stay ward
Outpatient department
Accident and Emergency unit
Procedure room
Administrative
services
HR management
Procurement
Occupational risk management
Communications/PRO
Management information systems
Case management
Occupational Health & Safety
Financial management
Facility management
Waiting areas
Record archive/department
Reception, help desk and Switchboard
Public areas
Clinical support services
Blood services
Laboratory
Health technology services
Pharmacy
Radiology
Medical Supplies
Therapeutic support services:
– Physio
– Occupational
– Speech
– Optometry
3 & 4days. 4 inspectors
1 team leader
1 admin officer
Support services
Facility Infrastructure
Mortuary services
CSSD
Cleaning services
Food services
Laundry services
Maintenance services including gardens
Waste management
Transport services
Security services

23. Functional areas of a Clinic
Non Clinical services
Clinical services
Management
Outpatient services
Clinic manager/ HOD
Clinical services
General services
Clinical support services
Maintenance and support
Pharmacy/ Medicine cupboard
2 clinics a day.

24. Functional areas of a CHC
Non Clinical services
CHC
Clinical services
Management
Outpatient services
CHC manager
Accident and Emergency unit
Maternity Obstetrics unit
Clinical services
Generic ward
Support services
Maintance and support
Clinical support services
Pharmacy/Medicine cupboard
Full day

25. Inspection Reports
The following reports will be given to the person in charge within 20 working days post inspection:
Standard technical report
Functional area technical report
Evidence report
Quality Improvement template
Comments relating to the findings will be expected from the health establishment within 20 working days post preliminary feedback meeting

26. INSPECTION PROCESS Inspections assess: Insert picture
systems, processes and procedures that promote and ensure quality health services
evidence that quality and safety are seen as important
that managers put in place systems to ensure basic quality of care is provided within the health establishment
what is seen at the time of inspection and not the reason why

27. . In conclusions
We want to ensure sure that the health care system in South Africa provide the best quality health care possible