1. Accreditation versus Governmental Supervision: Irish Perspective. Deirdre Mulholland Head of Standards and Methodology Healthcare Quality Directorate Health Information and Quality Authority October 2008

2. Health Information and Quality Authority Created by Health Act 2007 Government Body reporting to Minister of Health and Children Independent Authority driving improvements in safety and quality of health and social care. HIQA Mission: “ to drive high quality and safe care for people using our health and social services.”

3. Health Information and Quality Authority Functions: Setting Healthcare and Social Care standards Monitoring /inspecting quality and safety in Health and Social care Investigating serious adverse events Social care registration and inspection Health technology assessments Health information strategy

4. Accreditation in Ireland Accreditation systems developed in America, Canada etc. Voluntary accreditation scheme introduced in Ireland and rolled out across the country with development of a framework for accreditation of acute care services in 2005. Overseen by the Irish Health Services Accreditation Board which was integrated into HIQA in 2007. IHSAB Commissioned Research “ The Cost of Implementing Accreditation : What are the benefits?” University College Dublin and Irish Health Services Accreditation Board Dr Geraldine Doyle, Carolin Grampp.

5. Title: “ The Cost of Implementing Accreditation : What are the benefits?” University College Dublin and Irish Health Services Accreditation Board Dr Geraldine Doyle, Carolin Grampp. Sample Selected Three Sites – Large University Teaching Hospital (Field work Aug 2007) – An acute non-teaching Rural Hospital (Oct 2007) – Private not for profit Hospital ( May 2007).

6. Methodology Primary Data Collection – In Depth Interviews – Focus Groups – Survey – online and offline – Walk of Facilities Secondary Data Collection

7. Findings – Positive Consequences Breaking down of internal barriers Greater understanding of organisation Being aware of own role in organisation and contribution to it Knowing where to go for information/assistance Development of networks within and outside Paving the way for subsequent accreditation schemes, i.e. hygiene Some practices of process improvement

8. Critical Success Factors 1.Process of Accreditation and Accreditation Standards 2.Involvement of Professional groups 3.Resource Issues 4.External Factors

9. Process of accreditation and Accreditation Standards Tick box mentality- paper exercise Excessive supporting documentation evidence Repetition and Duplication Support from the accreditation body Uncertainty about the future of accreditation Proliferation of Inspection and audit processes

10. Involvement of Professional groups Difficult for staff not directly employed to become involved in accreditation due to job pressures. Accreditation process nurse dominated.

11. Resource Issues Financial Resources Lack of financial resources de-motivating Human Resources Huge commitment required Lack of organisation commitment Overlap with other regulator processes Physical Resources Existing facilities limiting

12. External Factors No financial or non financial incentives No recognition of quality by external agencies De-motivation by media reports.

13. Findings - Cost Study looked at cost from the perspective of the organisation and accreditation body Difficult as information not collected or not labelled as accreditation costs Conclusion – Accreditation does cost including clinical activities foregone Recommendation – Need better financial reporting systems

14. Recommendations from Study oQuality assurance of the delivery of health services be monitored and controlled through the adoption of a conceptual framework of quality. oFuture processes should be data driven using performance indicators with emphasis on patient outcomes oQuality assurance schemes should be mandatory. oShould use un-announced surveys and inspections and should be co-ordinated by HIQA. oUse the word Quality rather than accreditation oPatient involvement in quality assurance process

15. Recommendations from Study Engagement of medical practitioners Quality integral part of employment contracts Resources - accreditation body recognises cost but health professionals recognise cost neutral All reports of inspections and all performance data published on HIQA and hospital website

16. Challenges in the Irish System. Huge variability of quality in system Lack of clarity of concepts of quality and safety Funding flow Culture Politics – national/local Professional Politics Leadership Governance Change Management Information.

17. Accreditation In Ireland Lessons learnt – accreditation not for Ireland Challenges for Change System wide Challenges requiring leadership including clinical leadership. Establish new system while providing safe services and responding to serious safety issues.

18. Drivers for change Funding streams Financial/ Competitive incentives and sanctions Maturity of system - Performance management, governance, policies Public and service user expectations Information Regulatory changes Standards Guidelines Benchmarks/performance indicators Determine what system best suited and most effective to drive quality and safety in health and social care in the country

19. Way forward in Ireland. Health Act, 2007 established HIQA Regulation HIQA Social Services Inspectorate Inspection and registration of designated residential care centres for older people, children and people with disabilities. Licensing regulatory framework with legal sanctions and powers of enforcement. HIQA – sets and monitors Standards on safety and quality in relation to services provided by the HSE. Development of Quality and Safety Framework – Standards.

20. Quality and Safety Standards Framework Framework Domains – OECD Acceptability2 Accessibility5 Appropriateness3 Capacity1 Competence3 Continuity3 Effectiveness7 Efficiency4 Equity4 Patient centredness/responsiveness5 Safety3 Sustainability1 Timeliness2 Sources: WHO, UK DoH, US DoH, Commonwealth Fund, Canadian Institute for Health Information

21. Quality Domains –Access and equity –Safety –Effectiveness –Efficiency

22. Quality Elements –Patient orientation –Governance and leadership –Skills and education –Information management –Service design and Environment

23. Quality Elements Patient Orientation Governance and Leadership Skills and Education Information management Environment and Service Design Quality Domains Safety Effectiveness Efficiency Access + Fairness

24. Monitoring of Standards Methodology Assessments Investigations

25. Licensing in Healthcare Recommended by Commission on Patient Safety and Quality Assurance Propose that Core standards and developmental standards

26. Thank you Contact: Deirdre Mulholland Head of Standards and Methodology E-mail : dmulholland@hiqa.iedmulholland@hiqa.ie Tel No: +353 (0)1 293 1162 Mobile : +353 (0)87 7965049.