1. Quality Assurance and Hospital Accreditation Assoc.Prof. Jiruth Sriratanaban, M.D., M.B.A., Ph.D. Department of Preventive and Social Medicine Faculty of Medicine, Chulalongkorn University

2. Session Objectives To review the reasons why external quality assurance of hospitals is needed To summarize the different external quality assurance methods To clarify the differences between registration, certification, process-focused EQA, and participatory EQA To introduce Hospital Accreditation concepts

3. Session Objectives To summarize the three popular models of hospital accreditation in OECD countries To explain the costs and limitations of Hospital Accreditation To stimulate discussion among participants about the potential relevance of accreditation in their own countries and/or what other EQA methods are or could be applied

4. Content Hospital quality Ways to assure hospital quality External quality assurance Accreditation experiences

5. What is “Quality”? Product specification and standard Conformance to requirement Fitness for use Zero defect Customer satisfaction Ability to satisfy needs

6. Hospital Quality…? Inputs Staff, doctors, specialists Nurses Medicines Facilities Utilities Equipments Care environment

7. Hospital Quality…? Processes Patient care and support processes Management and improvement – identifying, learning from, correcting errors Patient experience (Perceptions) Waiting times, Information Responsiveness

8. Responsiveness to expectation Respect for person (Patient rights) Preserve dignity of a person Confidentiality Autonomy in choice Client orientation Prompt attention Amenities of adequate quality Access to social support network Choice of providers PatientSatisfaction

9. Results of care Health outcomes Mortality: Overall vs. Disease-specific In-hospital vs. 30-day Crude rate vs. Adjusted rate Morbidity Disease outcomes, e.g. Cure rate Adverse events, e.g. Infection rate Quality of Life (QOL)

10. High Quality vs. Low Quality Hospitals High-quality hospitals More competent staff Better equipped Fewer process errors Well managed Short waiting Satisfied patients Better health outcome Higher revenue/surplus More efficient ? More expensive ? Low-quality hospitals Fewer competent staff Poorer equipped More process errors Poorly managed Long waiting Dissatisfied patients Poor health outcome Poorer financial outlook Less efficient ? Cheaper ?

11. Quality ≠ Cost (empirical) Cost Quality C1C1 Q 1 Q 2 Q 3 A B C D E F Fleming (1989)

12. Some evidence ? Public vs. Private NFP vs. Private FP Private FP  Higher risk of death [US] (Devereaux, et al., CMAJ 2002) SyR Public (Gov)  More assets, equipment, more DR; Private FP  proportionally more support staff and fewer medical professionals; No stat diff. in mortality. [Guangdong, China] (Eggleston et al, BMC-HSR 2010) Public  More near-miss in OB cases [Indo] (Adisasmita et al, BMC Preg Childbirth, 2008) Private NFP/FP  Better drug supply, responsiveness, and effort; No diff in satisfaction or competence [Ambulatory HC, L&MIC] (Berendes et al, SR, PLoS Med 2011) Private  Less likely to die, but more likely to have unsuccessfully completed TB treatment [Setting, L&MIC] (Montagu et al, 2011) MetA

13. Common health system options for assuring hospital quality Licensure Quality Certification External Quality Assurance

14. Licensure Process by which a government authority grants permission to an individual practitioner or health care organization to operate or to engage in an occupation or profession

15. Licensure Ensure minimum standards, set at a minimal level to ensure an environment with minimal risk to health and safety Generally focus on structural aspects: Inputs and Facilities Rely upon (periodic) inspection

16. Certification Passing standards (Minimal?) Require hospital to collect and submit information demonstrating that they meeting standards Audit or site visit generally required Specific areas or functions More likely to include process standards and process measurements

17. External Quality Assurance Evolve from manufacturing sectors Objective assessment by external reviewers or auditors Published standards Optimal rather than Minimal Mainly focus on processes Require hospitals to monitor “results” or “performance”

18. External Quality Assurance ISO series (International Organization for Standardization) Generic standards –Process-focused Management system Professional evaluators Examples commonly applied: ISO-9000, ISO-14000, ISO- 15189

19. External Quality Assurance Accreditation Standards specific for health care providers, e.g. hospital Process-focused Health issues, e.g. patient safety, health promotion, clinical governance Management system and CQI Both professional and peer evaluators National vs. International

20. External Quality Assurance Pros / Cons for consideration Cost, usually involve : Consultation, Improvement, External assessment Opportunity for Learning Public appreciation Accreditation may be less known to the public Evolving standards over time

21. Experiences with Hospital Accreditation Mechanisms for recognition of institutional competence By an independent accrediting body (Usually) Participation by professional groups Applying hospital standards for optimal and achievable performance With emphasis on self assessment and continuous quality improvement Hospital survey conducted by external peer reviewers Voluntary participation (Usually)

22. Experiences with Hospital Accreditation Three common models Step-Wise Approach Types of Standards Standards Format Accrediting Body Country NoOutcomesFunctional Joint Commission on Accreditation of Health Care Organizations United States YesStructure, Process, and Outcomes Functional + Departmental Canadian Council on Health Services Accreditation Canada NoStructure and Process Departmental Australian Council on Healthcare Standards Australia

23. Experiences with Hospital Accreditation Voluntary vs. Mandatory Accreditation Historically all accreditation was voluntary May be required for participating in public health insurance schemes, e.g. USA Mandatory? in some countries, e.g. France, (Licensure effect) Accreditation in middle-income countries International : ISO, JCI Grown quickly in SEA: Medical hub, high-end market National (Grown during 1990s and early 2000s) –Thailand, Malaysia, South Africa Both, e.g. Thailand

24. Experiences with Hospital Accreditation Why National Accreditation has failed Difficult to create : Political will –Support from national health care purchasers Multi-year process to develop –Participation from professionals, as well as authorities –Development of standards, surveyors –Hospital improvement Limited membership will limit value / importance Maybe expensive –Scale of operation determine cost-benefit between International vs. National programs

25. Costs to Hospitals JCI: Avg. fee for survey (2010) = US$46,000 [JCI info] – US$ 100,000 [Asian Hospital & Healthcare Management] A case of one hospital in India = US$600,000 for upgrading QHA Trent, UK Zambia: US$10 000 per hospital to complete the cycle (Advocacy, Program administration, Education Accreditation activities) Thailand HA: Survey = 15,000 Baht/man-day (Min. 4 Man-day) ISO 9000: $10-25K for small/ mid-size companies (3 to 5 man-day audit with avg. cost of $3000 per man-day plus travel expenses.)

26. Accreditation of other health care providers Health care institutions Health centers, Clinics Nursing home, etc. Health care programs Managed health care plans Individual providers Tried in India, New Jersey USA, etc. But failed

27. Conclusions EQA is necessary for private (as well as public) hospitals EQA systems should be broadly applied to both public and private hospitals equally International accreditation schemes are useful, but too expensive to serve a role for the overall health market National accreditation programs are extremely useful, but difficult to create A lead-institution is required, with long-term commitment and political approval or backing, including from large health care purchasers