1. HOSPITAL REVITALISATION PERFORMANCE AND NATIONAL CORE STANDARDS PORTFOLIO COMMITTEE ON HEALTH Western Cape Department of Health 19 September 2012

2. Hospital Revitalisation Programme

3. Hospital Revitalisation projects – Status and Expenditure ProjectStatusConstruction Start Date Construction End Date Budget 2011/12 Expenditure 2011/12 Budget 2012/13 Expenditure 2012/13 George Hospital Phase 3 RetentionApr 2009Jun 201241 189 00036 298 0749 609 00011 781 199 Khayelitsha Hospital RetentionFeb 2009Oct 2011192 363 000180 432 86613 024 99710 539 678 Paarl Hospital Phase 2 RetentionMay 2009Mar 201235 839 00043 838 24612 679 9993 862 558 Vredenburg Hospital Phase 2A RetentionFeb 2009 Nov 20117 600 0008 141 46068 856 0007 165 177 Lentegeur LaundryConstruction Nov 2012Mar 2013400 000929 24134 800 0003 317 894 Mitchell’s Plain Hospital ConstructionOct 2009Feb 2013147 234 000143 916 445234 736 99578 214 497

4. Hospital Revitalisation projects – Status and Expenditure Continued ProjectStatusStart DateEnd DateBudget 2011/12 Expenditure 2011/12 Budget 2012/13 Expenditure 2012/13 Vredenburg Hospital Phase 2B Construction Feb 2012Oct 20147 600 0008 141 46068 855 9997 165 177 Worcester Hospital Phase 4 (completion project) ConstructionDec 2011Sep 201219 691 00022 353 01817 098 0009 504 054 G F Jooste Hospital Planning 001 000 0000 Paarl Hospital Psychiatric Unit Planning 800 00006 645 986 73 075 Tygerberg Hospital (PPP) Planning 2 000 000171 6334 000 000351 980 Valkenberg Hospital Planning 2 214 0004 883 65284 019 9942 723 824 Worcester Hospital Phase 5 Planning 100 0000500 0000

5. Hospital Revitalisation projects – Challenges and Mitigating Actions ChallengesMitigating Actions George Hospital Phase 3 This project was delayed due to additional work required at Emergency Centre. This work has now been completed. Worcester Hospital Phase 4 The contract with the previous contractor was terminated in 2011/12. The Implementing Department has instituted legal action against the previous contractor. Another contractor has since been appointed to bring this phase of the project to completion which should be achieved by the end of 2012. Mitchell’s Plain Hospital A fire on site in May 2012 destroyed the 80% complete Emergency Centre, which has delayed the project by approximately three months. The contractor is however making good progress on this project.

6. Hospital Revitalisation projects – Challenges and Mitigating Actions ChallengesMitigating Actions Valkenberg Hospital Delays in obtaining Peer Review approvals from National DOH. Delays negatively impact on cost escalation. Additional requests from NDOH are being addressed in an attempt to expedite approval. The Lentegeur Laundry project is being expedited to improve HRG expenditure. G F Jooste Hospital Delays in obtaining approval from National DOH for the briefing document. NDOH will be sending a delegation to Cape Town to pursue discussions. Projects under construction Delays in roll-out of digital radiologyFunding will be moved during the adjustment budget to ensure funding is spent

7. National Core Standards: Western Cape preliminary baseline results

8. National Core Standards Domains Priority Areas  Availability of medicines and supplies  Cleanliness  Improve patient safety  Infection prevention and control  Positive and caring attitudes  Waiting times

9. RATING OF MEASURES VITAL MEASURES: ensure that the safety of patients and staff are safeguarded so as not to result in unnecessary harm or death, ESSENTIAL MEASURES: are fundamental to the provision of safe, decent quality care (what is expected within available resources) DEVELOPMENTAL MEASURES: the elements of quality of care to which health management should aspire to achieve optimal care- do not constitute risk to patients.

10. Scores Two parts to the score: – Compliant or non compliant: Based on vital measures – Numeric score based on the other measures in place: A = 80%-100% B = 60%-79% C = 40% - 59% D = 20% - 39% E = 0% - 19%

11. An Example

12. Facilities audited

13. Compliance Facilities complying to minimum standards for waiting times: 50% (189/381) % of health facilities meeting national minimum cleanliness standard Hospitals: 82% PHC 30% % of health facilities compliant with physical safety and security standards Hospitals: 89% PHC 38% % of health facilities which meet national minimum stocking levels for vital tracer medicines Hospitals: 88% PHC: 45% % facilities complying to IPC Hospitals: 1.8% PHC: 1.3% % facilities complying to staff attitudes standards Hospital :7.3% PHC: 16.7%

14. Why performance is the way it is Hospitals have a much longer history of QA and IPC with dedicated staff for both and hospicentric guidelines and processes PHC facilities have a much shorter history of QA and IPC Limited capacity, currently only 1 QA and IPC person per district covering multiple PHC facilities Guidelines and SOP’ s are often targetting hospitals

15. Developmental Process NDoH developed tools and piloted them then provided HST to coordinate the baseline audit process in collaboration with provinces Two day training programme: Staff members audited own facilities and other facilities – In retrospect training was probably not adequate Data Dictionary not available – each auditor interprets varies aspects from his/her own terms of reference – Numerous abbreviations used in the checklists without explanation – Statistics on common health care associated infections demonstrate that they are in line with acceptable benchmarks. Not clear what acceptable is? Reference to Specific Policies Protocols, Guidelines – These are frequently updated and the questionnaires refer to specific polices and include the date of publication; if your is incorrect date even more up to date you are assessed as non compliant Committees – The questionnaires refer to facilities having a number of committees e.g. quality assurance, risk management, infection prevention and control, occupational health and safety etc., Small hospital or PHC facilities do not have the capacity to have a multitude of committees Risk rating sometimes problematic – A standard operating procedure is available which indicates how schedule 5 and 6 medicines are stored/controlled/distributed in accordance with the Medicines and Related Substances Act 101 of 1965. Change from and Essential to a Vital measures

16. The tool is developmental (some examples) Emergency Generator currently tested once a month for 30 minutes and with load. – NCS requires testing for 5 minutes weekly could damage the generator testing without load does not give you a good idea of the functioning of the generator Patient Satisfaction Survey in paediatric units – parents are asked to comment whether they are happy with the food served, parents are generally not happy with the food for themselves, as the patient food is made to be palatable to young children, not to adults IPC: – Need to have IPC practitioner at each facility even PHC – Need to establish hospital acquired infection surveillance system – N95 masks to be worn by staff to prevent transmission of TB but currently conflicting policy IPC guidelines recommends normal mask – Isolation facilities to manage haemorragic fever even at PHC facilities (only TBH has this) – IPC issues to be discussed at a specific IPC committee regardless of size

17. That being said… The process was very valuable No standards before but these now exist For the first time quality is everyone’s business – Clinicians, managers, infrastructure, HR, finance etc Very detailed comments have been given to NDoH, tools have been adapted further and piloted, awaiting new tools Risk rating has been changed to include critical, vital, essential and developmental

18. Plan of action Quality Improvement training for all QA managers Quality improvement plans developed Provincial Quality Improvement Committee – Policies, guidelines, norms, M&E District and Facility Quality Improvement Committee – Oversee implementation Patient Centred Quality of Care

19. Quite a paradigm shift… Does not replace patient safety and quality clinical care. Little to do with clinical, technological or scientific aspects of medicine. Care organised around the patient Needs and perspectives seen through the eyes of the patient. More than just completing tick sheets to assess compliance

20. WC PCE Framework 1.Reception services and folder registry 2.Clinical services/ clinical governance including pharmacy 3.Discharge and continuity of care 4.Community participation i.e. the service users and their families 5.Improving staff work life experience

21. Take home message NCS baseline audits done for all fixed facilities Very low compliance rates as vital measures are in place Very high numeric scores especially for hospitals meaning most measures are in place The tool is still under development and design issues especially related to PHC Department has a plan that is based on HC 2020 principle of patient centred quality of care

22. Thank You