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Measuring quality: SafeCare experience

Millicent Olulo OreraProgram Director – SafeCare Kenyam.olulo@pharmaccess.or.kewww.safe-care-orgPhiilipines, October 24, 2014

In resource-restricted settings...

ISQua-based accreditation systems such as implemented by COHSASA and JCI are difficult if not impossible to achieve

As a result, few facilities are accredited

Quality of care is unknown and benchmarking not possible

Often standards are lowered instead of having healthcare quality improved

The challenge The solution

A system for resource-restricted settings should:

Focus on progression

Be a specified, recognizable product, independently awarded

Be solutions-based with achievable goals

Have data widely available

Be sustainable

SafeCare, established 2011

Dutch NGO dedicated to strengthening health services in resource-restricted settings Netherlands

Council for Health Service Accreditation of South Africa, Accreditation body of Southern Africa South Africa

Accreditation body, Global leader in patient safety and quality with a presence in 90 countries worldwide USA

Organization Based in

International Society for Quality in Healthcare (ISQua),an international body that “accredits the accreditors”

ISQua

Who?

AccreditsWhat?

Accreditation bodies Service-specific external evaluation bodies (blood transfusion) Healthcare standards Surveyor training programs

Why? Confidence and credibility Impartial and independent review system

Principles

Innovative & realistic

Step-wise approach

Certificates

Local capacity

Innovative and realistic standards for healthcare providersin resource-restricted settings. ISQUa approved

Step-wise improvement process that can be measuredand used by governments, donors, health insurers,(social) investors, and banks

Improvements rewarded with certificates

Build local capacity and a sustainable model

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2

3

4

Principles (cont’d)

Practical & achievable

Scale & scope

Priorities first

Quality is not necessarily high-tech or high-cost.SafeCare allows for realistic, practical andachievable solutions

Facility level determines scale & scope

Standards are designed to address priorities

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6

7

SafeCare standards

Management and Leadership

Human Resource Management

Patient & Family Rights & Access to Care

Management of Information

Risk Management

Man

agem

ent

Clinical

Clin

ical

Sup

port Technology

In-patient Care

Operating Theater & Anesthetics

Primary Healthcare

Laboratory

Diagnostic Imaging

Medication Management

Support

Facility Management

Scale & scope determined by facility level

Standards for healthcare facilities

• are written statements

• that define the key functions, activities, processes and structures required for organisations to be in a position to provide quality services

• as determined by professional bodies, health care professionals, staff, patients and citizens.

Measuring the compliance of standards

Criteria are measurable elements that define the specific requirements needed, to ensure that the intention of the standards is met.Each criterion is evaluated separately.

The weighted average of criteria compliance indicates the level of standard compliance.

Standard

Criteria

Criteria

Criteria

Criteria

Evaluating the facility as a wholeThe average of service elements’ scores provides an overall evaluation of the facility.

Service Element

Service Element

StandardCriteria

Criteria

Criteria

CriteriaStandard

StandardCriteria

Criteria

Criteria

CriteriaStandard

StandardCriteria

Criteria

Criteria

CriteriaStandard

StandardCriteria

Criteria

Criteria

Criteria Standard

Performance Indicator

Performance Indicator

Performance Indicator

Performance Indicator

Overall Facility Score

6. Primary health care services6.1 Organisation and co-ordination

6.1.1 The service is organised to provide a safe and effective service and is co-ordinated with other relevant services in the referral hospital and in the community.

6.1.1 Criteria 6.1.1.1 The lines of communication between the health facility, referral hospital

and community services are clearly defined. 6.1.1.2 Relations are established, and contact is maintained with other relevant

services and agencies, including both governmental and non-governmental agencies.

6.1.1.3 An on-call roster is available for after hour, weekend and holidays

emergency coverage (e.g. for infectious diseases). 6.1.1.4 Arrangements are in place to ensure that adequate referral services are

available. 6.1.1.5 Radiology services are available for the level of care provided. 6.1.1.6 Laboratory services are available for the level of care provided. 6.1.1.7 Ultrasound services are available for the level of care provided.

6.1.1.8 There is an organised process for referring patients. 6.2 Facilities and equipment 6.2.1 The required furniture and equipment are available and

functioning appropriately.

PI

Standard

Criteria

Service Element

These we

score

Example standard

Assessing compliance with standards

DOCUMENTATION REVIEW

Preparation at facility

Organisational:documents:

Patient record audits!!

Observation

- Vigilant attentiveness Paying close and continuous attention

- Objectivity

- ValidationProtocols versus practice

Methods of assessment

INTERVIEWS

Triangulation

Team Work !

Services offered

Stepwise improvement

Baseline assessments

Assisted self-assessments

Data collection and reporting

External evaluation visits

Research on evidence-basedquality-improvement programs

SafeCare branding

Technical assistance

Training of local assessors

Quality control of local systems & data

Consultancy with respect to existing quality-improvement methodologies

Different branding

Certification Consultancy

Change is the Only Constant

“Change is disturbing when it is done to us. Change is exhilarating when it is done by us.” - Rosebeth Kantor

Rewarded by certificates

•Improvements rewarded with certificates

•Motivates clinics and staff

•Benchmarking of facilities

• Transparency for patients

Annual cycles of improvement and recognition

Focus

Plan-the process of improvement

Do the improvement, data collection & analysis

Check (results & lessons learnt)

Act (adopt, adjust, change)

The “Cycle”

Identification of priority areas

What is important in the SC report?• Which departments score lower than others?• Which criteria are critical and score NC?• Which criteria are severe and score NC?

These are your main priorities!

Example of a QIPGood hope medical clinicFebruary 2014 – January 2015

Information management

Before After

Before and after

Improved theatre services Innovative soap taps

Financing quality improvement

AfriDB: data collection & analysis

Preliminary reports are available within

30 minutes of submitting data

Measuring compliance with standards

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Antenatalguidelines

Referralcomplicatedpregnancies

Trained BirthAttendant

Oral Rehydration

Visit 1 Visit 2 Visit 3Visit 1:

N=730

Visit 2: N=88Visit 3: N=24

Measuring compliance with standards

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Diarrhoealguidelines

Hand washingfacilities

Wastemanagement

ARTadministration

guidelines

Visit 1 Visit 2 Visit 3Visit 1:

N=730

Visit 2: N=88Visit 3: N=24

SafeCare rolled out in NHIF Network

Launched on 25th June 2013

Building local capacity reduces costs and creates ownership

Benchmarking of clinics

0

50

100

150

200

250

300

0-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90 91-100

Num

ber o

f Clin

ics

Percent

Clinic distributionSC1 SC2 SC3

Benchmarking of facilities

0

25

50

75

100

Perc

ent

All countriesAverage % Low Score High Score

35

17

29

17 19

2934 32

2130 31 28

21

70

6051

4335

7470

47

7276

6861

7573 73

89

50

68

9286 90

7781 80

85

74

Safe

Care

sco

re

Service element

Best Practice – Hospital X1 - Dec 2011 2 - Oct 2012 3 - Apr 2014

Impact: Business & Output improvements

Preliminary data analysis of 150 clinics which had a baseline survey and a post-loan disbursement survey average

increase# OF PATIENT VISITS 22%

AV. ANNUAL PATIENT VISIT INCREASE IN # 512

ADDITIONAL REVENUES PER YEAR PER FACILITY IN $ 5,146

HIV/AIDS # OF HIV TESTS44%

MOTHER & CHILD CARE# ULTRASOUND SCANS

64%

# OF LAB TESTS 42%

# MALARIA TESTS 46%

# MALE CONDOMS DISTRIBUTED 50%

# FAMILY PLANNING SESSIONS 42%

LAB TESTS

BUSINESS

REPRODUCTIVE HEALTH