quality assurance and hospital accreditation
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Quality Assuranceand
Hospital Accreditation
Assoc.Prof. Jiruth Sriratanaban, M.D., M.B.A., Ph.D.
Department of Preventive and Social MedicineFaculty of Medicine, Chulalongkorn University
Session ObjectivesSession 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
Session ObjectivesSession 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
ContentContentHospital quality
Ways to assure hospital quality
External quality assurance
Accreditation experiences
What is “Quality”?What is “Quality”? Product specificat Product specificat
ion and standard ion and standard
Conformance to r Conformance to requirementequirement
Fitness for use Fitness for use
Zero defect Zero defect
Customer satisfac Customer satisfactiontion
Ability to satisfy n Ability to satisfy needseeds
Hospital Quality…?Hospital Quality…?
Inputs• Staff, doctors, specialists
• Nurses
• Medicines
Facilities• Utilities
• Equipments
• Care environment
Hospital Quality…?Hospital Quality…?
Processes• Patient care and support processes
• Management and improvement – identifying, learning from, correcting errors
Patient experience (Perceptions)• Waiting times, Information
• Responsiveness
Responsiveness to Responsiveness to expectationexpectation
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
PatientPatientSatisfactioSatisfactio
nn
Results of careResults 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)
High Quality vs. Low Quality HospitalsHigh 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 ?
Quality Quality ≠≠ Cost Cost (empirical(empirical))
Cost
Quality
C1
Q1 Q2 Q3
A
B
C
D
E
F
Fleming (1989)
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
Common health system Common health system options for assuring options for assuring
hospital qualityhospital quality
Licensure
Quality Certification
External Quality Assurance
LicensureLicensure
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
LicensureLicensureEnsure 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
CertificationCertificationPassing 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
ExternalExternalQuality Quality
AssuranceAssuranceEvolve 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”
ExternalExternalQuality Quality
AssuranceAssuranceISO series (International Organization for Standardization)
• Generic standards– Process-focused
• Management system
• Professional evaluators
• Examples commonly applied:• ISO-9000, ISO-14000, ISO- 15189
ExternalExternalQuality Quality
AssuranceAssuranceAccreditation• 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
ExternalExternalQuality Quality
AssuranceAssurancePros / 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
Experiences with Hospital Experiences with Hospital AccreditationAccreditation
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)
Experiences with Hospital Experiences with Hospital AccreditationAccreditation
Three common models
Country Accrediting Body
Standards Format
Types of Standards
Step-Wise Approach
United States
Joint Commission on Accreditation of
Health Care Organizations
Functional Outcomes No
Canada Canadian Council on Health Services
Accreditation
Functional + Departmental
Structure, Process, and
Outcomes
Yes
Australia Australian Council on Healthcare
Standards
Departmental Structure and Process
No
Experiences with Hospital Experiences with Hospital AccreditationAccreditation
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
Experiences with Hospital Experiences with Hospital AccreditationAccreditation
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
Costs to HospitalsJCI: 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 hospitalto complete the cycle(Advocacy, Programadministration, 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.)
Accreditation of other health Accreditation of other health care providerscare 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
ConclusionsConclusionsEQA 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
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