Quality Assurance and Hospital Accreditation

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Quality AssuranceandHospital Accreditation

• Assoc.Prof. Jiruth Sriratanaban, M.D., M.B.A.,
  Ph.D.
• Department of Preventive and Social Medicine
• Faculty of Medicine, Chulalongkorn University

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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

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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

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Content

• Hospital quality
• Ways to assure hospital quality
• External quality assurance
• Accreditation experiences

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What is Quality?

• Product specification and standard
• Conformance to requirement
• Fitness for use
• Zero defect
• Customer satisfaction
• Ability to satisfy needs

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Hospital Quality?

• Inputs
• Staff, doctors, specialists
• Nurses
• Medicines
• Facilities
• Utilities
• Equipments
• Care environment

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Hospital Quality?

• Processes
• Patient care and support processes
• Management and improvement identifying,
  learning from, correcting errors
• Patient experience (Perceptions)
• Waiting times, Information
• Responsiveness

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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

Patient Satisfaction
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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)

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High Quality vs. Low Quality Hospitals

• High-quality hospitals

• Low-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 ?

• Fewer competent staff
• Poorer equipped
• More process errors
• Poorly managed
• Long waiting
• Dissatisfied patients
• Poor health outcome
• Poorer financial outlook
• Less efficient ?
• Cheaper ?

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Quality ? Cost (empirical)
Fleming (1989)
Cost
B
F
A
C
E
C1
D
Q1 Q2 Q3
Quality
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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, LMIC
  (Berendes et al, SR, PLoS Med 2011)
• Private ? Less likely to die, but more likely to
  have unsuccessfully completed TB treatment
  Setting, LMIC (Montagu et al, 2011) MetA

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Common health system options for assuring
hospital quality

• Licensure
• Quality Certification
• External Quality Assurance

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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

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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

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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

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ExternalQuality 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

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ExternalQuality Assurance

• ISO series (International Organization for
  Standardization)
• Generic standards
• Process-focused
• Management system
• Professional evaluators
• Examples commonly applied
• ISO-9000, ISO-14000, ISO- 15189

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ExternalQuality 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

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ExternalQuality 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

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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)

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Experiences with Hospital Accreditation

• Three common models

Step-Wise Approach Types of Standards Standards Format Accrediting Body Country
No Outcomes Functional Joint Commission on Accreditation of Health Care Organizations United States
Yes Structure, Process, and Outcomes Functional Departmental Canadian Council on Health Services Accreditation Canada
No Structure and Process Departmental Australian Council on Healthcare Standards Australia
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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

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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

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Costs to Hospitals

• JCI Avg. fee for survey (2010) US46,000 JCI
  info US 100,000 Asian Hospital Healthcare
  Management
• A case of one hospital in India US600,000 for
  upgrading
• QHA Trent, UK
• Zambia US10 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.)

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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

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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