Making health care safer and better...
COHSASA has been involved in the development of standards for almost two decades. Many sets of standards have been developed to meet the specific requirements of clients and a few sub-Saharan countries have asked COHSASA to develop sets of standards specific to their country’s needs. Standards have been developed, piloted, used and refined for a range of healthcare establishments including hospitals, clinics, hospices, sub-acute facilities, rehabilitation centres and the management of HIV/AIDS across a continuum of care.
COHSASA is currently busy with the development of a set of standards for both individual and group GP practices.
Definition of standards for healthcare facilities
Healthcare facilities standards are statements that define the key functions, activities, processes and structures required for organisations to be in a position to provide quality services and as they are determined by professional bodies, health care professionals, staff, patients and citizens.
Many sets of COHSASA standards have been accredited by ISQua since 2002 which means they have all met the ISQua principles and requirements.
The four sets of COHSASA standards currently accredited are:
- Primary Health Care Services Standards(3rd Edition) (June 2010 through to May 2014).
- Emergency Medical Services Standards(2nd Edition) (June 2010 through to May 2014).
- COHSASA Hospital Standards (Version 6.6) (June 2010 through to July 2014).
- COHSASA Hospice Palliative Care Standards(3rd edition) (July 2014 through to July 2018.)
The current standards have been devised according to a set of principles developed by the International Society for Quality in Health Care (ISQua), and the collaboration of more than 40 countries, to guide the content and structure of accreditation standards for hospitals.
The JCIA (Joint Commission International Accreditation) of the United States, using the experience of 30 other countries, developed a set of international accreditation standards for hospitals, based on the ISQua principles. The JCIA appointed a 16-member international task force for this initiative. It consisted of experienced physicians, nurses, administrators and public policy experts from across the globe who actively guided the development of the international healthcare accreditation standards. Professor Stuart Whittaker, MD of COHSASA, was a member of that task force and contributed significantly to the development of the standards by introducing concepts and standards developed in South Africa.
While COHSASA recognises the importance of the international acceptance of our standards, such standards need to be relevant and adjusted to suit South African conditions.
COHSASA's Standards for Hospitals (Version 6.6) have been accredited by the international Society for Quality in Health Care (ISQua), from 2010 to 2014. This universal and comprehensive set of standards accommodates important global developments.
Because medical, nursing and health management science is in constant flux and change, COHSASA routinely assesses to what extent its standards remain relevant, feasible and applicable. Over the past 16 years, major professional bodies have assisted with the development and refinement of the standards. COHSASA continuously gauges the responses and comments of clients, professional field staff and the public regarding its standards. When further refinements are made to standards, COHSASA takes into account the feedback from over 500 facilities that have been in its programmes and there is a formal policy to review and update standards at regular, prescribed intervals with input from professionals and their representative organisations.
Standards are developed in five phases:
In the first ("normative") phase, COHSASA researches current international literature and consults professional bodies such as the Society of Anaesthesiologists of South Africa, the South African Association of Surgeons and other professional bodies for suggested standards and criteria.
During the second ("empirical") phase, these standards and criteria are tested in pilot healthcare facilities and further adapted to meet the specific needs of the South African situation.
In the third ("consensus") phase, the final standards are modified and consolidated to achieve a useful balance between academic ideals and reality at the coal-face, ensuring that patient care, patient and staff safety, and legality are not compromised.
In the fourth ("publishing") phase, the standards are published and circulated for comment among stakeholders.
In the fifth ("implementation") phase, standards are used as formal measures of performance in health facilities.
To ensure that integrated, coordinated care is provided, COHSASA develops and measures standards in all areas and departments of a healthcare facility. COHSASA looks at about 37 so-called Service Elements in which standards define systems required to enable the facility to provide quality care.
COHSASA's standards are grouped into both departments and the functions they serve across hospital departments. So, for example, the standards required for infection control would apply to all sections of a healthcare facility where it is appropriate to measure them. The following diagram shows how the standards are grouped:
The content of standards fits into the two general categories of patient care and management of the organisation. Standards that focus on patient care address at least: patient rights, access to care, continuum of care, patient assessment, care planning and the delivery of care and, when appropriate, education of the patient and his or her family.
Standards that focus on management of the organisation address at least: leadership of the organisation, roles and responsibilities of staff, management of information, creation and maintenance of a safe environment for patients, infection prevention and control, quality management and human resource management.
The programme sets common standards for all service areas that are based on essential functions:
- staff should be trained so that they can meet standards,
- policies and procedures should guide staff to achieve the objectives of the facility,
- there should be formally structured monitoring to measure the extent to which the organisation meets its objectives,
- there should be a formally structured reaction system (Quality Improvement) to allow the facility to move from where it is to its full potential.
In addition to these common and essential standards, there are service-specific standards that define the specific requirements of individual services, e.g. infection control in laundries, radiation protection in radiology departments, etc.
The analysis of standard assessment data is dependent on a computerised information "diagnostic" system, CoQIS (The COHSASA Quality Information System) which establishes the degree of compliance of criteria, standards and service elements.
The output is in the form of text and graphical reports that clearly show strengths and weaknesses of the facility as a whole, as well as those of individual departments and services.
The data and information generated in these processes is of fundamental value, not only in the standard assessment process, but also to the management of a facility. The reports can be used to identify deficiencies and monitor interventions that address problem areas.
COHSASA's information system is able to exclude standards that are scored as Not Applicable (NA) in a particular facility (for example, not all hospitals have a nuclear medicine capability). The system also has the capacity to allocate weighted values to criteria.
The criteria of a standard are those requirements of the standard that will be reviewed and assigned a score during the accreditation survey process. The criteria simply list what is required to be in full compliance with the standard. Each standard has intention statements to guide and educate staff regarding the requirements of criteria compliance with the standards.
The criteria, in turn, define each standard and specify the conditions required for compliance. The criteria are used to evaluate the degree to which facilities meet the standards in terms of quantity and quality. They may be:
Compliant (C) - if the condition is met
Partially compliant (PC) - if partially met
Non compliant (NC) - if there is no observable progress towards complying with the required condition
Standard compliance is determined by the evaluation of measurable elements (criteria) set to ensure that the intent of the standard is met. Criteria are assessed as fully compliant, partially compliant (more than 50% of the intent has been met), or not compliant (less than 50% of the intent has been met).
The system is designed to allocate scores to criteria according to their assessment. A fully compliant criterion is scored as 100. Non-compliant criteria are allocated scores determined by the impact that non-compliance would have on patient and staff safety and on the legal status of the facility.
These weighted scores are aggregated to give standard compliance scores. Standard scores are aggregated to score key systems and processes specific to each department/service essential for its safe, effective and efficient operation. The same scoring range is used for performance indicators, which, in turn, are aggregated to give service/department scores. Aggregated departmental/service scores provide a global score used to assess the overall compliance of the facility.
The table below illustrates the scoring process of the various assessment levels (criteria, standards, departments/services, major areas of operation and the facility as a whole). To be fully compliant, all departments in a facility must score above 80.
|Standard criteria scores||Compliance rating||Performance assessment|
There are more than 3800 measurable criteria in a comprehensive set of COHSASA hospital standards. Criteria that are partially compliant or non-compliant are known as deficiencies. The level of improvement can be indicated by the number or deficiencies at the baseline survey which have achieved compliance at the time of the external survey.