The programmes are continuously updated, adapted and improved as a result of ongoing research and input from participating facilities.

COHSASA offers two kinds of programmes:

• A conventional accreditation programme
• A Facilitated Accreditation Programme (FAP)

The FAP includes a capacity-building element, which empowers staff to understand the standards and the fundamental principles on which they are based. This means that health facilities have a clear vision of what systems and processes need to be in place for them to fulfil their particular mission statements.

In addition, the FAP aims to equip staff with quality assurance/improvement skills to enable them to implement and maintain the standards necessary for the best care of patients and the best use of resources.

COHSASA believes that:

• striving to meet organisational standards and processes created by and reached via professional consensus leads to good outcomes;
• the best way of providing a health service is through an integrated multi-disciplinary team approach;
• there are common essential functions within all health service areas that need to be carried out in order for these areas to function properly;
• while performance can be continually improved, the level of performance is never constant and depends on both internal and external factors, and
• healthcare facilities operate best in integrated multi-system environments.

Facilities may elect to contract with COHSASA’s Facilitated Accreditation Programme (FAP) or choose to implement the facilitation themselves in a conventional way. No facilitation is provided for alternate site facilities and psychiatric programmes unless it is requested, but many facilities opt to build COHSASA’s facilitation component into the accreditation programme.

COHSASA’s accreditation programmes differ slightly according to client requirements (with or without facilitation) and the type of facility being accredited, but the basic principles and the progression of the programme are the same.

The following is a description of the different phases of a typical public hospital facilitated accreditation programme, which lasts approximately two years.

The preparatory phase consists of an introductory stage and a project management stage.

Introductory stage
This consists of several visits. COHSASA’s initial visit is a presentation when we hand over the “Standard Assessment” manuals, situation analysis documentation, resource manuals and an overview of the programme with scheduled visits. Hospital staff are introduced to the concept and philosophy of quality improvement and the accreditation standards.

This visit also serves to help staff begin the initial process of selecting a steering committee with representatives from all services areas of the hospital and introduces a cornerstone of the programme — the integrated multidisciplinary approach. It is the steering committee that “drives” the process, ensuring that the various service areas become involved and committed in an integrated way.

The first visit also includes training the representatives from various service areas on how the process of self-evaluation is achieved. This includes training in document appraisal, the validation of data, and observation. Appropriate users of the CoQIS programme are identified and trained to evaluate and interrogate data.

In the second visit, COHSASA facilitators, in collaboration with representatives from all the service areas, complete a comprehensive assessment of all service elements of the health facility against the standards. The steering committee co-ordinates the evaluation process, known as the assisted baseline survey, and it is responsible for ensuring that all service areas and departments are fully aware of the programme.

The completed and checked data collection forms are taken back to COHSASA’s head office for processing. COHSASA captures this evaluation data in CoQIS and generates various reports that define areas of compliance and non-compliance with the standards, as well as the reasons for non-compliance.

During the third or so-called report-back visit, COHSASA gives feedback on the assisted baseline survey and provides each service area/department with its own report that shows which standards and criteria are compliant or not compliant. Each report provides reasons for non-compliance, indicating the seriousness of deviations from the standards. CoQIS provides a detailed overview of the compliance rates of services within the facility as a whole.

There is thus ongoing communication and support for the hospital during the preparatory phase because after each visit COHSASA's facilitators provide reports of the visit, their findings and agreed work schedules for the period up to the next visit.

This marks the start of the project management stage when hospital service areas work individually — and collectively — to identify the reasons for non-compliance and address them to achieve compliance.

Project management stage
During the project management stage, COHSASA’s facilitators visit the hospital every six to eight weeks for a minimum number of visits as defined by the contract. The role of these facilitators is to assist staff in addressing areas of non-conformance and to train them in the field of continuous quality improvement (CQI), clinical audit, project management, infection control and health and safety matters.

The first project management visit
During the first project management visit, COHSASA trains staff to use CoQIS (or hard-copy reports depending on whether the hospital opts for the CoQIS information programme or not) to identify areas that should be addressed first because they represent risk to patients, staff and the hospital. These are serious, non-compliant criteria that must be rectified as a priority.

Staff are trained to initiate action plans to address these deficiencies.
This process forms the foundation for the hospital improvement programme.

Subsequent project management meetings
COHSASA encourages each service area to participate fully in the programme, initially by taking part in the baseline survey, by being represented on the steering committee and by being encouraged to appoint small teams to work on areas of non-conformance with standards.

In addition, each of these areas is required to develop its own ongoing quality improvement programme linked to, and in harmony with, the overall hospital quality improvement programme.

These small teams address high priority deviations from the standards.
COHSASA facilitators show these teams how to define the problems associated with, and identify the causes of, non-conformance with standards as part of their CQI (Continuous Quality Improvement) training.

Facilitators also teach the teams the process of developing solutions to problems, how to choose the best solutions and how to implement them. An important part of this process is to evaluate the impact of these interventions and COHSASA lays great stress on ongoing monitoring via COQIS and the process of data collection, analysis and report-backs.

During the entire programme, the accreditation steering committee is required to maintain close links with all service areas/departments and to review, approve and co-ordinate all major projects.

Throughout the project management stage, COHSASA provides its clients in the Facilitated Accreditation Programme with progress reports. Where hospitals have chosen the COQIS option, they are able to monitor progress themselves.

CoQIS provides detailed graphical and written reports that show how individual service elements are progressing, outstanding areas of deficiency and the action required by the healthcare facility or governing authority to address them.

In addition, improvements in various performance indicators of patient care, both clinical and non-clinical, can be tracked.

The external survey
After the final project management visit, a COHSASA surveyor team — consisting of a doctor, a nurse and one other health professional (depending on the requirements of the facility) — carries out the external survey. The external survey report is made available to the hospital for comment before submission to COHSASA’s Technical Committee and its Board for the accreditation decision.

The accreditation decision
Hospitals that substantially comply with the standards - and have no critical non–compliant criteria that can compromise staff and patient safety and legal requirements - will be accredited for two years. When this period has expired, another evaluation will become necessary in order to retain accreditation status and ensure that standards within the accredited facility are maintained. On re-entry to the programme it is a realistic goal for a hospital that has maintained standards to achieve a three-year accreditation certificate.

Focus surveys
A hospital that has made substantial progress and is very close to achieving accreditation except for a limited number of defined criteria, which in the considered opinion of the Technical Committee can be rectified within a short time period, is awarded a Focus Survey. In these cases the requirements for accreditation are detailed in the external survey report.
This allows the hospital to concentrate on the priority areas.

The following is a diagram that shows the different stages of the programme:

The COHSASA quality improvement and accreditation programme has been designed to enable healthcare facility personnel at all levels to have direct access to quality improvement data so they can monitor their performance against multi-disciplinary organisational standards which are designed to provide quality care and the optimal management of facilities.

The key components of this programme include the following:

• Self evaluation and monitoring using a web-based information system
• Quality improvement programmes to achieve standard compliance
• External surveys to evaluate standard compliance using an impartial, internationally accredited agency for accreditation

The COHSASA Quality Information System - CoQIS - has been created with several objectives, one of the most important being to empower staff to implement quality systems themselves and accelerate buy-in to the overall quality improvement and accreditation programme.

CoQIS has been designed to help healthcare facilities meet internationally accredited standards of quality and to help them to achieve and maintain accreditation over time. The information provided by CoQIS enables hospital management and executive leaders to identify strengths and weaknesses and to make informed strategic decisions. Since CoQIS informs budgeting and planning, it can be used to evaluate the cost benefit of quality improvement interventions (including the CoQIS system itself).

At each hospital, staff will be trained to evaluate their facility using the accreditation standards, to input the data in the web-based information system and to extract information from the database so as to manage their facilities better. Hospital managers at each facility will thus be in a position to promptly identify shortfalls in any department/service in the facility and implement timely strategies before more expensive interventions are required down the line.

Central staff will be in a position at any time to use the application to evaluate any participating facility under their jurisdiction. The COHSASA programme will also allow for the monitoring of performance indicators and the evaluation of either an individual hospital or a group of hospitals. The programme has the capacity to allow hospitals to monitor clinical governance indicators on an ongoing basis. This monitoring process is not designed to be punitive but to encourage all staff to continuously improve performance.

COHSASA facilitators or subcontracted consultants provide training throughout the programme. The amount of training in these specialised fields varies depending on the needs of individual facilities.

Training in the use of CoQIS
Selected staff at facility and senior management level are trained how to use CoQIS in order to monitor progress in health facilities.

Quality assurance/improvement
Initially COHSASA was developed as an accrediting organisation that saw itself as principally carrying out evaluations of health facilities against agreed standards.

However, it soon became apparent that some healthcare facilities in South Africa were unfamiliar with the concept of external audit and needed extensive assistance both in understanding the concept and in preparing for such programmes. This training programme arose out of this need.

The continuous quality assurance/improvement (CQI) approach was chosen as a tool to assist hospitals in their quest to achieve compliance with the programme’s standards. The approach of the Quality Assurance Project of the University Research Corporation of the USA has been adopted and modified to the needs of the programme. This organisation has given COHSASA permission to use the documentation for this purpose.

This CQI approach is taught to healthcare facility steering committees and to the small teams of the service areas/departments. The aim is to apply the theory of CQI to address high-priority problems identified in baseline survey reports.

When necessary, participating facilities may identify two or three representatives who receive special training in quality assurance and who serve as a resource for the facility between COHSASA's visits.

During the programme, the small teams from service areas/departments are encouraged to present their CQI programmes to the steering committee. This helps develop a CQI approach throughout the facility and encourages interdisciplinary collaboration.

Incident Monitoring
Cohsasa has introduced an incident monitoring programme - the Advanced Incident Management System (AIMS) - that empowers healthcare services to improve performance by providing insight into how and why things go wrong.

The emphasis in the programme, which operates from a central call centre at Cohsasa, is to encourage staff to report adverse events and near misses and to move from a "blame" culture to a just culture.

Staff at hospitals phone in the incident which is recorded at the call centre in a state-of-the-art computer information system with user-friendly drop-down menus. AIMS uses a sophisticated web-based cascading questionnaire that takes seven and 10 minutes to complete. Once details of the incident are complete, an email is sent immediately to appropriate staff at the hospital for follow up. There is also a monthly summary report to provincial (or head office) staff for action.

It is hoped that by monitoring adverse events and linking them to non-compliant Cohsasa standards and criteria that targeted quality improvement initiatives will result in a diminution of clinical incidents and improved healthcare quality.

[ Back to Top]