Guidance on Designing Healthcare External Evaluation ... · PDF fileii iua Accreditation Interna ccredita ogr Guidance on Designing Healthcare External Evaluation Programmes including

Authors: Triona Fortune, Elaine O’ Connor and Barbara Donaldson

Guidance on Designing Healthcare External

Evaluation Programmes including Accreditation

2015

International Accreditation Programme (IAP) ISQua Accreditation

Guidance on Designing Healthcare External Evaluation Programmes including Accreditation i

Table of contentsAcknowledgements iii

ForewordISQua iv

ForewordWorldBank&WHO vi

ListofTables vii

GlossaryofTerms viii

Introduction 2

Chapter 1: Why develop an external evaluation programme? 4

1.1 Thegrowingdemandforexternalevaluationinhealthandsocialcare 4

1.2 Modelsofexternalevaluation 5

1.3 Benefitsofexternalevaluation 8

1.4 Challengesforexternalevaluationprogrammes 10

Chapter 2: Establishing the fundamentals 12

2.1 Definingthepurposeoftheexternalevaluationprogramme 12

2.2 Definingthescopeoftheexternalevaluationprogramme 15

2.3 Establishingtheroleofgovernment 18

2.4 Determiningincentives 21

2.5 Developingrelationshipswithstakeholders 24

Chapter 3: Setting up the external evaluation organisation 27

3.1 Establishingapreliminaryboardoradvisorycommittee 27

3.2 Proposingagovernanceboardandframework 28

3.3 Fundingoftheprogramme 30

3.4 Settingupstrategic,operationalandfinancialmanagementsystems 33

3.5 Timeframes 35

Chapter 4: Developing the standards 37

4.1 Theroleofstandards 37

4.2 Principlesforstandards 38

4.3 Referencingtoqualitydimensions 39

4.4 Developingthemeasurementsystem 40

Chapter 5: Developing assessment methodologies 43

5.1 Selection,trainingandevaluationofsurveyors 43

5.2 Developingthesurveymanagementprocess 46

5.3 Establishingtheaccreditation/certificationprocess 48

5.4 QualityAssurance 51

Chapter 6: Evaluating systems and achievements 52

6.1 Measuringperformanceinternally 52

6.2 Evaluatingindependently 53

6.3 Monitoringbyregulatoryagencies 53

6.4 Accreditingtheexternalevaluationbodies 53

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ISQua Accreditation International Accreditation Programme (IAP)

Guidance on Designing Healthcare External Evaluation Programmes including Accreditation

Table of contentsConclusions 54

References 55

Bibliography 58

Usefulwebresources 62

Appendix 1: Case Studies 64

Appendix1a.DanishCaseStudy 64

Appendix1b:JordanianCaseStudy 67

Appendix1c.NewZealandCaseStudy 69

Appendix1d:PracticeIncentiveProgram(PIP) 72

GuidanceonDesigningHealthcareExternalEvaluationProgrammesincludingAccreditation

©2015Publisher:TheInternationalSocietyforQualityinHealthCare,JoyceHouse,8-11LombardStreetEast,Dublin2,D02Y729,Ireland.


Guidance on Designing Healthcare External Evaluation Programmes including Accreditation iii

AcknowledgementsThisdocumentisbasedontheToolkitforAccreditationPrograms,2004developedbyCharlesShaw.TheInternationalSocietyforQualityinHealthCarewouldliketothankthefollowingfortheircontributionstothedevelopmentofthisdocument:

Reviewers

MarkBrandon,AACQA-Australia

StephenClark,AGPAL-Australia

HelenoCostaJunior,CBA-Brazil

CarstenEngel,IKAS-Denmark

EricdeRoodenbeke,InternationalHospitalFederation

CarlosGoesdeSouza,CHKS-UK

HelenHealey,DAPBC-Canada

SalmaJaouni,HCAC-Jordan

ThomasLeludec,HAS-France

Hung-JungLin,JCT-Taiwan

LenaLow,ACHS-Australia

KadarMarikar,MSQH-Malaysia

WendyNicklin,AccreditationCanada

BKRana,NABH-India

CharlesShaw,IndependentConsultant

PaulvanOstenberg,JCI-USA

KeesvanDun,NIAZ-TheNetherlands

StuartWhittaker,COHSASA-SouthAfrica

HongwenZhao,WHO

NittitaPrasopa-Plaizier,WHO

AkikoMaeda,WorldBank

DineshNair,WorldBank

RafaelCortez,WorldBank

AspecialacknowledgementtoAkikoMaedaandtheWorldBankforsupportingthisproject.

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Foreword Accreditationisanimportanttoolforimprovingthecaredeliveredbyhealthcaresystems,andoneofthekeyrolesoftheInternationalSocietyforQualityinHealthCare(ISQua)hasbeentoaccredittheaccreditors.However,accreditationhastoevolvetobebeneficial.Anincreaseinrequests-especiallyfromdevelopingeconomies-foradviceonestablishinganaccreditationprogrammepromptedISQuatoreviewtwoofitsmajortools:theToolkitforAccreditationPrograms,20041,andChecklistforDevelopmentofNewHealthcareAccreditationPrograms,20062.Thelastdecadehasseenconsiderablechanges,worldwide,tohealthcaresystemsandexternalevaluationprogrammes.Toreflectthesechanges,arevisiontotheexistingguidancewasdeemedinadequateandthisnewGuidancemanualwasthereforedeveloped.Webelievethisdocumentwillbesuitableforamuchwideraudience;itisdesignedforcountries,governmentsandpolicymakerswithinpublicorprivate,primary,secondaryortertiaryhealthcaresystems.ItisalsointendedasanaidforfundinganddevelopmentagenciessuchastheWorldBank,internationalaidagencies,theWorldHealthOrganization(WHO),MinistriesofHealth,othergovernmentagencies,groupsandorganisationswhowanttoimprovethequalityandsafetyofhealthcareintheircountry,regionorspecialtyarea.

Ithasnowbeenalmost100yearssincethefirstexternalevaluationprogramme,knownasaccreditation,wasestablished.Nearlyeverycountrycurrentlyhassomeformofexternalevaluation,whethervoluntaryormandatory.Thereareboth“aficionados”andcriticsofhealthcareaccreditation.Anyonewhohasdealtwithaccreditorscomingintotheirsitehaslikelyfeltthattheywerearbitrary,orfocusedonthingsthatwerelessthanimportant.However,accreditationgetsorganisationstopayattentiontothingstheymightotherwiseprefertoignoreorputoff.Whileitissometimesvoluntary,followingaseriesofadverseeventspolicymakersthenchangeittomandatoryinresponse.Whiletraditionallyaccreditationwasaprogrammefordevelopedeconomies,developingcountriesarenowequallyasinterested.Thisdocumenthasextendeditsscopebeyondhealthcareaccreditationprogrammestoincludeotherexternalevaluationprogrammessuchascertificationandlicensingastheyapplytoorganisations,notindividualpractitioners.Theseprogrammeshavedifferentscopesandorganisationalcoveragebutarebasedonthesameprincipleofevaluatingandimprovingperformanceagainstadefinedsetofstandards,usingexternalevaluators,toimprovethesafetyandqualityofhealthservicesforthepublic.

Accreditationisnotapanaceatoaddressallqualityimprovementissuesbutitcanprovideasystematicapproachthatidentifiesareaswhereimprovementsarenecessary,andwhenmandatory,can“liftalltheboats”,includingsomeofthelessstrongentitieswithinourhealthcaresystems.Whenusedwithtoolssuchaschecklistsandsupportedbytechnology,itcanbecomeapowerfulinstrumentforhealthcarereform.

Developinganexternalevaluationsystemisaprocessthatshouldbedesignedaccordingtoeachcountries’profile.Firstly,thepurposeshouldbeclearandsecondly,dependingonthedesiredoutcome,adecisionshouldbemadeastowhetheravoluntaryormandatorysystemisappropriate.Thisdocumentisnotdesignedasarigidguideline,ratherasadiverserangeofpracticeswhichshouldbediscussed.Itincludesadviceonbestpracticesforgovernance,developingstandardsandassessmentmethodologies.Italsoincludesrealcasestudiesfrombothdevelopedanddevelopingcountries.

Healthcarecontinuestoevolve;someofthekeychangesoccurringtodayarethatpopulationsareageing,whiletechnologyisbecomingsmarterandtherelationshipsbetweenprovidersandpatientsaretiltingsothatpatientsaremuchmoreempowered,andtheyarebecomingourpartners.WeallneedtostrivetoreachcountryspecificandglobalgoalssuchastheWorldHealthOrganization’smandateonUniversalHealthCoverage(UHC)by2020.


Guidance on Designing Healthcare External Evaluation Programmes including Accreditation v

GovernmentswillultimatelyberesponsibleforprovidingUHCandtheywillberequiredtodemonstrateefficientuseoflimitedpublicfundswhileprovidingsafequalityhealthcare.Externalevaluationsystemscanprovidethisassurance.

ISQuabelievesthataccreditationcancontinuetobeapowerfulforceforimprovementinthequalityofcarethatisdelivered.However,likeallqualityimprovementinitiatives,itmustevolvewiththetimestoreflecttheneedsofourhealthcaresystems.

Professor David W. Bates President International Society for Quality in Health Care August 2015

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ForewordWorld Bank and the World Health Organization

Thepublichasagrowingawarenessofandexpectationfortheirhealthcaretobeaccountable,safe,ofhighqualityandresponsivetotheirneeds.Globally,healthcarecostsarerising,puttingincreasingburdensonbothgovernmentsandhealthcareorganisations,astheytrytomeetthegrowingchallengeswithlimitedresources.GovernmentsareworkingtowardsUniversalHealthCoverage(UHC)asawaytoensurethattheirpopulationshaveequitableaccesstosafe,highqualityservices,withoutsufferingfinancialhardship.Thecriticalquestionremains:howcancountriesmaximiseaccesswhilstmaintainingsafeandqualityserviceswithinaffordablemargins?

Externalevaluationprogrammes,whichincludeaccreditation,certificationandlicensingofhealthcareinstitutions,areamongmeasuresthatcanhelpimproveorganisationalefficiencyandeffectivenessaswellasthesafetyandqualityofservices.However,implementationoftheseprogrammesisnotuniform.Thismaybeduetoalackofresourcesorexpertiseor,importantly,duetoalackofoperational‘know-how’ontheimplementationofsuchprogrammes.

Thisreportaimstoprovideapracticalguideforsettingupanexternalevaluationprogrammeatbothanationalandanorganisationallevel.Itwillhelpgovernmentsandpolicymakerstoidentifyanddeterminehealthsystems’prioritiesandgaps,sotheycanre-orienthealthcaresystemsandpoliciestomeetsuchgrowingchallenges.Thereportoffersarangeofapproachesandpracticalstepsonthesettingupofexternalevaluationprogrammes,includingcreatinganenablingenvironmentanddevelopinghumanandsystemcapacities.

Betterimplementationofexternalevaluationprogrammescancontributetoimprovedsafetybyrequiringservicestomeetstandards,andbyencouragingqualityimprovementthroughorganisationalandindividualprofessionaldevelopment.Suchprogrammes,ifadoptedandimplementedappropriatelyandconsistently,willcontributetoamoreresilient,moreaccountable,andmoreeffectivehealthcaresysteminthelongrun.

Itishopedthatthisreportwillencouragegovernmentsandhealthcareorganisationstoadoptandimplementexternalevaluationprogrammesinordertoachievesafe,highquality,resilientandsustainablehealthsystemsandservices.

Timothy Grant EvansSenior Director Health Nutrition and Population Global Practice The World Bank Group

Marie-Paule Kieny Assistant - Director General Health Systems and Innovation World Health Organization


Guidance on Designing Healthcare External Evaluation Programmes including Accreditation vii

List of Tables Table Page No.

Table1:Definitionsofaccreditation,certificationandlicensing 8

Table2:Comparisonofcapacitybuildingandregulatoryexternalevaluation 13

Table3:Potentialcompositionofapreliminary/interimboardoradvisorycommittee

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Glossary of Terms Accountability Responsibilityandrequirementtoanswerfortasksoractivities.This

responsibilitymaynotbedelegatedandshouldbetransparenttoallstakeholders.

Accreditation Aself-assessmentandexternalpeerreviewprocessusedbyhealthandsocialcareorganisationstoaccuratelyassesstheirlevelofperformanceinrelationtoestablishedstandardsandtoimplementwaystocontinuouslyimprovethehealthorsocialcaresystem.

Assessment Processbywhichthecharacteristicsandneedsofpatients,groups,populations,communities,organisationsorsituationsareevaluatedordeterminedsothattheycanbeaddressed.Theassessmentformsthebasisofaplanforservicesoraction.

Assessor Personwhoevaluatescharacteristicsandneeds.Forexternalevaluation,anassessoridentifiesandevaluatesevidencethatsetcriteriaarebeingmetandmakesrecommendationsforactiontoaddressanygaps.Alsoauditor,surveyor,externalevaluator.

Benchmarking Comparingtheresultsofservices’ororganisations’evaluationstotheresultsofotherinterventions,programmesororganisations,andexaminingprocessesagainstthoseofothersrecognisedasexcellent,asameansofmakingimprovements.Alsobenchmark.

Certification Processbywhichanauthorisedbody,eitheragovernmentalornon-governmentalorganisation(NGO),evaluatesandrecogniseseitheranindividual,organisation,objectorprocessasmeetingpre-determinedrequirementsorcriteria.Thepre-determinedrequirementsaresetoutinstandardswhicharedevelopedspecificallyforthepurposeofassessment.Thestandardsassesstheperformanceoftheorganisation,object,processorperson,mayfocusonspecificaspectsofperformanceandmayaddressmorethanlegalrequirements.

Clients Individualsororganisationsbeingservedortreatedbytheorganisation.Alsopatients,consumers,serviceusers.

External evaluation

Processinwhichanobjectiveindependentassessorgathersreliableandvalidinformationinasystematicwaybymakingcomparisonstostandards,guidelinesorpathwaysforthepurposeofenablingmoreinformeddecisionsandforassessingifpre-determinedandpublishedrequirementssuchasgoals,objectivesorstandardshavebeenmet.Anorganisation,object,processorindividualmaybeassessedandevaluationmaybeundertakenbypeers,includingorganisationsandprofessionals,privateprofessionalauditorsorconsultants,purchasers/funders/insurers,consumers/patientsorgovernments.

Health Outcome Healthstateorconditionattributabletotreatment,careorserviceprovided.

Leader Anindividualwhosetsexpectations,developsplansandimplementsprocedurestoassessandimprovethequalityoftheorganisation’sgovernance,management,clinicalandsupportfunctionsandprocesses.

Leadership Abilitytoprovidedirectionandcopewithchange.Itusuallyinvolvesestablishingavision,developingstrategiesforproducingthechangesneededtoimplementthevision,aligningpeople,motivatingandinspiringpeopletoovercomeobstacles.


Guidance on Designing Healthcare External Evaluation Programmes including Accreditation ix

Licensing Processbywhichagovernmentalauthoritygrantspermissiontoanindividualpractitionerorhealthandsocialcareorganisationtooperateorengageinanoccupationorprofession.Licensingregulationsaregenerallyestablishedtoensurethatanorganisationorindividualmeetsminimumstandardstoprotecthealthandsafety.Theoutputoflicensingistheawardingofadocumentorlicenceallowinganorganisationorpersontoprovideaservicewithinaspecifiedscope.

Medical tourism Travelofpeopletoanothercountryforthepurposeofobtainingmedicaltreatmentinthatcountry.

Organisational peer assessment

Aprocesswherebytheperformanceofanorganisationisevaluatedbymembersofsimilarorganisations.Alsopeerreview.

Outcome standards

Standardswhichaddresstheresults,consequencesoroutcomesoftheperformanceandmeasurementofactivities,systemsandfunctions.

Patient centredness

Focusontheexperienceofthepatient/clientfromtheirperspective,minimisingvulnerabilityandmaximisingcontrolandrespect.Alsopatient/clientfocus.

Patient / Client journey

Thepatient/clientpaththroughthecareortreatmentprocess–entry,assessment,planning,deliveryofcareortreatment,evaluation,follow-upandacrossservicesandproviders.Alsoclientcontinuumofcare.

Process standards

Standardswhichaddresstheinterrelatedprocessesofdifferentorganisationalandclinicalfunctionsandactivities.

Quality improvement

Ongoingresponsetoqualityassessmentdataaboutaservice,inwaysthatimprovetheprocessesbywhichservicesareprovidedtoclients.Alsocontinuousqualityimprovement(CQI).

Regulation Isaformofexternalevaluationbywhichabody,whoisauthorisedbylaw,assessesanorganisationorapersonagainstpre-determinedrequirements.Thepre-determinedrequirementsarederivedfromlegislationandtherefore,theregulatormaytakeanumberofactionsintheeventofnon-compliance.

Risk mitigation Asystematicreductionintheextentofexposuretoariskand/orthelikelihoodandconsequencesofitsoccurrence.

Self-assessment Aprocessbywhichanorganisationevaluatesitsownperformanceagainstsetcriteriaorstandards,identifiesstrengthsandgaps,andplansactionsforimprovement.

Standardisation Processofdevelopingandimplementingtechnical,serviceorotherstandards;thatcanhelptomaximizecompatibility,interoperability,safety,repeatabilityorquality.

Structure standards

Standardswhichaddresstherelativelystablecharacteristicsofhealthcareproviders,theirstaff,toolsandresources,andphysicalandorganisationalsettings.

System Asetofinteractingorinterdependentprocessesforminganintegrated,wholefunctionoractivity.

Transparency Operatinginsuchawaythatitiseasyforotherstoseewhatactionsareperformed;aprinciplethatallowsthoseaffectedbyadministrativedecisions,businesstransactionsorcharitableworktoknownotonlythebasicfactsandfiguresbutalsothemechanismsandprocesses.Usuallyrequiresdocumentedpoliciesandprocedures.

Universal health coverage

Thegoalofallpeoplehavingaccesstoandobtaininghealthpromotion,preventive,curative,rehabilitativeandpalliativehealthservicestheyneed,ofsufficientqualitytobeeffective,withoutsufferingfinancialhardshiptoavailofthem.

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Introduction Thepurposeofthisdocumentistoguidecountries,agenciesandothergroupsintheprocessofsettingupnewhealthorsocialcareexternalevaluationorganisationsorprogrammes.ItisalsointendedasanaidforfundinganddevelopmentagenciessuchastheWorldBank,internationalaidandtechnicalcooperationagencies,WorldHealthOrganization,MinistriesofHealth,othergovernmentagencies,groupsandorganisationswhowanttoimprovethequalityandsafetyofhealthcareintheircountry,regionorspecialtyarea.ItrevisestheInternationalSocietyforQualityinHealthCare(ISQua)ToolkitforAccreditationPrograms,20041,andISQuaChecklistforDevelopmentofNewHealthcareAccreditationPrograms,20062.Thisdocumenthasextendeditsscopebeyondhealthcareaccreditationprogrammestoincludeotherexternalevaluationprogrammessuchascertificationandlicensingastheyapplytoorganisations,notindividualpractitioners.Theseprogrammeshavedifferentscopesandorganisationalcoveragebutarebasedonthesameprincipleofevaluatingandimprovingperformanceagainstadefinedsetofstandardsorcriteria,usingexternalevaluators,toimprovethesafetyandqualityofhealthservicesforthepublic.

Accreditationcanbedefinedasaself-assessmentandexternalpeerreviewprocessusedbyhealthandsocialcareorganisationstoaccuratelyassesstheirlevelofperformanceinrelationtoestablishedstandardsandtoimplementwaystocontinuouslyimprovethehealthorsocialcaresystem.Certificationisaprocessbywhichanauthorisedbody,eitheragovernmentalornon-governmentalorganisation,evaluatesandrecognisesanorganisationasmeetingpre-determinedrequirementsorcriteria.Licensingisaprocessbywhichagovernmentalauthoritygrantspermissionforahealthcareorganisationtooperate.Licensingregulationsaregenerallyestablishedtoensurethatanorganisationorindividualmeetsminimumstandardstoprotecthealthandsafety.Forthepurposeofthisdocumentwewillrefertoanaccreditationbodybutthisincludesanyexternalevaluationprogrammeastheprinciplesremainthesame.

Thedocumentrefersmainlytohealthcareorganisationsbutisalsoapplicabletosocialcareorganisations.Init,thetermexternalevaluationisusedtocoveraccreditation,certification,licensingandotherstandardsbasedassessmentprogrammes.Thetermsurveyisusedtorefertosurvey,assessmentandaudit.Thetermsurveyorisusedtoincludesurveyors,assessorsandauditors.

Researchandexperiencehaveidentifiedthebenefitsofexternalevaluationprogrammessuchasimprovedorganisationalefficiencyandeffectiveness,improvedsafetyandquality,betterriskmitigation,improvedleadership,reducedliabilitycosts,bettercommunicationandteamwork,increasedsatisfactionofusersandstaff,andbetterpatientcare.However,therearechallengesinsettinguptheseprogrammes.Theprincipalthreatstonewexternalevaluationprogrammesappeartobeinconsistencyofgovernmentpolicy,unstablepolitics,unrealisticexpectationsandlackofprofessional/stakeholdersupport,continuingfinanceand/orincentives.Theeffectivenessandsustainabilityofanexternalevaluationorganisationorprogrammedependsultimatelyonmanyvariablefactorsintheparticularhealthcareenvironmentofthecountryororganisationinvolved.Italsodependsonthekindofprogrammeconcerned,andhowitisimplemented.

Tobesustainable,externalevaluationprogrammesneedongoinggovernmentand/orprivatesupport,asufficientlylargehealthcaremarketsize,stableprogrammefunding,diverseincentivestoencourageparticipation,andcontinualrefinementandimprovementintheexternalevaluationorganisation’soperationsandservicedelivery.

Thisguideaddressesthevariablesofpolicy,organisation,methodsandresources.Itoutlinesthereasonswhyanexternalevaluationprogrammemightbedeveloped,describesthedifferentmodels,andhighlightsthebenefitsandchallengesassociatedwithexternalevaluation.


Guidance on Designing Healthcare External Evaluation Programmes including Accreditation 3

Itthenprovidesguidanceonthestepsthatneedtobetakeninestablishinganewexternalevaluationorganisationincluding:

Establishingthefundamentalsofscopeandpurpose,anddefiningtheimportantrolesofgovernmentandincentivesintheexternalevaluationorganisation/programme.

Settingupoftheexternalevaluationorganisationalstructureincluding:establishinganadvisorycommittee;developingrelationshipswithstakeholders;designingagovernanceframework;embeddingthevaluesoffairnessandtransparency;andgettingoutsideassistanceandfunding.

Establishinggovernanceandmanagementsystemsincluding:staffing;financialandinformationsystems;andriskmanagementandperformanceimprovementsystems.Italsohighlightstheimportanceofallowingenoughtimeforthesestages.

Developingthestandardstobeusedbytheorganisationandthesystemformeasuringtheirachievement.

Developingthesurveyorandsurveymanagementsystemsincluding:theselectionandtrainingofsurveyors;thedesigningofprocessesandtechnologyformanagingsurveysandotherevents;developingandestablishingeducationservices;anddeterminingandestablishingtheprocessforawardingaccreditationorcertificationstatus.

Integratingintoallthesesystemsandprocesseswaysofmeasuringandevaluatingperformance.

ThisdocumentreflectsthebestpracticeguidelinesandstandardsdevelopedbytheInternationalSocietyforQualityinHealthCare(ISQua)aspartofitsInternationalAccreditationProgramme(IAP):ISQuaGuidelinesandStandardsforExternalEvaluationOrganisations,4thEditionVersion1.1,20143;ISQuaGuidelinesandPrinciplesfortheDevelopmentofHealthandSocialCareStandards,4thEditionVersion1.1,20144;andISQuaSurveyorTrainingStandardsProgramme,2ndEdition20095.

Theappendicesincludecasestudiesoutlininghowthreedifferenthealthcareexternalevaluationorganisationswereestablished.Twooftheorganisationsfeaturedareaccreditationorganisations.Thethirdfeaturedorganisationisanassessmentorganisationestablishedprimarilytoassessagainstgovernment-mandatedstandardsforcompulsorycertification.Appendix1ddescribesanAustralianPracticeIncentiveProgrammethatdemonstrateshowaccreditationcanbeusedasalevertoencouragequalityimprovement.

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Chapter 1: Why develop an external evaluation programme?Thischapterintroduceswhatahealthcareexternalevaluationprogrammeis;describessomeofthedifferentmodelsofexternalevaluation;outlinesthebenefitsofsuchprogrammes;andhighlightsthechallengeswhichmaybeencounteredinestablishingsuchprogrammes.

1.1 The growing demand for external evaluation in health and social care

Thereisgrowingworldwidedemand,concernandfocusonqualityandsafetyinhealthcare.UUniversalHealthCoverage(UHC)isnowakeyagendaitemfortheWorldBankandtheWorldHealthOrganizationandmanycountrieshaveadoptedorareabouttoadoptthissystemofequalhealthcareforall.Thegoalofuniversalhealthcoverageistoensurethatallpeopleobtainthehealthservicestheyneedwithoutsufferingfinancialhardshipwhenpayingforthem.Thisrequires:

Astrong,efficient,well-runhealthsystemwithgoodgovernance

Asystemforfinancinghealthservicesinanefficientandequitableway

Accesstoessentialmedicinesandtechnologiesandgoodhealthinformationsystems

Asufficientcapacityofwell-trained,motivatedhealthworkers6.

Thereisincreasingsupportfromgovernments,andfromfundingagencies,formechanisms,suchasaccreditation,tosupportUHC.GovernmentswillultimatelyberesponsibleforprovidingUHCandtheywillberequiredtodemonstrateefficientuseoflimitedpublicfundswhileprovidingsafequalityhealthcare.Externalevaluationprovidesassurancesthathealthcarefacilitieshavequalitysystemsinplaceandthedatatodemonstratetherequiredlevelofserviceprovision.Dependingonthecomprehensivenessofthestandardsagainstwhichhealthserviceperformanceisbeingmeasured,externalevaluationprogrammessuchasaccreditationandcertificationcancontributetoqualityimprovement,riskmitigation,patientsafety,improvedefficiencyandaccountability,andcancontributetothesustainabilityofthehealthcaresystem.Theycanprovideinformationonhowwellhealthservicesarebeingdelivered,identifyissues,andassistthedecision-makingoffunders,regulators,healthcareprofessionalsandthepublic.Externalevaluationsupportstransparency,benchmarkingandaccountability,sothatgovernmentfundingisallocatedinafairandequitablewayandsupportsacultureofchangeandqualityandanincreasedfocusonrisk.

Patientsexpecttoreceivesafecareandaredemandingqualityservicesthatmeettheirneeds.Theyexpecttobetreatedwithrespect,toreceiveservicesofanappropriateandconsistentstandardthataredeliveredwithcareandskill,thatminimiseriskandharm,complywithlegal,professionalandethicalstandards,andthatfacilitatecontinuityofcare.Patientsneedtoreceiveinformationabouttheirconditionandtreatmentinawaytheycanunderstand,tobeabletomakeinformedchoicesabouttheirtreatmentandtobecommunicatedwithopenlyandhonestly.Theywanttherighttocomplainifservicesdonotmeettheirneedsandexpectactiontobetakentoaddresstheproblem.



Theyhavearighttotrustthattheirhealthproviderorhospitalhassystemsandprocessesinplacetoprovidesuchpatient-centred,reliable,efficient,effectiveandresponsivecare.Anexternalevaluationprogrammebasedonbestpracticestandardswillmakeasignificantcontributiontoachievingthis.

Withpreventableerrorratesestimatedtobe83%indevelopingandtransitionalcountriesanda30%rateofadverseeventsassociatedwithdeaths,thesecountriesrequirenotonlymoreresourcestoimprovethesafetyandqualityofcare,butapoliticalenvironment,policiesandmechanismsthatsupportqualityinitiatives.Thecontributionofexternalevaluationorganisationscentredonpromotingimprovements,applyingstandardsandprovidingfeedbackisbeingincreasinglyrecognisedinthesecountries.Preventableerrorratesofover10%indevelopedcountriesarealsounacceptable.Aflourishingaccreditationprogrammeisoneelementoftheinstitutionalbasisforhighqualityhealthcare7.

1.2 Models of external evaluation

External evaluation

Isaprocessbywhichanobjectiveindependentassessorgathersreliableandvalidinformationinasystematicmannerbymakingcomparisonstostandards,guidelinesorpathwaysforthepurposeofenablingmoreinformeddecisionsandforassessingifpre-determinedandpublishedrequirementssuchasgoals,objectivesorstandardshavebeenmet.Anorganisation,object,processorindividualmaybeassessedandevaluationmaybeundertakenbypeers,includingorganisationsandprofessionals,privateprofessionalauditorsorconsultants,purchasers/funders/insurers,consumers/patientsorgovernments.

Thedistinguishingfeaturesofexternalevaluationareasfollows:

Itisaformalprocess

Theobjectbeingassessedisanorganisation,object,processorindividualperson

Assessmentisundertakenbyanobjective,independentassessor

Assessmentisagainstpre-determinedandpublishedrequirements/criteria

Itisdesignedsothatdecisionsarenotinfluencedbythosebeingassessed

Theassessmentresultsinadefinedoutput

Thereareanumberofmodelsofexternalevaluationanditshouldbeacknowledgedthattherecanbeconfusionregardingterminologyduetothediverseapplicationsoftheexternalevaluationmodels.Examplesofexternalevaluationmodelsincludethefollowing:

Accreditation

Accreditationmaybedefinedasaself-assessmentandexternalpeerreviewprocessusedbyhealthandsocialcareorganisationstoaccuratelyassesstheirlevelofperformanceinrelationtoestablishedstandardsandtoimplementwaystocontinuouslyimprovethehealthorsocialcaresystem.Althoughprimarilyappliedinrelationtoorganisations,processesmayalsobeaccredited.Accreditationstandardsassesstheorganisation’sorprocess’sabilitytofulfilitscoremissionandmayaddressmorethanlegalrequirements.Theyareusuallyrecognisedasoptimal,evidence-basedandachievableandaredesignedtoencouragecontinuousimprovement8.Theoutputofaccreditationisareportsummarisingthefindingsoftheassessmentandarecognitiondecisionregardingtheaccreditationstatus.

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Accreditationisoneofthelongestestablishedmodelsofexternalevaluation.Itisaself-assessmentandexternalpeerreviewprocessthatassessestheentireorganisationincludingbothclinicalandmanagementprocessesandactivities.Traditionally,healthandsocialcareorganisationsengagedinaccreditationonavoluntarybasisandaccreditationschemeswereprovidedbynon-governmentalagencies.However,therehasbeenashiftovertimetowardsgreatergovernmentalinvolvementinaccreditationwiththedevelopmentofnationalgovernmentfundedaccreditationprogrammesandashiftfromvoluntarytomandatoryparticipationinsuchschemes.Forexample,in2011theAustralianHealthMinistersendorsedtheNationalSafetyandQualityHealthService(NSQHS)Standardsandanationalaccreditationscheme.Asaresult,allhospitalsanddayprocedureservicesandthemajorityofpublicdentalservicesacrossAustralianowneedtobeaccreditedtotheNSQHSStandards.PrivatehealthserviceorganisationsarerequiredtoconfirmtheirrequirementsforaccreditationtoanystandardsinadditiontotheNSQHSStandardswiththerelevanthealthdepartment.Priorto2011,participationinaccreditationwasvoluntaryforAustralianhospitals9.

Certification

Certificationisaprocessbywhichanauthorisedbody,eitheragovernmentalornon-governmentalorganisation,evaluatesandrecogniseseitheranindividual,organisation,objectorprocessasmeetingpre-determinedrequirementsorcriteria.Thepre-determinedrequirementsaresetoutinstandardswhicharedevelopedspecificallyforthepurposeofassessment.Thestandardsassesstheperformanceoftheorganisation,object,processorperson,mayfocusonspecificaspectsofperformanceandmayaddressmorethanlegalrequirements.Theoutputofcertificationisareportsummarisingthefindingsoftheassessmentandarecognitiondecisionregardingthecertificationstatus.

Certificationmaybeusedbygovernmentsorotherauthorisedagenciestoassessthecomplianceofhealthcarefacilitiesorspecificdepartments/serviceswithinthosefacilitieswithasetofstandards.Thefocusisusuallyonessentialelementsbeinginplaceratherthanoncontinuousqualityimprovement.Thestandardsandcertificationmaynotbeorganisation-wide,butmayapplytoaparticularservice,e.g.physiotherapy.Governmentsmayauthoriseindependentassessmentorganisationstoassesshealthandsocialcareproviders’compliancewithgovernment-mandatedstandards.

AnexampleofacertificationschemeisISO:theInternationalOrganizationforStandardization.ISOprovidesstandards,e.g.ISO9000QualityManagement,againstwhichorganisationsorfunctionsmaybecertifiedbyISOaccreditedcertificationbodiesororganisations10.Althoughoriginallydesignedforthemanufacturingindustry,e.g.medicaldevices,thesehavebeenprimarilyappliedtoradiologyandlaboratorysystemsinhealthcare,andmoregenerallytoqualitysystemsinhospitalsandclinicaldepartments.ConformancewithISOstandardsisassessedbyprofessionalqualityauditorsandanynon-conformanceisfollowedupwithasubsequentaudit.

Whenappliedtoindividuals,certificationusuallyimpliesthattheindividualhasreceivedadditionaleducationandtraining,anddemonstratedcompetenceinaspecialtyareabeyondtheminimumrequirementssetforregistrationorlicensing.Forexample,adoctormaybecertifiedbyaprofessionalspecialtyboardinthepracticeofobstetrics8.

Therecanbeconfusionbetweenthetermsaccreditationandcertificationandtheyareoftenusedinterchangeably.However,accreditationusuallyappliesonlytoorganisations,whilecertificationmayapplytoindividuals,aswellasorganisations.



Regulation

Regulationisaformofexternalevaluationbywhichabody,authorisedbylaw,assessesanorganisationorapersonagainstpre-determinedrequirements.Thepre-determinedrequirementsarederivedfromlegislationandtherefore,theregulatormaytakeanumberofactionsintheeventofnon-compliance.

Licensing

Licensingisaprocessbywhichagovernmentalauthoritygrantspermissiontoanindividualpractitionerorhealthorsocialcareorganisationtooperateorengageinanoccupationorprofession.Licensingregulationsaregenerallyestablishedtoensurethatanorganisationorindividualmeetsminimumstandardstoprotectpublichealthandsafety.

Theoutputoflicensingistheawardingofadocumentorlicenceallowinganorganisationorpersontoprovideaservicewithinaspecifiedscope.

Organisationallicensingorregistrationisgrantedfollowinganon-siteinspectiontodetermineifminimumhealthandsafetystandardshavebeenmet.Maintenanceofregistrationorlicensureisanongoingrequirementforthehealthorsocialcareorganisationtocontinuetooperateandcareforpatientsorclients.

Individualorprofessionallicensingorregistrationisusuallygrantedaftersomeformofexaminationorproofofeducationandmayberenewedperiodicallythroughpaymentofafeeand/orproofofcontinuingeducationorprofessionalcompetence8.

Countriesmayhavemorethanonemodelofexternalevaluationinoperationinspecificsectors.Forexample,hospitalsmayberequiredtobelicensedandmeetspecificgovernment-mandatedstandardsinordertobeabletoprovidehealthservicesinaparticularcountry,butmaystillengagevoluntarilyinorganisationalaccreditationorcertificationprogrammesforspecificdepartmentsinthefacilitye.g.laboratorycertificationprogrammes.Individualhealthcarepractitionersmayneedtoberegisteredwiththeirprofessionalbodyinordertobeemployedinahospitalbuttheymayalsovoluntarilyundergoadditionaleducationinordertobecertifiedinarespectivefieldbyaprofessionalspecialtyboard.

Thekeycharacteristicsofaccreditation,licensingandcertificationaresetoutinTable1.

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Table 1: Definitions of accreditation, certification and licensing

Process Participation Issuing organisation

Object of evaluation

Components / Requirements

Standards

Accreditation Voluntaryormandatory

Non-governmentalorganisation(NGO)orgovernmentauthority

Organisation Compliancewithpublishedstandards,on-siteevaluation;compliancemaynotberequiredbylawand/orrequlations

Setatamaximumleveltostimulateimprovementovertime

Certification Voluntaryormandatory

Authorisedbody,eithergovernmentorNGO

Individual Evaluationofpre-determinedrequirements,additionaleducation/training,demonstratedcompetenceinspecialityarea

Setbynationalprofessionalorspecialityboards

Organisationorcomponent

Demonstrationthattheorganisationhasadditionalservices,technologyorcapacity

Industrystandards(e.g.ISO9000standards)evaluateconformancetodesignspecifications

Licensing Mandatory Governmentalauthority

Individual Regulationstoensureminimumstandards,exam,orproofofeducation/competence

SetataminimumleveltoensureanenvironmentwithminimumrisktohealthandsafetyOrganisation Regulationsto

ensureminimumstandards,on-siteinspection

1.3 Benefits of external evaluation

Externalevaluationhascontributedtoimprovingthequalityandsafetyofhealthcarefornearly100yearsandthemajorityofthepublishedliteraturerelatestoaccreditation.Researchonthebenefitsofcertification,regulationandlicensingissparse.Itmustbeacknowledgedthathistoricallytherehasbeenlimitedevidenceoftheimpactofaccreditationbutinrecentyearsmoreempiricalresearchhasbeenundertakentoidentifyandquantifythebenefits.

Someofthespecificbenefitsofaccreditationidentifiedintheliteratureincludeimpactsonstructuralelementsofqualityimprovementinhealthcareorganisationssuchasleadership,governanceandmanagement,andprocesselementssuchasorganisationalperformance11.



Fromaleadership,governanceandmanagementperspective,accreditationisperceivedas:providingaframeworkforhelpingtocreateandimplementsystemsandprocessesthatimproveoperationaleffectivenessandadvancepositivehealthoutcomes;providingorganisationswithawell-definedvisionforsustainablequalityimprovementinitiatives;andasameansofdemonstratingcredibilityandacommitmenttoqualityandaccountability.

Fromanorganisationalperformanceperspective,someoftheidentifiedbenefitsinclude:

Increaseshealthcareorganisations’compliancewithqualityandsafetystandards

Stimulatessustainablequalityimprovementeffortsandcontinuouslyraisesthebarwithregardtoqualityimprovementinitiatives,policiesandprocesses

Decreasesvariancesinpracticeamonghealthcareprovidersanddecision-makers

Highlightspracticesthatareworkingwell.Promotesthesharingofpolicies,proceduresandbestpracticesamonghealthcareorganisations11.

Accreditationhasalsobeenperceivedashavinganimpactonteamworkingbystrengtheninginterdisciplinaryteameffectivenessandpromotingcapacitybuilding,professionaldevelopmentandorganisationallearning11.

Similarly,arecentsynthesisof122empiricalstudiesthatexaminedeithertheprocessesorimpactsofaccreditationprogrammesconcludedthatresearchevidencegenerallypresentshealthserviceaccreditationasausefultooltostimulateimprovementinhealthserviceorganisationsandtopromotehighqualityorganisationprocesses.Someofthecitedstudiesfoundthataccreditationpromotesstandardisationofcareprocesses;increasedcompliancewithexternalprogrammesorguidelines;developmentoforganisationalculturesconducivetoqualityandsafety;implementationofcontinuousqualityimprovement(CQI)activities;andsuperiorleadership.Therewaslimitedevidenceshowingpositiveassociationsbetweenaccreditationandpatientoutcomemeasures.However,thiswasattributedtopoorresearchdesign12.

Acomparisonofaccreditationinlow-andmiddle-incomecountriesversushigher-incomecountriesshowedallprogrammespromoteimprovements,applystandardsandprovidefeedback.Accreditationprogrammesarecontributingtoincrementalimprovementsinqualitysystemsandclinicalprocessesinhealthsystemsaroundtheworldandareoneelementoftheinstitutionalbasisforhigh-qualityhealthcare7.

Arecentreviewexaminingtheuseofeconomicevaluationtechniquesinhealthservicesaccreditationresearchidentifiedthatnoformaleconomicevaluationofhealthservicesaccreditationhasbeencarriedouttodate.Italsohighlightedthattheimpactoreffectivenessofaccreditationhasbeenresearchedwithavarietyoffociandtodifferingdegrees.Theresearchdesignofsomestudies,particularlythosethatareobservationalorqualitativeinnature,makesitdifficulttoprovidestatisticallyrobustevidencefortheefficacyofaccreditationorcausality.Thelackofaclearrelationshipbetweenaccreditationandtheoutcomesmeasuredinbenefitstudiesmakesitdifficulttodesignandconducteconomicappraisalstudieswhereamorerobustunderstandingofthecostsandbenefitsinvolvedisrequired.Inturn,theabsenceofformaleconomicappraisalmeansitischallengingtoappraiseaccreditationincomparisontoothermethodstoimprovepatientsafetyandqualityofcare13.

Whiletheevidenceforthedirectimpactofaccreditationonpatient/clientoutcomesisinconclusive,theavailableresearchsuggeststhataccreditationmaycontributetoimprovinghealthoutcomesbystrengtheninginterdisciplinaryteameffectivenessandcommunicationandbyenhancingtheuseofindicatorsforevidence-baseddecisionmaking14.Thechallengeformatureexternalevaluationsystemsistobecomemoreoutcomedriven.Thisreducestheburdenofauditbutalsohelpstohighlightitsbenefits.

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1.4 Challenges for external evaluation programmes

Theprincipalthreatstonewexternalevaluationprogrammesinclude:inconsistencyofgovernmentpolicy;unstablepolitics;unrealisticexpectations;andlackofprofessional/stakeholdersupport,continuingfinanceand/orincentives.Tobesustainable,externalevaluationprogrammesneedanumberofelementstobeinplace,includingsomeofthefollowing:ongoinggovernmentand/orprivatesupport;asufficientlylargehealthorsocialcaremarketsize;stableprogrammefunding;diverseincentivestoencourageparticipation;andcontinualrefinementandimprovementintheexternalevaluationorganisation’soperationsandservicedelivery15(referChapter2).

Tobesustainableandcredible,newprogrammesneedsufficientnumbersoftrainedandskilledpersonnelandarealistictimeframeforthedevelopmentoftheprogramme.Theyneedtodemonstrateobjectivityandindependencewithtransparentproceduresfortheassessmentofhealthcareservicesandfordecisionsonaccreditationorcertificationawards.Theexpectationsofgovernmentsandstakeholdersaboutwhattheexternalevaluationprogrammecanachieveneedtoberealistic,inlinewiththepurposeandscopeforwhichithasbeendesignedandresourced,andinlinewiththegovernment’sbroaderstrategyorpolicyforhealthcarequalityandsafety.Withinthatstrategyorpolicythereneedstobeabalancebetweentheobjectivesofexternalcontrolorregulationandinternalorganisationaldevelopmentorimprovement.Attemptstoprescribeandcontroleveryprocessofacomplexsystemlikeahealthcareorganisationorservice,whichcannotbeunderstoodassimplyasumofanumberofdiscreteandpredictableprocesses,willevokeresistancefromstaff,andcanbecounterproductiveintermsofqualityandsafety.Healthandsocialcarestaffneedtobemotivatedandcommittedtoimprovingqualityratherthandirectedandsanctioned.

Expectationsofaccreditedorcertifiedhealthorsocialcareservicescanbeunrealisticallyhigh.Theexternalassessmentoforganisationsforthepurposesofaccreditationorcertificationisbasedonanon-sitesurveyorassessmentofcompliancewith,orachievementof,standards.Thisisasnapshotintimeanddoesnotguarantee,norisitmeanttoguarantee,ongoingperformanceatthesamelevel.However,externalevaluationorganisationswhothemselvesengageinanexternalevaluationprocess,suchasISQua’sInternationalAccreditationProgramme(IAP)areexpected,aspartofthisprocesstomonitorthecontinuedmaintenanceofstandardsandqualityimprovementsbytheorganisationstheyhaveaccreditedorcertified,e.g.submissionofactionplansandreportsoftheirimplementation,periodicself-assessmentorexternalreviews,randomreviews,follow-upofsignificantcomplaintsorsentinelevents.

Giventheamountofeffortandmoneyinvestedworldwideinexternalevaluationandregulationofhealthcaredelivery,andthecommonpursuitofvalidstandardsandreliablemeasurement,thereareeconomicandtechnicalreasonstoshareresearchandexperiencemoreactivelyintheinternationalcommunity.

AstudycomparingEuropeanhospitalsintermsofqualityandsafetywasfoundtobechallengingbecauseofthedifferenthospitalaccreditationandlicensingsystemsineachcountry;thedifferentindicatorscollected;differentdefinitionsofthesameindicators;differentmandatoryversusvoluntarydatacollectionrequirements;differenttypesoforganisationsoverseeingdatacollection;differentlevelsofaggregationofdata(country,region,hospital);anddifferentlevelsofpublicaccesstosuchdata.



Thismeansthatpatientsareunabletomakeinformedchoicesaboutwheretheyreceivetheirhealthcareindifferentcountriesandsomegovernmentswillremaininthedarkaboutthequalityandsafetyofcareavailabletotheircitizensascomparedtothatavailableinneighbouringcountries16.

Ongoingresearchisneededintothebenefitsandlimitationsofexternalevaluationinhealthcare.Tomeasuretheimpactofanynewprogramme,beforeandaftermeasurementsareneededoftheindicatorsthattheprogrammeisintendedtoaddress.

Thischapterhasintroduceddifferentexternalevaluationmodelsandhasoutlinedthebenefitsofexternalevaluationandthechallengesassociatedwithestablishinganewprogramme.Thefollowingchapterswillpresentthefactorsthatneedtobeconsideredwhendecidingwhichexternalevaluationmodeltoadoptinacountryandthestepstobeundertakenwhensettingupanexternalevaluationorganisationandprogramme.

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Chapter 2: Establishing the FundamentalsThischapteroutlinestheinitialdecisionsthatneedtobemadewhenanewexternalevaluationprogrammeisbeingestablished:thepurposeoftheprogramme;itsscope;theroleofgovernment;andtheincentivesthatmaybeneededtoensurehealthandsocialcareorganisationsparticipate.Italsohighlightstheimportanceofidentifyingwhothemainstakeholdersmaybeandwhatexternalinfluencesfortheprogrammewilllooklike.

2.1 Defining the purpose of the external evaluation programme

Oneofthefirststepsinthedevelopmentofanewexternalevaluationprogrammeistodetermineitspurpose.

Factorstoconsiderindeterminingthepurposeofanexternalevaluationprogrammeororganisationincludethefollowing:

Developmental or regulatory

AccordingtotheWorldBank17,governmentsregulatehealthservicesinordertoguideprivateactivityandachievenationalhealthobjectives.Regulationcanbeusedforcontrol,withinstrumentsthatusetheforceoflawtoensurethatservicesprovidedadheretolegalrequirements.Instrumentsthataimtocontrolinclude:licensing,restrictionsondangerousclinicalpracticeandregistration.Examplesinclude:basiclegislationonhealthpersonnelsuchasregistrationandlicensingrequirements,whichcanalsobeusedtosetminimumrequirementsforhealthservicesorfacilitiestooperate.Regulationcanalsousefinancialornon-financialincentivesthatchangethebehaviourofprivatehealthcareproviders.Theadvantagesofusingincentive-basedregulationisthatitavoidstheinformational,administrativeandpoliticalconstraintsthatcontrol-basedinterventionsentail.Accreditation,certificationandcontractsareexamplesofincentive-basedregulation.However,indevelopingcountries,regulationisoftenineffectivebecauseofthelowlevelofenforcementandinsufficientresources.

Standards-based external evaluation

Standards-basedaccreditationisaprogrammethatcontributestodevelopinganorganisation,andisdesignedtoimprovethequalityaswellasthesafetyofhealthservices.

Accreditationprogrammesmonitorandpromote,viaselfandexternalassessment,healthcareorganisationperformanceagainstpre-determinedoptimalstandards18.Theyalsoaimtocontributetotheprovisionofhighqualityandsafehealthcareservicesandtoimprovepatienthealthoutcomes.

Certificationmaybesimilarlystandards-basedandusearatingsystemthatencouragesimprovementovertimebutitsfocusisusuallymoreoncontinuingcompliancewithcriteriaandthestandardsmaybemorelimited.Licensingmaybeusedwhenthepriorityisensuringbasichealthandsafetyrequirementsaremetinorderforahealthcareorganisationtooperateandwillusuallybefacilityfocused.



Values and objectives underpinning a new programme

Asurveyofhealthcareaccreditationorganisationsrevealedthatqualityimprovementwasthereasonhealthcareorganisationsparticipatedinaccreditation.Ontheotherhand,thegovernmentagendacommonlyfocusedmoreontheprotectionofpublicmoneyandpublichealthasapriority,meaningreducingvariationinpracticetoincreaseefficiencyandimprovepatientsafety,consistentwithWHOglobalinitiatives15.

Valuesorprinciplesmayrelatetofeaturessuchasleadership,asystemandprocessapproach,multidisciplinaryteamwork,capacitybuildingandtraining,patientcentredness,devolveddecision-makingandaccountability,evidence-baseddecisionsforcontinuousimprovementandperformance-basedincentives.

Objectivesofexternalevaluationprogrammesidentifiedinsomedevelopingcountrieshaveincluded:improvingleadershipofaqualityhealthsystem;improvingresourcesandcapacityofthesystemandstaff;improvingperformancebyclearlydefiningtherolesandresponsibilitiesofstaffatalllevels;developingthestructures,systemsandcapacitytosupportqualityimprovement;strengtheningthefocusandroleofhealthserviceconsumersandotherstakeholders;andimprovinghealthservicesthroughsystematicimplementationofstandards.

Thefollowingtablecomparescapacitybuildingandregulatoryexternalevaluationapproaches15.

Table 2: Comparison of capacity building and regulatory external evaluation

Capacity building Regulatory

Purpose Dynamic,organisationalimprovement

Static,control

Terminology Accreditation,certification Licensing,regulation

Governance Non-governmentalorganisation,stakeholders

National/regionalgovernmentagency

PrimaryCustomers Healthcareproviders Government

Secondarycustomers Patients,professions,healthcareinsurers

Population,politicians,publicfinance

Incentivesforhealthcareorganisationstoparticipate

Ethical,commercial Legal,mandatory

Uptake Voluntaryself-selectiontoavailableprograms

Allinstitutionsinallsectors

Standards Definedbynon-governmentalorganisation,optimal,achievable,encouragequalityimprovement

Definedbyregulation,minimalacceptable

Funding Self-financing State

Cross-bordermobility Limitedbylanguage,culture Limitedbypoliticalborders

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Possiblepurposesorobjectivesofanexternalevaluationprogrammemightbeto:

Improvetheperformanceofhealthservicesbysettingandmeasuringtheachievementofstandards

Increasepublicsafetyandreducerisksassociatedwithinjuryandinfectionsforpatients/clientsandstaff

Increasepublicconfidenceinthequalityofhealthcareservices

Promoteaccountabilityofhealthservicestofundersandthepublic.

How do these values and objectives relate to plans for health reform in general, and to the national quality strategy in particular?

Thenextimportantstepistoidentifyifthereareplansforhealthand/orsocialcarereforminthecountryorregionandifthereareanynationalorregionalqualitystrategiesorplansinplace.Reformplansoutlinethechangesthatagovernmentintendstomaketoaparticularsectorandoutlinesthespecificactionsthatitwilltaketoachievethosereforms.Forexample,agovernmentmayoutlineinareformplanthatitintendstoestablishanexternalevaluationorganisationandwhattheroleorpurposeofthisorganisationwillbe.Aqualitystrategyprovidesanagreeddirectionandidentifiesthemostimportantactivitiesforimprovingqualityinthehealthandsocialcaresectorinthecountryorregion.Ithelpstoidentifythestrengthsofthesystemandalsotheconstraintsthatpreventtheprovisionofaqualityservice.Aqualitystrategymayoutlinetheroleorwillhelptoidentifyorclarifytherolethatexternalevaluationisexpectedtoplayinachievingthecountryorregion’squalityvision.

Thesefactorswillguideallfurtherdecisions-theroleofthegovernment,relationshipswithstakeholders,thegovernanceandmanagementframework,thestandardsorcriteriatobeusedforassessment,theassessmentprocess,andtheoutcomeoflicensing,certificationoraccreditation.

Thecasestudyexamplesbelowprovidefurtherinsightintothefactorsthatinfluencedtheestablishmentofexternalevaluationagenciesindifferentjurisdictions.



Case Studies – Foundation of the programme

IKAS – Danish Institute for Quality and Accreditation in Healthcare Country: DenmarkTheDanishaccreditationprogramme(DDKM)wasestablishedaspartofthe“NationalStrategyforQualityDevelopmentintheHealthcareSystem–JointGoalsandActionPlan2002-2006”.Thestrategywasdevelopedbythenational,regionalandlocalpoliticalauthoritiesincooperationwithstakeholderorganisations,representingprofessionalsandconsumers.

Atthattime,anumberofhospitalsalreadyhadpositiveexperienceswithaccreditationprovidedbyinternationalaccreditors–oneoftheintentionsofthestrategywastospreadthistotheentirehealthcaresystem,basedonaDanishmodel.

Health Care Accreditation Council (HCAC) Country: JordanTheHCACisthenationalhealthcareaccreditationagencyofJordan.Severalreasonswerestatedforwhytheprogrammewasdevelopedincludingtoimprovethequalityofhospitalsandtoenhancemedicaltourism.Inaddition,itwasaresponsetopubliccomplaintsofpoorqualityofcareandaneedtoimprovetheentirehealthcaresysteminthecountry.

Health and Disability Auditing New Zealand Ltd (HDANZ) Country: New ZealandThecommencementoftheHealthandDisabilityServices(Safety)Acton1July2002representedasignificantchangeintheregulatoryenvironmentintheNewZealandhealthanddisabilitysector.ThisActreplacedseveralpreviouspiecesoflegislationandchangedthewayinwhichresidentialandhospitalserviceswerelicensedorregistered.Inaddition,theActintroducedhealthanddisabilitystandardsforhospitals,resthomesandresidentialdisabilityservicesaimedatimprovingsafetylevelsandqualityofcarethatbecamemandatoryfrom1October2004.TheActrequiredthatdesignatedauditagencies(DAAs)areapprovedbytheDirectorGeneralofHealthforthepurposeofauditingtheseservicestothosestandards.

2.2 Defining the scope of the external evaluation programme

Oncethepurposeisestablisheditisimportanttodefinetheinitialscopeoftheprogramme.Thepurposeofanewexternalevaluationprogrammemaydependonthegovernment’spriorities,thenationalhealthreformorqualitystrategies,availablefunding,thecommitmentofstakeholdersandtheproblemsorissuesthatneedtobeaddressed.

Factorstoconsiderindefiningthescopeoftheexternalevaluationprogrammeincludethefollowing:

Primary or hospital care?

Traditionally,accreditationhasbeendevelopedforhospitalsoragedcarefacilitiesandthenmovedoutwardstowardshomesupport,hospiceandothercommunityservicesandthentoregionalnetworksornetworksofpreventiveandcurativeservices.

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However,indevelopingcountriesthemosturgentneedmaybeforimprovedprimaryandcommunitycareandtheprogrammewillinitiallybedevelopedtocoverprimarycareclinicsandoutreachservices,althoughtheremaybesomeresourceadvantagesindevelopingprimarycareandhospitalprogrammesatthesametime.

Oftenitiseasiertodevelopfacilitiesbasedprogrammesfirst,startingwithcorestandardsandexternalevaluationforsingleinstitutions,e.g.acutehospitals,polyclinicsorhealthcentres.Standardscanthenbedevelopedformorespecialisedservices,e.g.resthomesorhospicecareormentalhealth,followedbythelinkagesbetweenthem,preventivehealthorhealthnetworks,andtheycanthenbecoveredbytheprogramme.Assessmentofsingleunits,servicesordepartmentscouldofferlargeorganisationsagradualentrytoafullprogrammebutitdoesnotcarrythebenefitsofintegrationandorganisationconsistency.Itmayhidetheopportunitiesforimprovementwhichfrequentlylieincommunicationbetweenservicesratherthanwithinthem.However,therearemanyservicespecificexternalevaluationprogrammeswhichareoperatedeitherbyalargergenericprogramme,orbyaproviderorassociationwhichworksonlyinthatarea,e.g.palliativecare,laboratorymedicine,speechtherapy,autism,generalpractice,agedcare,andcommunityservices.

Someprogrammeshavestartedwithtertiaryhospitalsandservices,withtheintentionofexpandingtosecondarycareserviceslater.SomeprogrammesinNorthAmerica(e.g.AccreditationCanada)accreditentirehealthnetworksandregionsandareapplyingaccreditationacrossthecontinuumofcare.SomegovernmentalprogrammesinEuropeaddresspublichealthpriorities(suchascardiachealth,cancerservices)byassessinglocalperformanceofpreventivetotertiaryservicesagainstnationalserviceframeworks.Insuchprogrammes,measuresmayincludetheapplicationofevidence-basedmedicine(process)andthemeasurementofpopulationhealthgain(outcome)butmanyhealthdeterminants,e.g.housing,educationandpoverty,remainoutsidethescopeofhealthcareexternalevaluationprogrammes.

However,currentbestpracticeistoprovideaprogrammethatfocusesonthepatientorclientandtheirjourneythroughtheservice,hospital,networkorcareprogrammeandthecontinuityofserviceorcareforthatindividualorfamilyacrosstheentirecontinuumofcare.

Historically,externalevaluationprogrammeshavesettheirscopeinawaywhichcompartmentalisescareandserviceratherthanoptimisingqualityoutcomesforthepatientorclient.

Public or Private coverage?

Mostexternalevaluationprogrammesofferservicestobothpublicandprivatesectorservices,althoughsomearerestrictedtoeitherthepublicorprivatesector.Evaluatingacrosssectorshasadvantagestohealthcareorganisationsinfacilitatingthefocusonthepatientorclientjourney,providingalevelplayingfieldforcomparingandbenchmarkingpotentialcompetitors,tosurveyorsinlearningfromanothersectorandtoself-financingprogrammesinhavingalargerpotentialmarket.Sometimeseithertheprivateorpublicsectorhasthesize,resourcesandincentivessuchasfundingincentives,medicalinsuranceandcompetitiveadvantagetoadoptanexternalevaluationprogrammeearlier.Medicaltourismisanotherlargeincentive.Toattractpatientswhoarecrossingnationalbordersinsearchofaffordableandtimelyhealthcare,privateandpublichealthservicesneedaccreditationorcertificationtodemonstratetheircompetenceandsafety.



Manymedicaltourismcompaniesarenowinvolvedinorganisingcross-borderhealthservicesandithasbeenrecommendedthatthecaretheyarrangeshouldonlybeataccreditedinternationalhealthfacilities.Otherrecommendationsincludethemedicaltourismcompaniesthemselveshavingtoundergoanaccreditationreview;standardstoensurepatientsmakeinformedchoices;andcontinuityofcareasanintegralfeatureofcross-bordercare19.

Thecasestudiesprovidesomefurtherinsightsintohowthescopeofexternalevaluationagenciesindifferentjurisdictionswasdetermined.

Case Studies – Scope of the programme

IKAS – Danish Institute for Quality and Accreditation in Healthcare Country: DenmarkPublicandprivatehospitals,pharmacies,municipalities(primarycareservices,includinglong-termcare),ambulanceprovidersandGeneralPractitioners(GPs)allparticipateinDDKM.

Health Care Accreditation Council (HCAC) Country: JordanTheHCACisthenationalhealthcareaccreditationagencyofJordan.Theorganisationsetsstandardsforhospitals,primaryhealthcarecentres,familyplanningandreproductivehealth,transportservices(ambulances),cardiaccare,anddiabetesmellitus.HCACsurveysagainstthestandardsandawardsaccreditation.HCACalsoprovidesconsultationandeducationtopreparehealthcarefacilitiesforaccreditationandofferscertificationcourses.

Health and Disability Auditing New Zealand Ltd (HDANZ) Country: New ZealandThecommencementoftheHealthandDisabilityServices(Safety)Acton1July2002representedasignificantchangeintheregulatoryenvironmentintheNewZealandhealthanddisabilitysector.ThisActreplacedseveralpreviouspiecesoflegislationandchangedthewayinwhichresidentialandhospitalserviceswerelicensedorregistered.HDANZ’sscopewasdeterminedbytheSafetyAct–theassessmentofstandardsisalegalrequirementforpublicandprivatehospitals,resthomesandresidentialdisabilityservices.StandardsNewZealand(SNZ)isresponsiblefortheNewZealandstandardsandthisincludesotherssuchasforhomesupport,alliedhealth,anddaysurgeryprocedures.

Critical mass: economy, consistency, equity, objectivity

Largercountriescanachieveeconomiesofscale;smallercountries(perhapswithapopulationoflessthan5million),orlargeoneswhichchoosetodevolvetheprocesstoregionalgovernment,e.g.Italy,orethnicgroups,e.g.Aboriginal,havetosharetheconsiderablecostsofinfrastructureanddevelopmentamongasmallernumberofhealthcareorganisations(givinghigherunitcosts).Ifthesurveyorworkforceisvoluntary,thismayalsomeanhavingasmallerchoiceofsurveyors(givingmorepotentialforconflictofinterest).However,thereareoptionssuchascontractingoremployingasmallerpaidsurveyorworkforceorcontractingsurveyorsfromothercountriesforsurveys.

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Otheroptionsforenhancingtheopportunitiesforsmallerprogrammesinclude:

Sharingaprogrammewithaneighbouringregionorstatewhichhassimilarcultureandlanguage

Designingonenationalprogramme,ratherthanseveralregionalones

Providingnationalstandards,guidelinesortoolsforregionalagenciesordesignatedassessmentorganisations

Usingasingleorganisationtoprovidemultipleaccreditationprogrammes

Usingthesameorganisationoragencyasacentreforresearchanddevelopmentofotherqualitymethods,e.g.performanceindicators,clinicalguidelines,patientsurveys,technologicalassessment

Obtainingaccreditationservicesfromanotherregionorstate.

2.3 Establishing the role of government

Thedevelopmentofanexternalevaluationprogrammemaybepartofbroaderhealthreforms,orpartofanoverallgovernmentalstrategyforqualityimprovementandatransitionfromacentralisedsystemtoonewhichismoreopenandindependent.Itmaybenecessaryforthehealthministrytore-defineitsowndutiesandresponsibilitiesinthecontextofareformedorganisationalstructureofthehealthsystem.

Therelationshipsbetweendepartmentsofgovernmentwhichhaveamajorimpactonqualitymaybeunclear.Therolesofagenciesresponsibleforsuchareasaspublichealth,bloodproducts,pharmaceuticalsormedicaldevicesandinspectoratesresponsibleforsuchaspectsascontroloftheenvironment,safety,radiationatnationalorlocallevelneedtobeclarifiedaspartoftheoverallqualityplan.Disseminationofthisstructureandplanwouldalsoprovideanopportunitytodevelopastrategyforactivecommunicationoftheaimsandoperationofanintegratedqualitysystem.

Government controlled or not?

Specifictoexternalevaluationisthequestionofwhethertheprogrammeshouldbeorganisedandadministereddirectlyandsolelywithintheministryofhealth,likelicensing,orbyanindependentbodytotallyunconnectedtogovernment,orbysomethingbetweenthesetwoextremes–whichhasbecomemorecommon.Thelegitimateandnecessaryroleofgovernmentisthelicensingofhealthcarefacilities,usingbasicsafetystandardsorcriteria.Licensingofindividualmedicalpractitionersmaybeagovernmentfunctionbutisusuallycarriedoutbyamedicalcouncil.However,therearechallengesforgovernmentalexternalevaluationprogrammeswhichinclude:

Inconsistentpolicyandmanagementwithchangesingovernment

Reviewingandupdatingstandardsconsistentlyandinatimelyway

Publicperceptionofgovernmentthatistoolowtomakethemcredibleassessorsofhealthcare

Conflictofinterestbetweengovernmentrolesaspurchaser,regulatorandinsurer,andlackofindependenceandcontinuity

Delegationofpowerstolocalareas,whichmayresultinmultiplegovernmentprogrammesduplicatingdevelopmentandongoingcostsofrunningtheprogrammes.



Somecountries,suchasFranceandSaudiArabia,havemadeparticipationinaccreditationbyhealthcareorganisationslegallycompulsory,butmostcountriesmerelyauthorisethefunctionsoftheexternalevaluationorganisation.Two-thirdsofaccreditationorganisationssurveyedin2010weresupportedbyenablinglegislation.However,manyindependentprogrammesthrivewithoutit.Fiveaccreditationorganisationswerestrugglingorinactive,despitebeingsupportedbyapublishedgovernmentstrategy.Ifenablinglegislationisnotessentialandnationalstrategiesoftenchangewithministersandgovernments,externalevaluationorganisationsmustchoosereliablepartnersforsurvival15.

Need for government support

Tobesuccessful,externalevaluationprogrammesoftenneedgovernmentsupportandcollaborationandtoberecognisedasanimportantpartofthenationalhealthqualitystrategy.Thesupportmaybethroughfunding,providingincentivesforparticipantssuchaslimitingotherformsofinspectionoraudit,orrecognisingtheprogrammesasalegitimateandessentialpartoftheoverallhealthqualitystrategy.

Somefunctions,suchasthedefinitionofstandards,theassessmentofcomplianceandthegradingofawardsmaybetotallyindependentormaybesharedbetweengovernmentandindependentexternalevaluationorganisations.Somegovernments,forexample,NewZealand,havedevelopedorapprovedstandardsthattheyrequirehealthcareorganisationstomeet.However,thegovernmenthavedevolvedtheprocessofassessmentofcompliancewiththestandardsandfollow-uptoensurethestandardsarebeingmaintainedtoindependentdesignatedauditing,accreditationorcertificationorganisations.Theseorganisationsinturnneedtobeinternationallyrecognisedbya3rdpartyaccreditorsuchasISQua.InAustralia,asimilarsystemoperatesthroughtheAustralianCommissiononSafetyandQualityinHealthCarewhichhasdevelopednationalqualityandsafetystandards.Theaccreditationofhealthcareorganisationswhomeetthenationalqualityandsafetystandardshasbeendevolved.

Themandatoryrequirementforexternalevaluation,asintheaboveexamples,isanincreasingtrendasgovernmentsseektoimprovethequalityandsafetyofhealthservices.

Keyroleswhichgovernmentsmightplayinsupportingexternalevaluationinclude:

Enablingtheexternalevaluationprocess,e.g.throughpolicydecisionssuchasbyreciprocalrecognitionofassessments;jointdevelopmentofstandards;avoidingconflictsuchasperverseincentivesandcompetingmechanismsforassessment

Providingleverage,e.g.byaccordingpreferencetoaccreditedorcertifiedfacilities,servicesornetworkssuchasreimbursementtariffsandpaymentprocedures

Usingaccreditationorcertificationasacriterioninitsownpurchasingdecisions,e.g.indefiningpreferredprovidersandcontractmonitoring

Regulatingindividualsandinstitutions,e.g.byensuringconsistencyanddistinctionbetweenlicensingandaccreditation

Acknowledgingorendorsingaccreditationorcertificationprogrammesagainstdefinedcriteriatomaintainstandards,avoidduplicationandpotentialexploitation

Providingfinancialsupportinestablishingprogrammesand/orcontributingtothefundingofprogrammes’continuingdevelopment.

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Theextentofgovernmentsupportandinvolvementintheexternalevaluationprogrammemayalsodependonthecountry’soverallstageofdevelopment.Indevelopingcountries,wheretheremaybeamorelimitedhealthindustryorwhereprofessionalorganisationsmaynothavetheresourcesorfinancialcapacitytoinitiateanexternalevaluationprogramme,governmentorganisationsmaybeneededtoestablishsuchprogrammes.Forexample,inKenya,theNationalHealthInsuranceFund(theinsurer)managesaccreditation;theirstandards,knownastheKenyaQualityModel,weredevelopedbyabroadcoalitionofprofessionalsoutsideoftheInsuranceFundandaresupportedbytheMinistryofHealth.InGhanainWestAfrica,theNationalHealthInsuranceSchemeoriginallyplacedresponsibilityforaccreditationwithingovernment;thattaskisnowbeingtransferredtoanindependentbody20.

Thecasestudieshighlightthenatureoftherelationshipsbetweenexternalevaluationagenciesandgovernmentsindifferentjurisdictions.

Case Studies – Role of the government

IKAS – Danish Institute for Quality and Accreditation in Healthcare Country: DenmarkIKASandtheDanishaccreditationprogramme(DDKM)wereestablishedbyanagreementbetweentheregionalandlocalpoliticalauthorities,whoareresponsiblefordeliveringhealthcare,andthenationalgovernmentthatsetstheoverarchingpoliticalpriorities,includingtheeconomicframe,andisthehealthcarelegislatorandregulator.ThefirststepinthedevelopmentofDDKMwasthedevelopmentofacooperationagreementbetweenthegovernmentandtheregionsofajointmodelforqualityassessmentwhichincludedprovisionsforthefundingforDDKM.IKASisaformalindependentorganisationbutthegovernmentprovidespartofthefundingforIKAS.

Health Care Accreditation Council (HCAC) Country: JordanTheHCACisaprivate,not-for-profitshareholdingcompanyregisteredundertheMinistryofTradeandIndustry.

Health and Disability Auditing New Zealand Ltd (HDANZ) Country: New ZealandTheSafetyActrequiredthatdesignatedauditagencies(DAAs)whomonitorcompliancewithhealthanddisabilitystandardsforhospitals,resthomesandresidentialdisabilityservicesareapprovedbytheDirectorGeneralofHealthforthepurposeofauditingtheseservicestothosestandards.HDANZisaprivate,independentlyownedcompany.ItislinkedtogovernmentasaMinistryofHealth(MOH)approveddesignatedauditingagencyandfortheseservicesHDANZsubmitstheauditreporttotheMoHwhoissuesthecertificate.HDANZwasdesignatedasanapproveddesignatedauditingagencyinOctober2002.



2.4 Determining incentives

Iftheexternalevaluationprogrammeisnotmandatory,evidencesuggeststhatincentivesareusefultopromoteandsustainit.Possibleincentivesforhealthcareorganisationstoparticipateinanexternalevaluationprogrammeinclude:

Organisationaldevelopment:self-assessment,team-building,benchmarking,guidedpathways

Increasedpublicfundingsuchashealthinsurancefundpaymentsmoderatedbyaccreditationorcertificationstatus,additionalgovernmentsubsidy,e.g.peraccreditedorcertifiedbed,orsomeotherlinkagetocorefundingorreimbursement

Effectiveexchangeofdatabetweenexternalevaluationprogrammesandinsuranceprogrammestoinformtheirpurchasingdecisionsandpayments

Preferencefromprivateinsurers:insurersprefertodealwithfacilitiesorserviceswhoseclinicalandmanagementprocesseshavebeenindependentlyverified;theyalsomakereimbursementsimplerandfasterforsuchorganisations

Marketadvantage:publicrecognitionbringsstatusandadvantageinacompetitivemarketwhichcanattractpatients/clients,staffandincome

Reductionofliabilityinsurancecosts:premiumsreflectreducedriskrating

Exemptionsfromregulatoryinspection:e.g.thestateissuesalicencetoanaccreditedorcertifiedfacilityonthebasisthataccreditationorcertificationstandardsincludeandexceedlicensingstandards(“deemedstatus”);thismaybeaconditionofreceivingpublicfunding

Linkagetotrainingposts:statusconditionalonaccreditationorcertification

Nationalqualitycompetitions:forexample,makingaccreditationorcertificationstatusoneofthejudgingcriteria.

Healthcareorganisationsmaybediscouragedfromparticipatinginanexternalevaluationprogrammeby:

Thecostintermsoftime,management,andmoney

Fearsabouttheoutcome-sanctionsforshortcomings,lossofstaffmoraleifdeniedtheawardofaccreditationorcertification,misuseofperformancedata,andofgainingtheawardandthenlosingitwhenstandardsgetmoredemanding

Lackofrecognitionfortheresourcesinvested

Lackofinformationaboutthebenefits

Resistancefromhealthcareprofessionalsandotherstaffandthefailuretorecruitclinicalandotherstaffchampions

Thedifficultiesofeffectingculturechangewithoutexternalsupportand

Failuretorecogniseandcelebratetheachievementsofparticipatingorganisations.

Considerationalsoneedstobegivenatthistimetotheissueofconsequenceswhenorganisationsdonotachieveormeettheaccreditationorcertificationstandardstotheacceptablelevel.Whataretheconsequences,ifany,fortheseorganisations?Forexample,dotheconsequencesincludefinancialsanctions?

Thecasestudiesprovideexamplesofsomeoftheincentivesputinplaceforexternalevaluationprogrammes.

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Case Studies – Incentives for external evaluation programmes

IKAS – Danish Institute for Quality and Accreditation in Healthcare Country: DenmarkDDKM(Danishaccreditationprogramme)isnotrequiredbyanylegislation,butisbasedonagreementsasfollows:

Publichospitals:allhospitalsparticipatebyagreementbetweenNationalandRegionalgovernments

Privatehospitals:voluntary,butparticipationisaprerequisitetoobtainacontracttotreatpatientsfortheregions(alsorequiredbysomeinsurancecompanies)

Pharmacies:voluntary,financialincentiveinplace

Municipalities(primarycareservices,includinglong-termcare):voluntary,noincentivesinplace

Ambulanceoperators:prerequisitetoobtaincontractwithRegions

Generalpractitioners:mandatory(withsomeminorexceptions)byagreementbetweentheRegionsandtheOrganisationofGeneralPractitionersinDenmark;financialcompensationaspartoftheagreement.

Health Care Accreditation Council (HCAC) Country: JordanAccreditationisvoluntary.Therearenoincentives(laws,regulation,insurancerequirements)inthecountryforaccreditation.

Health and Disability Auditing New Zealand Ltd (HDANZ) Country: New ZealandTheSafetyAct2002introducedhealthanddisabilitystandardsforhospitals,resthomesandresidentialdisabilityservicesaimedatimprovingsafetylevelsandqualityofcarethatbecamemandatoryfrom01October2004.UndertheSafetyAct2002,serviceproviderssuchashospitals,resthomesandresidentialdisabilityserviceprovidersmustbecertified.FromSeptember2005,physiotherapyserviceswererequiredtobecertifiediftheywishedtoprovideservicesundertheNewZealandAccidentCompensationScheme(ACC)physiotherapyservicescontract.FromSeptember2012,healthfundersmadecertificationmandatoryforhomesupportprovidersandfromMarch2013,ahealthinsuranceproviderSouthernCrossHealthSocietymadecertificationmandatoryfortheiraffiliatedproviders.



Practice Incentive Program (PIP) Country: AustraliaTheAustralianGovernmentintroducedthePracticeIncentiveProgram(PIP)in1998.ThePIPisaimedatsupportinggeneralpracticeactivitiesthatencouragecontinuingimprovementsandqualitycare,enhancecapacityandimproveaccessandhealthoutcomesforpatients21.

Inthe2015-16AustralianGovernmentBudget,inexcessof$1.5bnoverfouryears22wasallocatedtothePIPtosupportthecontinuationofincentivepaymentstogeneralpractices.

ThePIPisusedasaleverbygovernmenttoinfluencebehaviouralchangewithinthegeneralpracticeenvironment.ToaccesspaymentsunderthePIP,practicesmustmeettheeligibilityrequirements,includingthatapracticemustbeaccreditedorregisteredforaccreditationagainsttheRoyalAustralianCollegeofGeneralPractitioners(RACGP)Standardsforgeneralpracticesandmustmaintainfullaccreditation.

Approximately80%ofallpracticesthatmeettheRACGPdefinitionofageneralpracticeparticipateinaccreditationand,therefore,mayaccessPIPpayments.

TherearethreetypesofpaymentsavailableunderthePIP21:

1. Practice Payments

ThemajorityofpaymentsthroughthePIParemadetopracticesandfocusonthoseaspectsofgeneralpracticethatcontributetoqualitycare.Thesepaymentsareintendedtosupportthepracticetopurchasenewequipment,upgradefacilitiesorincreaseremunerationforGPsworkingatthepractice.

2. Service Incentive Payments

ServiceIncentivePayments(SIPs)aregenerallymadetoGPstorecogniseandencouragetheprovisionofspecifiedservicestoindividualpatients.TheCervicalScreening,AsthmaandDiabetesincentiveshaveserviceincentivepaymentcomponents,andtheAgedCareAccessIncentiveisaserviceincentivepaymentonly.

3. Rural Loading Payments

PracticesparticipatinginthePIP,withamainpracticelocationsituatedoutsidecapitalcitiesandothermajormetropolitancentres,areautomaticallypaidaruralloading.

TherearetenindividualincentivesavailabletogeneralpracticesandGPsunderthePIP23:(SeeAppendix1dforfurtherinformation)

SincetheinceptionofthePIPin1998,successiveAustralianGovernmentshavecommittedtoongoingfundingfortheprogram;andduringthistime,haveretainedtherequirementthatapracticemustbeaccredited,orregisteredforaccreditation,andmustmaintainfullaccreditationinordertoaccesssuchpayments.

GiventhelevelofparticipationinaccreditationbyAustraliangeneralpractices,itcanbeassumedthatthehighlyincentivisedPIPhasbeeninstrumentalinencouragingpracticestoengageintheprocess,andinturnhashadapositiveimpactbysupportingpracticestofocusonimprovementsandqualityoutcomes.

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2.5 Developing relationships with stakeholders

Anotherkeyexerciseatthisstageistoidentifyormapouttheothermainstakeholdersinthequalityandsafetyarenainthecountryorregion;theirrole;andtheirlinktotheexternalevaluationprogramme.Thismaybedifferentforeachcountryorregionandthisexercisewillhelptoestablishwhatexternalinfluencesfortheprogrammewilllooklikeandwhatthenatureoftherelationshipwiththeotherstakeholdersshouldbe.Forinstance,iftheexternalevaluationorganisationdoesnotitselfmanagerelatedfunctionsatanationalorregionallevel,thenitneedstodefinecommunicationsandrelationshipswithotherdepartmentsandagenciestoharmonisethesettingandassessmentofhealthcarestandards,toavoidwasteandconflictbetweensystems,andtominimisethe“burdenofaudit”onhealthcareorganisations.Aneworganisationshouldseekwherepossibletointegrateandbuilduponexistingsystemsofstandardsandinspections.Forexample,byestablishingaprocesstorecogniseexistingISOormandatedaudits.Inaddition,thereareanumberoforganisationsinternationallywhodefineandassessstandards,andwithwhomtheycouldusefullycollaborate,ISQuabeingone.

Keystakeholderswithwhomtheexternalevaluationorganisationmayconsiderdevelopingrelationshipswithincludethefollowing:

Consumer groups

Representativesofarecognisedconsumers’councilorassociationshouldbeinvolvedinthecreationandsupportoftheproposedexternalevaluationorganisationasameansofmakinghealthservicesmoretransparentandaccessibletothepublic.Theyshouldhelpdefinewhatstandardsandservicesthepublicshouldexpectfromhealthcareproviders,anddevelopandpromotereliableandconsistentmethodsformeasuringthem.Theymayassistwithdevelopingaconsumercodeofrights.Consumerandpatientrepresentativesmayalsobepartoftheadvisorycommitteeoftheexternalevaluationorganisationandlatersitonthegovernanceboard.

Regulatory inspectorates and other external agencies

Thesemightincludestatutorybodieswithresponsibilityforareassuchasfiresafety,radiation,medicaldevicesafety,hygieneandhealthdatacollectionagencies.Therelationshipbetweenthecountry’sorregion’sISOaccreditationorganisationandthehealthserviceaccreditationorcertificationorganisationneedstobeexploredanddefined.Relationshipsalsoneedtobebuiltwiththeassessmentorganisationthatcertifieslaboratories,x-raydepartmentsorothertechnicalservicesandorganisationstorelevantISOstandards,tounderstandeachother’sneedsandrequirementsandpossiblycoordinateactivitiesandassessments.

Keyrelevantlegislativerequirementssuchasforbuildings,healthandsafetyinemployment,equalopportunities,consumerrightsorwastemanagementcanbemorespecificallyreferencedintheexternalevaluationorganisation’sstandardsinconsultationwiththerelevantagenciesresponsible.Specifictechnicalstandardsorregulatoryrequirementsrelatingtosafetysuchasinfectioncontrol,firesafety,equipmentsafetyandemergencypreparednesscanbeintegratedintothestandardsascriteriaandassessedaspartofthesurveyorassessmentvisit.

Mostaccreditationorcertificationorganisationsassumethatstatutoryinspectionsarecarriedoutasintended,andexpecttoexaminesafetycertificates,suchasforradiationprotectionaspartoftheirownsurveys,butinsomecountriesthestatutoryradiationprotectionagencydoesnothavetheresourcestocarryoutitsowninspectionsandmayturntotheaccreditationorcertificationorganisationtoprovideitsownexpertise.



Aprocessneedstobedevelopedtodeterminewhichalternativeevaluationsarerobustenoughtobeacceptedasproofofcompliance.

Public and community health bodies

Linksbetweenthesebodiesandtheexternalevaluationorganisationwouldgiveanopportunitytosharedatatodescribetheimpactonpopulationandcommunityhealthandontheperformanceofprovidersandthehealthcaredeliverysystem.Wherecountriescurrentlyemployinspectorstoregulatehealthcarefacilities,theinspectors’rolecouldbemodifiedtoincludeassistinglocalfacilitiestoprepareforexternalevaluationsurveysbytheorganisationwhenitisestablished,andtomonitortheimplementationoftheensuingrecommendationsforimprovement.Thiswouldrequireinitialandcontinuingeducationprogrammes.

Technical agencies

Relationshipswithagenciesforaspectssuchashealthtechnologyassessment,clinicalguidelines,clinicalpathwaysandpatient/consumersafetyareuseful,especiallytoenableconsultationandadviceonthedevelopmentofappropriateevidence-basedstandardsandforkeepinginformationandcommunicationscurrent.

Professional bodies

Independentbodiessuchasmedicalacademiesorcouncilswillofferwisdomandadvicetotheorganisationandberecognisedforthatpurpose.Otherbodiesresponsibleforsuchdutiesassupervisingtrainingorlicensingorregisteringclinicians(doctors,nurses,dentists,pharmacists,alliedhealthprofessionals)willcontributetothesettingofstandardsandtotheirlocalassessment.

Inparticular,theroleofprofessionalchambers,associationsandcollegesneedstobedefinedwithrespectto:

Professionalregulation

Settingandmonitoringofclinicalperformancestandards

Monitoringofclinicalpracticeaccordingtothesestandards

Developmentanddisseminationofqualityimprovementmethods.

Thefunctionsofstatutorybodiesshouldbedefinedinrelationtovoluntaryassociationsandtotheexternalevaluationorganisation.Theorganisationshouldworkwithlocalgovernmentministries,insurancefundsandprofessionalassociationsandchamberstodevelopconsistentincentivesformeasurableachievementofagreednationalstandardsofprocessandoutcomeinprimary,ambulatoryandhospitalcare.

Health insurance funds

Usingcontractedserviceprovidersoffersanalternativetothetraditionalcentralisedmodelinhealthcaremanagement.Inseveralcountries,lawsonhealthcareinsurancespecifythatonlyaccreditedorganisations,fromeitherthepublicorprivatesector,havetherighttosigncontractstoprovideservicesundercompulsoryinsurance.Theexternalevaluationorganisationcanworkwithhealthinsurancefundstohelpthemobtainandprotectbestvaluefromavailablefundingbyrecognisingaccreditationorcertificationforitsimpactonqualityimprovement.

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External assistance

Afurthergroupofstakeholderswithwhomanexternalevaluationorganisationmayinteractwouldbeindividuals,organisationsorgroupsprovidingexternalassistance.Externalassistanceisavailablefromanumberofsourcesincluding:

Internationalexternalevaluationbusinessesorinitiatives

Internationalaidorganisationsandtechnicalcorporations

Internationalexperts

Neighbouringexternalevaluationorganisations

ISQua.

Assistancemaybeforanypartorallofthecomponentsofanexternalevaluationprogramme.Beforeengagingformalexternalassistance,itisimportantthat:

Theprojectspecificationshavebeenscopedoutandareappropriate

Competencycriteriaforselectionofexternalassistanceincluderelevantexperiencewithhealthorsocialcarestandardsbasedexternalevaluation

ReferencesandadvicearesoughtfromexperiencedaccreditationorsimilarorganisationsandISQua.

Mostaccreditationorganisationshavebasedtheirstandardsonexistingresearch,clinicalpracticeguidelines,inputfromexpertsandotheraccreditationandtechnicalstandards.Neworganisationscan,inconsultationwiththeownersofthesestandards,chooseamodelthatbestreflectstheirpurpose,scopeandculturalcontext,andthenadaptthosestandardsorbuildonthemtomakethemappropriatetothelocalcontext.ItisimportantthatthestandardsadheretotheISQuaGuidelinesandPrinciplesfortheDevelopmentofHealthandSocialCareStandards4astheseareacceptedasbestpracticebyorganisationsandsothattheycanbecomeinternationallyaccredited(SeeChapter4formoreinformation).

ISQua’sGuidelinesandStandardsforExternalEvaluationOrganisations3andforSurveyorTrainingStandardsProgramme5provideguidanceonwhatstructures,systems,processesandevaluationmethodsneedtobeinplacetobeabestpracticeorganisation.WhenorganisationsseekISQuaaccreditation,theygetassistancewiththeirself-assessmentandtheycanhaveamocksurveypriortoaninternationalaccreditationsurvey.

Informationspecifictohealthcareexternalevaluationiswidelyavailable-seeweblinksinthebibliographysection.

Thenextchapterwillfocusontheinitialstepsinvolvedinsettingupanexternalevaluationorganisationincludinghowtoinvolveandengagewithotherstakeholdersaspartofthisprocess.



Chapter 3: Setting up the External Evaluation OrganisationThischapterfocusesontheprocessofestablishinganexternalevaluationorganisationandthedifferentstagesinthisprocess.Thisprocessmaybedifferentforeachcountryorregiondependingongovernmentpolicy,thestakeholdersinvolvedandthesizeofthehealthorsocialcaresector.Thecasestudyexamplesoutlinetheapproachesadoptedindifferentcountries.

3.1 Establishing a preliminary board or advisory committee

Theimpetusforsettingupanaccreditationorcertificationorganisationmaycomefromanumberofpossiblestakeholders:MinistryofHealth,healthprofessionalassociations,consumerorganisations,privateinsurers,universitydepartments,voluntarymembershipsocieties,healthservicecharitiesoraidorganisations.Theinitiativemaycomefromacompanyorgroupofindividualswhoseeamarketopportunity,e.g.asassessorsofgovernmentstandards.Ifthepurposeoftheprogrammeisclear,itisnotdifficulttoidentifywhomitwillserveandwhomitwillaffect.Traditional,profession-drivenprogrammeshavetendedtobuildlinkswithregulatorsandconsumers,thusbecomingmoreaccountableandtransparent.Morerecentprogrammeshavebeenmoreinfluencedbycommercialprovidersandinsurersoractivelysupportedbygovernment.

Onewayofinvolvingrelevantstakeholderswhohaveorwillhaveaninterestinthesuccessoftheneworganisationisthroughsettingupapreliminaryboardoranadvisorycommitteetoestablishtheorganisation.Thisenablesthemtofeeltheyhaveastakeintheorganisationanditsworkandtoprovideadviceandexpertise.

Thepreliminaryboardoradvisorycommitteewillprovideguidanceanddirectiononthepracticalaspectsofestablishingtheexternalevaluationprogrammeincluding:

Clarifyingtheroleoftheexternalevaluationprogrammeinthecontextofotherdepartmentsandagenciesworkinginthequalityandsafetyarenainthecountryorjurisdictione.g.otherexternalevaluationprogrammes

Fundingoftheexternalevaluationprogramme

Governanceframeworkfortheexternalevaluationorganisation

Theuseofexternalassistancefordevelopmentanddeliveryoftheexternalevaluationprogramme.

Thecompositionoftheinterimboardoradvisorycommitteewillbeuniqueforeachcountrydependingongovernmentpolicyandtherangeofstakeholdersworkinginthequalityandsafetyarena.Somemembersfromthisboardorcommitteemayformthebasisforthegovernanceboardintheestablishedorganisation.Table3outlinessuggestedmembersofapreliminaryboardoradvisorycommittee.

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Table 3: Potential composition of a preliminary board or advisory committee

Stakeholder Group

Examples of representatives

Government MinistryofHealthand/orotherrelateddepartmentse.g.Finance.Localgovernmente.g.municipality,canton,oblastlevel

Consumergroups

Recognisednationalconsumercouncil/associationoradvocacyorganisation

Externalevaluationorganisations

Regulatoryandotherexternalevaluationagenciesworkinginthequalityandsafetyarenainthecountryorjurisdictione.g.statutorybodieswithresponsibilityforareassuchashealthandsafety,radiation,medicaldevices,medicines,regulatoryinspectorates,certificationagencies

Serviceproviders

Publicandprivateprovidersincountryorregione.g.nationalrepresentativebodiessuchasnationalhospitalassociationornationaldisabilityserviceprovidersassociation/forum

Professionalbodies

Independentbodieswithresponsibilityforthelicensingorregistrationofhealthandsocialcareprofessionalsorthesupervisionoftrainingsuchasmedicalacademiesorcouncils

Academia Universitiesorcollegeswhodelivereducationandtrainingprogrammesforhealthandsocialcareprofessionals

Technicalagencies

Nationalagencieswithaspecificrolee.g.healthtechnologyassessments,clinicalguidelinesandpathways,patient/consumersafety

Independent Independentexperts,neighbouringexternalevaluationorganisations,internationalexternalevaluationinitiatives

3.2 Proposing a governance board and framework

Oneofthefirsttasksfortheinterimboardwillbetodevelopadraftgovernanceframeworkfortheexternalevaluationorganisationorprogramme,withaformalconstitution,governanceboardanddraftpoliciesandprocedures.Forcredibilityandinlinewithbestpractice,acommitmentshouldbemadethattheorganisationwillbeestablishedinlinewiththeISQuaGuidelinesandStandardsforExternalEvaluationOrganisations3(currently4thedition,2014,butnotethattheseareupdatedonaregularbasisandthelatestonesshouldalwaysbeobtained).

3.2.1 Governance body

Ifitistobeanon-governmentalorganisation,itispreferablefortheorganisationtohaveaboardcomprisingandaccountabletothevariousstakeholderorganisationsratherthanthegovernment.Theboardshouldrepresentprofessional,publicandgovernmentalinterestsandbringpersonalqualitiestothegovernanceoftheorganisation,suchasfinance,legalandpublicrelations,butbedominatedbynoneofthem.Forexample,inMalaysiaaccreditationprogrammesaredeliveredbytheMalaysianSocietyforQualityinHealth(MSQH),whichwasestablishedbytheMalaysianMinistryofHealthinassociationwiththePrivateHospitalAssociationandtheMalaysianMedicalAssociation.AllthreeorganisationsarerepresentedontheboardofMSQH24.



Typically,independentboardsincludeconsumers;representativesofprofessionalassociationssuchasnurses,managersanddoctors;industryassociationssuchashospitalsorresthomes;fundingagencies;andstatutorybodies.Someboardsarenowappointedaccordingtoskillsets,expertiseandexperienceratherthanchosenbyrepresentativestakeholderorganisationsbecauseoftheperceivedconflictsofinteresttherepresentativemembersmayhave,beingtheprovider,consumerandsometimesalsopurchaseroftheexternalevaluation.Governmentrepresentativesinparticularmayhaveaperceivedconflictofinterest.

Publicinvolvementgoesbeyondthesharingofinformation;italsodemandsthesharingofauthority.Manyexternalevaluationorganisationshaverepresentativesofpatientsandthepublicintheirgovernancestructuretoensuretheirinvolvementinthedevelopmentofpolicyandstandardsandinensuringthatagreedproceduresarefollowedthroughouttheexternalevaluationprocess.

Aspergoodgovernancepractice,membersofthegoverningbodymustbeorientedtotheirrolesandhaveongoinginformationandeducationtoassistthemintheirrole.Theyshouldbeguidedbyasetofgovernancepolicies.

Case Studies – Composition of governing board

IKAS – Danish Institute for Quality and Accreditation in Healthcare Country: DenmarkIKASandDDKMwereestablishedbyanagreementbetweentheregionalandlocalpoliticalauthorities,whoareresponsiblefordeliveringhealthcare,andthenationalgovernmentthatsetstheoverarchingpoliticalpriorities,includingtheeconomicframe,andisthehealthcarelegislatorandregulator.ThegovernmentisrepresentedontheboardofIKAS;theChairoftheBoardisagovernmentrepresentative,aDirectoroftheDanishHealthandMedicinesagency.

Health Care Accreditation Council (HCAC) Country: JordanTheboardofdirectorsismadeupofrepresentativesforallhealthcaresectorsinJordan,medicalandnursingprofessions,andeducation.

3.2.2 Governance framework

Theexternalevaluationorganisationneedstobesetupasalegalentity,orapartofone,withclearlegalresponsibilitiesforallitsexternalevaluationactivities.IfitispartofaMinistryorgovernmentagency,thisindependenceisparticularlyimportant.

Theorganisation’sgovernancearrangementsneedtobeclearlydescribedinadeed,constitutionorsimilardocumentthatdefinespowers,accountabilityandresponsibilityincluding:

Thecompositionofthegoverningbody

Theprocessforappointingitsmembers

Linesofaccountabilityincludinglinesofaccountabilityoutofthelegalentity

Thetermsofreferenceofthegoverningbodyandanyofitscommittees

Responsibilityandrulesformakingdecisionssuchasonaccreditationorcertificationawards.

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Theorganisationrequiresaclearvisionandmissionorpurposeandstrategicdirectiontoprovidethebasisfortheorganisation’splanninganddirectionandmustbeguidedbyadefinedsetofvalueswhicharereflectedinallservicesandactivities.Itisalsoimportantthattheorganisationhasanexplicitsetofethicalprinciplestoinformalldecision-makingandacodeofconductoutliningtheexpectedbehavioursofthoseworkinginand/oronbehalfoftheorganisation.Otherresponsibilitiesforoverseeing,monitoringandapprovalalsoneedtobedefined3.

3.2.3 Committing to fairness and transparency

Externalevaluationorganisationswhichhavesucceededinmakingimprovementsinclienthealthcareorganisationshavegenerallydonesobystimulatinginternalmotivationandcommitmenttoself-assessmentandchange.Thisrequiresacultureoftransparencyandacceptanceofpersonalandorganisationalresponsibilityamongmanagement,cliniciansandotherstaff.Howeversuchacultureisnotuniversal,especiallyinhierarchicalsystems.Externalevaluationorganisationscannotrelyonhealthprofessionals’ethicsandself-regulationtoensureanopenandfairculturethatpromotesqualityimprovement.Thecommitmenttofairnessandtransparencymustbebuiltintothegovernanceframeworkandthewaysofleadingtheorganisation.

Insettingupthenewexternalevaluationorganisation,acommitmentmustbemadethatitwill:

Usetransparentandobjectivesystems,decision-makingandreporting

Befreefromundueinfluencebyanyparty

Avoidconflictsofinterest

Establishafaircomplaintsandappealssystem

Designandpublishproceduresforcontracting,facilitation,assessment,reportingandaccreditationorcertificationdecisionstopromoteconfidenceand

Putarrangementsinplacethatensurethatexternalevaluationactivitiesarestrictlyseparatedfromconsultancy.

Thiscommitmentshouldbedefinedinpolicies,includingonerequiringaccreditationorcertificationdecisionstobemadesolelybasedontherelevantstandards,thefindingsofthesurveyors/assessorsandotherobjectiveevidencerelatedtothestandards.Agrowingtrendisfordecisionsonaccreditationstatustobemadebasedonaformulaic,mathematicallyorientedapproach,whichavoidsanyperceptionofbias3.

3.3 Funding of the programme

Mostnewexternalevaluationorganisationsrequireatleasttwoyearstoestablishtheirorganisationand/orprogramme,longerbeforetheyaresustainable,andlongerstillbeforetheyareself-financing.Inshort,politicalandfinancialsupportgenerallyneedstobeconsistentbeyondtheterminofficeofmosthealthministersandmanygovernments.Externalfundingfromgovernment,healthinsurers,aidorganisationsorotherpartnerswillberequiredfor:

Establishmentoftheexternalevaluationorganisation

Initialdevelopmentandtestingofthestandards

Marketing

Possiblysubsidisingtherunningoftheorganisationforthefirstfewyearsorayearafterbreak-even.



However,theinitialset-upcostsmaybemuchlessforexternalevaluationorganisationswhoseroleistoaccreditorcertifyhealthorsocialcareorganisationsagainstgovernment-mandatedstandardsorsimilar.Inthissituation,thereisanidentifiedpotentialclientpool,therewillbeguaranteedpaymentofcostsoftheassessmentbyeithertheclientsorthegovernmentandtheremaybeashortertimeperiodinwhichclientsarerequiredtobeassessed(SeetheexamplefromHDANZintheCaseStudiessection).

Formostotherorganisationsthenumberofpotentialclienthealthorsocialcareorganisationswillbeakeydeterminantofprogrammecosts,aswillotherfactorssuchaswhethertheprogramme:

Isasinglenationalprogramme,regionalorsectorspecific

Islimitedinitiallytoapriorityfocus,e.g.nursinghomes,ortotheentirehealthsystem

Issupplementingorreplacingexistingexternalassessments

Isdevelopmentfocused,requiringtrainingandeducationofclients

Developsitsownstandards

Employsspecialistexpertise.

Oneofthemajorpotentialcostsforanexternalevaluationorganisationwillbethesurveyorworkforceandinparticularwhethertheyarepaidorvoluntary.Traditionally,accreditationorganisationshaverelieduponparticipatingaccreditedinstitutionstoprovideorloanstafftoworkassurveyorsandtopromotetheconceptofpeerreview.Certificationagenciesusuallyemployorcontracttheirassessmentpersonnelonapaidbasis,sometimessupplementedbytechnicalexperts.However,accreditationorganisationsarenowalsoincreasinglypayingsurveyorsasemployedorcontractedpersonnel,orusingamixofbothpaidandvoluntary.Theorganisationwouldneedtoconsiderfactorssuchastheavailabilityofsuitablepersonnelinthecountrytoactassurveyors;thefeasibilityofsuitablepersonnelbeingreleasedbytheirorganisationstoworkassurveyors;andthenumberofandcostsofemployingfullorpart-timesurveyorswhendecidingonwhichapproachtotake.

Thoroughsystemdesignandtestingwillbeanothercost,aswilltheinvestmentincommunications,informationmanagementandmarketing.

Althoughasustainableexternalevaluationorganisationanditsprogrammeareconstantlyunderdevelopment,thestart-upcostsmaylast3-5yearsbeforeatestedandvaluedproductissufficientlymarketabletobegintorecoveroperationalcostsfromclientorganisations.Whethertheychoosetoparticipate,orwhethertheycanaffordto,dependsontheincentivesandsanctionsprovidedandexistingoperatingbudgets.

Duringthefirstyear,theorganisationmaymanagewithasmallcorestaff,severalworkinggroupsandlowoverheads;howevercostsincreaserapidlywiththeadditionof,surveyortraining,documentproductionandthedirectcostsoffieldtesting.Insomecountriesexternalexpertiseisrequiredandmustbefactoredintothestart-upcosts.Atthenextstage,whentheinitialdevelopmentiscompletedandtheorganisationisreadytoofferaccreditationorcertification,itmayfaceanotherchallenge;thefastertherateofuptake,thefasteritmustinvesttobuildcapacity.Fundingshouldbeprofiledtoreflectthisgrowth.

Atthesametimeasobtainingfunding,incentivesneedtobenegotiatedifpossible.

Thecasestudiesoutlinetheexperiencesofexternalevaluationagenciesindifferentcountriesintermsoffundingarrangements.

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Case Studies – Funding

IKAS – Danish Institute for Quality and Accreditation in Healthcare Country: Denmark

Set-up costsWhenIKASwasbeingestablished,adecisionwasmadetoseekexternalassistancetohelpwiththeestablishmentoftheorganisationandthedevelopmentoftheaccreditationprogramme.ArequestfortenderwasissuedtointernationalaccreditingorganisationstoprovideconsultancyservicesfortheestablishmentofIKASandthedevelopmentofDDKM.TheUnitedKingdombasedinternationalaccreditationorganisationCHKSwasawardedthecontracttoassistwiththeestablishmentofIKASasanaccreditationorganisation;thedevelopmentofstandards;andthetrainingofsurveyors.

Funding of the accreditation schemeIKASisanindependentorganisationbutreceivesanindex-linkedannualgrantfromthecentralgovernment,regionsandlocalgovernment.PublicclientssuchaspublichospitalsorpharmaciesdonothavetopayanyfeestoparticipateinDDKM.Otherprivateclientspayafeethatcoversdirectexpensesplusanoverhead.

Health Care Accreditation Council (HCAC) Country: Jordan

Initial fundingTheoriginalfundingtodeveloptheHCACcamethroughtheJordanHealthcareAccreditationprojectfundedbytheUnitedStatesAgencyforInternationalDevelopment(USAID)andgrants.TheHCACisaprivate,not-for-profitshareholdingcompanyregisteredundertheMinistryofTradeandIndustry.SinceMarch2013,HCAChasbeenfinanciallysustainablethroughchargingfeesforservicesofferedincludingsurveys,educationandconsultation.

Health and Disability Auditing New Zealand Ltd (HDANZ) Country: New Zealand

HDANZisaprivate,independentlyownedcompany.ItislinkedtogovernmentasaMinistryofHealth(MOH)approveddesignatedauditingagency.HDANZauditstheseservicesonbehalfoftheMOHandsubmitsauditreportstotheMOHwhothenissuesthecertificatestotheservices.

ServiceproviderspayfeestoHDANZforsurveyandmonitoringvisits.CertificationhasbeenmandatoryfortheMOHSafetyActsinceOctober2002.FromSeptember2005,itbecamemandatoryforphysiotherapyservicesiftheywantedtoprovideservicesundertheNewZealandAccidentCompensationScheme(ACC)physiotherapyservicescontract.FromSeptember2012,healthfundersmadecertificationmandatoryforhomesupportprovidersandfromMarch2013,ahealthinsuranceproviderSouthernCrossHealthSocietymadecertificationmandatoryfortheiraffiliatedproviders.



3.4 Setting up strategic, operational and financial management systems

Oncethegovernanceboardhasbeenestablishedandthegovernanceframeworkhasbeendeveloped,thenextstepistostafftheexternalevaluationorganisationandtodevelopthemanagementsystems.

3.4.1 Staffing the organisation

Themostimportanttaskofanyboardistoappointthechiefexecutive,withtheappropriateskillsandexperiencefortherole.Thegoverningboardmaydelegateaccountability,authorityandresponsibilityformanagingtheexternalevaluationorganisationtoachiefexecutive.Theresponsibilitiesformanagingtheorganisation,thelevelofauthorityandthechiefexecutive’srelationshipandaccountabilitytotheboardneedtobedefinedinajobdescriptionorsimilardocument.Itisalsotheboard’sroletoconfirmstrategicandoperationalplans,toreceiveregularreportsonachievementofgoalsandtargetsandtoreviewthechiefexecutive’sperformanceannuallyagainstsetperformancetargets3.

Afterthechiefexecutivehasbeenemployed,personnelneedtobeselected,trainedandpaid,includingemployedstaff,secondedstaff,e.g.surveyors,andsub-contractorse.g.legal,statistical,marketing,communications.Sometimesfinancialandinformationtechnologystaffarecontracted.

Inlargerorganisations,staffmaybestructuredintofunctionalunitssuchas:

Surveyplanningandmanagement

Surveyorrecruitmentanddevelopment

Standardsresearch,developmentandrevision

Usereducationanddevelopment

Technicalsupportstaff–financial,humanresources,informationmanagement

Administration.

Smallerorganisationscanbesustainedonveryfewcorestaffiftheyhavesignificantsupportfromunpaidexpertsandstaffsecondedfromemploymentinhealthandsocialcareservices.Staffingnumbersandskilllevelsneedtobeplannedandtransparentpoliciesdevelopedforrecruitment,selectionandappointment;orientation;healthandsafety;ongoingtraining;andregularperformanceassessment.Personnelrecordswithdefinedcontentneedtobeestablishedforallstaff.

Itisimportantthatthelinesofresponsibilitywithintheexternalevaluationorganisationareclearlydefined;madeknowntoallstaff;andthatthereareprocessesinplacetoensurethatstaffandsurveyorsarefreefrominfluencebythosewhohaveadirectinterestintheservicesandaccreditation/certificationdecisions.Thelinesofauthority,responsibilityandallocationoffunctionsintheexternalevaluationorganisationmaybeoutlinedinanorganisationalchartororganogram.Thelinesofresponsibilitymaybeoutlinedtostaffaspartoftheirorientationandupdatesprovidedwheneverthereisachangeofresponsibilities.

Afinancialsystemneedstobesetuptodevelopbudgetsandrecordandtrackincomeandexpenditureandpast,currentandprojectedfinancialpositions.Itneedstobeabletoproducetimelyreportstoassiststafftomanagetheirbudgets.Controlandauditsystemswillbeneededtoprotectassetsandensurethetransparencyoffinancialtransactions.

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3.4.2 Developing the system for financial sustainability

Initialbudgetingischallenginganddependsonhowmuchfundingisreceivedfordevelopmentorhowmuchoftheset-upcostsneedtobeincludedinthebudget.Provisionusuallyneedstobemadeforexternalassistanceandexpertise.Someorganisationsconsiderguidedfacilitationand/ortrainingonthesurveystandardsandprocessasanintegralpartofthedevelopmentprocess.Othersprovideseparateconsultancy(includinggeneraleducationanddevelopment)forwhichtheychargeafeewhichcanbebudgetedfor.

Ifclienthealthcareorganisationsarerequiredtopayonaneventbasis,ongoingcostswilldependonthelengthanddepthofsurveys(whichareinfluencedbythestandards),lengthofthesurveycycle,mid-termmonitoringsystem,theefficiencyofscheduling,surveylogistics,reporthandlingandawardadjudication.Budgetshavetopredictwheneventssuchastraining,on-sitesurveys,andmid-termsurveillancevisitswilloccurandhowmuchtheywillcost.Anypostponementorcancellationcannegativelyaffectanticipatedcashflow.Someorganisationsincludealldocumentationanddirectsurveycosts,e.g.surveyortravelandaccommodation,intoasingle-pricepackagepersurveybutcostsandrevenuesarestilldependentontheeventoccurring.Anumberofaccreditationorganisationshavemovedtoamembershiporsubscriptionbasedfinancialsystem,wherebyclientsbecomemembersoftheaccreditationprogrammeandarechargedaregularannualfeebasedonanticipatedcostsoverthewholeaccreditationcycle,includingoverheads,education,guidance,standards,tools,surveyandmid-termprogressvisits.Whileitstillrequiresbudgetforecastingofthenumberandtypeofclients,itlimitstheuncertaintyofwhetherandwheneventswillhappenandhascontributedtotheongoingsustainabilityofanumberofaccreditationorganisations.

Amarketingprogrammeandbudgetwillbeneededbymostnewexternalevaluationorganisationstopubliciseitself,theservicesitoffersandthebenefitsofitsprogrammetoattracthealthcareproviders.Gettingasustainablemarketshareofclientorganisationswillbefundamentaltoitssuccess.Widermarketingandpublicitywillbeneededforpotentialinsurers,fundersandthegeneralpublic.

3.4.3 Establishing information systems

Informationmanagementcoversbothtechnologicalandpaperbasedinformation,includingeducationalandmarketingresources.Internalinformationsystemsareessentialforplanning,operationsandfinance,buttheyalsoneedtohavethecapacitytocollect,aggregateandcomparedataovertimewithinandbetweenparticipatingorganisations,standardsandsurveyors,suchas:

Dataofcompliancewithachievementofindividualcriteriaorstandards

Profilesofparticipatingorganisations

Calculationofstandardscores,functionscores,andoverallscoreforeachorganisation

Aggregatedresultsforcomparisonovertime,functionandplace

Profilesofindividualsurveyorsandtheirparticipation

Surveyschedulingandmanagement

Overallimpactofprogramme.

Datawhichshowthatparticipatingorganisationshavemadeimprovementsassociatedwiththeprogrammesincethefirst(baseline)contactareessentialtodemonstratethevalueoftheprogrammetothehealthcaresystem3.



3.4.4 Addressing risk management and performance improvement

Theexternalevaluationorganisationmustmodelthesafetyandqualityapproachitexpectsfromitsclientorganisations.Arobustriskmanagementframeworkthatidentifiesandmanagesrisksandpromotessafetymustbeimplemented.Whilemostoftheseorganisationsdemonstrateasafetyculture,itneedstobedemonstratedbyestablishingaqualityimprovementpolicyandframework.Essentialtothiswillbethedocumentationofpoliciesandproceduresforallfunctions,thedevelopmentanduseofkeyqualityindicatorswhichcanbemonitoredandbenchmarkedovertimeorwithsimilarorganisations,theuseofauditsandreviewstoensurecompliancewithpoliciesandprocedures,documentedqualityimprovementprojectsandatransparentcomplaintssystemthatisavailabletostaff,surveyors,clientsandotherstakeholders3.

3.4.5 Providing education services

Mostexternalevaluationprogrammesprovideavarietyofeducationandtrainingasanessentialcomponentoftheirservices.Educationservicesneedtobesystematicallydesignedandimplementedtomeetqualitystandardsandclientneeds.Theseinclude:

Inductionanddevelopmentofstaff

Orientationandongoingeducationofmembersofthegoverningboard

Initialandcontinuingtrainingofsurveyors

Generalpreparationofparticipatingorganisationsandtheirstaffasabasiccomponentoftheirparticipation

Specificmethodsofinternalqualityimprovementrequiredtomeetexternalevaluationstandards,suchasinfectioncontrol,riskmanagement,performancemeasurement,patient/clientsurveys–theseareusuallyadditionaltoservicescoveredbyfeesandarechargedseparately

Qualityimprovementprogrammesforthehealthorsocialcaresectorsingeneral.

Thesetrainingandeducationprogrammesandcoursesandtheirresourcesneedtobeplanned,scheduledandcosted.Informationprovidedneedstobekeptup-to-dateandbasedoncurrentresearchandevidence.Trainersandeducators,whetherinternalorexternal,needtohavethecompetenceandexpertisetodelivertheprogrammes.

3.5 Timeframes

Themostcommonlyunderestimatedresourceisthetimeneededtoplan,design,buildanddeliverasustainablenewexternalevaluationorganisation.Thepaceatwhichthiscanbedoneislimitedlargelybyfactorsoutsidethecontroloftheorganisation,notablybytheprevailingcultureandattitudestowardsleadership,innovation,improvement,team-workingandtransparency.

Inpracticethedevelopmentstages,whichmayoverlap,are:

Policydecisiontodevelopanexternalevaluationorganisation/programmeanddefiningitsscope

Optionappraisalonexistingmodelsandtheiradaptation

Settinguptheorganisationstructureandobtainingoffunding

Developmentandtestingofstandards

Developmentandtestingofassessmentmethodologies

Surveyorselectionandtraining

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Pilottesting,educationandmarketingcampaigns

Revisionofstandardsandmethodsbasedonfeedbackfrompiloting

First“live”surveys

Firstaccreditation/certificationrecognitionstatusdecisions.

Thisprocessislikelytotakeatleasttwoyearsbutcantakemuchlonger(Thecasestudiesoutlinetheorderofdevelopmentandthetimescalesinvolvedforthethreedifferentagencies.PleaserefertoAppendices1a,bandcforfurtherinformation.).

Takingtimetoestablishcommunicationwithallstakeholdersandthepublicandcontinualupdatingofinformationastheorganisationdevelops,isessentialforsuccess.

Thefollowingchaptersfocusonandprovidemoredetailinrelationtothedevelopmentandtestingofstandards;thedevelopmentofassessmentmethodologiesandmechanismsforevaluatingsystemsandperformance.



Chapter 4: Developing the standardsThischapterfocusesonthedifferentelementsrequiredwhendevelopingstandards.Itincludestheuseofqualitydimensionsandtheimportanceofareliableandvalidmeasurementscale.

Thestandardsusedordevelopedbyexternalevaluationorganisationsarethemostfundamentalelementoftheirprogramme.Whilenotalwaysrealistic,itisadvisabletoconsiderwhatevaluationmethodologywillbeusedwhilethestandardsarestillinthedevelopmentphase.Thestandardswillhelptoinformthepublicwhattoexpectfromhealthandsocialcareprovidersandwillactasabenchmarkagainstwhichprovidersandthegovernmentcanmeasurequality.Thestandardswillformtheframeworkforself-assessmentandinternalaudits.

Standardsdevelopmentcanoftencommencepriortothesettingupofgovernanceandmanagementsystemsintheexternalevaluationorganisationandcantaketwoormoreyearstocomplete.Fundersmaywanttoknowtheshapeandcontentofthestandardsbeforetheycommittofundingtheorganisation.Separatefundingisoftenavailableforthestandardsdevelopmentprocess.

4.1 The role of standards

Anexternalevaluationorganisation’sstandardshavetoreflectitspurposeandcoverthekeyfunctionsandprocessesofthehealthcareorsocialcaresectorsthatarebeingevaluated.Similarly,ifstandardsareownedormandatedbygovernment,theyneedtoreflectthepurposeforwhichgovernmentintendsthem.Theyhavetoreflectlegislativerequirements,safetyandgoodpractice.Theyshouldberelevant,understandable,measurable,beneficialandachievable(RUMBA)25.

Standardsalsoneedtoberealisticandreflecttheavailabilityofresources,especiallyindevelopingcountrieswhereresourcelimitationscansignificantlyimpactahealthcareorganisation’sabilitytoachieveoptimalperformance.Forexample,MalaysiaandThailandbeganwithrelativelyachievableaccreditationstandardsbutcommittedtocontinueupdatingandimprovingtheseovertime.Inthiscontext,Malaysiahaspublishedthe4theditionoftheirhospitalstandardssincetheaccreditationprogrammebeganin1999.Thailandhasalsomadeprogressivechanges,introducingastepwiserecognitionprogrammein2004andpatientsafetygoalsin200620.Standardscanalsobeprioritisedandincrementalimprovementsmadeinachievingthemcanberecognisedandrewarded.InIndia,theNationalAccreditationBoardforHospitals&HealthcareProviders(NABH)hasdevelopedPre-AccreditationEntryLevelcertificationstandards,inconsultationwithvariousstakeholdersinthecountry,whoseaimistointroducequalityandaccreditationtohealthcareorganisationsastheirfirststeptowardsawarenessandcapacitybuilding.OnceorganisationshavemetthePre-AccreditationEntryLevelcertificationstandards,theycanthenprepareandmoveontothenextstage–ProgressiveLevelandcanthenworktowardsFullAccreditationstatus.Thismethodologyprovidesastepbystepphasedapproachforhealthcareorganisations26.

Thelong-establishedaccreditationorganisationsgenerallybeganwithstandardsandsurveyswhichreflectedmanagementunits,e.g.departments.Theyalsotendedtofocusonstructures,e.g.staffingarrangements,funding,equipmentorcommittees.Mostprogrammesnowfocustheirstandardsandassessmentsonaclientfocusedcontinuumofcareorpatient’sjourneyratherthanmanagementunitsandonprocessesandoutcomesratherthanstructures.

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However,fordevelopingcountries,basicstructuralstandardsmaystillbeanimportantstartingpoint.Externalevaluationmaybeprimarilyavehiclefortakingstockanddevelopinggreaterequalityofstructureandaccesswherethehealthcaresystemhaswideregionalandsocialdivisions.Inthiscase,thehealthsystemmustbeabletomobiliseresourcesinordertorespondappropriatelytotheprioritieswhichareobjectivelydemonstratedthroughtheexternalevaluationprocess.Forexample,participantsfromexternalevaluationorganisationsinlowandmiddle-incomecountriesattendinga2013workshopinBangkok,Thailandhighlightedthatstandardsareimportantintheircountriestoimprovetheoverallqualityofcareandnotjusttodifferentiatebetweenhospitalsthatpassanaccreditationvisitandthosethatdonot.Inmanylowandmiddle-incomecountries,institutionsthatfailtomeetstandardsmaystillbetheonlyavailablesourceofcareforpartsofthepopulationandtherefore,itisimportantthatthereisafocusonimprovingthecaretheydoprovide20.

4.2 Principles for standards

Standardsaredevelopedandwritteninmanydifferentwaysandaredesignedtomeetthepurposeandscopeoftheparticularexternalevaluationprogramme,asdiscussedinChapter2.However,theymustbeuser-friendly,abletomeetthepurposesforwhichtheyhavebeendesigned,andbeabletomeasureachievementinaconsistentway.Evidence-basedmechanismsbywhichstandardsaredeveloped,promulgated,reinforced,auditedandevaluatedareneeded.Linkingthewritingofstandards,includingthewording,structure,design,focusandcontent,todemonstratingimprovedoutcomesrequiresfurtherinvestigation27.

ISQuahasfocusedonaddressingthisgapbydevelopingprinciplestoguidethedevelopmentofhealthandsocialcarestandardsandenabletheirassessmentandaccreditation.Thesewereoriginallydevelopedin2000,andrevisedonnumerousoccasions.Themostrecent4theditionwaspublishedin20144.TheprinciplesarebasedontheInstituteforMedicine(IOM)qualitydimensions28,ofeffectivequalityperformance,efficientorganisationalperformance,safetyandpatientfocus.TheISQuaPrinciples(2014)4alsogiveguidanceonhowtodevelopandmeasurestandards.ISQuarecommendsthatthedevelopmentandcontentofallstandardsshouldmeetitsinternationallyacceptedbestpracticeprinciples.

Thepurposeofsomeexternalevaluationorganisationsistoassess,andsometimescertify,healthandsocialcareorganisationsagainstgovernmentstandardsorthestandardsofanotherexternalevaluationorganisation,perhapsadaptedtolocalcircumstances.Forthecredibilityofitsownassessments,theseorganisationsshouldencouragetheownersofthestandardstogetthemISQuaaccredited.

TheISQuaPrinciplescoverallthefunctionsofahealthcareorsocialcareorganisation,fromgovernance,tomanagement,toclientcare,toquality.Theyare:

1. StandardsDevelopment:Standardsareplanned,formulatedandevaluatedthroughadefinedandrigorousprocess.

2. StandardsMeasurement:Standardsenableconsistentandtransparentratingandmeasurementofachievement.

3. OrganisationalRole,PlanningandPerformance:Standardsassessthecapacityandefficiencyofhealthandsocialcareorganisations.

4. SafetyandRisk:Standardsincludemeasurestomanageriskandtoprotectthesafetyofpatients/serviceusers,staffandvisitors.



5. Patient/ServiceUserFocus:Thestandardsfocusonpatients/serviceusersandreflectthecontinuumofcare.

6. QualityPerformance:Standardsrequireserviceproviderstoregularlymonitor,evaluateandimprovethequalityofservices4.

StepsfordevelopingstandardsinlinewiththeISQuaPrinciplesforStandards4include:

Reviewingotherexternalevaluationorganisationstandards,currentresearchandevidence,recognisedguidelines,recommendationsfromWHOandotherprofessionalorganisationsandexperts

Incorporatinglegislative,technicalandsafetyrequirements

Incorporatingbestpracticewhereevidenceisavailable

Ensuringthestandardsareclientfocused,coverthefunctionsorsystemsofawholeorganisationorservice,addressthedimensionsofquality,andsupportqualityimprovement

Consultingstakeholdergroups,includingconsumergroups

Involvingstakeholdersinstandardsdevelopmentcommitteesandworkinggroups

Developingtheratingsystemformeasuringcompliancewith/againstthestandards

Testingthestandardsandthewaytheyareratedthroughself-assessmentandpilotsurveys

Usingfeedbackfromtestingtoimprovethestandardsandratingsystem

Developingguidelinestoassistuserstointerpretandapplythestandards

Ensuringthestandardsareapprovedbytheexternalevaluationorganisationgoverningbody

ApplyingforISQuastandardsaccreditation.

Thisdevelopmentprocessmaytaketwoyearsormoreifthestandardsarebeingfullydeveloped.Withtherapidlychanginghealthcareenvironment,12monthswouldbeanappropriatetimeframefororganisationsadaptingotherorganisations’standards.

4.3 Referencing to quality dimensions

Standardscanbegroupedaroundqualitydimensionstodemonstratetheirrelationshiptoquality.ThesixqualitydimensionsasdefinedwithintheInstituteofMedicine(IOM)reportCrossingtheQualityChasm,arethemostcommonlyreferenced28.

Safe S

Timely T

Efficient E

Equitable E

Effective E

Patient-centered P

Bydefiningthedimensionsofquality,organisationsareabletoensurethattheirinclusioncanbejustifiedbutcanalsomeasureachievementinrelationtothosedimensions,demonstratingthatqualityisnotanoptionalextrabuttheessenceofagoodandacceptableservice.Whenstandardsaredevelopedthecriteriashouldaddressallofthequalitydimensions.

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Codesofpatient/consumerrightshavenowbeendevelopedoradoptedinmanycountries.Thesearedesignedtoprotectanindividual’srightswhentheyaccesshealthorsocialcareservicesanddescribewhattheirrightsarewhenaccessingsuchservices.Insomejurisdictions,thecodesofpatient/consumerrightsarespecifiedinorunderpinnedbylegislationandserviceprovidersarerequiredtohaveprocessesinplacetomeetthem.Insuchcasesthecodesofpatient/consumerrightsmaybereferencedinthestandardsasthiswillprovideameansofassessinghowserviceprovidersaremeetingpatient/consumerrights.Inothercountries,codesofpatient/consumerrightshavebeendevelopedbyorganisationssuchasnationalconsumeroradvocacyorganisationsandserviceprovidersmayadoptthemonavoluntarybasis.Referencingthecodesofpatient/consumerrightsinstandardsisonewayofhelpingtoensurethatstandardsarefocusedonthepatient/consumer.Thisinturnwillhelpserviceproviderstofocusondeliveringpatient/consumerfocusedcarethatmeetstheirneedsandprotectstheirrights.

Matureaccreditationorganisationshavenowmovedtodesigningtheirstandardstoreflectthepatient/consumerjourneyorpathwayandthensurveyorsmay,aspartofthesurveyprocess,traceorfollowselectedpatients’/consumers’journeystocheckateachstageifthestandardsweremetforthatindividualandtheirfamily.

Manysetsofstandardslabelsomecriteriaascoreorcompulsory,usuallybasedonsafetyandrisk.Thecorecriteriaareusuallythenrequiredtobemetoradefinedratioofthemmet,e.g.80%.Thesecorecriteriamaybeusedforlicensingorregulationpurposes.

4.4 Developing the measurement system

Theratingscaleshouldreflectthepurposeofthestandards,betransparentandenableuserstorateandmeasurestandards,criteriaorelementsconsistently.Ayes/noscaleisgoodfordeterminingcomplianceornon-compliancewithacriterionorstandard,especiallyformeasuringstructuralelements,soitsuseshouldreflectthenatureofthestandards.Itleaveslessscopeforrecommendationsforimprovementwhereacriterionismainlymet,butsomeelementsaremissing.

Likert-typeratingscalesareparticularlysuitedforstandardswithastrongqualityimprovementapproach,e.g.3,5or7pointscales,oftenwithdescriptionsforeachpointorsomeofthepoints.Thesedescriptionsmayrelatetoprinciplessuchascompliance,consistency,evidenceandimplementation.

Thereisatendencyforassessorstofavouramiddleorneutralpoint,soanevenpointscalesuchasafourpointscalecangiveaclearcut-offpointastowhetherthecriterionismetornotbutstillprovideagraduatedmeasureofhowwellitismetorhowbadlyitisnotmet.Theclearerthedescriptors,themoreconsistenttheassessmentsarelikelytobe.

Aswellasameasurementsystemforratingeachmeasureablecriterion,elementorstandard,asystemisneededtodetermineifthestandardsaremetoverallwhichwillbethebasisforawardingaccreditationorcertificationwherethatisapplicable.Inastudycomparingtheorganisationalattributesofaccreditationprogrammesinlow-andmiddle-incomecountrieswiththoseinhigher-incomecountries,itwasfoundthatthelow-andmiddle-incomecountries’programmesweremorelikelytouseaformulaicmathematicallyorientedapproachtomakeaccreditationdecisions7.Traditionally,accreditationorganisationsreliedonaccreditationpanelstomakedecisionsbutthiswasnotalwaysatransparentprocess,thebasisofthedecisionwasnotalwaysclear,itcouldbemorepronetobiasorexternalinfluenceandwasalsolikelytoresultinappealsagainstthedecision.



Therefore,bestpracticeistodetermineoverallachievementofstandardsbasedonaformulawhichincludesthelevelofachievementoforcompliancewiththemeasureableelementsofthestandards,riskandotherelementsofthestandardssuchascorecriteriaorhighprioritycriteria.

Someorganisationsmeasureonlyatthecriterionlevel,sotheiroveralldecisionwillbebasedonachievementofcriteriawhileothersusetheoverallratingsofthecriteriawithineachstandardtorateachievementofthestandard,sotheiroveralldecisionwillbebasedonachievementofthestandards.Forexample,themethodologycouldbethatallcoreorcompulsorycriteriamustbemet,orallcriteriaorstandardsmustbemetatadefinedlevelsuchas3or4ona4pointscale,ornostandardsmustberatedatbelowacertainlevel.

Liketherestofthestandards,theratingscaleneedstobedevelopedinconsultationwithstakeholdersandthesatisfactionofusersregularlyassessed.Aswiththestandardsthemselves,theratingscaleneedstobetestedandpilotedbeforeusetoensureitisreliableandcanproduceconsistentandfairresults.

Thecasestudyexampleshighlighttheapproachestostandardsdevelopmentadoptedindifferentcountries.

Case Studies – Development of standards

IKAS – Danish Institute for Quality and Accreditation in Healthcare Country: Denmark

Range of standardsIKAShasdevelopedallstandardsusedinitsprogrammes.Theywerefirstdevelopedforhospitalsandcommunitypharmacies.Standardshavesincebeendevelopedforprimarycareservices,deliveredbymunicipalities,andforambulanceservices.Currentlystandardsarebeingdevelopedforgeneralpractitionersandspecialistphysicians.Overthecomingyears,allhealthcareprofessionswhooperateoutsideofhospitalsintheirownofficeorpremiseswillbecovered.

Development processStandardsweredevelopedbythemegroups(forrelatedgroupsofstandards)ofstandarddevelopers,consistingofseniorprofessionals,appointedbytheRegionsandtheAssociationofDanishPharmacies.IKASandHQS/CHKSservedasadvisorsandsecretariatforthegroups.

Rating scaleCompliancewithstandardsisassessedbyscoringanumberofelements(forthehospitalstandardsroughly450)accordingtoafourpointscale(Fully/Largely/Partially/NotMet),wherethetwoupperlevelsindicateasatisfactoryperformance(exceptforcertainsafetycriticalstandards,whereonlyFullyMetisconsideredsatisfactory).Anyelementnotmettosatisfactionwillrequirefollowup,andifnotcorrected,resultsinaccreditationwithcomments.AnAccreditationAwardPaneldecides,guidedbycertainrules,whetherthenatureand/oramountofthecommentsprecludeaccreditation–ifso,statusas“notaccredited”isawardedandpublished.

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Health Care Accreditation Council (HCAC) Country: Jordan

Range of standardsAsthenationalaccreditationagencyofJordan,HCACsetsstandardsforhospitals,primaryhealthcarecentres,familyplanningandreproductivehealth,transportservices(ambulances),cardiaccare,anddiabetesmellitus.HCACsurveysagainstthestandardsandawardsaccreditation.

Development processAllthestandardsaredevelopedinJordan.Nostandardsdevelopedbyotherorganisationsareused.Hospitalstandardsweredevelopedfirst,thenstandardsforprimarycarecentres,familyplanningandreproductivehealth,transportservices(ambulances),cardiaccare,anddiabetesmellitus.

Rating scaleStandardsareclassifiedascritical,coreandstretch.100%ofcriticalstandardsmustbemet;andaspecifiedpercentageofbothcoreandstretchstandardsmustbemetinorderforaservicetobeaccredited.

Health and Disability Auditing New Zealand Ltd (HDANZ) Country: New Zealand

HDANZisaprivate,independentlyownedcompany.ItislinkedtogovernmentasaMinistryofHealth(MOH)approveddesignatedauditingagency.HDANZauditstheseservicesonbehalfoftheMOHandsubmitsauditreportstotheMOHwhothenissuesthecertificatestotheservices.

ServiceproviderspayfeestoHDANZforsurveyandmonitoringvisits.CertificationhasbeenmandatoryfortheMOHSafetyActsinceOctober2002.FromSeptember2005,itbecamemandatoryforphysiotherapyservicesiftheywantedtoprovideservicesundertheNewZealandAccidentCompensationScheme(ACC)physiotherapyservicescontract.FromSeptember2012,healthfundersmadecertificationmandatoryforhomesupportprovidersandfromMarch2013,ahealthinsuranceproviderSouthernCrossHealthSocietymadecertificationmandatoryfortheiraffiliatedproviders.

Theratingscaleforcomplianceagainstthehealthanddisabilitysectorstandardsis:

CI=Continuousimprovement

FA=Fullyattained

PA=Partiallyattained

UA=Unattained

TheMinistryofHealthusestheassessmentratingstodeterminecertification.Thelengthofcertificationcanvaryfromonetofouryearsdependingonthelevelofachievementofthestandards.

Thenextchapteroutlinesthefactorstobeconsideredindevelopingassessmentmethodologies.



Chapter 5: Developing assessment methodologiesThischapterexploresfactorstobeconsideredinthedevelopmentoftheassessmentmethodologysuchastheselection,trainingandevaluationofsurveyors;thedevelopmentofthesurveymanagementprocess;andtheestablishmentofprocessesfordeterminingtheaccreditationorcertificationstatus.

Asurveyagainststandardscanbeachievedbyeitheradesktoprevieworanon-sitesurvey.Desktopreviewsmaybesuitableforsomespecialitiessuchasdiagnosticimagingorclinicalpathwayssuchasstrokecare.Fororganisationsanon-sitesurveyisrecommended,whichcanbeplannedorunannounced.

Surveyorsarethemaininterfaceoftheexternalevaluationorganisationwithitsclients,andthesurveyisthekeyeventonwhichtheclientswilljudgetheorganisation.Itisessentialthatsurveyorsandthesurveyandawardprocessesaremanagedconsistently,transparentlyandwell.

5.1 Selection, training and evaluation of surveyors

Accreditationorganisationsgenerallyusetheterm“surveyors”whilecertificationorganisationsusuallyusetheterms“assessors”or“auditors”todescribethepersonnelwhovisit,assessanddraftreports.Regulatorybodiesmayusetheterm“inspectors”.Theyarecentraltothecredibility,objectivityandsustainabilityoftheorganisation.Accreditationsurveyorsaregenerallyregardedaspeerreviewers–doctors,nurses,managersandalliedhealthprofessionals–whounderstandtheworktheirpeersdobuttheirroleistoassessprocessesandsystemsratherthantheirpeers’performance.Auditorsareprofessionalqualityauditors,usuallycertifiedassuch,whocanauditorassessacrossindustriesanddonotneedtobeahealthcareprofessionalpeer.Inthisguidetheterm“surveyor”isusedtocoverallassessmentpersonnelandtheterm“survey”tocoverallexternalassessments.

Paid or voluntary?

AspreviouslyhighlightedinChapter3(SeeSection3.3Fundingoftheprogramme),accreditationorganisationshavetraditionallyrelieduponparticipatingaccreditedinstitutionstoprovideorloanstafftoworkassurveyorsandtopromotetheconceptofpeerreview.Thishastheadvantageofreducingsurveycosts,maintainingtheacceptabilityandindependenceofpeerreview,andsharingtheexperienceandknowledgeofaccreditationwidelythroughoutthehealthsystem.However,itassumesthattherearepersonnelwithenoughexperiencewhoareableandwillingtobesecondedbytheiremployerstobetrainedassurveyorswithoutcreatingaconflictofinterest.Tomaintainskilllevelsandcurrencywithstandardsandsystems,surveyorsshouldbeexpectedtoundertakeaminimumnumberofworkingdays(usuallyten)ayear.Itcanbeachallengeforthemtogetreleasedfromtheirfull-timejobforthisamountoftime.

Certificationorganisationsusuallyemployorcontracttheirassessmentpersonnelonapaidbasis,supplementedbytechnicalexperts.However,ashighlightedinChapter3(SeeSection3.3Fundingoftheprogramme),accreditationorganisationsarenowalsoincreasinglypayingsurveyorsasemployedorcontractedpersonnel,orusingamixofbothpaidandvoluntary.Surveyorsmostlycomefromahealthbackgroundandhavepreviouslybeeninvolvedinaccreditationprogrammes.

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Theadvantagesofhavingamorestableworkforceofpaidsurveyorsistheirgreateravailability,thereducednumberofsurveyorsneeded,reduceddemandforrecruitmentcampaignsandnewtrainingprogrammesandmorereliableandconsistentperformanceoftherolebecauseoftheincreasedfrequencyofundertakingsurveysandwritingreports.

Selecting and appointing

Thefirststepsindevelopingasurveyorworkforceareto:

Determinethenumber,skillmixandmixofpaid/employedorvoluntarysurveyorsneededfortheplannedprogrammeofwork(thenumberswillneedtobeincreasedasmoreorganisationsjointheprogramme)

Definetherequiredcompetencies,includingpersonalattributes,professionalqualificationsandexperience,knowledgeandskillsetsrelevanttotheprogramme.

Thenumberofsurveyorstoberecruitedshouldbeestimatedfromthevolumeofsurveysplanned,theirduration(intermsofsurveyordays),thenumberofdayseachsurveyorwouldprovideperyear,thenumberofsurveyorswithdrawingeachyearandthepaid/voluntarymixofsurveyors.Theirprofessionalbackground,cultureandskillsshouldreflectthefunctionandscopeoftheprogramme.Recruitmentmaybedonebyadvertisinginrelevantpublications,sendingnoticestoallpotentialclientorganisationsandprofessionalassociations,anddirectlyapproachinglikelycandidates.

Surveyorsshouldbeappointedthroughaclearlystatedandfairlyappliedprocessinaccordancewiththedefinedcompetenciesandthenumbersdetermined.Competenciescouldinclude:

Personalattributes,includingtheabilitytocommunicateeffectivelyandtoworkasateammember

Professionalqualificationsandexperience,usuallyataseniorlevel

Currenthealthcareorsocialcaresectorknowledge

Skillsintheareascoveredbytheprogramme.

Whethersurveyorsareseconded(ontheirusualsalary),oremployeddirectlybytheexternalevaluationorganisation,theymustbecommittedtocomplywiththerulesofthatorganisation,particularlywithrespecttoconfidentialityandindependence.Iftheexternalevaluationorganisationemploysthemdirectly,itmayhavetoacceptadditionallegalresponsibilityandhavetoprovideadditionalliabilityinsurance.

Trainingtobeasurveyorandundertakingtheroleisaformofprofessionaldevelopmentandisrecognisedassuchbymanyprofessionalcollegesandassociations.Surveyorsbecomefamiliarwiththestandardsandsurveyprocessesandareabletolearnfortheirownpracticefromwhattheyobserveintheorganisationsinwhichtheysurvey.Theyinturnbecomeeducatorsofthestafftheysurvey,abletoidentifyareaswheretheycanimproveandbestpracticemethodsortoolstheycoulduse.

Training

Afterselection,surveyorswillthenneedtobeeitheremployedorcontracted,andtrainedandorientedtotherole.Trainingcannotbeginuntilatleastdraftstandardsandproceduresareavailable.Inestablishedorganisations,trainingisprovidedbyexistingsurveyorsandstaff;neworganisationsgenerallyuseexpertisefromotherprogrammes,atleastforinitialtraining.



Theinitialtrainingprogrammecanbeofonetofivedaysdurationandshouldcovertopicssuchas:

Standards’interpretation

Surveyprocess

Interviewingandobservationskills

Documentationreview

Specificareas,e.g.safety,infectioncontrol

Reportwritingtechniques

Traineesthenneedtobeevaluatedtodeterminetheirsuitabilityfortherole.Mockassessmentsareoftenincludedsothattraineescandemonstratetheiraptitude.Theythenusuallygoononeormoresurveyvisitsasobserversortraineeswithamentortoaccustomthemtotheroleandfurthertesttheirsuitability.Theyneedmanualsandotherresourcestoassistthem.Programmesareincreasinglyusingtechnologyon-sitefortherecordingoftheassessmentanduseofthisalsoneedstobepartofthetraining.

Thesurveyortrainingprogrammeofaccreditationorganisationsinlow-andmiddle-incomecountriestendtobesurveyorcertificationprogrammesandorganisationsindevelopedcountriesarealsomovinginthisdirection.Suchcertificationprovidesarecognisedstatusforthesurveyorbutmayalsoprovidetheopportunityformorerigorousevaluationofperformanceandongoingtraininganddevelopment.Certificationprogrammesgenerallyexpecttheirauditorsorassessorstobecertified.

Ongoing development and evaluation

Surveyorsmustbeprovidedwithongoingtraininganddevelopmentopportunities,andbeevaluatedregularlytoensuretheirongoingcompetence.Externalevaluationorganisationsneedtodefinecriteriaforselecting,training,retraininganddeselectingsurveyors.Someorganisationshaveanindependentcommitteetomonitorinter-raterreliabilityofthesurveyandratingperformanceofsurveyorsand/orsatisfactionsurveysbyanindependentthirdparty,aswellasin-housesurveyteamassessments.Itiscommontoaskclientorganisationstoevaluatethestandards,thesurvey,andtheperformanceofthesurveyorsaftertheexternalsurvey.Theseevaluationsaremostusefuliftheyrelatetotheindividualsratherthanjusttheteam.Allthesereports,andparticipationincontinuingtraining,contributetothesystematicappraisalofeachsurveyor.

Wherethereisasurveyorcertificationprogramme,surveyorsmustmeettheannualrequirementstomaintaintheircertification.

TheISQuaSurveyorTrainingProgrammeStandards(2009)5provideguidanceonsettingupthesetrainingprogrammeswhichcanthenbeISQuaaccredited.TheISQuaGuidelinesandStandardsforExternalEvaluationOrganisationsalsocontainastandard(Standard6)onsurveyormanagement3.

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5.2 Developing the survey management process

Contracting with the client organisation

Thereshouldbeadefinedprocesstoensurethatparticipatingorganisationsareawareoftheirrightsandresponsibilitiesinrelationtotheexternalevaluationprogramme,andthattheyunderstandtheproceduresandresponsibilitiesoftheprogramme.Thisusuallyinvolvesastandardcontractorserviceagreementbetweentheapplicanthealthcareorsocialcareorganisationandtheexternalevaluationprogramme.

Trainingandeducationalsupportareoftenprovidedbytheprogrammeforthestaffoftheclientorganisationasanintegralpartofthepreparatoryprocess.Thismayincludeforexample:projectmanagertraining,standardsinterpretation,andinternalassessmentandself-assessmenttraining.Whereself-assessmentisacomponentofitsprogramme,theexternalevaluationorganisation’sstaffcanguidetheclientastohowtoundertakeandcompletethis.Self-assessmentagainstthepublishedstandardsdevelopsinsightandcommitment,andreducestheburdenofexternalassessmentbecauseithelpsorganisationstoidentify,understandandresolvetheirownproblems.Manyprogrammesconsiderthisinternalisationtobeakeyfactorintherapidlyincreasingcompliancewithstandardswhichcanbedemonstratedinparticipatingorganisationsinthemonthspriortoexternalsurvey.Itisimportanttodeterminewhatisincludedwithintheprogrammefeesandwhattraining/educationalsupportisprovidedatanadditionalfee.

Manyprogrammesprovidefacilitators,suchasprogrammestaffortrainedsurveyors,tosupportclientorganisationstoprepareonfirstenteringtheprogramme,andtofeedbacktotheprogrammeanyproblemswithsystemsorprocesses.Thisacknowledgesthattheearlyexternalsurveysareasmuchatestofthestandards,surveyorsandproceduresastheyareoftheorganisationbeingvisited.Thefacilitatorsshouldnotbepermittedtotakepartinorinfluencetheexternalsurvey.Theycanarrangetraining,participateasatrainer,adviseclientsoninterpretationofthestandardsorwhatneedstobeinplacetomeetthestandardsbuttheycanonlyprovidegenericadvicethatisfreelyavailableinthepublicdomain.Theymustnotgiveanyadviceonhowthingsshouldbedoneorprovideanytechnicalassistancesuchaspreparingorproducingdocumentationorprocedures,orgivingclient-specificadvice,instructionsorsolutions.Thiswouldberegardedasconsultancywhichmustbestrictlyseparatedfromexternalevaluationactivities.

Apre-surveyreviewormocksurveycanalsobeavaluablepartofpreparation.Itidentifieswhethertheclientorganisationisinterpretingthestandardscorrectlyandhasappropriatedocumentationasevidenceofhowitmeetsdifferentcriteriaaswellasindicatingtheclient’sprogresstowardssurveyreadiness.Italsoprovidesagoodpracticerunforstaffsotheyknowwhattoexpectfromtheactualsurvey.

Planning and conducting the survey

Planningthescopeofthesurvey,durationandthesizeofthesurveyteamshouldbetransparent,basedontheneedsoftheorganisationandthepoliciesoftheexternalevaluationbody.Thesurveyorteamfortheexternalsurveyshouldincludeanappropriatemixofskillsandexperienceandavoidconflict(s)ofinterest.Amoreexperiencedteamleaderisgenerallychosentoguidetheprocess.Datesfortheexternalsurveyareusuallyset6-12monthsinadvancetoallowforself-assessmentandpreparationandpossiblyamocksurvey.

Thestandardsmustbeincorporatedintoatoolinwhichsurveyorscanmakefindings,ratingsandrecommendationsforimprovement.Theself-assessmentcanbeincludedinthetoolifthisispartoftheprocess.Thetoolmaybeonpaperorloadedintoatabletorsimilartechnologicaldevice.



Sitevisitsmayextendfromhalfadayforonesurveyorforasmallruralprimarycareclinictotwoweeksforlargeteamsforahealthcarenetwork.Smallhospitalsorresthomesoftenusetwopeoplefortwodays(foursurveyordays);largeronescommonlyusethreepeopleforfivedays.Timeforsurveyorpreparation,travel,teambriefingandreportcompletionmustbeaddedtothese“on-site”estimates.Attheendofthevisit,mostorganisationsprovidetimefortheteamtoprepareareportbackoffindingswhichtheypresentatameetingtotheleadershipoftheclientorganisationandpreferablyalsotostaff.Thisenablestheclienttocorrectanyerrorsatthetimeandmeansthereshouldbenosurpriseswhentheyreceivethefinalreport.

Theefficiencyofthesurveyvisitandthetransparencyandconsistencyoftheprocesscanbeimprovedthroughtheprovisionoftoolsandguidelinestoassistthesurveyors;thoroughpreparationbytheorganisationbeingsurveyedandthesurveyors;thetimelysubmissionofcompleteandaccurateself-assessmentsandotherpre-visitdocuments;arealisticsurveytimetable;explicitsamplingprocedures;specifieddocumentsbeingmadereadilyavailableforreviewonsite;andtimemanagement.Increasingthenumberofsurveyordaysmaynothelp,butwillcertainlyincreasethecomplexityandcostofthevisit.

Writing the report

Thesurveyorswriteareportoftheirfindingsandratingofachievementagainstthestandardseitherwhilestillon-siteattheendofthevisitorafterwards.Doingthiselectronicallycontributestothespeedwithwhichthereportcanbesubmitted.Newexternalevaluationorganisationsshouldincludethee-generationofthereportaspartoftheirprogrammeifpossible.Itisimportantthatstricttimelinesareputonthisprocess,otherwisethesurveyorscangetbacktotheirusualworkplaceandtrytocatchuponthatworkbeforefinishingthereport.Adelayatthisstageleadstoadelayinmakingtheawarddecisionwhichisfrustratingfortheclient.Thereportissubmittedtotheexternalevaluationorganisationwhichmusthaveprocessesforeditingandreviewingthereportstoensuretheyarecomplete,accurate,balanced,constructiveandconsistentwiththeintentofthestandards.

Performance indicators

Theexternalevaluationorganisationshoulddeterminewhatindicatorsitrequiresitsclientorganisationstomonitor.Theseshouldcoverthedifferentmanagement,safetyandclinicalfunctionsofthehealthcareorganisationandmayincludethingssuchascomplaints,patient/clientsatisfaction,staffsatisfaction,staffturnover,financialratios,adverseevents,accidents,clinicalindicatorssuchasfallsandinfections,andmedicationerrors.Thesedemonstratethattheclientorganisationhasthecapacitytogenerateandanalyseperformancedataaspartofaninternalqualityimprovementprogrammeandisusingtheresultstomakeimprovements.

Sometimesthecollection,analysisandpublicationoftheresultsofindicatordataispartofthescopeoftheexternalevaluationorganisation.Inthesecases,theremustbeprocessestoensuretheindicatorshavestandardiseddefinitionsandnumeratorsanddenominators,thatthedatacollectedisclean,complete,accurateandtimely.Thedatacanthenprovidecomparablemeasuresofachievementovertimeforahealthcareorganisationorbetweensimilarorganisationsintermsofprocessesandoutcomesinclinical,safety,financialorotherareas3.

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5.3 Establishing the accreditation / certification process

Responsibilities for accreditation / certification

Theexternalevaluationorganisationisresponsibleforsettingthecriteriafordeterminingaccreditationorcertificationstatus,andthedecisiononwhetherornottograntaccreditationstatusismadeinaccordancewiththecriteriaonthebasisofthefindingsinthesurveyreport.Thesecriteriashouldensure:

Transparencyfororganisationsbeingaccreditedorcertified,forsurveyorsandforthepublic

Considerationfortheclientsoftheserviceandtheirsafety

Decisionsbasedontheachievementofthestandards

Considerationofhowaccreditationorcertificationstatuswillfacilitatefurtherqualityimprovement

Consistencybetweenawarddecisions

Anon-adversarialprocessforappeals.

Basis for recognition decisions

Earlierprogrammesbasedtherecognitiondecisionoraccreditationstatusprimarilyonthecapacityforgoodclinicalcare,demonstratedbycompliancewithaccreditationstandards,buttheemphasishasnowshiftedtowardsoverallperformance.Neweraccreditationprogrammes,especiallyindevelopingandunder-resourcedcountries,mayneed,atleastinitially,tofocusonandtorewardtheexistenceofbasicinfrastructureanddemonstratedprogresstowards,ratherthanabsolutecompliancewith,thepublishedstandards.Differentprogrammesmayhavedifferentpriorityconcerns,e.g.criticalfunctionalareassuchaspatientcare,infectioncontrol,qualityimprovementormanagementoftheenvironment;patientsafetygoalssuchaspatientidentification,highalertmedications,wrong-sitesurgeryorcommunicationamongcaregivers;orareasofdifficultysuchasinformationflow,patientrecordsormedicalequipmentsurveillance.

Incasethereisanydisputeabouttherecognitiondecision,atransparent,independentandclearlydescribedappealsprocessisnecessary.

Timeframe for recognition decisions

Havingworkedhardtopreparefortheexternalsurvey,staffandmanagementofclientorganisationsareeagertoreceiveatimelydecisionfromtheexternalevaluationorganisation.Manyprogrammesstillaimtoprovidethemajorityofdecisionswithintwomonthsofthesurvey,althoughthoseusingelectronictechnologyforreportsandformulaiccriteriafordecisionmakingareabletomakethedecisionsmuchquicker.Asthedelayincreases,thereportanddecisionbecomeincreasinglyirrelevant,staffbecomedemotivatedandimprovementisnotsustained.Theadjudicationprocessmustthereforebetransparentandthorough,butalsotimely.

Duration and maintenance of accreditation

Accreditationstatusisnormallyawardedforaperiodofbetweenoneandfouryears.Sometimestherearedifferentgradesofachievement,e.g.conditional,orwithcommendations,orexemplary.ISQuacriterianowrequiremonitoringbytheexternalevaluationorganisationofthecontinuedmaintenanceofstandardsandqualityimprovementsbyaccreditedorcertifiedorganisations.



Monitoringcouldincludesubmissionofanactionplanfollowingtheawardwithtimeframesformakingimprovementsrecommendedinthereportandregularupdatesonprogresswithimplementation.Inmostprogrammes,themajorityofreportrecommendationsaftertheexternalsurveyareaboutimprovingsystemsintheorganisationratherthanaboutincreasingresourcesand,aswiththepreparation,theorganisationshouldbeincurringmuchofthatcostanywaysoitshouldnotbeabarriertoimprovement.Othermonitoringmayrequireareviewofspecifieddocumentsthatweredeemedincomplete,inadequateormissing;annualormid-termvisitsandrandomreviews.Longerintervalsbetweenexternalsurveystendtoinstilafalsesenseofsecurityandremovethemomentumforinternalimprovement.

Publication of results

Theextentandmethodsofpublicdisclosureofsurveyfindingsandaccreditationorcertificationawardsmustbeagreedinadvancebytheexternalevaluationorganisationandthevariousstakeholders.Thepublicshouldhaveaccesstoinformationaboutwhichorganisationsareaccreditedorcertified.Someorganisationsarenowpublishingthesurveyreportsorasummaryofthem.Regulatorybodiesareusuallymandatedtopublishfullreports.

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Example: Public disclosure of accreditation reports: Japan

TheJapanCouncilforQualityHealthCare(JCQHC)wasfoundedin1995andhasdevelopedstandardsandcriteriaforaccreditationandbegancarryingouton-siteassessmentsin1997.JapanhasauniversalhealthinsurancesystemandsoJapanesepeoplehavearighttoreceivemedicalcareatanyhealthcareorganisationandhospitalscannotrefuseanypatients.Hospitalaccreditationisvoluntaryandrequiresanapplicationfee.HospitalsreceivescoresforeachiteminallareaswithcommentsfromJCQHCinthestandardaccreditationprocess.TherearetwoformsofdisclosureofhospitalaccreditationreportsinJapan:

1. Self-disclosuretothepublicdirectlybyhospitals;

2. DisclosurebytheJCQHCwithagreementfromthehospitalconcerned.

Hospitalsarenotpermittedtodiscloseonlyselectedpartsoftheiraccreditationreportasthepurposeofdisclosureofaccreditationreportsistogiveconsumersaccessnotonlytofavourableaspectsofthereportbutalsotoinformationaboutthoseaspectsoftheservicethatrequireimprovement.ThedatadisclosedbytheJCQHCtothepublicincludesummarycommentsandaccreditationscoresforalltheitemsassessed.

AstudywasperformedinJapantoexaminetheassociationbetweenaccreditationscoresandthedisclosureofaccreditationreports.Thisincludedaquestionnairetohospitalswhodisclosedtheiraccreditationreportstogatherdataabouthospitalcharacteristicsalongwithperceptionsaboutthepublicdisclosureofaccreditationreports.Atotalof547ofthe817hospitalsaccreditedbyJCQHCparticipatedinthestudy.Commentsaboutthedisclosureofaccreditationreportswerecategorisedintofivegeneralsubjectareas:(1)impactofdisclosureonthepublic,(2)advantagestothehospital,(3)riskstothehospital,(4)JCQHCdisclosure,and(5)hospitalself-disclosureofinformation—thatis,voluntarydisclosurebythehospitalby,forexample,apamphletoranoticeonallbillboardsinthehospital.Feedbackfromparticipatinghospitals,highlightedthatmosthospitals(60%)perceivedisclosureasgoodforconsumersandhospitals;withmosthospitalswhodisclosedtheirreportstotheJCQHC(80.5%)agreeingthat“disclosureprovidesincentivesforimprovingthequalityofcarebecauseconsumersinthecommunityreadaccreditationreports”.

Atotalof508(93%)oftheparticipatinghospitalsdisclosedtheiraccreditationreportsontheJCQHCwebsite.Publichospitalsweresignificantlymorecommittedtopublicdisclosurethanprivatehospitals,andlargerhospitalsweresignificantlymorelikelytoparticipateinpublicdisclosurethansmallerhospitals.Accreditationscoreswerepositivelyrelatedtothepublicdisclosureofhospitalaccreditationreports.Scoresforpatientfocusedcareandeffortstomeetcommunityneedsweresignificantlyhigherinactivelydisclosinghospitalsthaninnon-disclosinghospitals.Amongthelargehospitals,scoresforsafetymanagementweresignificantlyhigherinhospitalsadvocatingdisclosurethaninnon-disclosinghospitals.

MosthospitalswhoagreedtodisclosurebytheJCQHC(410/508–80.7%)reportedthattheirpublicdisclosurewashelpful.Atotalof489ofthe547respondents(89.4%)indicatedthattheyalsodisclosedtheiraccreditationreportsthemselves:366disclosedonlytheiraccreditationstatusand123disclosedmorethanthis.ThestudyfoundthatsignificantlymoreofthehospitalswhoagreedtodisclosureoftheirreportbytheJCQHCalsoreleasedinformationthanthosewhowerenotinfavourofdisclosurebytheJCQHC.

Thestudyfindingssuggestthatpublicdisclosureofaccreditationreportsshouldbeencouragedtoimprovepublicaccountabilityandthequalityofcare.Theauthorshighlightedthatthereisaneedforfurtherresearchtoexploretheinteractionbetweenpublicdisclosure,processesandoutcomes29.



5.4 Quality Assurance

Externalevaluationorganisationsneedtobeabletodemonstratetheirintegrity,objectivityandreliability.Mechanismsinclude:

Theprogramme’sstandards,surveyprocessesandcriteriaforaccreditationorcertificationawardsaremadepubliclyavailable

Surveyorsareselected,trainedandevaluatedagainstexplicitpublishedcriteria

Surveyteamsaretailoredtoeachindividualclientorganisation,accordingtopublishedcriteria,toavoidanyconflictofinterest

Thesurveyteamreportsinitialfindingsbacktotheclientorganisationbeforeleavingthesite,especiallyinrelationtothoselikelytogeneraterecommendations,inordertochecktheobservationandtoensuretherearenosurpriseslater

Teamreportsarepreparedandagreedjointlyandincompliancewithprocedureswhichareoftendefinedinasurveyors’handbook

Teamreportsareindependentlycheckedwithintheexternalevaluationorganisationforcontent,consistencyandcompliancewithprocedures

Finaldraftreportsarereferredtotheclientorganisationforverificationbeforetheaccreditationorcertificationdecision

Accreditationorcertificationawardsaremadebyapanelorstaffindependentoftheprocess,basedontheteam’sreportandinlinewithdefineddecision-makingcriteriaorformulae,notbytheteamitself3.

Thefinalchapterwilllookatevaluationsystemsthatneedtobeestablished.

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Chapter 6: Evaluating systems and achievementsExternalevaluationorganisationsneedtosetanexampleofqualityimprovementwithintheirownorganisation.Thisincludesdefining,monitoringandimprovingtheirownperformance.Thischapteroutlinessomeofthemechanismswhichexternalevaluationorganisationscanemploytodothis.

6.1 Measuring performance internally

Internalaudits,indicatorsandqualityimprovementprojectswillformpartoftheoverallqualityframeworkoftheorganisation.

Indicatordataroutinelycollectedbyexternalevaluationorganisationsandreportedtogoverningboardsinclude:

Recruitment,drop-outofparticipatingorganisations

Denialrate(proportionoforganisationsrefusedaccreditationorcertification)

Reportturnaroundtimes(fromsurveydatetofinalreportortoawarddecision)

Financialperformance,suchasactualagainstbudgetandvariousfinancialratios

Websitehits

Surveyorrecruitment,trainingandevaluation

Clientsatisfactionwithsurveyors,educationservices,thesurveyprocess,thesurveyvisitandotherproductsprovidedbytheprogramme

Staffsatisfaction

Surveyorsatisfaction

Satisfactionofotherstakeholders.

TheISQuaorganisationstandardsrequiretheexternalevaluationorganisationtoevaluatetheperformanceofvariousfunctions(suchasgovernance,humanresourcesmanagement,surveyorandsurveymanagementandaccreditationorcertificationprocessesandoutcomes),bycollectingdataondefinedindicatorsandothermeasuresofperformance,analysingit,makingimprovementsandevaluatingachievements3.

Externalevaluationorganisationstypicallyundertakemanydevelopmentandimprovementinitiatives.Theseneedtobetreatedasqualityprojectsandtheobjectives,actions,timeframes,responsibilities,progressandresultsdocumented.TheseprojectdocumentswillformanimportantpartoftheevidenceneededwhentheorganisationundergoesitsownexternalevaluationsurveythroughISQua.

Auditsneedtobescheduled,resultsdocumentedandactionstakenasaresultrecordedandevaluated.Auditscanaddressanumberofareas;forexample,auditscanbeconductedofstaff,surveyorandclientrecords;awarddecisions;healthandsafety;andthecomplaintsregister.



6.2 Evaluating independently

Independentevaluationsofnewaccreditationorganisationshavebeencommissioned,oftenbygovernmentsorasconditionsofreceivinginitialdevelopmentfunding.ExamplesfromAustralia,SouthAfrica,ZambiaandtheUKdocumentbenefitsperceivedbyorganisationsandtheirusers,butincludelittledataonindividualorpopulationhealthimprovements1.

AWHOstudyofexternalqualityassessmentprogrammesformaternalandchildhealthconcludedin2002thatthesebringbenefitstoclients,thecommunity,staffandtheservice,summarisedas30:

Thelinkages,networksandstructureswhichhavebeendevelopedand/orimprovedtoinfluencethepolitical,legislative,economic,socio-culturalandpublichealthenvironmentwithinwhichservicesoperate(enablingmechanisms)

Thereorganisationand/ordevelopmentofthehealthcaredeliverysystemsattheservicelevel

Thechangeinattitudeand/ordevelopmentofskillsandknowledgeofhealthservicestaff

Improvementstohealthfacilitiesandequipment

Aclient-centredandclients’rightsapproachtohealthcarewherebyservicesconsultwithandsupportclients,areneedsbasedandabletodeliverbettercaretoclientsandthecommunity.

6.3 Monitoring by regulatory agencies

Someregulatorybodies,e.g.inUSAandCanada,monitorindependentaccreditationprogrammes,primarilybyrepresentationonthegoverningboardorbychecksonselectedsurveys.ThefederalgovernmentfollowTheJointCommissioninto5%ofsurveysin“deemedstatus”hospitalswithinafewweeksofthevisittovalidatereports;theNationalCommitteeforQualityAssurance(NCQA)inUSAhasaproportionofco-visits;andtheAccreditationAssociationforAmbulatoryHealthCare(AAAHC)hasasimilarproportionofpost-accreditationvalidationsurveysofambulatorycarecentres.InSouthAfrica,theprovincialgovernment,whichisalsothecontractor,providesmonitoringbyco-visiting.InNewZealand,theMinistryofHealtharrangesmonitoringauditsof5%ofallcertificationauditsundertakenbyindependentdesignatedauditagencies1.

6.4 Accrediting the external evaluation bodies

TheInternationalSocietyforQualityinHealthCare’s(ISQua’s)InternationalAccreditationProgrammehasbeeninexistencesince1999and“accreditstheaccreditors”.Thescopeoftheprogrammehasbeenextendedfromtheevaluationofnationalhealthcareaccreditationorganisations,theirstandardsandsurveyortraining,toincludeotherstandardsbasedcertificationandauditorganisations.

TheInternationalAccreditationProgramme(IAP)providesthreeproductsforhealthandsocialcareexternalevaluationbodies:

Surveyandaccreditationtointernationalstandardsforexternalevaluationorganisations

Standardsassessmentandaccreditationtointernationalprinciplesforhealthcareandsocialcarestandards

Assessmentandaccreditationofsurveyortrainingprogrammes.

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Theinternationalstandardsforexternalevaluationorganisationsaretheoutcomeofseveralyearsofdevelopment,testing,peerreviewandconsultationwiththeinternationalaccreditationcommunity.Theyweredesignedtoaddressthequalityofallaspectsandfunctionsofanaccreditationbody,broadlyincorporatingtheInternationalStandardsOrganisation(ISO)requirementsforcertificationbodies,theBaldrigecriteriaforperformanceexcellence,andcriteriafororganisationalexcellencefromtheaccreditationstandardsofanumberofnationalaccreditationbodies.Thesestandardsassessthekeybusinessfunctionsaswellasbestpracticeinassessmentmethodologies,surveyormanagementandawardrecognition.

Thestandardsandprinciplesandtheircriteriaareintendedtoguideexternalevaluationorganisationsintheirdevelopmentbyidentifyingbestpracticeprocessesandsystemsandprovidinganassessmentprocessandrecognitionsystemforachievementofthese.

Manysmalleranddevelopingprogrammescannotjustifytheresourcesrequiredforfullinternationalrecognitionbuttheycouldembarkonadefinedprogressionofdevelopmentandstandardisationstartingfromself-assessment,topeerreview,andaimingeventuallyforinternationalaccreditation.

ISQuaprovidestechnicalandadvisoryservicessuchasself-assessmentreviewandmocksurveystoassistexternalevaluationorganisationsdeveloptheirprogrammesandprepareforinternationalaccreditation.

ISQuarequiresatleastonesetoftheorganisation’sstandardstobeISQuaaccreditedbeforetheorganisationcanentertheorganisationaccreditationprogramme.

ConclusionsThisdocumenthasaimedtohighlightsomeofthequestions,issuesandchallengeswhichneedtobeaddressedbeforedecidingonandimplementinganexternalevaluationprogramme.Thedecisionsmademustbespecifictothevalues,healthpoliciesorstrategiesandorganisationsofindividualcountries,regionsandcaresectors.Stepshavebeenidentifiedthatneedtobetakentoensurethatthefoundationissetforasustainableorganisation.Theordermaybedifferent,butthefundamentalsmustbeestablishedfirst.Somestepsmaybedoneinparallel,forexampleobtainingfunding,negotiatingincentivesanddevelopingstandards,orestablishingthegovernanceframeworkandmanagementsystems.



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22 AustralianGovernmentDepartmentofHealth.Budget2015–2016PortfolioBudgetStatements2015-16BudgetRelatedPaperNo.1.10HealthPortfolio.Canberra:AustralianGovernmentDepartmentofHealth;2015.p96.Availablefrom:http://www.health.gov.au/internet/budget/publishing.nsf/Content/2015-2016_Health_PBS_sup1/$File/2015-16_Health_PBS_0.0_Complete.pdf

23 AustralianGovernmentDepartmentofHumanServices.PracticeIncentivesProgram[Internet].Adelaide:AustralianGovernmentDepartmentofHumanServices;(undated).Availablefrom:http://www.humanservices.gov.au/health-professionals/services/practice-incentives-programme/

24 MalaysianSocietyforQualityinHealth.MSQH–CommitteeMembers[Internet].KualaLumpar:MalaysianSocietyforQualityinHealth.Availablefrom:http://www.msqh.com.my/msqh/ct-menu-item-3/2013-07-29-06-13-01/ct-menu-item-9

25 ShawCD.DevelopinghospitalaccreditationinEurope.Copenhagen:WHORegionalOfficeforEurope;2004.Availablefrom:http://www.unifesp.br/hsp/acred.pdf

26 NationalAccreditationBoardforHospitals&HealthcareProviders.Introduction–HospitalEntryLevel[Internet].NewDelhi:NationalAccreditationBoardforHospitals&HealthcareProviders.Availablefrom:http://nabh.co/Hospital-EntryLevel.aspx

27 GreenfieldD,PawseyM,HinchcliffR,MoldovanMandBraithwaiteJ.Thestandardofhealthcareaccreditationstandards:areviewofempiricalresearchunderpinningtheirdevelopmentandimpact.BMC Public Health Services Research.2012;12:329.

28 InstituteofMedicine(IOM).CrossingtheQualityChasm:ANewHealthSystemforthe21stCentury.WashingtonD.C.:NationalAcademyPress,2001.Availablefrom:http://www.iom.edu/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx



29 ItoHandSugawaraH.Relationshipbetweenaccreditationscoresandthepublicdisclosureofaccreditationreports:acrosssectionalstudy.Qual Saf Health Care.2005;14(2):87-92.

30 MahaffeyA.InPursuitofQualityImprovement:Areviewofexperiencesofexternalqualityassessmentsatreproductivehealthservices.Geneva:WorldHealthOrganization,2003.

58



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Useful web resourcesTheInternationalSocietyforQualityinHealthCare(ISQua)isnotresponsibleforexternalwebsitecontent.PleasenotethatmanyorganisationshaveEnglishlanguagecontentontheirwebsitesandwherepossiblethedirectlinktosuchmaterialisprovided.However,insomeinstancesthewebsitecontentisonlyavailableinthenativelanguage.

AccreditationCanada http://accreditation.ca/

AgencyforQualityandAccreditationinHealthandSocialWelfare,Croatia

http://aaz.hr/

AmericanAccreditationCouncil http://www.americanaccreditationcouncil.com/

AmericanAssociationforAccreditationofAmbulatorySurgeryFacilitiesInternational

http://www.aaaasfi.org/

AmericanAssociationofBloodBanks http://www.aabb.org/

AustralianAgedCareQualityAgency http://www.aacqa.gov.au/

AustralianCommissiononSafetyandQualityinHealthCare

http://www.safetyandquality.gov.au/

AustralianGeneralPracticeAccreditationLtd(AGPAL)

http://www.agpal.com.au/

CanadianAccreditationCouncil http://www.cacohs.com/

CHKS,UnitedKingdom http://www.chks.co.uk/

ConsortiumforBrazilianAccreditation(CBA) http://www.cbacred.org.br/

DAAGroupLtd http://www.daagroup.co.nz/

DNVGLBusinessAssurance http://www.dnvba.com/

Global-MarkPtyLtd http://www.global-mark.com.au/

HauteAuthoritédeSanté,France http://www.has-sante.fr/portail/jcms/r_1455134/fr/about-has

HealthAccreditationService,Columbia http://www.icontec.org/

HealthandDisabilityAuditingNewZealandLtd(HDANZ)

http://www.healthaudit.co.nz/

HealthandDisabilityAuditingAustraliaPtyLtd

http://www.hdaau.com.au/

HealthCareAccreditationCouncil,Jordan http://www.hcac.jo/

IKAS,TheDanishInstituteforQualityandAccreditationinHealthcare

http://www.ikas.dk/IKAS/English.aspx

JapanCouncilforQualityHealthCare http://jcqhc.or.jp/pdf/top/english.pdf

JointCommissionInternational http://www.jointcommissioninternational.org/

JointCommissionofTaiwan http://www.tjcha.org.tw/FrontStage/aboutus_en.html



MalaysianSocietyforQualityinHealth http://www.msqh.com.my/

MinistryofHealthNewZealand–HealthandDisabilityServicesStandards

http://www.health.govt.nz/our-work/regulation-health-and-disability-system/certification-health-care-services/health-and-disability-services-standards

NationalAccreditationBoardforHospitalsandHealthcareProviders,India

http://www.nabh.co/

QualityInnovationPerformance,Australia http://www.qip.com.au/

JointCommissionofTaiwan http://www.tjcha.org.tw/FrontStage/aboutus_en.html

TheAustralianCouncilonHealthcareStandards

http://www.achs.org.au/

TheHealthcareAccreditationInstitute(PublicOrganisation),Thailand

http://www.ha.or.th/

TheCouncilforHealthServiceAccreditationofSouthernAfrica

http://www.cohsasa.co.za/

TheDiagnosticAccreditationProgram,BritishColumbia,Canada

http://www.dap.org/

TheNetherlandsInstituteforAccreditationinHealthcare(NIAZ)

http://en.niaz.nl/

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Appendix 1 - Case StudiesAppendix 1a.

IKAS – Danish Institute for Quality and Accreditation in Healthcare Country: Denmark Contributed by: Carsten Engel

Foundation of the programme

TheDanishaccreditationprogramme(DDKM)wasestablishedaspartofthe“NationalStrategyforQualityDevelopmentintheHealthcareSystem–JointGoalsandActionPlan2002-2006”.Thestrategywasdevelopedbythenational,regionalandlocalpoliticalauthoritiesincooperationwithstakeholderorganisations,representingprofessionalsandconsumers.

Atthattime,anumberofhospitalsalreadyhadpositiveexperienceswithaccreditationprovidedbyinternationalaccreditors–oneoftheintentionsofthestrategywastospreadthistotheentirehealthcaresystem,basedonaDanishmodel.

IKASisformallyanindependentorganisation,butIKASandDDKMwereestablishedbyanagreementbetweentheregionalandlocalpoliticalauthorities,whoareresponsiblefordeliveringhealthcare,andthenationalgovernmentthatsetstheoverarchingpoliticalpriorities,includingtheeconomicframe,andisthehealthcarelegislatorandregulator.

ThegovernmentprovidespartofthefundingforIKAS.ThegovernmentisrepresentedontheBoardofIKAS;theChairoftheBoardisagovernmentrepresentative(adirectoroftheDanishHealthandMedicinesAuthority).

Development steps

ThefollowingstepsdescribetheinitialdevelopmentofDDKM.Theprogrammehassincebeenextensivelydeveloped,basedontheexperiencesobtained.

1. Cooperationagreementbetweenthegovernmentandtheregionsontheestablishmentofajointmodelforqualityassessment,includingprovisionsforthefundingforDDKM(2004)

2. AppointmentofaBoardbythepartiestothecooperationagreementandendorsementofbylawsforIKAS

3. EstablishmentofIKASasanorganisation(2005)

4. Tenderforconsultancybyanestablishedinternationalaccreditor,resultinginacontractwithHQS/CHKSforsupporttodevelopstandards,establishIKASasanaccreditationorganisation,andtrainsurveyors

5. Developmentoffirsttwosetsofstandards(hospitalsandpharmacies)bythemegroups(forrelatedgroupsofstandards)ofstandarddevelopers,consistingofseniorprofessionals,appointedbytheRegionsandtheAssociationofDanishPharmacies.IKASandHQS/CHKSservedasadvisorsandsecretariatforthegroups.

6. Publichearing,whichforthehospitalstandardsresultedinanextendedrevisionbyaneditorialgroupwithmembersfromIKASandtheRegions,followedbyasecondhearing.

7. Pilottestingofstandardsforusability(forclients)andunderstandability

8. SubmissionofstandardsforISQuaaccreditation



9. DevelopmentofanITsystemtosupportimplementationandexternalassessment

10. Developmentofaratingsystem

11. Developmentofinformationforhospitalsandpharmaciesandholdingaseriesofcoursesforkeypersonsinclientorganisations

12. Developmentofasurveymethodology,describedinahandbook

13. Selectionandtrainingofsurveyors

14. AppointmentandtrainingofanAccreditationAwardsPanel

15. Developmentandimplementationofprocessestoprocesssurveyreports

16. PreparationforISQuaaccreditationasanexternalevaluationorganisationandofthesurveyortrainingprogramme(obtainedearly2011).

Thestandardsactuallyledthedevelopmentprocess;steps9–15overlappedeachotherandthelaterphasesofstandarddevelopment,butcontinueduptothecommencementofsurveys,1½yearsafterfinalisingthestandards.

Thefirstsurveywasconducted4½yearsaftertheestablishmentofIKAS.

Funding & incentives

Intermsoffunding,IKAShasanindex-linkedannualgrantfromthecentralgovernment,regionsandlocalgovernment.Therearenofeesforpublicclientsorpharmacies.Otherprivateclientspayafeethatcoversdirectexpensesplusanoverhead.

Theprogrammeisnotrequiredbyanylegislation,butisbasedonagreementsasfollows:

Publichospitals:allhospitalsparticipatebyagreementbetweenNationalandRegionalgovernments

Privatehospitals:voluntary,butparticipationisaprerequisitetoobtainacontracttotreatpatientsfortheregions(alsorequiredbysomeinsurancecompanies)

Pharmacies:voluntary,financialincentiveinplace

Municipalities(primarycareservices,includinglong-termcare):voluntary,noincentivesinplace

Ambulanceoperators:prerequisitetoobtaincontractwithRegions

Generalpractitioners:mandatory(withsomeminorexceptions)byagreementbetweentheRegionsandtheOrganisationofGeneralPractitionersinDenmark;financialcompensationaspartoftheagreement.

Standards and measurement

IKAShasdevelopedallstandardsusedinitsprogrammes.Theywerefirstdevelopedforhospitalsandforcommunitypharmacies.Standardshavesincebeendevelopedforprimarycareservices,deliveredbymunicipalities,andforambulanceservices.Currentlystandardsarebeingdevelopedforgeneralpractitionersandspecialistphysicians.Overthecomingyears,allhealthcareprofessionsprovidingoffice-basedservices,outsideofhospitals,willbecovered.

Compliancewithstandardsisassessedbyscoringanumberofelements(forthehospitalstandardsroughly450)accordingtoafourpointscale(Fully/Largely/Partially/NotMet),wherethetwoupperlevelsindicateasatisfactoryperformance(exceptforcertainsafetycriticalstandards,whereonlyFullyMetisconsideredsatisfactory).Anyelementnotmettosatisfactionwillrequirefollowup,andifnotcorrected,resultsinaccreditationwithcomments.AnAccreditationAwardPaneldecides,guidedbycertainrules,whetherthenatureand/oramountofthecommentsprecludeaccreditation–ifso,statusas“notaccredited”isawardedandpublished.

66



Assessment methodology and focus

Theassessmentmethodologyusedisexternalsurveywithextensiveuseoftracermethodology.Thefocusisonexploringtheimplementationofsafeprocessesandinvestigatingtheuseofqualitydataforimprovementactivities.

Qualityimprovementisfundamental.ThereisanextensivesetofnationalqualityregistersinDenmark,andoneofthepurposesofDDKMistosupportandassessthatdataisnotjustcollected,butalsousedforqualityimprovement.Demonstrationofcompletedandevaluatedimprovementactivitiesisrequiredfromthesecondaccreditationcycle.

Surveyorsareactiveseniorhealthcareprofessionalswhoarecontractedfor15surveydaysperyear.Inaddition,theyareobligatedtoparticipateincontinuoustrainingactivities.

Barriers

Developmentofanaccreditationprogrammefromscratchismuchlikebuildingabridgewhileyouarecrossingit.Evenwiththebestsupportfromconsultants,therearealotoflessonstobelearnedwhentheprogrammeisappliedinpractice.Afullpilottest,includingcompleteimplementationandexternalassessment,wouldbeideal,butwouldaddaconsiderabledelay.

Lessons learned

Onelessonlearnedisthatwhileitaddstothelegitimacyoftheprogrammethatstandardsaredevelopedinvolvingalargenumberofhealthcareprofessionalsasstandarddevelopers,astrongeditorialprocessisneededifthisistoresultinauniformandbalancedstandardset.Furthermore,thesetypesofstandarddeveloperswillalmostexclusivelyfocusonthestandardsasimplementationguides;itmaybeachallengetoassessperformanceinareliableanduniformway.Tosupportreliableassessment,thestandardsmustincludealotofguidanceforsurveyors,bothastomethodologyandtorating,whileavoidingsurveysbecomingexercisesof“tickingcheckboxes”.

Wehaveunderestimatedtheneedtocommunicatethatthestandardsaredifferentfromregulatoryrules.Thelattercontainspecificdirectionsthatmustbestrictlyadheredto,whereasmany(albeitnotall)standardsexpressagoaltostrivefororrequiretheclienttodefinethespecifics,accordingtolocalneedsandpriorities.Youwillmeetclientsaskingtobetoldexactlywhattodo,andyouwillmeetexamplesof“overimplementation”,whereclientsdemandtheirstafftorigidlyapplythesamestandardisedprocedurestoallpatients;anexamplecouldbehospitalsbelievingthatthestandardsrequirethemtoscreenallpatientsformalnutrition,regardlessofthelikelihoodforacertainpatientortypeofpatienttobemalnourished.Thisis,inourexperience,animportantsourceofresistancetoaccreditationamongstaff.

Oursurveysareannouncedandareprecededbyalotofpreparationbytheclients.Manyoftheirstaffperceivethisasbuildinganicepicturetoshowthesurveyors,butnotnecessarilygivingafairpictureoftherealperformance;theriskisthatpreparingforaccreditationisseenbystaffasashow,designedtoobtainacertificate,morethanasavalueaddingactivity.Doingunannouncedorpartiallyunannouncedsurveyswouldnodoubtaddtothefacevalidityofaccreditation.Wearecurrentlypreparingacontrolledstudytoinvestigatethemeritsofunannouncedsurveys.

Onetypicalwaytoarticulateresistanceistoaskfortheevidenceforaccreditation.Whileyoumustarguethataccreditationisacomplexinterventionthatcannotbebackedbyevidenceofthesametypeasadrugtreatment,designofaformalevaluationaspartoftheprogrammeshouldbeconsidered.

Moreinformation,includingaccreditationstandards,canbefoundathttp://www.ikas.dk/IKAS/English.aspx



Appendix 1b.

Health Care Accreditation Council (HCAC) Country: Jordan Contributed by: Ed Chappy


Severalreasonswerestatedforwhytheprogrammewasdevelopedincludingtoimprovethequalityofhospitalsandtoenhancemedicaltourism.Inaddition,itwasaresponsetopubliccomplaintsofpoorqualityofcareandaneedtoimprovetheentirehealthcaresysteminthecountry.

TheHCACisthenationalhealthcareaccreditationagencyofJordan.Theorganisationsetsstandardsforhospitals,primaryhealthcarecentres,familyplanningandreproductivehealth,transportservices(ambulances),cardiaccare,anddiabetesmellitus.HCACsurveysagainstthestandardsandawardsaccreditation.HCACalsoprovidesconsultationandeducationtopreparehealthcarefacilitiesforaccreditationandofferscertificationcourses.

TheHCACisaprivate,not-for-profitshareholdingcompanyregisteredundertheMinistryofTradeandIndustry.TheboardofdirectorsismadeupofrepresentativesforallhealthcaresectorsinJordan,medicalandnursingprofessions,andeducation.

Development steps

1. Decisiononfundingandincentives

2. Standardsorcriteriadevelopmentifapplicable

3. Survey/Assessmentmanagementprocesses

4. Developmentofmanuals,tools,educationprogrammesforclientsorothers

5. Selectionandtrainingofsurveyors/assessors

6. Typeofproposedgovernanceboardandframework,constitution

7. Settingupofgovernanceboard,governancepoliciesandprocedures

8. Developmentofmanagementsystems,strategicandoperationalplans

9. Accreditation/Certificationprocesses

10. Monitoring,reviewandevaluationsystems

11. Developmentanduseofwebsite,portalorotherelectronicaids

Adecisionwastakentodevelopstandards,prepare17pilothospitalsfromthepublic,private,university,andmilitarysectorsforaccreditationandthencreatetheagencybasedondemandforaccreditation.

Thefirstsetofhospitalstandardsweredevelopedin2005,surveyorstrainedin2006andtheagency(HCAC)establishedinDecember2007.ThefirsthospitalaccreditedusingHCACstandardswasinMarch2008.

Thefirstservicesdevelopedwereconsultationandeducationservicestopreparehospitalsforaccreditationandmockandaccreditationsurveys.Thenpreparationofprimaryhealthcarecentrestomeetstandardsandmockandaccreditationsurreysforthemwereadded.Later,localandregionalconsultationandeducationsurveysandcertificationcoursesforinfectionpreventionstaff,riskmanagers,andqualityimprovementcoordinatorswereadded.

68 © Guidance on Designing Healthcare External Evaluation Programmes including Accreditation

Funding and incentives

TheoriginalfundingtodeveloptheHCACcamethroughtheJordanHealthcareAccreditationprojectfundedbytheUnitedStatesAgencyforInternationalDevelopment(USAID)andgrants.SinceMarch2013,HCAChasbeenfinanciallysustainablethroughchargingfeesforservicesofferedincludingsurveys,educationandconsultation.

Accreditationisvoluntary.Therearenoincentives(laws,regulation,insurancerequirements)inthecountryforaccreditation.


AllthestandardsaredevelopedinJordan.Nostandardsdevelopedbyotherorganisationsareused.Hospitalstandardsweredevelopedfirst,thenstandardsforprimarycarecentres,familyplanningandreproductivehealth,transportservices(ambulances),cardiaccare,anddiabetesmellitus.

Standardsareclassifiedascritical,coreandstretch.100%ofcriticalstandardsmustbemet;andaspecifiedpercentageofbothcoreandstretchstandardsmustbemetinorderforaservicetobeaccredited.

Assessment methodology & focus

Mockandaccreditationsurveysareused.Thefocusisonqualityimprovement.

Surveyorsarecertifiedfortwoyearsandarepaidpersurvey.Staffaretrainedassurveyorsbutareonlyusedinemergencieswhenasurveyorisillorforotherreasonscannotdoasurvey.

Challenges

Themainchallengewasdecidingwheretheorganisationwasgoingtobeplacedinthecountry–MinistryofHealth,othergovernmentagency,professionalassociation,orasanindependentcompany.Thesecondchallengewastodeterminehowitwouldbefunded.

Lessons learned

Everycountrymustdeveloptheirsystembasedontheirneedsandgoals.

Seewhatothercountriesaredoingbutcreateyourownsystem.

Manyactivitiescanbedoneinparallelandyoudonotneedtowaituntilonetaskisdonebeforeproceedingtothenext(donothavetowaitfortheagencytobedevelopedbeforestandardsaredeveloped).

Recognisethataccreditationisabusinessandlookattheagencyasanyotherbusinesswithstrategic,business,andoperationalplansandbusinessprocesses.

Donotneglecttheneedtomarketaccreditationtothepopulationaswellashealthcarefacilitiesandprofessionals.

Partnerwithclientsandmaintainarelationshipafterandbetweenaccreditations.

Lookataccreditationasameansofimprovingtheentirehealthcaresystem,notjusthospitals.

Seeaccreditationasonemeanstoquality,nottheonlymeans.

Alwaysseekwaystodothingsbetter,whichmaybedifferentfromwhateveryoneelseisdoing.


© Guidance on Designing Healthcare External Evaluation Programmes including Accreditation 69

Appendix 1c.

Health and Disability Auditing New Zealand Ltd (HDANZ) Country: New Zealand Contributed by: Jim duRose


ThecommencementoftheHealthandDisabilityServices(Safety)Acton1July2002representedasignificantchangeintheregulatoryenvironmentintheNewZealandhealthanddisabilitysector.ThisActreplacedseveralpreviouspiecesoflegislationandchangedthewayinwhichresidentialandhospitalserviceswerelicensedorregistered.Inaddition,theActintroducedhealthanddisabilitystandardsforhospitals,resthomesandresidentialdisabilityservicesaimedatimprovingsafetylevelsandqualityofcarethatbecamemandatoryfrom1October2004.TheActrequiredthatdesignatedauditagencies(DAAs)areapprovedbytheDirectorGeneralofHealthforthepurposeofauditingtheseservicestothosestandards.

HDANZbecamedesignatedinOctober2002.In20043rdpartyaccreditationwaswithInternationalAccreditationNewZealand(IANZ).DuetoachangeinIANZ’slegislationtheycouldnolongeraccreditHDANZandinDecember2008HDANZdecidedtoproceedwithISQuaaccreditation.TheobjectivewastohaveaseamlesstransitionfromIANZandthiswasachievedbyAugust2009.Also,asofDecember2008,theMinistryofHealthdidnotrequire3rdpartyaccreditationbutafewmonthslaterthisbecamearequirementtomaintaindesignation.

HDANZ’sscopewasdeterminedbytheSafetyAct–theassessmentofstandardsisalegalrequirementforpublicandprivatehospitals,resthomesandresidentialdisabilityservices.StandardsNewZealand(SNZ)isresponsiblefortheNewZealandstandardsandthisincludesotherssuchasforHomeSupport,AlliedHealth,andDaysurgeryprocedures.

HDANZisalso3rdpartyaccreditedwithISQuainordertoauditandcertifyservicestothesestandards.

HDANZisaprivate,independentlyownedcompany.ItislinkedtothegovernmentasaMoHapproveddesignatedauditingagencyandfortheseservices,HDANZsubmitstheauditreporttotheMoHwhoissuesthecertificate

Development steps

1. Typeofproposedgovernanceboardandframework,constitution

2. Decisiononfundingandincentives

3. Developmentofmanagementsystems,strategicandoperationalplans

4. Settingupofgovernanceboard,governancepoliciesandprocedures

5. Survey/Assessmentmanagementprocesses

6. Accreditation/Certificationprocesses

7. Selectionandtrainingofsurveyors/assessors

8. Monitoring,reviewandevaluationsystems

9. Developmentofmanuals,tools,educationprogrammesforclientsorothers

10. Developmentanduseofwebsite,portalorotherelectronicaids–HDANZhadawebsiteearlyonbutwebbasedassessmenttoolswereintroducedin2008.

Thefirstassessmentwasundertakenapproximately6-8monthsafterHDANZwasestablished.


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Therewasnotrialperiodbutpre-audit“gapanalysis”workwascommonplaceformostservicesbeforetheycompletedtheirfirstassessmentin2003/04.

Atfirst,HDANZprovidedassessmentservicesforallservicesundertheSafetyAct:resthomes,geriatrichospitals,maternity,surgical,hospice,mentalhealth,disabilityservicesandaddictionservices.ThesecontinuebutalsoHDANZcertifieshomecare,alliedhealth/physiotherapyservices,daysurgery/office-basedservicesandcommunityservices.HDANZalsocompletesfundercontractauditingwithNGOprovidersforawiderangeofpersonalhealthandmentalhealthandaddictionservices.GeneralpracticereviewsarecompletedonbehalfofPrimaryCareOrganisations(PHO).HDANZalsoassiststheRoyalCollegeofGeneralPractitioners(RNZCGP)withtheirCornerstonegeneralpracticeaccreditationprogrammebyindependentlyreviewingreportsandissuingarecommendationforaccreditation.

Funding & incentives

ServiceproviderspayfeestoHDANZforsurveyandmonitoringvisits.CertificationhasbeenmandatoryfortheMoHSafetyActsinceOctober2002.FromSeptember2005,itbecamemandatoryforphysiotherapyservicesiftheywantedaspecialcontractfromtheAccidentCompensationCorporation(ACC).FromSeptember2012,healthfundersmadeitmandatoryforHomeSupportproviders.FromMarch2013,SouthernCrossHealthSocietyinsurancemadecertificationmandatoryfortheiraffiliatedproviders.


StandardsNewZealandisresponsibleforthestandards.In2003,themainstandardswereHealthandDisabilitySectorStandardsandthisincludesInfectionControlandRestraintMinimisation.Thesewereupdatedin2008.In2003,HomeandCommunitySupportStandardswereissuedbySNZandthesewereupdatedin2012.In2005,AlliedHealthStandardsandDaystaysurgerystandardswereissuedbySNZ.

Theratingscaleis:

CI=ContinuousimprovementFA=FullyAttainedPA=PartiallyattainedUA=Unattained

TheMinistryofHealthusestheassessmentratingstodeterminecertification.Thelengthofcertificationcanvaryfromonetofouryearsdependingonthelevelofachievementofthestandards.

Assessment methodology & focus

Auditteamsareformedforon-sitevisitsandreportingtotherelevantstandards.Thisincludesdocumentation,observation,clientrecordssampling,tracermethodology,andinterviewingofstaff,management,clientsandfamily.

Qualityimprovementisthefocusandatthesametimetheproviderhastohaveachievedthestandardsbeingassessed,notingthatareasidentifiedforfurtherwork(PA/UAratings)havetohaveprogressreportedandarereviewedatthesurveillanceaudit.

AssessorsarepaidpereventandinadditiontothetwooperationalcompanyDirectorswhoauditthereisoneemployeeauditor.HDANZmaintainstwoseparateauditornetworks;oneisforDAA/otherserviceswhichincludesabout20assessorsandisamixoflead,clinical,consumers,technicalexperts,culturalandfinancialauditorsandtheotherisforPhysiotherapyserviceswithanauditornetworkof8auditors.



Challenges

InOctober2002therewere10DAAsandallbutHDANZhadaformalstatusineitherISQuahealthaccreditationatthetimeornon-healthISOcertification.

DevelopmentofHDANZ’sservicesandtheinfrastructuretodeliverarangeofaudits.

Settingupthequalitymanagementsystem.

Lessons learned

Earlyinvestmentinacustomerrelationshipdatabasewasveryimportantandthenlaterimprovedatidentifyingsub-groupsformarketingandotherinformation.

Thetwokeydriversforthisbusinessarea)operationalefficiencywithcompetentadministrationstaffandb)assessorcompetency.

Addedvalueforgovernanceandrobustorganisationalmanagementfrommaintaininga3rdpartyaccreditationstatus.

Sounddecisionasgrowthoccurredtostructureintoprogrammes.

Costsneedtobecloselymonitoredandmanagedastheycaneasilyescalateotherwise.

Outsourcingthefinancialsin2009wasapositivedecision.

MaintainingNZQAauditortrainingcourseapprovalforcredibilityandHDANZpurposedespitenotbeingarevenuegenerator.

2008investmentintoamarketingcoursereapedsubstantialdividends.

Tobeperceivedastheexpert.

Board/governancedevelopmentinhindsightcouldhavebeenmoreofapriorityearlieron.

Appendix 1d.

Practice Incentive Program (PIP) Country: Australia Contributed by: Steve Clark

TheAustralianGovernmentintroducedthePracticeIncentiveProgram(PIP)in1998.ThePIPisaimedatsupportinggeneralpracticeactivitiesthatencouragecontinuingimprovementsandqualitycare,enhancecapacityandimproveaccessandhealthoutcomesforpatients21.

Inthe2015-16AustralianGovernmentBudget,inexcessof$1.5bnoverfouryears22wasallocatedtothePIPtosupportthecontinuationofincentivepaymentstogeneralpractices.

ThePIPisusedasaleverbygovernmenttoinfluencebehaviouralchangewithinthegeneralpracticeenvironment.ToaccesspaymentsunderthePIP,practicesmustmeettheeligibilityrequirements,includingthatapracticemustbeaccreditedorregisteredforaccreditationagainsttheRoyalAustralianCollegeofGeneralPractitioners(RACGP)Standards for general practicesandmustmaintainfullaccreditation.

Approximately80%ofallpracticesthatmeettheRACGPdefinitionofageneralpracticeparticipateinaccreditationand,therefore,mayaccessPIPpayments.

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TherearethreetypesofpaymentsavailableunderthePIP21:

1. Practice Payments

ThemajorityofpaymentsthroughthePIParemadetopracticesandfocusonthoseaspectsofgeneralpracticethatcontributetoqualitycare.Thesepaymentsareintendedtosupportthepracticetopurchasenewequipment,upgradefacilitiesorincreaseremunerationforGPsworkingatthepractice.

2. Service Incentive Payments

ServiceIncentivePayments(SIPs)aregenerallymadetoGPstorecogniseandencouragetheprovisionofspecifiedservicestoindividualpatients.TheCervicalScreening,AsthmaandDiabetesincentiveshaveserviceincentivepaymentcomponents,andtheAgedCareAccessIncentiveisaserviceincentivepaymentonly.

3. Rural Loading Payments

PracticesparticipatinginthePIP,withamainpracticelocationsituatedoutsidecapitalcitiesandothermajormetropolitancentres,areautomaticallypaidaruralloading.

TherearetenindividualincentivesavailabletogeneralpracticesandGPsunderthePIP23:

After-hours Incentive,supportinggeneralpracticestohaveappropriatearrangementsinplacethatensuretheirpatientshaveaccesstoqualityafter-hourscare.

Asthma Incentive,whichaimstoencourageGPstobettermanagetheclinicalcareofpeoplewithmoderatetosevereasthma.

Cervical Screening Incentive,whichaimstoencourageGPstoscreenunder-screenedwomenforcervicalcancer,andtoincreaseoverallscreeningrates.

Diabetes Incentive,whichaimstoencourageGPstoprovideearlierdiagnosisandeffectivemanagementofpeoplewithestablisheddiabetesmellitus.

eHealth Incentive,whichaimstoencouragegeneralpracticestokeepup-to-datewiththelatestdevelopmentsineHealthandadoptneweHealthtechnologyasitbecomesavailable.

GP Aged Care Access Incentive,whichaimstoencourageGPstoprovideincreasedandcontinuingservicesinResidentialAgedCareFacilities.

Indigenous Health Incentive,whichaimstosupportgeneralpracticesandIndigenoushealthservicestoprovidebetterhealthcareforAboriginaland/orTorresStraitIslanderpatients,includingbestpracticemanagementofchronicdisease.

Procedural GP payment,whichaimstoencourageGPsinruralandremoteareastomaintainlocalaccesstosurgical,anaestheticandobstetricservices.

Quality Prescribing Incentive,whichaimstoencouragepracticestokeepup-to-datewithinformationonthequalityuseofmedicines.

Teaching payments,whichaimtoencouragegeneralpracticestoprovideteachingsessionstoundergraduateandgraduatemedicalstudentswhoarepreparingforentryintotheAustralianmedicalprofession.

SincetheinceptionofthePIPin1998,successiveAustralianGovernmentshavecommittedtoongoingfundingfortheprogramme;andduringthistime,haveretainedtherequirementthatapracticemustbeaccredited,orregisteredforaccreditation,andmustmaintainfullaccreditationinordertoaccesssuchpayments.

GiventhelevelofparticipationinaccreditationbyAustraliangeneralpractices,itcanbeassumedthatthehighlyincentivisedPIPhasbeeninstrumentalinencouragingpracticestoengageintheprocess,andinturnhashadapositiveimpactbysupportingpracticestofocusonimprovementsandqualityoutcomes.

International Society for Quality in Health CareJoyce House, 8-11 Lombard Street East

Dublin 2, IrelandPh: +353 1 670 6750 Fax: +353 1 671 0395

Web: www.isqua.org