Quality Assuranceand

Hospital Accreditation

Assoc.Prof. Jiruth Sriratanaban, M.D., M.B.A., Ph.D.

Department of Preventive and Social MedicineFaculty of Medicine, Chulalongkorn University

Session ObjectivesSession Objectives

To review the reasons why external quality assurance of hospitals is needed

To summarize the different external quality assurance methods

To clarify the differences between registration, certification, process-focused EQA, and participatory EQA

To introduce Hospital Accreditation concepts

Session ObjectivesSession Objectives

To summarize the three popular models of hospital accreditation in OECD countries

To explain the costs and limitations of Hospital Accreditation

To stimulate discussion among participants about the potential relevance of accreditation in their own countries and/or what other EQA methods are or could be applied

ContentContentHospital quality

Ways to assure hospital quality

External quality assurance

Accreditation experiences

What is “Quality”?What is “Quality”? Product specificat Product specificat

ion and standard ion and standard

Conformance to r Conformance to requirementequirement

Fitness for use Fitness for use

Zero defect Zero defect

Customer satisfac Customer satisfactiontion

Ability to satisfy n Ability to satisfy needseeds

Hospital Quality…?Hospital Quality…?

Inputs• Staff, doctors, specialists

• Nurses

• Medicines

Facilities• Utilities

• Equipments

• Care environment

Hospital Quality…?Hospital Quality…?

Processes• Patient care and support processes

• Management and improvement – identifying, learning from, correcting errors

Patient experience (Perceptions)• Waiting times, Information

• Responsiveness

Responsiveness to Responsiveness to expectationexpectation

Respect for person (Patient rights)• Preserve dignity of a person• Confidentiality• Autonomy in choice

Client orientation• Prompt attention• Amenities of adequate quality• Access to social support network• Choice of providers

PatientPatientSatisfactioSatisfactio

nn

Results of careResults of care

Health outcomes• Mortality:

• Overall vs. Disease-specific• In-hospital vs. 30-day• Crude rate vs. Adjusted rate

• Morbidity• Disease outcomes, e.g. Cure rate• Adverse events, e.g. Infection rate

• Quality of Life (QOL)

High Quality vs. Low Quality HospitalsHigh Quality vs. Low Quality Hospitals

High-quality hospitals

More competent staff

Better equipped

Fewer process errors

Well managed

Short waiting

Satisfied patients

Better health outcome

Higher revenue/surplus

More efficient ?

More expensive ?

Low-quality hospitals

Fewer competent staff

Poorer equipped

More process errors

Poorly managed

Long waiting

Dissatisfied patients

Poor health outcome

Poorer financial outlook

Less efficient ?

Cheaper ?

Quality Quality ≠≠ Cost Cost (empirical(empirical))

Cost

Quality

C1

Q1 Q2 Q3

A

B

C

D

E

F

Fleming (1989)

Some evidence ?Public vs. Private NFP vs. Private FP

Private FP Higher risk of death [US] (Devereaux, et al., CMAJ 2002) SyR

Public (Gov) More assets, equipment, more DR; Private FP proportionally more support staff and fewer medical professionals; No stat diff. in mortality. [Guangdong, China] (Eggleston et al, BMC-HSR 2010)

Public More near-miss in OB cases [Indo] (Adisasmita et al, BMC Preg Childbirth, 2008)

Private NFP/FP Better drug supply, responsiveness, and effort; No diff in satisfaction or competence [Ambulatory HC, L&MIC] (Berendes et al, SR, PLoS Med 2011)

Private Less likely to die, but more likely to have unsuccessfully

completed TB treatment [Setting, L&MIC] (Montagu et al, 2011) MetA

Common health system Common health system options for assuring options for assuring

hospital qualityhospital quality

Licensure

Quality Certification

External Quality Assurance

LicensureLicensure

Process by which a government authority grants permission to an individual practitioner or health care organization to operate or to engage in an occupation or profession

LicensureLicensureEnsure minimum standards, set at a minimal level to ensure an environment with minimal risk to health and safety

• Generally focus on structural aspects: Inputs and Facilities

Rely upon (periodic) inspection

CertificationCertificationPassing standards (Minimal?)

• Require hospital to collect and submit information demonstrating that they meeting standards

• Audit or site visit generally required

Specific areas or functions

More likely to include process standards and process measurements

ExternalExternalQuality Quality

AssuranceAssuranceEvolve from manufacturing sectors

Objective assessment by external reviewers or auditors

Published standards

• Optimal rather than Minimal

• Mainly focus on processes

• Require hospitals to monitor “results” or “performance”

ExternalExternalQuality Quality

AssuranceAssuranceISO series (International Organization for Standardization)

• Generic standards– Process-focused

• Management system

• Professional evaluators

• Examples commonly applied:• ISO-9000, ISO-14000, ISO- 15189

ExternalExternalQuality Quality

AssuranceAssuranceAccreditation• Standards specific for health care

providers, e.g. hospital• Process-focused• Health issues, e.g. patient safety, health

promotion, clinical governance• Management system and CQI• Both professional and peer evaluators• National vs. International

ExternalExternalQuality Quality

AssuranceAssurancePros / Cons for consideration

• Cost, usually involve : Consultation, Improvement, External assessment

• Opportunity for Learning

• Public appreciation• Accreditation may be less known to the public

• Evolving standards over time

Experiences with Hospital Experiences with Hospital AccreditationAccreditation

Mechanisms for recognition of institutional competence

By an independent accrediting body (Usually)• Participation by professional groups

Applying hospital standards for optimal and achievable performance

With emphasis on self assessment and continuous quality improvement

Hospital survey conducted by external peer reviewers

Voluntary participation (Usually)

Experiences with Hospital Experiences with Hospital AccreditationAccreditation

Three common models

Country Accrediting Body

Standards Format

Types of Standards

Step-Wise Approach

United States

Joint Commission on Accreditation of

Health Care Organizations

Functional Outcomes No

Canada Canadian Council on Health Services

Accreditation

Functional + Departmental

Structure, Process, and

Outcomes

Yes

Australia Australian Council on Healthcare

Standards

Departmental Structure and Process

No

Experiences with Hospital Experiences with Hospital AccreditationAccreditation

Voluntary vs. Mandatory Accreditation• Historically all accreditation was voluntary• May be required for participating in public health

insurance schemes, e.g. USA• Mandatory? in some countries, e.g. France,

(Licensure effect)

Accreditation in middle-income countries• International : ISO, JCI

• Grown quickly in SEA: Medical hub, high-end market

• National (Grown during 1990s and early 2000s)– Thailand, Malaysia, South Africa

• Both, e.g. Thailand

Experiences with Hospital Experiences with Hospital AccreditationAccreditation

Why National Accreditation has failed• Difficult to create :

• Political will– Support from national health care purchasers

• Multi-year process to develop– Participation from professionals, as well as authorities– Development of standards, surveyors– Hospital improvement

• Limited membership will limit value / importance• Maybe expensive

– Scale of operation determine cost-benefit between International vs. National programs

Costs to HospitalsJCI: Avg. fee for survey (2010) = US$46,000 [JCI info] – US$ 100,000 [Asian Hospital & Healthcare Management]

• A case of one hospital in India = US$600,000 for upgrading

QHA Trent, UK

Zambia: US$10 000 per hospitalto complete the cycle(Advocacy, Programadministration, Education Accreditation activities)

Thailand HA: Survey = 15,000 Baht/man-day (Min. 4 Man-day)

ISO 9000: $10-25K for small/ mid-size companies (3 to 5 man-day audit with avg. cost of $3000 per man-day plus travel expenses.)

Accreditation of other health Accreditation of other health care providerscare providers

Health care institutions

• Health centers, Clinics

• Nursing home, etc.

Health care programs

Managed health care plans

Individual providers• Tried in India, New Jersey USA, etc. But

failed

ConclusionsConclusionsEQA is necessary for private (as well as public) hospitals

EQA systems should be broadly applied to both public and private hospitals equally

International accreditation schemes are useful, but too expensive to serve a role for the overall health market

National accreditation programs are extremely useful, but difficult to create

A lead-institution is required, with long-term commitment and political approval or backing, including from large health care purchasers