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IMPLEMENTING THE NEW QUALITY

ASSURANCE
FRAMEWORK

B Y : C H R I S T I N E J O Y A L O N D AY
BSN 4
IM P L EMENTAT ION O F T H E Q A FR A M EWOR K I NVO LVES T H E FO L LO W I NG I NT ER R EL AT ED
A CT I VI T I ES: rough its accreditation program, PhilHealth
verifies the qualifications and capabilities of
health care providers to deliver the desired and
expected quality of health care services, prior to
conferring to them the privilege of participating
in the NHIP
accreditation program is founded on the ideas on
assessment of health care introduced in 1966 by
Lebanon-born public health expert Avedis
Donabedian (1919-2000), and which now
constitute the principal paradigm in the
evaluation of health care provision (Frenk 2000).
Donabedians ideas describe the relationship
between tructures, processes and outcomes and
posit that an organization with the right
structures and processes in place will produce
better outcomes.

In PhilHealth, the Accreditation Department takes charge of accrediting health


care providers. Teams of skilled surveyors conduct two levels of assessments:
first, they evaluate compliance with documentary requirements.; and second,
PhilHealths they visit the provider site
Accreditation Program to evaluate actual operations.
new quality assurance framework reorients the
accreditation program to focus on improving
outcomes with outcome-based standards and a
continuous quality improvement program. However,
as outcomes can not be improved without
appropriate structures and processes, these two
factors must be developed with the improvement of
specific outcomes in mind.

Philip Crosby - Quality is Free (1979)


focus of quality is conformance.
PhilHealths accreditation program shall incorporate this Applied to the health care setting, it means
new approach. It shall require organizations to demonstrate compliance with standards. An important
a commitment to quality (and to continuous improvement), component of the accreditation process is
and assessment shall determine whether they are doing determination of compliance with set
what they say they are doing. Standards.
These standards are used to assess a health
care organizations performance in service
provision the focus is on what the
organization actually does, not its capability.
PhilHealth accreditation standards shall be redeveloped in consultation with the health care industry.
They should be equally applicable to all health care organizations regardless of whether they are a
hospital, day surgery unit, community service, or some other type of health care organization.
As standards underpin the accreditation process, they have to focus on the dimensions of quality care as
well as on the organizational cross-dimensional support functions essential to the provision of this care.
They should reflect contemporary best practice principles, be achievable, easily understood and
measurable.

Section 58 of the PhilHealth Implementing Rules and Regulations (2000) includes the following health
care providers as participants in the NHIP, to wit:

A. Institutional Health Care Providers B. Independent Health Care Professionals


Hospitals Physicians
Out-patient Clinics Dentists
Health Maintenance Organizations Nurses
(HMOs) Midwives
Preferred Provider Organizations (PPOs) Pharmacists
Community-Based Health Care Other duly licensed health care
Organizations professionals
An accredited provider is privileged to participate in the NHIP for a prescribed
duration, subject to renewal.Accreditation requirements are detailed in the IRR.
To demonstrate compliance with standards and provide practical advice on how to
apply them in different care settings, PhilHealth shall design appropriate clinical
practice guidelines.
Guidelines and clinical pathways in the reduction of variations in practice and
consequently, in outcomes. Thus, even as PhilHealth shall continue to identify high
volume and high impact services, it shall also continue its work on designing
appropriate clinical practice guidelines. These guidelines should eventually, through
education and implementation strategies, be adopted as operational pathways in
health service provider Organizations
Monitoring is an important component in the evaluation of an organizations
performance as it allows measurement and assessment of patient care and other
service processes provided by health care provider organization.
PhilHealth shall develop a limited range of indicators to measure performance in the
abovementioned dimensions of health care quality and cross-dimensional issues. The main
focus shall be on supporting the evaluation of the effectiveness of select clinical pathways.
PhilHealth shall require all service providers to collect, report, and, most importantly, provide
evidence of action on results based on the PhilHealth indicator set.

The following few basic issues should be considered:

Are the measures manageable Over time, review of monitoring


Can the health care provider using existing resources and shall highlight areas where useful
organization effectively monitor all information systems (both within information is being generated. If a
of the measures identified as being PhilHealth and within monitoring program does not
relevant to PhilHealth? If not, provider organizations)? It may be provide meaningful information,
PhilHealth shall determine which preferable to monitor just a few then it may be more appropriate to
measures are priorities in terms of performance measuresbut direct resources to the monitoring
targeted areas for improvement. effectively do so than monitor all of other performance areas.
measures.
Performance targets shall be established and the frequency with which these targets are met
(or not met) shall provide quantitative evidence on the quality of the service. As PhilHealth
aims to foster the use of data and targets as part of the quality improvement process within
the health service provider organizations, reviewing the reasons for less-than-expected
achievements can facilitate improvements in outcomes, structures or processes.
Patients have a fundamental right to participate in health care decisions and delivery. However,
they need to have information to effectively participate. High quality, dependable information
on the performance of health care organizations is not currently available to the public in the
Philippines.

Disseminating Performance Results: The U.S. Experience


In the United States, several studies have reported increased efforts to improve quality of care following release
of national data on hospital mortality rates. Despite criticism, large corporations, who make big health insurance
payments for their personnel, are examples of consumers who have utilized their purchasing clout to collect
hospital performance data and release them to their employees to help them make informed health care choices.
This is in response to the clamor for
evaluations to focus more on data regarding physicians and hospitals, and not on the different health plans
available. As providers have opposed public release of performance data due partly to the resistance to being
subjected to a public performance evaluation, fears have been raised about providers refusing to deal with
complicated cases to protect their performance scores. Researchers, however, have failed to find evidence of this
kind of reaction (Galvin and Milstein 2002).
PhilHealth shall determine which information it will make available and to whom. While the
ability of PhilHealth members to properly use and draw appropriate conclusions from
accreditation and other quality performance data remains debatable, it will be only through the
dissemination and use of the data that health care providers and the community can appreciate
and understand performance data
As PhilHealth shall develop valid and reliable performance measures, it shall be in a unique
position to provide health care provider organizations with aggregated data for performance
comparisons. This data can be used to further give impetus to the quality improvement agenda.

END