Accreditation as a Regulatory Tool and QA:

Learning from the Asia Experience

Assoc. Assoc. Prof. Jiruth Sriratanaban, M.D., M.B.A., Ph.D.
Department of Preventive and Social Medicine Faculty of Medicine, Chulalongkorn University

Outline
Health system needs for quality assurance and hospital accreditation System options for managing quality Hospital accreditation (HA) as regulatory incentive in Thailand

Roles of the Health System

Respect for patient rights and more client orientation

World Health Report (2000)

Health outcome improvement

Some of major challenges for Thailands health care systems Inequity due to mal-distribution of health resources malIncreasing health care expenditure Introduction of close-ended payment mechanisms by closethe major health security schemes Expansions of business health sectors and the governmental Medical hub policies

Threats against quality of health care

Alarming information from Adverse events studies

study HMPS UTCOS QAHCS UK Denmark Thailand(1) date 1984 1992 1992 19991999-2000 1998 2003 2003 Rate (%) 3.7 5.4 16.6 16. 11.7 11. 9.0 9.1 Death 13.6 % 13. 5.6 % 4.9 % 8.0%% Preventable

54% 54% 51% 51% 48% 48% 71% 71%

System options for assuring quality of hospital Care

System resources management (e.g., financing reform, autonomous hospitals) Licensure (Legal requirement for operation) Quality audit (e.g., standards and guidelines) Quality assurance and quality management systems (e.g., ISO, MBNQA, etc.) Quality improvement (e.g., TQM, CQI, Indicators comparison, Benchmarking, etc.) Quality assessment and accreditation Public disclosure of information on provider quality

Proposed Conceptual framework for the Master plan for managing quality under NHSS (Sriratanaban, et al. 2005) 2005) Promoting quality
Hospital accreditation

1 Determination of Quality requirement

Correcting quality
Policy and management decision making

Promotion of 3 standards and guidelines

Regulations Payment System mgt. Information

Resource s
Management systems for quality

Quality monitoring

Health services

y Health outcomes y Practices y Satisfaction y Complaints

Beneficiaries empowerment and participation 5

Hospital accreditation as a regulatory incentive

Improve quality of health care Patient safety and risk management Evidence-based practice Continuous learning and improvement Stimulate and improve integration and management of health services Reduce variation in care and health care costs Strengthen the publics confidence in the quality of health care

What is Hospital Accreditation ?

Mechanisms for recognition of institutional competence By an independent accrediting body (Usually) Participation by professional groups Applying hospital standards for optimal and achievable performance Emphasis on continuous quality improvement Hospital survey by external peer reviewers Voluntary participation (Usually)

Examples of HA programs in Asia

Many countries in Asia have hospital accreditation programs, for example, Taiwan Korea Indonesia Japan Thailand Malaysia India (In certain states),

Thailand
Began as a research and development project in 1997 under the Health System Research Institute (HSRI) with financial support from WHO, TRF and HSRI of Thailand Collaboration for Hospital Quality Improvement and Accreditation Institute for Hospital Quality Improvement and Accreditation (HA-Thailand) (HATechnical support by external consultants from Canada (Adapted Canadian approach to HA) 35 pilot public and private hospitals

Quality improvement Plan Do cycle

Act Check
Hospital QA/
Standard

Quality hospital

CQI Accredit Accredit

RM

HA standard framework (Thailand 1999-2005) 1999-2005)

Health needs and customers expectations

Governance and policy directions

[1], [2]

Resource management
[3], [4], [5], [6], [7]

Professional systems, patient rights and organizational ethics

[11], [12], [13], [14],

Analysis, measurement and improvement

[8], [9]

Input

Patient care process and services

[10], [15], [16], [17], [18], [19], [20] Patients and other customers

Output

Health outcomes, Satisfaction

Information and knowledge management Part IV Health care Patient and customer Financial Human resources Organization effectiveness Leadership and Social Health Promotion

Strategic planning

Staff focus

Leadership Focus on patients And Patient rights

MBNQA/TQA Model

Results Process management

Part I

Key hospital systems Part II

Hospital and Health care services Standards 2006

Risk, Safety and Quality Professional management Environmental management Infection prevention and control Medical record system Medication system Medical laboratory system Radiological system Work with communities Patient care processes

Part III Patient care processes Entry Patient Assessment Planning (Care & Discharge) Care Delivery Patient & Family Empowerment Continuity of Care

Institute of Hospital Quality Improvement and Accreditation, THAILAND

Accreditation Survey
Leadership interview Clinical and support staff and team interviews Patient and family interviews Observation of patient care and services provided Building tour and observation of patient care areas Review of written documents Review of patients medical records Evaluation of the organizations achievement of outcome measures

Accredited hospital means



Organization commitment on quality improvement Adequacy of health care resources with efficient management Existence of quality assurance and continuous quality improvement Existence of mechanisms to promote professional standards and ethics Service provision that protects patient rights and promotes organization ethical practices Quality patient care processes

Potential impacts
Health system governance System design and development System financing Population health Knowledge management and transfer Clinical effectiveness Patient empowerment and decision-making decisionProfessional and personal development Management development Quality system development

Number of HA-accredited HAand HPH-certified hospitals HPH60 Number of new accredited or certified hospitals 50 40 150 30 100 20 10 0 Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan- Apr- Jul- Oct- Jan04 04 04 05 05 05 05 06 06 06 06 07 Time (Month / Year) HA HPH HPHA Acc.HA Acc.HPH Acc.HPHA 50 250 200 Accumulated number

Purchasing quality health care

 Social Security Scheme endorsement of HA Special quota of registered beneficiaries for accredited providers  National Health Insurance Scheme movement Financial support for HA consultation programs Financial bonus for accredited providers  Impacts for national health service systems Health promoting hospital Use of evidence-based practice Disease management programs by NHSO Humanized health care initiatives

Lessons learned: Government roles in supporting accreditation

 Policy endorsement  Leverage for accredited hospitals and other financial incentives  Consideration in purchasing decisions  Alignment of HA with other regulating mechanisms  Program acknowledgement  Program financing

Lessons learned: Major barriers to successful implementation

Unclear purpose and unrealistic expectations Inappropriate technical approach Failure to involve stakeholders Lack of motivation (Provider) Poor cooperation among professional and governmental bodies