QUALITY MANAGEMENT ACTORS AND INSTRUMENTS AND THEIR INSTITUTIONAL LINKS TO SOCIAL HEALTH PROTECTION MECHANISMS

1. QUALITY MANAGEMENT ACTORS AND INSTRUMENTS AND THEIR INSTITUTIONAL LINKS TO SOCIAL HEALTH PROTECTION MECHANISMS Presented by Dr George Midiwo General Manager Standards and Quality Assurance , National Hospital Insurance Fund ,Kenya  Membership registration Current membership 1.8 million?? Benefit coverage 10 million dependants Informal sector ????? On registration thye isuued with a photo card Most hospitals are vconnected to the main frame data base ,the use of card redaers at point of sale (pos) assit in surveillanec and maintanance of current infoamation and records benefits Currently a fee for service payment(a rebate) mechanism is in place, for the reimbursement of claims . A minimum\ benefit package is availed to all members uniformly Different hospitals have different payment rates between 800 – 2200 shs ($12.1 –$33.3)per day per patient. Over 400 hospitals contracted and accredited. The increase in the daily rebate poisitively affected the quality of service and nhif put in place the contracts. the minimum benefit package is spelt out in Contract types A,B,C Contract A- this contract dose not allow any co-payment and is fully comprehensive.This contract usually applies to Government facilities. contracting Contract B- this contract provides for a comprehensive medical service but does allow co payment for surgery above the minimum stated limit of 8,000 shs.this contract applies to mainly mission and some private hospitals. Contract C- this contract provides for options of co-payment on medical and surgical cases.This contract usually applies to private and elite hospitals. Quality assurance of benefits Accreditation is carried out every two years. Assessment done using the nhif accreditation manual(edition 1-2005 &2-2007)& small hospitals manual-2006. Manuals developed on the basis of KQM-Kenya quality model and divided in to 6 levels of care; Level 1- outpatient clinics and dispensaries Level 2- health centres Level 3- sub district hospitals Level 4- district hospitals Level 5- provincial general hospitals Level 6- teaching and referral hospitals Quality management and access Quality management is an integral part of Social health. The provision of access to affordable and acceptable quality health care is determined by equitable distribution of resources The inequality in access to health care & lack of adherence to standards , created opportunity for the development of strategies in relation to the improvement of quality. KQM CONCEPT APPROACH As one of the strategies in place to improve quality, the Department of Standards and Regulatory Services (DSRS) under the Ministry of Health designed the Kenya Quality Model.(KQM) The KQM provides a definition of quality in health care in Kenya as “ The totality of features and characteristics of Kenya health care systems that bear on its ability to satisfy stated or implied needs.” KQM is An Integrated Approach “to Improve Quality in Health Care’’ KQM –cont’d KQM was designed to Increase efficiency and effectiveness in the use of available resources Provides conceptual framework for quality improvement (QI) and is integrated into the quality management tools. KQM further classifies standards in three levels- Structures input like leadership,staff,policy supplies ,equipment & e.t.c Processes through- puts i.e actions and activities of giving care Outcomes – results of health service delivery KQM tools master checklist- designed to apply the KQM concept in routine work and the on going health sector reform Kenya health standards- Accreditation manuals Service provider Contracts Kqm pillars KQM –QM PRINCIPLES KQM has adopted the following quality management principles; Customer focus Leadership People involvement Systems approach to management Process orientation Continuous quality improvement Factual approach to decision making The 12 Dimensions KQM tools master checklist- designed to apply the KQM concept in routine work and the on going health sector reform Kenya health standards- Accreditation manual Service provider Contracts Role of checklist in KQM implementation Helps to critically examine each dimension of KQM. Provides an idea of the quality of care that a health facility offers. Is a vital (self-)assessment tool. Is useful point of reference to guide quality improvement activities. Provides critical insight into quality gaps. Is a good monitoring and evaluation tool for QI activities. Quality assessment checklist The checklist is one of the core pillars of KQM KQM has 12 dimensions as represented in the checklist The checklist comprises the 7 KQM principles The Kenya health standards and a master checklist form a core element if the Kenya quality module Master checklist Structure Leadership; staff; policy(s & g); district plans; supplies;equipment;transport; referral; financial management. Process Client-provider interaction; continuous QI; program management. Outcome/results Users/clients ;Performance of facility;PHC program;Staff;society aseline study in kisumu district from June –06 to date Study carried out on 8 hospitals in kisumu district from June 2006 to October 2007 They were trained on quality improvement in June 2006 and the results according to the 12 dimensions are as follows Lessons learnt and challenges Mission hospitals are more successful than government. Quality to be everybody’s business Good leadership is a must Staff are the most important resource In all the institutions visited-motivation,financial management and process orientation were a problem. Deaths and brain drain high staff turnover at medical facilities. Continued population growth.

2. Presentation Outline Nhif Vision and mission Historical background of nhif KQM Quality management tools Experiences on Quality improvement KQM results

3. Historical background of nhif Established in 1966 by an act of parliament . To cover all Kenyans in formal employment. Nhif act reviewed in 1998 and cover expanded to the informal sector Contributions currently graduated between 100- 320 shillings – ($ 1.5 - $ 4.8) monthly for the formal sector. For the informal sector contributions are at 160 shs ( $ 2.4 ) monthly.

4. Membership registration formal sector 1,800 000 Informal sector 200,000 Benefit coverage approx 10 million dependants

5. Mode of financing health services by NHIF Currently the mode used for the reimbursement of claims is a rebate system. Hospitals have different payment rates graduated between 800 –2200 shs ($12.1 –$33.3) per patient,per day. This rebate covers consultations,drugs,bed charges,nursing services, etc. In most cases the rebate is enough to cover the costs incurred. Members have access to over 400 Accredited and Contracted hospitals.

6. Benefits NHIF has increased health financing by over 100% in the Last 3 years. This has had a positive influence on the quality of service. NHIF put in place contracts as a measure to control fraud and hold service providers liable to professional care given. Benefits are defined in three different kinds of NHIF accredited healthcare provider contracts. The minimum benefit package is spelt out in Contract types A,B,C

7. contracting Contract A- This contract dose not allow any co-payment and is fully comprehensive to particular health providers.This contract applies to Government facilities. Contract B- This contract provides for a comprehensive medical service but does allow co payment for surgeries, which is capped at an agreed upon sum. This contract applies to mainly Mission and some Private hospitals. Contract C- This contract provides for options of co-payment on Medical and Surgical cases.This contract usually applies to Private and Elite hospitals.

8. Quality assurance of benefits Minimum standard benefit package of care spelt out in the accreditation manuals. Manuals developed on the basis of KQM-Kenya quality model and divided into 6 levels of care; Level 1- outpatient clinics and dispensaries Level 2- health centres Level 3- sub district hospitals Level 4- district hospitals Level 5- provincial general hospitals Level 6- teaching and referral hospitals

9. ACCREDITATION Accreditation is an on going process Assessment done using KQM tools post assessment scores are tallied against a graduated scale in order to determine eventual rebates

10. KQM DEFINITION The KQM provides a definition of quality in health care in Kenya “ The totality of features and characteristics of Kenya health care systems that bear on its ability to satisfy stated or implied needs.” KQM is An Integrated Approach “to Improve Quality in Health Care’’ The Kenya Quality Model (KQM)was designed by the Department of Standards and Regulatory Services (DSRS) under the Ministry of Health

11.   KQM CONCEPT APPROACH  KQM was designed to Increase efficiency and effectiveness in the use of available resources KQM further classifies standards into - Structure standards Processes standards Outcomes standards

12. KQM pillars Integrates; EBM-development and dissemination of standards and guidelines TQM-application of QM principles,use of master checklist and adherence to s & g PP-promotion of community involvement and participation

13. KQM –QM PRINCIPLES KQM has adopted the following quality management principles; Customer focus Leadership People involvement Systems approach to management Process orientation Continuous quality improvement Factual approach to decision making

14. The 12 Dimensions STRUCTURE

15. KQM tools master checklist- designed to apply the KQM concept in routine work and the on going health sector reform Kenya health standards- Accreditation manual Service provider Contracts Client satisfaction surveys Community perception surveys Performance measurements and monitoring using- audit , quality performance indicators.

16. Quality management training NHIF currently has a training program on quality management based on the KQM. Training curriculum developed. Increased capacity from 20 personnel to 500 currently. 40 certified Trainers on Quality Management 40 Auditors of Quality in Healthcare several hospitals assisted with the development of guidelines.

17. Quality improvement Results using the master checklist The checklist is the main tool of KQM. The Kenya health standards and a master checklist form the core element of the Kenya quality model Quality improvement teams are established in hospitals and generates quality reports every 4 months to the accrediting body (NHIF) Quality audits are carried out biannually and regular Quality assurance tools applied.

28. Results con’t Informed leadership is a must for quality improvement in institutions Well trained Staff are the most important resource In all the institutions-motivation,financial management and process orientation were a problem. Health financing should be tied to the quality of care provided to bring rapid improvement

29. Results con’t Success of the KQM in the OBA project The MOH, NCAPD and KFW developed a project targeting to purchase outputs through a voucher system. NHIF was subcontracted to provide technical expertise for accreditation and ensure the quality of service offered by facilities . The objective is to provide Safe motherhood, Family planning & Gender violence recovery for the economically disadvantaged population through a voucher system The KQM has successfully addressed the issues of access by the poor to quality health services ,in this project.

30. Results con’t Average length of stay (ALOS)-is a key measure of service in inpatient care. KQM has enabled NHIF to bring down ALOS in the 400 accredited hospitals from an average of 12 days in 2003 to an average of 6 days in 2006. KQM –minimum benefit package defined in contracts.pilot underway on out patient & GRD Claims payment improved from 90 days to 14 days currently. Electronic identification of members at points of service

31. Thank you Asante Sanaa