Standards as a basis for quality healthcare

1. Standards as a basis for quality healthcare Presentation to public health sector managers October – November 2011

2. What Bill says about norms & standards • Norms & standards central concept of Bill, and OHSC: • Must advise Minister on setting of regulated norms and standards • Must undertake certain activities to enforce norms and standards • The core functions of the OHSC revolve round norms & standards: • Monitoring compliance with regulated norms & standards • Inspecting institutions to ascertain compliance • Certifying institutions in terms of their compliance • Through the ombudsman, investigating serious breaches of norms & standards

3. International practice on standards & compliance Regulators & accreditation bodies consulted or researched: • United Kingdom (Care Quality Commission, Health Ombud3333) • France (Haute Autorité de Santé) • Canada (Accreditation Canada) • Australia (Australian Council on Health Care Standards & Australian Commission on Safety & Quality in Health Care) • Malaysia (Malaysian Society for Quality in Health) • South Africa (Various)

4. Lessons on development of standards • Responsibility for setting standards varies: Health departments, accreditation bodies or independent structures • Different types of standards: • Norm-referenced (relative standing) vs criterion-based (trends or progress over time) • Input, process, output / outcome • Standards are invariably evidence-based: Shaped by expert inputs & usually representing wide consensus • Standards must cover aspects that are important & relevant and have a clear impact on care • Standards complement performance measurement & health system monitoring

5. International experience of measuring compliance • Classic approaches: licensing, certification, accreditation • Evolution of ‘accreditation’ with increase in government-led & mandatory/regulatory approach (away from voluntary and peer-review) • Often linked to financing (NHI) or health reform initiatives • Increased interest internationally in quality, quality management, quality assurance & improvement as part of management. Started in industry, spread to services

6. Strengths & weaknesses of inspections & audits • Strength is in: • Level of detail, requirement for evidence, & independent verification by informed peers • Weakness is in: • Long cycle, focus on inputs or system components, distorted picture through preparation for announced visits, possible conflict of interest (player and referee)

7. Perspectives on quality & standards development • Definitions of quality • ‘Getting best results from available resources’ • ‘Meeting specified standards’ • Other definitions: subjective or dependent on particular viewpoints • How are standards developed and why? • How were our NCS developed? What is their purpose?

8. Definitions of ‘standards and norms’ Standards • Explicit, predetermined expectations set by a competent authority that defines the acceptable performance levels National Core Standards • Constitute a statement of expected levels of performance that forms the basis for providing quality care • Specify expected best practice in a given context Norms • May be used interchangeably with standards • Often expressed in quantitative terms as a rate of provision Example: 3 beds per 1000 population

9. Domains of National Core Standards • Cross-cutting: apply to all aspects of healthcare • Reflect various risks to quality • Domains are: • Patient rights • Patient safety, clinical governance & clinical care • Clinical support services • Public health • Leadership and governance • Operational management • Facilities and infrastructure • Six critical standards prioritised for ‘fast track’

10. Standards enable better quality of care National healthcare standards drive better quality of care and ensure a minimum standard of care at institutions across the country. This is because they are: Unambiguous: set clear rules for managers and personnel (not discretionary) Enabling: assist health workers to perform their duties with confidence and certainty (and required support) Objective: evidence-based, specific and measured by actual outputs Realistic: health facilities at all levels have the capacity to implement these standards, which are universally recognised Tested: the NCS have been put into effect in many institutions with clear and positive impact on quality

11. Standards reflect values • National healthcare standards embody the essential values of the professions that drive the “business” of healthcare • Founded on simple respect: respect of health workers for patients is unconditional but ideally respect should be mutual •  A reminder of commitment: prompt professionals to recall their intention to do their best for patients •  A source of pride: by helping health workers achieve better care, standards can generate a senseprofessional self-respect •  Standards are not a burdensome add-on: they derive from the ethos at the heart of professional healthcare •  Have a universal character: NCS locally derived but similar to those in other countries - common roots in professional practice

12. Standards cover whole health system Standards reflect the complexity of health services. They must be driven as a coordinated system • Teamwork a prerequisite for meeting standards: all staff need to perform as individuals & pull together as a team • Failure to perform on one standard may negateor undermine performance on another standard •  Patients judge quality of healthcare in terms of their total experience • Leadership is an essential ingredient for good performance against standards • All teams need a leader, especially where members perform varied but interdependent tasks • Standards make clear demands on managers to shoulder responsibility

13. Accountability part of standards process Failure to adhere to standards will have clear consequences for facilities & health depts as we shift to inspection against regulated standards • Office of Health Standards Compliance to be set up as an official regulator of health establishments • Meeting the National Core Standards will prepare establishments for regulation • Meeting essential standards is a matter of public interest. Results of OHSC inspections will be made public and non-compliance will become visible • Standards help locate responsibility for performance: they are a tool for calling individuals or structures to account within facilities or at a higher level

14. Publications & resources on NCS • Books (three books & outline of their purpose) • Full standards and criteria • Full standards only • Extract of six ‘fast track’ priorities • Detailed measurement tools and checklists • By functional area • Compendium of documents • To be produced by facility • Available for reference (policies, SOPS)

15. ‘Popular’ materials on NCS • For patients • A leaflet on ‘fast track’ standards + feedback form • For staff of health establishments • Two informational posters • Easy-to-access information on NCS • To be read, not just looked at • Two promotional posters • Based on messages to health sector on NCS • SAMPLE POSTERS are NOT final designs • Photos are PLACEHOLDERS to be REPLACED by commissioned photos or illustrations

19. Fast track to quality healthcare Critical standards for patient-centred service  The National Core Standards for Healthcare Establishments are all critical to achieving high quality services Some standards are especially important to the patient’s experience of healthcare These standards are the key to patient-centred healthcare in our hospitals, community health centres and clinics Improve values & attitudes

20. Keep facility buildings, grounds & equipment spotless Reduce waiting times & queues

21. Provide good quality, reliable care & keep patients safe

22. Prevent transmission of infections in facilities Ensure availability of medicines, equipment & supplies

23. Messages on NSC to users & public • National Core Standards spell out clearlywhat you are entitled to expect when you use or visit a hospital or clinic anywhere in South Africa, whether the health facility is public or private • Health standards are based partly on what patients think is important to good healthcare. So standards help health managers to be more sensitive to your needs • Health standards should build your confidence to complain when you receive poor care. You should have no doubts about what is correct and what is unacceptable

24. Messages to public (2) • Health standards help health managers and health workers do a better job for you by giving them clear direction. They also encourage health workers to join together as a team to ensure that all the standards are met • Health standards are also based on scientific knowledge and experience of what enables health facilities to get good results when treating patients. Our standards are similar to those in many other countries

25. Compliance & ‘consequences’ Questions for reflection • Will standards and norms be implemented if there are no clear consequences? • Which works best – positive or negative consequences? Or a combination? • What is most helpful to frontline managers and staff in ensuring compliance? Who needs to do/provide what? • Who should ‘carry the can’ if patients do not experience acceptable & effective care?