Inspection of health establishments

1. Inspection of health establishments Examples of best practice and lessons from experienced regulators

2. What the Bill says • The inspectorate will be a key unit of the OHSC • It will measure compliance with prescribed norms and standards • Inspectors will have defined powers • Inspection visits can be routine/four-yearly or ad hoc for high risk situations or for serious complaints • Inspectors must either certify establishments as compliant or issue a notice detailing action needed to achieve compliance or withdraw such certification • Bill contains provisions of PAIA & principles of administrative justice (fair and equal, right to reply & to appeal) • Inspectorate can report, recommend, advise and communicate

3. Areas covered by scoping • Accreditation/licensing/certification • Approaches to inspection • Functions of inspectorate • Culture of unit • Staff models and competencies • Training and performance management • Prioritisation methodologies • Governance and operational models • Inspections with ‘teeth’ or ‘in partnership’

4. Key lessons or possible ideas • Initially take partnership approach to ‘inspections’ • Ensure sufficient enforcement powers to respond with authority • Base inspection teams in regions, or draw members from regions, to reduce travel • Design robust governance and quality control • Ensure inspection consistency and compliance; highest ethical standards • Employ inspectors with knowledge of health systems & of relevant management competencies • (Initially) prioritise high risk facilities

5. Interim activities (in NDOH) • First group of inspectors recruited and undergoing training in 2011 • Inspections starting January 2012 • Initially establishments/provinces will request inspection • Use/validate updated version of current tool • Will probably use more than six priority standards (perhaps full Core Standards) but this is to be finalised and will be communicated

6. Investigation of complaints& role of ombudsperson Examples of best practice and lessons from experienced ombuds and complaints units

7. What the Bill says • The OHSC shall: • Include the ombudsperson as a core component • Ensure that health care users’ complaints relating to breaches of norms & standards are considered, investigated properly and dealt with expeditiously • May refer complaints to other entities • Ombudsperson is appointed by Minister and: • Is intended to act in an independent & impartial manner • Has powers of inspectors and may use inspectors • Makes recommendations on action to be taken

8. International & national scoping: definitions Adjudicative or determinative Investigative or administrative Patient redress: an explanation that is fast, understanding but neutral, & reflects a correct/expert analysis of the root cause(s) Recommend action to parties (apology, redress) Failure to comply can result in referral for other action • Alternative dispute resolution (quasi-court) • Independent - powers to find against specified institution • Powers to compel action including payment of costs and/or compensation

9. Lessons learned and ideas • Complaints • Efficient, user-friendly process essential for registering complaints – this has a major impact on perceptions of aggrieved patients • Consistent approach in finalising complaints vital • Clarity required regarding categories of complaints to be dealt with in order to guide complainants • Transparency important in terms of process of receiving and investigating complaints • Ombudsperson • Essence is fairness and impartiality in carrying out adjudicative functions/exercising determinative powers • Needs knowledge of the law and of healthcare

10. Interim activities • Analysis of all existing complaints escalated to national department • Advisory panel of clinicians and specialists designated by DG (to be expanded as needed) • Requests for information will be made to provinces in relation to cases selected for investigation • Panel will determine need for on-site visit & inform provinces • Draft report & recommendations to be discussed with province and facility • Process will inform future analysis & investigation tools

11. Early Warning System Examples of best practice and lessons from experienced regulators

12. What the Bill says • The OHSC must: • Monitor indicators of risk as an early warning system relating to serious breaches of norms and standards • The OHSC may: • Collect or request information on norms & standards from establishments & users • Liaise with other regulatory authorities to share or exchange information to monitor: • Matters of common interest • A specific complaint or investigation • Collect or request any information relating to prescribed norms and standards from health establishments and users

13. Early warning & risk profiling practices • Concept of Early Warning System (EWS) taken from other fields. Involves collection of information on specific events to trigger prompt intervention • Concept of Quality Risk Profile – a rating for each institution – used by Care Quality Commission (UK). Countries now moving towards this include US, France, Australia • Data mapping involves collecting existing information from a range of sources (routine and ad hoc) • Registration a key component in some countries: ‘semi-permanent’ information; may include self-assessment • Real-time surveillance of small set of very critical indicators

14. Lessons learned and ideas • Mechanism essential for targeting or prioritising inspections as well as alerting management to need for corrective action • Concept starting to become more widespread - compensates for weaknesses of routine inspections but cannot replace them • EWS/ QRP not reliant on a single organisation or process; depends on coordination and ‘working together’ • Should be underpinned by a robust information system & sound processes pulling information from a range of sources • A critical subset of indicators reported pro-actively / in real time but requiring immediate action (surveillance) • Establishment of an EWS needs consultation, standardisation and phasing-in

15. Interim activities • Quality seminar to be held on 21 November on ‘The measurement of quality’ to: • Refine discussion document based on scoping work done • Debate proposed list of indicators for monitoring & surveillance • Follow-through to cover both DoH systems and future OHSC requirements and processes • Pilot of proposals in a number of districts including: • Subset of critical surveillance indicators (Reportable Events indicating Danger in the Health System - REDS)

16. Examples of REDS indicators in other countries • Three criteria for REDS: Serious breach of quality; risk to patient safety; & need for immediate response • REDS in leadership & governance • Vacancy of CEO post • Death of staff member on duty • REDS in area of patient safety • Maternal death • Patient fall resulting in death or permanent disability • Medication error resulting in death or permanent disability • REDS in area of patient rights • In-patient suicides • Confirmed MRSA infections

17. Communications & Stakeholder Relations Examples of best practice and lessons from experienced regulators

18. What the Bill & other laws say • The Bill gives OHSC mandate to publish on matters related to norms and standards • National Health Act protects patient records & confidentiality, supports patient’s right to information about own healthcare • Promotion of Access to Information Act promotes government & corporate transparency but respects individual rights to privacy & business confidentiality • OHSC must strike similar balance between public accountability on state of healthcare & respect for particular rights of patients & organisations

19. Scoping C&SHR in regulatory & investigatory settings • Post-1994 regulators use Communication and Stakeholder Relations (C&SHR) strategically to encourage voluntary compliance(Competition Commission, National Credit Regulator, Council for Medical Schemes, the ‘new’ SARS) • Complaints units and ombuds offices use C&SHR to market their services and develop public awareness of rights • Regulators & other authorities use communication as a catalyst for action to rectify non-compliance by publishing outcomes of reporting and inspections (Care Quality Commission in UK, Dept of Labour on BEE)

20. Lessons learned from regulators • OHSC would fit the mould of a ‘new generation regulator’ where C&SHR contribute to voluntary compliance • Guiding health establishments to achieve voluntary compliance does notmean OHSC is a ‘soft’ regulator • There is no contradiction or dishonesty in a regulator interacting both with health facilities & with consumers to improve quality of care • Image is critical to OHSC’s success. It must be seen as impartial, fair & competent • Image depends on real performance not on ‘spin’. Communication must reflect & support OHSC’s actual work

21. C&SHR activities Oct 2011 – March 2012 • Two purposes: • Promote NCS as a tool for quality care • Inform stakeholders of OHSC developments • Major activities • Consultation & communication with provinces • Production of materials for staff & patients • Four posters for health workers • Patient leaflet with feedback form • Development of teams of ‘champions’ to address patients • Communication to general public • Media briefings & releases: Quality Month, quality symposium, OHSC developments & milestones • Radio campaign in Jan on quality care. Interactive features, using SMS & facebook • Meetings with key stakeholders