Accreditation as a Regulatory Tool and QA: Learning from the Asia Experience 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 Lessons learned from Thailand HA

Roles of the Health System World Health Report (2000) Respect for patient rights and more client orientation Health outcome improvement

Some of major challenges for Thailand’s health care systems Inequity due to mal-distribution of health resourcesInequity due to mal-distribution of health resources Increasing health care expenditureIncreasing health care expenditure Introduction of close-ended payment mechanisms by the major health security schemesIntroduction of close-ended payment mechanisms by the major health security schemes Expansions of business health sectors and the governmental “Medical hub” policiesExpansions of business health sectors and the governmental “Medical hub” policies Threats against quality of health care

Alarming information from Adverse events studies studydate Rate (%) DeathPreventable HMPS % - UTCOS % 54% QAHCS % 51% UK %48% Denmark Thailand (1) %

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) Promotin g quality Correctin g quality Determination of Quality requirement Promotion of standards and guidelines Resourc es Beneficiaries empowerment and participation Regulations Payment System mgt. Information Quality monitoring  Health outcomes  Practices  Satisfaction  Complaints Policy and management decision making Management systems for quality Health services 1 Hospital accreditation

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 public’s 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,Many countries in Asia have hospital accreditation programs, for example, –Taiwan –Korea –Indonesia –Japan –Thailand –Malaysia –India (In certain states), etc.

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 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 Collaboration for Hospital Quality Improvement and Accreditation Institute for Hospital Quality Improvement and Accreditation (HA-Thailand) Institute for Hospital Quality Improvement and Accreditation (HA-Thailand) Technical support by external consultants from Canada (Adapted Canadian approach to HA) Technical support by external consultants from Canada (Adapted Canadian approach to HA) 35 pilot public and private hospitals 35 pilot public and private hospitals

Quality improvement cycle Plan Do CheckAct Quality hospital Hospital CQI Accredit QA/ Standard RM

HA standard framework (Thailand ) Governance and policy directions [1], [2] Resource management [3], [4], [5], [6], [7] Patient care process and services [10], [15], [16], [17], [18], [19], [20] Analysis, measurement and improvement [8], [9] Patients and other customers Professional systems, patient rights and organizational ethics [11], [12], [13], [14], Input Output Health needs and customers’ expectations Health outcomes, Satisfaction

Institute of Hospital Quality Improvement and Accreditation, THAILAND Leadership Strategic planning Focus on patients And Patient rights Staff focus Process management Results Information and knowledge management Key hospital systems 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 Entry Patient Assessment Planning (Care & Discharge) Care Delivery Patient & Family Empowerment Continuity of Care Health care Patient and customer Financial Human resources Organization effectiveness Leadership and Social Health Promotion Hospital and Health care services Standards 2006 Part IV Part III Part II Part I Patient care processes MBNQA/TQA Model

Accreditation Survey Leadership interviewLeadership interview Clinical and support staff and team interviewsClinical and support staff and team interviews Patient and family interviewsPatient and family interviews Observation of patient care and services providedObservation of patient care and services provided Building tour and observation of patient care areasBuilding tour and observation of patient care areas Review of written documentsReview of written documents Review of patients’ medical recordsReview of patients’ medical records Evaluation of the organization’s achievement of outcome measuresEvaluation of the organization’s achievement of outcome measures

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

Potential impacts Health system governanceHealth system governance System design and developmentSystem design and development System financingSystem financing Population healthPopulation health Knowledge management and transferKnowledge management and transfer Clinical effectiveness Patient empowerment and decision-making Professional and personal development Management development Quality system development

Number of HA-accredited and HPH-certified hospitals

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  Technical support networks  Public relations and reward systems

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 Under-funding and lack of governmental commitment Failure to learn