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 Respect for patient rights and more client orientation World Health Report (2000) Health outcome improvement Some of major challenges for Thailand’s health care systems • Inequity due to mal-distribution of health resources • Increasing health care expenditure • Introduction of close-ended payment mechanisms by the 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 date Rate (%) Death Preventable HMPS 1984 3.7 13.6 % - UTCOS 1992 5.4 5.6 % 54% QAHCS 1992 16.6 4.9 % 51% UK 1999-2000 11.7 8.0%% 48% Denmark 1998 9.0 - - Thailand(1) 2003 9.1 - 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) Promoting quality 1 Determination of Quality requirement Hospital accreditation Correcting quality Promotion of 3 standards and guidelines Resources Regulations Payment System mgt. Information Management systems for quality Health services Policy and management decision making 2 Quality monitoring  Health outcomes  Practices  Satisfaction  Complaints 4 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 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, –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 Collaboration for Hospital Quality Improvement and Accreditation Institute for Hospital Quality Improvement and Accreditation (HA-Thailand) Technical support by external consultants from Canada (Adapted Canadian approach to HA) 35 pilot public and private hospitals Quality improvement cycle Plan Do Quality hospital Act Check CQI Hospital QA/ Standard RM Accredit Accredit HA standard framework (Thailand 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], Input Patient care process and services [10], [15], [16], [17], [18], [19], [20] Analysis, measurement and improvement [8], [9] Output Patients and other customers Health outcomes, Satisfaction Information and knowledge management Part IV Staff focus Strategic planning Leadership Results Focus on patients And Patient rights Part I Process management Health care Patient and customer Financial Human resources Organization effectiveness Leadership and Social Health Promotion MBNQA/TQA Model 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 organization’s 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 • Professional and personal development • Management development • Quality system development Number of HA-accredited and HPH-certified hospitals 250 50 200 40 150 30 100 20 50 10 0 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 Accumulated number Number of new accredited or certified hospitals 60 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