Authors: Triona Fortune, Elaine O’ Connor and Barbara Donaldson
Guidance on Designing Healthcare External
Evaluation Programmes including Accreditation
2015
International Accreditation Programme (IAP) ISQua Accreditation
Guidance on Designing Healthcare External Evaluation Programmes including Accreditation i
Table of contentsAcknowledgements iii
ForewordISQua iv
ForewordWorldBank&WHO vi
ListofTables vii
GlossaryofTerms viii
Introduction 2
Chapter 1: Why develop an external evaluation programme? 4
1.1 Thegrowingdemandforexternalevaluationinhealthandsocialcare 4
1.2 Modelsofexternalevaluation 5
1.3 Benefitsofexternalevaluation 8
1.4 Challengesforexternalevaluationprogrammes 10
Chapter 2: Establishing the fundamentals 12
2.1 Definingthepurposeoftheexternalevaluationprogramme 12
2.2 Definingthescopeoftheexternalevaluationprogramme 15
2.3 Establishingtheroleofgovernment 18
2.4 Determiningincentives 21
2.5 Developingrelationshipswithstakeholders 24
Chapter 3: Setting up the external evaluation organisation 27
3.1 Establishingapreliminaryboardoradvisorycommittee 27
3.2 Proposingagovernanceboardandframework 28
3.3 Fundingoftheprogramme 30
3.4 Settingupstrategic,operationalandfinancialmanagementsystems 33
3.5 Timeframes 35
Chapter 4: Developing the standards 37
4.1 Theroleofstandards 37
4.2 Principlesforstandards 38
4.3 Referencingtoqualitydimensions 39
4.4 Developingthemeasurementsystem 40
Chapter 5: Developing assessment methodologies 43
5.1 Selection,trainingandevaluationofsurveyors 43
5.2 Developingthesurveymanagementprocess 46
5.3 Establishingtheaccreditation/certificationprocess 48
5.4 QualityAssurance 51
Chapter 6: Evaluating systems and achievements 52
6.1 Measuringperformanceinternally 52
6.2 Evaluatingindependently 53
6.3 Monitoringbyregulatoryagencies 53
6.4 Accreditingtheexternalevaluationbodies 53
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ISQua Accreditation International Accreditation Programme (IAP)
Guidance on Designing Healthcare External Evaluation Programmes including Accreditation
Table of contentsConclusions 54
References 55
Bibliography 58
Usefulwebresources 62
Appendix 1: Case Studies 64
Appendix1a.DanishCaseStudy 64
Appendix1b:JordanianCaseStudy 67
Appendix1c.NewZealandCaseStudy 69
Appendix1d:PracticeIncentiveProgram(PIP) 72
GuidanceonDesigningHealthcareExternalEvaluationProgrammesincludingAccreditation
©2015Publisher:TheInternationalSocietyforQualityinHealthCare,JoyceHouse,8-11LombardStreetEast,Dublin2,D02Y729,Ireland.
International Accreditation Programme (IAP) ISQua Accreditation
Guidance on Designing Healthcare External Evaluation Programmes including Accreditation iii
AcknowledgementsThisdocumentisbasedontheToolkitforAccreditationPrograms,2004developedbyCharlesShaw.TheInternationalSocietyforQualityinHealthCarewouldliketothankthefollowingfortheircontributionstothedevelopmentofthisdocument:
Reviewers
MarkBrandon,AACQA-Australia
StephenClark,AGPAL-Australia
HelenoCostaJunior,CBA-Brazil
CarstenEngel,IKAS-Denmark
EricdeRoodenbeke,InternationalHospitalFederation
CarlosGoesdeSouza,CHKS-UK
HelenHealey,DAPBC-Canada
SalmaJaouni,HCAC-Jordan
ThomasLeludec,HAS-France
Hung-JungLin,JCT-Taiwan
LenaLow,ACHS-Australia
KadarMarikar,MSQH-Malaysia
WendyNicklin,AccreditationCanada
BKRana,NABH-India
CharlesShaw,IndependentConsultant
PaulvanOstenberg,JCI-USA
KeesvanDun,NIAZ-TheNetherlands
StuartWhittaker,COHSASA-SouthAfrica
HongwenZhao,WHO
NittitaPrasopa-Plaizier,WHO
AkikoMaeda,WorldBank
DineshNair,WorldBank
RafaelCortez,WorldBank
AspecialacknowledgementtoAkikoMaedaandtheWorldBankforsupportingthisproject.
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ISQua Accreditation International Accreditation Programme (IAP)
Guidance on Designing Healthcare External Evaluation Programmes including Accreditation
Foreword Accreditationisanimportanttoolforimprovingthecaredeliveredbyhealthcaresystems,andoneofthekeyrolesoftheInternationalSocietyforQualityinHealthCare(ISQua)hasbeentoaccredittheaccreditors.However,accreditationhastoevolvetobebeneficial.Anincreaseinrequests-especiallyfromdevelopingeconomies-foradviceonestablishinganaccreditationprogrammepromptedISQuatoreviewtwoofitsmajortools:theToolkitforAccreditationPrograms,20041,andChecklistforDevelopmentofNewHealthcareAccreditationPrograms,20062.Thelastdecadehasseenconsiderablechanges,worldwide,tohealthcaresystemsandexternalevaluationprogrammes.Toreflectthesechanges,arevisiontotheexistingguidancewasdeemedinadequateandthisnewGuidancemanualwasthereforedeveloped.Webelievethisdocumentwillbesuitableforamuchwideraudience;itisdesignedforcountries,governmentsandpolicymakerswithinpublicorprivate,primary,secondaryortertiaryhealthcaresystems.ItisalsointendedasanaidforfundinganddevelopmentagenciessuchastheWorldBank,internationalaidagencies,theWorldHealthOrganization(WHO),MinistriesofHealth,othergovernmentagencies,groupsandorganisationswhowanttoimprovethequalityandsafetyofhealthcareintheircountry,regionorspecialtyarea.
Ithasnowbeenalmost100yearssincethefirstexternalevaluationprogramme,knownasaccreditation,wasestablished.Nearlyeverycountrycurrentlyhassomeformofexternalevaluation,whethervoluntaryormandatory.Thereareboth“aficionados”andcriticsofhealthcareaccreditation.Anyonewhohasdealtwithaccreditorscomingintotheirsitehaslikelyfeltthattheywerearbitrary,orfocusedonthingsthatwerelessthanimportant.However,accreditationgetsorganisationstopayattentiontothingstheymightotherwiseprefertoignoreorputoff.Whileitissometimesvoluntary,followingaseriesofadverseeventspolicymakersthenchangeittomandatoryinresponse.Whiletraditionallyaccreditationwasaprogrammefordevelopedeconomies,developingcountriesarenowequallyasinterested.Thisdocumenthasextendeditsscopebeyondhealthcareaccreditationprogrammestoincludeotherexternalevaluationprogrammessuchascertificationandlicensingastheyapplytoorganisations,notindividualpractitioners.Theseprogrammeshavedifferentscopesandorganisationalcoveragebutarebasedonthesameprincipleofevaluatingandimprovingperformanceagainstadefinedsetofstandards,usingexternalevaluators,toimprovethesafetyandqualityofhealthservicesforthepublic.
Accreditationisnotapanaceatoaddressallqualityimprovementissuesbutitcanprovideasystematicapproachthatidentifiesareaswhereimprovementsarenecessary,andwhenmandatory,can“liftalltheboats”,includingsomeofthelessstrongentitieswithinourhealthcaresystems.Whenusedwithtoolssuchaschecklistsandsupportedbytechnology,itcanbecomeapowerfulinstrumentforhealthcarereform.
Developinganexternalevaluationsystemisaprocessthatshouldbedesignedaccordingtoeachcountries’profile.Firstly,thepurposeshouldbeclearandsecondly,dependingonthedesiredoutcome,adecisionshouldbemadeastowhetheravoluntaryormandatorysystemisappropriate.Thisdocumentisnotdesignedasarigidguideline,ratherasadiverserangeofpracticeswhichshouldbediscussed.Itincludesadviceonbestpracticesforgovernance,developingstandardsandassessmentmethodologies.Italsoincludesrealcasestudiesfrombothdevelopedanddevelopingcountries.
Healthcarecontinuestoevolve;someofthekeychangesoccurringtodayarethatpopulationsareageing,whiletechnologyisbecomingsmarterandtherelationshipsbetweenprovidersandpatientsaretiltingsothatpatientsaremuchmoreempowered,andtheyarebecomingourpartners.WeallneedtostrivetoreachcountryspecificandglobalgoalssuchastheWorldHealthOrganization’smandateonUniversalHealthCoverage(UHC)by2020.
International Accreditation Programme (IAP) ISQua Accreditation
Guidance on Designing Healthcare External Evaluation Programmes including Accreditation v
GovernmentswillultimatelyberesponsibleforprovidingUHCandtheywillberequiredtodemonstrateefficientuseoflimitedpublicfundswhileprovidingsafequalityhealthcare.Externalevaluationsystemscanprovidethisassurance.
ISQuabelievesthataccreditationcancontinuetobeapowerfulforceforimprovementinthequalityofcarethatisdelivered.However,likeallqualityimprovementinitiatives,itmustevolvewiththetimestoreflecttheneedsofourhealthcaresystems.
Professor David W. Bates President International Society for Quality in Health Care August 2015
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Guidance on Designing Healthcare External Evaluation Programmes including Accreditation
ForewordWorld Bank and the World Health Organization
Thepublichasagrowingawarenessofandexpectationfortheirhealthcaretobeaccountable,safe,ofhighqualityandresponsivetotheirneeds.Globally,healthcarecostsarerising,puttingincreasingburdensonbothgovernmentsandhealthcareorganisations,astheytrytomeetthegrowingchallengeswithlimitedresources.GovernmentsareworkingtowardsUniversalHealthCoverage(UHC)asawaytoensurethattheirpopulationshaveequitableaccesstosafe,highqualityservices,withoutsufferingfinancialhardship.Thecriticalquestionremains:howcancountriesmaximiseaccesswhilstmaintainingsafeandqualityserviceswithinaffordablemargins?
Externalevaluationprogrammes,whichincludeaccreditation,certificationandlicensingofhealthcareinstitutions,areamongmeasuresthatcanhelpimproveorganisationalefficiencyandeffectivenessaswellasthesafetyandqualityofservices.However,implementationoftheseprogrammesisnotuniform.Thismaybeduetoalackofresourcesorexpertiseor,importantly,duetoalackofoperational‘know-how’ontheimplementationofsuchprogrammes.
Thisreportaimstoprovideapracticalguideforsettingupanexternalevaluationprogrammeatbothanationalandanorganisationallevel.Itwillhelpgovernmentsandpolicymakerstoidentifyanddeterminehealthsystems’prioritiesandgaps,sotheycanre-orienthealthcaresystemsandpoliciestomeetsuchgrowingchallenges.Thereportoffersarangeofapproachesandpracticalstepsonthesettingupofexternalevaluationprogrammes,includingcreatinganenablingenvironmentanddevelopinghumanandsystemcapacities.
Betterimplementationofexternalevaluationprogrammescancontributetoimprovedsafetybyrequiringservicestomeetstandards,andbyencouragingqualityimprovementthroughorganisationalandindividualprofessionaldevelopment.Suchprogrammes,ifadoptedandimplementedappropriatelyandconsistently,willcontributetoamoreresilient,moreaccountable,andmoreeffectivehealthcaresysteminthelongrun.
Itishopedthatthisreportwillencouragegovernmentsandhealthcareorganisationstoadoptandimplementexternalevaluationprogrammesinordertoachievesafe,highquality,resilientandsustainablehealthsystemsandservices.
Timothy Grant EvansSenior Director Health Nutrition and Population Global Practice The World Bank Group
Marie-Paule Kieny Assistant - Director General Health Systems and Innovation World Health Organization
International Accreditation Programme (IAP) ISQua Accreditation
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List of Tables Table Page No.
Table1:Definitionsofaccreditation,certificationandlicensing 8
Table2:Comparisonofcapacitybuildingandregulatoryexternalevaluation 13
Table3:Potentialcompositionofapreliminary/interimboardoradvisorycommittee
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Guidance on Designing Healthcare External Evaluation Programmes including Accreditation
Glossary of Terms Accountability Responsibilityandrequirementtoanswerfortasksoractivities.This
responsibilitymaynotbedelegatedandshouldbetransparenttoallstakeholders.
Accreditation Aself-assessmentandexternalpeerreviewprocessusedbyhealthandsocialcareorganisationstoaccuratelyassesstheirlevelofperformanceinrelationtoestablishedstandardsandtoimplementwaystocontinuouslyimprovethehealthorsocialcaresystem.
Assessment Processbywhichthecharacteristicsandneedsofpatients,groups,populations,communities,organisationsorsituationsareevaluatedordeterminedsothattheycanbeaddressed.Theassessmentformsthebasisofaplanforservicesoraction.
Assessor Personwhoevaluatescharacteristicsandneeds.Forexternalevaluation,anassessoridentifiesandevaluatesevidencethatsetcriteriaarebeingmetandmakesrecommendationsforactiontoaddressanygaps.Alsoauditor,surveyor,externalevaluator.
Benchmarking Comparingtheresultsofservices’ororganisations’evaluationstotheresultsofotherinterventions,programmesororganisations,andexaminingprocessesagainstthoseofothersrecognisedasexcellent,asameansofmakingimprovements.Alsobenchmark.
Certification Processbywhichanauthorisedbody,eitheragovernmentalornon-governmentalorganisation(NGO),evaluatesandrecogniseseitheranindividual,organisation,objectorprocessasmeetingpre-determinedrequirementsorcriteria.Thepre-determinedrequirementsaresetoutinstandardswhicharedevelopedspecificallyforthepurposeofassessment.Thestandardsassesstheperformanceoftheorganisation,object,processorperson,mayfocusonspecificaspectsofperformanceandmayaddressmorethanlegalrequirements.
Clients Individualsororganisationsbeingservedortreatedbytheorganisation.Alsopatients,consumers,serviceusers.
External evaluation
Processinwhichanobjectiveindependentassessorgathersreliableandvalidinformationinasystematicwaybymakingcomparisonstostandards,guidelinesorpathwaysforthepurposeofenablingmoreinformeddecisionsandforassessingifpre-determinedandpublishedrequirementssuchasgoals,objectivesorstandardshavebeenmet.Anorganisation,object,processorindividualmaybeassessedandevaluationmaybeundertakenbypeers,includingorganisationsandprofessionals,privateprofessionalauditorsorconsultants,purchasers/funders/insurers,consumers/patientsorgovernments.
Health Outcome Healthstateorconditionattributabletotreatment,careorserviceprovided.
Leader Anindividualwhosetsexpectations,developsplansandimplementsprocedurestoassessandimprovethequalityoftheorganisation’sgovernance,management,clinicalandsupportfunctionsandprocesses.
Leadership Abilitytoprovidedirectionandcopewithchange.Itusuallyinvolvesestablishingavision,developingstrategiesforproducingthechangesneededtoimplementthevision,aligningpeople,motivatingandinspiringpeopletoovercomeobstacles.
International Accreditation Programme (IAP) ISQua Accreditation
Guidance on Designing Healthcare External Evaluation Programmes including Accreditation ix
Licensing Processbywhichagovernmentalauthoritygrantspermissiontoanindividualpractitionerorhealthandsocialcareorganisationtooperateorengageinanoccupationorprofession.Licensingregulationsaregenerallyestablishedtoensurethatanorganisationorindividualmeetsminimumstandardstoprotecthealthandsafety.Theoutputoflicensingistheawardingofadocumentorlicenceallowinganorganisationorpersontoprovideaservicewithinaspecifiedscope.
Medical tourism Travelofpeopletoanothercountryforthepurposeofobtainingmedicaltreatmentinthatcountry.
Organisational peer assessment
Aprocesswherebytheperformanceofanorganisationisevaluatedbymembersofsimilarorganisations.Alsopeerreview.
Outcome standards
Standardswhichaddresstheresults,consequencesoroutcomesoftheperformanceandmeasurementofactivities,systemsandfunctions.
Patient centredness
Focusontheexperienceofthepatient/clientfromtheirperspective,minimisingvulnerabilityandmaximisingcontrolandrespect.Alsopatient/clientfocus.
Patient / Client journey
Thepatient/clientpaththroughthecareortreatmentprocess–entry,assessment,planning,deliveryofcareortreatment,evaluation,follow-upandacrossservicesandproviders.Alsoclientcontinuumofcare.
Process standards
Standardswhichaddresstheinterrelatedprocessesofdifferentorganisationalandclinicalfunctionsandactivities.
Quality improvement
Ongoingresponsetoqualityassessmentdataaboutaservice,inwaysthatimprovetheprocessesbywhichservicesareprovidedtoclients.Alsocontinuousqualityimprovement(CQI).
Regulation Isaformofexternalevaluationbywhichabody,whoisauthorisedbylaw,assessesanorganisationorapersonagainstpre-determinedrequirements.Thepre-determinedrequirementsarederivedfromlegislationandtherefore,theregulatormaytakeanumberofactionsintheeventofnon-compliance.
Risk mitigation Asystematicreductionintheextentofexposuretoariskand/orthelikelihoodandconsequencesofitsoccurrence.
Self-assessment Aprocessbywhichanorganisationevaluatesitsownperformanceagainstsetcriteriaorstandards,identifiesstrengthsandgaps,andplansactionsforimprovement.
Standardisation Processofdevelopingandimplementingtechnical,serviceorotherstandards;thatcanhelptomaximizecompatibility,interoperability,safety,repeatabilityorquality.
Structure standards
Standardswhichaddresstherelativelystablecharacteristicsofhealthcareproviders,theirstaff,toolsandresources,andphysicalandorganisationalsettings.
System Asetofinteractingorinterdependentprocessesforminganintegrated,wholefunctionoractivity.
Transparency Operatinginsuchawaythatitiseasyforotherstoseewhatactionsareperformed;aprinciplethatallowsthoseaffectedbyadministrativedecisions,businesstransactionsorcharitableworktoknownotonlythebasicfactsandfiguresbutalsothemechanismsandprocesses.Usuallyrequiresdocumentedpoliciesandprocedures.
Universal health coverage
Thegoalofallpeoplehavingaccesstoandobtaininghealthpromotion,preventive,curative,rehabilitativeandpalliativehealthservicestheyneed,ofsufficientqualitytobeeffective,withoutsufferingfinancialhardshiptoavailofthem.
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ISQua Accreditation International Accreditation Programme (IAP)
Guidance on Designing Healthcare External Evaluation Programmes including Accreditation
Introduction Thepurposeofthisdocumentistoguidecountries,agenciesandothergroupsintheprocessofsettingupnewhealthorsocialcareexternalevaluationorganisationsorprogrammes.ItisalsointendedasanaidforfundinganddevelopmentagenciessuchastheWorldBank,internationalaidandtechnicalcooperationagencies,WorldHealthOrganization,MinistriesofHealth,othergovernmentagencies,groupsandorganisationswhowanttoimprovethequalityandsafetyofhealthcareintheircountry,regionorspecialtyarea.ItrevisestheInternationalSocietyforQualityinHealthCare(ISQua)ToolkitforAccreditationPrograms,20041,andISQuaChecklistforDevelopmentofNewHealthcareAccreditationPrograms,20062.Thisdocumenthasextendeditsscopebeyondhealthcareaccreditationprogrammestoincludeotherexternalevaluationprogrammessuchascertificationandlicensingastheyapplytoorganisations,notindividualpractitioners.Theseprogrammeshavedifferentscopesandorganisationalcoveragebutarebasedonthesameprincipleofevaluatingandimprovingperformanceagainstadefinedsetofstandardsorcriteria,usingexternalevaluators,toimprovethesafetyandqualityofhealthservicesforthepublic.
Accreditationcanbedefinedasaself-assessmentandexternalpeerreviewprocessusedbyhealthandsocialcareorganisationstoaccuratelyassesstheirlevelofperformanceinrelationtoestablishedstandardsandtoimplementwaystocontinuouslyimprovethehealthorsocialcaresystem.Certificationisaprocessbywhichanauthorisedbody,eitheragovernmentalornon-governmentalorganisation,evaluatesandrecognisesanorganisationasmeetingpre-determinedrequirementsorcriteria.Licensingisaprocessbywhichagovernmentalauthoritygrantspermissionforahealthcareorganisationtooperate.Licensingregulationsaregenerallyestablishedtoensurethatanorganisationorindividualmeetsminimumstandardstoprotecthealthandsafety.Forthepurposeofthisdocumentwewillrefertoanaccreditationbodybutthisincludesanyexternalevaluationprogrammeastheprinciplesremainthesame.
Thedocumentrefersmainlytohealthcareorganisationsbutisalsoapplicabletosocialcareorganisations.Init,thetermexternalevaluationisusedtocoveraccreditation,certification,licensingandotherstandardsbasedassessmentprogrammes.Thetermsurveyisusedtorefertosurvey,assessmentandaudit.Thetermsurveyorisusedtoincludesurveyors,assessorsandauditors.
Researchandexperiencehaveidentifiedthebenefitsofexternalevaluationprogrammessuchasimprovedorganisationalefficiencyandeffectiveness,improvedsafetyandquality,betterriskmitigation,improvedleadership,reducedliabilitycosts,bettercommunicationandteamwork,increasedsatisfactionofusersandstaff,andbetterpatientcare.However,therearechallengesinsettinguptheseprogrammes.Theprincipalthreatstonewexternalevaluationprogrammesappeartobeinconsistencyofgovernmentpolicy,unstablepolitics,unrealisticexpectationsandlackofprofessional/stakeholdersupport,continuingfinanceand/orincentives.Theeffectivenessandsustainabilityofanexternalevaluationorganisationorprogrammedependsultimatelyonmanyvariablefactorsintheparticularhealthcareenvironmentofthecountryororganisationinvolved.Italsodependsonthekindofprogrammeconcerned,andhowitisimplemented.
Tobesustainable,externalevaluationprogrammesneedongoinggovernmentand/orprivatesupport,asufficientlylargehealthcaremarketsize,stableprogrammefunding,diverseincentivestoencourageparticipation,andcontinualrefinementandimprovementintheexternalevaluationorganisation’soperationsandservicedelivery.
Thisguideaddressesthevariablesofpolicy,organisation,methodsandresources.Itoutlinesthereasonswhyanexternalevaluationprogrammemightbedeveloped,describesthedifferentmodels,andhighlightsthebenefitsandchallengesassociatedwithexternalevaluation.
International Accreditation Programme (IAP) ISQua Accreditation
Guidance on Designing Healthcare External Evaluation Programmes including Accreditation 3
Itthenprovidesguidanceonthestepsthatneedtobetakeninestablishinganewexternalevaluationorganisationincluding:
Establishingthefundamentalsofscopeandpurpose,anddefiningtheimportantrolesofgovernmentandincentivesintheexternalevaluationorganisation/programme.
Settingupoftheexternalevaluationorganisationalstructureincluding:establishinganadvisorycommittee;developingrelationshipswithstakeholders;designingagovernanceframework;embeddingthevaluesoffairnessandtransparency;andgettingoutsideassistanceandfunding.
Establishinggovernanceandmanagementsystemsincluding:staffing;financialandinformationsystems;andriskmanagementandperformanceimprovementsystems.Italsohighlightstheimportanceofallowingenoughtimeforthesestages.
Developingthestandardstobeusedbytheorganisationandthesystemformeasuringtheirachievement.
Developingthesurveyorandsurveymanagementsystemsincluding:theselectionandtrainingofsurveyors;thedesigningofprocessesandtechnologyformanagingsurveysandotherevents;developingandestablishingeducationservices;anddeterminingandestablishingtheprocessforawardingaccreditationorcertificationstatus.
Integratingintoallthesesystemsandprocesseswaysofmeasuringandevaluatingperformance.
ThisdocumentreflectsthebestpracticeguidelinesandstandardsdevelopedbytheInternationalSocietyforQualityinHealthCare(ISQua)aspartofitsInternationalAccreditationProgramme(IAP):ISQuaGuidelinesandStandardsforExternalEvaluationOrganisations,4thEditionVersion1.1,20143;ISQuaGuidelinesandPrinciplesfortheDevelopmentofHealthandSocialCareStandards,4thEditionVersion1.1,20144;andISQuaSurveyorTrainingStandardsProgramme,2ndEdition20095.
Theappendicesincludecasestudiesoutlininghowthreedifferenthealthcareexternalevaluationorganisationswereestablished.Twooftheorganisationsfeaturedareaccreditationorganisations.Thethirdfeaturedorganisationisanassessmentorganisationestablishedprimarilytoassessagainstgovernment-mandatedstandardsforcompulsorycertification.Appendix1ddescribesanAustralianPracticeIncentiveProgrammethatdemonstrateshowaccreditationcanbeusedasalevertoencouragequalityimprovement.
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ISQua Accreditation International Accreditation Programme (IAP)
Guidance on Designing Healthcare External Evaluation Programmes including Accreditation
Chapter 1: Why develop an external evaluation programme?Thischapterintroduceswhatahealthcareexternalevaluationprogrammeis;describessomeofthedifferentmodelsofexternalevaluation;outlinesthebenefitsofsuchprogrammes;andhighlightsthechallengeswhichmaybeencounteredinestablishingsuchprogrammes.
1.1 The growing demand for external evaluation in health and social care
Thereisgrowingworldwidedemand,concernandfocusonqualityandsafetyinhealthcare.UUniversalHealthCoverage(UHC)isnowakeyagendaitemfortheWorldBankandtheWorldHealthOrganizationandmanycountrieshaveadoptedorareabouttoadoptthissystemofequalhealthcareforall.Thegoalofuniversalhealthcoverageistoensurethatallpeopleobtainthehealthservicestheyneedwithoutsufferingfinancialhardshipwhenpayingforthem.Thisrequires:
Astrong,efficient,well-runhealthsystemwithgoodgovernance
Asystemforfinancinghealthservicesinanefficientandequitableway
Accesstoessentialmedicinesandtechnologiesandgoodhealthinformationsystems
Asufficientcapacityofwell-trained,motivatedhealthworkers6.
Thereisincreasingsupportfromgovernments,andfromfundingagencies,formechanisms,suchasaccreditation,tosupportUHC.GovernmentswillultimatelyberesponsibleforprovidingUHCandtheywillberequiredtodemonstrateefficientuseoflimitedpublicfundswhileprovidingsafequalityhealthcare.Externalevaluationprovidesassurancesthathealthcarefacilitieshavequalitysystemsinplaceandthedatatodemonstratetherequiredlevelofserviceprovision.Dependingonthecomprehensivenessofthestandardsagainstwhichhealthserviceperformanceisbeingmeasured,externalevaluationprogrammessuchasaccreditationandcertificationcancontributetoqualityimprovement,riskmitigation,patientsafety,improvedefficiencyandaccountability,andcancontributetothesustainabilityofthehealthcaresystem.Theycanprovideinformationonhowwellhealthservicesarebeingdelivered,identifyissues,andassistthedecision-makingoffunders,regulators,healthcareprofessionalsandthepublic.Externalevaluationsupportstransparency,benchmarkingandaccountability,sothatgovernmentfundingisallocatedinafairandequitablewayandsupportsacultureofchangeandqualityandanincreasedfocusonrisk.
Patientsexpecttoreceivesafecareandaredemandingqualityservicesthatmeettheirneeds.Theyexpecttobetreatedwithrespect,toreceiveservicesofanappropriateandconsistentstandardthataredeliveredwithcareandskill,thatminimiseriskandharm,complywithlegal,professionalandethicalstandards,andthatfacilitatecontinuityofcare.Patientsneedtoreceiveinformationabouttheirconditionandtreatmentinawaytheycanunderstand,tobeabletomakeinformedchoicesabouttheirtreatmentandtobecommunicatedwithopenlyandhonestly.Theywanttherighttocomplainifservicesdonotmeettheirneedsandexpectactiontobetakentoaddresstheproblem.
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Theyhavearighttotrustthattheirhealthproviderorhospitalhassystemsandprocessesinplacetoprovidesuchpatient-centred,reliable,efficient,effectiveandresponsivecare.Anexternalevaluationprogrammebasedonbestpracticestandardswillmakeasignificantcontributiontoachievingthis.
Withpreventableerrorratesestimatedtobe83%indevelopingandtransitionalcountriesanda30%rateofadverseeventsassociatedwithdeaths,thesecountriesrequirenotonlymoreresourcestoimprovethesafetyandqualityofcare,butapoliticalenvironment,policiesandmechanismsthatsupportqualityinitiatives.Thecontributionofexternalevaluationorganisationscentredonpromotingimprovements,applyingstandardsandprovidingfeedbackisbeingincreasinglyrecognisedinthesecountries.Preventableerrorratesofover10%indevelopedcountriesarealsounacceptable.Aflourishingaccreditationprogrammeisoneelementoftheinstitutionalbasisforhighqualityhealthcare7.
1.2 Models of external evaluation
External evaluation
Isaprocessbywhichanobjectiveindependentassessorgathersreliableandvalidinformationinasystematicmannerbymakingcomparisonstostandards,guidelinesorpathwaysforthepurposeofenablingmoreinformeddecisionsandforassessingifpre-determinedandpublishedrequirementssuchasgoals,objectivesorstandardshavebeenmet.Anorganisation,object,processorindividualmaybeassessedandevaluationmaybeundertakenbypeers,includingorganisationsandprofessionals,privateprofessionalauditorsorconsultants,purchasers/funders/insurers,consumers/patientsorgovernments.
Thedistinguishingfeaturesofexternalevaluationareasfollows:
Itisaformalprocess
Theobjectbeingassessedisanorganisation,object,processorindividualperson
Assessmentisundertakenbyanobjective,independentassessor
Assessmentisagainstpre-determinedandpublishedrequirements/criteria
Itisdesignedsothatdecisionsarenotinfluencedbythosebeingassessed
Theassessmentresultsinadefinedoutput
Thereareanumberofmodelsofexternalevaluationanditshouldbeacknowledgedthattherecanbeconfusionregardingterminologyduetothediverseapplicationsoftheexternalevaluationmodels.Examplesofexternalevaluationmodelsincludethefollowing:
Accreditation
Accreditationmaybedefinedasaself-assessmentandexternalpeerreviewprocessusedbyhealthandsocialcareorganisationstoaccuratelyassesstheirlevelofperformanceinrelationtoestablishedstandardsandtoimplementwaystocontinuouslyimprovethehealthorsocialcaresystem.Althoughprimarilyappliedinrelationtoorganisations,processesmayalsobeaccredited.Accreditationstandardsassesstheorganisation’sorprocess’sabilitytofulfilitscoremissionandmayaddressmorethanlegalrequirements.Theyareusuallyrecognisedasoptimal,evidence-basedandachievableandaredesignedtoencouragecontinuousimprovement8.Theoutputofaccreditationisareportsummarisingthefindingsoftheassessmentandarecognitiondecisionregardingtheaccreditationstatus.
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ISQua Accreditation International Accreditation Programme (IAP)
Guidance on Designing Healthcare External Evaluation Programmes including Accreditation
Accreditationisoneofthelongestestablishedmodelsofexternalevaluation.Itisaself-assessmentandexternalpeerreviewprocessthatassessestheentireorganisationincludingbothclinicalandmanagementprocessesandactivities.Traditionally,healthandsocialcareorganisationsengagedinaccreditationonavoluntarybasisandaccreditationschemeswereprovidedbynon-governmentalagencies.However,therehasbeenashiftovertimetowardsgreatergovernmentalinvolvementinaccreditationwiththedevelopmentofnationalgovernmentfundedaccreditationprogrammesandashiftfromvoluntarytomandatoryparticipationinsuchschemes.Forexample,in2011theAustralianHealthMinistersendorsedtheNationalSafetyandQualityHealthService(NSQHS)Standardsandanationalaccreditationscheme.Asaresult,allhospitalsanddayprocedureservicesandthemajorityofpublicdentalservicesacrossAustralianowneedtobeaccreditedtotheNSQHSStandards.PrivatehealthserviceorganisationsarerequiredtoconfirmtheirrequirementsforaccreditationtoanystandardsinadditiontotheNSQHSStandardswiththerelevanthealthdepartment.Priorto2011,participationinaccreditationwasvoluntaryforAustralianhospitals9.
Certification
Certificationisaprocessbywhichanauthorisedbody,eitheragovernmentalornon-governmentalorganisation,evaluatesandrecogniseseitheranindividual,organisation,objectorprocessasmeetingpre-determinedrequirementsorcriteria.Thepre-determinedrequirementsaresetoutinstandardswhicharedevelopedspecificallyforthepurposeofassessment.Thestandardsassesstheperformanceoftheorganisation,object,processorperson,mayfocusonspecificaspectsofperformanceandmayaddressmorethanlegalrequirements.Theoutputofcertificationisareportsummarisingthefindingsoftheassessmentandarecognitiondecisionregardingthecertificationstatus.
Certificationmaybeusedbygovernmentsorotherauthorisedagenciestoassessthecomplianceofhealthcarefacilitiesorspecificdepartments/serviceswithinthosefacilitieswithasetofstandards.Thefocusisusuallyonessentialelementsbeinginplaceratherthanoncontinuousqualityimprovement.Thestandardsandcertificationmaynotbeorganisation-wide,butmayapplytoaparticularservice,e.g.physiotherapy.Governmentsmayauthoriseindependentassessmentorganisationstoassesshealthandsocialcareproviders’compliancewithgovernment-mandatedstandards.
AnexampleofacertificationschemeisISO:theInternationalOrganizationforStandardization.ISOprovidesstandards,e.g.ISO9000QualityManagement,againstwhichorganisationsorfunctionsmaybecertifiedbyISOaccreditedcertificationbodiesororganisations10.Althoughoriginallydesignedforthemanufacturingindustry,e.g.medicaldevices,thesehavebeenprimarilyappliedtoradiologyandlaboratorysystemsinhealthcare,andmoregenerallytoqualitysystemsinhospitalsandclinicaldepartments.ConformancewithISOstandardsisassessedbyprofessionalqualityauditorsandanynon-conformanceisfollowedupwithasubsequentaudit.
Whenappliedtoindividuals,certificationusuallyimpliesthattheindividualhasreceivedadditionaleducationandtraining,anddemonstratedcompetenceinaspecialtyareabeyondtheminimumrequirementssetforregistrationorlicensing.Forexample,adoctormaybecertifiedbyaprofessionalspecialtyboardinthepracticeofobstetrics8.
Therecanbeconfusionbetweenthetermsaccreditationandcertificationandtheyareoftenusedinterchangeably.However,accreditationusuallyappliesonlytoorganisations,whilecertificationmayapplytoindividuals,aswellasorganisations.
International Accreditation Programme (IAP) ISQua Accreditation
Guidance on Designing Healthcare External Evaluation Programmes including Accreditation 7
Regulation
Regulationisaformofexternalevaluationbywhichabody,authorisedbylaw,assessesanorganisationorapersonagainstpre-determinedrequirements.Thepre-determinedrequirementsarederivedfromlegislationandtherefore,theregulatormaytakeanumberofactionsintheeventofnon-compliance.
Licensing
Licensingisaprocessbywhichagovernmentalauthoritygrantspermissiontoanindividualpractitionerorhealthorsocialcareorganisationtooperateorengageinanoccupationorprofession.Licensingregulationsaregenerallyestablishedtoensurethatanorganisationorindividualmeetsminimumstandardstoprotectpublichealthandsafety.
Theoutputoflicensingistheawardingofadocumentorlicenceallowinganorganisationorpersontoprovideaservicewithinaspecifiedscope.
Organisationallicensingorregistrationisgrantedfollowinganon-siteinspectiontodetermineifminimumhealthandsafetystandardshavebeenmet.Maintenanceofregistrationorlicensureisanongoingrequirementforthehealthorsocialcareorganisationtocontinuetooperateandcareforpatientsorclients.
Individualorprofessionallicensingorregistrationisusuallygrantedaftersomeformofexaminationorproofofeducationandmayberenewedperiodicallythroughpaymentofafeeand/orproofofcontinuingeducationorprofessionalcompetence8.
Countriesmayhavemorethanonemodelofexternalevaluationinoperationinspecificsectors.Forexample,hospitalsmayberequiredtobelicensedandmeetspecificgovernment-mandatedstandardsinordertobeabletoprovidehealthservicesinaparticularcountry,butmaystillengagevoluntarilyinorganisationalaccreditationorcertificationprogrammesforspecificdepartmentsinthefacilitye.g.laboratorycertificationprogrammes.Individualhealthcarepractitionersmayneedtoberegisteredwiththeirprofessionalbodyinordertobeemployedinahospitalbuttheymayalsovoluntarilyundergoadditionaleducationinordertobecertifiedinarespectivefieldbyaprofessionalspecialtyboard.
Thekeycharacteristicsofaccreditation,licensingandcertificationaresetoutinTable1.
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ISQua Accreditation International Accreditation Programme (IAP)
Guidance on Designing Healthcare External Evaluation Programmes including Accreditation
Table 1: Definitions of accreditation, certification and licensing
Process Participation Issuing organisation
Object of evaluation
Components / Requirements
Standards
Accreditation Voluntaryormandatory
Non-governmentalorganisation(NGO)orgovernmentauthority
Organisation Compliancewithpublishedstandards,on-siteevaluation;compliancemaynotberequiredbylawand/orrequlations
Setatamaximumleveltostimulateimprovementovertime
Certification Voluntaryormandatory
Authorisedbody,eithergovernmentorNGO
Individual Evaluationofpre-determinedrequirements,additionaleducation/training,demonstratedcompetenceinspecialityarea
Setbynationalprofessionalorspecialityboards
Organisationorcomponent
Demonstrationthattheorganisationhasadditionalservices,technologyorcapacity
Industrystandards(e.g.ISO9000standards)evaluateconformancetodesignspecifications
Licensing Mandatory Governmentalauthority
Individual Regulationstoensureminimumstandards,exam,orproofofeducation/competence
SetataminimumleveltoensureanenvironmentwithminimumrisktohealthandsafetyOrganisation Regulationsto
ensureminimumstandards,on-siteinspection
1.3 Benefits of external evaluation
Externalevaluationhascontributedtoimprovingthequalityandsafetyofhealthcarefornearly100yearsandthemajorityofthepublishedliteraturerelatestoaccreditation.Researchonthebenefitsofcertification,regulationandlicensingissparse.Itmustbeacknowledgedthathistoricallytherehasbeenlimitedevidenceoftheimpactofaccreditationbutinrecentyearsmoreempiricalresearchhasbeenundertakentoidentifyandquantifythebenefits.
Someofthespecificbenefitsofaccreditationidentifiedintheliteratureincludeimpactsonstructuralelementsofqualityimprovementinhealthcareorganisationssuchasleadership,governanceandmanagement,andprocesselementssuchasorganisationalperformance11.
International Accreditation Programme (IAP) ISQua Accreditation
Guidance on Designing Healthcare External Evaluation Programmes including Accreditation 9
Fromaleadership,governanceandmanagementperspective,accreditationisperceivedas:providingaframeworkforhelpingtocreateandimplementsystemsandprocessesthatimproveoperationaleffectivenessandadvancepositivehealthoutcomes;providingorganisationswithawell-definedvisionforsustainablequalityimprovementinitiatives;andasameansofdemonstratingcredibilityandacommitmenttoqualityandaccountability.
Fromanorganisationalperformanceperspective,someoftheidentifiedbenefitsinclude:
Increaseshealthcareorganisations’compliancewithqualityandsafetystandards
Stimulatessustainablequalityimprovementeffortsandcontinuouslyraisesthebarwithregardtoqualityimprovementinitiatives,policiesandprocesses
Decreasesvariancesinpracticeamonghealthcareprovidersanddecision-makers
Highlightspracticesthatareworkingwell.Promotesthesharingofpolicies,proceduresandbestpracticesamonghealthcareorganisations11.
Accreditationhasalsobeenperceivedashavinganimpactonteamworkingbystrengtheninginterdisciplinaryteameffectivenessandpromotingcapacitybuilding,professionaldevelopmentandorganisationallearning11.
Similarly,arecentsynthesisof122empiricalstudiesthatexaminedeithertheprocessesorimpactsofaccreditationprogrammesconcludedthatresearchevidencegenerallypresentshealthserviceaccreditationasausefultooltostimulateimprovementinhealthserviceorganisationsandtopromotehighqualityorganisationprocesses.Someofthecitedstudiesfoundthataccreditationpromotesstandardisationofcareprocesses;increasedcompliancewithexternalprogrammesorguidelines;developmentoforganisationalculturesconducivetoqualityandsafety;implementationofcontinuousqualityimprovement(CQI)activities;andsuperiorleadership.Therewaslimitedevidenceshowingpositiveassociationsbetweenaccreditationandpatientoutcomemeasures.However,thiswasattributedtopoorresearchdesign12.
Acomparisonofaccreditationinlow-andmiddle-incomecountriesversushigher-incomecountriesshowedallprogrammespromoteimprovements,applystandardsandprovidefeedback.Accreditationprogrammesarecontributingtoincrementalimprovementsinqualitysystemsandclinicalprocessesinhealthsystemsaroundtheworldandareoneelementoftheinstitutionalbasisforhigh-qualityhealthcare7.
Arecentreviewexaminingtheuseofeconomicevaluationtechniquesinhealthservicesaccreditationresearchidentifiedthatnoformaleconomicevaluationofhealthservicesaccreditationhasbeencarriedouttodate.Italsohighlightedthattheimpactoreffectivenessofaccreditationhasbeenresearchedwithavarietyoffociandtodifferingdegrees.Theresearchdesignofsomestudies,particularlythosethatareobservationalorqualitativeinnature,makesitdifficulttoprovidestatisticallyrobustevidencefortheefficacyofaccreditationorcausality.Thelackofaclearrelationshipbetweenaccreditationandtheoutcomesmeasuredinbenefitstudiesmakesitdifficulttodesignandconducteconomicappraisalstudieswhereamorerobustunderstandingofthecostsandbenefitsinvolvedisrequired.Inturn,theabsenceofformaleconomicappraisalmeansitischallengingtoappraiseaccreditationincomparisontoothermethodstoimprovepatientsafetyandqualityofcare13.
Whiletheevidenceforthedirectimpactofaccreditationonpatient/clientoutcomesisinconclusive,theavailableresearchsuggeststhataccreditationmaycontributetoimprovinghealthoutcomesbystrengtheninginterdisciplinaryteameffectivenessandcommunicationandbyenhancingtheuseofindicatorsforevidence-baseddecisionmaking14.Thechallengeformatureexternalevaluationsystemsistobecomemoreoutcomedriven.Thisreducestheburdenofauditbutalsohelpstohighlightitsbenefits.
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ISQua Accreditation International Accreditation Programme (IAP)
Guidance on Designing Healthcare External Evaluation Programmes including Accreditation
1.4 Challenges for external evaluation programmes
Theprincipalthreatstonewexternalevaluationprogrammesinclude:inconsistencyofgovernmentpolicy;unstablepolitics;unrealisticexpectations;andlackofprofessional/stakeholdersupport,continuingfinanceand/orincentives.Tobesustainable,externalevaluationprogrammesneedanumberofelementstobeinplace,includingsomeofthefollowing:ongoinggovernmentand/orprivatesupport;asufficientlylargehealthorsocialcaremarketsize;stableprogrammefunding;diverseincentivestoencourageparticipation;andcontinualrefinementandimprovementintheexternalevaluationorganisation’soperationsandservicedelivery15(referChapter2).
Tobesustainableandcredible,newprogrammesneedsufficientnumbersoftrainedandskilledpersonnelandarealistictimeframeforthedevelopmentoftheprogramme.Theyneedtodemonstrateobjectivityandindependencewithtransparentproceduresfortheassessmentofhealthcareservicesandfordecisionsonaccreditationorcertificationawards.Theexpectationsofgovernmentsandstakeholdersaboutwhattheexternalevaluationprogrammecanachieveneedtoberealistic,inlinewiththepurposeandscopeforwhichithasbeendesignedandresourced,andinlinewiththegovernment’sbroaderstrategyorpolicyforhealthcarequalityandsafety.Withinthatstrategyorpolicythereneedstobeabalancebetweentheobjectivesofexternalcontrolorregulationandinternalorganisationaldevelopmentorimprovement.Attemptstoprescribeandcontroleveryprocessofacomplexsystemlikeahealthcareorganisationorservice,whichcannotbeunderstoodassimplyasumofanumberofdiscreteandpredictableprocesses,willevokeresistancefromstaff,andcanbecounterproductiveintermsofqualityandsafety.Healthandsocialcarestaffneedtobemotivatedandcommittedtoimprovingqualityratherthandirectedandsanctioned.
Expectationsofaccreditedorcertifiedhealthorsocialcareservicescanbeunrealisticallyhigh.Theexternalassessmentoforganisationsforthepurposesofaccreditationorcertificationisbasedonanon-sitesurveyorassessmentofcompliancewith,orachievementof,standards.Thisisasnapshotintimeanddoesnotguarantee,norisitmeanttoguarantee,ongoingperformanceatthesamelevel.However,externalevaluationorganisationswhothemselvesengageinanexternalevaluationprocess,suchasISQua’sInternationalAccreditationProgramme(IAP)areexpected,aspartofthisprocesstomonitorthecontinuedmaintenanceofstandardsandqualityimprovementsbytheorganisationstheyhaveaccreditedorcertified,e.g.submissionofactionplansandreportsoftheirimplementation,periodicself-assessmentorexternalreviews,randomreviews,follow-upofsignificantcomplaintsorsentinelevents.
Giventheamountofeffortandmoneyinvestedworldwideinexternalevaluationandregulationofhealthcaredelivery,andthecommonpursuitofvalidstandardsandreliablemeasurement,thereareeconomicandtechnicalreasonstoshareresearchandexperiencemoreactivelyintheinternationalcommunity.
AstudycomparingEuropeanhospitalsintermsofqualityandsafetywasfoundtobechallengingbecauseofthedifferenthospitalaccreditationandlicensingsystemsineachcountry;thedifferentindicatorscollected;differentdefinitionsofthesameindicators;differentmandatoryversusvoluntarydatacollectionrequirements;differenttypesoforganisationsoverseeingdatacollection;differentlevelsofaggregationofdata(country,region,hospital);anddifferentlevelsofpublicaccesstosuchdata.
International Accreditation Programme (IAP) ISQua Accreditation
Guidance on Designing Healthcare External Evaluation Programmes including Accreditation 11
Thismeansthatpatientsareunabletomakeinformedchoicesaboutwheretheyreceivetheirhealthcareindifferentcountriesandsomegovernmentswillremaininthedarkaboutthequalityandsafetyofcareavailabletotheircitizensascomparedtothatavailableinneighbouringcountries16.
Ongoingresearchisneededintothebenefitsandlimitationsofexternalevaluationinhealthcare.Tomeasuretheimpactofanynewprogramme,beforeandaftermeasurementsareneededoftheindicatorsthattheprogrammeisintendedtoaddress.
Thischapterhasintroduceddifferentexternalevaluationmodelsandhasoutlinedthebenefitsofexternalevaluationandthechallengesassociatedwithestablishinganewprogramme.Thefollowingchapterswillpresentthefactorsthatneedtobeconsideredwhendecidingwhichexternalevaluationmodeltoadoptinacountryandthestepstobeundertakenwhensettingupanexternalevaluationorganisationandprogramme.
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ISQua Accreditation International Accreditation Programme (IAP)
Guidance on Designing Healthcare External Evaluation Programmes including Accreditation
Chapter 2: Establishing the FundamentalsThischapteroutlinestheinitialdecisionsthatneedtobemadewhenanewexternalevaluationprogrammeisbeingestablished:thepurposeoftheprogramme;itsscope;theroleofgovernment;andtheincentivesthatmaybeneededtoensurehealthandsocialcareorganisationsparticipate.Italsohighlightstheimportanceofidentifyingwhothemainstakeholdersmaybeandwhatexternalinfluencesfortheprogrammewilllooklike.
2.1 Defining the purpose of the external evaluation programme
Oneofthefirststepsinthedevelopmentofanewexternalevaluationprogrammeistodetermineitspurpose.
Factorstoconsiderindeterminingthepurposeofanexternalevaluationprogrammeororganisationincludethefollowing:
Developmental or regulatory
AccordingtotheWorldBank17,governmentsregulatehealthservicesinordertoguideprivateactivityandachievenationalhealthobjectives.Regulationcanbeusedforcontrol,withinstrumentsthatusetheforceoflawtoensurethatservicesprovidedadheretolegalrequirements.Instrumentsthataimtocontrolinclude:licensing,restrictionsondangerousclinicalpracticeandregistration.Examplesinclude:basiclegislationonhealthpersonnelsuchasregistrationandlicensingrequirements,whichcanalsobeusedtosetminimumrequirementsforhealthservicesorfacilitiestooperate.Regulationcanalsousefinancialornon-financialincentivesthatchangethebehaviourofprivatehealthcareproviders.Theadvantagesofusingincentive-basedregulationisthatitavoidstheinformational,administrativeandpoliticalconstraintsthatcontrol-basedinterventionsentail.Accreditation,certificationandcontractsareexamplesofincentive-basedregulation.However,indevelopingcountries,regulationisoftenineffectivebecauseofthelowlevelofenforcementandinsufficientresources.
Standards-based external evaluation
Standards-basedaccreditationisaprogrammethatcontributestodevelopinganorganisation,andisdesignedtoimprovethequalityaswellasthesafetyofhealthservices.
Accreditationprogrammesmonitorandpromote,viaselfandexternalassessment,healthcareorganisationperformanceagainstpre-determinedoptimalstandards18.Theyalsoaimtocontributetotheprovisionofhighqualityandsafehealthcareservicesandtoimprovepatienthealthoutcomes.
Certificationmaybesimilarlystandards-basedandusearatingsystemthatencouragesimprovementovertimebutitsfocusisusuallymoreoncontinuingcompliancewithcriteriaandthestandardsmaybemorelimited.Licensingmaybeusedwhenthepriorityisensuringbasichealthandsafetyrequirementsaremetinorderforahealthcareorganisationtooperateandwillusuallybefacilityfocused.
International Accreditation Programme (IAP) ISQua Accreditation
Guidance on Designing Healthcare External Evaluation Programmes including Accreditation 13
Values and objectives underpinning a new programme
Asurveyofhealthcareaccreditationorganisationsrevealedthatqualityimprovementwasthereasonhealthcareorganisationsparticipatedinaccreditation.Ontheotherhand,thegovernmentagendacommonlyfocusedmoreontheprotectionofpublicmoneyandpublichealthasapriority,meaningreducingvariationinpracticetoincreaseefficiencyandimprovepatientsafety,consistentwithWHOglobalinitiatives15.
Valuesorprinciplesmayrelatetofeaturessuchasleadership,asystemandprocessapproach,multidisciplinaryteamwork,capacitybuildingandtraining,patientcentredness,devolveddecision-makingandaccountability,evidence-baseddecisionsforcontinuousimprovementandperformance-basedincentives.
Objectivesofexternalevaluationprogrammesidentifiedinsomedevelopingcountrieshaveincluded:improvingleadershipofaqualityhealthsystem;improvingresourcesandcapacityofthesystemandstaff;improvingperformancebyclearlydefiningtherolesandresponsibilitiesofstaffatalllevels;developingthestructures,systemsandcapacitytosupportqualityimprovement;strengtheningthefocusandroleofhealthserviceconsumersandotherstakeholders;andimprovinghealthservicesthroughsystematicimplementationofstandards.
Thefollowingtablecomparescapacitybuildingandregulatoryexternalevaluationapproaches15.
Table 2: Comparison of capacity building and regulatory external evaluation
Capacity building Regulatory
Purpose Dynamic,organisationalimprovement
Static,control
Terminology Accreditation,certification Licensing,regulation
Governance Non-governmentalorganisation,stakeholders
National/regionalgovernmentagency
PrimaryCustomers Healthcareproviders Government
Secondarycustomers Patients,professions,healthcareinsurers
Population,politicians,publicfinance
Incentivesforhealthcareorganisationstoparticipate
Ethical,commercial Legal,mandatory
Uptake Voluntaryself-selectiontoavailableprograms
Allinstitutionsinallsectors
Standards Definedbynon-governmentalorganisation,optimal,achievable,encouragequalityimprovement
Definedbyregulation,minimalacceptable
Funding Self-financing State
Cross-bordermobility Limitedbylanguage,culture Limitedbypoliticalborders
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ISQua Accreditation International Accreditation Programme (IAP)
Guidance on Designing Healthcare External Evaluation Programmes including Accreditation
Possiblepurposesorobjectivesofanexternalevaluationprogrammemightbeto:
Improvetheperformanceofhealthservicesbysettingandmeasuringtheachievementofstandards
Increasepublicsafetyandreducerisksassociatedwithinjuryandinfectionsforpatients/clientsandstaff
Increasepublicconfidenceinthequalityofhealthcareservices
Promoteaccountabilityofhealthservicestofundersandthepublic.
How do these values and objectives relate to plans for health reform in general, and to the national quality strategy in particular?
Thenextimportantstepistoidentifyifthereareplansforhealthand/orsocialcarereforminthecountryorregionandifthereareanynationalorregionalqualitystrategiesorplansinplace.Reformplansoutlinethechangesthatagovernmentintendstomaketoaparticularsectorandoutlinesthespecificactionsthatitwilltaketoachievethosereforms.Forexample,agovernmentmayoutlineinareformplanthatitintendstoestablishanexternalevaluationorganisationandwhattheroleorpurposeofthisorganisationwillbe.Aqualitystrategyprovidesanagreeddirectionandidentifiesthemostimportantactivitiesforimprovingqualityinthehealthandsocialcaresectorinthecountryorregion.Ithelpstoidentifythestrengthsofthesystemandalsotheconstraintsthatpreventtheprovisionofaqualityservice.Aqualitystrategymayoutlinetheroleorwillhelptoidentifyorclarifytherolethatexternalevaluationisexpectedtoplayinachievingthecountryorregion’squalityvision.
Thesefactorswillguideallfurtherdecisions-theroleofthegovernment,relationshipswithstakeholders,thegovernanceandmanagementframework,thestandardsorcriteriatobeusedforassessment,theassessmentprocess,andtheoutcomeoflicensing,certificationoraccreditation.
Thecasestudyexamplesbelowprovidefurtherinsightintothefactorsthatinfluencedtheestablishmentofexternalevaluationagenciesindifferentjurisdictions.
International Accreditation Programme (IAP) ISQua Accreditation
Guidance on Designing Healthcare External Evaluation Programmes including Accreditation 15
Case Studies – Foundation of the programme
IKAS – Danish Institute for Quality and Accreditation in Healthcare Country: DenmarkTheDanishaccreditationprogramme(DDKM)wasestablishedaspartofthe“NationalStrategyforQualityDevelopmentintheHealthcareSystem–JointGoalsandActionPlan2002-2006”.Thestrategywasdevelopedbythenational,regionalandlocalpoliticalauthoritiesincooperationwithstakeholderorganisations,representingprofessionalsandconsumers.
Atthattime,anumberofhospitalsalreadyhadpositiveexperienceswithaccreditationprovidedbyinternationalaccreditors–oneoftheintentionsofthestrategywastospreadthistotheentirehealthcaresystem,basedonaDanishmodel.
Health Care Accreditation Council (HCAC) Country: JordanTheHCACisthenationalhealthcareaccreditationagencyofJordan.Severalreasonswerestatedforwhytheprogrammewasdevelopedincludingtoimprovethequalityofhospitalsandtoenhancemedicaltourism.Inaddition,itwasaresponsetopubliccomplaintsofpoorqualityofcareandaneedtoimprovetheentirehealthcaresysteminthecountry.
Health and Disability Auditing New Zealand Ltd (HDANZ) Country: New ZealandThecommencementoftheHealthandDisabilityServices(Safety)Acton1July2002representedasignificantchangeintheregulatoryenvironmentintheNewZealandhealthanddisabilitysector.ThisActreplacedseveralpreviouspiecesoflegislationandchangedthewayinwhichresidentialandhospitalserviceswerelicensedorregistered.Inaddition,theActintroducedhealthanddisabilitystandardsforhospitals,resthomesandresidentialdisabilityservicesaimedatimprovingsafetylevelsandqualityofcarethatbecamemandatoryfrom1October2004.TheActrequiredthatdesignatedauditagencies(DAAs)areapprovedbytheDirectorGeneralofHealthforthepurposeofauditingtheseservicestothosestandards.
2.2 Defining the scope of the external evaluation programme
Oncethepurposeisestablisheditisimportanttodefinetheinitialscopeoftheprogramme.Thepurposeofanewexternalevaluationprogrammemaydependonthegovernment’spriorities,thenationalhealthreformorqualitystrategies,availablefunding,thecommitmentofstakeholdersandtheproblemsorissuesthatneedtobeaddressed.
Factorstoconsiderindefiningthescopeoftheexternalevaluationprogrammeincludethefollowing:
Primary or hospital care?
Traditionally,accreditationhasbeendevelopedforhospitalsoragedcarefacilitiesandthenmovedoutwardstowardshomesupport,hospiceandothercommunityservicesandthentoregionalnetworksornetworksofpreventiveandcurativeservices.
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ISQua Accreditation International Accreditation Programme (IAP)
Guidance on Designing Healthcare External Evaluation Programmes including Accreditation
However,indevelopingcountriesthemosturgentneedmaybeforimprovedprimaryandcommunitycareandtheprogrammewillinitiallybedevelopedtocoverprimarycareclinicsandoutreachservices,althoughtheremaybesomeresourceadvantagesindevelopingprimarycareandhospitalprogrammesatthesametime.
Oftenitiseasiertodevelopfacilitiesbasedprogrammesfirst,startingwithcorestandardsandexternalevaluationforsingleinstitutions,e.g.acutehospitals,polyclinicsorhealthcentres.Standardscanthenbedevelopedformorespecialisedservices,e.g.resthomesorhospicecareormentalhealth,followedbythelinkagesbetweenthem,preventivehealthorhealthnetworks,andtheycanthenbecoveredbytheprogramme.Assessmentofsingleunits,servicesordepartmentscouldofferlargeorganisationsagradualentrytoafullprogrammebutitdoesnotcarrythebenefitsofintegrationandorganisationconsistency.Itmayhidetheopportunitiesforimprovementwhichfrequentlylieincommunicationbetweenservicesratherthanwithinthem.However,therearemanyservicespecificexternalevaluationprogrammeswhichareoperatedeitherbyalargergenericprogramme,orbyaproviderorassociationwhichworksonlyinthatarea,e.g.palliativecare,laboratorymedicine,speechtherapy,autism,generalpractice,agedcare,andcommunityservices.
Someprogrammeshavestartedwithtertiaryhospitalsandservices,withtheintentionofexpandingtosecondarycareserviceslater.SomeprogrammesinNorthAmerica(e.g.AccreditationCanada)accreditentirehealthnetworksandregionsandareapplyingaccreditationacrossthecontinuumofcare.SomegovernmentalprogrammesinEuropeaddresspublichealthpriorities(suchascardiachealth,cancerservices)byassessinglocalperformanceofpreventivetotertiaryservicesagainstnationalserviceframeworks.Insuchprogrammes,measuresmayincludetheapplicationofevidence-basedmedicine(process)andthemeasurementofpopulationhealthgain(outcome)butmanyhealthdeterminants,e.g.housing,educationandpoverty,remainoutsidethescopeofhealthcareexternalevaluationprogrammes.
However,currentbestpracticeistoprovideaprogrammethatfocusesonthepatientorclientandtheirjourneythroughtheservice,hospital,networkorcareprogrammeandthecontinuityofserviceorcareforthatindividualorfamilyacrosstheentirecontinuumofcare.
Historically,externalevaluationprogrammeshavesettheirscopeinawaywhichcompartmentalisescareandserviceratherthanoptimisingqualityoutcomesforthepatientorclient.
Public or Private coverage?
Mostexternalevaluationprogrammesofferservicestobothpublicandprivatesectorservices,althoughsomearerestrictedtoeitherthepublicorprivatesector.Evaluatingacrosssectorshasadvantagestohealthcareorganisationsinfacilitatingthefocusonthepatientorclientjourney,providingalevelplayingfieldforcomparingandbenchmarkingpotentialcompetitors,tosurveyorsinlearningfromanothersectorandtoself-financingprogrammesinhavingalargerpotentialmarket.Sometimeseithertheprivateorpublicsectorhasthesize,resourcesandincentivessuchasfundingincentives,medicalinsuranceandcompetitiveadvantagetoadoptanexternalevaluationprogrammeearlier.Medicaltourismisanotherlargeincentive.Toattractpatientswhoarecrossingnationalbordersinsearchofaffordableandtimelyhealthcare,privateandpublichealthservicesneedaccreditationorcertificationtodemonstratetheircompetenceandsafety.
International Accreditation Programme (IAP) ISQua Accreditation
Guidance on Designing Healthcare External Evaluation Programmes including Accreditation 17
Manymedicaltourismcompaniesarenowinvolvedinorganisingcross-borderhealthservicesandithasbeenrecommendedthatthecaretheyarrangeshouldonlybeataccreditedinternationalhealthfacilities.Otherrecommendationsincludethemedicaltourismcompaniesthemselveshavingtoundergoanaccreditationreview;standardstoensurepatientsmakeinformedchoices;andcontinuityofcareasanintegralfeatureofcross-bordercare19.
Thecasestudiesprovidesomefurtherinsightsintohowthescopeofexternalevaluationagenciesindifferentjurisdictionswasdetermined.
Case Studies – Scope of the programme
IKAS – Danish Institute for Quality and Accreditation in Healthcare Country: DenmarkPublicandprivatehospitals,pharmacies,municipalities(primarycareservices,includinglong-termcare),ambulanceprovidersandGeneralPractitioners(GPs)allparticipateinDDKM.
Health Care Accreditation Council (HCAC) Country: JordanTheHCACisthenationalhealthcareaccreditationagencyofJordan.Theorganisationsetsstandardsforhospitals,primaryhealthcarecentres,familyplanningandreproductivehealth,transportservices(ambulances),cardiaccare,anddiabetesmellitus.HCACsurveysagainstthestandardsandawardsaccreditation.HCACalsoprovidesconsultationandeducationtopreparehealthcarefacilitiesforaccreditationandofferscertificationcourses.
Health and Disability Auditing New Zealand Ltd (HDANZ) Country: New ZealandThecommencementoftheHealthandDisabilityServices(Safety)Acton1July2002representedasignificantchangeintheregulatoryenvironmentintheNewZealandhealthanddisabilitysector.ThisActreplacedseveralpreviouspiecesoflegislationandchangedthewayinwhichresidentialandhospitalserviceswerelicensedorregistered.HDANZ’sscopewasdeterminedbytheSafetyAct–theassessmentofstandardsisalegalrequirementforpublicandprivatehospitals,resthomesandresidentialdisabilityservices.StandardsNewZealand(SNZ)isresponsiblefortheNewZealandstandardsandthisincludesotherssuchasforhomesupport,alliedhealth,anddaysurgeryprocedures.
Critical mass: economy, consistency, equity, objectivity
Largercountriescanachieveeconomiesofscale;smallercountries(perhapswithapopulationoflessthan5million),orlargeoneswhichchoosetodevolvetheprocesstoregionalgovernment,e.g.Italy,orethnicgroups,e.g.Aboriginal,havetosharetheconsiderablecostsofinfrastructureanddevelopmentamongasmallernumberofhealthcareorganisations(givinghigherunitcosts).Ifthesurveyorworkforceisvoluntary,thismayalsomeanhavingasmallerchoiceofsurveyors(givingmorepotentialforconflictofinterest).However,thereareoptionssuchascontractingoremployingasmallerpaidsurveyorworkforceorcontractingsurveyorsfromothercountriesforsurveys.
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ISQua Accreditation International Accreditation Programme (IAP)
Guidance on Designing Healthcare External Evaluation Programmes including Accreditation
Otheroptionsforenhancingtheopportunitiesforsmallerprogrammesinclude:
Sharingaprogrammewithaneighbouringregionorstatewhichhassimilarcultureandlanguage
Designingonenationalprogramme,ratherthanseveralregionalones
Providingnationalstandards,guidelinesortoolsforregionalagenciesordesignatedassessmentorganisations
Usingasingleorganisationtoprovidemultipleaccreditationprogrammes
Usingthesameorganisationoragencyasacentreforresearchanddevelopmentofotherqualitymethods,e.g.performanceindicators,clinicalguidelines,patientsurveys,technologicalassessment
Obtainingaccreditationservicesfromanotherregionorstate.
2.3 Establishing the role of government
Thedevelopmentofanexternalevaluationprogrammemaybepartofbroaderhealthreforms,orpartofanoverallgovernmentalstrategyforqualityimprovementandatransitionfromacentralisedsystemtoonewhichismoreopenandindependent.Itmaybenecessaryforthehealthministrytore-defineitsowndutiesandresponsibilitiesinthecontextofareformedorganisationalstructureofthehealthsystem.
Therelationshipsbetweendepartmentsofgovernmentwhichhaveamajorimpactonqualitymaybeunclear.Therolesofagenciesresponsibleforsuchareasaspublichealth,bloodproducts,pharmaceuticalsormedicaldevicesandinspectoratesresponsibleforsuchaspectsascontroloftheenvironment,safety,radiationatnationalorlocallevelneedtobeclarifiedaspartoftheoverallqualityplan.Disseminationofthisstructureandplanwouldalsoprovideanopportunitytodevelopastrategyforactivecommunicationoftheaimsandoperationofanintegratedqualitysystem.
Government controlled or not?
Specifictoexternalevaluationisthequestionofwhethertheprogrammeshouldbeorganisedandadministereddirectlyandsolelywithintheministryofhealth,likelicensing,orbyanindependentbodytotallyunconnectedtogovernment,orbysomethingbetweenthesetwoextremes–whichhasbecomemorecommon.Thelegitimateandnecessaryroleofgovernmentisthelicensingofhealthcarefacilities,usingbasicsafetystandardsorcriteria.Licensingofindividualmedicalpractitionersmaybeagovernmentfunctionbutisusuallycarriedoutbyamedicalcouncil.However,therearechallengesforgovernmentalexternalevaluationprogrammeswhichinclude:
Inconsistentpolicyandmanagementwithchangesingovernment
Reviewingandupdatingstandardsconsistentlyandinatimelyway
Publicperceptionofgovernmentthatistoolowtomakethemcredibleassessorsofhealthcare
Conflictofinterestbetweengovernmentrolesaspurchaser,regulatorandinsurer,andlackofindependenceandcontinuity
Delegationofpowerstolocalareas,whichmayresultinmultiplegovernmentprogrammesduplicatingdevelopmentandongoingcostsofrunningtheprogrammes.
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Somecountries,suchasFranceandSaudiArabia,havemadeparticipationinaccreditationbyhealthcareorganisationslegallycompulsory,butmostcountriesmerelyauthorisethefunctionsoftheexternalevaluationorganisation.Two-thirdsofaccreditationorganisationssurveyedin2010weresupportedbyenablinglegislation.However,manyindependentprogrammesthrivewithoutit.Fiveaccreditationorganisationswerestrugglingorinactive,despitebeingsupportedbyapublishedgovernmentstrategy.Ifenablinglegislationisnotessentialandnationalstrategiesoftenchangewithministersandgovernments,externalevaluationorganisationsmustchoosereliablepartnersforsurvival15.
Need for government support
Tobesuccessful,externalevaluationprogrammesoftenneedgovernmentsupportandcollaborationandtoberecognisedasanimportantpartofthenationalhealthqualitystrategy.Thesupportmaybethroughfunding,providingincentivesforparticipantssuchaslimitingotherformsofinspectionoraudit,orrecognisingtheprogrammesasalegitimateandessentialpartoftheoverallhealthqualitystrategy.
Somefunctions,suchasthedefinitionofstandards,theassessmentofcomplianceandthegradingofawardsmaybetotallyindependentormaybesharedbetweengovernmentandindependentexternalevaluationorganisations.Somegovernments,forexample,NewZealand,havedevelopedorapprovedstandardsthattheyrequirehealthcareorganisationstomeet.However,thegovernmenthavedevolvedtheprocessofassessmentofcompliancewiththestandardsandfollow-uptoensurethestandardsarebeingmaintainedtoindependentdesignatedauditing,accreditationorcertificationorganisations.Theseorganisationsinturnneedtobeinternationallyrecognisedbya3rdpartyaccreditorsuchasISQua.InAustralia,asimilarsystemoperatesthroughtheAustralianCommissiononSafetyandQualityinHealthCarewhichhasdevelopednationalqualityandsafetystandards.Theaccreditationofhealthcareorganisationswhomeetthenationalqualityandsafetystandardshasbeendevolved.
Themandatoryrequirementforexternalevaluation,asintheaboveexamples,isanincreasingtrendasgovernmentsseektoimprovethequalityandsafetyofhealthservices.
Keyroleswhichgovernmentsmightplayinsupportingexternalevaluationinclude:
Enablingtheexternalevaluationprocess,e.g.throughpolicydecisionssuchasbyreciprocalrecognitionofassessments;jointdevelopmentofstandards;avoidingconflictsuchasperverseincentivesandcompetingmechanismsforassessment
Providingleverage,e.g.byaccordingpreferencetoaccreditedorcertifiedfacilities,servicesornetworkssuchasreimbursementtariffsandpaymentprocedures
Usingaccreditationorcertificationasacriterioninitsownpurchasingdecisions,e.g.indefiningpreferredprovidersandcontractmonitoring
Regulatingindividualsandinstitutions,e.g.byensuringconsistencyanddistinctionbetweenlicensingandaccreditation
Acknowledgingorendorsingaccreditationorcertificationprogrammesagainstdefinedcriteriatomaintainstandards,avoidduplicationandpotentialexploitation
Providingfinancialsupportinestablishingprogrammesand/orcontributingtothefundingofprogrammes’continuingdevelopment.
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Theextentofgovernmentsupportandinvolvementintheexternalevaluationprogrammemayalsodependonthecountry’soverallstageofdevelopment.Indevelopingcountries,wheretheremaybeamorelimitedhealthindustryorwhereprofessionalorganisationsmaynothavetheresourcesorfinancialcapacitytoinitiateanexternalevaluationprogramme,governmentorganisationsmaybeneededtoestablishsuchprogrammes.Forexample,inKenya,theNationalHealthInsuranceFund(theinsurer)managesaccreditation;theirstandards,knownastheKenyaQualityModel,weredevelopedbyabroadcoalitionofprofessionalsoutsideoftheInsuranceFundandaresupportedbytheMinistryofHealth.InGhanainWestAfrica,theNationalHealthInsuranceSchemeoriginallyplacedresponsibilityforaccreditationwithingovernment;thattaskisnowbeingtransferredtoanindependentbody20.
Thecasestudieshighlightthenatureoftherelationshipsbetweenexternalevaluationagenciesandgovernmentsindifferentjurisdictions.
Case Studies – Role of the government
IKAS – Danish Institute for Quality and Accreditation in Healthcare Country: DenmarkIKASandtheDanishaccreditationprogramme(DDKM)wereestablishedbyanagreementbetweentheregionalandlocalpoliticalauthorities,whoareresponsiblefordeliveringhealthcare,andthenationalgovernmentthatsetstheoverarchingpoliticalpriorities,includingtheeconomicframe,andisthehealthcarelegislatorandregulator.ThefirststepinthedevelopmentofDDKMwasthedevelopmentofacooperationagreementbetweenthegovernmentandtheregionsofajointmodelforqualityassessmentwhichincludedprovisionsforthefundingforDDKM.IKASisaformalindependentorganisationbutthegovernmentprovidespartofthefundingforIKAS.
Health Care Accreditation Council (HCAC) Country: JordanTheHCACisaprivate,not-for-profitshareholdingcompanyregisteredundertheMinistryofTradeandIndustry.
Health and Disability Auditing New Zealand Ltd (HDANZ) Country: New ZealandTheSafetyActrequiredthatdesignatedauditagencies(DAAs)whomonitorcompliancewithhealthanddisabilitystandardsforhospitals,resthomesandresidentialdisabilityservicesareapprovedbytheDirectorGeneralofHealthforthepurposeofauditingtheseservicestothosestandards.HDANZisaprivate,independentlyownedcompany.ItislinkedtogovernmentasaMinistryofHealth(MOH)approveddesignatedauditingagencyandfortheseservicesHDANZsubmitstheauditreporttotheMoHwhoissuesthecertificate.HDANZwasdesignatedasanapproveddesignatedauditingagencyinOctober2002.
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2.4 Determining incentives
Iftheexternalevaluationprogrammeisnotmandatory,evidencesuggeststhatincentivesareusefultopromoteandsustainit.Possibleincentivesforhealthcareorganisationstoparticipateinanexternalevaluationprogrammeinclude:
Organisationaldevelopment:self-assessment,team-building,benchmarking,guidedpathways
Increasedpublicfundingsuchashealthinsurancefundpaymentsmoderatedbyaccreditationorcertificationstatus,additionalgovernmentsubsidy,e.g.peraccreditedorcertifiedbed,orsomeotherlinkagetocorefundingorreimbursement
Effectiveexchangeofdatabetweenexternalevaluationprogrammesandinsuranceprogrammestoinformtheirpurchasingdecisionsandpayments
Preferencefromprivateinsurers:insurersprefertodealwithfacilitiesorserviceswhoseclinicalandmanagementprocesseshavebeenindependentlyverified;theyalsomakereimbursementsimplerandfasterforsuchorganisations
Marketadvantage:publicrecognitionbringsstatusandadvantageinacompetitivemarketwhichcanattractpatients/clients,staffandincome
Reductionofliabilityinsurancecosts:premiumsreflectreducedriskrating
Exemptionsfromregulatoryinspection:e.g.thestateissuesalicencetoanaccreditedorcertifiedfacilityonthebasisthataccreditationorcertificationstandardsincludeandexceedlicensingstandards(“deemedstatus”);thismaybeaconditionofreceivingpublicfunding
Linkagetotrainingposts:statusconditionalonaccreditationorcertification
Nationalqualitycompetitions:forexample,makingaccreditationorcertificationstatusoneofthejudgingcriteria.
Healthcareorganisationsmaybediscouragedfromparticipatinginanexternalevaluationprogrammeby:
Thecostintermsoftime,management,andmoney
Fearsabouttheoutcome-sanctionsforshortcomings,lossofstaffmoraleifdeniedtheawardofaccreditationorcertification,misuseofperformancedata,andofgainingtheawardandthenlosingitwhenstandardsgetmoredemanding
Lackofrecognitionfortheresourcesinvested
Lackofinformationaboutthebenefits
Resistancefromhealthcareprofessionalsandotherstaffandthefailuretorecruitclinicalandotherstaffchampions
Thedifficultiesofeffectingculturechangewithoutexternalsupportand
Failuretorecogniseandcelebratetheachievementsofparticipatingorganisations.
Considerationalsoneedstobegivenatthistimetotheissueofconsequenceswhenorganisationsdonotachieveormeettheaccreditationorcertificationstandardstotheacceptablelevel.Whataretheconsequences,ifany,fortheseorganisations?Forexample,dotheconsequencesincludefinancialsanctions?
Thecasestudiesprovideexamplesofsomeoftheincentivesputinplaceforexternalevaluationprogrammes.
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Case Studies – Incentives for external evaluation programmes
IKAS – Danish Institute for Quality and Accreditation in Healthcare Country: DenmarkDDKM(Danishaccreditationprogramme)isnotrequiredbyanylegislation,butisbasedonagreementsasfollows:
Publichospitals:allhospitalsparticipatebyagreementbetweenNationalandRegionalgovernments
Privatehospitals:voluntary,butparticipationisaprerequisitetoobtainacontracttotreatpatientsfortheregions(alsorequiredbysomeinsurancecompanies)
Pharmacies:voluntary,financialincentiveinplace
Municipalities(primarycareservices,includinglong-termcare):voluntary,noincentivesinplace
Ambulanceoperators:prerequisitetoobtaincontractwithRegions
Generalpractitioners:mandatory(withsomeminorexceptions)byagreementbetweentheRegionsandtheOrganisationofGeneralPractitionersinDenmark;financialcompensationaspartoftheagreement.
Health Care Accreditation Council (HCAC) Country: JordanAccreditationisvoluntary.Therearenoincentives(laws,regulation,insurancerequirements)inthecountryforaccreditation.
Health and Disability Auditing New Zealand Ltd (HDANZ) Country: New ZealandTheSafetyAct2002introducedhealthanddisabilitystandardsforhospitals,resthomesandresidentialdisabilityservicesaimedatimprovingsafetylevelsandqualityofcarethatbecamemandatoryfrom01October2004.UndertheSafetyAct2002,serviceproviderssuchashospitals,resthomesandresidentialdisabilityserviceprovidersmustbecertified.FromSeptember2005,physiotherapyserviceswererequiredtobecertifiediftheywishedtoprovideservicesundertheNewZealandAccidentCompensationScheme(ACC)physiotherapyservicescontract.FromSeptember2012,healthfundersmadecertificationmandatoryforhomesupportprovidersandfromMarch2013,ahealthinsuranceproviderSouthernCrossHealthSocietymadecertificationmandatoryfortheiraffiliatedproviders.
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Practice Incentive Program (PIP) Country: AustraliaTheAustralianGovernmentintroducedthePracticeIncentiveProgram(PIP)in1998.ThePIPisaimedatsupportinggeneralpracticeactivitiesthatencouragecontinuingimprovementsandqualitycare,enhancecapacityandimproveaccessandhealthoutcomesforpatients21.
Inthe2015-16AustralianGovernmentBudget,inexcessof$1.5bnoverfouryears22wasallocatedtothePIPtosupportthecontinuationofincentivepaymentstogeneralpractices.
ThePIPisusedasaleverbygovernmenttoinfluencebehaviouralchangewithinthegeneralpracticeenvironment.ToaccesspaymentsunderthePIP,practicesmustmeettheeligibilityrequirements,includingthatapracticemustbeaccreditedorregisteredforaccreditationagainsttheRoyalAustralianCollegeofGeneralPractitioners(RACGP)Standardsforgeneralpracticesandmustmaintainfullaccreditation.
Approximately80%ofallpracticesthatmeettheRACGPdefinitionofageneralpracticeparticipateinaccreditationand,therefore,mayaccessPIPpayments.
TherearethreetypesofpaymentsavailableunderthePIP21:
1. Practice Payments
ThemajorityofpaymentsthroughthePIParemadetopracticesandfocusonthoseaspectsofgeneralpracticethatcontributetoqualitycare.Thesepaymentsareintendedtosupportthepracticetopurchasenewequipment,upgradefacilitiesorincreaseremunerationforGPsworkingatthepractice.
2. Service Incentive Payments
ServiceIncentivePayments(SIPs)aregenerallymadetoGPstorecogniseandencouragetheprovisionofspecifiedservicestoindividualpatients.TheCervicalScreening,AsthmaandDiabetesincentiveshaveserviceincentivepaymentcomponents,andtheAgedCareAccessIncentiveisaserviceincentivepaymentonly.
3. Rural Loading Payments
PracticesparticipatinginthePIP,withamainpracticelocationsituatedoutsidecapitalcitiesandothermajormetropolitancentres,areautomaticallypaidaruralloading.
TherearetenindividualincentivesavailabletogeneralpracticesandGPsunderthePIP23:(SeeAppendix1dforfurtherinformation)
SincetheinceptionofthePIPin1998,successiveAustralianGovernmentshavecommittedtoongoingfundingfortheprogram;andduringthistime,haveretainedtherequirementthatapracticemustbeaccredited,orregisteredforaccreditation,andmustmaintainfullaccreditationinordertoaccesssuchpayments.
GiventhelevelofparticipationinaccreditationbyAustraliangeneralpractices,itcanbeassumedthatthehighlyincentivisedPIPhasbeeninstrumentalinencouragingpracticestoengageintheprocess,andinturnhashadapositiveimpactbysupportingpracticestofocusonimprovementsandqualityoutcomes.
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2.5 Developing relationships with stakeholders
Anotherkeyexerciseatthisstageistoidentifyormapouttheothermainstakeholdersinthequalityandsafetyarenainthecountryorregion;theirrole;andtheirlinktotheexternalevaluationprogramme.Thismaybedifferentforeachcountryorregionandthisexercisewillhelptoestablishwhatexternalinfluencesfortheprogrammewilllooklikeandwhatthenatureoftherelationshipwiththeotherstakeholdersshouldbe.Forinstance,iftheexternalevaluationorganisationdoesnotitselfmanagerelatedfunctionsatanationalorregionallevel,thenitneedstodefinecommunicationsandrelationshipswithotherdepartmentsandagenciestoharmonisethesettingandassessmentofhealthcarestandards,toavoidwasteandconflictbetweensystems,andtominimisethe“burdenofaudit”onhealthcareorganisations.Aneworganisationshouldseekwherepossibletointegrateandbuilduponexistingsystemsofstandardsandinspections.Forexample,byestablishingaprocesstorecogniseexistingISOormandatedaudits.Inaddition,thereareanumberoforganisationsinternationallywhodefineandassessstandards,andwithwhomtheycouldusefullycollaborate,ISQuabeingone.
Keystakeholderswithwhomtheexternalevaluationorganisationmayconsiderdevelopingrelationshipswithincludethefollowing:
Consumer groups
Representativesofarecognisedconsumers’councilorassociationshouldbeinvolvedinthecreationandsupportoftheproposedexternalevaluationorganisationasameansofmakinghealthservicesmoretransparentandaccessibletothepublic.Theyshouldhelpdefinewhatstandardsandservicesthepublicshouldexpectfromhealthcareproviders,anddevelopandpromotereliableandconsistentmethodsformeasuringthem.Theymayassistwithdevelopingaconsumercodeofrights.Consumerandpatientrepresentativesmayalsobepartoftheadvisorycommitteeoftheexternalevaluationorganisationandlatersitonthegovernanceboard.
Regulatory inspectorates and other external agencies
Thesemightincludestatutorybodieswithresponsibilityforareassuchasfiresafety,radiation,medicaldevicesafety,hygieneandhealthdatacollectionagencies.Therelationshipbetweenthecountry’sorregion’sISOaccreditationorganisationandthehealthserviceaccreditationorcertificationorganisationneedstobeexploredanddefined.Relationshipsalsoneedtobebuiltwiththeassessmentorganisationthatcertifieslaboratories,x-raydepartmentsorothertechnicalservicesandorganisationstorelevantISOstandards,tounderstandeachother’sneedsandrequirementsandpossiblycoordinateactivitiesandassessments.
Keyrelevantlegislativerequirementssuchasforbuildings,healthandsafetyinemployment,equalopportunities,consumerrightsorwastemanagementcanbemorespecificallyreferencedintheexternalevaluationorganisation’sstandardsinconsultationwiththerelevantagenciesresponsible.Specifictechnicalstandardsorregulatoryrequirementsrelatingtosafetysuchasinfectioncontrol,firesafety,equipmentsafetyandemergencypreparednesscanbeintegratedintothestandardsascriteriaandassessedaspartofthesurveyorassessmentvisit.
Mostaccreditationorcertificationorganisationsassumethatstatutoryinspectionsarecarriedoutasintended,andexpecttoexaminesafetycertificates,suchasforradiationprotectionaspartoftheirownsurveys,butinsomecountriesthestatutoryradiationprotectionagencydoesnothavetheresourcestocarryoutitsowninspectionsandmayturntotheaccreditationorcertificationorganisationtoprovideitsownexpertise.
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Aprocessneedstobedevelopedtodeterminewhichalternativeevaluationsarerobustenoughtobeacceptedasproofofcompliance.
Public and community health bodies
Linksbetweenthesebodiesandtheexternalevaluationorganisationwouldgiveanopportunitytosharedatatodescribetheimpactonpopulationandcommunityhealthandontheperformanceofprovidersandthehealthcaredeliverysystem.Wherecountriescurrentlyemployinspectorstoregulatehealthcarefacilities,theinspectors’rolecouldbemodifiedtoincludeassistinglocalfacilitiestoprepareforexternalevaluationsurveysbytheorganisationwhenitisestablished,andtomonitortheimplementationoftheensuingrecommendationsforimprovement.Thiswouldrequireinitialandcontinuingeducationprogrammes.
Technical agencies
Relationshipswithagenciesforaspectssuchashealthtechnologyassessment,clinicalguidelines,clinicalpathwaysandpatient/consumersafetyareuseful,especiallytoenableconsultationandadviceonthedevelopmentofappropriateevidence-basedstandardsandforkeepinginformationandcommunicationscurrent.
Professional bodies
Independentbodiessuchasmedicalacademiesorcouncilswillofferwisdomandadvicetotheorganisationandberecognisedforthatpurpose.Otherbodiesresponsibleforsuchdutiesassupervisingtrainingorlicensingorregisteringclinicians(doctors,nurses,dentists,pharmacists,alliedhealthprofessionals)willcontributetothesettingofstandardsandtotheirlocalassessment.
Inparticular,theroleofprofessionalchambers,associationsandcollegesneedstobedefinedwithrespectto:
Professionalregulation
Settingandmonitoringofclinicalperformancestandards
Monitoringofclinicalpracticeaccordingtothesestandards
Developmentanddisseminationofqualityimprovementmethods.
Thefunctionsofstatutorybodiesshouldbedefinedinrelationtovoluntaryassociationsandtotheexternalevaluationorganisation.Theorganisationshouldworkwithlocalgovernmentministries,insurancefundsandprofessionalassociationsandchamberstodevelopconsistentincentivesformeasurableachievementofagreednationalstandardsofprocessandoutcomeinprimary,ambulatoryandhospitalcare.
Health insurance funds
Usingcontractedserviceprovidersoffersanalternativetothetraditionalcentralisedmodelinhealthcaremanagement.Inseveralcountries,lawsonhealthcareinsurancespecifythatonlyaccreditedorganisations,fromeitherthepublicorprivatesector,havetherighttosigncontractstoprovideservicesundercompulsoryinsurance.Theexternalevaluationorganisationcanworkwithhealthinsurancefundstohelpthemobtainandprotectbestvaluefromavailablefundingbyrecognisingaccreditationorcertificationforitsimpactonqualityimprovement.
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External assistance
Afurthergroupofstakeholderswithwhomanexternalevaluationorganisationmayinteractwouldbeindividuals,organisationsorgroupsprovidingexternalassistance.Externalassistanceisavailablefromanumberofsourcesincluding:
Internationalexternalevaluationbusinessesorinitiatives
Internationalaidorganisationsandtechnicalcorporations
Internationalexperts
Neighbouringexternalevaluationorganisations
ISQua.
Assistancemaybeforanypartorallofthecomponentsofanexternalevaluationprogramme.Beforeengagingformalexternalassistance,itisimportantthat:
Theprojectspecificationshavebeenscopedoutandareappropriate
Competencycriteriaforselectionofexternalassistanceincluderelevantexperiencewithhealthorsocialcarestandardsbasedexternalevaluation
ReferencesandadvicearesoughtfromexperiencedaccreditationorsimilarorganisationsandISQua.
Mostaccreditationorganisationshavebasedtheirstandardsonexistingresearch,clinicalpracticeguidelines,inputfromexpertsandotheraccreditationandtechnicalstandards.Neworganisationscan,inconsultationwiththeownersofthesestandards,chooseamodelthatbestreflectstheirpurpose,scopeandculturalcontext,andthenadaptthosestandardsorbuildonthemtomakethemappropriatetothelocalcontext.ItisimportantthatthestandardsadheretotheISQuaGuidelinesandPrinciplesfortheDevelopmentofHealthandSocialCareStandards4astheseareacceptedasbestpracticebyorganisationsandsothattheycanbecomeinternationallyaccredited(SeeChapter4formoreinformation).
ISQua’sGuidelinesandStandardsforExternalEvaluationOrganisations3andforSurveyorTrainingStandardsProgramme5provideguidanceonwhatstructures,systems,processesandevaluationmethodsneedtobeinplacetobeabestpracticeorganisation.WhenorganisationsseekISQuaaccreditation,theygetassistancewiththeirself-assessmentandtheycanhaveamocksurveypriortoaninternationalaccreditationsurvey.
Informationspecifictohealthcareexternalevaluationiswidelyavailable-seeweblinksinthebibliographysection.
Thenextchapterwillfocusontheinitialstepsinvolvedinsettingupanexternalevaluationorganisationincludinghowtoinvolveandengagewithotherstakeholdersaspartofthisprocess.
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Chapter 3: Setting up the External Evaluation OrganisationThischapterfocusesontheprocessofestablishinganexternalevaluationorganisationandthedifferentstagesinthisprocess.Thisprocessmaybedifferentforeachcountryorregiondependingongovernmentpolicy,thestakeholdersinvolvedandthesizeofthehealthorsocialcaresector.Thecasestudyexamplesoutlinetheapproachesadoptedindifferentcountries.
3.1 Establishing a preliminary board or advisory committee
Theimpetusforsettingupanaccreditationorcertificationorganisationmaycomefromanumberofpossiblestakeholders:MinistryofHealth,healthprofessionalassociations,consumerorganisations,privateinsurers,universitydepartments,voluntarymembershipsocieties,healthservicecharitiesoraidorganisations.Theinitiativemaycomefromacompanyorgroupofindividualswhoseeamarketopportunity,e.g.asassessorsofgovernmentstandards.Ifthepurposeoftheprogrammeisclear,itisnotdifficulttoidentifywhomitwillserveandwhomitwillaffect.Traditional,profession-drivenprogrammeshavetendedtobuildlinkswithregulatorsandconsumers,thusbecomingmoreaccountableandtransparent.Morerecentprogrammeshavebeenmoreinfluencedbycommercialprovidersandinsurersoractivelysupportedbygovernment.
Onewayofinvolvingrelevantstakeholderswhohaveorwillhaveaninterestinthesuccessoftheneworganisationisthroughsettingupapreliminaryboardoranadvisorycommitteetoestablishtheorganisation.Thisenablesthemtofeeltheyhaveastakeintheorganisationanditsworkandtoprovideadviceandexpertise.
Thepreliminaryboardoradvisorycommitteewillprovideguidanceanddirectiononthepracticalaspectsofestablishingtheexternalevaluationprogrammeincluding:
Clarifyingtheroleoftheexternalevaluationprogrammeinthecontextofotherdepartmentsandagenciesworkinginthequalityandsafetyarenainthecountryorjurisdictione.g.otherexternalevaluationprogrammes
Fundingoftheexternalevaluationprogramme
Governanceframeworkfortheexternalevaluationorganisation
Theuseofexternalassistancefordevelopmentanddeliveryoftheexternalevaluationprogramme.
Thecompositionoftheinterimboardoradvisorycommitteewillbeuniqueforeachcountrydependingongovernmentpolicyandtherangeofstakeholdersworkinginthequalityandsafetyarena.Somemembersfromthisboardorcommitteemayformthebasisforthegovernanceboardintheestablishedorganisation.Table3outlinessuggestedmembersofapreliminaryboardoradvisorycommittee.
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Table 3: Potential composition of a preliminary board or advisory committee
Stakeholder Group
Examples of representatives
Government MinistryofHealthand/orotherrelateddepartmentse.g.Finance.Localgovernmente.g.municipality,canton,oblastlevel
Consumergroups
Recognisednationalconsumercouncil/associationoradvocacyorganisation
Externalevaluationorganisations
Regulatoryandotherexternalevaluationagenciesworkinginthequalityandsafetyarenainthecountryorjurisdictione.g.statutorybodieswithresponsibilityforareassuchashealthandsafety,radiation,medicaldevices,medicines,regulatoryinspectorates,certificationagencies
Serviceproviders
Publicandprivateprovidersincountryorregione.g.nationalrepresentativebodiessuchasnationalhospitalassociationornationaldisabilityserviceprovidersassociation/forum
Professionalbodies
Independentbodieswithresponsibilityforthelicensingorregistrationofhealthandsocialcareprofessionalsorthesupervisionoftrainingsuchasmedicalacademiesorcouncils
Academia Universitiesorcollegeswhodelivereducationandtrainingprogrammesforhealthandsocialcareprofessionals
Technicalagencies
Nationalagencieswithaspecificrolee.g.healthtechnologyassessments,clinicalguidelinesandpathways,patient/consumersafety
Independent Independentexperts,neighbouringexternalevaluationorganisations,internationalexternalevaluationinitiatives
3.2 Proposing a governance board and framework
Oneofthefirsttasksfortheinterimboardwillbetodevelopadraftgovernanceframeworkfortheexternalevaluationorganisationorprogramme,withaformalconstitution,governanceboardanddraftpoliciesandprocedures.Forcredibilityandinlinewithbestpractice,acommitmentshouldbemadethattheorganisationwillbeestablishedinlinewiththeISQuaGuidelinesandStandardsforExternalEvaluationOrganisations3(currently4thedition,2014,butnotethattheseareupdatedonaregularbasisandthelatestonesshouldalwaysbeobtained).
3.2.1 Governance body
Ifitistobeanon-governmentalorganisation,itispreferablefortheorganisationtohaveaboardcomprisingandaccountabletothevariousstakeholderorganisationsratherthanthegovernment.Theboardshouldrepresentprofessional,publicandgovernmentalinterestsandbringpersonalqualitiestothegovernanceoftheorganisation,suchasfinance,legalandpublicrelations,butbedominatedbynoneofthem.Forexample,inMalaysiaaccreditationprogrammesaredeliveredbytheMalaysianSocietyforQualityinHealth(MSQH),whichwasestablishedbytheMalaysianMinistryofHealthinassociationwiththePrivateHospitalAssociationandtheMalaysianMedicalAssociation.AllthreeorganisationsarerepresentedontheboardofMSQH24.
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Typically,independentboardsincludeconsumers;representativesofprofessionalassociationssuchasnurses,managersanddoctors;industryassociationssuchashospitalsorresthomes;fundingagencies;andstatutorybodies.Someboardsarenowappointedaccordingtoskillsets,expertiseandexperienceratherthanchosenbyrepresentativestakeholderorganisationsbecauseoftheperceivedconflictsofinteresttherepresentativemembersmayhave,beingtheprovider,consumerandsometimesalsopurchaseroftheexternalevaluation.Governmentrepresentativesinparticularmayhaveaperceivedconflictofinterest.
Publicinvolvementgoesbeyondthesharingofinformation;italsodemandsthesharingofauthority.Manyexternalevaluationorganisationshaverepresentativesofpatientsandthepublicintheirgovernancestructuretoensuretheirinvolvementinthedevelopmentofpolicyandstandardsandinensuringthatagreedproceduresarefollowedthroughouttheexternalevaluationprocess.
Aspergoodgovernancepractice,membersofthegoverningbodymustbeorientedtotheirrolesandhaveongoinginformationandeducationtoassistthemintheirrole.Theyshouldbeguidedbyasetofgovernancepolicies.
Case Studies – Composition of governing board
IKAS – Danish Institute for Quality and Accreditation in Healthcare Country: DenmarkIKASandDDKMwereestablishedbyanagreementbetweentheregionalandlocalpoliticalauthorities,whoareresponsiblefordeliveringhealthcare,andthenationalgovernmentthatsetstheoverarchingpoliticalpriorities,includingtheeconomicframe,andisthehealthcarelegislatorandregulator.ThegovernmentisrepresentedontheboardofIKAS;theChairoftheBoardisagovernmentrepresentative,aDirectoroftheDanishHealthandMedicinesagency.
Health Care Accreditation Council (HCAC) Country: JordanTheboardofdirectorsismadeupofrepresentativesforallhealthcaresectorsinJordan,medicalandnursingprofessions,andeducation.
3.2.2 Governance framework
Theexternalevaluationorganisationneedstobesetupasalegalentity,orapartofone,withclearlegalresponsibilitiesforallitsexternalevaluationactivities.IfitispartofaMinistryorgovernmentagency,thisindependenceisparticularlyimportant.
Theorganisation’sgovernancearrangementsneedtobeclearlydescribedinadeed,constitutionorsimilardocumentthatdefinespowers,accountabilityandresponsibilityincluding:
Thecompositionofthegoverningbody
Theprocessforappointingitsmembers
Linesofaccountabilityincludinglinesofaccountabilityoutofthelegalentity
Thetermsofreferenceofthegoverningbodyandanyofitscommittees
Responsibilityandrulesformakingdecisionssuchasonaccreditationorcertificationawards.
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Theorganisationrequiresaclearvisionandmissionorpurposeandstrategicdirectiontoprovidethebasisfortheorganisation’splanninganddirectionandmustbeguidedbyadefinedsetofvalueswhicharereflectedinallservicesandactivities.Itisalsoimportantthattheorganisationhasanexplicitsetofethicalprinciplestoinformalldecision-makingandacodeofconductoutliningtheexpectedbehavioursofthoseworkinginand/oronbehalfoftheorganisation.Otherresponsibilitiesforoverseeing,monitoringandapprovalalsoneedtobedefined3.
3.2.3 Committing to fairness and transparency
Externalevaluationorganisationswhichhavesucceededinmakingimprovementsinclienthealthcareorganisationshavegenerallydonesobystimulatinginternalmotivationandcommitmenttoself-assessmentandchange.Thisrequiresacultureoftransparencyandacceptanceofpersonalandorganisationalresponsibilityamongmanagement,cliniciansandotherstaff.Howeversuchacultureisnotuniversal,especiallyinhierarchicalsystems.Externalevaluationorganisationscannotrelyonhealthprofessionals’ethicsandself-regulationtoensureanopenandfairculturethatpromotesqualityimprovement.Thecommitmenttofairnessandtransparencymustbebuiltintothegovernanceframeworkandthewaysofleadingtheorganisation.
Insettingupthenewexternalevaluationorganisation,acommitmentmustbemadethatitwill:
Usetransparentandobjectivesystems,decision-makingandreporting
Befreefromundueinfluencebyanyparty
Avoidconflictsofinterest
Establishafaircomplaintsandappealssystem
Designandpublishproceduresforcontracting,facilitation,assessment,reportingandaccreditationorcertificationdecisionstopromoteconfidenceand
Putarrangementsinplacethatensurethatexternalevaluationactivitiesarestrictlyseparatedfromconsultancy.
Thiscommitmentshouldbedefinedinpolicies,includingonerequiringaccreditationorcertificationdecisionstobemadesolelybasedontherelevantstandards,thefindingsofthesurveyors/assessorsandotherobjectiveevidencerelatedtothestandards.Agrowingtrendisfordecisionsonaccreditationstatustobemadebasedonaformulaic,mathematicallyorientedapproach,whichavoidsanyperceptionofbias3.
3.3 Funding of the programme
Mostnewexternalevaluationorganisationsrequireatleasttwoyearstoestablishtheirorganisationand/orprogramme,longerbeforetheyaresustainable,andlongerstillbeforetheyareself-financing.Inshort,politicalandfinancialsupportgenerallyneedstobeconsistentbeyondtheterminofficeofmosthealthministersandmanygovernments.Externalfundingfromgovernment,healthinsurers,aidorganisationsorotherpartnerswillberequiredfor:
Establishmentoftheexternalevaluationorganisation
Initialdevelopmentandtestingofthestandards
Marketing
Possiblysubsidisingtherunningoftheorganisationforthefirstfewyearsorayearafterbreak-even.
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However,theinitialset-upcostsmaybemuchlessforexternalevaluationorganisationswhoseroleistoaccreditorcertifyhealthorsocialcareorganisationsagainstgovernment-mandatedstandardsorsimilar.Inthissituation,thereisanidentifiedpotentialclientpool,therewillbeguaranteedpaymentofcostsoftheassessmentbyeithertheclientsorthegovernmentandtheremaybeashortertimeperiodinwhichclientsarerequiredtobeassessed(SeetheexamplefromHDANZintheCaseStudiessection).
Formostotherorganisationsthenumberofpotentialclienthealthorsocialcareorganisationswillbeakeydeterminantofprogrammecosts,aswillotherfactorssuchaswhethertheprogramme:
Isasinglenationalprogramme,regionalorsectorspecific
Islimitedinitiallytoapriorityfocus,e.g.nursinghomes,ortotheentirehealthsystem
Issupplementingorreplacingexistingexternalassessments
Isdevelopmentfocused,requiringtrainingandeducationofclients
Developsitsownstandards
Employsspecialistexpertise.
Oneofthemajorpotentialcostsforanexternalevaluationorganisationwillbethesurveyorworkforceandinparticularwhethertheyarepaidorvoluntary.Traditionally,accreditationorganisationshaverelieduponparticipatingaccreditedinstitutionstoprovideorloanstafftoworkassurveyorsandtopromotetheconceptofpeerreview.Certificationagenciesusuallyemployorcontracttheirassessmentpersonnelonapaidbasis,sometimessupplementedbytechnicalexperts.However,accreditationorganisationsarenowalsoincreasinglypayingsurveyorsasemployedorcontractedpersonnel,orusingamixofbothpaidandvoluntary.Theorganisationwouldneedtoconsiderfactorssuchastheavailabilityofsuitablepersonnelinthecountrytoactassurveyors;thefeasibilityofsuitablepersonnelbeingreleasedbytheirorganisationstoworkassurveyors;andthenumberofandcostsofemployingfullorpart-timesurveyorswhendecidingonwhichapproachtotake.
Thoroughsystemdesignandtestingwillbeanothercost,aswilltheinvestmentincommunications,informationmanagementandmarketing.
Althoughasustainableexternalevaluationorganisationanditsprogrammeareconstantlyunderdevelopment,thestart-upcostsmaylast3-5yearsbeforeatestedandvaluedproductissufficientlymarketabletobegintorecoveroperationalcostsfromclientorganisations.Whethertheychoosetoparticipate,orwhethertheycanaffordto,dependsontheincentivesandsanctionsprovidedandexistingoperatingbudgets.
Duringthefirstyear,theorganisationmaymanagewithasmallcorestaff,severalworkinggroupsandlowoverheads;howevercostsincreaserapidlywiththeadditionof,surveyortraining,documentproductionandthedirectcostsoffieldtesting.Insomecountriesexternalexpertiseisrequiredandmustbefactoredintothestart-upcosts.Atthenextstage,whentheinitialdevelopmentiscompletedandtheorganisationisreadytoofferaccreditationorcertification,itmayfaceanotherchallenge;thefastertherateofuptake,thefasteritmustinvesttobuildcapacity.Fundingshouldbeprofiledtoreflectthisgrowth.
Atthesametimeasobtainingfunding,incentivesneedtobenegotiatedifpossible.
Thecasestudiesoutlinetheexperiencesofexternalevaluationagenciesindifferentcountriesintermsoffundingarrangements.
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Case Studies – Funding
IKAS – Danish Institute for Quality and Accreditation in Healthcare Country: Denmark
Set-up costsWhenIKASwasbeingestablished,adecisionwasmadetoseekexternalassistancetohelpwiththeestablishmentoftheorganisationandthedevelopmentoftheaccreditationprogramme.ArequestfortenderwasissuedtointernationalaccreditingorganisationstoprovideconsultancyservicesfortheestablishmentofIKASandthedevelopmentofDDKM.TheUnitedKingdombasedinternationalaccreditationorganisationCHKSwasawardedthecontracttoassistwiththeestablishmentofIKASasanaccreditationorganisation;thedevelopmentofstandards;andthetrainingofsurveyors.
Funding of the accreditation schemeIKASisanindependentorganisationbutreceivesanindex-linkedannualgrantfromthecentralgovernment,regionsandlocalgovernment.PublicclientssuchaspublichospitalsorpharmaciesdonothavetopayanyfeestoparticipateinDDKM.Otherprivateclientspayafeethatcoversdirectexpensesplusanoverhead.
Health Care Accreditation Council (HCAC) Country: Jordan
Initial fundingTheoriginalfundingtodeveloptheHCACcamethroughtheJordanHealthcareAccreditationprojectfundedbytheUnitedStatesAgencyforInternationalDevelopment(USAID)andgrants.TheHCACisaprivate,not-for-profitshareholdingcompanyregisteredundertheMinistryofTradeandIndustry.SinceMarch2013,HCAChasbeenfinanciallysustainablethroughchargingfeesforservicesofferedincludingsurveys,educationandconsultation.
Health and Disability Auditing New Zealand Ltd (HDANZ) Country: New Zealand
HDANZisaprivate,independentlyownedcompany.ItislinkedtogovernmentasaMinistryofHealth(MOH)approveddesignatedauditingagency.HDANZauditstheseservicesonbehalfoftheMOHandsubmitsauditreportstotheMOHwhothenissuesthecertificatestotheservices.
ServiceproviderspayfeestoHDANZforsurveyandmonitoringvisits.CertificationhasbeenmandatoryfortheMOHSafetyActsinceOctober2002.FromSeptember2005,itbecamemandatoryforphysiotherapyservicesiftheywantedtoprovideservicesundertheNewZealandAccidentCompensationScheme(ACC)physiotherapyservicescontract.FromSeptember2012,healthfundersmadecertificationmandatoryforhomesupportprovidersandfromMarch2013,ahealthinsuranceproviderSouthernCrossHealthSocietymadecertificationmandatoryfortheiraffiliatedproviders.
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3.4 Setting up strategic, operational and financial management systems
Oncethegovernanceboardhasbeenestablishedandthegovernanceframeworkhasbeendeveloped,thenextstepistostafftheexternalevaluationorganisationandtodevelopthemanagementsystems.
3.4.1 Staffing the organisation
Themostimportanttaskofanyboardistoappointthechiefexecutive,withtheappropriateskillsandexperiencefortherole.Thegoverningboardmaydelegateaccountability,authorityandresponsibilityformanagingtheexternalevaluationorganisationtoachiefexecutive.Theresponsibilitiesformanagingtheorganisation,thelevelofauthorityandthechiefexecutive’srelationshipandaccountabilitytotheboardneedtobedefinedinajobdescriptionorsimilardocument.Itisalsotheboard’sroletoconfirmstrategicandoperationalplans,toreceiveregularreportsonachievementofgoalsandtargetsandtoreviewthechiefexecutive’sperformanceannuallyagainstsetperformancetargets3.
Afterthechiefexecutivehasbeenemployed,personnelneedtobeselected,trainedandpaid,includingemployedstaff,secondedstaff,e.g.surveyors,andsub-contractorse.g.legal,statistical,marketing,communications.Sometimesfinancialandinformationtechnologystaffarecontracted.
Inlargerorganisations,staffmaybestructuredintofunctionalunitssuchas:
Surveyplanningandmanagement
Surveyorrecruitmentanddevelopment
Standardsresearch,developmentandrevision
Usereducationanddevelopment
Technicalsupportstaff–financial,humanresources,informationmanagement
Administration.
Smallerorganisationscanbesustainedonveryfewcorestaffiftheyhavesignificantsupportfromunpaidexpertsandstaffsecondedfromemploymentinhealthandsocialcareservices.Staffingnumbersandskilllevelsneedtobeplannedandtransparentpoliciesdevelopedforrecruitment,selectionandappointment;orientation;healthandsafety;ongoingtraining;andregularperformanceassessment.Personnelrecordswithdefinedcontentneedtobeestablishedforallstaff.
Itisimportantthatthelinesofresponsibilitywithintheexternalevaluationorganisationareclearlydefined;madeknowntoallstaff;andthatthereareprocessesinplacetoensurethatstaffandsurveyorsarefreefrominfluencebythosewhohaveadirectinterestintheservicesandaccreditation/certificationdecisions.Thelinesofauthority,responsibilityandallocationoffunctionsintheexternalevaluationorganisationmaybeoutlinedinanorganisationalchartororganogram.Thelinesofresponsibilitymaybeoutlinedtostaffaspartoftheirorientationandupdatesprovidedwheneverthereisachangeofresponsibilities.
Afinancialsystemneedstobesetuptodevelopbudgetsandrecordandtrackincomeandexpenditureandpast,currentandprojectedfinancialpositions.Itneedstobeabletoproducetimelyreportstoassiststafftomanagetheirbudgets.Controlandauditsystemswillbeneededtoprotectassetsandensurethetransparencyoffinancialtransactions.
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3.4.2 Developing the system for financial sustainability
Initialbudgetingischallenginganddependsonhowmuchfundingisreceivedfordevelopmentorhowmuchoftheset-upcostsneedtobeincludedinthebudget.Provisionusuallyneedstobemadeforexternalassistanceandexpertise.Someorganisationsconsiderguidedfacilitationand/ortrainingonthesurveystandardsandprocessasanintegralpartofthedevelopmentprocess.Othersprovideseparateconsultancy(includinggeneraleducationanddevelopment)forwhichtheychargeafeewhichcanbebudgetedfor.
Ifclienthealthcareorganisationsarerequiredtopayonaneventbasis,ongoingcostswilldependonthelengthanddepthofsurveys(whichareinfluencedbythestandards),lengthofthesurveycycle,mid-termmonitoringsystem,theefficiencyofscheduling,surveylogistics,reporthandlingandawardadjudication.Budgetshavetopredictwheneventssuchastraining,on-sitesurveys,andmid-termsurveillancevisitswilloccurandhowmuchtheywillcost.Anypostponementorcancellationcannegativelyaffectanticipatedcashflow.Someorganisationsincludealldocumentationanddirectsurveycosts,e.g.surveyortravelandaccommodation,intoasingle-pricepackagepersurveybutcostsandrevenuesarestilldependentontheeventoccurring.Anumberofaccreditationorganisationshavemovedtoamembershiporsubscriptionbasedfinancialsystem,wherebyclientsbecomemembersoftheaccreditationprogrammeandarechargedaregularannualfeebasedonanticipatedcostsoverthewholeaccreditationcycle,includingoverheads,education,guidance,standards,tools,surveyandmid-termprogressvisits.Whileitstillrequiresbudgetforecastingofthenumberandtypeofclients,itlimitstheuncertaintyofwhetherandwheneventswillhappenandhascontributedtotheongoingsustainabilityofanumberofaccreditationorganisations.
Amarketingprogrammeandbudgetwillbeneededbymostnewexternalevaluationorganisationstopubliciseitself,theservicesitoffersandthebenefitsofitsprogrammetoattracthealthcareproviders.Gettingasustainablemarketshareofclientorganisationswillbefundamentaltoitssuccess.Widermarketingandpublicitywillbeneededforpotentialinsurers,fundersandthegeneralpublic.
3.4.3 Establishing information systems
Informationmanagementcoversbothtechnologicalandpaperbasedinformation,includingeducationalandmarketingresources.Internalinformationsystemsareessentialforplanning,operationsandfinance,buttheyalsoneedtohavethecapacitytocollect,aggregateandcomparedataovertimewithinandbetweenparticipatingorganisations,standardsandsurveyors,suchas:
Dataofcompliancewithachievementofindividualcriteriaorstandards
Profilesofparticipatingorganisations
Calculationofstandardscores,functionscores,andoverallscoreforeachorganisation
Aggregatedresultsforcomparisonovertime,functionandplace
Profilesofindividualsurveyorsandtheirparticipation
Surveyschedulingandmanagement
Overallimpactofprogramme.
Datawhichshowthatparticipatingorganisationshavemadeimprovementsassociatedwiththeprogrammesincethefirst(baseline)contactareessentialtodemonstratethevalueoftheprogrammetothehealthcaresystem3.
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3.4.4 Addressing risk management and performance improvement
Theexternalevaluationorganisationmustmodelthesafetyandqualityapproachitexpectsfromitsclientorganisations.Arobustriskmanagementframeworkthatidentifiesandmanagesrisksandpromotessafetymustbeimplemented.Whilemostoftheseorganisationsdemonstrateasafetyculture,itneedstobedemonstratedbyestablishingaqualityimprovementpolicyandframework.Essentialtothiswillbethedocumentationofpoliciesandproceduresforallfunctions,thedevelopmentanduseofkeyqualityindicatorswhichcanbemonitoredandbenchmarkedovertimeorwithsimilarorganisations,theuseofauditsandreviewstoensurecompliancewithpoliciesandprocedures,documentedqualityimprovementprojectsandatransparentcomplaintssystemthatisavailabletostaff,surveyors,clientsandotherstakeholders3.
3.4.5 Providing education services
Mostexternalevaluationprogrammesprovideavarietyofeducationandtrainingasanessentialcomponentoftheirservices.Educationservicesneedtobesystematicallydesignedandimplementedtomeetqualitystandardsandclientneeds.Theseinclude:
Inductionanddevelopmentofstaff
Orientationandongoingeducationofmembersofthegoverningboard
Initialandcontinuingtrainingofsurveyors
Generalpreparationofparticipatingorganisationsandtheirstaffasabasiccomponentoftheirparticipation
Specificmethodsofinternalqualityimprovementrequiredtomeetexternalevaluationstandards,suchasinfectioncontrol,riskmanagement,performancemeasurement,patient/clientsurveys–theseareusuallyadditionaltoservicescoveredbyfeesandarechargedseparately
Qualityimprovementprogrammesforthehealthorsocialcaresectorsingeneral.
Thesetrainingandeducationprogrammesandcoursesandtheirresourcesneedtobeplanned,scheduledandcosted.Informationprovidedneedstobekeptup-to-dateandbasedoncurrentresearchandevidence.Trainersandeducators,whetherinternalorexternal,needtohavethecompetenceandexpertisetodelivertheprogrammes.
3.5 Timeframes
Themostcommonlyunderestimatedresourceisthetimeneededtoplan,design,buildanddeliverasustainablenewexternalevaluationorganisation.Thepaceatwhichthiscanbedoneislimitedlargelybyfactorsoutsidethecontroloftheorganisation,notablybytheprevailingcultureandattitudestowardsleadership,innovation,improvement,team-workingandtransparency.
Inpracticethedevelopmentstages,whichmayoverlap,are:
Policydecisiontodevelopanexternalevaluationorganisation/programmeanddefiningitsscope
Optionappraisalonexistingmodelsandtheiradaptation
Settinguptheorganisationstructureandobtainingoffunding
Developmentandtestingofstandards
Developmentandtestingofassessmentmethodologies
Surveyorselectionandtraining
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Pilottesting,educationandmarketingcampaigns
Revisionofstandardsandmethodsbasedonfeedbackfrompiloting
First“live”surveys
Firstaccreditation/certificationrecognitionstatusdecisions.
Thisprocessislikelytotakeatleasttwoyearsbutcantakemuchlonger(Thecasestudiesoutlinetheorderofdevelopmentandthetimescalesinvolvedforthethreedifferentagencies.PleaserefertoAppendices1a,bandcforfurtherinformation.).
Takingtimetoestablishcommunicationwithallstakeholdersandthepublicandcontinualupdatingofinformationastheorganisationdevelops,isessentialforsuccess.
Thefollowingchaptersfocusonandprovidemoredetailinrelationtothedevelopmentandtestingofstandards;thedevelopmentofassessmentmethodologiesandmechanismsforevaluatingsystemsandperformance.
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Chapter 4: Developing the standardsThischapterfocusesonthedifferentelementsrequiredwhendevelopingstandards.Itincludestheuseofqualitydimensionsandtheimportanceofareliableandvalidmeasurementscale.
Thestandardsusedordevelopedbyexternalevaluationorganisationsarethemostfundamentalelementoftheirprogramme.Whilenotalwaysrealistic,itisadvisabletoconsiderwhatevaluationmethodologywillbeusedwhilethestandardsarestillinthedevelopmentphase.Thestandardswillhelptoinformthepublicwhattoexpectfromhealthandsocialcareprovidersandwillactasabenchmarkagainstwhichprovidersandthegovernmentcanmeasurequality.Thestandardswillformtheframeworkforself-assessmentandinternalaudits.
Standardsdevelopmentcanoftencommencepriortothesettingupofgovernanceandmanagementsystemsintheexternalevaluationorganisationandcantaketwoormoreyearstocomplete.Fundersmaywanttoknowtheshapeandcontentofthestandardsbeforetheycommittofundingtheorganisation.Separatefundingisoftenavailableforthestandardsdevelopmentprocess.
4.1 The role of standards
Anexternalevaluationorganisation’sstandardshavetoreflectitspurposeandcoverthekeyfunctionsandprocessesofthehealthcareorsocialcaresectorsthatarebeingevaluated.Similarly,ifstandardsareownedormandatedbygovernment,theyneedtoreflectthepurposeforwhichgovernmentintendsthem.Theyhavetoreflectlegislativerequirements,safetyandgoodpractice.Theyshouldberelevant,understandable,measurable,beneficialandachievable(RUMBA)25.
Standardsalsoneedtoberealisticandreflecttheavailabilityofresources,especiallyindevelopingcountrieswhereresourcelimitationscansignificantlyimpactahealthcareorganisation’sabilitytoachieveoptimalperformance.Forexample,MalaysiaandThailandbeganwithrelativelyachievableaccreditationstandardsbutcommittedtocontinueupdatingandimprovingtheseovertime.Inthiscontext,Malaysiahaspublishedthe4theditionoftheirhospitalstandardssincetheaccreditationprogrammebeganin1999.Thailandhasalsomadeprogressivechanges,introducingastepwiserecognitionprogrammein2004andpatientsafetygoalsin200620.Standardscanalsobeprioritisedandincrementalimprovementsmadeinachievingthemcanberecognisedandrewarded.InIndia,theNationalAccreditationBoardforHospitals&HealthcareProviders(NABH)hasdevelopedPre-AccreditationEntryLevelcertificationstandards,inconsultationwithvariousstakeholdersinthecountry,whoseaimistointroducequalityandaccreditationtohealthcareorganisationsastheirfirststeptowardsawarenessandcapacitybuilding.OnceorganisationshavemetthePre-AccreditationEntryLevelcertificationstandards,theycanthenprepareandmoveontothenextstage–ProgressiveLevelandcanthenworktowardsFullAccreditationstatus.Thismethodologyprovidesastepbystepphasedapproachforhealthcareorganisations26.
Thelong-establishedaccreditationorganisationsgenerallybeganwithstandardsandsurveyswhichreflectedmanagementunits,e.g.departments.Theyalsotendedtofocusonstructures,e.g.staffingarrangements,funding,equipmentorcommittees.Mostprogrammesnowfocustheirstandardsandassessmentsonaclientfocusedcontinuumofcareorpatient’sjourneyratherthanmanagementunitsandonprocessesandoutcomesratherthanstructures.
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However,fordevelopingcountries,basicstructuralstandardsmaystillbeanimportantstartingpoint.Externalevaluationmaybeprimarilyavehiclefortakingstockanddevelopinggreaterequalityofstructureandaccesswherethehealthcaresystemhaswideregionalandsocialdivisions.Inthiscase,thehealthsystemmustbeabletomobiliseresourcesinordertorespondappropriatelytotheprioritieswhichareobjectivelydemonstratedthroughtheexternalevaluationprocess.Forexample,participantsfromexternalevaluationorganisationsinlowandmiddle-incomecountriesattendinga2013workshopinBangkok,Thailandhighlightedthatstandardsareimportantintheircountriestoimprovetheoverallqualityofcareandnotjusttodifferentiatebetweenhospitalsthatpassanaccreditationvisitandthosethatdonot.Inmanylowandmiddle-incomecountries,institutionsthatfailtomeetstandardsmaystillbetheonlyavailablesourceofcareforpartsofthepopulationandtherefore,itisimportantthatthereisafocusonimprovingthecaretheydoprovide20.
4.2 Principles for standards
Standardsaredevelopedandwritteninmanydifferentwaysandaredesignedtomeetthepurposeandscopeoftheparticularexternalevaluationprogramme,asdiscussedinChapter2.However,theymustbeuser-friendly,abletomeetthepurposesforwhichtheyhavebeendesigned,andbeabletomeasureachievementinaconsistentway.Evidence-basedmechanismsbywhichstandardsaredeveloped,promulgated,reinforced,auditedandevaluatedareneeded.Linkingthewritingofstandards,includingthewording,structure,design,focusandcontent,todemonstratingimprovedoutcomesrequiresfurtherinvestigation27.
ISQuahasfocusedonaddressingthisgapbydevelopingprinciplestoguidethedevelopmentofhealthandsocialcarestandardsandenabletheirassessmentandaccreditation.Thesewereoriginallydevelopedin2000,andrevisedonnumerousoccasions.Themostrecent4theditionwaspublishedin20144.TheprinciplesarebasedontheInstituteforMedicine(IOM)qualitydimensions28,ofeffectivequalityperformance,efficientorganisationalperformance,safetyandpatientfocus.TheISQuaPrinciples(2014)4alsogiveguidanceonhowtodevelopandmeasurestandards.ISQuarecommendsthatthedevelopmentandcontentofallstandardsshouldmeetitsinternationallyacceptedbestpracticeprinciples.
Thepurposeofsomeexternalevaluationorganisationsistoassess,andsometimescertify,healthandsocialcareorganisationsagainstgovernmentstandardsorthestandardsofanotherexternalevaluationorganisation,perhapsadaptedtolocalcircumstances.Forthecredibilityofitsownassessments,theseorganisationsshouldencouragetheownersofthestandardstogetthemISQuaaccredited.
TheISQuaPrinciplescoverallthefunctionsofahealthcareorsocialcareorganisation,fromgovernance,tomanagement,toclientcare,toquality.Theyare:
1. StandardsDevelopment:Standardsareplanned,formulatedandevaluatedthroughadefinedandrigorousprocess.
2. StandardsMeasurement:Standardsenableconsistentandtransparentratingandmeasurementofachievement.
3. OrganisationalRole,PlanningandPerformance:Standardsassessthecapacityandefficiencyofhealthandsocialcareorganisations.
4. SafetyandRisk:Standardsincludemeasurestomanageriskandtoprotectthesafetyofpatients/serviceusers,staffandvisitors.
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5. Patient/ServiceUserFocus:Thestandardsfocusonpatients/serviceusersandreflectthecontinuumofcare.
6. QualityPerformance:Standardsrequireserviceproviderstoregularlymonitor,evaluateandimprovethequalityofservices4.
StepsfordevelopingstandardsinlinewiththeISQuaPrinciplesforStandards4include:
Reviewingotherexternalevaluationorganisationstandards,currentresearchandevidence,recognisedguidelines,recommendationsfromWHOandotherprofessionalorganisationsandexperts
Incorporatinglegislative,technicalandsafetyrequirements
Incorporatingbestpracticewhereevidenceisavailable
Ensuringthestandardsareclientfocused,coverthefunctionsorsystemsofawholeorganisationorservice,addressthedimensionsofquality,andsupportqualityimprovement
Consultingstakeholdergroups,includingconsumergroups
Involvingstakeholdersinstandardsdevelopmentcommitteesandworkinggroups
Developingtheratingsystemformeasuringcompliancewith/againstthestandards
Testingthestandardsandthewaytheyareratedthroughself-assessmentandpilotsurveys
Usingfeedbackfromtestingtoimprovethestandardsandratingsystem
Developingguidelinestoassistuserstointerpretandapplythestandards
Ensuringthestandardsareapprovedbytheexternalevaluationorganisationgoverningbody
ApplyingforISQuastandardsaccreditation.
Thisdevelopmentprocessmaytaketwoyearsormoreifthestandardsarebeingfullydeveloped.Withtherapidlychanginghealthcareenvironment,12monthswouldbeanappropriatetimeframefororganisationsadaptingotherorganisations’standards.
4.3 Referencing to quality dimensions
Standardscanbegroupedaroundqualitydimensionstodemonstratetheirrelationshiptoquality.ThesixqualitydimensionsasdefinedwithintheInstituteofMedicine(IOM)reportCrossingtheQualityChasm,arethemostcommonlyreferenced28.
Safe S
Timely T
Efficient E
Equitable E
Effective E
Patient-centered P
Bydefiningthedimensionsofquality,organisationsareabletoensurethattheirinclusioncanbejustifiedbutcanalsomeasureachievementinrelationtothosedimensions,demonstratingthatqualityisnotanoptionalextrabuttheessenceofagoodandacceptableservice.Whenstandardsaredevelopedthecriteriashouldaddressallofthequalitydimensions.
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Codesofpatient/consumerrightshavenowbeendevelopedoradoptedinmanycountries.Thesearedesignedtoprotectanindividual’srightswhentheyaccesshealthorsocialcareservicesanddescribewhattheirrightsarewhenaccessingsuchservices.Insomejurisdictions,thecodesofpatient/consumerrightsarespecifiedinorunderpinnedbylegislationandserviceprovidersarerequiredtohaveprocessesinplacetomeetthem.Insuchcasesthecodesofpatient/consumerrightsmaybereferencedinthestandardsasthiswillprovideameansofassessinghowserviceprovidersaremeetingpatient/consumerrights.Inothercountries,codesofpatient/consumerrightshavebeendevelopedbyorganisationssuchasnationalconsumeroradvocacyorganisationsandserviceprovidersmayadoptthemonavoluntarybasis.Referencingthecodesofpatient/consumerrightsinstandardsisonewayofhelpingtoensurethatstandardsarefocusedonthepatient/consumer.Thisinturnwillhelpserviceproviderstofocusondeliveringpatient/consumerfocusedcarethatmeetstheirneedsandprotectstheirrights.
Matureaccreditationorganisationshavenowmovedtodesigningtheirstandardstoreflectthepatient/consumerjourneyorpathwayandthensurveyorsmay,aspartofthesurveyprocess,traceorfollowselectedpatients’/consumers’journeystocheckateachstageifthestandardsweremetforthatindividualandtheirfamily.
Manysetsofstandardslabelsomecriteriaascoreorcompulsory,usuallybasedonsafetyandrisk.Thecorecriteriaareusuallythenrequiredtobemetoradefinedratioofthemmet,e.g.80%.Thesecorecriteriamaybeusedforlicensingorregulationpurposes.
4.4 Developing the measurement system
Theratingscaleshouldreflectthepurposeofthestandards,betransparentandenableuserstorateandmeasurestandards,criteriaorelementsconsistently.Ayes/noscaleisgoodfordeterminingcomplianceornon-compliancewithacriterionorstandard,especiallyformeasuringstructuralelements,soitsuseshouldreflectthenatureofthestandards.Itleaveslessscopeforrecommendationsforimprovementwhereacriterionismainlymet,butsomeelementsaremissing.
Likert-typeratingscalesareparticularlysuitedforstandardswithastrongqualityimprovementapproach,e.g.3,5or7pointscales,oftenwithdescriptionsforeachpointorsomeofthepoints.Thesedescriptionsmayrelatetoprinciplessuchascompliance,consistency,evidenceandimplementation.
Thereisatendencyforassessorstofavouramiddleorneutralpoint,soanevenpointscalesuchasafourpointscalecangiveaclearcut-offpointastowhetherthecriterionismetornotbutstillprovideagraduatedmeasureofhowwellitismetorhowbadlyitisnotmet.Theclearerthedescriptors,themoreconsistenttheassessmentsarelikelytobe.
Aswellasameasurementsystemforratingeachmeasureablecriterion,elementorstandard,asystemisneededtodetermineifthestandardsaremetoverallwhichwillbethebasisforawardingaccreditationorcertificationwherethatisapplicable.Inastudycomparingtheorganisationalattributesofaccreditationprogrammesinlow-andmiddle-incomecountrieswiththoseinhigher-incomecountries,itwasfoundthatthelow-andmiddle-incomecountries’programmesweremorelikelytouseaformulaicmathematicallyorientedapproachtomakeaccreditationdecisions7.Traditionally,accreditationorganisationsreliedonaccreditationpanelstomakedecisionsbutthiswasnotalwaysatransparentprocess,thebasisofthedecisionwasnotalwaysclear,itcouldbemorepronetobiasorexternalinfluenceandwasalsolikelytoresultinappealsagainstthedecision.
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Therefore,bestpracticeistodetermineoverallachievementofstandardsbasedonaformulawhichincludesthelevelofachievementoforcompliancewiththemeasureableelementsofthestandards,riskandotherelementsofthestandardssuchascorecriteriaorhighprioritycriteria.
Someorganisationsmeasureonlyatthecriterionlevel,sotheiroveralldecisionwillbebasedonachievementofcriteriawhileothersusetheoverallratingsofthecriteriawithineachstandardtorateachievementofthestandard,sotheiroveralldecisionwillbebasedonachievementofthestandards.Forexample,themethodologycouldbethatallcoreorcompulsorycriteriamustbemet,orallcriteriaorstandardsmustbemetatadefinedlevelsuchas3or4ona4pointscale,ornostandardsmustberatedatbelowacertainlevel.
Liketherestofthestandards,theratingscaleneedstobedevelopedinconsultationwithstakeholdersandthesatisfactionofusersregularlyassessed.Aswiththestandardsthemselves,theratingscaleneedstobetestedandpilotedbeforeusetoensureitisreliableandcanproduceconsistentandfairresults.
Thecasestudyexampleshighlighttheapproachestostandardsdevelopmentadoptedindifferentcountries.
Case Studies – Development of standards
IKAS – Danish Institute for Quality and Accreditation in Healthcare Country: Denmark
Range of standardsIKAShasdevelopedallstandardsusedinitsprogrammes.Theywerefirstdevelopedforhospitalsandcommunitypharmacies.Standardshavesincebeendevelopedforprimarycareservices,deliveredbymunicipalities,andforambulanceservices.Currentlystandardsarebeingdevelopedforgeneralpractitionersandspecialistphysicians.Overthecomingyears,allhealthcareprofessionswhooperateoutsideofhospitalsintheirownofficeorpremiseswillbecovered.
Development processStandardsweredevelopedbythemegroups(forrelatedgroupsofstandards)ofstandarddevelopers,consistingofseniorprofessionals,appointedbytheRegionsandtheAssociationofDanishPharmacies.IKASandHQS/CHKSservedasadvisorsandsecretariatforthegroups.
Rating scaleCompliancewithstandardsisassessedbyscoringanumberofelements(forthehospitalstandardsroughly450)accordingtoafourpointscale(Fully/Largely/Partially/NotMet),wherethetwoupperlevelsindicateasatisfactoryperformance(exceptforcertainsafetycriticalstandards,whereonlyFullyMetisconsideredsatisfactory).Anyelementnotmettosatisfactionwillrequirefollowup,andifnotcorrected,resultsinaccreditationwithcomments.AnAccreditationAwardPaneldecides,guidedbycertainrules,whetherthenatureand/oramountofthecommentsprecludeaccreditation–ifso,statusas“notaccredited”isawardedandpublished.
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Health Care Accreditation Council (HCAC) Country: Jordan
Range of standardsAsthenationalaccreditationagencyofJordan,HCACsetsstandardsforhospitals,primaryhealthcarecentres,familyplanningandreproductivehealth,transportservices(ambulances),cardiaccare,anddiabetesmellitus.HCACsurveysagainstthestandardsandawardsaccreditation.
Development processAllthestandardsaredevelopedinJordan.Nostandardsdevelopedbyotherorganisationsareused.Hospitalstandardsweredevelopedfirst,thenstandardsforprimarycarecentres,familyplanningandreproductivehealth,transportservices(ambulances),cardiaccare,anddiabetesmellitus.
Rating scaleStandardsareclassifiedascritical,coreandstretch.100%ofcriticalstandardsmustbemet;andaspecifiedpercentageofbothcoreandstretchstandardsmustbemetinorderforaservicetobeaccredited.
Health and Disability Auditing New Zealand Ltd (HDANZ) Country: New Zealand
HDANZisaprivate,independentlyownedcompany.ItislinkedtogovernmentasaMinistryofHealth(MOH)approveddesignatedauditingagency.HDANZauditstheseservicesonbehalfoftheMOHandsubmitsauditreportstotheMOHwhothenissuesthecertificatestotheservices.
ServiceproviderspayfeestoHDANZforsurveyandmonitoringvisits.CertificationhasbeenmandatoryfortheMOHSafetyActsinceOctober2002.FromSeptember2005,itbecamemandatoryforphysiotherapyservicesiftheywantedtoprovideservicesundertheNewZealandAccidentCompensationScheme(ACC)physiotherapyservicescontract.FromSeptember2012,healthfundersmadecertificationmandatoryforhomesupportprovidersandfromMarch2013,ahealthinsuranceproviderSouthernCrossHealthSocietymadecertificationmandatoryfortheiraffiliatedproviders.
Theratingscaleforcomplianceagainstthehealthanddisabilitysectorstandardsis:
CI=Continuousimprovement
FA=Fullyattained
PA=Partiallyattained
UA=Unattained
TheMinistryofHealthusestheassessmentratingstodeterminecertification.Thelengthofcertificationcanvaryfromonetofouryearsdependingonthelevelofachievementofthestandards.
Thenextchapteroutlinesthefactorstobeconsideredindevelopingassessmentmethodologies.
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Chapter 5: Developing assessment methodologiesThischapterexploresfactorstobeconsideredinthedevelopmentoftheassessmentmethodologysuchastheselection,trainingandevaluationofsurveyors;thedevelopmentofthesurveymanagementprocess;andtheestablishmentofprocessesfordeterminingtheaccreditationorcertificationstatus.
Asurveyagainststandardscanbeachievedbyeitheradesktoprevieworanon-sitesurvey.Desktopreviewsmaybesuitableforsomespecialitiessuchasdiagnosticimagingorclinicalpathwayssuchasstrokecare.Fororganisationsanon-sitesurveyisrecommended,whichcanbeplannedorunannounced.
Surveyorsarethemaininterfaceoftheexternalevaluationorganisationwithitsclients,andthesurveyisthekeyeventonwhichtheclientswilljudgetheorganisation.Itisessentialthatsurveyorsandthesurveyandawardprocessesaremanagedconsistently,transparentlyandwell.
5.1 Selection, training and evaluation of surveyors
Accreditationorganisationsgenerallyusetheterm“surveyors”whilecertificationorganisationsusuallyusetheterms“assessors”or“auditors”todescribethepersonnelwhovisit,assessanddraftreports.Regulatorybodiesmayusetheterm“inspectors”.Theyarecentraltothecredibility,objectivityandsustainabilityoftheorganisation.Accreditationsurveyorsaregenerallyregardedaspeerreviewers–doctors,nurses,managersandalliedhealthprofessionals–whounderstandtheworktheirpeersdobuttheirroleistoassessprocessesandsystemsratherthantheirpeers’performance.Auditorsareprofessionalqualityauditors,usuallycertifiedassuch,whocanauditorassessacrossindustriesanddonotneedtobeahealthcareprofessionalpeer.Inthisguidetheterm“surveyor”isusedtocoverallassessmentpersonnelandtheterm“survey”tocoverallexternalassessments.
Paid or voluntary?
AspreviouslyhighlightedinChapter3(SeeSection3.3Fundingoftheprogramme),accreditationorganisationshavetraditionallyrelieduponparticipatingaccreditedinstitutionstoprovideorloanstafftoworkassurveyorsandtopromotetheconceptofpeerreview.Thishastheadvantageofreducingsurveycosts,maintainingtheacceptabilityandindependenceofpeerreview,andsharingtheexperienceandknowledgeofaccreditationwidelythroughoutthehealthsystem.However,itassumesthattherearepersonnelwithenoughexperiencewhoareableandwillingtobesecondedbytheiremployerstobetrainedassurveyorswithoutcreatingaconflictofinterest.Tomaintainskilllevelsandcurrencywithstandardsandsystems,surveyorsshouldbeexpectedtoundertakeaminimumnumberofworkingdays(usuallyten)ayear.Itcanbeachallengeforthemtogetreleasedfromtheirfull-timejobforthisamountoftime.
Certificationorganisationsusuallyemployorcontracttheirassessmentpersonnelonapaidbasis,supplementedbytechnicalexperts.However,ashighlightedinChapter3(SeeSection3.3Fundingoftheprogramme),accreditationorganisationsarenowalsoincreasinglypayingsurveyorsasemployedorcontractedpersonnel,orusingamixofbothpaidandvoluntary.Surveyorsmostlycomefromahealthbackgroundandhavepreviouslybeeninvolvedinaccreditationprogrammes.
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Theadvantagesofhavingamorestableworkforceofpaidsurveyorsistheirgreateravailability,thereducednumberofsurveyorsneeded,reduceddemandforrecruitmentcampaignsandnewtrainingprogrammesandmorereliableandconsistentperformanceoftherolebecauseoftheincreasedfrequencyofundertakingsurveysandwritingreports.
Selecting and appointing
Thefirststepsindevelopingasurveyorworkforceareto:
Determinethenumber,skillmixandmixofpaid/employedorvoluntarysurveyorsneededfortheplannedprogrammeofwork(thenumberswillneedtobeincreasedasmoreorganisationsjointheprogramme)
Definetherequiredcompetencies,includingpersonalattributes,professionalqualificationsandexperience,knowledgeandskillsetsrelevanttotheprogramme.
Thenumberofsurveyorstoberecruitedshouldbeestimatedfromthevolumeofsurveysplanned,theirduration(intermsofsurveyordays),thenumberofdayseachsurveyorwouldprovideperyear,thenumberofsurveyorswithdrawingeachyearandthepaid/voluntarymixofsurveyors.Theirprofessionalbackground,cultureandskillsshouldreflectthefunctionandscopeoftheprogramme.Recruitmentmaybedonebyadvertisinginrelevantpublications,sendingnoticestoallpotentialclientorganisationsandprofessionalassociations,anddirectlyapproachinglikelycandidates.
Surveyorsshouldbeappointedthroughaclearlystatedandfairlyappliedprocessinaccordancewiththedefinedcompetenciesandthenumbersdetermined.Competenciescouldinclude:
Personalattributes,includingtheabilitytocommunicateeffectivelyandtoworkasateammember
Professionalqualificationsandexperience,usuallyataseniorlevel
Currenthealthcareorsocialcaresectorknowledge
Skillsintheareascoveredbytheprogramme.
Whethersurveyorsareseconded(ontheirusualsalary),oremployeddirectlybytheexternalevaluationorganisation,theymustbecommittedtocomplywiththerulesofthatorganisation,particularlywithrespecttoconfidentialityandindependence.Iftheexternalevaluationorganisationemploysthemdirectly,itmayhavetoacceptadditionallegalresponsibilityandhavetoprovideadditionalliabilityinsurance.
Trainingtobeasurveyorandundertakingtheroleisaformofprofessionaldevelopmentandisrecognisedassuchbymanyprofessionalcollegesandassociations.Surveyorsbecomefamiliarwiththestandardsandsurveyprocessesandareabletolearnfortheirownpracticefromwhattheyobserveintheorganisationsinwhichtheysurvey.Theyinturnbecomeeducatorsofthestafftheysurvey,abletoidentifyareaswheretheycanimproveandbestpracticemethodsortoolstheycoulduse.
Training
Afterselection,surveyorswillthenneedtobeeitheremployedorcontracted,andtrainedandorientedtotherole.Trainingcannotbeginuntilatleastdraftstandardsandproceduresareavailable.Inestablishedorganisations,trainingisprovidedbyexistingsurveyorsandstaff;neworganisationsgenerallyuseexpertisefromotherprogrammes,atleastforinitialtraining.
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Theinitialtrainingprogrammecanbeofonetofivedaysdurationandshouldcovertopicssuchas:
Standards’interpretation
Surveyprocess
Interviewingandobservationskills
Documentationreview
Specificareas,e.g.safety,infectioncontrol
Reportwritingtechniques
Traineesthenneedtobeevaluatedtodeterminetheirsuitabilityfortherole.Mockassessmentsareoftenincludedsothattraineescandemonstratetheiraptitude.Theythenusuallygoononeormoresurveyvisitsasobserversortraineeswithamentortoaccustomthemtotheroleandfurthertesttheirsuitability.Theyneedmanualsandotherresourcestoassistthem.Programmesareincreasinglyusingtechnologyon-sitefortherecordingoftheassessmentanduseofthisalsoneedstobepartofthetraining.
Thesurveyortrainingprogrammeofaccreditationorganisationsinlow-andmiddle-incomecountriestendtobesurveyorcertificationprogrammesandorganisationsindevelopedcountriesarealsomovinginthisdirection.Suchcertificationprovidesarecognisedstatusforthesurveyorbutmayalsoprovidetheopportunityformorerigorousevaluationofperformanceandongoingtraininganddevelopment.Certificationprogrammesgenerallyexpecttheirauditorsorassessorstobecertified.
Ongoing development and evaluation
Surveyorsmustbeprovidedwithongoingtraininganddevelopmentopportunities,andbeevaluatedregularlytoensuretheirongoingcompetence.Externalevaluationorganisationsneedtodefinecriteriaforselecting,training,retraininganddeselectingsurveyors.Someorganisationshaveanindependentcommitteetomonitorinter-raterreliabilityofthesurveyandratingperformanceofsurveyorsand/orsatisfactionsurveysbyanindependentthirdparty,aswellasin-housesurveyteamassessments.Itiscommontoaskclientorganisationstoevaluatethestandards,thesurvey,andtheperformanceofthesurveyorsaftertheexternalsurvey.Theseevaluationsaremostusefuliftheyrelatetotheindividualsratherthanjusttheteam.Allthesereports,andparticipationincontinuingtraining,contributetothesystematicappraisalofeachsurveyor.
Wherethereisasurveyorcertificationprogramme,surveyorsmustmeettheannualrequirementstomaintaintheircertification.
TheISQuaSurveyorTrainingProgrammeStandards(2009)5provideguidanceonsettingupthesetrainingprogrammeswhichcanthenbeISQuaaccredited.TheISQuaGuidelinesandStandardsforExternalEvaluationOrganisationsalsocontainastandard(Standard6)onsurveyormanagement3.
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5.2 Developing the survey management process
Contracting with the client organisation
Thereshouldbeadefinedprocesstoensurethatparticipatingorganisationsareawareoftheirrightsandresponsibilitiesinrelationtotheexternalevaluationprogramme,andthattheyunderstandtheproceduresandresponsibilitiesoftheprogramme.Thisusuallyinvolvesastandardcontractorserviceagreementbetweentheapplicanthealthcareorsocialcareorganisationandtheexternalevaluationprogramme.
Trainingandeducationalsupportareoftenprovidedbytheprogrammeforthestaffoftheclientorganisationasanintegralpartofthepreparatoryprocess.Thismayincludeforexample:projectmanagertraining,standardsinterpretation,andinternalassessmentandself-assessmenttraining.Whereself-assessmentisacomponentofitsprogramme,theexternalevaluationorganisation’sstaffcanguidetheclientastohowtoundertakeandcompletethis.Self-assessmentagainstthepublishedstandardsdevelopsinsightandcommitment,andreducestheburdenofexternalassessmentbecauseithelpsorganisationstoidentify,understandandresolvetheirownproblems.Manyprogrammesconsiderthisinternalisationtobeakeyfactorintherapidlyincreasingcompliancewithstandardswhichcanbedemonstratedinparticipatingorganisationsinthemonthspriortoexternalsurvey.Itisimportanttodeterminewhatisincludedwithintheprogrammefeesandwhattraining/educationalsupportisprovidedatanadditionalfee.
Manyprogrammesprovidefacilitators,suchasprogrammestaffortrainedsurveyors,tosupportclientorganisationstoprepareonfirstenteringtheprogramme,andtofeedbacktotheprogrammeanyproblemswithsystemsorprocesses.Thisacknowledgesthattheearlyexternalsurveysareasmuchatestofthestandards,surveyorsandproceduresastheyareoftheorganisationbeingvisited.Thefacilitatorsshouldnotbepermittedtotakepartinorinfluencetheexternalsurvey.Theycanarrangetraining,participateasatrainer,adviseclientsoninterpretationofthestandardsorwhatneedstobeinplacetomeetthestandardsbuttheycanonlyprovidegenericadvicethatisfreelyavailableinthepublicdomain.Theymustnotgiveanyadviceonhowthingsshouldbedoneorprovideanytechnicalassistancesuchaspreparingorproducingdocumentationorprocedures,orgivingclient-specificadvice,instructionsorsolutions.Thiswouldberegardedasconsultancywhichmustbestrictlyseparatedfromexternalevaluationactivities.
Apre-surveyreviewormocksurveycanalsobeavaluablepartofpreparation.Itidentifieswhethertheclientorganisationisinterpretingthestandardscorrectlyandhasappropriatedocumentationasevidenceofhowitmeetsdifferentcriteriaaswellasindicatingtheclient’sprogresstowardssurveyreadiness.Italsoprovidesagoodpracticerunforstaffsotheyknowwhattoexpectfromtheactualsurvey.
Planning and conducting the survey
Planningthescopeofthesurvey,durationandthesizeofthesurveyteamshouldbetransparent,basedontheneedsoftheorganisationandthepoliciesoftheexternalevaluationbody.Thesurveyorteamfortheexternalsurveyshouldincludeanappropriatemixofskillsandexperienceandavoidconflict(s)ofinterest.Amoreexperiencedteamleaderisgenerallychosentoguidetheprocess.Datesfortheexternalsurveyareusuallyset6-12monthsinadvancetoallowforself-assessmentandpreparationandpossiblyamocksurvey.
Thestandardsmustbeincorporatedintoatoolinwhichsurveyorscanmakefindings,ratingsandrecommendationsforimprovement.Theself-assessmentcanbeincludedinthetoolifthisispartoftheprocess.Thetoolmaybeonpaperorloadedintoatabletorsimilartechnologicaldevice.
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Sitevisitsmayextendfromhalfadayforonesurveyorforasmallruralprimarycareclinictotwoweeksforlargeteamsforahealthcarenetwork.Smallhospitalsorresthomesoftenusetwopeoplefortwodays(foursurveyordays);largeronescommonlyusethreepeopleforfivedays.Timeforsurveyorpreparation,travel,teambriefingandreportcompletionmustbeaddedtothese“on-site”estimates.Attheendofthevisit,mostorganisationsprovidetimefortheteamtoprepareareportbackoffindingswhichtheypresentatameetingtotheleadershipoftheclientorganisationandpreferablyalsotostaff.Thisenablestheclienttocorrectanyerrorsatthetimeandmeansthereshouldbenosurpriseswhentheyreceivethefinalreport.
Theefficiencyofthesurveyvisitandthetransparencyandconsistencyoftheprocesscanbeimprovedthroughtheprovisionoftoolsandguidelinestoassistthesurveyors;thoroughpreparationbytheorganisationbeingsurveyedandthesurveyors;thetimelysubmissionofcompleteandaccurateself-assessmentsandotherpre-visitdocuments;arealisticsurveytimetable;explicitsamplingprocedures;specifieddocumentsbeingmadereadilyavailableforreviewonsite;andtimemanagement.Increasingthenumberofsurveyordaysmaynothelp,butwillcertainlyincreasethecomplexityandcostofthevisit.
Writing the report
Thesurveyorswriteareportoftheirfindingsandratingofachievementagainstthestandardseitherwhilestillon-siteattheendofthevisitorafterwards.Doingthiselectronicallycontributestothespeedwithwhichthereportcanbesubmitted.Newexternalevaluationorganisationsshouldincludethee-generationofthereportaspartoftheirprogrammeifpossible.Itisimportantthatstricttimelinesareputonthisprocess,otherwisethesurveyorscangetbacktotheirusualworkplaceandtrytocatchuponthatworkbeforefinishingthereport.Adelayatthisstageleadstoadelayinmakingtheawarddecisionwhichisfrustratingfortheclient.Thereportissubmittedtotheexternalevaluationorganisationwhichmusthaveprocessesforeditingandreviewingthereportstoensuretheyarecomplete,accurate,balanced,constructiveandconsistentwiththeintentofthestandards.
Performance indicators
Theexternalevaluationorganisationshoulddeterminewhatindicatorsitrequiresitsclientorganisationstomonitor.Theseshouldcoverthedifferentmanagement,safetyandclinicalfunctionsofthehealthcareorganisationandmayincludethingssuchascomplaints,patient/clientsatisfaction,staffsatisfaction,staffturnover,financialratios,adverseevents,accidents,clinicalindicatorssuchasfallsandinfections,andmedicationerrors.Thesedemonstratethattheclientorganisationhasthecapacitytogenerateandanalyseperformancedataaspartofaninternalqualityimprovementprogrammeandisusingtheresultstomakeimprovements.
Sometimesthecollection,analysisandpublicationoftheresultsofindicatordataispartofthescopeoftheexternalevaluationorganisation.Inthesecases,theremustbeprocessestoensuretheindicatorshavestandardiseddefinitionsandnumeratorsanddenominators,thatthedatacollectedisclean,complete,accurateandtimely.Thedatacanthenprovidecomparablemeasuresofachievementovertimeforahealthcareorganisationorbetweensimilarorganisationsintermsofprocessesandoutcomesinclinical,safety,financialorotherareas3.
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5.3 Establishing the accreditation / certification process
Responsibilities for accreditation / certification
Theexternalevaluationorganisationisresponsibleforsettingthecriteriafordeterminingaccreditationorcertificationstatus,andthedecisiononwhetherornottograntaccreditationstatusismadeinaccordancewiththecriteriaonthebasisofthefindingsinthesurveyreport.Thesecriteriashouldensure:
Transparencyfororganisationsbeingaccreditedorcertified,forsurveyorsandforthepublic
Considerationfortheclientsoftheserviceandtheirsafety
Decisionsbasedontheachievementofthestandards
Considerationofhowaccreditationorcertificationstatuswillfacilitatefurtherqualityimprovement
Consistencybetweenawarddecisions
Anon-adversarialprocessforappeals.
Basis for recognition decisions
Earlierprogrammesbasedtherecognitiondecisionoraccreditationstatusprimarilyonthecapacityforgoodclinicalcare,demonstratedbycompliancewithaccreditationstandards,buttheemphasishasnowshiftedtowardsoverallperformance.Neweraccreditationprogrammes,especiallyindevelopingandunder-resourcedcountries,mayneed,atleastinitially,tofocusonandtorewardtheexistenceofbasicinfrastructureanddemonstratedprogresstowards,ratherthanabsolutecompliancewith,thepublishedstandards.Differentprogrammesmayhavedifferentpriorityconcerns,e.g.criticalfunctionalareassuchaspatientcare,infectioncontrol,qualityimprovementormanagementoftheenvironment;patientsafetygoalssuchaspatientidentification,highalertmedications,wrong-sitesurgeryorcommunicationamongcaregivers;orareasofdifficultysuchasinformationflow,patientrecordsormedicalequipmentsurveillance.
Incasethereisanydisputeabouttherecognitiondecision,atransparent,independentandclearlydescribedappealsprocessisnecessary.
Timeframe for recognition decisions
Havingworkedhardtopreparefortheexternalsurvey,staffandmanagementofclientorganisationsareeagertoreceiveatimelydecisionfromtheexternalevaluationorganisation.Manyprogrammesstillaimtoprovidethemajorityofdecisionswithintwomonthsofthesurvey,althoughthoseusingelectronictechnologyforreportsandformulaiccriteriafordecisionmakingareabletomakethedecisionsmuchquicker.Asthedelayincreases,thereportanddecisionbecomeincreasinglyirrelevant,staffbecomedemotivatedandimprovementisnotsustained.Theadjudicationprocessmustthereforebetransparentandthorough,butalsotimely.
Duration and maintenance of accreditation
Accreditationstatusisnormallyawardedforaperiodofbetweenoneandfouryears.Sometimestherearedifferentgradesofachievement,e.g.conditional,orwithcommendations,orexemplary.ISQuacriterianowrequiremonitoringbytheexternalevaluationorganisationofthecontinuedmaintenanceofstandardsandqualityimprovementsbyaccreditedorcertifiedorganisations.
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Monitoringcouldincludesubmissionofanactionplanfollowingtheawardwithtimeframesformakingimprovementsrecommendedinthereportandregularupdatesonprogresswithimplementation.Inmostprogrammes,themajorityofreportrecommendationsaftertheexternalsurveyareaboutimprovingsystemsintheorganisationratherthanaboutincreasingresourcesand,aswiththepreparation,theorganisationshouldbeincurringmuchofthatcostanywaysoitshouldnotbeabarriertoimprovement.Othermonitoringmayrequireareviewofspecifieddocumentsthatweredeemedincomplete,inadequateormissing;annualormid-termvisitsandrandomreviews.Longerintervalsbetweenexternalsurveystendtoinstilafalsesenseofsecurityandremovethemomentumforinternalimprovement.
Publication of results
Theextentandmethodsofpublicdisclosureofsurveyfindingsandaccreditationorcertificationawardsmustbeagreedinadvancebytheexternalevaluationorganisationandthevariousstakeholders.Thepublicshouldhaveaccesstoinformationaboutwhichorganisationsareaccreditedorcertified.Someorganisationsarenowpublishingthesurveyreportsorasummaryofthem.Regulatorybodiesareusuallymandatedtopublishfullreports.
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Example: Public disclosure of accreditation reports: Japan
TheJapanCouncilforQualityHealthCare(JCQHC)wasfoundedin1995andhasdevelopedstandardsandcriteriaforaccreditationandbegancarryingouton-siteassessmentsin1997.JapanhasauniversalhealthinsurancesystemandsoJapanesepeoplehavearighttoreceivemedicalcareatanyhealthcareorganisationandhospitalscannotrefuseanypatients.Hospitalaccreditationisvoluntaryandrequiresanapplicationfee.HospitalsreceivescoresforeachiteminallareaswithcommentsfromJCQHCinthestandardaccreditationprocess.TherearetwoformsofdisclosureofhospitalaccreditationreportsinJapan:
1. Self-disclosuretothepublicdirectlybyhospitals;
2. DisclosurebytheJCQHCwithagreementfromthehospitalconcerned.
Hospitalsarenotpermittedtodiscloseonlyselectedpartsoftheiraccreditationreportasthepurposeofdisclosureofaccreditationreportsistogiveconsumersaccessnotonlytofavourableaspectsofthereportbutalsotoinformationaboutthoseaspectsoftheservicethatrequireimprovement.ThedatadisclosedbytheJCQHCtothepublicincludesummarycommentsandaccreditationscoresforalltheitemsassessed.
AstudywasperformedinJapantoexaminetheassociationbetweenaccreditationscoresandthedisclosureofaccreditationreports.Thisincludedaquestionnairetohospitalswhodisclosedtheiraccreditationreportstogatherdataabouthospitalcharacteristicsalongwithperceptionsaboutthepublicdisclosureofaccreditationreports.Atotalof547ofthe817hospitalsaccreditedbyJCQHCparticipatedinthestudy.Commentsaboutthedisclosureofaccreditationreportswerecategorisedintofivegeneralsubjectareas:(1)impactofdisclosureonthepublic,(2)advantagestothehospital,(3)riskstothehospital,(4)JCQHCdisclosure,and(5)hospitalself-disclosureofinformation—thatis,voluntarydisclosurebythehospitalby,forexample,apamphletoranoticeonallbillboardsinthehospital.Feedbackfromparticipatinghospitals,highlightedthatmosthospitals(60%)perceivedisclosureasgoodforconsumersandhospitals;withmosthospitalswhodisclosedtheirreportstotheJCQHC(80.5%)agreeingthat“disclosureprovidesincentivesforimprovingthequalityofcarebecauseconsumersinthecommunityreadaccreditationreports”.
Atotalof508(93%)oftheparticipatinghospitalsdisclosedtheiraccreditationreportsontheJCQHCwebsite.Publichospitalsweresignificantlymorecommittedtopublicdisclosurethanprivatehospitals,andlargerhospitalsweresignificantlymorelikelytoparticipateinpublicdisclosurethansmallerhospitals.Accreditationscoreswerepositivelyrelatedtothepublicdisclosureofhospitalaccreditationreports.Scoresforpatientfocusedcareandeffortstomeetcommunityneedsweresignificantlyhigherinactivelydisclosinghospitalsthaninnon-disclosinghospitals.Amongthelargehospitals,scoresforsafetymanagementweresignificantlyhigherinhospitalsadvocatingdisclosurethaninnon-disclosinghospitals.
MosthospitalswhoagreedtodisclosurebytheJCQHC(410/508–80.7%)reportedthattheirpublicdisclosurewashelpful.Atotalof489ofthe547respondents(89.4%)indicatedthattheyalsodisclosedtheiraccreditationreportsthemselves:366disclosedonlytheiraccreditationstatusand123disclosedmorethanthis.ThestudyfoundthatsignificantlymoreofthehospitalswhoagreedtodisclosureoftheirreportbytheJCQHCalsoreleasedinformationthanthosewhowerenotinfavourofdisclosurebytheJCQHC.
Thestudyfindingssuggestthatpublicdisclosureofaccreditationreportsshouldbeencouragedtoimprovepublicaccountabilityandthequalityofcare.Theauthorshighlightedthatthereisaneedforfurtherresearchtoexploretheinteractionbetweenpublicdisclosure,processesandoutcomes29.
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5.4 Quality Assurance
Externalevaluationorganisationsneedtobeabletodemonstratetheirintegrity,objectivityandreliability.Mechanismsinclude:
Theprogramme’sstandards,surveyprocessesandcriteriaforaccreditationorcertificationawardsaremadepubliclyavailable
Surveyorsareselected,trainedandevaluatedagainstexplicitpublishedcriteria
Surveyteamsaretailoredtoeachindividualclientorganisation,accordingtopublishedcriteria,toavoidanyconflictofinterest
Thesurveyteamreportsinitialfindingsbacktotheclientorganisationbeforeleavingthesite,especiallyinrelationtothoselikelytogeneraterecommendations,inordertochecktheobservationandtoensuretherearenosurpriseslater
Teamreportsarepreparedandagreedjointlyandincompliancewithprocedureswhichareoftendefinedinasurveyors’handbook
Teamreportsareindependentlycheckedwithintheexternalevaluationorganisationforcontent,consistencyandcompliancewithprocedures
Finaldraftreportsarereferredtotheclientorganisationforverificationbeforetheaccreditationorcertificationdecision
Accreditationorcertificationawardsaremadebyapanelorstaffindependentoftheprocess,basedontheteam’sreportandinlinewithdefineddecision-makingcriteriaorformulae,notbytheteamitself3.
Thefinalchapterwilllookatevaluationsystemsthatneedtobeestablished.
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Chapter 6: Evaluating systems and achievementsExternalevaluationorganisationsneedtosetanexampleofqualityimprovementwithintheirownorganisation.Thisincludesdefining,monitoringandimprovingtheirownperformance.Thischapteroutlinessomeofthemechanismswhichexternalevaluationorganisationscanemploytodothis.
6.1 Measuring performance internally
Internalaudits,indicatorsandqualityimprovementprojectswillformpartoftheoverallqualityframeworkoftheorganisation.
Indicatordataroutinelycollectedbyexternalevaluationorganisationsandreportedtogoverningboardsinclude:
Recruitment,drop-outofparticipatingorganisations
Denialrate(proportionoforganisationsrefusedaccreditationorcertification)
Reportturnaroundtimes(fromsurveydatetofinalreportortoawarddecision)
Financialperformance,suchasactualagainstbudgetandvariousfinancialratios
Websitehits
Surveyorrecruitment,trainingandevaluation
Clientsatisfactionwithsurveyors,educationservices,thesurveyprocess,thesurveyvisitandotherproductsprovidedbytheprogramme
Staffsatisfaction
Surveyorsatisfaction
Satisfactionofotherstakeholders.
TheISQuaorganisationstandardsrequiretheexternalevaluationorganisationtoevaluatetheperformanceofvariousfunctions(suchasgovernance,humanresourcesmanagement,surveyorandsurveymanagementandaccreditationorcertificationprocessesandoutcomes),bycollectingdataondefinedindicatorsandothermeasuresofperformance,analysingit,makingimprovementsandevaluatingachievements3.
Externalevaluationorganisationstypicallyundertakemanydevelopmentandimprovementinitiatives.Theseneedtobetreatedasqualityprojectsandtheobjectives,actions,timeframes,responsibilities,progressandresultsdocumented.TheseprojectdocumentswillformanimportantpartoftheevidenceneededwhentheorganisationundergoesitsownexternalevaluationsurveythroughISQua.
Auditsneedtobescheduled,resultsdocumentedandactionstakenasaresultrecordedandevaluated.Auditscanaddressanumberofareas;forexample,auditscanbeconductedofstaff,surveyorandclientrecords;awarddecisions;healthandsafety;andthecomplaintsregister.
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6.2 Evaluating independently
Independentevaluationsofnewaccreditationorganisationshavebeencommissioned,oftenbygovernmentsorasconditionsofreceivinginitialdevelopmentfunding.ExamplesfromAustralia,SouthAfrica,ZambiaandtheUKdocumentbenefitsperceivedbyorganisationsandtheirusers,butincludelittledataonindividualorpopulationhealthimprovements1.
AWHOstudyofexternalqualityassessmentprogrammesformaternalandchildhealthconcludedin2002thatthesebringbenefitstoclients,thecommunity,staffandtheservice,summarisedas30:
Thelinkages,networksandstructureswhichhavebeendevelopedand/orimprovedtoinfluencethepolitical,legislative,economic,socio-culturalandpublichealthenvironmentwithinwhichservicesoperate(enablingmechanisms)
Thereorganisationand/ordevelopmentofthehealthcaredeliverysystemsattheservicelevel
Thechangeinattitudeand/ordevelopmentofskillsandknowledgeofhealthservicestaff
Improvementstohealthfacilitiesandequipment
Aclient-centredandclients’rightsapproachtohealthcarewherebyservicesconsultwithandsupportclients,areneedsbasedandabletodeliverbettercaretoclientsandthecommunity.
6.3 Monitoring by regulatory agencies
Someregulatorybodies,e.g.inUSAandCanada,monitorindependentaccreditationprogrammes,primarilybyrepresentationonthegoverningboardorbychecksonselectedsurveys.ThefederalgovernmentfollowTheJointCommissioninto5%ofsurveysin“deemedstatus”hospitalswithinafewweeksofthevisittovalidatereports;theNationalCommitteeforQualityAssurance(NCQA)inUSAhasaproportionofco-visits;andtheAccreditationAssociationforAmbulatoryHealthCare(AAAHC)hasasimilarproportionofpost-accreditationvalidationsurveysofambulatorycarecentres.InSouthAfrica,theprovincialgovernment,whichisalsothecontractor,providesmonitoringbyco-visiting.InNewZealand,theMinistryofHealtharrangesmonitoringauditsof5%ofallcertificationauditsundertakenbyindependentdesignatedauditagencies1.
6.4 Accrediting the external evaluation bodies
TheInternationalSocietyforQualityinHealthCare’s(ISQua’s)InternationalAccreditationProgrammehasbeeninexistencesince1999and“accreditstheaccreditors”.Thescopeoftheprogrammehasbeenextendedfromtheevaluationofnationalhealthcareaccreditationorganisations,theirstandardsandsurveyortraining,toincludeotherstandardsbasedcertificationandauditorganisations.
TheInternationalAccreditationProgramme(IAP)providesthreeproductsforhealthandsocialcareexternalevaluationbodies:
Surveyandaccreditationtointernationalstandardsforexternalevaluationorganisations
Standardsassessmentandaccreditationtointernationalprinciplesforhealthcareandsocialcarestandards
Assessmentandaccreditationofsurveyortrainingprogrammes.
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Theinternationalstandardsforexternalevaluationorganisationsaretheoutcomeofseveralyearsofdevelopment,testing,peerreviewandconsultationwiththeinternationalaccreditationcommunity.Theyweredesignedtoaddressthequalityofallaspectsandfunctionsofanaccreditationbody,broadlyincorporatingtheInternationalStandardsOrganisation(ISO)requirementsforcertificationbodies,theBaldrigecriteriaforperformanceexcellence,andcriteriafororganisationalexcellencefromtheaccreditationstandardsofanumberofnationalaccreditationbodies.Thesestandardsassessthekeybusinessfunctionsaswellasbestpracticeinassessmentmethodologies,surveyormanagementandawardrecognition.
Thestandardsandprinciplesandtheircriteriaareintendedtoguideexternalevaluationorganisationsintheirdevelopmentbyidentifyingbestpracticeprocessesandsystemsandprovidinganassessmentprocessandrecognitionsystemforachievementofthese.
Manysmalleranddevelopingprogrammescannotjustifytheresourcesrequiredforfullinternationalrecognitionbuttheycouldembarkonadefinedprogressionofdevelopmentandstandardisationstartingfromself-assessment,topeerreview,andaimingeventuallyforinternationalaccreditation.
ISQuaprovidestechnicalandadvisoryservicessuchasself-assessmentreviewandmocksurveystoassistexternalevaluationorganisationsdeveloptheirprogrammesandprepareforinternationalaccreditation.
ISQuarequiresatleastonesetoftheorganisation’sstandardstobeISQuaaccreditedbeforetheorganisationcanentertheorganisationaccreditationprogramme.
ConclusionsThisdocumenthasaimedtohighlightsomeofthequestions,issuesandchallengeswhichneedtobeaddressedbeforedecidingonandimplementinganexternalevaluationprogramme.Thedecisionsmademustbespecifictothevalues,healthpoliciesorstrategiesandorganisationsofindividualcountries,regionsandcaresectors.Stepshavebeenidentifiedthatneedtobetakentoensurethatthefoundationissetforasustainableorganisation.Theordermaybedifferent,butthefundamentalsmustbeestablishedfirst.Somestepsmaybedoneinparallel,forexampleobtainingfunding,negotiatingincentivesanddevelopingstandards,orestablishingthegovernanceframeworkandmanagementsystems.
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Useful web resourcesTheInternationalSocietyforQualityinHealthCare(ISQua)isnotresponsibleforexternalwebsitecontent.PleasenotethatmanyorganisationshaveEnglishlanguagecontentontheirwebsitesandwherepossiblethedirectlinktosuchmaterialisprovided.However,insomeinstancesthewebsitecontentisonlyavailableinthenativelanguage.
AccreditationCanada http://accreditation.ca/
AgencyforQualityandAccreditationinHealthandSocialWelfare,Croatia
http://aaz.hr/
AmericanAccreditationCouncil http://www.americanaccreditationcouncil.com/
AmericanAssociationforAccreditationofAmbulatorySurgeryFacilitiesInternational
http://www.aaaasfi.org/
AmericanAssociationofBloodBanks http://www.aabb.org/
AustralianAgedCareQualityAgency http://www.aacqa.gov.au/
AustralianCommissiononSafetyandQualityinHealthCare
http://www.safetyandquality.gov.au/
AustralianGeneralPracticeAccreditationLtd(AGPAL)
http://www.agpal.com.au/
CanadianAccreditationCouncil http://www.cacohs.com/
CHKS,UnitedKingdom http://www.chks.co.uk/
ConsortiumforBrazilianAccreditation(CBA) http://www.cbacred.org.br/
DAAGroupLtd http://www.daagroup.co.nz/
DNVGLBusinessAssurance http://www.dnvba.com/
Global-MarkPtyLtd http://www.global-mark.com.au/
HauteAuthoritédeSanté,France http://www.has-sante.fr/portail/jcms/r_1455134/fr/about-has
HealthAccreditationService,Columbia http://www.icontec.org/
HealthandDisabilityAuditingNewZealandLtd(HDANZ)
http://www.healthaudit.co.nz/
HealthandDisabilityAuditingAustraliaPtyLtd
http://www.hdaau.com.au/
HealthCareAccreditationCouncil,Jordan http://www.hcac.jo/
IKAS,TheDanishInstituteforQualityandAccreditationinHealthcare
http://www.ikas.dk/IKAS/English.aspx
JapanCouncilforQualityHealthCare http://jcqhc.or.jp/pdf/top/english.pdf
JointCommissionInternational http://www.jointcommissioninternational.org/
JointCommissionofTaiwan http://www.tjcha.org.tw/FrontStage/aboutus_en.html
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MalaysianSocietyforQualityinHealth http://www.msqh.com.my/
MinistryofHealthNewZealand–HealthandDisabilityServicesStandards
http://www.health.govt.nz/our-work/regulation-health-and-disability-system/certification-health-care-services/health-and-disability-services-standards
NationalAccreditationBoardforHospitalsandHealthcareProviders,India
http://www.nabh.co/
QualityInnovationPerformance,Australia http://www.qip.com.au/
JointCommissionofTaiwan http://www.tjcha.org.tw/FrontStage/aboutus_en.html
TheAustralianCouncilonHealthcareStandards
http://www.achs.org.au/
TheHealthcareAccreditationInstitute(PublicOrganisation),Thailand
http://www.ha.or.th/
TheCouncilforHealthServiceAccreditationofSouthernAfrica
http://www.cohsasa.co.za/
TheDiagnosticAccreditationProgram,BritishColumbia,Canada
http://www.dap.org/
TheNetherlandsInstituteforAccreditationinHealthcare(NIAZ)
http://en.niaz.nl/
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Appendix 1 - Case StudiesAppendix 1a.
IKAS – Danish Institute for Quality and Accreditation in Healthcare Country: Denmark Contributed by: Carsten Engel
Foundation of the programme
TheDanishaccreditationprogramme(DDKM)wasestablishedaspartofthe“NationalStrategyforQualityDevelopmentintheHealthcareSystem–JointGoalsandActionPlan2002-2006”.Thestrategywasdevelopedbythenational,regionalandlocalpoliticalauthoritiesincooperationwithstakeholderorganisations,representingprofessionalsandconsumers.
Atthattime,anumberofhospitalsalreadyhadpositiveexperienceswithaccreditationprovidedbyinternationalaccreditors–oneoftheintentionsofthestrategywastospreadthistotheentirehealthcaresystem,basedonaDanishmodel.
IKASisformallyanindependentorganisation,butIKASandDDKMwereestablishedbyanagreementbetweentheregionalandlocalpoliticalauthorities,whoareresponsiblefordeliveringhealthcare,andthenationalgovernmentthatsetstheoverarchingpoliticalpriorities,includingtheeconomicframe,andisthehealthcarelegislatorandregulator.
ThegovernmentprovidespartofthefundingforIKAS.ThegovernmentisrepresentedontheBoardofIKAS;theChairoftheBoardisagovernmentrepresentative(adirectoroftheDanishHealthandMedicinesAuthority).
Development steps
ThefollowingstepsdescribetheinitialdevelopmentofDDKM.Theprogrammehassincebeenextensivelydeveloped,basedontheexperiencesobtained.
1. Cooperationagreementbetweenthegovernmentandtheregionsontheestablishmentofajointmodelforqualityassessment,includingprovisionsforthefundingforDDKM(2004)
2. AppointmentofaBoardbythepartiestothecooperationagreementandendorsementofbylawsforIKAS
3. EstablishmentofIKASasanorganisation(2005)
4. Tenderforconsultancybyanestablishedinternationalaccreditor,resultinginacontractwithHQS/CHKSforsupporttodevelopstandards,establishIKASasanaccreditationorganisation,andtrainsurveyors
5. Developmentoffirsttwosetsofstandards(hospitalsandpharmacies)bythemegroups(forrelatedgroupsofstandards)ofstandarddevelopers,consistingofseniorprofessionals,appointedbytheRegionsandtheAssociationofDanishPharmacies.IKASandHQS/CHKSservedasadvisorsandsecretariatforthegroups.
6. Publichearing,whichforthehospitalstandardsresultedinanextendedrevisionbyaneditorialgroupwithmembersfromIKASandtheRegions,followedbyasecondhearing.
7. Pilottestingofstandardsforusability(forclients)andunderstandability
8. SubmissionofstandardsforISQuaaccreditation
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9. DevelopmentofanITsystemtosupportimplementationandexternalassessment
10. Developmentofaratingsystem
11. Developmentofinformationforhospitalsandpharmaciesandholdingaseriesofcoursesforkeypersonsinclientorganisations
12. Developmentofasurveymethodology,describedinahandbook
13. Selectionandtrainingofsurveyors
14. AppointmentandtrainingofanAccreditationAwardsPanel
15. Developmentandimplementationofprocessestoprocesssurveyreports
16. PreparationforISQuaaccreditationasanexternalevaluationorganisationandofthesurveyortrainingprogramme(obtainedearly2011).
Thestandardsactuallyledthedevelopmentprocess;steps9–15overlappedeachotherandthelaterphasesofstandarddevelopment,butcontinueduptothecommencementofsurveys,1½yearsafterfinalisingthestandards.
Thefirstsurveywasconducted4½yearsaftertheestablishmentofIKAS.
Funding & incentives
Intermsoffunding,IKAShasanindex-linkedannualgrantfromthecentralgovernment,regionsandlocalgovernment.Therearenofeesforpublicclientsorpharmacies.Otherprivateclientspayafeethatcoversdirectexpensesplusanoverhead.
Theprogrammeisnotrequiredbyanylegislation,butisbasedonagreementsasfollows:
Publichospitals:allhospitalsparticipatebyagreementbetweenNationalandRegionalgovernments
Privatehospitals:voluntary,butparticipationisaprerequisitetoobtainacontracttotreatpatientsfortheregions(alsorequiredbysomeinsurancecompanies)
Pharmacies:voluntary,financialincentiveinplace
Municipalities(primarycareservices,includinglong-termcare):voluntary,noincentivesinplace
Ambulanceoperators:prerequisitetoobtaincontractwithRegions
Generalpractitioners:mandatory(withsomeminorexceptions)byagreementbetweentheRegionsandtheOrganisationofGeneralPractitionersinDenmark;financialcompensationaspartoftheagreement.
Standards and measurement
IKAShasdevelopedallstandardsusedinitsprogrammes.Theywerefirstdevelopedforhospitalsandforcommunitypharmacies.Standardshavesincebeendevelopedforprimarycareservices,deliveredbymunicipalities,andforambulanceservices.Currentlystandardsarebeingdevelopedforgeneralpractitionersandspecialistphysicians.Overthecomingyears,allhealthcareprofessionsprovidingoffice-basedservices,outsideofhospitals,willbecovered.
Compliancewithstandardsisassessedbyscoringanumberofelements(forthehospitalstandardsroughly450)accordingtoafourpointscale(Fully/Largely/Partially/NotMet),wherethetwoupperlevelsindicateasatisfactoryperformance(exceptforcertainsafetycriticalstandards,whereonlyFullyMetisconsideredsatisfactory).Anyelementnotmettosatisfactionwillrequirefollowup,andifnotcorrected,resultsinaccreditationwithcomments.AnAccreditationAwardPaneldecides,guidedbycertainrules,whetherthenatureand/oramountofthecommentsprecludeaccreditation–ifso,statusas“notaccredited”isawardedandpublished.
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Assessment methodology and focus
Theassessmentmethodologyusedisexternalsurveywithextensiveuseoftracermethodology.Thefocusisonexploringtheimplementationofsafeprocessesandinvestigatingtheuseofqualitydataforimprovementactivities.
Qualityimprovementisfundamental.ThereisanextensivesetofnationalqualityregistersinDenmark,andoneofthepurposesofDDKMistosupportandassessthatdataisnotjustcollected,butalsousedforqualityimprovement.Demonstrationofcompletedandevaluatedimprovementactivitiesisrequiredfromthesecondaccreditationcycle.
Surveyorsareactiveseniorhealthcareprofessionalswhoarecontractedfor15surveydaysperyear.Inaddition,theyareobligatedtoparticipateincontinuoustrainingactivities.
Barriers
Developmentofanaccreditationprogrammefromscratchismuchlikebuildingabridgewhileyouarecrossingit.Evenwiththebestsupportfromconsultants,therearealotoflessonstobelearnedwhentheprogrammeisappliedinpractice.Afullpilottest,includingcompleteimplementationandexternalassessment,wouldbeideal,butwouldaddaconsiderabledelay.
Lessons learned
Onelessonlearnedisthatwhileitaddstothelegitimacyoftheprogrammethatstandardsaredevelopedinvolvingalargenumberofhealthcareprofessionalsasstandarddevelopers,astrongeditorialprocessisneededifthisistoresultinauniformandbalancedstandardset.Furthermore,thesetypesofstandarddeveloperswillalmostexclusivelyfocusonthestandardsasimplementationguides;itmaybeachallengetoassessperformanceinareliableanduniformway.Tosupportreliableassessment,thestandardsmustincludealotofguidanceforsurveyors,bothastomethodologyandtorating,whileavoidingsurveysbecomingexercisesof“tickingcheckboxes”.
Wehaveunderestimatedtheneedtocommunicatethatthestandardsaredifferentfromregulatoryrules.Thelattercontainspecificdirectionsthatmustbestrictlyadheredto,whereasmany(albeitnotall)standardsexpressagoaltostrivefororrequiretheclienttodefinethespecifics,accordingtolocalneedsandpriorities.Youwillmeetclientsaskingtobetoldexactlywhattodo,andyouwillmeetexamplesof“overimplementation”,whereclientsdemandtheirstafftorigidlyapplythesamestandardisedprocedurestoallpatients;anexamplecouldbehospitalsbelievingthatthestandardsrequirethemtoscreenallpatientsformalnutrition,regardlessofthelikelihoodforacertainpatientortypeofpatienttobemalnourished.Thisis,inourexperience,animportantsourceofresistancetoaccreditationamongstaff.
Oursurveysareannouncedandareprecededbyalotofpreparationbytheclients.Manyoftheirstaffperceivethisasbuildinganicepicturetoshowthesurveyors,butnotnecessarilygivingafairpictureoftherealperformance;theriskisthatpreparingforaccreditationisseenbystaffasashow,designedtoobtainacertificate,morethanasavalueaddingactivity.Doingunannouncedorpartiallyunannouncedsurveyswouldnodoubtaddtothefacevalidityofaccreditation.Wearecurrentlypreparingacontrolledstudytoinvestigatethemeritsofunannouncedsurveys.
Onetypicalwaytoarticulateresistanceistoaskfortheevidenceforaccreditation.Whileyoumustarguethataccreditationisacomplexinterventionthatcannotbebackedbyevidenceofthesametypeasadrugtreatment,designofaformalevaluationaspartoftheprogrammeshouldbeconsidered.
Moreinformation,includingaccreditationstandards,canbefoundathttp://www.ikas.dk/IKAS/English.aspx
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Appendix 1b.
Health Care Accreditation Council (HCAC) Country: Jordan Contributed by: Ed Chappy
Foundation of the programme
Severalreasonswerestatedforwhytheprogrammewasdevelopedincludingtoimprovethequalityofhospitalsandtoenhancemedicaltourism.Inaddition,itwasaresponsetopubliccomplaintsofpoorqualityofcareandaneedtoimprovetheentirehealthcaresysteminthecountry.
TheHCACisthenationalhealthcareaccreditationagencyofJordan.Theorganisationsetsstandardsforhospitals,primaryhealthcarecentres,familyplanningandreproductivehealth,transportservices(ambulances),cardiaccare,anddiabetesmellitus.HCACsurveysagainstthestandardsandawardsaccreditation.HCACalsoprovidesconsultationandeducationtopreparehealthcarefacilitiesforaccreditationandofferscertificationcourses.
TheHCACisaprivate,not-for-profitshareholdingcompanyregisteredundertheMinistryofTradeandIndustry.TheboardofdirectorsismadeupofrepresentativesforallhealthcaresectorsinJordan,medicalandnursingprofessions,andeducation.
Development steps
1. Decisiononfundingandincentives
2. Standardsorcriteriadevelopmentifapplicable
3. Survey/Assessmentmanagementprocesses
4. Developmentofmanuals,tools,educationprogrammesforclientsorothers
5. Selectionandtrainingofsurveyors/assessors
6. Typeofproposedgovernanceboardandframework,constitution
7. Settingupofgovernanceboard,governancepoliciesandprocedures
8. Developmentofmanagementsystems,strategicandoperationalplans
9. Accreditation/Certificationprocesses
10. Monitoring,reviewandevaluationsystems
11. Developmentanduseofwebsite,portalorotherelectronicaids
Adecisionwastakentodevelopstandards,prepare17pilothospitalsfromthepublic,private,university,andmilitarysectorsforaccreditationandthencreatetheagencybasedondemandforaccreditation.
Thefirstsetofhospitalstandardsweredevelopedin2005,surveyorstrainedin2006andtheagency(HCAC)establishedinDecember2007.ThefirsthospitalaccreditedusingHCACstandardswasinMarch2008.
Thefirstservicesdevelopedwereconsultationandeducationservicestopreparehospitalsforaccreditationandmockandaccreditationsurveys.Thenpreparationofprimaryhealthcarecentrestomeetstandardsandmockandaccreditationsurreysforthemwereadded.Later,localandregionalconsultationandeducationsurveysandcertificationcoursesforinfectionpreventionstaff,riskmanagers,andqualityimprovementcoordinatorswereadded.
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Funding and incentives
TheoriginalfundingtodeveloptheHCACcamethroughtheJordanHealthcareAccreditationprojectfundedbytheUnitedStatesAgencyforInternationalDevelopment(USAID)andgrants.SinceMarch2013,HCAChasbeenfinanciallysustainablethroughchargingfeesforservicesofferedincludingsurveys,educationandconsultation.
Accreditationisvoluntary.Therearenoincentives(laws,regulation,insurancerequirements)inthecountryforaccreditation.
Standards and measurement
AllthestandardsaredevelopedinJordan.Nostandardsdevelopedbyotherorganisationsareused.Hospitalstandardsweredevelopedfirst,thenstandardsforprimarycarecentres,familyplanningandreproductivehealth,transportservices(ambulances),cardiaccare,anddiabetesmellitus.
Standardsareclassifiedascritical,coreandstretch.100%ofcriticalstandardsmustbemet;andaspecifiedpercentageofbothcoreandstretchstandardsmustbemetinorderforaservicetobeaccredited.
Assessment methodology & focus
Mockandaccreditationsurveysareused.Thefocusisonqualityimprovement.
Surveyorsarecertifiedfortwoyearsandarepaidpersurvey.Staffaretrainedassurveyorsbutareonlyusedinemergencieswhenasurveyorisillorforotherreasonscannotdoasurvey.
Challenges
Themainchallengewasdecidingwheretheorganisationwasgoingtobeplacedinthecountry–MinistryofHealth,othergovernmentagency,professionalassociation,orasanindependentcompany.Thesecondchallengewastodeterminehowitwouldbefunded.
Lessons learned
Everycountrymustdeveloptheirsystembasedontheirneedsandgoals.
Seewhatothercountriesaredoingbutcreateyourownsystem.
Manyactivitiescanbedoneinparallelandyoudonotneedtowaituntilonetaskisdonebeforeproceedingtothenext(donothavetowaitfortheagencytobedevelopedbeforestandardsaredeveloped).
Recognisethataccreditationisabusinessandlookattheagencyasanyotherbusinesswithstrategic,business,andoperationalplansandbusinessprocesses.
Donotneglecttheneedtomarketaccreditationtothepopulationaswellashealthcarefacilitiesandprofessionals.
Partnerwithclientsandmaintainarelationshipafterandbetweenaccreditations.
Lookataccreditationasameansofimprovingtheentirehealthcaresystem,notjusthospitals.
Seeaccreditationasonemeanstoquality,nottheonlymeans.
Alwaysseekwaystodothingsbetter,whichmaybedifferentfromwhateveryoneelseisdoing.
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Appendix 1c.
Health and Disability Auditing New Zealand Ltd (HDANZ) Country: New Zealand Contributed by: Jim duRose
Foundation of the programme
ThecommencementoftheHealthandDisabilityServices(Safety)Acton1July2002representedasignificantchangeintheregulatoryenvironmentintheNewZealandhealthanddisabilitysector.ThisActreplacedseveralpreviouspiecesoflegislationandchangedthewayinwhichresidentialandhospitalserviceswerelicensedorregistered.Inaddition,theActintroducedhealthanddisabilitystandardsforhospitals,resthomesandresidentialdisabilityservicesaimedatimprovingsafetylevelsandqualityofcarethatbecamemandatoryfrom1October2004.TheActrequiredthatdesignatedauditagencies(DAAs)areapprovedbytheDirectorGeneralofHealthforthepurposeofauditingtheseservicestothosestandards.
HDANZbecamedesignatedinOctober2002.In20043rdpartyaccreditationwaswithInternationalAccreditationNewZealand(IANZ).DuetoachangeinIANZ’slegislationtheycouldnolongeraccreditHDANZandinDecember2008HDANZdecidedtoproceedwithISQuaaccreditation.TheobjectivewastohaveaseamlesstransitionfromIANZandthiswasachievedbyAugust2009.Also,asofDecember2008,theMinistryofHealthdidnotrequire3rdpartyaccreditationbutafewmonthslaterthisbecamearequirementtomaintaindesignation.
HDANZ’sscopewasdeterminedbytheSafetyAct–theassessmentofstandardsisalegalrequirementforpublicandprivatehospitals,resthomesandresidentialdisabilityservices.StandardsNewZealand(SNZ)isresponsiblefortheNewZealandstandardsandthisincludesotherssuchasforHomeSupport,AlliedHealth,andDaysurgeryprocedures.
HDANZisalso3rdpartyaccreditedwithISQuainordertoauditandcertifyservicestothesestandards.
HDANZisaprivate,independentlyownedcompany.ItislinkedtothegovernmentasaMoHapproveddesignatedauditingagencyandfortheseservices,HDANZsubmitstheauditreporttotheMoHwhoissuesthecertificate
Development steps
1. Typeofproposedgovernanceboardandframework,constitution
2. Decisiononfundingandincentives
3. Developmentofmanagementsystems,strategicandoperationalplans
4. Settingupofgovernanceboard,governancepoliciesandprocedures
5. Survey/Assessmentmanagementprocesses
6. Accreditation/Certificationprocesses
7. Selectionandtrainingofsurveyors/assessors
8. Monitoring,reviewandevaluationsystems
9. Developmentofmanuals,tools,educationprogrammesforclientsorothers
10. Developmentanduseofwebsite,portalorotherelectronicaids–HDANZhadawebsiteearlyonbutwebbasedassessmenttoolswereintroducedin2008.
Thefirstassessmentwasundertakenapproximately6-8monthsafterHDANZwasestablished.
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Therewasnotrialperiodbutpre-audit“gapanalysis”workwascommonplaceformostservicesbeforetheycompletedtheirfirstassessmentin2003/04.
Atfirst,HDANZprovidedassessmentservicesforallservicesundertheSafetyAct:resthomes,geriatrichospitals,maternity,surgical,hospice,mentalhealth,disabilityservicesandaddictionservices.ThesecontinuebutalsoHDANZcertifieshomecare,alliedhealth/physiotherapyservices,daysurgery/office-basedservicesandcommunityservices.HDANZalsocompletesfundercontractauditingwithNGOprovidersforawiderangeofpersonalhealthandmentalhealthandaddictionservices.GeneralpracticereviewsarecompletedonbehalfofPrimaryCareOrganisations(PHO).HDANZalsoassiststheRoyalCollegeofGeneralPractitioners(RNZCGP)withtheirCornerstonegeneralpracticeaccreditationprogrammebyindependentlyreviewingreportsandissuingarecommendationforaccreditation.
Funding & incentives
ServiceproviderspayfeestoHDANZforsurveyandmonitoringvisits.CertificationhasbeenmandatoryfortheMoHSafetyActsinceOctober2002.FromSeptember2005,itbecamemandatoryforphysiotherapyservicesiftheywantedaspecialcontractfromtheAccidentCompensationCorporation(ACC).FromSeptember2012,healthfundersmadeitmandatoryforHomeSupportproviders.FromMarch2013,SouthernCrossHealthSocietyinsurancemadecertificationmandatoryfortheiraffiliatedproviders.
Standards and measurement
StandardsNewZealandisresponsibleforthestandards.In2003,themainstandardswereHealthandDisabilitySectorStandardsandthisincludesInfectionControlandRestraintMinimisation.Thesewereupdatedin2008.In2003,HomeandCommunitySupportStandardswereissuedbySNZandthesewereupdatedin2012.In2005,AlliedHealthStandardsandDaystaysurgerystandardswereissuedbySNZ.
Theratingscaleis:
CI=ContinuousimprovementFA=FullyAttainedPA=PartiallyattainedUA=Unattained
TheMinistryofHealthusestheassessmentratingstodeterminecertification.Thelengthofcertificationcanvaryfromonetofouryearsdependingonthelevelofachievementofthestandards.
Assessment methodology & focus
Auditteamsareformedforon-sitevisitsandreportingtotherelevantstandards.Thisincludesdocumentation,observation,clientrecordssampling,tracermethodology,andinterviewingofstaff,management,clientsandfamily.
Qualityimprovementisthefocusandatthesametimetheproviderhastohaveachievedthestandardsbeingassessed,notingthatareasidentifiedforfurtherwork(PA/UAratings)havetohaveprogressreportedandarereviewedatthesurveillanceaudit.
AssessorsarepaidpereventandinadditiontothetwooperationalcompanyDirectorswhoauditthereisoneemployeeauditor.HDANZmaintainstwoseparateauditornetworks;oneisforDAA/otherserviceswhichincludesabout20assessorsandisamixoflead,clinical,consumers,technicalexperts,culturalandfinancialauditorsandtheotherisforPhysiotherapyserviceswithanauditornetworkof8auditors.
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Challenges
InOctober2002therewere10DAAsandallbutHDANZhadaformalstatusineitherISQuahealthaccreditationatthetimeornon-healthISOcertification.
DevelopmentofHDANZ’sservicesandtheinfrastructuretodeliverarangeofaudits.
Settingupthequalitymanagementsystem.
Lessons learned
Earlyinvestmentinacustomerrelationshipdatabasewasveryimportantandthenlaterimprovedatidentifyingsub-groupsformarketingandotherinformation.
Thetwokeydriversforthisbusinessarea)operationalefficiencywithcompetentadministrationstaffandb)assessorcompetency.
Addedvalueforgovernanceandrobustorganisationalmanagementfrommaintaininga3rdpartyaccreditationstatus.
Sounddecisionasgrowthoccurredtostructureintoprogrammes.
Costsneedtobecloselymonitoredandmanagedastheycaneasilyescalateotherwise.
Outsourcingthefinancialsin2009wasapositivedecision.
MaintainingNZQAauditortrainingcourseapprovalforcredibilityandHDANZpurposedespitenotbeingarevenuegenerator.
2008investmentintoamarketingcoursereapedsubstantialdividends.
Tobeperceivedastheexpert.
Board/governancedevelopmentinhindsightcouldhavebeenmoreofapriorityearlieron.
Appendix 1d.
Practice Incentive Program (PIP) Country: Australia Contributed by: Steve Clark
TheAustralianGovernmentintroducedthePracticeIncentiveProgram(PIP)in1998.ThePIPisaimedatsupportinggeneralpracticeactivitiesthatencouragecontinuingimprovementsandqualitycare,enhancecapacityandimproveaccessandhealthoutcomesforpatients21.
Inthe2015-16AustralianGovernmentBudget,inexcessof$1.5bnoverfouryears22wasallocatedtothePIPtosupportthecontinuationofincentivepaymentstogeneralpractices.
ThePIPisusedasaleverbygovernmenttoinfluencebehaviouralchangewithinthegeneralpracticeenvironment.ToaccesspaymentsunderthePIP,practicesmustmeettheeligibilityrequirements,includingthatapracticemustbeaccreditedorregisteredforaccreditationagainsttheRoyalAustralianCollegeofGeneralPractitioners(RACGP)Standards for general practicesandmustmaintainfullaccreditation.
Approximately80%ofallpracticesthatmeettheRACGPdefinitionofageneralpracticeparticipateinaccreditationand,therefore,mayaccessPIPpayments.
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TherearethreetypesofpaymentsavailableunderthePIP21:
1. Practice Payments
ThemajorityofpaymentsthroughthePIParemadetopracticesandfocusonthoseaspectsofgeneralpracticethatcontributetoqualitycare.Thesepaymentsareintendedtosupportthepracticetopurchasenewequipment,upgradefacilitiesorincreaseremunerationforGPsworkingatthepractice.
2. Service Incentive Payments
ServiceIncentivePayments(SIPs)aregenerallymadetoGPstorecogniseandencouragetheprovisionofspecifiedservicestoindividualpatients.TheCervicalScreening,AsthmaandDiabetesincentiveshaveserviceincentivepaymentcomponents,andtheAgedCareAccessIncentiveisaserviceincentivepaymentonly.
3. Rural Loading Payments
PracticesparticipatinginthePIP,withamainpracticelocationsituatedoutsidecapitalcitiesandothermajormetropolitancentres,areautomaticallypaidaruralloading.
TherearetenindividualincentivesavailabletogeneralpracticesandGPsunderthePIP23:
After-hours Incentive,supportinggeneralpracticestohaveappropriatearrangementsinplacethatensuretheirpatientshaveaccesstoqualityafter-hourscare.
Asthma Incentive,whichaimstoencourageGPstobettermanagetheclinicalcareofpeoplewithmoderatetosevereasthma.
Cervical Screening Incentive,whichaimstoencourageGPstoscreenunder-screenedwomenforcervicalcancer,andtoincreaseoverallscreeningrates.
Diabetes Incentive,whichaimstoencourageGPstoprovideearlierdiagnosisandeffectivemanagementofpeoplewithestablisheddiabetesmellitus.
eHealth Incentive,whichaimstoencouragegeneralpracticestokeepup-to-datewiththelatestdevelopmentsineHealthandadoptneweHealthtechnologyasitbecomesavailable.
GP Aged Care Access Incentive,whichaimstoencourageGPstoprovideincreasedandcontinuingservicesinResidentialAgedCareFacilities.
Indigenous Health Incentive,whichaimstosupportgeneralpracticesandIndigenoushealthservicestoprovidebetterhealthcareforAboriginaland/orTorresStraitIslanderpatients,includingbestpracticemanagementofchronicdisease.
Procedural GP payment,whichaimstoencourageGPsinruralandremoteareastomaintainlocalaccesstosurgical,anaestheticandobstetricservices.
Quality Prescribing Incentive,whichaimstoencouragepracticestokeepup-to-datewithinformationonthequalityuseofmedicines.
Teaching payments,whichaimtoencouragegeneralpracticestoprovideteachingsessionstoundergraduateandgraduatemedicalstudentswhoarepreparingforentryintotheAustralianmedicalprofession.
SincetheinceptionofthePIPin1998,successiveAustralianGovernmentshavecommittedtoongoingfundingfortheprogramme;andduringthistime,haveretainedtherequirementthatapracticemustbeaccredited,orregisteredforaccreditation,andmustmaintainfullaccreditationinordertoaccesssuchpayments.
GiventhelevelofparticipationinaccreditationbyAustraliangeneralpractices,itcanbeassumedthatthehighlyincentivisedPIPhasbeeninstrumentalinencouragingpracticestoengageintheprocess,andinturnhashadapositiveimpactbysupportingpracticestofocusonimprovementsandqualityoutcomes.
International Society for Quality in Health CareJoyce House, 8-11 Lombard Street East
Dublin 2, IrelandPh: +353 1 670 6750 Fax: +353 1 671 0395
Web: www.isqua.org