elliot b msibi (acting ceo ohsc) & prof ethelwynn l

Ensuring quality and safety in health care: Inspection

and measuring tools used during inspections by the

Office of Health Standards Compliance (OHSC).

Elliot B Msibi (Acting CEO OHSC) &

Prof Ethelwynn L Stellenberg

(Stellenbosch University)

STTI RESEARCH CONFERENCE CAPE TOWN

21 JULY 2016

1

Objectives for discussion

• Vision and mission of OHSC

• Evolution of the process of policy reform

• National Core Standards for Health Establishments in South Africa” (2011)

• Learning Activities

• National Core Standards: Assessment tools and methods

• Group activities

• Feedback

• Conclusion

2

Vision & Mission of the OHSC

3

Our vision:Safe and Quality Healthcare for all South

Africans

Our Mission:We act independently, impartially, fairly and fearlessly in guiding, monitoring and enforcing health care safety and quality standards in health establishments to serve the

people of South Africa

Evolution of the process of policy reform

Quasi regulation Explicit regulation

Mock Inspection started Dec 2011

4

“National Core Standards for Health

Establishments in South Africa” (2011)

• A single set of National standards,

• Existing requirements (“nothing new”)

• Focused at facility level, how patients

receive care

• Participative and learning process of

development

• Comprehensive (though core only),

prescriptive

• Structured into crosscutting “Domains”

• Detailed tool for external assessment

• Future consequences - mandatory

compliance, link to funding

Objectives

1. Common

framework

2. Assess /

monitor

compliance

3. Prepare for

regulation

5

6

National Core Standards

7 Domains = areas of risk Standards (ca. 100) with explanatory criteria specify performance required / expected to

reduce risk

Evidence required to show that standards are met specified in measures, for different

areas of a health establishment

Captured on-site into database for immediate reporting

Learning Activities

After attending this workshop you will be able to:

• Have an understanding and insight into the use of

the inspection tools and measuring tools.

• Demonstrate the use of the inspection and

measuring tools used during inspections by the

OHSC

7

8

National Core Standards

Assessment tools and methods

8

9

Content of toolkits - parts

– Documents – Standards, abridged and 6 priorities versions

– Database – DHIS 14 module

– tools

– Checklists

– Scoring Methodology

– Self assessments / external audits

– Reports

9

10

Functional area codes

To generate tools, which are produced per

department

To generate customised tools of a selection of

departments

Codes depend on the type of facility:

PHC codes – codes is a “C” as second letter e.g.

PC01

CHC codes – end with C e.g.. PC01C

Hospital codes - no additional letters in code

Functional areas in a HospitalManagement departments

Code

Health establishment managers office: CEO or

hospital manager

M01

Communications/PRO M03

Facility Infrastructure M04

Financial management M05

HR Management M06

Infection Control M07

Management information system M08

Procurement M10

Occupational health and safety M12

Clinical management group (NSM, Infection

control, Clinical manager, Quality manager,

OHS)

M14

Case Management M16

Legal/ Insurance Division M17

Clinical departmentsCode

Accident and Emergency Unit P01

Outpatient department P02

Maternity Ward inch maternity theatres P03

Medical ward P04

Surgical ward P05

Paediatric ward P06

Generic wards: measure is generic to any ward,

day ward

P07

Therapeutic support services: OT, Physio,

speech therapy, audiology, social work,

psychology, dietician

P08

Speciality wards/ services: ICU, HCU, burn units,

oncology, dialysis units,

P09

ICU neonatal P09.1

Operating theatre incl cath labs P10

Psychiatric ward P11

Clinical support departmentsBlood services C01

Laboratory C02

Health technology Services C03

Pharmacy C04

Radiology C0511

Functional areas in a Hospital (Cont.)

Support departmentsCode

CSSD S01

Cleaning services S02

Food services S03

Laundry services S04

Maintenance services includes garden S05

Record archive/department S06

Waste Management S07

Transport services: ambulances, patient transport, staff

transport, other vehicles

S08

Security services S09

Entrance, reception and help desk S10

Patient administration S11

Mortuary services S12

Public areas: internal corridors, smoking areas, waiting areas S13

12 12

13

Functional areas in Primary Health CentersPrimary Healthcare Centers

CHC relevant codes PHC relevant codes

District office Manager MC01 MC01

CHC manager MC14 MC14

Clinic manager/HOD MC14.A MC14.A

Pharmacy/ Dispensary/Medicine room CC04 CC04

Clinical Services PC01 PC01

Accident and emergency/casualty

department

P01C

Maternity units/MOU P03C

Day wards/ generic ward P07C

Maintenance support SC01 SC01

Food services S03C

13

Functional areas in Primary Health Centers (Cont.)

Management

Health establishment

managers office: Clinic

Manager/HOD

MC14A

Patient care areas

Clinical services (Consultation

rooms, counselling rooms)

PC01

Clinical Support

Pharmacy/Medicine

cupboards

CC04

General Services

Maintenance support SC01

Management

Health establishment managers

office: Clinic Manager/HOD

MC14C

Patient care areas

Clinical Services PC01C

Clinical Support

Pharmacy/Medicine cupboards CC04C

General Services

Maintenance support SC01C

Patient care areas

Patient care areasACCIDENT AND EMERGENCY

UNIT

PO1C

MATERNITY WARD incl

maternity theatres

P03C

Generic wards / Measure is

generic to any ward or day

ward

P07_1C

Generic wards / Measure is generic

to any ward or day ward

P07_2C

Generic wards / Measure is generic

to any ward or day ward

P07_3C

Operating theatre incl cath labs P10_1C

Operating theatre incl cath labs P10_2C

General Services

Food Services S03C

14

15

TOOLS

15

17

Various types of tools can be generated :

PHC or CHC

Hospital- public, private,

Priority area

Department specific

Generic hospital and PHC tools are available in PDF rather

than using the codes to generate the tools

Can still be customised to the facility or just for a department

using the requisite codes

TOOLS

17

Tools Layout: Example

Department or functional area

DomainCriteria

Measure

18 18

Tools: Example

Score – the compliant (1) or non compliant (0) score for that

question. If it is checklist then fraction of 1 is the score i.e. 0.75

Denotes risk level X - EXTREMEV = vitalE= essential D= developmental

Assessment type – method used to assess compliance,

observation, document analysis etc.

Notes section for comments or observations

19 19

Scoring methodology

The score for each measure is either:

• 1 for compliant or

• 0 for non compliant

• Partially compliant is not rated numerically

• Not applicable (N/A) if it does not apply to facility

2121

Outcomes – interpretation

OUTCOMEThe first score is the “outcome” score which is either “compliant” or “non

compliant”.

COMPLIANT

For a facility to be “compliant” it must meet ALL EXTREME measures

NON COMPLIANT

If the facility is “non compliant” on even one EXTREME measure this

is a “non compliant” result.

The EXTREME measures are those most likely to cause serious harm to

both patients safety and staff and are therefore not negotiable for

compliance to be awarded to a facility.

22 22

Outcome – interpretation (Cont.)

CUT OFFS

• Extreme (X) < 100%: any measure failed

in this risk rating will result in non compliance

• Vital (V) < 90%

• Essential (E) < 80%

• Developmental (D) < 60%

23 23

Assessment methodologies

Type code Description

Doc Document review and analysis –

• check for availability of a document, policy or protocol e.g. patient records, personal

files, policies or guidelines

• review content of a document to serve as evidence that the standard has been

fulfilled egg minutes of meetings, reports and plans

OBS Observation – directly observe staff carrying out their duties or performing certain

functions e.g. observe infection control and hand hygiene practices, performance of

procedures or the way patients are counselled.

PI Patient interview – one on one interviews with a small sample of patients to ask

specific questions using a structured checklist

SI Staff interview - one on one interviews with a small sample of staff to ask specific

questions using a structured checklist

PRA Patient record assessment – review of the content of the patients records to serve as

evidence for compliance

24 24

Document review and analysis (Doc)

For example: “There is a job description for a senior clinician”.

The assessor checks for availability of the job description.

Full list of documents required in Standards available in “Assessment

and Implementation Guide”

Check the following:

• whether the document exists;

• the document is signed; and

• up to date

• minutes of meeting - last 6 months.

• policies or guidelines - not more than 36 months old.

25 25

Document review and analysis (Doc) (Cont.)

A more detailed document review and also include for

example: “The job descriptions indicate clear

accountabilities, responsibilities and authority”.

The job description will need to be assessed, to see

whether it states what the person’s accountabilities and

responsibilities are and what authority they have (who do

they report to and who reports to them.)

26 26

When doing staff interviews, it is important to:

•Briefly and simply explain the purpose

• Reassure that the objective is to improve services, so an honest

response will be appreciated.

• Reassure that their views are confidential

• Ask one question at a time.

• Ask staff members specific questions

• Ask the question in a neutral manner

• May have to explain the question further, or probe to get to the heart

of the question

• Be polite, listen carefully, and do not make false promises

Always thank the staff member for their valuable contribution and time.

27 27

Staff interviews (SI)

Patient interviews (PI)

Here are some points to note:

• Briefly and simply explain the purpose

• Reassure that the objective is to improve services, so an honest

response will be appreciated.

• Advantageous for the assessor to be able to speak in the local

language, otherwise a translator will be required

• It is important to establish rapport, and relax the patient to elicit real

answers.

• Reassure the patient that the information is confidential

Always thank the patients for their valuable feedback, and for their time.

28 28

Observation by the assessor (obs.)

The assessor needs to “see” if the listed measures are present or not.

• Important to note only if evidence is observed then it can be marked with 1 = yes

• Observation may rely on the assessor’s professional judgment

• for example: the way patients are treated “with respect and dignity”; “the toilets are clean”, “the ward is overcrowded”

29 29

Patient records assessment (pra)

• Selected patient records (files or charts) assessed for content

• The number of files to be audited will be stipulated on the Assessment

Tool or checklist.

• If it is not recorded in the file, it was not done.

• Read through the patient file to ascertain if the information is captured

in another area of the record

• if an aspect is not applicable then mark N/A. E.g. Check the blood test

results are in the file but that patient had no blood tests performed then

this would be N/A.

30 30

31

CHECKLISTS

31

Checklist - Example

Grouped by:

Domain

Department

Criterion

The safety of patients who

require resuscitation is

assured

Planned number of

responses

No. Functional Yes Comments

totals

1

2

3

4

5

Actual Score ( Sum of positive responses) HIGH RISK MEASURES

Maximum possible score ( Sum of all questions minus the not applicable

responses)

Tracheal tubes Paediatric as appropriate

Manual resuscitator device / ambubag (adult)

AED machine/ECG monitor / defibrillator, pads, paddles and

electrodes

Laryngoscope with 2 blades

Tracheal tubes adult as appropriate

Instructions: Instructions: Check the contents of the emergency trolley against the list below. Ask if the equipment is functional and

assign a Y for yes and N for No. Only for the highlighted equipment check if an operator’s manual is available.

Only for the highlighted equipment check if the consumables used in the equipments operations is available.

Question / Aspect Functional NO

VITAL MEASURES

Number of questions Unit where assessed Type of assessment

26 1 P07|P10|P01|P02|P09 OBS

MC14|MC14A|PX01|PX09|PX07

CHECKLIST DOMAIN 2 - PATIENT SAFETY, 2.4 Clinical Risk

Specific safety protocols are in place for high risk groups of patients

Number of checklist Checklist reference Measure

2.4.3.3.4 Emergency Trolleys CHECKLIST - Emergency

trolleys are standardised,

appropriately stocked and

regularly and checked

32 32

Scoring of checklistsCHECKLIST DOMAIN 1, PATIENT RIGHTS

1.4 Continuity of careManagement of referrals preserves the quality of patient care

Number of checklist Criterion Checklist reference Measure

1.4.1.1.5 An effective health care referral policy and system exists for the district which takes into consideration the continuity of care, emergency care management, infrastructure and resources required.

Transferred patient files The files of the last 3 patients transferred out of the health establishment contain copies of a referral letter sent to the receiving establishment.

Number of questions Planned number of responses Unit where assessed Type of assessment

1 3P01|P07|P09|MC14|MC14A PRAInstructions: Locate the files of 3 patients who were transferred OUT OF THE establishment and check if they contain a copy of the letter written by the transferring health professional requesting transfer and detailing the patients’ health status and reason for referral and detailing the accepting health professionals’ name. Mark Yes or No

No. Question / Aspect Yes No Comments1Patient file 12Patient file 23Patient file 3

Actual Score ( Sum of positive responses)

Maximum possible score ( Sum of all questions minus the not applicable responses)

3

34 34

No. Functional Yes

1

Y

2 Y

3 Y

4 Y

5Y

Actual Score ( Sum of positive responses) HIGH RISK MEASURES 5 0


responses)

5




electrodes




VITAL MEASURES

To possible score (Sum of all the questions minus the ones that were not relevant)

35

Scoring of checklists

Scoring of checklists

No. Functional Yes

1

Y

2 Y

3 Y

4 Y

5NA

Actual Score ( Sum of positive responses) HIGH RISK MEASURES 4 0


responses)

4




electrodes




VITAL MEASURES

1

Now say “manual

resuscitator adult” was not

applicable because this

was an emergency trolley

in a paediatric ward.

Then the maximum

possible score changes

from 5 to 4

If all items are functional

the score is 4/4 or 1 again

36 36