elliot b msibi (acting ceo ohsc) & prof ethelwynn l · pdf file ·...
TRANSCRIPT
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Item type Presentation
Format Text-based Document
Title Ensuring Quality and Safety in Healthcare: Inspection andMeasuring Tools Used During Inspections by OHSC
Authors Msibi, Elliot B.; Stellenberg, Ethelwynn L.
Downloaded 20-May-2018 06:21:59
Link to item http://hdl.handle.net/10755/617351
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
Maximum possible score ( Sum of all questions minus the not applicable
responses)
5
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
Question / Aspect Functional NO
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
Maximum possible score ( Sum of all questions minus the not applicable
responses)
4
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
Question / Aspect Functional NO
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