Partnerships in Hospice Accreditation.pdf - Hospice Palliative Care ...

Ms Esme Pudule
Prof Stuart Whittaker (CEO, COHSASA)
(HPCA National Accreditation Officer)

Content of Presentation
• The History of the HPCA_COHSASA Partnership
• Brief overview of the HPCA evaluation process and the
COHSASA accreditation programme
• The systems approach to quality improvement
• Safety and quality of hospice palliative care programmes
• Future opportunities for collaboration and partnership

Hospice Development through
Mentorship and Accreditation
Vision: Palliative care for all
Mission: by supporting member hospices and partner
organisation to promote quality in life, dignity in death
and support in bereavement to all persons living with a
life-threatening illness
HPCA is committed to supporting its member hospices
and to assist them to develop into key palliative care
resources in the respective health districts.

Brief Overview of HPCA Evaluation
Process prior to COHSASA Accreditation
1998: The first HPCA clinical standards were introduced
1998- 2003: A process of peer review assessment was
implemented and member hospices were awarded an
HPCA certificate for compliance

Beginning Our Journey in 2003
HPCA-COHSASA Collaboration initiated by:
Prof JP van Niekerk
And
Professor Stuart Whittaker
The First meeting was held in August 2003
PEPFAR funding became available
in 2004

Brief History of HPCA-COHSASA Partnership
2004: 1 st edition of HPCA palliative care standards was
introduced and the 1 st training of HPCA surveyors by
COHSASA
2005: The COHSASA accreditation programme was
initiated
2009: 2 nd edition of HPCA palliative care standards
received ISQua accreditation
2009: HPCA implemented an internal star rating process

Initial HPCA surveyor training by COHSASA -2004
Surveyor training in 2009
Surveyor training in 2010

HPCA Star rating process prior to the
COHSASA accreditation process
STAR 4
STAR 5
COHSASA
Accreditation
STAR 3
STAR 2
STAR 1

90
80
82
Number of HPCA members
2009/10 - 2011/12
70
60
50
40
30
20
10
0
61
28 29 27 27
24
21 21
21
16 14
14
8 8
5
Number of HPCA
members (2009/10)
Number of HPCA
members (2010/11)
53
40
Number of HPCA
members (2011/12)
Affilliates
Star 1
Star 2
Star 3
Star 4
Star 5

HPCA Membership Star Rating
HPCA
MEMBERSHIP
RATING
ASSESSMENT
TOOL
ASSESSMENT
REQUIREMENT
STAR 1
*
STAR 2
**
Star 1 Assessment • Overall score of 80%
• Compliant with all critical
criteria
Star 2 Assessment • Overall score of 80%
• Compliant with all critical
criteria

HPCA
MEMBERSHIP
RATING
STAR 3
***
STAR 4
****
STAR 5
*****
ASSESSMENT
TOOL
2 nd edition of
HPCA/COHSASA
palliative care
standards
HPCA/COHSASA
palliative care
standards
HPCA/COHSASA
palliative care
standards
ASSESSMENT
REQUIREMENT
• >60% in SE 1, 2, 3, 6, 7, 8, 9, (+10 and 11 where
applicable)
• Overall average of at least 50% and an average of
not
less than 40% in SE 4, 5 and 12
• >70% in SE 1, 2, 3, 6, 7, 8, 9, (+10 and 11 where
applicable)
• At least 60% in SE 4, 5 and 12
(A Cohsasa survey will only be requested when >80%
is achieved in all except 2 SEs which need to score at
least 75%)
• >80% in all SE’s.
• Compliant with all critical criteria

The introduction of accreditation

GHANA
COHSASA
The Council for Health Service
Accreditation of Southern Africa
(COHSASA):
• is a not-for-profit internationally
accredited accreditation organisation
established in 1995;
• has worked with 777 healthcare facilities in
11 African countries, including South
Africa;
• is working with HPCA since 2003 as a
partner in accrediting compliant facilities

The Donabedian influence
In 1950, the “father of quality” Armenian Professor Avedis Donabedian
introduced a framework for conceptualizing health care into three interactive
components:
Standards
Structure
Groupings of
interrelated
elements
Process
That act together
in an environment
/ setting
Outcomes
To achieve good/
bad outcomes
Indicators
And continuous
quality improvement
A number of his followers started the International Society for
Quality in Health Care (ISQua)

The International Society for Quality in
Healthcare (ISQua)
• A not-for-profit organisation.
• Established in 1985 to discuss the assurance of quality in
medicine.
• Vision and mission:
Driving continued improvement in the quality and safety of
healthcare worldwide through education, research, collaboration
and the dissemination of evidenced-based knowledge.
The International Accreditation Council developed within the
ISQua organisation

What is Accreditation?
Accreditation (A Rooney and P vanOstenburg):
“A formal process by which a recognized body, usually a nongovernmental
organization (NGO), assesses and recognizes that a
health care organization meets applicable pre-determined and
published standards.
Accreditation standards are usually regarded as optimal and
achievable, and are designed to encourage continuous improvement
efforts within accredited organizations.
Follow-up accreditation surveys are typically conducted every two to
three years.”
(Rooney AL, vanOstenberg PR. Licensure, accreditation, and certification: approaches to
health services quality. Center for Human Services (CHS), 1999.)

Accreditation programmes developed
around the world
By 2000 there were 36
identified.
The number of
programmes has
doubled every five
years since 1990.
(Graph: Charles Shaw)

ISQua Internationally Accredited Accreditation Bodies
(Re-accreditation required every 4 years)
As at January 2011, 17 of the 42 accrediting bodies had been accredited by ISQua
Accredited Organisations
Date of First
Accreditation
Health and Disability Auditing New Zealand - HDANZ 1996
The Australian Council on Healthcare Standard - ACHS 1997
Accreditation Canada 1998
Council for Health Service Accreditation of Southern Africa - COHSASA 2002/6/10
Australian General Practice Accreditation Limited / Quality in Practice -
QIP/AGPAL
2005/11
Quality Improvement Council and the QIC Accreditation Program, Australia - QIC 2006
Taiwan Joint Commission on Healthcare Accreditation - TJCHA 2006
Standards of the Joint Commission International, - JCI 2007
Healthcare Accreditation Quality Unit, United Kingdom - CHKS-HAQU 2007
Malaysian Society for Quality in Health - MSQH 2008
American Association of Blood Banks, Accreditation and Quality Programme - AABB 2009
Aged Care Standards and Accreditation Agency, Australia - ACSAA 2009
Health Care Accreditation Council of Jordan - HCAC 2009
Health Accreditation System of Instituto Colombiano de Normas Técnicas y Certificación,
Co - ICONTEC
2009
Global-Mark Pty Ltd, Healthcare Certification Programme 2009
Netherlands Institute for Accreditation in Healthcare - NIAZ 2009
Haute Autorité de santé – HAS in France 2010

The tools: Standards
Standards:
define the key functions, activities, processes and
structures required in order to provide quality
services
Should be determined by professional bodies,
health care professionals, staff, patients and
citizens.

ISQua principles: the foundation for
standards for healthcare facilities
1. Patient/client- focused
2. Encompass management and support infrastructure.
3. Focus on quality and performance improvement.
4. Comprehensive standards (facility-wide)
5. Reflect quality dimensions.
6. Define planning and evaluation process.
7. Can be objectively measured.

Developing standards:
a road map
Five phases:
• Normative
• Empirical (piloting)
• Consensus
• Publication
• Implementation

Standards cover systems required for quality care
Fundraising
Holistic
care
Patients
Administration
(system = a set of interacting and interdependent
entities that form an integrated whole)

Having standards is not enough,
they must be evaluated and
implemented accurately

1. Surveyors
are trained to
understand
standards
4. COHSASA
surveys
conducted
The process of
implementing
standards and
improving quality
care in HPCA
member hospices
2. HPCA
Mentorship
approach for
development
of PC
programmes
3. HPCA
Internal
surveys
conducted to
assess progress
from Star 1-4

When it is believed that a facility substantially complies with
the standards it undergoes an external survey
• Pre-accreditation process
• HPCA surveyors conduct an internal
survey - Star 4 sites
• Required compliance score of above 80% in ALL
service elements including all critical criteria
• Quality improvement - Structured clinical audits
and non - clinical quality activities

Survey process (cont.)
• Survey team (2-3 members for 2- 2½ days)
1. Documentation review (policies and
procedures, patient record audit, minutes, HR
management and training records, etc.)
2. Assessment of facilities and equipment
3. Staff interviews (clinical, reception, practice
manager)

Architecture and Data Capture Process
Aggregated criteria scores are used to determine standard scores, which in turn are
aggregated to PIs, SEs and Overall Facility Scores
Criteria
Standards
Performance
Indicators
COHSASA data capture process:
Criteria assessments are entered directly into
database using guidelines.
Services and
departments
Elements
OVERALL
Facility
assessment
score
Scores in each of these areas:
• range from 0 to 100
• give a measure of the performance in that area as shown below:
100 – 90 (Excellent)
89 – 80 (Good)
79 – 40 (Weak)
39 – 5 (Poor)

Hospice 1
Hospice 2
Hospice 3
Hospice 4
Hospice 5
Hospice 6
Hospice 7
Hospice 8
Hospice 9
The Quality Assurance Reporting System
Quality Information System should:
• provide continuous access to current standard
compliance data.
• enable management at all levels to make informed
decisions.
• support ongoing quality improvement programmes.
• assist facilities to reach and maintain accreditation
standards.
• be a tool for the ongoing monitoring of performance
indicators.
3. Performance indicator scores
100
99
98
97
96
95
94
93
1. Facility overall scores
99 99 98 98 97 99 99 95 99
2. Facility department scores
4. Quality improvement monitoring instrument

Accreditation award process
Accreditation
report
Technical
committee
Board

The Graded Recognition Certification
Programme
The Graded Recognition Certification Programme was developed to
assist facilities that do not reach accreditation level
This helps overcome the “all or nothing” fear and motivates facilities to keep
improving after the external survey:
Pre-accreditation grade
– entry level (roughly 60 - 70% compliance)
Pre-accreditation grade
– intermediate level (roughly 85 - 75% compliance)
Full accreditation

DRAKENSTEIN
HOSPICE
GRAHAMSTOWN
HOSPICE
ST FRANCIS
HOSPICE
HELDERBERG
HOSPICE
KNYSNA
SEDGEFIELD
HOSPICE
ST JOSEPH'S CARE
HOSPICE
WITS HOSPICE
SUNGARDENS
HOSPICE
WITS HOSPICE
Overall Survey Scores for Hospice facilities:
2005 - 2006
100
80
60
40
20
0
EXTERNAL FOCUS
99 99 98 97 97 97 96 96 96
99 89 82 82 87 82 83

Average Hospice Survey Scores per year:
External 2005 - 2012
100
80
60
40
20
0
70 93 95 97 98 96 98 98
2005 2006 2007 2008 2009 2010 2011 2012

Geographic representation of Accredited
Hospice Sites: 2012
2yr accreditation
3yr accreditation

Future opportunities for
collaboration and partnership
1. Continued external surveys by COHSASA of member
sites.
2. Improved MER process through the implementation
of CoQIS in HPCA internal assessment process.
3. Integrating principles of palliative care standards
beyond hospice settings.
4. Expanding capacity of HPCA surveyors beyond
hospice settings.

ACKNOWLEDGEMENTS