Assoc. Prof. Jiruth Sriratanaban, Accreditation as a Regulatory Tool and QA: Learning from the Asia Experience Assoc. Prof. Jiruth Sriratanaban, M.D., M.B.A., Ph.D. Department of Preventive and Social Medicine Faculty of Medicine, Chulalongkorn University

Outline Health system needs for quality assurance and hospital accreditation System options for managing quality Hospital accreditation (HA) as regulatory incentive in Thailand Lessons learned from Thailand HA

Roles of the Health System Respect for patient rights and more client orientation Why does a health system need quality assurance and hospital accreditation? According to the World Health Report 2000 by WHO, improving health outcome is one of the major objectives of the health system. In order to do so, service delivery or service provision and responsiveness of the system to people expectation are critical determinants. That implies quality of health care services. Health outcome improvement World Health Report (2000)

Some of major challenges for Thailand’s health care systems Inequity due to mal-distribution of health resources Increasing health care expenditure Introduction of close-ended payment mechanisms by the major health security schemes Expansions of business health sectors and the governmental “Medical hub” policies Threats against quality of health care

Alarming information from Adverse events studies study date Rate (%) Death Preventable HMPS 1984 3.7 13.6 % - UTCOS 1992 5.4 5.6 % 54% QAHCS 16.6 4.9 % 51% UK 1999-2000 11.7 8.0%% 48% Denmark 1998 9.0 Thailand(1) 2003 9.1 71% A number of studies in the U.S., as well as in UK and Denmark, worked on adverse events in hospitals. Usually, medical record review was applied. These studies identified adverse event rates ranging from 3.2 to 16.6 percent.

System options for assuring quality of hospital Care System resources management (e.g., financing reform, autonomous hospitals) Licensure (Legal requirement for operation) Quality audit (e.g., standards and guidelines) Quality assurance and quality management systems (e.g., ISO, MBNQA, etc.) Quality improvement (e.g., TQM, CQI, Indicators comparison, Benchmarking, etc.) Quality assessment and accreditation Public disclosure of information on provider quality

Proposed Conceptual framework for the Master plan for managing quality under NHSS (Sriratanaban, et al. 2005) Promoting quality Correcting quality Determination of Quality requirement Promotion of standards and guidelines Resources Beneficiaries empowerment and participation Regulations Payment System mgt. Information Quality monitoring Health outcomes Practices Satisfaction Complaints Policy and management decision making Management systems for quality 2 3 4 5 Health services 1 Hospital accreditation

Hospital accreditation as a regulatory incentive Improve quality of health care Patient safety and risk management Evidence-based practice Continuous learning and improvement Stimulate and improve integration and management of health services Reduce variation in care and health care costs Strengthen the public’s confidence in the quality of health care

What is Hospital Accreditation ? Mechanisms for recognition of institutional competence By an independent accrediting body (Usually) Participation by professional groups Applying hospital standards for optimal and achievable performance Emphasis on continuous quality improvement Hospital survey by external peer reviewers Voluntary participation (Usually)

Examples of HA programs in Asia Many countries in Asia have hospital accreditation programs, for example, Taiwan Korea Indonesia Japan Thailand Malaysia India (In certain states), etc. Hospital accreditation has been increasingly popular among Asian countries. For instance, Taiwan in 1986 Korea and Indonesia in 1995 Japan in 1997 Thailand and Malaysia in 1999 There are also accreditation program in certain states of India.

Thailand Began as a research and development project in 1997 under the Health System Research Institute (HSRI) with financial support from WHO, TRF and HSRI of Thailand Collaboration for Hospital Quality Improvement and Accreditation Institute for Hospital Quality Improvement and Accreditation (HA-Thailand) Technical support by external consultants from Canada (Adapted Canadian approach to HA) 35 pilot public and private hospitals

Quality improvement cycle Plan Do Check Act Quality hospital Hospital CQI Accredit QA/ Standard RM

HA standard framework (Thailand 1999-2005) Governance and policy directions [1], [2] Resource management [3], [4], [5], [6], [7] Patient care process and services [10], [15], [16], [17], [18], [19], [20] Analysis, measurement and improvement [8], [9] Patients and other customers Professional systems, patient rights and organizational ethics [11], [12], [13], [14], Input Output Health needs and customers’ expectations Health outcomes, Satisfaction

Information and knowledge management Hospital and Health care Leadership Strategic planning Focus on patients And Patient rights Staff focus Process management Results Information and knowledge management Key hospital systems Risk, Safety and Quality Professional management Environmental management Infection prevention and control Medical record system Medication system Medical laboratory system Radiological system Work with communities Patient care processes Entry Patient Assessment Planning (Care & Discharge) Care Delivery Patient & Family Empowerment Continuity of Care Health care Patient and customer Financial Human resources Organization effectiveness Leadership and Social Health Promotion Hospital and Health care services Standards 2006 Part IV Part III Part II Part I MBNQA/TQA Model Institute of Hospital Quality Improvement and Accreditation, THAILAND

Accreditation Survey Leadership interview Clinical and support staff and team interviews Patient and family interviews Observation of patient care and services provided Building tour and observation of patient care areas Review of written documents Review of patients’ medical records Evaluation of the organization’s achievement of outcome measures

Accredited hospital means … Organization commitment on quality improvement Adequacy of health care resources with efficient management Existence of quality assurance and continuous quality improvement Existence of mechanisms to promote professional standards and ethics Service provision that protects patient rights and promotes organization ethical practices Quality patient care processes

Potential impacts Health system governance Clinical effectiveness System design and development System financing Population health Knowledge management and transfer Clinical effectiveness Patient empowerment and decision-making Professional and personal development Management development Quality system development

Number of HA-accredited and HPH-certified hospitals

Purchasing quality health care… Social Security Scheme endorsement of HA Special quota of registered beneficiaries for accredited providers National Health Insurance Scheme movement Financial support for HA consultation programs Financial bonus for accredited providers Impacts for national health service systems Health promoting hospital Use of evidence-based practice Disease management programs by NHSO Humanized health care initiatives

Lessons learned: Government roles in supporting accreditation Policy endorsement Leverage for accredited hospitals and other financial incentives Consideration in purchasing decisions Alignment of HA with other regulating mechanisms Program acknowledgement Program financing Technical support networks Public relations and reward systems

Lessons learned: Major barriers to successful implementation Unclear purpose and unrealistic expectations Inappropriate technical approach Failure to involve stakeholders Lack of motivation (Provider) Poor cooperation among professional and governmental bodies Under-funding and lack of governmental commitment Failure to learn