1. 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

2. 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

3. 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)

4. 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

5. 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
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.

6. 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

7. 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

8. 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

9. 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)

10. 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.

11. 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

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

13. 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

14. 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

15. 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

16. 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

17. 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

18. Number of HA-accredited and HPH-certified hospitals

19. 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

20. 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

21. 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