The SafeCare Initiative: Introducing standards and a structured stepwise improvement process for basic health care providers in Resource Restricted Settings
Del
iver
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Quality improvement and assurance: creating a virtuous circle
Fina
ncin
g Demand • Out-of-pocket
expenses • Access to health
care • Ownership/
empowerment • Solidarity
Supply • Quality • Cost/ efficiency • Risk/ investment • Data
Patient • Consumer purchasing power
• Willingness to pre-pay
Higher Higher QUALITY
IMPROVEMENT
Higher
Higher
Health Insurance
Donor/governments (tax)
Prepayment by users
Government (public)
Loans Investments
(private)
quality standards & improvement solutions for resource restricted settings in combination with targeted financing create an opportunity to create a virtuous cycle
Certifying quality contributes to Trust
Patients : know where to go (branding) increased revenue for private providers
Healthcare providers: can get better access to loans, insurers and patients
Banks :can provide loans based on quality plans and can rely on external validation
Donors : can allocate their funds to clear opportunities and monitor results
Insurers: can choose or reward better performing providers Governments: can be provided with a basis for a legal
framework to monitor and regulate
Aspects of quality
Relational quality how do we address the patient? (e.g. reception, doctor-patient relationship), how does the patient perceive quality ?
Technical quality professional capacity (e.g. skills, education, diplomas)
Functional quality what is helpful for the care received by the patient (e.g. hygiene)
Organizational quality organizing work and workflow, governance structure, etc.
accreditation
Quality improvement and upgrading of facilities
Licensing: Healthcare
facilities and and healthcare professionals
(doctors, nursers)
Government Independent accreditation/ recognition body
Licensing and accreditation
mandatory ‘voluntary’
SafeCare Initiative
Mission: Place the issue of safe
health care provision on the
agenda in resource-restricted
settings and create a platform
for like-minded organisations
and people who wish to provide
safe health care despite
resource constraints
SafeCare principles
• Development of innovative and realistic standards for healthcare providers in resource restricted settings, ISQua approved.
• Development of a step-wise improvement process that can be measured and used by governments, donors, health insurers, (social) investors and loan providers.
• Reward improvements with certificates
Standards tailored to HC provider categories
1
2
3
4
5
Tertiary (teaching) hospital- providing majority of specialized medical care .
Referral hospital providing a broad spectrum of medical care
Primary health center (minimum one MD, nurse and lab technician)
Basic health center offering primary health and maternal care(min. one clinical officer)
Health shop/nurse driven clinic: advice on basic health care issues 6
District Hospital (or faith based/private hospital) providing 24 hrs services
International standards, local solutions
“Quality is not necessarily high-tech or high cost” SafeCare allows for realistic, practical and achievable solutions in resource restricted settings
SafeCare graded recognition leading to accreditation
SafeCare Essentials phase
Graded recognition Phase: SafeCare standards Accreditation
Full standards compliance
Minimal patient safety standards Continuous quality improvement
Work with MOH for toolbox inspectorate
External evaluation
0 months 12 months once/2years
Work with K-Met, Tunza and NHIF
SafeCare: graded recognition
graded recognition SafeCare standards + tools
accreditation COHSASA/JCI
External evaluation Full standards compliance
Local facilitation
Certificate awarded
Facilitation of QI is done by technical assistance partners (e.g. K-MET, PSI)
Evaluation of QI is done by SafeCare
0 months 12 months
Stepwise certification leading towards accreditation
Accreditation
Safe Care Certificates of Improvement can be awarded, based on measured improvement
Compliance to quality standards
Accreditation COHSASA/JCI
Safe Care recognition letter of entry
Excellent
Good
Extremely poor
Poor
Variable
Reasonable
Summary of areas covered by hospital standards Phase 1: graded recognition
Areas covered by SafeCare
Primary Health Care
Service standards
Use of SafeCare standards and tools in an annual cycle: 1. assessment baseline 2. upgrading plan 3. technical assistance 4. assessment follow-up 5. certificates
Afri-QA: tools for local data collection
AfriDB: server for data storage and analysis Service elements Within 3 hours
after submission of data through AfriQA, a TEMP report is available on AfriDB
Certificates of Improvement
Average Facility scores across five Nigeria Clinics
66 57 55 51 47 0
102030405060708090
100
PHC 1 (Level 4) PHC 2 (Level 1) PHC 3 (Level 3) PHC 4 (Level 1) PHC 5 (Level 1)
A deeper look: average scores 5 Nigerian clinics per service element
51 60 47 57 76 54 46 62 48 50 62 49 0
102030405060708090
100
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SE Score
Scores per service element
37,2
23,2
48,2 38,1
0
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Ghana Kenya Nigeria Tanzania
Med
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scor
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Overall Score per Country
Nonparametric test equality of medians: p-value 0.000
n=10 n=48 n=13 n=26
Country scores are significantly different, but this is confounded by: geographic setting, maturity of QI program (more rural clinics in Kenya and 3 year HIF implementation clinics in Nigeria)
Overall Scores per Geographic Location
median score location
Equality of medians test
service element Rural Peri-Urban Urban p-value 1 Management and Leadership 25.2 33.1 34.4 0.033 2 Human Resource Management 17.0 22.8 25.6 0.026 3 Patient Rights and Access to Care 24.0 33.0 38.4 0.004 4 Management of Information 18.9 25.8 30.0 0.026 5 Risk Management 10.3 16.7 16.0 0.117 6 Primary Health Care Services 26.4 37.2 39.0 0.004 7 In-patient Care 34.5 44.0 50.5 0.134 8 Operating Theatre and Anaesthetic Services 34.4 37.9 49.8 0.033 9 Laboratory Services 21.2 33.9 35.1 0.244 10 Diagnostic Imaging Services 22.5 33.7 47.3 0.472 11 Medication Management 23.7 36.6 43.1 0.005 12 Facility Management Services 20.8 35.9 42.2 0.001 13 Support Services 20.9 24.4 21.7 0.799 OVERALL SCORE 22.1 31.3 34.5 0.001
Nonparametric test equality of medians: p-value 0.001
Rural facilities have lower median scores than urban facilities for 8/13 Service Elements
Assessment score per Service Element
Median score country
Equality of medians test Service element Ghana Kenya Nigeria Tanzania p-value 1 Management and Leadership 36.6 26.4 53.9 37.7 0.000 2 Human Resource Management 28.6 17.3 43.4 32.5 0.000 3 Patient Rights and Access to Care 36.5 25.3 49.1 42.0 0.000 4 Management of Information 29.8 21.0 47.4 32.1 0.000 5 Risk Management 23.4 11.4 41.3 19.5 0.000 6 Primary Health Care Services 43.6 29.3 52.2 49.2 0.000 7 In-patient Care 50.0 35.4 49.5 48.1 0.028 8 Operating Theatre and Anaesthetic Services 44.3 35.1 32.8 39.1 0.693 9 Laboratory Services 37.9 20.8 63.2 43.1 0.000 10 Diagnostic Imaging Services 38.5 29.4 52.1 43.8 0.030 11 Medication Management 38.5 27.5 56.9 44.8 0.000 12 Facility Management Services 43.9 23.1 57.1 45.6 0.000 13 Support Services 35.1 21.0 41.7 22.7 0.000 OVERALL SCORE 37.2 23.2 48.2 38.1 0.000
• All median Service Element scores are significantly different between countries (except #8)
• Risk Management invariaby scores lowest
Scores per number of patient visits
median score # visits/month
Equality of medians test
service element 0-499 500-999 1000-1999 >2000 p-value 1 Management and Leadership 22.2 27.5 33.1 41.0 0.060 2 Human Resource Management 16.6 18.4 23.9 35.7 0.014 3 Patient Rights and Access to Care 22.4 27.1 29.5 40.7 0.040 4 Management of Information 17.9 23.9 26.0 31.6 0.014 5 Risk Management 9.8 12.4 19.8 22.8 0.004 6 Primary Health Care Services 26.7 31.5 37.2 49.1 0.024 7 In-patient Care Excluded 33.6 35.6 51.9 0.010 8 Operating Theatre and Anaesthetic Services Excluded 40.6 37.5 32.0 0.744 9 Laboratory Services 21.8 29.4 29.9 37.6 0.635 10 Diagnostic Imaging Services Excluded 30.7 34.9 41.1 0.511 11 Medication Management 23.8 29.9 34.1 46.0 0.077 12 Facility Management Services 22.3 29.0 28.8 46.1 0.125 13 Support Services 20.3 17.6 27.1 30.8 0.032 OVERALL SCORE 20.8 26.2 31.3 38.9 0.024
For 9/13 Service Elements, facilities with higher patient loads demonstrate higher scores
Higher Q scores when nearest facility is closer by
median score Distance Equality of
medians test service element <30min 30min or more p-value 1 Management and Leadership 33.1 24.9 0.001 2 Human Resource Management 26.1 16.6 0.000 3 Patient Rights and Access to Care 33.0 25.0 0.030 4 Management of Information 25.9 18.1 0.006 5 Risk Management 16.9 10.3 0.006 6 Primary Health Care Services 37.2 26.4 0.006 7 In-patient Care Excluded
8 Operating Theatre and Anaesthetic Services Excluded 9 Laboratory Services 31.3 20.0 0.074
10 Diagnostic Imaging Services Excluded 11 Medication Management 37.5 26.0 0.029
12 Facility Management Services 35.1 21.6 0.006 13 Support Services 25.0 13.5 0.005 OVERALL SCORE 31.3 21.3 0.006
Facilities that have a neigboring facility within a 30 minutes distance demonstrate significantly higher median Service Element scores. Competition effect?
Accomplishments to date
• 200+ facilities in the program • 35 facilitators and surveyors trained in Ghana, Nigeria, Tanzania and
Kenya • APHIAplus: USAID program for Kenya, SafeCare as external validation
for social franchises (such as PSI/MSI), approved • TA to MOHS Nigeria for TA to institutionalize stepwise certification for
healthcare facilities in Nigeria • TA to the NHIF Kenya to develop stepwise certification of healthcare
facilities in the new outpatient scheme • Collaboration with MOH Kenya to implement country-wide mapping of
patient safety using SafeCare essentials be one of the tools for a new licensing structure for healthcare facilities
Thank you for your attention www.safe-care.org