Auditing the level of care
The set of national core standards (NCS) includes tools for use in self-assessment by public hospitals in South Africa, as well as some additional documents to guide interpretation and preparation. The current situation in South Africa is one where the unacceptable quality of care does not meet public expectations, and where the results the money spent on health care in part due to a lack of compliance with basic requirements.
A decision has been made to contribute to strengthening the health system by enhancing public accountability through enforcing the mandatory compliance to a set of national standards and norms and linking this compliance in the long term to requirements for NHI funding.
The standards were therefore approved in late 2010 as a quality assurance tool for the country. These are organisational standards for hospitals and primary health clinics that cover the "platform" for quality assurance systems and service delivery (not the quality of clinical care at this point).
They reflect what is expected from managers and staff in order to deliver basic decent care in South Africa.
The NCS are not mandatory at this point, but will form the basis of future prescribed and regulated standards and norms for quality. They will also form the basis for future inspections of all establishments in order to certify them as compliant.
Standards are intended to give guidance to staff and managers about what to do as standard practice, to show what needs to be improved, to measure whether they are compliant, and to show how they compare to other places.
A facility that is meeting standards is one where management and staff are making sure that basic requirements are in place and that quality and safety are important to everyone all the time.
The set of measurement tools are designed to audit compliance with the NCS. This is an audit process and auditing of compliance is based on evidence, not simply reported compliance.
The electronic audit tool lists the evidence required for each criterion in the NCS in the form of 547 discrete "measures".
It uses different assessment methods to collect this evidence (review of documents or patient files, interviews with staff or with patients, observation), and for 89 measures, requires that a checklist be used to capture a set of information (16% of all measures are checklists). The different "functional areas" where the evidence should be found have been listed for different types of establishment, grouped broadly into management, patient care, clinical support and general support services (for example cleaning and kitchens).
The evidence is compiled into a set of questionnaires and checklists for the different functional areas of the facility, which are generated and filled in manually, with the results then being captured back into the database, preferably immediately.
One measure or piece of evidence may be looked for in different areas to check how widely the standard is implemented.
Evidence and documents
The examination of evidence is necessary to strengthen the assessment of the inspectors that the establishment has complied with the requirements of the standards.
It is important to always remember that the audit is looking for evidence that quality and safety are seen as important and are on the management agenda in a meaningful way, and are actually being implemented. Written evidence may take the form of patient records, minutes of meetings or may include electronic documents and emails, as long as it they have been signed-off.
Evidence is needed for accountability, verification, and legal compliance requirements.
It applies both to how the management of an establishment guides the staff working there through the delegation of tasks or the reliable implementation of protocols, as well as whether and how national or other policies, guidelines and best practice are followed.
Evidence also supports the establishment's responsibility to ensure institutional memory is not just in the realm of a single individual but available to all who require it.
The institution should always know where critical documents are in case they are needed; the delegation of tasks or the reliable implementation of standard procedures or best practices needs a clear mandate to enable management follow-up.
This applies both to how the management of an establishment guides the staff working there, as well as whether and how national or other policies, guidelines and best practice are followed.
A paper trail is also needed for accountability, verification and legal compliance requirements. Reports can be produced immediately by the database, and will give a picture of the actual state of compliance of the establishment.
To measure how wide the gaps in compliance are as well as to help to prioritise the work to be done to fill them, each measure has been classified based on risk.
Risks to quality and safety are seen in relation to the safety of clinical patient care; the systems in place to manage the services; the management of resources like funds, staff and assets; and risks to the reputation of the establishment and how patients experience care.
A standard risk classification method is used that was developed for assessing quality risks in healthcare.
This reflects how serious a failure in this area could be (what is the possible risk), based on what the impact could be and how likely such a failure is to happen.
These two dimensions or axes are filled in using a matrix to come up with four groups of risk.
Reports contain an executive summary with two main sections:
• A dashboard which shows the overall score of the establishment plus the scores for each of the priority areas and domains;
• Summary tables and graphs detailing the risk rated measure scores within the priority areas, domains, functional areas and by type of evidence provided.
The body of the report contains the detailed list of all measures in which non-compliance was assessed. These lists can be generated by functional area, by domain or by priority area.
Each measure has a score of non-compliance and comments to guide the managers to identify what areas to correct.
Each report is accompanied by a quality improvement plan template which lists all measures with non-compliance and provides space for the facility to add its action plan to address this, who will perform it and by when.
It also contains a column to allow for actions planned to be tracked and status of each measures to be determined.
All reports are colour coded to show how far off the establishment is from complying, either with the score or with the risk threshold level. It is possible to see at a glance where the strengths and weaknesses of an establishment are. The areas that are yellow need only a small amount of effort to become green, while the red (and especially the brown) areas need immediate work as they constitute a possible risk to decent care and to patient safety.
Quality improvement guide
This guide provides practical tools and everyday guidance to assist managers to implement robust and effective quality improvement programmes to meet the compliance requirements of the NCS.
It should accompany any analysis of the NCS report and be used to develop quality improvement plans to meet the standards.