A quality healthcare system is one of the foundations on which any society builds itself. Unfortunately, the quality of healthcare in South Africa has not been able to meet public expectations for quite some time.
This is the view of Dr Carol Marshall, chief director at the office of standards compliance at the department of health. She was speaking at the national department of health's quality seminar in Boksburg in November.
The seminar focused on providing guidance to hospital chief executives on compliance with quality standards and norms, with the relevant monitoring tools and to discuss the actions needed.
"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 national health insurance funding," said Marshall.
As part of this, government approved the national core standards (NCS) in late 2010 to be used as a quality assurance tool for the country.
The NCS provides organisational standards for hospitals and private healthcare clinics and is focused on quality assurance systems and service delivery, but not the quality of clinical care. It therefore reflects what is expected from managers and non-medical staff to deliver basic, decent care in South Africa.
"Although the NCS is not mandatory at this point, it will form the basis of future regulated standards and norms for quality. It will also form the basis of future inspections of all establishments, to certify them as compliant."
Marshall said these 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 health facilities.
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.
"Healthcare is not a post office or supermarket check-out. This is a highly technical, high-risk environment in which you cannot leave it up to people to decide if they want to follow the rules or not," she said.
"This means that the department needs to send a message to staff that they have to do what they are supposed to do. Unlike many other industries, if people do not get qua-lity of service in healthcare, they can lose their lives.
"I have been amazed by the level of dedication of staff in my experience of interfacing with them over the years. Certainly more than half the staff that are on the ground work hard and are committed to trying their best.
"What is frustrating is that frontline managers often don't get every-thing they need to make the best decisions. In the past, the hospital supply chain has not been given the importance it should have had, but that is set to change."
She said that some of the problems have been budget challenges, and uninformed decisions on budget cuts being made by those who do not have the necessary knowledge of healthcare.
"A person cannot manage a hospital if that individual does not have experience in healthcare. An example of this is knowing the right kind of disinfectant to buy, instead of just getting a cheaper retail product. South Africa needs properly qualified staff and support systems in place to provide quality healthcare for its citizens," she said.
"Quality is not something that only resides with the quality assurance manager but needs to be embraced by all the leadership and employees of the hospital."
A watchful eye
According to Marshall, some of the hospital chief executives and district managers feel following an assessment that the department is unfair to them and that certain things are not their fault. However, she stressed that the office of standards compliance is not there to judge but simply to measure.
"There has been a shift in perceptions on what matters in the healthcare sector. In the past, it was a case of chief executives being measured on how effectively they met budgets and that was their focus.
"With the support of the minister of health, the message is clear. The industry needs to focus on how patients are treated. This has assisted greatly in changing the perceptions of the chief executives and helping them to refocus on quality healthcare."
She said that when she started assessments five years ago, the general quality of healthcare in many parts of the country was terrible. Today, people know about standards and are starting to understand what it is that they are supposed to be doing.
"However, in the past we were so busy trying to change things that we did not plan to evaluate our work. The result is that today we do not have a true base line to measure ourselves against. To really know how far we have come will take time, but the legislative framework is now there to assist us."
Auditing the process
Part of the process is to ensure that regular audits take place and that quality and safety are important and on the management agenda in a meaningful way.
During their assessments, inspectors review written evidence of compliance (in the form of patient records or minutes of meetings), or even electronic documents and emails as long as they have been signed off. "Evidence is needed for accountability, verification and legal compliance requirements. It applies to how the management of an establishment guides the staff working there, how they delegate tasks or reliably implement protocols.
"They must also follow national or other policies, guidelines and best practice."
Evidence also supports the hospital management'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 if 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 practices are followed. A paper trail is also needed for accountability, verification and legal compliance requirements," she said.
Marshall said quality is not a destination but a journey.
"The better you get at it, the more challenging it becomes, because the more you realise how much still needs to be done. There are measures to ensure that the healthcare providers in South Africa at least get the basics right to be part of the national health insurance."
A large part of this is also to inform the public of what is happening to improve healthcare in the country. She cites a classic study done in the US, which found that even in first-world systems, the level of medical error in healthcare is in the region of 7 to 10%.
"South Africa is certainly not better than that. However, people need to understand that while mistakes can happen in such a complex environment, it is how we learn from those mistakes, how they are addressed and how quality is maintained that will lead to increased standards."