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The 10 years’ Experience in Residential
Home Accreditation Scheme in
Hong Kong
1
MS. Stella Yuk-har CHEUNG Executive Director, Hong Kong Association of Gerontology
Ms. Alice, Dick Wah CHIU
Accreditation Officer, Hong Kong Association of Gerontology
Outline
1. Pilot Accreditation Scheme in Hong
Kong
2. Residential Aged Care Accreditation
Scheme (RACAS)
3. Improvement in the quality of
service of participating homes
2
3
PILOT ACCREDITATION
SCHEME
Part One
3
Background of Pilot
Accreditation Scheme
4
The Need for Quality
Improvement in Long Term Care • In recent years there have been concern
on the variation in quality of care amongst
institutions for older people
• Standardization of practice also becomes
a concern for governments especially on
the provision of funding to aged care
facilities to guarantee the value for money
5
International Developments in
Quality Monitoring • United States – Joint Commission on
Accreditation of Healthcare Organizations - 1988
• Canada – Canadian Council on Health Services Accreditation - 1995
• Australia – Aged Care Standards and Accreditation Agency – 1998
• England – National Care Standards Commission – 2002
6
Quality Assurance in Long
Term Care • Licensing – basic legal requirement for
practice
• Accreditation – system of continuous
quality improvement, mostly voluntary.
However it will require incentives for
operators to join, e.g. market force,
insurance back up, public funding related
7
Standards-based approach to
quality evaluation • A standard is defined as an explicit,
predetermined expectation that describes
an organization’s acceptable performance
level:
– Structure Standards
– Process Standards
– Outcome Standards
8
Pilot Project on Accreditation System
for Residential Care Services for the
Elders in Hong Kong
• A 2-year Pilot Project on Accreditation
System for Residential Care Services for
the Elders through a Lotteries Fund grant
from July 2002 to October 2004 by Hong
Kong Association of Gerontology
9
Objectives of the Pilot Project • To set up a system of voluntary accreditation of
residential care services for elders
• To promote the quality of care through
promulgation of the quality process and
outcome monitoring
• To define the cost of the accreditation
mechanism and the future charging mechanism
• To serve as a service quality reference
benchmark for purchase of service
10
Phases of the pilot project • Phase 1 Review of overseas accreditation
systems and consultation with RCHEs (July
- Dec 2002)
• Phase 2 First Pilot Accreditation (Jan - June
2003)
• Phase 3 Second Pilot Accreditation(July -
December 2003)
• Phase 4 Formulation of Accreditation
System in Hong Kong
11
International Advisors
• Experienced administrators and assessors
from United Kingdom, Australia and United
States are invited to be advisor of the
Accreditation Scheme in areas of
accreditation mechanism, standards and
assessor training
12
International Trends in
Accreditation • Co-exists with licensing
• Largely operated by independent bodies
• Serves to promote continuous quality
improvement
• Builds on the concept of peer review, which
provides education and consultation in the
process, with due emphasis on quality control
of assessors through training
• Should be process and outcome-focused
13
Major Findings from Pilot
Project
14
Report of Pilot Accreditation
Project 2004
15
Experience for Hong Kong • Accreditation of residential care homes is a
positive experience in all countries studied
and is able to improve quality of residential
homes
• Local operators of RCHEs are increasingly
aware of the importance of quality
development
• International experience in implementation of
accreditation have resulted in an agreeable
content of accreditation
16
Experience for Hong Kong
Proposed Accreditation
Standards and Mechanism
17
Accreditation Standards
• 40 Standards
• Domain A - Governance (1-5)
• Domain B - Environment (6-9)
• Domain C - Service Flow and Care Process
(10-26)
• Domain D - Information management and
communication (27-28)
• Supplementary instrument (29-40)
18
Accreditation Standards
• Domain A - Governance
• 1 - Total Quality Management
• 2 - Service Ethics
• 3 - Risk Management
• 4 - Purchase of Service
• 5 - Occupational Safety and Health
19
Accreditation Standards
• Domain B - Environment
• 6 - Environment and Facilities
• 7 - Provision of Services
• 8 - Food and Environmental Hygiene
• 9 - Community Partnership
20
Accreditation Standards • Domain C - Service Flow and Care Process
• 10 - Post-admission care
• 11 - Medication management
• 12 - Continence management
• 13 - Skin care and bedsore prevention
• 14 - Fall management
• 15 - Feeding
• 16 - Nutrition
21
Accreditation Standards
• 17 - Mobility assessment and management
• 18 - Use of physical and chemical restraints
• 19 - Transfer skills
• 20 - Infection control
• 21 - Management of cognitive, emotional,
sensory and communication ability of the
residents
• 22 - Pain management
22
Accreditation Standards
• 23 - Death and bereavement
• 24 - Special nursing procedures
• 25 - Psychological support and social care
• 26 - Recreational and community activities
23
Accreditation Standards
• Domain D - Information Management and
Communication
• 27 - Information management
• 28 - Communication
24
Accreditation Standards
• Supplementary instrument
• 29 - Provision of information
• 30 - Review and update policies and
procedures
• 31 - Records
• 32 - Roles and responsibilities
• 33 - Human resource management
• 34 - Financial management
25
Accreditation Standards
• 36 - Legal responsibilities
• 37 - Safe environment
• 38 - Entry and exit
• 39 - Assessment of residents’ needs
• 40 - Protection of residents’ rights
26
Readiness for RCHE Accreditation
• Acceptance from RCHEs
- NGO home
- Private home
• Appropriate Standards and Instrument
• Availability of Assessors
• Acceptance from professionals
27
The implementation of
Accreditation System in HK
28
29
Residential Aged Care
Accreditation Scheme (RACAS)
Part Two
29
Hong Kong Association of
Gerontology
• Residential Aged Care
Accreditation Scheme
• Launched from March 2005
30
Residential Aged Care Accreditation
Scheme
• Voluntary participation
• A peer review quality improvement system
based on set standards
31
Functions
• Accreditation of Residential Care Homes
• Research & Development
• Information Dissemination
32
Accreditation of Homes
• To set up structure
• To establish and review quality standards
relating to residential care
• To set up accreditation procedures &
conduct the accreditation process for
participating residential homes
• To train and accredit assessors for
accreditation
33
Structure
• Advisory Committee
• Steering Committee
• International Advisors
• Accreditation Committee
• Appeal Committee
• Complaint Handling Committee
34
RACAS Structure
35
Advisory Committee
• Social Welfare Department
• Department of Health
• Hospital Authority
• Hong Kong Council of Social Service
• Representatives from Private Home
Associations
36
Advisory Committee
37
Steering Committee
• Professionals including Geriatricians,
Nurses, Social Workers
• Operators of Residential Homes including
NGOs and Private Homes
• Academics in Nursing and Social Work
• Elderly and Carer
38
Steering Committee
39
Accreditation Standard
40
Accreditation Standard
41
• 2008 Awarded the “Certificate of
Accreditation” by the International
Society for Quality in Health Care
(ISQua).
• The only residential home
accreditation scheme in Hong
Kong that is approved by ISQua
• The Accreditation Scheme is the
only residential home accreditation
scheme in Hong Kong that is
approved by ISQua
International Recognition
42
The Accreditation Scheme was awarded
ISQua’s Certificate of Accreditation
• Confirmed that the 40 accreditation criteria in
the Accreditation Scheme meet international
standards
• All participating homes with a valid Accreditation
Certificate have reached an appropriate
standard in their service.
• The Accreditation Scheme allows elderly and
their family members to choose residential
homes with reference to a reliable yardstick.
43
In July 2009, we updated the criteria of
accreditation.
Subcriteria from 214 to 225
Accreditation Standard
44
Accreditation procedures
&
On-site
accreditation process
45
46
11
11
11
Accreditation Cycle
• Major assessment once every 5 years
• Annual Review
47
Accreditation Mechanism
• Voluntary
• Preliminary screening questions
• 1 day of pre-assessment training
• Submission of documents and internal audit
• On-site accreditation 3 - 5 days though peer
review based on set 40 standards (Assess
caring procedures, document review &
interview to service users and stakeholders)
48
Accreditation Mechanism
• Oral presentation
• Accreditation Committee Meeting
• Announcement and appeal
49
A sign bearing the words “Residential
Aged Care Accreditation Scheme” will
be posted at the participating
residential homes.
Certificate and label grant to the
Accredited Residential Homes
50
Professional Assessors
Training of Assessors
A 5-day programme and 3-5 day on-
site accreditation training
Trained professional assessors: over
270
51
April 2003 to Dec 2010
8 training courses (2 in pilot project)
Assessors Working Background
Institution NGO Private Home
Hospital Authority
Department of Health
Training Institution
Other＊ Total
No 145 28 52 2 21 29 277
Percentage 52.3% 10.1% 18.8% 0.7% 7.6% 10.5% 100%
52
Assessor Professional Background
Profession Nurse Social Worker
Physiotherapist Occupational Therapist
Doctor Total
No 160 79 14 21 3 277
Percentage 57.8% 28.5% 5.0% 7.6% 1.1% 100%
Professional Assessors(with
valid certificate 2011 Aug)
Assessor Number
Nurse 55
Doctor 0
Social Worker 44
Physiotherapist 10
Occupational Therapist 4
Total 113
53
Ceremony of graduated
Assessors
54
Ceremony of graduated
Assessors
55
Research & Development
• Development of Accreditation System is a
continuous process.
• A systematic arrangement in monitoring the standards, compliance situation and international trends in accreditation.
• Data collected from the accreditation would constitute useful reference for the government towards policy formulation and service development.
56
Information Dissemination
• Information and results of the accreditation of
residential homes will serve as reference for
the government, home operators,
professionals and the public.
• Information will also serve to facilitate the
consumers in making informed choice of
appropriate residential homes.
57
Quality Manual
• Published in November 2008
• Three major parts
Part I：Principle of Quality
Part II：Clinical guidelines
Part III： Practical management of quality
improvement in residential home
• 21units
Newspapers/Newsletters
59
Information Dissemination
• Channels of dissemination include regular
newspaper announcement
• Promotional pamphlets and regularly
Newsletter on accredited home
• Internet
•香港老年學會網頁 www.hkag.org
•醫院管理局智友網 smart patient website：www.smartpatient.ha.org.hk
60
61
IMPROVEMENT IN THE
QUALITY OF SERVICE OF
PARTICIPATING HOMES
Part 3
61
The present situation of the
participating residential homes
62
Residential homes participated in
RACAS from 2002
Over 100 residential homes have
participated
63
Types of residential Homes
participated accreditation (till 30/10/2011)
Home No. No. of Residential Homes in HK
Type Government fully
Subvented 36 131
Private 60 587
Self-financing
homes 6 54
Contract homes 4 16
Total 106 788
Size of
residential
homes
<101 beds 33
>100 beds 73
Total 106
64
Residential homes attained full
Accreditation
Year
New Home Total no. of Residential Homes participated in accreditation
2003(Pilot Scheme) 39 39
2004(Pilot Scheme) 1 40
2005(RACAS Launch) 11( Pilot Scheme) 40
2006 14(1 Pilot Scheme) 53
2007 2 55
2008 8 63
2009 22 (5 Pilot scheme) 80
2010 10 90
2011 (till Nov.) 11 101(6 left without complete the accreditation process)
5 (in progress) 106
65
Improvement of quality of
service in participating homes
in past 10 years
• Develop a comprehensive set of quality
management and supervision system
66
Quality improvement
• Most common Recommendations of
Accreditation
• Increase satisfactory rate
• Improvement quality standard-staff training
• Individual Example (2 private residential
homes & 1 subvented home)
67
The most common recommendations for improvement
in the initial accreditation assessment
68
The most common recommendation for improvement
in the initial accreditation assessment
Priority Accreditation Standard No. of
recommendations
1 Standard 8 Food and environment hygiene 128
2 Standard 20 Infection control 114
3 Standard 11 Medication management 68
4 Standard 6 Environment and facilitates 61
5 Standard 15 Feeding 54
6 Standard 3 Risk management 45
7 Standard 37 Safe environment 44
8 Standard 27 Information management 36
9 Standard 18 Use of physical and chemical restraints 35
10 Standard 1 Total quality management 34
11 Standard 16 Nutrition 34
12 Standard 39 Assessment of residents’ needs 32
13 Standard 12 Continence management 31
69
Standard 8
Food and environment hygiene
70
Infection control
71
Medication management
72
Environment and facilitates
73
Feeding
74
Risk management
75
Safe environment
76
Information management
77
Use of physical and chemical restraints
78
Total quality management
79
Nutrition
80
Assessment of residents’ needs
81
Continence management
82
Satisfactory rate of residents
and relatives • Increase in satisfactory level of residents and
their relatives in 19 accredited home after 4
years accreditation
83
No of Homes Before
accreditation
percentage of
homes which have
a satisfactory rate
of over 80%
After 3 years of
accreditation
percentage of
homes which
have a
satisfactory rate
of over 80%
Percentage
19
68.4
95 26.6%
Staff Training
• After 4 years of accreditation
• Increase in the number of staff undergoing
continuous professional training
– 80% of all participating homes
– 100% of the private participating homes
84
Staff Training
85
Private
Home
Government
fully Subvented
Total number of Staff received
training Before Accreditation
141 509
650 1st Yearly Review
188 520 708 2nd Yearly Review
152 496 648 3rd yearly review
164 616 780
Average from 1st yearly review to 3rd yearly review
168 544 712
Comparison between before accreditation with the
average of 3 years after accreditation 19.15% 6.88% 8.71%
Residential care homes for the elderly (RCHE)
Example 1 : RCHE “I”
Profile of RCHE “I”
Type of RCHE Private home
No. of beds 123
No. of residents before accreditation
85
No. of staff 19
86
Example 1 : RCHE 1
Items Before Accreditation
After Accreditation
Change %
Occupancy rate 70.06% 79.22% ↑9.16%
Degree of residents' satisfaction 90.00% 91.67% ↑1.67%
Degree of family members' satisfaction
90.00% 91.67% ↑1.67%
Toilet training rate 2.27% 20.37% ↑18.1%
Fall rate 1.54% 0.91% ↓0.63%
Fall and injury rate 1.54% 0.86% ↓0.68%
No. of staff training (per head) 14 (73.6%) 16(84.2%) ↑2 (10.6%)
87
Example 1 : RCHE 1
88
Must improvement (non-compliance)
Need improvement (partial compliance)
Continuous improvement
7 items 8 items 16 items
Standard 1 Total quality management
Standard 5 Occupational safety and
health
Standard 8 Food and environment
hygiene
Standard 16 Nutrition
Standard 17 Mobility assessment and
management
Standard 33 Human resource
management
Standard 37 Safe environment
Major recommendations of must improvement in the first year accreditation
assessment
Example 2 : RCHE “S”
89
Profile of RCHE S
Type of RCHE Private home
No. of beds 61
No. of residents before accreditation
34
No. of staff
16
Example 2 : RCHE “S”
90
Items Before Accreditation
After Accreditation
Change %
Occupancy rate 56.02% 91.44% ↑35.42%
Must improvement (non-compliance)
Need improvement (partial compliance)
Continuous improvement
25 items 26 items 13 items
Example 2 : RCHE “S”
91
Standard 3 Risk management
Standard 6 Environment and facilities
Standard 8 Food and environment
hygiene
Standard 11 Medication management
Standard 12 Continence management
Standard 15 Feeding
Standard 16 Nutrition
Standard 18 Use of physical and chemical
restraints
Standard 20 Infection control
Standard 21 Cognitive, emotional,
sensory and communication ability of residents
Standard 25 Psychological support and
social care
Standard 27 Information
Standard 29 Provision of information
Standard 39 Assessment of residents’
needs
Standard 40 Protection of residents’
right
Major recommendations of must improvement in the first year accreditation
assessment
Example 3: RCHE “P”
92
Profile of RCHE P
Type of RCHE Subvented home
No. of beds 318
No. of residents 310
No. of staff 152
Example 3: RCHE “P”
93
Items Before Accreditation
After Accreditation
Change %
Occupancy rate 97.54% 96.49% ↓1.05%
Toilet training rate 0.28% 12.08% ↑11.8%
Fall rate 7.04% 6.74% ↓0.3%
Fall and injury rate 3.65% 2.14% ↓1.51%
No. of staff training (per head) 106 (69.7%) 124.67 (82.0%)
↑18.67 (↑12.3%)
Example 3: RCHE “P”
94
Must improvement (non-compliance)
Need improvement (partial compliance)
Continuous improvement
0 item 7 items 9 items
Standard 3 Risk management
Standard 6 Environment and
facilities
Standard 12 Continence management
Standard 25 Psychological support
and social care
Major recommendations of Need improvement in the first year accreditation
assessment
Example 3: RCHE “P”
95
Standard 4 Purchase of service
Standard 6 Environment and
facilities
Standard 8 Food and environment
hygiene
Standard 16 Nutrition
Standard 21 Cognitive, emotional,
sensory and communication ability
of residents
Standard23 Death and bereavement
Standard 27 Information
Major recommendations of Continuous improvement in the first year
accreditation assessment
Accredited Home
• Over 97% of participating residential
homes joined RACAS expressed that
RACAS can improve the quality of service.
96
To encourage residential homes to attain a
higher standard of service than the baseline
requirements
Hong Kong Outstanding Residential
Home Award 2009
97
In 2009, with the support of the following eight
professional bodies, the Hong Kong Outstanding
Residential Homes Award 2009 was held.
Collaborating Organizations:
Senior Citizen Home Safety Association
The Hong Kong Council of Social Service
The Hong Kong Association of Senior Citizens
Hong Kong Physiotherapy Association
The Hong Kong Dietitians Association
The Hong Kong Geriatrics Society
Hong Kong Occupational Therapy Association Hong Kong College of Gerontology Nursing
98
Hong Kong Outstanding Residential Home Award 2009
「Hong Kong Outstanding
Residential Home Award 2009」
99
The Way Forward
• Residential Aged Care Accreditation
Scheme(RACAS) will work closely with
professionals and various sectors
including government and non-
governmental organizations to enhance
the quality improvement of residential
homes in Hong Kong
100
Towards enhancing Quality of
Residential Homes in Hong Kong
101
The safeguards to quality in
residential homes • Regulatory measures - proper licensing,
inspection and appropriate sanction
• Manpower in residential homes
• Education and training of professional and front-
line care staff
• Financial resources – Long Term Care
Financing
• Accreditation to set standards for practice and
encouragement of quality improvement
102
Hong Kong Association of
Gerontology
• Enquiry about Residential Aged Care
Accreditation Scheme – www.hkag.org
103
