The SafeCare Initiative: Introducing standards and a structured stepwise improvement process for basic health care providers in Resource Restricted Settings

Del

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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

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48,2 38,1

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Ghana Kenya Nigeria Tanzania

Med

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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