While COHSASA’s 10 years have been marked by triumphs and setbacks, it’s moments like these when Wentworth Hospital in Durban celebrated its THE COUNCIL accreditation at the start of the new millennium FOR HEALTH that linger forever… SERVICE ACCREDITATION OF SOUTHERN We’ve come a long way AFRICA COHSASA HAS been working in demonstrated the value of this local recognition that COHSASA meets the field of quality improvement in approach in improving the delivery of agreed international standards South African healthcare facilities quality health care to all our citizens. specifically developed and tested for over 10 years. Part of the for healthcare external evaluation In the past ten years of operation, Proudly South African movement, bodies. with COHSASA’s work in 595 COHSASA has achieved global In August 2004 COHSASA facilities in both the public and recognition and is one of only a became the first organisation in private sector, the following handful of internationally accredited the world to undertake the milestones have been reached: accrediting bodies recognised by development of standards for the the International Society for Quality In 1994, the Pilot Accreditation evaluation and management of HIV in Health Care (ISQua). Programme for South African and AIDS within a district and Health Services was launched as a across the continuum of care – from Since its inception, COHSASA has research and development prevention and VCT to terminal care. focused on providing South African programme in the Faculty of (Continued on page 2) solutions for South African problems. Medicine at the University of This has resulted in the development Stellenbosch under the of facilitated accreditation directorship of Dr Stuart programmes for South African Whittaker. The programme grew healthcare facilities that enable rapidly and, in October 1995, specific identification of areas of COHSASA was registered as a strength and deficiency. Through a not-for-gain organisation. process of ongoing training, The first hospital to be accredited monitoring and evaluation, skills in South Africa – the Medi-Clinic transfer to local staff enables facilities Group’s Louis Leipoldt Hospital in to become accredited as centres of Bellville – was issued with a two- excellence for healthcare provision. year COHSASA accreditation Because of the legacies of the past, certificate on June 1, 1995. many facilities in South Africa face The first public sector hospital New Chairman significant obstacles in provision of to be accredited – Addington for COHSASA health care, including problems with Hospital in Durban – was awarded finance, physical infrastructure, a two-year accreditation on Mr Albert N Ramukumba, medication and consumables supply, November 21, 1997. B.Dent.Ther (Hons), AMP as well as staffing shortages. To COHSASA signed the first major (Manchester), PDH (UCT), assist facilities to overcome these contract to accredit 29 public PG Dip. in HIV/AIDS deficiencies and acting in response sector hospitals in KwaZulu-Natal (Medunsa), formerly Chief to local needs, COHSASA developed on November 12, 1998. Executive Officer of the the graded accreditation process – In May 2002, COHSASA’s Hospital Association of unique in the world – that allows all standards were recognised by the South Africa (HASA), facilities in the country to access International Society for Quality in has been appointed as world-class accreditation processes Health Care (ISQua) as meeting its Chairperson of the that are tailored to their specific principles. COHSASA Board of Directors. Cohsasa Bulletin requirements. Responses to In September 2002 COHSASA Speaking soon after his these programmes over the was accredited by ISQua for four election, Mr Ramukumba last decade have repeatedly years. This is formal, worldwide May 2006 said he believes in teamwork and aims to encourage full North West participation from Board Province Quality members to carry COHSASA Summit into the future. New Chief Operations Manager In December 2005, QI evolution in windblown staff Free State Hospitals celebrated COHSASA’s 10th birthday in Injection safety inside Cape Town. North West Province Quality Summit SENIOR OFFICIALS and hospital staff of the North West Province assembled at a hotel near Rustenberg during the November 2005 Quality Month to take stock of service provision in their facilities.
The province has just completed its first contract with COHSASA. Eight of its hospitals earned Progress Awards, seven received Entry Awards and one achieved an Intermediate Award. Klerksdorp/Tshepong Hospital was awarded a three-year accreditation and Witrand Psychiatric Hospital was accredited for two years.
The aims of the summit – Restoring Dignity through Quality Health Service – were to create a common understanding and awareness of quality and quality assurance and to gain clarification of the role of quality assurance and its relationship to other programmes initiated in the province. The rationale was to give impetus to QA activities and mark Quality Month in South Africa. COHSASA was invited to attend and gave feedback on the status of the hospitals in the province participating in its programmes, and encouraged the institutions to continue with the process of quality improvement.
In his presentation, Dr Stuart Whittaker, CEO of COHSASA, said his organisation could assist the province to improve the quality of health services provided to the public, but that the programmes were not a ‘magic bullet’. He said quality improvement is an investment over time and that if standards are to be fully maintained and become ingrained in everyday hospital practice, the hospitals needed to make a long-term commitment.
COHSASA celebrates 10 years In 2005, the Council for Health Service Accreditation of Southern Africa celebrated a decade of involvement in quality improvement for healthcare facilities. A special dinner was held at a city restaurant after COHSASA’s Board meeting in November. Those who attended this historic event were, from left (back row): Magda van Wyk from the Board of Healthcare Funders, Professor GJ van Zyl, Head of the School of Medicine in the Faculty of Health Sciences at the University of the Free State, Dr Shadrack Mazaza, member of the QUALSA Board of Directors (Clinical Governance Executive and Chairman of the Clinical Governance Exco), Dr Louis Claassens, Director: Quality Assurance for the National Department of Health and Fanie Maritz, COHSASA’s auditor. Front row: Dr Helene Visser, Manager of Quality Assurance and Training for City Health in Cape Town, Professor Marie Muller, Dean of the Department of Nursing and Education at Johannesburg University, Dr Jill Hurst, Hospital Manager of Addington, Mr Albert Ramukumba (Chairman), Dr Stuart Whittaker (CEO) and Dr Deon Moulder (Deputy Chairman). FROM TOP Absent: Tevern Japhta from the South African Quality Institute. The two-day summit was hosted by Connie Masiangoaka of the Quality Assurance Unit of the North West Province Enjoying a tea break were (from left to right): Salvation Baloyi, Matipi Kgaje, Esther Viljoen and We’ve come a long way (Continued from first page) Eunice Abrams On December 17, 2004 COHSASA became an accredited member of the Proudly South African Participants broke into smaller groups to discuss campaign. aspects of quality care In January 2005 COHSASA assisted the World Health Organisation (WHO) to launch its World Attentive audience in the main hall Alliance for Patient Safety in Durban, which aims to conduct studies around the world to determine the Grissel Ncedana from COHSASA making friends nature and the extent of adverse events in developing countries. Key players at the Quality Summit In 10 years COHSASA has provided valuable input for global health bodies: it formed part of the Joint Commission on Accreditation of Healthcare Organizations task team to develop healthcare standards; is part of the editorial team of the ISQua Journal; and regularly provides input for the World Health Organisation on issues of patient safety, quality assurance and accreditation.
2 FROM THE OFFICE OF THE CEO
IT IS DIFFICULT to fully comprehend and the maintenance of standards. It that a decade has gone by since the has become crucial to view Council for Health Service participation in an accreditation Accreditation of Southern Africa first programme not as a “one-off” hit registered as a not-for-profit with a magic bullet, but rather as a The CEO of COHSASA, organisation in 1995. long-term investment that pays huge Dr Stuart Whittaker dividends in terms of patient safety, COHSASA has enjoyed its share of credibility, avoidance of waste and both success and disappointment minimisation of costly lawsuits. over the past 10 years and like all pioneers heading out on that rough, In ten years, COHSASA has COHSASA has made New Board member rocky road due West, there have positioned itself as only one of four a difference to the been a number of obstacles along health accrediting bodies in the the way. Uncertainty has been part world to be recognised as meeting quality of health care in of this journey, but it has also been the competency requirements of the Southern Africa the reason why – at least it can now International Society for Quality in be said – that COHSASA does know Health Care Inc. (ISQua). COHSASA’s endemic weaknesses, trends that what works and what doesn’t, and professional standards – derived endanger patient safety and because of the wisdom gained and from the collective wisdom of 41 patterns of poor administration that implemented, has made a countries around the world – have result in waste and duplication. difference to the quality of health been gleaned and honed by local care in Southern Africa. representative bodies, tested locally, After an intense and extensive and have been officially recognised process, COHSASA has notched up Health facilities in COHSASA’s as meeting the principles of ISQua. a world first: the first set of standards quality improvement programme are that evaluate how effectively HIV now beginning to meet international COHSASA is a member of the disease is being managed across a professional standards. In the public Proudly South African movement district with its component network sector, this has proved to be more and has been invited to share what it of hospitals, clinics, hospices and difficult than first thought. However, knows about improving the quality community services. The HIV and TERVERN JAPHTHA, acting it is now known that with enabled of health in the developing world on AIDS District Evaluation Tool (HIV- CEO of the South African and committed management in many international podiums around DET) systematically evaluates the Quality Institute in Pretoria, has place, it is possible for any facility the globe. Our experience over time quality of HIV care provided to patients been formally appointed as a (even those with poor resource on a wide range of issues that in a geographically defined district. COHSASA Board member. Mr bases) to achieve accreditation. impact on accreditation and quality Japhta brings to the COHSASA assurance processes in our country Over the years COHSASA has To meet these specific challenges, board business skills he learnt has become a valuable asset. partnered with both local and two compensatory systems have while studying for a B.Admin international organisations to been pioneered: facilitated Operations have increased in degree (Public Administration conduct research. These links have accreditation and the graded geographical impact too, with and Business Management) at become the firm foundation leading system of recognition. Instead of COHSASA now working in six of the the University of Pretoria and a to further collaboration with major leaving hospitals to their own nine provinces in South Africa, as Diploma (Quality Management players in global health such as the devices, COHSASA sends teams to well as having contracts in Namibia, Technician) from the College of World Health Organisation. assist with understanding and Botswana and Rwanda. The work Production Technology. implementing the standards and has taken place in 595 different COHSASA will soon be embarking He has been with the South provide training (in infection control, facilities of all kinds in both the on a major infection control African Quality Institute leadership, resuscitation, quality private and the public sector. Sets of improvement programme with an since 2000, serving in assurance) in identified areas. standards have been developed for international partner and the several capacities including hospitals, clinics, and psychiatric development of an adverse event The graded system of accreditation marketing, strategy, financial hospitals, rehabilitation centres; reporting system to improve patient means that instead of hospitals and and personnel management, sub-acute care centres and safety. These initiatives are part of clinics becoming despondent about and corporate governance. He emergency services. an international movement to not meeting the standards first time is a member of the Boards of improve the current status of patient round, they are awarded certificates COHSASA has developed one of the Directors of the South African safety throughout the world. at defined levels of progress (Entry health accreditation industry’s most Auditors and Training and Intermediate) that encourage sophisticated computerised systems I am extremely grateful to all those Certification Association further participation until the to keep clients informed about who have participated in COHSASA’s (SAATCA), the South African quality assurance process becomes progress. The system provides first 10 years. Some of our Excellence Foundation and the institutionalised and endemic, rather feedback which comprehensively achievements have been quite Ulwazi Ubuntu CC. We than viewed as an add-on at the end outlines and prioritises deficiencies, remarkable. welcome him to COHSASA. of a long day. maps progress and tracks client I would like to extend a thank you to commitment to the process of In this decade, it has become all those who have believed – and improving health care. extremely clear that accreditation is contributed to – the vision of merely the “cherry on the top” and Reports generated are a valuable ensuring that all Southern Africans that the most important component management tool for facilities and receive equitable and quality of the COHSASA programme is the overseeing authorities because they healthcare. The journey continues … quality improvement process itself isolate and identify individual and – Dr Stuart Whittaker
3 COHSASA appoints new Chief Operations Manager JACQUI STEWART, a recognised expert in leadership at the most senior levels in the UK’s National Health Service (NHS), has joined COHSASA as Chief Operations The corporate ethos I have found in COHSASA Manager. makes me believe I have found the right Her return to this country (she organisation in which to practise those values graduated as a nurse from the I believe in – honesty, integrity, and doing the best Victoria Hospital in Wynberg, Cape I possibly can with that which is available Town, in 1978, receiving the Award for Outstanding Achievement) constitutes a determined swim against the tide: coming back to development and skills to motivate others. A leader invest her global knowledge in a leadership lead for will guide people to a goal and give developing country when so many the Directorate of them enough space to achieve it on other health professionals are Health and Social their own,” she says. Care in the Midlands leaving our shores. She will also take over the day-to- and the east of day operations of COHSASA from “I have returned to South Africa England. because there is a worthwhile job CEO Dr Stuart Whittaker so that he Currently studying will be able to spend more time on that needs doing and I hope I can Jacqui Stewart, the new Chief Operations Manager contribute something.The corporate for her Doctorate in planning, strategy and research ethos I have found in COHSASA Professional Health projects. Studies at Middlesex makes me believe I have found the action because her observations led Who else – in the space of one University, Ms Stewart believes that right organisation in which to her to conclude that most month – could change jobs, change health management should ensure practise those values I believe in – participants were used to lectures countries, become part of the that people have what they need to honesty, integrity, and doing the and conferences only. senior management team of an do the job. They also need to best I possibly can with that which is organisation, return to the country “We needed to get people to take an understand the value one brings as a available,” she says. she has just left (the UK) for a active interest in their own learning manager to support those giving wedding, skip across to America, In February and April 2005 process and asked them to submit direct patient care. Ms Stewart visited Mpumalanga evaluations on what they had learnt. move house, get a banking account with a team from the UK. Her brief It was extremely rewarding for me “I enjoy developing the capacity and in SA and host a family for was to provide leadership and when one particularly pessimistic capability of people, finding the Christmas … all with the tranquil management input into the individual sent back an evaluation talent and watching it grow. Here in demeanour of Mona Lisa on Valium? South Africa, it will be about sharing COHSASA Health Executive saying that while he had not Obviously someone very special. Development Programme for CEOs anticipated learning much from the my knowledge with COHSASA staff and medical, nursing and exercise, he had indeed learnt a and helping health managers who administrative managers. The team great deal to take with him into the have gone through the COHSASA went on a reconnaissance trip to the next phase of his career,” she says. programme to manage and lead, Rob Ferreira and Shongwe hospitals “We also asked the leaders to take a reach their goals and grow,” she before conducting the training at single COHSASA standard and says. regional centres. work as a team on a project to She will also be helping to train "Quality in improve that standard within their These on-site visits are part of facilitators and extending the Health hospital. The results were great with health care can Ms Stewart’s firm belief that one Executive Development Programme a tangible enthusiasm to share what cannot develop people without in the provinces where COHSASA be defined as they had done.” understanding the context they works. Her ultimate and ideal goal, work in and the challenges that go Before returning to SA, Ms Stewart however, will be to “work herself out meeting agreed with it. For example, when she was was the Programme Director of a job” in the sense that capacity standards that with the East Kent Health Authority (Director of Career Development and capability will have increased to she took the trouble to go into the and Succession Planning) at the an extent where developing define the leadership will be on everyone’s field for home visits with the doctors Leadership Centre of the NHS expectations of in the early hours of the morning on Modernisation Agency. agenda. the Sunday of a Bank Holiday She has occupied many key With an outlook fired by a healthy health care weekend. In this way she could positions in NHS organisations over balance between idealism and understand the conditions they professionals, the years, including Senior Nurse in realism, Ms Stewart has a strong work under and match it with the the Harefield Hospital Transplant belief in the human ability to patients and necessary support and, where Unit, Director of Primary Care transcend the limits of education possible, resources. the community" Development for East Kent Family and environment. A substantial part of the training Health Services, Performance “I do not believe all leaders are born. Dr Stuart Whittaker, 2005 method used in Mpumalanga was Director for the East Kent Health I believe they can be developed. We participation and using actual Authority, Project Director for the need leaders in all spheres of an experiences to bring theory to life. Kent and Medway Health organisation, not just at the top. True This was a deliberate course of Authority, as well as organisational leadership is having vision and the 4 MESSAGE FROM THE ACTING CHAIRMAN AT 10-YEAR CELEBRATION
THE COUNCIL FOR Health Service Accreditation of Southern Africa was founded in 1995 with the mission to empower Southern African healthcare facilities to deliver quality, cost effective and compassionate care through an integrated quality improvement and accreditation approach.
Accreditation is a formal process by which a recognised organisation assesses and certifies that a healthcare facility meets applicable, predetermined, published standards. These standards are regarded as optimal and achievable. They are also designed to encourage continuous improvement of patient care. Accreditation is a voluntary process in which healthcare facilities choose to participate rather than be coerced by legislation.
ISQua (the International Society for Quality in Health Care) in 2002 recognised the COHSASA standards as complying with international principles. There are 45 countries that have healthcare accreditation organisations, of which only four have current international accreditation.
1. South Africa – COHSASA 2. Australia – ACHS 3. New Zealand – NZCHS 4. Canada – CCHSA
Health care funders and consumers are applying pressure on healthcare The accreditation standards provide the Dr Deon Moulder, providers to prove that they deliver quality patient care. Hospital performance foundation to develop a structure that can be the Acting Chairman, measures and quality improvement methods are complex interventions and pictured at COHSASA’s applied to the whole hospital, i.e. non-clinical 10th birthday. not easy to evaluate. as well as clinical services. This must be seen He is also a director of as a holistic approach to enable management, the Medi-Clinic Private COHSASA standards provide a mechanism for healthcare facilities to structure Health Care Group. administration and patient care professionals and implement quality improvement methodology. Avedis Donabedian, the working as a multi-disciplinary team to founder of healthcare quality assurance, defined the following categories that produce good patient and business should be assessed to evaluate and improve patient care: outcomes. 1. Structure: Resources to deliver care and equipment An organisation cannot be successful in - Credentials of doctors continuous improvement without laying the - Infrastructure foundation of the quality system, i.e. structure. - Standard procedures Business and clinical process will be effective if 2. Process: The care itself the structure is sound and this will result in the - How the diagnosis is made desired outcomes. - Which procedures are performed It is for this reason that COHSASA has - What medication is used become an essential part of quality 3. Outcomes: The valued results of care assurance in the healthcare business. - Life enhancement - Relief of suffering – DW Moulder, Acting Chairman of the Board of COHSASA, November 2005 - Satisfied consumers
COHSASA visits Deputy Minister of Health A DELEGATION OF COHSASA senior staff visited the Deputy Minister of Health, Ms Nozizwe Madlala-Routledge, at her offices in Parliament to present a review of COHSASA’s work in Southern Africa to date. The presentation outlined common problems encountered in public sector hospitals and how standards have been developed to manage HIV within all service points in a district.
From left, Dr Morris Mathebula, programme manager of the HIV and AIDS District Evaluation Tool (HIV-DET), Dr Stuart Whittaker, CEO of COHSASA, Ms Nizizwe Madlala-Routledge, Mr Gerard Locke, healthcare technology management consultant for COHSASA, and Ms Grissel Ncedana, Chief Facilitator of COHSASA.
5 Addington Hospital celebrates its second COHSASA accreditation
QIPresults in lower epilepsy rate Theuns Oosthuizen - By Dr Theuns Oosthuizen, Clinical Clinical Manager at Witrand Hospital in the North West Province Manager at Witrand Hospital
WHEN I WAS appointed as Clinical Manager for Witrand Hospital in the North West Province, one of my first observations was the high epilepsy rate at the facility. This obviously carried the potential for serious adverse events given the disease profile of the inpatient population.
Witrand Hospital is a 1152-bed mental health institution rendering services to three broad disease groups treated in a 60-bed psychiatric unit, a 15-bed Representatives of Addington Hospital crowded into the auditorium in 2002 to physical medicine and rehabilitation unit and 1077 beds for mentally hear what they were letting themselves in for the second time around. retarded patients.
It was clear that in trying to address the problem of an unacceptably high ADDINGTON HOSPITAL IN Durban, KwaZulu-Natal, has been seizure rate (specifically in the mentally retarded section), a few quality accredited by COHSASA for a second time. improvement processes would have to be used to identify the root cause or Attending the ceremony to present the certificate, Dr Stuart Whittaker, causes. Through a series of corrective measures we hoped to achieve a CEO of COHSASA, said the occasion affirmed a cherished notion for decrease in the rate of seizures. him that, “given sufficient support and encouragement, health care in These processes included development of a Quality Improvement South Africa’s public sector can be transformed to meet the increasing Programme (QIP), an analysis of patient profiles regarding the diagnosis of demands of a society having to grapple with serious public health epilepsy as part of their mental retardation, as well as the daily data of concerns: the AIDS pandemic, TB, malaria and many other chronic epileptic seizures. illnesses.” This data needed to be evaluated against best practice epilepsy diagnosis He said he found the professional level of Addington’s participation in and management policy (clinical audit) with root causes identified and the accreditation very encouraging, as they have a firm grasp of the addressed. These root causes include incorrect doses or non-administration quality improvement concept. of anti-epileptic drugs, mentally retarded patients not swallowing their drugs “It means that this hospital has reached – and I hope will continue to and co- morbidity of other diseases. reach – quality standards approved not only by all the relevant It was necessary to undertake in-service training for all stakeholders to professional bodies in South Africa but also by ISQua – the ensure a common understanding of the diagnostic features and treatment International Society for Quality in Health Care – an organisation that regimes of different epileptic syndromes. Furthermore, all staff received in- represents some 30 countries around the world,” said Whittaker. service training regarding the diagnosis and management of epilepsy and On its journey to quality, Addington Hospital has brought about many best practice guidelines. impressive improvements. At ground level, several programmes are in place that have won awards, including a patients’ complaint and compliments audit; an in-house preventative maintenance programme; a 24-hour rotating equipment pool and a preventative programme for occupational exposure to HIV.
On November 21, 1997 Addington Hospital became the first public sector hospital to receive a COHSASA accreditation certificate, remaining accredited for two years until 1999. There was a time lapse between programmes, and the hospital re-entered the accreditation programme in October 2002. Addington has now received a second accreditation award, valid until March 2007, making it one of the first public sector hospitals to receive a second COHSASA accreditation on re-entry into the programme.
In 2000 and 2001 the hospital won a silver medal in the Premier’s and Price Waterhouse Coopers Awards for Good Governance. In 2001, it achieved the Best Practice award for a needle-stick injuries contribution to a preventive programme for occupational exposure to AIDS, and in 2002 scooped the Gold Medal for the Premier’s and Price Waterhouse Coopers Good Governance Award.
Delegates have a tea break
6 The first step was to capture doctors and re-signed or adapted number of after-hour consultations electronic data of all 850 if applicable. Copies were handed for epileptic fits and a decrease in inpatients, identify epileptic patient over to dispensary. medication for the treatment of numbers and the frequency of It was then identified that stock acute seizures. seizures. This revealed that 33% of issued in bulk to the wards led It was a learning experience for the patients at Witrand Hospital were to incorrect administration team who developed and epileptic and that the initial (evidenced by clinical audit and implemented the QIP. They did not epilepsy rate was 19,1%. repeated blood levels of anti- have all the knowledge in the The second step was to develop a epileptic drugs making no sense). beginning but by implementing a best practice guideline for the This systems-related problem was number of quality improvement diagnosis and management of subsequently corrected through processes after identifying a epilepsy. Available best practice implementation of a pre-packed problem and its cause, they realised guidelines were researched on the dosette dispensing system via the that systems are often the culprit. Internet from worldwide sources pharmacy. Wards with the highest and a guideline was developed. number of epileptic patients were Systems in health need people to A clinical audit form was then given first priority. implement them and thus designed and completed for every Other causes for the patient to have motivation and continuing in- patient who had an epileptic fits, i.e. the possible side effects of service training is a daily task. We attack. This was analysed by the anti-epileptic drugs and the used a multi-professional team Eastern Cape Clinical Manager’s office against development of hyponatremia approach and it resulted in an enters the COHSASA the best practice guideline and a associated with the syndrome of overall organisational achievement. root cause identified. inappropriate antidiuretic hormone PROGRAMME This QIP is an example of the quality A number of causes emerged, secretion (SIADH) with electrolyte improvement spiral that works to ranging from systems failures to disturbances, were identified via full The following hospitals in the this day. We focused on the patient, patient co-morbidity factors and blood counts and electrolyte tests. Eastern Cape have entered implemented quality improvement staff error. These were addressed In certain patients the choice of an into the COHSASA Facilitated through teamwork, understood in order of priority. anti-epileptic drug was changed. Accreditation Programme: systems and processes and re- At the time, the institution used Night duty staff allocations were organised them where necessary, All Saints Hospital separate medication prescription adjusted to create higher levels of used the best available information, Bedford Orthopaedic Hospital and administration systems, supervision and decrease the did not ignore the human element, Bisho Hospital which resulted in nurses having to workload of the professional nurses and now we can celebrate because Cecilia Makiwane Hospital transcribe scripts to administer who rotated through the wards in an we see the effect of this QIP in Dora Nginza Hospital prescribed medication. This effort to administer all medication. patient care daily. Fort England Hospital system could lead to errors. The above-mentioned actions Frere Hospital Doctors customarily would only To ensure sustainability, all epileptic resulted in a drop in the epilepsy Frontier Hospital prescribe chronic treatment once fits are monitored daily. Root causes seizure rate from 19,1% of all epileptic Grey Hospital every three months. To ensure that found are addressed with ward patients at the start of the quality Komani Hospital prescriptions were not outdated, doctors and staff. It has become an improvement programme to only Livingstone Hospital all 850 chronic medication scripts ingrained part of the ward round. My 1,5% of patients for the third quarter Madwaleni Hospital were captured electronically and sincere thanks go to all my colleagues of the 2005/2006 financial year. Nelson Mandela Academic the format changed to a and staff who were part of this QIP Hospital prescription as well as 31-day It definitely had other positive and who sustain it to this day. PE Provincial Hospital administration format. This was outputs regarding the quality of life Rietvlei Hospital printed monthly, checked by for some patients: a decrease in the St Barnabas Hospital St Elizabeth's Hospital St Lucy's Hospital St Patrick's Hospital Taylor Bequest Hospital Eastern Cape implements a Umtata General Hospital Umzimkulu Hospital Zithulele Hospital national imperative Once accredited, each of the hospitals will receive two IN A DEVELOPMENT that may have a considerable impact on the quality of health care delivered to the people of the maintenance visits (one per Eastern Cape, the province’s Department of Health has entered 23 facilities into the COHSASA quality improvement year) to ensure that standards and accreditation programme. are sustained. The audits will Among these facilities – which include four major hospital complexes, psychiatric hospitals and district hospitals – are focus on high-risk areas within hospitals that are part of the National Department of Health’s revitalisation programme. the hospitals identified during the implementation of the Under the supervision of Dr BN Mjamba-Matshoba, Chief Director of the Quality Health Care Assurance Systems Facilitated Accreditation Directorate of the Eastern Cape, the province joins several other regions across the country in a drive to meet basic Programme and a randomised best practices and improved standards of health care as envisioned in the National Department of Health’s key assessment of all areas to strategic objectives. determine the degree to which the standards have been “In our experience, a long-term investment in continuous quality improvement and accreditation leads to improved maintained and/or improved. patient care. The COHSASA programme has proved to be an appropriate management tool that – if picked up and used – empowers health facilities to provide a safer and better service to its patients,” says Dr Stuart Whittaker, CEO of COHSASA.
7 QI evolution in Free State Hospitals COHSASA’s unique IT IS PART OF the uplifting history of the Free State that five of the first batch of 12 hospitals that entered into the COHSASA programme in 2001 achieved accreditation awards – this represented the highest percentage accreditation score achieved by any province in the country.
The hospitals that did not achieve accreditation were given either Entry assets or Intermediate pre-accreditation awards from the portfolio of COHSASA has spent the past ten years researching and developing quality COHSASA’s Graded Recognition programme and the drive for quality improvement and accreditation programmes specifically designed for has been continuing ever since. South African healthcare facilities.
Mr Shadrack Shuping, Executive COHSASA is the only healthcare-accrediting organisation in South Africa Manager of the Free State accredited by the International Society for Quality in Health Care (ISQua). Department of Health, has said COHSASA has developed standards in collaboration with local professional that the subsequent decision by bodies to ensure they constitute a blueprint for excellence. the Department to enrol all 31 Our 6th edition of Hospital Standards is recognised by the International hospitals in the COHSASA Society for Quality in Health Care as meeting its principles. process was inspired by its desire to maintain a sustainable COHSASA has a unique computerised information system to ensure an level of quality hospital services objective, scientific scoring of standards compliance within hospital in the province. departments, in hospitals overall and across hospitals within specific districts and regions. “Quality services for us means improved patient COHSASA has developed a multi-tiered reporting system that provides safety, comprehensive risk valuable information for hospitals and regional, provincial and national management, the cost-effective managers. use of resources and client Quality Improvement Programmes are developed in response to customer satisfaction. We are excited All roads lead to ... needs. that we are achieving the results We are a Proudly South African NGO committed to capacity building and we are: they are the sweet fruits This is one of the most empowerment. of hard labour.” frequent signs that COHSASA facilitators see when they We are affiliated to the South African Quality Institute as its only healthcare Henna van Zyl, Manager of the partner. Quality Assurance Directorate travel on the dusty byways for the Free State Provincial and back roads of South COHSASA has wide national and international networks and works closely Health Department, says the Africa. Dirkie van Jaarsveld, with the World Health Organisation, the Joint Commission on Accreditation decision was taken some time one of our facilitators who of Healthcare Organisations, the International Society for Quality in Health ago to take action to address often finds herself in remote Care and the German Society for Technical Co-operation – Die Deutsche the quality of public healthcare parts of the country, captured Gesellschaft für Technische Zusammenarbeit (GTZ) GmbH. in the province. After examining this one with a graffiti quality We have multi-disciplinary standards, revised every two years, for hospitals, several options, the department improvement solution: Fix it. clinics, step-down facilities and HIV district management that are a chose to go the internationally blueprint for excellent practice and the optimal use of resources. accepted accreditation route. The COHSASA system is a valuable management tool for hospitals, “We now have policies and structures in place that are key to provincial services and national services. maintaining high standards of quality healthcare,” says van Zyl. “During The COHSASA programme can be used by the National Department of the accreditation process, a lot of team building has taken place. There Health, provincial health services and private hospital groups as a has also been a lot of development in the hospitals and among the surveillance tool (we can monitor a whole discipline, e.g. infection control personnel, which has not been restricted to management and or resuscitation). management processes, but is reflected across all categories of staff.” Ours is a scientifically validated quality improvement training programme. Dr Stuart Whittaker, CEO of COHSASA, says that the Free State provincial government has clearly demonstrated a commitment to We can call on a trained team of medical and academic experts. deliver the highest possible standards of quality healthcare to members Over the last 10 years, we have developed world-class instruments and of the public. tools specifically tailored for the South African environment. He pointed out, however, that some of the hospitals’ accreditation certificates have lapsed and that it was “really important” that these hospitals re-enter the programme. “Without ongoing external vigilance Mission that inspires staff to meet and maintain standards there is a human To empower Southern African healthcare facilities to deliver tendency to let things slip. Facilities need to be motivated by the quality, cost-effective and compassionate care through an knowledge that external audits take place regularly. Part of COHSASA’s integrated quality improvement and accreditation approach strength is that it helps hospitals to maintain standards over time. It is important to build on improvements that have been built up over time and to sustain the momentum.” Vision To enable all Southern Africans to receive equitable and The accreditation certificates of two of the five hospitals - Bongani quality health care Regional in Welkom and Nala District in Bothaville have recently expired but the Free State Psychiatric Complex, Universitas Academic in Bloemfontein (previously accredited from 1997 to 1999) and the Mafube District in Frankfort hold their accreditation certificates until November this year. 8 FACILITATOR TRAINING a central operation COHSASA trains at COHSASA health executives in Mpumalanga FULL-TIME AND part-time facilitators attended a staff COHSASA HELD AN executive training session at the COHSASA training course for Mpumalanga head office in December 2005. Department of Health hospital In addition to training sessions managers and administrators at White held in August and April, this two- River in the last quarter of 2005 – the day training workshop included third of similar workshops held this discussions on challenges faced year. Aspects of the training course in the field, new sets of standards included an outline of various quality and amendments to existing improvement concepts, the difficulties ones. involved in implementing such programmes, guidance on Also up for review were the establishing infection control and risk special requirements for assessment programmes, and areas of COHSASA standards that concern about health and safety and COHSASA Standards Developer, Mrs Lyn Rayment, has a well-earned cup of tea evaluate management of HIV healthcare technology management. during the training of Mpumalanga health managers. across the spectrum of care (HIV District Evaluation Tool), an CEO of COHSASA, Dr Stuart introduction to the NDOH Health Whittaker, outlined progress from it was difficult to replace deep- Gerard Locke, COHSASA’s clinical Charter, and reviews of staff baselines in the Mpumalanga seated, bad habits with new ones. engineer, presented areas of general policies as well as the processes hospitals and the areas that need Some of the solutions offered concern about health and safety and that apply to facilitators’ further attention. Participants were included the notion of identifying healthcare technology management. operations. These included an asked to outline why some hospitals “champions” of quality and This was followed by another group update on the refinements to do better than others, why hospitals appointing quality co-ordinators session where participants were database reports that will help find it difficult to meet the standards at facility level to drive the process asked to identify deficiencies within facilitators to monitor the degree and what can be done to improve forward. There were also their institutions that could present of an institution’s performance the current situation. The interactive suggestions that special time slots problems with regard to health and and commitment to the session resulted in valuable should be assigned for staff to safety in general, deficiencies that programme, and the consistent feedback: including the fact that dedicate to the programme and that could be in direct contravention of application of criteria scores. hospitals that do well in the staff should be sensitised to use any of the relevant Acts of Parliament COHSASA programme have COHSASA standards as part of their or other regulations, standards, Dr Stuart Whittaker, CEO of committed, motivated managers everyday duties. guidelines, etc and any other COHSASA, said that the who build team spirit. problems that could present risks to A presentation on the prevention facilitators’ workshops were the patients, staff and visitors or to Reasons given for the difficulties and control of infection by Lyn significant events in the the institutions themselves. company’s annual activities experienced by some hospitals in Rayment, head of COHSASA’s because they gave all staff – both meeting the standards included lack Standards Development and Evaluation results revealed that those based at head office and of understanding of the programme Training, was followed by another participants’ perception of the those in the field – the opportunity by both managers and staff or the group session in which the workshop was very positive. Three to review their activities and wrong attitude or approach towards participants were asked to identify further workshops for hospital consider improvements where the programme. Many staff felt that areas of potential infection risks in managers and Mpumalanga district they might apply. it increased their workload and that their institutions. Delegates were health staff are set for the future. charged to return to their institutions Presenters were: Dr Stuart “We deal with issues facilitators and undertake risk assessments Whittaker (CEO of COHSASA), Mrs experience in the field and find before documenting comprehensive Lyn Rayment, head of Standards solutions. We are not just infection control programmes for Development and Training, Mr consultants. We prioritise their hospitals. deficiencies for our clients so they Gerard Locke, COHSASA’s Clinical can use our programme as a Engineer and Ms G Ncedana, management tool,” he said. COHSASA’s Chief Facilitator. “Armed with the information we give them, hospitals are empowered to make improvements in the best possible FROM TOP LEFT Part of the facilitator training programme order and thereby features a healthy debate about achieve maximum reaching consensus as to whether a effect.” criterion is compliant or not. A group of COHSASA facilitators provide input into the Charter of the Public and Private Health Sectors for the National Department of Health.
9 Is the Mpumalanga Department of Health turning a corner?
AFTER A SPATE of negative publicity, the Mpumalanga Department of Health may be turning a corner: some of the hospitals have set up quality improvement projects that are delivering positive results for patients and saving taxpayers’ money.
The changes in these hospitals – known as quality improvement projects – have come about because of requirements for compliance with professional standards in the programme administered by the Council for Health Service Accreditation of Southern Africa (COHSASA).
Dr Keith Michael, Chief Director of Hospital Services for the Mpumalanga Province, says that from his perspective at the provincial level, the greatest advantage of the COHSASA programme is its power as an objective monitoring instrument.
“Although we knew that some hospitals were performing better than others, we had no way of monitoring progress or decline, objectively,” he said. “The programme has clearly identified those hospitals that require special attention and support from district and/or provincial office level.”
The Mpumalanga Department of Health has entered 26 hospitals into the COHSASA Facilitated Accreditation Programme. The full extent of the hospitals’ achievements and progress will be known in the near future when they undergo an evaluation survey to establish what levels of compliance they have reached with professional standards.
WITBANK HOSPITAL reports ...
Last month, the nursing sister in as to where the Klebsiella was likely Champions of Quality in Mpumalanga… (from left): Dr Juliet Mannya, CEO of the Witbank, Impungwe and Bernice Samuel Complex, Josh Motlhamme, Director of charge of infection control at to be colonising. Nkangala District Health, Andre Hansen, Principal Pharmacist at Bernice Samuel Witbank Hospital, Ms Nkobo Kobeli, Hospital and Miss Nkobo Kobeli, sister in charge of Infection Control at Witbank She closed down the affected ward Hospital. discovered three positive cases of and set up an intense systemised Klebisiella infection. She picked cleaning programme – a difficult these up during regular surveillance task given the perennial problem of of laboratory results and by staff shortages. staff and visitors wore the correct should be an integral part of our monitoring trends in wound protective clothing such as gowns, daily routine. The drive to improve infection as required by COHSASA’s New patients were admitted to a head covers, gloves and masks. quality brings with it the opportunity standards. She immediately began clean, isolated ward while the post- to document our difficulties, She rallied her ‘link’ infection control an intensive ‘manhunt’ for the culprit natal ward was being scrubbed out. prioritise our actions and then do nurses (manning every ward and – an organism that was causing a She then broadened her search to something about it,” said Dr recently trained in infection control) to disturbing rate of wound sepsis and include the neonatal wards, the baby Mannya. “Too often we hear the ensure that stocks for hand washing – spiking temperatures among room and the labour wards. She plaintive comment that our staff soap, clean towels and sparkling C-section patients in the post-natal checked the theatres for rats, have a ‘low morale’. It is true that our hand basins – were available. Then wards. although she did not find any. She staff feel overwhelmed at times, but she monitored the results. examined the records of all patients using the quality improvement Backing her all the way and with septic wounds to establish an methodology we can do things right encouraging her efforts was the By mid-February, although she was incidence rate. She created separate – the first time, the right way. It is CEO of the complex of three still hunting for the actual source of areas for wound dressings, where time to meet the challenge head on Mpumalanga hospitals (Witbank, the Klebsiella bacteria, the number of new patients were treated from a and to move ahead. COHSASA has Bernice Samuel and Impungwe), septic cases had dropped from 90% dressing room and infected patients got the toolbox that will assist us to Dr Juliet Mannya. of post-natal caesarean cases to were treated at their bedsides. do so”. 20% and, arguably, lives had been Using an infection prevention After a long, hard search – and saved. approach as defined in COHSASA’s when she had found one person standards, Miss Kobeli isolated the whose hands contained the Dr Juliet Mannya, overseeing CEO affected patients and took throat bacteria – she immediately began of the Witbank, Impungwe and the and nasal swabs from a sample of her battle plan. She galvanised key Bernice Samuel hospitals said, the staff and patients. She took staff to oversee a hand-washing “COHSASA came into our lives environmental swabs from the campaign in all suspect areas of the when we needed it most. What this darker corners of the hospital and post-natal wards, the labour wards, organisation brings is work that we from theatre instruments and the CSSD and the operating theatre. should be doing already: these cleaning cupboards – all the places Then she embarked on a drive to quality improvement processes and that featured in her risk assessment ensure that all professional, cleaning the actions that flow from them
10 BERNICE SAMUEL HOSPITAL reports ...
Saving the tax payer’s money Hansen (who gets to work an hour earlier to implement his quality Andre Hansen, Principal Pharmacist improvement project) compared the at Bernice Samuel Hospital, noticed amount of medicine dispensed with stock losses in the ward dispensary the weekly figures at stocktaking and instituted a weekly and noticed a discrepancy. Within reconciliation of drugs handed out three months, the discrepancy had with a regular Friday afternoon fallen from R12 288 (medicines not stocktake. accounted for) in December 2005 A policy was agreed on how and to R8 764 in January 2006 to when the dispensary was to be R4 400 in February this year, with locked and staff were asked to figures continuing to fall every week. ABOVE: Many hands … Damaria Molepo (left) and Petro de Beer (right), COHSASA facilitators in record how many pills and “I now have hard data – proof – to Mpumalanga who have assisted Infection Control Sister at Witbank medicines were handed out each Hospital, Miss Nkobo Kobeli, with her quality improvement project. record the discrepancies. I believe time the dispensary was unlocked – that the audit will save the hospital particularly after hours and over at least R12 000 a month in stock weekends. At first, staff resisted the that is lost or unaccounted for. If we initiative and were reluctant to extrapolate that figure, it comes to follow through with the new policy about R144 000 a year,” he said. but, according to Hansen, visits from COHSASA “definitely contributed” RIGHT: A move to change … to an increase of over 50% of Chief Director of Hospital Services in Mpumalanga, Dr Keith Michael, nursing staff adhering to the is working with the province’s Quality policies. Assurance Unit to bring about improvements. From left: Aurelia Mkhize, Beauty Nkuna, Sipho Motau (Head of the QA Unit), Mavis Motshwene and Johanna Mashego.
One of the many success stories of Three Medi-Clinics the Panorama NICU is Jarryd Grootboom, who at 410 grams was join international programme one of the smallest surviving babies in the country. This little boy who was born at 26 weeks gestation has SANDTON MEDI-CLINIC, Panorama Medi-Clinic and Welkom Medi-Clinic have joined the international grown into a healthy and happy Vermont-Oxford Network that audits the outcomes of tiny babies. three-year-old and is living proof that quality neonatal care can The improved survival rate of micro-premature infants – those with a birth weight below 1000 g – over the greatly improve the outcome of past two decades is attributed to the improved care of mothers during pregnancy and delivery as well as to these premature infants. improved newborn intensive care facilities such as sophisticated ventilators, feeding techniques, medical and nursing care.
Healthcare providers such as newborn intensive care units and hospitals are accountable to both the consumers (parents of sick babies) and purchasers (medical aid schemes) for the quality and safety of medical care. Accurate information regarding the care provided by a specific newborn unit could help to fulfil these obligations.
For this reason, newborn intensive care units in the Medi-Clinic group have joined the Vermont-Oxford Network Database, situated in Burlington, Vermont, USA. More than 400 newborn intensive care units worldwide voluntarily submit data on the babies treated in their intensive care units. The information ranges from birth weight, duration of ventilation, type of milk feeding, deaths and complications in the different weight categories to weight of the baby at discharge.
Welkom Medi-Clinic's neonatal intensive care unit has been part of the Vermont-Oxford network since August last year, submitting information to the network. To date, 140 records have been processed. The Panorama Medi-Clinic neonatal ICU joined the Vermont-Oxford Network in June 2001 and, since then, 700 newborn high-risk infants have been entered in the network's extended database.
One of the many success stories of the Panorama NICU is Jarryd Grootboom who, at 410 grams, was one of the smallest surviving babies in the country. This little boy who was born at 26 weeks gestation has grown into a healthy and happy three-year-old and is living proof that quality neonatal care can greatly improve the outcome of premature infants.
11 Making Medical Injections Safer (MMIS) and Mindset Health Channel bring health education to urban and rural areas via new technology
Dr Rose COHSASA WAS INVITED to attend on-demand information on critical Mulumba, a signing ceremony to mark a new health topics such as injection safety, Country Director partnership between the MMIS healthcare waste management, and of the JSI Research and project and the Mindset Network, infection prevention and control. Training Institute, with signal carrier Sentech. This will Healthcare providers and workers who has been visiting bring health education to hospitals waiting for services will be able to COHSASA and health facilities in nine view videos on infection control and provinces, as well as an additional injection safety. 80 facilities. The partnership has The goal of the partnership is to the support of the National improve the infrastructure currently Department of Health (NDOH) and available to educate healthcare will enable healthcare workers and COHSASA teams up to improve workers and patients on key health the public in both urban and rural topics and to create an environment areas to access training and injection safety that supports positive health information through satellite behaviour changes. This will COHSASA HAS TEAMED up with John Snow Inc Research and Training transmission. Institute of Boston, USA, to conduct a preliminary pilot study to test a increase the success of – and questionnaire for their Making Medical Injections Safer (MMIS) project. With support from MMIS, a John improve the service delivery of – Snow Research and Training prevention, care, management and The MMIS project is designed to assist hospitals in improving the Institute project funded by the US treatment programmes of major administration of injections. The exploratory group will be looking at the President’s Emergency Plan for AIDS diseases, including HIV and AIDS. safe administration of injections, waste management of used syringes Relief (PEPFAR) through the Centers Inequalities in health education and and needles, the prevention of needle-stick injuries and other infections, for Disease Control and Prevention communication will also be as well as stock control. (Department of Health and Human addressed by using technology to Poor injection and sharp waste disposal practices for preventive and Services), the Mindset Health reach rural areas. curative services pose an avoidable risk of transmission of deadly Channel will enable staff to access diseases such as HIV/AIDS, hepatitis B and hepatitis C to consumers, healthcare providers, and communities. In 2004, as part of the President’s Emergency Plan for AIDS Relief (PEPFAR) focusing on countries with high HIV prevalence, JSI Research and Training Institute, Inc, and its subcontractors – Program for Appropriate Technology in Health (PATH), Academy for Educational Development (AED) and the Manoff Group – were awarded funds through the Centers for Disease Control and Prevention (CDC) and the US Agency for International Development (USAID) to implement ‘Rapid Interventions to Decrease Unsafe Injections’ in 11 countries. The project is commonly known as Making Medical Injections Safer (MMIS). In 2009, at the end of the five- year project, MMIS and national counterparts will establish an environment where patients, health care workers and the community are better protected from the medical transmission of HIV and other blood- borne pathogens.
Pilot studies to test the JSI questionnaire have been conducted in the North West Province and, subject to peer research and ethical clearance, may soon go nationwide. We’d like your views The COHSASA BULLETIN is designed to obtain feedback from our clients, the public and other stakeholders on information in this newsletter, as well as to find out what you would like to read about. While it is principally an information source on the work that COHSASA is doing in sub-Saharan Africa to improve health care in both the public and private sectors, your thoughts and views on issues of quality improvement, accreditation and the subjects at hand are welcome.
If you wish to subscribe to the COHSASA BULLETIN, kindly access the subscription order form on our website at www.cohsasa.co.za
Address all other comments, complaints, letters and feedback to [email protected] Tel: +27 21 531 4225
EDITOR: Marilyn Keegan SUB-EDITOR: Carol Balchin PROOF READER: Paddy O’Leary
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