Esteemed colleagues,
CEOs from hospitals around the country,
Managers from provinces and the National Department of Health (DoH).
Today’s seminar is testimony that government is forging ahead with the implementation of the National Health Insurance scheme. Very soon, we hope that Parliament will pass the National Health Amendment Bill to establish the Independent Office of Health Standards Compliance (OHSC). The Office of Health Standards Compliance will be responsible to monitor our health facilities’ compliance to issues of quality. We need to use this seminar to reflect on where we are and the context within which this is happening in relation to quality of care.
Our government has made the decision to protect healthcare, even in the face of significant fiscal challenges. Health care spending, overall, will continue to increase. But not at previous rates, but spending will increase.
That doesn’t mean that every line of the healthcare budget will increase. They won’t. We will need to shift spending from one part of the system to another because there are areas where we’re not getting best value for public money. And other areas where new investments will generate savings elsewhere or improve quality of care. The National Health Insurance (NHI) scheme will allow us to invest in health care like never before and put us in a position to provide quality care.
Let me start with the context relating to the multi-dimensional approach we are using to improve our services.
Firstly, our development of National Health Insurance is a major initiative to expand the universal coverage of high quality care, through improved financing and service delivery innovations.
At the same time, our service model is being re-structured to place far more emphasis on a primary healthcare approach rather than the current costly and ineffective curative focus. It also includes the design and implementation of key programmes focusing on this primary health care (PHC) approach and expansion of the coverage of cost-effective interventions.
Improvements in the supply, capacity and management of our human resources are the focus of a number of initiatives, as are similar improvements in the supply and management of our infrastructure and health technology.
These should all however be seen also within the context of the quality of the care we provide. As many have said, we have spent the last 18 years dealing (quite successfully) with a legacy of poor and grossly inequitable access to care. The question we need to answer now is “access to what?” Is it access to effective, timely, safe and acceptable care?
I think we do know the answers. Yes there are pockets of excellence and dedication. Yes the quality of clinical care in our academic hospitals can be comparable with that offered anywhere. However we also know the flip-side – do we even have to list it? Sadly, the findings and reports of unacceptable care, from external assessments as well as from patients and communities are only too frequent. There is also evidence of extensive lack of compliance with basic procedures, in both clinical and non-clinical settings that is impacting on effectiveness and efficiency of services.
As we all know, there are many definitions of quality. Quality is important from several points of view or when using different definitions of quality. Quality can best be achieved through a planned set of actions designed to provide the end-user with the product they expect to receive. The goal of establishing the Independent Office of Health Standards Compliance is to ensure that patient care is of acceptable standards: documentation is clear, consistent, accurate, complete, and timely, and that it satisfies stated or implied requirements quality patient care.
It is important in its own right, in terms of meeting the expectations of users for receiving care that they consider acceptable, and this is a major focus of our discussions.
It is a recognised contributing factor to achieving universal coverage in terms of the impact that the acceptability of care can have on utilisation of services, as well as the availability of services being delivered as promised.
Lastly, improved quality impacts on achieving improved health outcomes through reducing unintended harm or medical error by improving the safety and reliability of clinical care given to patients, and this is influenced by more than choosing the correct interventions or by clinical knowledge and competence, it is also a result of the systems and processes that are in place, or are lacking.
Our response to these areas of poor quality has also been through several different channels.
The most important is probably in leadership, which the commitment of the Minister and Deputy Minister has been clear to all.
As everyone is aware, our National Core Standards for quality care in establishments has been extensively discussed, published and disseminated throughout the country. Our priority focus has been on 6 priority core standards that are of most concern to users, and a simple consumer-friendly version is currently being tested as a statement of commitment from the services. A detailed audit tool has been developed to measure compliance with these standards and has gone through 3 rounds of piloting and testing.
It was used in a nation-wide baseline audit of all public health establishments conducted in 2011/12 to cover the 6 priority areas. Final results are expected shortly.
The results of these audits have been used by joint national/provincial improvement teams whose job has been to determine the root causes of the critical problems and to ensure that processes are in place to correct them. This appears to have been very successful so far and the first review is planned before the end of the year.
Standing behind all of these interventions however is the legislative framework soon to be in place to establish the independent Office of Health Standards Compliance. This will enable the regulation of clear national standards and norms, and their measurement that is objective and uniform, and permits benchmarking and enforcement.
The Bill to amend our Health Act will hopefully be law within a year. The Office of Standards Compliance already operating within the DoH with a small initial team of inspectors carrying out external inspections to check on level of compliance and whether improvements can be seen. I am happy to say that in some cases yes, we do see improvements; and tomorrow will hear some of the success stories, even though from only a small pool at the moment, as coverage of these external inspections is still low.
In fact, this period prior to the law coming into effect is a valuable opportunity to learn and test, both for the inspectors but most especially for the facilities. Will they be compliant when the future regulator arrives?
The law is a powerful tool. It reflects political commitment to the stated goals in a way that few other things do – and this Bill has received extremely wide support from all stakeholders up to now. It also emphasises the obligatory and universal nature of the required compliance with the law, and confers powers to obtain information and publish findings. Perhaps most importantly, it does mean there are consequences when there is persistent and proven non-compliance.
Obviously for people in your position, this is of great importance. That is why it would be important that Chief Executive Officers (CEOs) see this process as one that will ensure they must make things work – but it will also make it important that those who support them make things work too. Across-the-board non-compliance in certain areas will suggest that the responsibility lies above the individual establishments, hence the provision in the Bill for a written response from the “person in charge of a health establishment” setting out the reasons for (persistent) non-compliance. Everyone is going to have to pull together to correct some of the problems that are undermining care for patients at delivery level.
This Seminar is happening in terms of the future legislated function of “provide guidance to providers on compliance with prescribed norms and standards”. This is a very specific and critical audience: the CEOs of hospitals, who will discuss how they can use the guidance given over these two days to inform their own action and their roles, and what they need to get from who in terms of support in order to make things happen.
Resources may be a limiting factor in some cases and we would like to hear about these instances – however it is clear from the success stories that these are not the whole story. There are improvements in management and in processes that can make an impact, using the resources we have.
This is not to say however that CEOs can make all these changes alone – in many cases what they need is not more resources but a more enabling environment – the powers to take decisions, to buy toilet paper for instance. So the improvements in management and processes have to happen all the way up the system – including in the national department, if our establishments will indeed be compliant and will offer better care.
What we would like to achieve in these 2 days is to share with you the tools that the office will be using to so assess you and how you can also use them to assess yourselves, and how this information can be used to solve the problems you face in providing better care and achieving compliance.
What is your role as CEOs and what are the enabling factors for you? Who needs to be tasked with ensuring they are in place? Will the approach being developed for the future OHSC be able to effectively improve the quality of care, which is our common goal?
We are aware that we were not able to accommodate all those who would have liked to and who needed to be here, and we have already committed to your Heads of Department that next year, the Office will be available to facilitate similar processes of providing guidance in each province.
Your inputs and feedback over these two days will help us to make these provincial encounters more effective, and will also help us to make the future office more effective in the way in which it interfaces as a regulator with the service providers it regulates.
I thank you all for your efforts and your participation in these coming 2 days.
