Program director
Country Representative of the World Health Organisation (WHO), Mrs Stella Anyangwe
Members of the Executive Councils (MECs) from provinces
Representatives of the World Health Organisation (WHO)
Representatives of the United Nations Children’s Fund (UNICEF)
Representatives of the Congress of South African Trade Unions (COSATU)
Representatives of the donor community and our partners
Heads of Provincial Departments of Health
Senior management of the national and provincial Departments of Health
Representatives of other government departments
Honourable guests
Ladies and gentlemen
Good morning!
It is a great honour and privilege for me to share this time with you here today in this important summit. It is indeed a great achievement for us to be here together to work on this project that will contribute towards significant improvement of quality of health services in the public sector and in the private sector.
Our hope is that this summit will provide an opportunity for all of us to apply our collective mind to proposals that will add value to our efforts to improve the health profile of all South Africans. We hope that we will emerge from this summit with approved or endorsed core standards for health establishments. It is also our desire that this summit converts each and every one of us present here today into champions of change, and champions that we need to effect positive change in priority areas identified for immediate implementation of plans aimed at improvement of quality of services.
Improving the health profile of all South Africans through the transformation of health services and attainment of good health outcomes has been identified as one of the top priorities of the new government. The ten point plan for 2009 to 2014 and the 2009 health sector plan of action have been approved by Cabinet and widely disseminated throughout the health sector. Quality is one of those key priorities. These plans are products of an intensive and all-inclusive process of analysis and consultation. Most of you have attended meetings and have been part of discussions and further consultations that have taken place since May 2009 over these plans. The Minister of Health and I have on numerous occasions invited you through your organisations and institutions to study these plans and to actively participate in their implementation. We are pleased by the positive response we have received thus far.
Improving the quality of care is a priority for government during this term of governance. This priority is part of the plan to overhaul the health system to deliver a better life for all. In our Plan of Action under the priority that focuses on the implementation of the National Health Insurance (NHI), we have stated specifically that we will establish a national quality management and accreditation body. Further in the POA, we have undertaken to develop and implement a detailed plan to improve quality in 1000 public facilities. This work is progressing very well.
November, as we all know, is quality month. Many of us met here a year ago, on 21 November 2008 to be exact, in a first colloquium on quality. The event this year is taking place at a time when improving the quality of care is firmly recognised as a major priority if we are to correct our poor outcomes relative to our spending on health, as well as the widespread perceptions of inadequate care, long waiting times and uncaring staff.
Our discussions during these two days therefore should go right to the heart of what we aim to achieve together over the coming years. The wide range of participants present today illustrates clearly the very inclusive process that has been followed in this area from the beginning. We recognise that quality of care is something that affects us all and must be an outcome of our combined efforts.
At the first Colloquium on quality last year, we tabled a discussion document on our way forward. We concluded after our discussions that we needed to reach consensus on a common set of standards for quality care, needed to clarify what structures were appropriate to our aims and needed to work together to achieve this.
We also met in April when we tapped into the collective wisdom of those who joined us regarding the establishment of a ministerial advisory committee. I would therefore like to update you on what we have achieved thus far. You will also be informed of plans developed since then.
We are now at a point where a detailed strategy and a national quality plan that covers all our public services are awaiting final review by the National Health Council and formal approval. An outline of the strategy has been distributed for your information today.
Three core attributes or principles underpin how quality is seen to impact on the system as a whole. Firstly, recognition of the values and professional ethics that underpin the entire strategy and are built into all our actions including at the level of each and every service delivery unit. This is to ensure that a culture of quality becomes the norm in all we do.
Secondly, focus on enhancing accountability for delivering quality care. This refers to accountability that is based on documented compliance with national standards and linked to incentive systems such as performance management. This accountability is also linked to professional development and other non-monetary rewards. Accountability will also be reflected in the consequences for non-compliance.
Thirdly, our national quality programme will be built on nurturing and supporting a skills base throughout our services that will ensure recognised and effective quality improvement methodology is used by management and staff to ensure we get the best possible results with the resources we have.
Standards
Because of the importance of standards, I am going to spend a bit of time going through the national standards. We have been busy during the past year in revising them, as a framework that will guide and underpin the delivery of quality care and provide alignment and leadership. These standards have been developed together with our partners and will be reviewed by all of us today.
Standards are a statement of expected performance. These core standards reflect the basic requirements expected of all managers for us to provide safe and decent care in South Africa. They are not a new or additional requirement. They reflect, in an accessible form, what is already approved policy. Once the final version is approved by the National Health Council, they will form the basis for us to accredit all establishments in the country over the coming five years.
In producing this revised version, we have taken account of all that we learned as well as ensuring we reflect the new directions that the government is taking. We have retained the use of broad “domains” to cluster important aspects of care together, as the feedback we received indicated that this helped managers to identify and focus on critical aspects. I am going to spend time taking you through the standards and highlighting for you just what our expectations are for the performance of our health system.
We have placed patient rights first in this revised version. The very first standards cover the expectation that patients are treated with respect and dignity. To those using our public services, the attitude of our staff, the environment within which they are treated and the length of time they have to wait are at the top of their list of “expected performance.” Unfortunately these are often aspects where our performance is sadly lacking.
You will also notice that we have retained the strong focus on patient safety, but as part of the overall emphasis on good clinical care and the essential aspects of clinical governance that make this possible. It is recognised throughout the world that unintended medical error is a significant problem even in the best healthcare systems. Our system is certainly no exception. However, we need to take this very seriously and strengthen our systems to ensure safe and effective clinical care.
The overall poor outcomes from our health system can in part be attributed to the worrying degree to which we do not implement all the excellent guidelines and protocols that exist, for reasons that vary between the public and private sectors but which undermine our capacity to achieve the Millennium Development Goals (MDGs) and to improve the health status of our people.
Clinical support services are now a stand-alone area of focus or domain. These services are absolutely essential in the diagnosis and treatment of our patients and are a critical element in the quality and effectiveness of our clinical care. These first three domains together are what we are about these are our “core business” of caring for our patients.
The domain of “public health” is a challenging one for us, because even in the public sector our approach to health care is focused largely on the treatment on the individual patient who walks through our door. In the private sector this is the only approach. We have reflected what we expect managers of health establishments to do in relation to their catchment’s populations.
In our original set of national care standards, a key weakness we were not actually assessing was the degree to which the management of the establishment and the systems that supported them, such as the clinic committee or hospital board, or the district or provincial office, ensured that things got done and that quality improved. This over-arching management and leadership requirement has therefore now been separated into a domain of leadership and corporate governance. This is in line with the first priority as stated in our POA.
Then we come to the engine room of our health system. The domains of operational management and facilities management are what keeps the show on the road or fails to do so. Firstly, human resource management; let me say up front that there have been very strong and loud voices saying that this should be a separate domain, that our staff are so critical to our work that they should actually be the first domain even before our patients. Those who hold this view say so because of their strong belief that without our staff nothing else will work. We do agree that our staff is critical and essential. Our staff is in fact the primary “internal clients” of our system. We do also agree that our performance in this regard does not match what is expected. However, we are of the opinion that to separate off the management of staff from all other aspects of day-to-day management simply would not make sense, but they are here in first place in this domain even before financial management.
Throughout these two support domains, we have worked very closely with the national department units and the National Treasury to ensure that we do in fact capture the most critical problems in these areas. We also wanted to ensure that we are echoing and reinforcing the work they are doing to improve performance.
In concluding this overview of the standards, I want to make a few general points.
The national standards are intended to cover public and private sectors, primary care as well as hospitals. We recognise that not all standards will be applicable everywhere. In discussions with some of the private sector providers, it is apparent that they support domains covering direct patient care. The details of how quality patient care is achieved, as set out in the other domains, will however differ according to how the human resource and financial model works. They will also differ in some instances because the private sector has management systems that they consider to be more effective and efficient than public sector systems.
On the other hand, the incentive systems in the private sector may not always work towards ensuring the best overall health outcomes and value for money for the country. I am pleased to announce that we intended to take them up on their offer to work with us to identify those best practices on both sides that can strengthen the health system as a whole. This is in fact some of the preparatory work needed for making the implementation of the National Health Insurance (NHI) a success.
These are core standards. They do not aim to replace the many other sets of detailed standards that already exist. These complement them through acting as a primary screen and ultimately will inform the regulated or mandatory requirements. They will also need to be periodically reviewed and updated in order to improve the standards and to reflect new policies and guidelines.
Measuring performance
Let us now turn to measuring how we are doing. Obviously a system of periodic audit cannot be the only mechanism for measuring performance. It is also essential to have reliable monitoring systems that will measure key indicators on a regular basis. These indicators are being finalised and will be shared with all of you in the coming months. They will reflect selected aspects of the core standards, with a focus on the most critical priorities.
We will also be taking very seriously the system we already have for measuring what our clients think of us, namely our complaints systems. Through an improved system and call centre, complaints will be used to identify things are not as they should be. Through internal mechanisms or through an external ombudsperson if needed, we will investigate the causes of such system failures, provide an honest and supportive explanation and apology to the complainant and make sure they don’t happen again in the affected institution as well as across the system as a whole.
If we are to see these standards become reality, experience has taught us that we must move beyond documents and intentions, and hold people accountable for ensuring that this happens. The measurement and benchmarking of actual performance will therefore be critical. The standards you have in front of you are not a tool for actual assessment. In order to achieve this, the detailed assessment tools will be tested in the first few months of 2010, for public sector hospitals and for primary health care.
As part of this process, we will also be seeking international recognition of our standards and assessment tools in order to ensure that they meet accepted benchmarks as being reliable and measurable.
I spoke about accountability. Accountability rests on being able to measure performance against agreed standards. It also however rests on there being incentives for achieving compliance or clear consequences for not doing so. This would have obvious implications for people’s work and careers. The implications in the future for eligibility for funding under the National Health Insurance (NHI) scheme are also critically important.
We have therefore taken a decision that the measurement or audit of performance and the decisions on whether or not an establishment or ultimately a provincial or national office is or is not complaint cannot be carried out by those who fall under the authority of those they are expected to assess. One cannot be player and referee. The potential for undue influence is just too great.
The national quality management and accreditation body mentioned above will report directly to the Minster of Health. The operating model for such a body is being developed through a process that includes a review of national and international systems and best practices for this, and will be based on a detailed business case. It will also involve an amendment to the existing National Health Act, and the development of the relevant regulations. These will all be tabled for public discussion prior to promulgation in accordance with legal requirements.
Improvement
The last area I want to touch on is that of making sure that quality actually improves. We recognise that quality assurance as described above, including the setting of standards and the measurement of compliance , will not by itself and automatically turn things around. We will not succeed if we continue to follow our practices of the past decade, which was the issuing of guidelines, launching initiatives and expecting that things would change. We need to ask ourselves very seriously as to why have we not succeeded with all the initiatives we have launched, and why our excellent policies and guidelines are were not implemented.
Nothing I have outlined above is new, and much of it is basic, it is what we are all expected to do. Why then are we not doing it? The Minister of Health met last week with all the district managers and hospital CEOs and their top management teams in the country and he asked the same question, “Tell me why you are not doing this?”
We have therefore selected from the long list of things we know we have to do, six areas of priority. These have been selected based on reviews, reports, surveys, appraisals but also on patient complaints and reports in the media of the “horror stories” the patient who died in the queue, the baby bathed in boiling water, the mother who fell out of bed, the nurses who sat drinking tea rather than assisting a critically injured patient! We all know the stories and we all know the reality that they reflect.
The areas that we have committed ourselves to turn around are improving patient safety, strengthening infection prevention and control, ensuring the availability of essential medicines and supplies, reducing waiting times, ensuring the cleanliness of our facilities, and spreading a positive and caring attitude throughout the system.
We have committed ourselves to reach 1 000 facilities, which are 25 percent of our entire public service network, before the end of March.
Is this possible? Well, of course we could “meet out target” by simply calling on everyone to comply and then asking for reports form the provinces to tell us that their hospitals and clinics are doing as we ask.
This time however, we will not simply be issuing a “call to action,” though we are also doing this. We will be ensuring that the knowledge, skills and support that our staff need to actually solve the problems and remove the obstacles are progressively developed and shared across the system. We are aware of many excellent initiatives that do exist across our country. Tomorrow night we will be recognising those who have been chosen as the role models for us all, the finalists in the annual service excellence awards. We are determined to expand these pockets of excellence.
The approach we will be taking with this quality improvement initiative or “campaign for quality” will be based on work done in individual facilities, by our staff that provides care directly to our patients, rather than being driven by the national and provincial offices. Because we know that a huge amount is already happening, we have started by identifying or recruiting the projects that already exist in one or more of the six priority areas and that are known either to our provincial staff or to our partners. We have already identified at least 514 projects in the public sector and 137 quality improvement projects in the private sector.
Some of you might ask as to why identify what already exists. It is because within these projects lie many lessons for us. What has worked and what has not worked? Why? What critical barriers had to be removed? What can they share with the hospital next door or at the other end of the country that is trying to achieve the same thing? What does the provincial office have to sort out in order to enable things to improve? Where is it the national department that is the cause of the problem? What has one district or province already sorted out which another district or province needs to copy?
So it is about obstacles and best practices, but it is about more than that. It is also fundamentally about the “how”, not simply about the “what”. We all know the “what” where we fail is in how to do it. How to implement the standards or the guidelines in our particular environment and with our particular staff team and community? So a very critical and essential part of this campaign for quality will be sharing the methods and skills of quality improvement throughout the system.
We all know that in industry the issue of “quality” is one of the core goals of management. It is about what keeps the clients buying and the company making profits. We should also know that the lessons from industry have been adopted by the “service industry” and that in the past two decades the concepts and methods of continuous quality improvement have taken front and centre stage for those striving to be the best, namely to provide the best service and achieve the best outcomes.
And yet we in South Africa and especially in the public sector have not kept pace with modern thinking on this. We have seldom adopted these recognised tools of effective management as part of what managers do. Instead, they are the responsibility of an assistant director or chief professional nurse who reports in turn to a manager who reports to another manager who may perhaps once in a while get to speak to the CEO or District Manager, provincial or national Director. So we do not know that there are methods to analyse our processes and results, develop and test how to do things better and to scale-up success or if we know we do not practice it.
So this “campaign for quality” will not just make us aware of what we should be doing anyway. It will also make sure that we have the knowledge and skills to analyse our own situation and to make improvements that work. It will help us to build on what already exists, invest in sharing lessons across a learning network and empower supervisors and managers to be able to coach and mentor those they support.
This will not happen overnight. This is a journey, not a destination and nor is it a journey of a single month or even a single year. However, we are convinced that over the coming years we will see real and significant changes in our health services. The campaign for quality will be one of the contributing pillars to this change, alongside the many other critical things already underway.
Advisory committee and participation
We also want to announce that the ministerial advisory committee whose work you helped us to design in April will be established, and in accordance with your advice to us it will be a single body that will ensure the coherence of our approach. The notice requesting nominations will be published in the government gazette following approval by the national health council. We have decided however not to proceed with the nomination of an interim committee but rather to focus on the formal body. We thank those who agreed to assist us in this way. They have been invited to join us today. We ask them to please consider putting forward their names for the advisory committee.
In order to achieve this we will need every one of you and my last appeal is therefore to all of you. You have seen the objectives of this summit on your programmes and know that today we will be discussing the quality assurance aspects of our work, especially the national core standards and tomorrow the six priority areas for improvement. However what is not on the programme but is nevertheless one of the most critical outputs of this summit is that we want to be able to count on a resource that is priceless! We want from this Summit is to have at least 300 champions for quality, who will personally contribute to turning around the health system to become one we are all proud of and one that provides quality care for our people and quality management for our staff.
I thank you.
Issued by: Department of Health
24 November 2009
