institutionalizing quality standards in health care

1

Shirley B. Domingo, MD, MPHVice President

PRO NCR & Rizal

“ The Noblest Search is the Search for Excellence.”

Lyndon B. Johnson

Legal Mandate

• R.A. 7875 (as amended by R.A. 9241) Sec. 37. Quality Assurance

…health care providers shall take part in programs of quality assurance, utilization review, and technology assessment …

• IRR Rule IX, PhilHealth shall…– Implement a QAP applicable to all HCPs for delivery of

health services – Ensure that health services are of quality necessary to

achieve the desired health outcomes and member satisfaction

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Accreditation

Payment

Health care

Premiums

Coverage

Relationship bet. Phil Health, the health care providers andits members.

VALUE

QUALITY

Minimal threshold standards

Inspection - “find what’s wrong”

Focus on inputs

Improvement of Process and Outcomes

Continuous quality improvement

Self-assessment and demonstrating achievements

Rationale for Benchbook Standards

• Legal mandate• Existing standards do not promote quality improvement culture among

hospitals• Need to influence provider behavior to increase likelihood of better

outcomes at affordable costs- member protection• Tougher competition (Provider)• Frequent medical errors- safety issues lawsuits! • Rising demand and costs, limited health expenditures/resources -

efficiency• Concern with variation in health care practice, outcomes and costs• Patient satisfaction

Relative Performance of Government and Private HospitalsGovernment Private

Leadership and Management

Most could present an assessment of their performance. Annual activities and targets are well documented

Difficulty identifying proof of assessment of their performance/ not always documented

Patient Care

Procurement policies for drugs are not readily available (local government)

Procurement policies for drugs are readily available

Human Resource Management

Recruitment, selection, and hiring policies are usually not available (local government)

Most have these policies

Safe Practice and Environment

Preventive and corrective maintenance services are not readily available which may be a result of delayed procurement of services as these services were not assured from vendor when the equipment was purchased.

L3 and hospitals usually have good safety programs compared to government hospitals. Personnel responsible of maintaining security and conduct of preventive and corrective maintenance of equipment are always available

Government vs Private

National Performance

• Accreditation

• HTA

• Peer Review

• Feedback Mechanism

• Performance Monitoring – Utilization Review– Outcomes Assessment

• Medical evaluation of claims/PNDF

• Program Review/Formulation of policies

Implementing a Quality Assurance Program

Providers being accredited by PhilHealth:

• Professionals

– Physicians– Dentists– Midwives

• Institutions– Hospitals– Rural health units/ health

centers (RHU)– Ambulatory surgical clinics

(ASC)– Maternity clinics– TB-DOTS centers– Free-standing dialysis

centers– OUTPATIENT MALARIA

PROVIDER (OMP)

Performance Area Standards n=78

Criteria n=141

Indicators n=239

Core Indicators

n=51

Patient Rights 6 14 19 1

Patient Care 30 75 112 15

Leadership & Mgt

6 4 14 3

HR Mgt 8 19 27 2

Info Mgt 5 11 15 3

Safe Practice 16 16 40 25

Improving Performance

7 2 12 2

Benchbook Awards

Patient Rights & Organizational Ethics

Goal:

• To improve patient outcomes by respecting patients’ rights and ethically relating with patients and other organizations

Indicators:

Policies and procedures for patient’s needs for confidentiality,privacy, security, religious counselling

Policies and procedures to resolve patient’s complaints

Policies to resole ethical issues arising from patient care

Patient Care

Goals:

• The organization is accessible to the community that it aims to serve

• The entry processes meet patient needs and are supported by effective systems and a suitable environment

Indicators:

• Presence of services addressing most common diseases of the community

Patient CareGoals:

• Comprehensive assessment of every patient enables the planning and delivery of patient care

• The health care team develops in partnership with the patients a coordinated plan of care with goals

• Care is delivered to ensure the best possible outcomes for the patient

Indicator:

• Policies and procedures regarding preoperative and pre anesthetic assessment

• Quality control of the diagnostic examination

Patient Care

Goals:• The health care team routinely and systematically evaluates and

improves the effectiveness and efficiency of care delivered to patients

• Care is coordinated between the organization and other health care providers in the community to ensure that the needs of the patient are continuously met (Discharge)

Indicator:• Multidisciplinary team in the formulation of adopted clinical

protocols

Leadership & ManagementGoals:

• The organization is effectively and efficiently governed and managed according to its values and goals to ensure that care produces the desired health outcomes, and is responsive to patients’ and community needs

• The organization ensures that services provided by external contractors meet appropriate standards

Indicators:

• Presence of staff satisfaction survey

• Policies and procedures are known to all levels of the work force.

Human Resource ManagementGoals:

• The organization provides the right number and mix of competent staff to meet the needs of its internal and external customers and to achieve its goals (Planning)

Indicators:

• Policies and procedures to orient new employees and hospital policies

• New personnel are adequately supervised


Goals:

• Recruitment , selection and appointment of staff comply with statutory requirements and are consistent with the organization’s human resource policies

• A comprehensive program of staff training and development meets individual and organizational needs

Indicator:

• Recruitment and selections are consistent with organizational policies

Information ManagementGoals:

• Collection and aggregation of data are done for patient care, management of services, education and research

• Integrity, safety, access and security of records are maintained and statutory requirements are met (Records management

Indicator:

• Proof that charts are checked for completeness and accuracyPolicy on record storage, safekeeping, retention and disposal

Safe Practice & EnvironmentGoals:

• Patients, staff and other individuals within the organization are provided a safe, functional and effective environment of care

• A comprehensive maintenance program ensures a clean and safe environment

Indicator:

• Safe and efficient use of medical equipment according to specifications.

Safe Practice & Environment

Goals:• Risks of acquisition and transmission of infections among

patients, employees, physicians and other personnel, visitors and trainees are identified and reduced

• The provision of equipment and supplies supports the organization’s role

Indicators:• Presence of an infection control program• Procedure of isolation of nosocomial infections

Safe Practice & Environment

Goals:• The organization demonstrates its commitment to

environmental issues by considering and implementing strategies to achieve environmental sustainability (Energy and waste management)

Indicator:• Procedures on waste disposal involving the reuse,

reduction and recycling

Improving Performance

Goals:

• The organization continuously and systematically improves its performance by invariably doing the right thing the right way the first time and meeting the needs of its internal and external clients

Indicators:

• Presence of quality improvement programs

• CPGs

Benchbook Self-Assessment Process & Accreditation

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Minimum Requirement for Accreditation

Center of Safety

Compliance to 100% of CORE indicators AND60% Compliance to each of the following:

• Patient’s Rights and Organizational Ethics

• Patient Care • Safe Practice and Environment

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Center of Quality


•Patient’s Rights and Organizational Ethics •Patient Care •Safe Practice and Environment•Leadership and Management•Human Resource Management•Information Management

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Center of Excellence

Compliance to 100% of CORE indicators AND90% Compliance to each of the 7 performance areas

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What if we cannot meet the minimum requirements?

Provisional Accreditation


•Patient’s Rights and Organizational Ethics, •Safe Practice and Environment •Patient Care

DenialFailure to meet cut off for provisional accreditation

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Frequently hard to comply indicators/ evidences

1. Patient’s Rights and Organizational Ethics

• Per validation, patients are seldom informed of their rights and responsibilities

• Policy on patient and family education and their involvement in care decision-making

• Monitoring reports related to patient or family education program/policy

• Policies and procedures that address patients' needs for communication

• Provision of mechanisms to respect privacy (e.g. partition between patient beds especially in government hospitals)

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1. Patient’s Rights and Organizational Ethics

• Policies and procedures on codes of professional conduct. Some have copies of statutory standards such as the following but have no issuance adopting them:

– Codes of professional standards (PRC, PMA, PNA, PAMET, CSC, DOLE, etc)

– Patient detention (RA 9434) and

– Anti-deposit law (RA 8344)

– Sexual harassment law (RA 7877)

• Presence of programs on improving staff awareness on codes of professional conduct and other statutory standards

• Policies and procedures on monitoring compliance to codes of professional conduct relevant to their respective discipline

• Presence of an Ethics Committee

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2. Patient Care• Policies and procedures on patient waiting time

• Monitoring and evaluation reports on patient waiting time

• Policies and procedures on informing patients for any cause of delay in the delivery of services

• Some patients admitted or their families are not appropriately informed by authorized qualified personnel of their disease, condition or disability, its severity, likely prognosis, benefits and possible adverse effects of various treatment options and the likely costs of treatment

• Patients and/or their families are seldom informed of the need and availability of resources to continue care after discharge

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2. Patient Care

• Comprehensive history and PE within 24 hours from admission

• Doctors’ progress notes done regularly

• Policies and procedures for the standard performance, monitoring and quality control of diagnostic examinations

• Adopted/developed protocols, CPGs or pathways containing:

– goals to be achieved

– services to be provided

– patient education strategies to be implemented

– time frames to be met

– resources to be used

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2. Patient Care

• Policies and procedures on implementation/compliance to clinical pathways

• Charts with clinical pathway-covered conditions.

• Policies and procedures on duplicate assessments and treatments performed by trainees

• Monitoring reports in compliance to policies and procedures on duplicate assessments and treatments

• Policies and procedures promoting interactive, appropriate and relevant educational programs for patients

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2. Patient Care

• Policies and procedures regarding selection and procurement of medical devices and equipment based on organization’s case mix, staff expertise, service capability, scientific evidence and government policies

• Patient chart from medical records, look at the discharge orders. It should contain all of the following:

– May go home order

– Home medications (if applicable)

– Follow up visits/schedule

– Home care/advise

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3. Leadership and Management

• Analysis, conclusion and recommendation based on staff satisfaction survey

• Proof that policies and procedures are reviewed and revised as necessary

4. Human Resource Management

• Training needs assessment system

• End-of-training assessment report

5. Information Management

• Lack of qualified staff involved in data definition, generation, collection and aggregation (no training on medical record management)

• Charts are often incomplete

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6. Safe Practice and Environment

• Not all operating manuals of equipment are present

• Existence of safety programs and/or management plans for hospital safety

• Proper waste segregation and labeling of waste receptacles

• Policies and procedures on risk identification, assessment and control, security risks, use of personal protective equipment, etc.

• Risk assessment reports

• Preventive and corrective maintenance logbook for equipment

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6. Safe Practice and Environment

• Procurement policy and plan for equipment which considers the following:– intended use

– cost benefits

– infection control

– safety

– waste creation and disposal

– Storage

• Late issuance of pertinent licenses/permits by respective agencies (e.g. ECC, Fire safety permit, including PNRI)

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7. Improving Performance

• Presence, Implementation and evaluation of quality improvement programs

• Implementation of CPGs (development or adoption)

• Proof of better services and patient outcomes

• Implementation of patient satisfaction survey (including analysis)

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Feedback and Experiences during hospital survey

Positive

• Hospitals appreciate standards set by Benchbook, standards are for the benefit of their facility

• Hospitals find implementation of quality framework helpful

• Although compliance to Benchbook requires exertion of much effort by hospitals, in the end, they recognize that the things they have done are actually needed to improve their hospital operations

• Many hospital administrators claim that the process of crafting policies and procedures and documentation of monitoring and evaluation, among others, helps them in their work as hospital administrators

• Surveyors appreciate it more if hospitals tag their documents based on the indicators of the Benchbook

• Once the preliminary results are presented to the hospital management, the latter is very much eager to comply with their deficiencies the soonest time possible

Accreditation Reforms

• Third Party Accreditation– Delegate accreditation functions exclusive of the decision-

making function to duly recognized third party accreditation agencies

• On-line Application for Accreditation

• Preferred Provider Scheme/ Contracting

– No out of pocket payment for PHIC members, provider will be granted faster claims processing

New Accreditation Schemes

• Strong collaboration with Licensing of the DOH

- Core indicators to be adopted by licensing

- Licensed hospitals shall be automatically accredited as Center of Safety but has to sign a performance commitment with Philhealth

• All government hospitals to be automatically accredited

“Excellent firms don’t believe in excellence- only in constant improvement and constant

change.”

Tom Peters

WARRANTIES OF ACCREDITATIONRepresentation of eligibilitiesCompliance to pertinent laws/rules & regulations/policies/administrative orders and issuesClinical servicesConduct of clinical services, records, preparations of claims and undertakings of participation in the NHIPManagement Information SystemAdministrative investigations/regular surveys.domiciliary visitations on the conduct of op-erations in the exercise of the privilege of accreditation.

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Benchbook Indicators

• Developed through consultative meetings• Stakeholders suggested indicators for each standard

and criteria • Stakeholders agreed to set some indicators as CORE

indicators • Survey tool which contains CORE indicators pilot tested

in 2008• Revision of some indicators and listing/delisting of CORE

indicators

How does Benchbook measure against the principles underlying ISQua Standards?

• Leadership through effective planning, governance and management • Customer focus to meet the needs of internal and external

customers, both existing and potential • Organizational performance through the management of processes

and outcomes and the transparency of decision-making • Continuous quality improvement based on innovation, evidence, best

practice and evaluation to better meet the needs of customers • Valuing people by appropriately selecting, training and appraising

personnel and maintaining good relationships • Safety by providing safe work environments and complying with

statutory requirements.

Source: http://www.isqua.org/Accreditations.aspx?men=29

Trends of Health Expenditure by Source of Funds

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

100,000

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Years

In M

illi

on

Pe

so

s

National

Local

Social healthinsurance

Out-of-Pocket

Other private

Source: Philippine National Health Account

Quality Dimensions

• Safety• Efficiency• Appropriateness• Accessibility• Effectiveness• Consumer Participation

they recognize the authority of PhilHealth to any inspection or investigation

accept the program of quality assurance, payment mechanism and utilization review of the NHIP

shall guarantee safe, adequate, and standard medical care

its personnel shall adhere to a strict Code of Ethics

they agree to adhere to practice guidelines or protocols, peer reviews and other QA activities

Warranties of Accreditation, Institutions

The Quality Problem is Large

1

10

100

1,000

10,000

100,000

1 10 100 1,000 10,000 100,000 1,000,000 10,000,000

Number of encounters for each fatality

To

tal l

ives

lost

per

yea

r

REGULATEDDANGEROUS(>1/1000)

ULTRA-SAFE(<1/100K)

HealthCare

Mountain Climbing

Bungee Jumping

Driving

Chemical Manufacturing

Chartered Flights

Scheduled Airlines

European Railroads

Nuclear Power

Source: Leape, Lucian

U.S. Healthcare Is Hazardous:

• 7% of patients suffer a medication error

• Every patient admitted to an ICU suffers adverse event

• 44,000- 98,000 deaths

• $50 billion in total costs

Back

Legal Mandate

• IRR Rule IX, PhilHealth shall…

– Implement a Quality Assurance Program applicable to all Health Care Providers for delivery of health services

– Ensure that health services are of quality necessary to achieve the desired health outcomes and member satisfaction

PhilHealth’s Mission

To ensure adequate financial access of every Filipino to QUALITY HEALTH SERVICES through the effective and efficient administration of the National

Health Insurance Program

Minimal threshold standards

Inspection - “find what’s wrong”

Focus on inputs

Improvement of Process and Outcomes

Continuous quality improvement

Self-assessment and demonstrating achievements

Calls for improvement of systems and processes,

focuses on customer orientation, collection and assessment of relevant performance data, and

timely action on the results of these data.

2007

Requirement of CQI Program for accreditation of hospitals-PC 12 s 2006

Full Implementation of Benchbook as Standard for Accreditation

2nd year of implementationReview of standards, indicators and evidences

2010

2011

History of the Benchbook Standards

Benchbook on Performance Improvement of Health Services was published

2004

7 Areas of Benchbook Standards

• Patient Rights and Organizational Ethics

• Patient Care

• Leadership and Management

• Human Resource Management

• Information Management

• Safe Practice and Environment

• Improving Performance

Commitment to Quality

Begins with management …

• ensures support for the deployment of activities

• it is up to the hospital leadership to allow, let alone encourage, the development of a CQI culture in their hospital.

Benchbook Awards

Relative Performance of Government and Private HospitalsGovernment Private

Leadership and Management

Most could present an assessment of their performance. Annual activities and targets are well documented

Difficulty identifying proof of assessment of their performance/ not always documented

Patient Care

Procurement policies for drugs are not readily available (local government)

Procurement policies for drugs are readily available


Recruitment, selection, and hiring policies are usually not available (local government)

Most have these policies

Safe Practice and Environment

Preventive and corrective maintenance services are not readily available which may be a result of delayed procurement of services as these services were not assured from vendor when the equipment was purchased.

L3 and hospitals usually have good safety programs compared to government hospitals. Personnel responsible of maintaining security and conduct of preventive and corrective maintenance of equipment are always available

Government vs Private

National Performance

“Excellent firms don’t believe in excellence- only in constant improvement and constant

change.”

Tom Peters

Background:

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Universal Health Care

Bawat Pilipino miyembro, Bawat miyembro protektado, Kalusugan natin segurado.

General Appropriations Act of 2012 (RA 10155)

• Automatic accreditation of all gov’t health care providers effective April 1, 2012

• Subject to the guidelines to be issued by DBM, DOH and PhilHealth

DOH AO 2011-0020: Streamlining of Licensure and Accreditation of Hospitals

• Automatic accreditation of all licensed hospitals as Centers of Safety

• Benchbook core indicators incorporated in DOH licensing standards

• Subject to “appropriate rules and guidelines”

Streamlining of Licensure and Accreditation

• Published January 14, 2012, Philippine Star• Effective January 29, 2012

• But will only apply to licensed hospitals if the licensure standards already incorporated the 51 core indicators of the Benchbook standards for hospitals

• Status: DOH is still finalizing the survey tool

Third Party Accreditation:COQ/COEDirections Implementation

Recognition of Accreditation of Hospitals granted by International Accrediting Organizations

• Recognize accreditation issued by ISQua accredited organizations for Centers of Quality and Excellence

• No pre-accreditation survey of hospitals accredited by international organizations

•Non-withholding of necessary/essential services to patients applicable to licensed service capability.•Compliance to policies on the implementation of case rate and/or “no balance billing” (if applicable).•No Writ of Execution issued against the applicant provider by PhilHealth three (3) years prior to application of accreditation.•No negative monitoring findings, e.g., irrational drug use, over/underutilization of services, etc, that remain uncorrected for the year preceding the applicable period.

Automatic Accreditation of Government HCPs• Primary Care Benefit Provider (PCB): health units, outpatient

clinics of Levels 2, 3, and 4 DOH licensed hospitals, L1 hospitals with a L2 laboratory and licensed radiology service referral facilities with physician as certified by PHIC or CHDs

• MCP + NCP Provider: facilities certified BEmONC with NS• Anti-TB DOTS Providers: health units/DOH-licensed hospitals that

are certified as DOTS Facilities• Outpatient Malaria Package (OMP) Provider: certified by DOH• Outpatient Animal Bite Benefit (OABB) Provider: certified by

DOH• Other facilities: such as, but not limited to, Ambulatory Surgical

Clinics, Free-standing Dialysis Clinics, etc.• Other service providers as identified by the Corporation

• All government – employed health care providers, duly licensed by the Professional Regulatory Commission shall be deemed accredited, if applicable as a professional provider of applicable PHIC benefit.

“Automatic Accreditation”

• No more pre-accreditation survey will be conducted by PHIC

• Automatic accreditation is only for entry, all HCPs shall be subject to Corporate rules and regulations

• Exclusion: – Hospitals applying as Centers of Quality and

Excellence– Some Outpatient Benefit Package Providers:

mostly private

Regular Process

Registration PCSurvey DeliberationEligible

to Participat

e

Subject to Corporate Rules and

Regulations

•Submit PDR•Pay Fee

Sign PC

PASIssue

Notice/ID

SC/AC

Thank you!

institutionalizing quality standards in health care

Economy & Finance