7. QUALITY ASSURANCE AND QUALITY IMPROVEMENT MECHANISMS 7.1 What does the NHI Bill say about accreditation and quality? The NHI Bill positions the accreditation of health service providers as a mechanism to ensure the quality of health services provided. The Bill states that accreditation of health service providers includes certification from the Office of Health Standards Compliance (OHSC) (page 21, section 39): “In order to be accredited by the Fund, a health care service provider or health establishment, as the case may be, must (a) be in possession of and produce proof of certification by the Office of Health Standards Compliance and proof of registration by a recognised statutory health professional council, as the case may be.” The NHI Bill then goes on to explain that the first phase of implementation will improve quality through certification (page 47, section 2.2.1): “The intermediate preparatory phase involves improving the quality of the health system by first certifying the health facilities to ensure they meet the requirements of the Office of Health Standards Compliance.” The Bill also makes some reference to purchasing care (it refers to contracting) from accredited public and private providers (page 20, section 37.1.2(b-c): “A contracting unit for primary health care… must assist the fund to b) identify accredited public and private health care service providers at primary care facilities; c) manage contracts entered into with accredited health care service providers, health establishments and suppliers in the relevant sub-district in the prescribed manner and subject to the prescribed conditions”. Furthermore, in the Schedule to the Bill a “provider payment” is defined as “payment to providers in a way that creates appropriate incentives for efficiency in the provision of quality and accessible health care services using a uniform reimbursement strategy”. However, there is no detail provided on how the creation of these incentives is envisaged to take place.
7.2 How to measure quality The measurement of quality of health services is a complex undertaking, owing to the multi-dimensionality and depth of the concept of quality itself. It is therefore useful to differentiate which aspects of quality are being measured, and by which measures. Quality measurements can be broadly grouped as structural measures, process measures and outcome measures as per Donabedian’s framework (Figure 3).31
Figure 3: Donabedian’s quality framework 31
STRUCTURE
PROCESS
OUTCOME
Physical and organisational
Focus on the care delivered
Effect of health care on
characteristics where
to patients e.g. services,
the status of patients
health care occurs
diagnostics, or treatments
and populations
The certification of health facilities by the OHSC (which is one of the prerequisites for provider accreditation as per the NHI Bill) ensures that facilities meet a minimum set of requirements, through measuring the structural aspects.32 Given their tangibility, structural aspects are the easiest to measure and assess but they lend themselves to less frequent assessment. While structural quality serves as a necessary foundation for the provision of quality care, it is not sufficient on its own to reflect the quality of care delivered.32
26
|
UNIVERSAL HEALTH COVERAGE PATHWAYS FOR SOUTH AFRICA
