Interim CEO of the Council for Health Service Accreditation of Southern Africa (COHSASA), Jacqui Stewart, talks about the importance of eHealth in achieving and maintaining standards in healthcare facilities, and COHSASA’s aspiration of becoming a continent-wide African enterprise.

Tell about your healthcare background and role as acting CEO?

I trained as a nurse in Cape Town and then went to England to specialise. My last job in the National Health Service was at the Modernisation Agency Leadership Centre. I came back to Cape Town in 2005 after COHSASA’s previous CEO, Professor Stuart Whittaker, asked if we could assist with some leadership and management development to support the COHSASA accreditation programme. The Centre has since closed down but in the run up to its closing, I was asked by Prof Whittaker to join COHSASA as Chief Operations Manager, a post I took up in December 2005.

Over the years I’ve been involved in a wide variety of activities for COHSASA including operations, marketing, facilitation, training, client liaison and as of January 2015, Interim CEO.

What was the vision that led to COHSASA?

When COHSASA came into being in 1995, Prof Whittaker and his colleagues were looking at how quality improvements and accreditation could be used to level up the South African health system, because at that time it was obviously very uneven. They found that the accreditation process in some sectors was relatively simple; however, in the public healthcare sector there was a need to really help people to move through the process, making it a much longer process.

Having that insight, COHSASA developed a graded recognition programme, called the Facilitated Accreditation Programme, which acknowledged the possibility that public facilities entering the accreditation programme would not achieve accreditation in the first instance. So rather than making it a pass or fail outcome, a recognition grade is given, either at an entry level or intermediate level. The programme has been really successful and has led to the accreditation of a lot of hospitals and clinics in South Africa’s public sector.

How does COHSASA’s approach differ between the public and private sector?

The private sector obviously wants to provide good patient care and they watch the bottom line very closely. So while the private sector was on board from the start, we had to demonstrate the value of accreditation to their bottom line. The private sector has robust standards, so once the facility is accredited, patients are assured of safe, quality healthcare.

In the public sector it’s more of a quality improvement process. An issue in the public sector is that staff move around a lot, so they take part in the quality improvement and accreditation programme but then they move on. So while having a step-wise accreditation approach may take longer, it provides staff with a sense of security that they know what they are doing. They are given support, they know they are working according to standards and it gives them a safe environment from which to work within.

But your standards don’t differ between sectors and countries?

We have a fundamental belief that the standards should be the same in both sectors but we’ve adjusted our approach to meet the needs of both sectors. We’ve also made our terminology more generic so that the same information can be applied to different countries. For example, if you specifically refer to occupational health legislation of SA, it will have to be changed for another country so using more generic terms means we’ve got a wealth of data that can be used to compare the progress of different countries across Africa.

COHSASA has worked with more than 600 facilities throughout Sub-Saharan Africa. Is it part of your plan to be the leading body within Africa?

It’s been a dream to be an all-African enterprise for a long time. The challenge, however, is that most countries want their own accreditation body, which costs money. We’ve been working closely with a number of ministries of health who are interested in setting up their own accreditation body but what we’re finding is that they’ve got a lot of work to do on quality improvement and it’s more appropriate to invest in performance improvement activities rather than trying to start accrediting. Currently, we are only one of a few accredited African bodies that consider the African context in their standards. body.

In the NHS, funding is often based on meeting performance criteria and set standards. Do you think such an approach is necessary, or could even work, within our public health system?

I think SA is a long way off from having such a system in place, however, in other parts of Africa they are looking at performance-based funding. I think it’s unfair to put performance-based funding in place before there’s a performance improvement programme – which should be the first step. The government is trying to do that with the National Core Standards for Health by ensuring that there’s at least a minimum standard in every healthcare facility.

Once those standards are in place, then I think it’s good to offer some kind of performance incentive. However, it’s risky if it’s not well managed; and you’ve got be careful about the indicators you choose to identify performance improvements against because if it’s just numbers then it’s easy, but outcomes are far more difficult to measure accurately.

What’s your opinion on the significance of standards in the move to eHealth?

eHealth is absolutely the logical way to go to achieve connected, patient-centred healthcare. However, while working for the NHS I saw millions of pounds wasted on developing systems that didn’t work, so a key factor for us is getting the specification right: what is it that we want the system to do and why do we want it to do it? Only once we know that can we even begin to bring developers on board to figure out how that might be done.

The great thing about standards is that they give you a blueprint for good practice. Throughout a patient’s journey within a hospital or clinic, they experience many of the systems and functions of the healthcare processes, so standards help healthcare staff to first of all, know what it is that they are supposed to do in terms of policies or protocols and second, gives them something to measure quality against. We’ve made a point of making our standards easy to understand so as to guide staff to do the right thing the first time round and therefore create a safe environment. For example, if there are protocols for looking after a baby with diarrhoea, staff can see it, read it and follow it, and then over time they can do clinical audits to see how well they have been managing babies with diarrhoea. We’ve found that standards create good discipline as it prevents staff from cutting corners because they know what they are meant to do.

Standards are easily transferable to electronic formats. COHSASA’s Quality Information System (CoQIS) is a web-based system that enables staff to keep a history of their activities as they proceed through the programme, what progress they’ve made and what their short comings are. It also enables them to filter by particular standards so they can look for, for example, what went wrong with a patient’s care to understand the causes and what is required to improve or prevent it, and that can then be monitored over time. As we move forward with different eHealth systems, we’ll have even more opportunity to monitor.

Let’s talk about CoQIS. Is there a need, at this stage, for CoQIS to be interoperable with other eHealth systems?

One of the overriding benefits of CoQIS as a web-based system is that our clients can access information 24/7 and the information is formatted in a way that is useable. They can manipulate it and prioritise interventions – this move to digital alone has been an enabler for quality improvements across the board because the data is now actionable information.

Currently, it’s a stand-alone system, but in the next iteration we want to look at how it can exchange information with other eHealth systems, particularly our patient safety system, PatSIS, because the two are inextricably linked in terms of what goes on at the bedside.  If you improve quality, you will eventually reduce adverse events over time.

In the longer term, we want to focus to shift to patient-centred eHealth applications so that patients themselves know where to access good quality, safe care. However, we don’t want to take that step too quickly because the parameters for both patients and our clients need refinement – we see it as a journey but we one we must take because patient-focus is becoming very important.

Could the data generated by your systems be used to reduce medical litigation?

In the Free State, the data indicated that delays in transferring patients were directly affecting maternal deaths. In response, the Province invested in better transport which resulted in maternal deaths dropping by 48% between 2011 and 2013. So, yes – when the data our systems generate is properly applied and acted upon, it could have an impact on the number of claims we see every year in the industry.

Tell us about your workshops.

We’re running workshops on quality improvement methods and risk management because we found that even though people know the risks associated with healthcare facilities, when it comes to planning for or dealing with an event, they often don’t know what to do. The same applies to improvement methods and we’ve developed a workshop to specifically address how to put a quality improvement plan or performance improvement plan in place. Our workshops have attracted our existing clients as well as other healthcare professionals who want to learn basic tools and techniques on the subjects.

What are COHSASA’s plans for the future?

We have coordinated a bid for South Africa to host the 2018 International Society for Quality in Healthcare (ISQua) Conference in Cape Town. ISQua currently has 37 countries as members. In 2012 ISQua introduced tracking of quality and safety in developing and emerging countries and we wanted to be able to demonstrate the work that has been done across Africa and what we’ve done.

The conference sees about 1,500 delegates from across the globe attend, and I believe Cape Town is an obvious location because of what it has to offer as a city. The bid has support from the Premier, the Mayor and the MEC, and we have written to request support from the Minister as well. It would be wonderful if South Africa could host the conference in 2018 and until then, will continue to work to elevating and maintaining quality standards in the healthcare industry.

Anyone who’d like to find out more about our workshops or the work that we do can visit or contact Dr Katrin Kleijnhans, COHSASA’s Professional Developer at 021 5314225.

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