Leveraging the full value and impact of accreditation.

Providing high quality and safe patient care is a challenge in the current rapidly changing and complex health care environment. A variety of independent tools and methodologies contribute to this effort, e.g. regulatory requirements, quality improvement tools and accreditation methodologies. A concern is that each alone will not achieve the tipping point in health care quality that is required. This paper suggests that the methodology and application of accreditation have the potential to be the force to bring these approaches into alignment and ultimately measurably improve the quality of care.

SafeCare: An Innovative Approach for Improving Quality Through Standards, Benchmarking, and Improvement in Low- and Middle- Income Countries.

BACKGROUND: In low- and middle-income countries (LMICs), patients often have limited access to high-quality care because of a shortage of facilities and human resources, inefficiency of resource allocation, and limited health insurance. SafeCare was developed to provide innovative health care standards; surveyor training; a grading system for quality of care; a quality improvement process that is broken down into achievable, measurable steps to facilitate incremental improvement; and a private sector-supported health financing model. METHODS: Three organizations-PharmAccess Foundation, Joint Commission International, and the Council for Health Service Accreditation of Southern Africa-launched SafeCare in 2011 as a formal partnership. Five SafeCare levels of improvement are allocated on the basis of an algorithm that incorporates both the overall score and weighted criteria, so that certain high-risk criteria need to be in place before a facility can move to the next SafeCare certification level. A customized quality improvement plan based on the SafeCare assessment results lists the specific, measurable activities that should be undertaken to address gaps in quality found during the initial assessment and to meet the nextlevel SafeCare certificate. RESULTS: The standards have been implemented in more than 800 primary and secondary facilities by qualified local surveyors, in partnership with various local public and private partner organizations, in six sub-Saharan African countries (Ghana, Kenya, Nigeria, Namibia, Tanzania, and Zambia). CONCLUSION: Expanding access to care and improving health care quality in LMICs will require a coordinated effort between institutions and other stakeholders. SafeCare's standards and assessment methodology can help build trust between stakeholders and lay the foundation for country-led quality monitoring systems.

Effect of Community Engagement Interventions on Patient Safety and Risk Reduction Efforts in Primary Health Facilities: Evidence from Ghana.

BACKGROUND: Patient safety and quality care remain major challenges to Ghana's healthcare system. Like many health systems in Africa, this is largely because demand for healthcare is outstripping available human and material resource capacity of healthcare facilities and new investment is insufficient. In the light of these demand and supply constraints, systematic community engagement (SCE) in healthcare quality assessment can be a feasible and cost effective option to augment existing quality improvement interventions. SCE entails structured use of existing community groups to assess healthcare quality in health facilities. Identified quality gaps are discussed with healthcare providers, improvements identified and rewards provided if the quality gaps are closed. PURPOSE: This paper evaluates whether or not SCE, through the assessment of health service quality, improves patient safety and risk reduction efforts by staff in healthcare facilities. METHODS: A randomized control trail was conducted in 64 primary healthcare facilities in the Greater Accra and Western regions of Ghana. Patient risk assessments were conducted in 32 randomly assigned intervention and control facilities. Multivariate multiple regression test was used to determine effect of the SCE interventions on staff efforts towards reducing patient risk. Spearman correlation test was used to ascertain associations between types of community groups engaged and risk assessment scores of healthcare facilities. FINDINGS: Clinic staff efforts towards increasing patient safety and reducing risk improved significantly in intervention facilities especially in the areas of leadership/accountability (Coef. = 10.4, p<0.05) and staff competencies (Coef. = 7.1, p<0.05). Improvement in service utilization and health resources could not be attributed to the interventions because these were outside the control of the study and might have been influenced by institutional or national level developments between the baseline and follow-up period. Community groups that were gender balanced, religious/faith-based, and had structured leadership appeared to be better options for effective SCE in healthcare quality assessment. CONCLUSION: Community engagement in healthcare quality assessment is a feasible client-centered quality improvement option that should be discussed for possible scale-up in Ghana and other resource poor countries in Africa.

Comparison of Perceived and Technical Healthcare Quality in Primary Health Facilities: Implications for a Sustainable National Health Insurance Scheme in Ghana.

BACKGROUND: Quality care in health facilities is critical for a sustainable health insurance system because of its influence on clients' decisions to participate in health insurance and utilize health services. Exploration of the different dimensions of healthcare quality and their associations will help determine more effective quality improvement interventions and health insurance sustainability strategies, especially in resource constrained countries in Africa where universal access to good quality care remains a challenge. PURPOSE: To examine the differences in perceptions of clients and health staff on quality healthcare and determine if these perceptions are associated with technical quality proxies in health facilities. Implications of the findings for a sustainable National Health Insurance Scheme (NHIS) in Ghana are also discussed. METHODS: This is a cross-sectional study in two southern regions in Ghana involving 64 primary health facilities: 1,903 households and 324 health staff. Data collection lasted from March to June, 2012. A Wilcoxon-Mann-Whitney test was performed to determine differences in client and health staff perceptions of quality healthcare. Spearman's rank correlation test was used to ascertain associations between perceived and technical quality care proxies in health facilities, and ordered logistic regression employed to predict the determinants of client and staff-perceived quality healthcare. RESULTS: Negative association was found between technical quality and client-perceived quality care (coef. = -0.0991, p<0.0001). Significant staff-client perception differences were found in all healthcare quality proxies, suggesting some level of unbalanced commitment to quality improvement and potential information asymmetry between clients and service providers. Overall, the findings suggest that increased efforts towards technical quality care alone will not necessarily translate into better client-perceived quality care and willingness to utilize health services in NHIS-accredited health facilities. CONCLUSION: There is the need to intensify client education and balanced commitment to technical and perceived quality improvement efforts. This will help enhance client confidence in Ghana's healthcare system, stimulate active participation in the national health insurance, increase healthcare utilization and ultimately improve public health outcomes.

Association between health worker motivation and healthcare quality efforts in Ghana.

BACKGROUND: Ghana is one of the sub-Saharan African countries making significant progress towards universal access to quality healthcare. However, it remains a challenge to attain the 2015 targets for the health related Millennium Development Goals (MDGs) partly due to health sector human resource challenges including low staff motivation. PURPOSE: This paper addresses indicators of health worker motivation and assesses associations with quality care and patient safety in Ghana. The aim is to identify interventions at the health worker level that contribute to quality improvement in healthcare facilities. METHODS: The study is a baseline survey of health workers (n = 324) in 64 primary healthcare facilities in two regions in Ghana. Data collection involved quality care assessment using the SafeCare Essentials tool, the National Health Insurance Authority (NHIA) accreditation data and structured staff interviews on workplace motivating factors. The Spearman correlation test was conducted to test the hypothesis that the level of health worker motivation is associated with level of effort by primary healthcare facilities to improve quality care and patient safety. RESULTS: The quality care situation in health facilities was generally low, as determined by the SafeCare Essentials tool and NHIA data. The majority of facilities assessed did not have documented evidence of processes for continuous quality improvement and patient safety. Overall, staff motivation appeared low although workers in private facilities perceived better working conditions than workers in public facilities (P <0.05). Significant positive associations were found between staff satisfaction levels with working conditions and the clinic's effort towards quality improvement and patient safety (P <0.05). CONCLUSION: As part of efforts towards attainment of the health related MDGs in Ghana, more comprehensive staff motivation interventions should be integrated into quality improvement strategies especially in government-owned healthcare facilities where working conditions are perceived to be the worst.