The three organisations each contribute skills and experience to transform healthcare facilities from an entry or baseline position where they are providing poor healthcare to one approaching excellence.
The Joint Commission International provides the essentials tool that helps facilities to assess whether they ready to enter into a quality improvement programme. They need to have a core set of quality and safety standards in place. As the facilities move towards the right and upwards in the diagram, they are undergoing quality improvement programs by COHSASA and are receiving training, technical assistance and infrastructure upgrading from both PharmAccess and the Joint Commission. When the facilities start improving their compliance with standards, the progress is recognised in a series of five “steps” or certificates of improvement. Finally, they reach a point of substantial compliance with standards and receive full accreditation from COHSASA.
Our stepwise improvement program
1: Very modest quality strength. The facility is licensed to provide healthcare services but the day-to-day processes are not guided by policies or procedures resulting in potential high risk of unsafe procedures.
2: Modest quality strength. The facility is starting to operate according to structured processes and procedures, some of which are captured in written guidelines and SOPs. However healthcare quality is still likely to fluctuate.
3: Medium quality strength. The facility is accustomed to operating according to standardized procedures, and has started to monitor implementation. Healthcare quality can still fluctuate in high risk situations due to lack of securing of procedures.
4: Strong quality systems. The facility is regularly monitoring the implementation of treatment guidelines and standard operating procedures through internal record reviews and (clinical) audits. Most high risk processes and procedures are controlled.
5: Continuous quality improvement systems. The facility has instituted measures to monitor and evaluate policy implementation and the findings are reviewed to ensure that appropriate corrective action is taken if necessary. The management team is engaged in evaluating quality of care, and the facility is ready to begin the process of applying for accreditation from an international agency.
Accreditation status: Excellent quality systems. The facility has a proven track record of continuous quality improvement, is in substantial compliance with the SafeCare standards, and meets the decision rules for accreditation by an independent organization such as COHSASA.