HOSPITAL REVITALISATION PERFORMANCE AND NATIONAL CORE STANDARDS

PORTFOLIO COMMITTEE ON HEALTHWestern Cape Department of Health

19 September 2012

Hospital Revitalisation Programme

Hospital Revitalisation projects – Status and Expenditure

Project Status Construction Start Date

Construction End Date

Budget 2011/12

Expenditure2011/12

Budget 2012/13

Expenditure 2012/13

George Hospital Phase 3 Retention Apr 2009 Jun 2012 41 189 000 36 298 074 9 609 000 11 781 199

Khayelitsha Hospital Retention Feb 2009 Oct 2011 192 363 000 180 432 866 13 024 997 10 539 678

Paarl Hospital Phase 2 Retention May 2009 Mar 2012 35 839 000 43 838 246 12 679 999 3 862 558

Vredenburg Hospital Phase 2A Retention Feb 2009 Nov 2011 7 600 000 8 141 460 68 856 000 7 165 177

Lentegeur Laundry Construction Nov 2012 Mar 2013 400 000 929 241 34 800 000 3 317 894

Mitchell’s Plain Hospital Construction Oct 2009 Feb 2013 147 234 000 143 916 445 234 736 995 78 214 497

Hospital Revitalisation projects – Status and Expenditure Continued

Project Status Start Date

End Date Budget 2011/12

Expenditure 2011/12

Budget 2012/13

Expenditure 2012/13

Vredenburg Hospital Phase 2B

ConstructionFeb 2012 Oct 2014 7 600 000 8 141 460 68 855 999 7 165 177

Worcester Hospital Phase 4 (completion project)

Construction Dec 2011 Sep 2012 19 691 000 22 353 018 17 098 000 9 504 054

G F Jooste Hospital

Planning0 0 1 000 000 0

Paarl Hospital Psychiatric Unit

Planning800 000 0 6 645 986 73 075

Tygerberg Hospital (PPP)

Planning2 000 000 171 633 4 000 000 351 980

Valkenberg Hospital

Planning2 214 000 4 883 652 84 019 994 2 723 824

Worcester Hospital Phase 5

Planning100 000 0 500 000 0

Hospital Revitalisation projects – Challenges and Mitigating Actions

Challenges Mitigating Actions

George Hospital Phase 3This project was delayed due to additional work required at Emergency Centre.

This work has now been completed.

Worcester Hospital Phase 4The contract with the previous contractor was terminated in 2011/12.

The Implementing Department has instituted legal action against the previous contractor. Another contractor has since been appointed to bring this phase of the project to completion which should be achieved by the end of 2012.

Mitchell’s Plain HospitalA fire on site in May 2012 destroyed the 80% complete Emergency Centre, which has delayed the project by approximately three months.

The contractor is however making good progress on this project.

Hospital Revitalisation projects – Challenges and Mitigating Actions

Challenges Mitigating Actions

Valkenberg HospitalDelays in obtaining Peer Review approvals from National DOH.Delays negatively impact on cost escalation.

Additional requests from NDOH are being addressed in an attempt to expedite approval.The Lentegeur Laundry project is being expedited to improve HRG expenditure.

G F Jooste HospitalDelays in obtaining approval from National DOH for the briefing document.

NDOH will be sending a delegation to Cape Town to pursue discussions.

Projects under constructionDelays in roll-out of digital radiology Funding will be moved during the adjustment budget to

ensure funding is spent

National Core Standards: Western Cape preliminary

baseline results

National Core Standards Domains• Priority Areas Availability of medicines and

supplies

Cleanliness

Improve patient safety

Infection prevention and control

Positive and caring attitudes

Waiting times

RATING OF MEASURES

• VITAL MEASURES: ensure that the safety of patients and staff are safeguarded so as not to result in unnecessary harm or death,

• ESSENTIAL MEASURES: are fundamental to the provision of safe, decent quality care (what is expected within available resources)

• DEVELOPMENTAL MEASURES: the elements of quality of care to which health management should aspire to achieve optimal care- do not constitute risk to patients.

Scores

• Two parts to the score:– Compliant or non compliant: Based on vital

measures– Numeric score based on the other measures in

place:• A = 80%-100%• B = 60%-79%• C = 40% - 59%• D = 20% - 39%• E = 0% - 19%

An Example

Facilities audited

Name of District/Facilities Audited Time frames Central HospitalRegional and Specialised

District Hospitals TB Hospitals

NO. of PHC (CHC, CDC, Clinics, Satellites) Facilities

GRAND TOTAL

TOTAL Metro District Health Services August/September 2011 3 7 9 2 129 150

TOTAL Eden District Monday, August 01, 2011 0 1 1 6 53 61TOTAL Central Karoo District Monday, August 01, 2011 0 0 4 1 12 17

TOTAL Cape Winelands DistrictNovember/December 2011 and January 2012

0 1 4 2 56 63

TOTAL Overberg District January/ February 2012 0 0 4 0 30 34

TOTAL West Coast District January/February 2012 0 0 7 1 49 57

GRAND TOTAL 3 9 29 12 329 382

HST Baseline National Core Standards Audits - 2011

Compliance

Facilities complying to minimum standards for waiting times:

50% (189/381)

% of health facilities meeting national minimum cleanliness standard

Hospitals: 82%PHC 30%

% of health facilities compliant with physical safety and security standards

Hospitals: 89% PHC 38%

% of health facilities which meet national minimum stocking levels for vital tracer medicines

Hospitals: 88%PHC: 45%

% facilities complying to IPC Hospitals: 1.8%PHC: 1.3%

% facilities complying to staff attitudes standards

Hospital :7.3%PHC: 16.7%

Why performance is the way it is

• Hospitals have a much longer history of QA and IPC with dedicated staff for both and hospicentric guidelines and processes

• PHC facilities have a much shorter history of QA and IPC

• Limited capacity, currently only 1 QA and IPC person per district covering multiple PHC facilities

• Guidelines and SOP’ s are often targetting hospitals

Developmental Process• NDoH developed tools and piloted them then provided HST to coordinate the baseline audit process in

collaboration with provinces

• Two day training programme: Staff members audited own facilities and other facilities– In retrospect training was probably not adequate

• Data Dictionary not available – each auditor interprets varies aspects from his/her own terms of reference – Numerous abbreviations used in the checklists without explanation– Statistics on common health care associated infections demonstrate that they are in line with acceptable benchmarks. Not clear

what acceptable is?

• Reference to Specific Policies Protocols, Guidelines– These are frequently updated and the questionnaires refer to specific polices and include the date of publication; if your is

incorrect date even more up to date you are assessed as non compliant

• Committees– The questionnaires refer to facilities having a number of committees e.g. quality assurance, risk management, infection

prevention and control, occupational health and safety etc., Small hospital or PHC facilities do not have the capacity to have a multitude of committees

• Risk rating sometimes problematic– A standard operating procedure is available which indicates how schedule 5 and 6 medicines are stored/controlled/distributed

in accordance with the Medicines and Related Substances Act 101 of 1965. Change from and Essential to a Vital measures

The tool is developmental (some examples)

• Emergency Generator currently tested once a month for 30 minutes and with load. – NCS requires testing for 5 minutes weekly

• could damage the generator• testing without load does not give you a good idea of the functioning of the generator

• Patient Satisfaction Survey in paediatric units– parents are asked to comment whether they are happy with the food served, parents are

generally not happy with the food for themselves, as the patient food is made to be palatable to young children, not to adults

• IPC:– Need to have IPC practitioner at each facility even PHC– Need to establish hospital acquired infection surveillance system– N95 masks to be worn by staff to prevent transmission of TB but currently conflicting policy

• IPC guidelines recommends normal mask– Isolation facilities to manage haemorragic fever even at PHC facilities (only TBH has this)– IPC issues to be discussed at a specific IPC committee regardless of size

That being said…• The process was very valuable

• No standards before but these now exist

• For the first time quality is everyone’s business– Clinicians, managers, infrastructure, HR, finance etc

• Very detailed comments have been given to NDoH, tools have been adapted further and piloted, awaiting new tools

• Risk rating has been changed to include critical, vital, essential and developmental

Plan of action

• Quality Improvement training for all QA managers

• Quality improvement plans developed• Provincial Quality Improvement Committee– Policies, guidelines, norms, M&E

• District and Facility Quality Improvement Committee– Oversee implementation

• Patient Centred Quality of Care

Quite a paradigm shift…• Does not replace patient safety and quality clinical care.

• Little to do with clinical, technological or scientific aspects of medicine.

• Care organised around the patient

• Needs and perspectives seen through the eyes of the patient.

• More than just completing tick sheets to assess compliance

WC PCE Framework

1. Reception services and folder registry2. Clinical services/ clinical governance including pharmacy3. Discharge and continuity of care 4. Community participation i.e. the service users and their families5. Improving staff work life experience

Take home message• NCS baseline audits done for all fixed facilities

• Very low compliance rates as vital measures are in place

• Very high numeric scores especially for hospitals meaning most measures are in place

• The tool is still under development and design issues especially related to PHC

• Department has a plan that is based on HC 2020 principle of patient centred quality of care

Thank You