A Case Study on Hospital Accreditation in Thailand and Quality Improvement at King Chulalongkorn Memorial Hospital: Part 1

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1 A Case Study on Hospital Accreditation in Thailand and Quality Improvement at King Chulalongkorn Memorial Hospital: Part 1 Jiruth Sriratanaban, M.D., M.B.A., Ph.D. Faculty of Medicine, Chulalongkorn University Written for the Flagship course in Health Sector Reform of the World Bank Institute, in co-operation with Center for Health Economics, Faculty of Economic, Chulalongkorn University 1. The country profile Thailand has a population of approximately 67 million with a predominantly public health service system. Ethnically the country is quite homogeneous with 95% being Thai and Buddhists and 3% Moslems and around 0.5% hill tribes. The population growth rate at present is 1.2% per annum. Demographically, the country is undergoing a rapid transition towards an aging population although the proportion of elderly population is only around 8% at present. With respect to the economy, Thailand used to have an average growth of 7% per year before the 1997 economic crisis. During the late 80 s and early 90 s there were double digit growth of GDP. This resulted in 25 times increase in income per capita and decrease in the proportion of people below poverty line. However, with the crisis, the picture has changed dramatically. The country GDP suffered negative growth in 1997 and The income per capita in dollar term was projected to be only 1993 US$. The proportion of people below poverty line was also projected to increase by 11.6%. Although the recent numbers in improved to positive growth, the country has not totally recovered. Politically the country is a democratic country with elected governments. Although elected governments have been the norm in Thai politics for the last 25 years, they suffered from high turnover with a government life span averaging less than 2 years. Most recently it has developed the first constitution which could be claimed to be broad-based and drafted by the general public rather than elected members of the House of Representatives. This has lead to a significant change in the general political atmosphere, especially in the demand for good governance. The recent economic crisis has also added to the concern over good governance at the national level as well as at the local level. This has been viewed as crucial move to better stabilize the country s socio-economic development.

2 2 2. Health, health seeking behavior and health expenditure profile In general, Thailand s health system is in the epidemiological transition from communicable and vaccine-preventable diseases as major causes of death to noncommunicable diseases. The situation can be characterized by satisfactory improvement in physical dimension of health, but deteriorating mental health status. Between 1964 and 1996, the Thais life expectancy at birth increased from 55.9 to 70.0 years in male and 62.0 to 75.0 years in female. The World Health Report 2000 reported that the Thai s disability adjusted life expectancy (DALE) was at 62.0 years, ranked 99 th among 191 countries. However, statistics suggested the decline of mental health status despite no specific indicators. Suicide and mental disorders, which rose from 5.4 in 1986 to 7.0 per 100,000 population in 1997, and from 21.0 to 30.7 per 1,000 population, respectively. Health problems with rising trends include HIV/AIDS, tuberculosis, chronic diseases, occupational diseases, and traffic accidents. The health care systems in Thailand has evolved from self-reliance, in the past, using local wisdom for health promotion and curative care, to the current systems of modern medicine and technology. With the expansion of modern health care delivery systems both in the public and private sectors, Thais are moving toward using more health facility-based services. The percentage of self-care and self medication reduced from 54.1 percent in 1970, to 48.0 percent in 1991, and to 17.6 percent in During the same period, the use of public health services rose from 15.5 percent to 28.9 percent and to 44.0 percent, respectively. The use of private sector services changed from 22.7 percent to 16.1 percent and to 24.3 percent, respectively. The 1999 Health and Welfare Survey the nation-wide survey conducted by the Office of National Statistics, found that self care and self medication was 21.2 percent while some 19.2 percent of the population used rural health centers, and 19.0 percent went to private clinics. The percentage of using public district hospitals, public provincial hospitals and private hospitals were 14.9, 15.6 and 4.8 percent, respectively. People living in urban areas were more likely to use private facilities than public ones, while public facilities were main sources of care in rural areas. People also demand more responsive health care services than ever before. With respect to health care financing, Thailand has recently spent around 5.5 to 6.2 percent of gross domestic product (GDP) on health. The absolute amounts have increased dramatically since The trend may partly reflect expansion of the health service sector, and/or the change of health seeking behaviors of the population. Drug expenditure has also increased. (See Figure 1) A Thai individual may be covered by either one of the three major health welfare and insurance schemes. The schemes have somewhat different health benefit packages and apply different payment mechanisms. (See Figure 2) The average expenses per capita vary widely among the three schemes. Furthermore, studies have shown that there are gaps between schemes in terms of patient satisfaction with quality of medical care, general services and access.

3 3 Figure 1 National health expenditure and drug expenditure: total and percentages of the gross domestic product (GDP) of the country Source: Modified from Thailand Health Profile , Bureau of Health Policy and Plan, MoPH Figure 2 Major health welfare and insurance schemes in Thailand in 2003 Major welfare and insurance schemes National Health Security scheme Social Security scheme Civil Servant Medical Benefit scheme Private insurance Population coverage Approx. 46 million Approx. 10 million Approx. 7 million Approx. 6 million Benefits Financing Major payment mechanisms General - Outpatient including tax, Per- prescription: Capitation head - Inpatient: DRG with budget global budget allocated Health promotion and to UC disease prevention: fund Fee schedule Include curative care, health promotion, and disease prevention Provider: Contracted public and private hospitals and primary care units Only curative and shortterm rehabilitative care Provider: Contracted public and private hospitals and networks Primarily out-patient and in-patient curative and rehabilitative care Provider: Public hospitals Acute care, inpatient and outpatient settings Provider: Public and private hospitals Three-tier contribution: employees, employers, government General tax Premium - Capitation for outpatient and inpatient care, including prescription. Fee-for-services; Some restrictions on benefits which need patient copayment. Fee-for-services; Some do retrospective utilization review on hospital billing. Sources: National Health Security Office, Thailand, 2003 Thailand Health Profile , Bureau of Health Policy and Plan, MoPH

4 4 3. Hospitals in the country Health care infrastructures of the country are pluralistic. Although people in Thailand can seek health care from various sources such as health centers and private clinics, hospitals are still major health service providers. A majority of hospitals and hospital beds in the country are publicly-owned by the Ministry of Public Health (MOPH). Most private facilities used to be rather small hospitals until recently that many of them were expanded and new medium-to-large-sized private hospitals ( beds) were built. (See Figure 3) This was attributed to the rapid economic growth in the 90 s as well as the government s investment promotion policies. However, hospitals are mal-distributed. They are mostly located in the Bangkok area, as shown in Figure 4. Figure 3 Number and Proportion of Hospital by Institution, Number and percentage of hospitals (%) Year MoPH Other State Local Private Total ministries enterprises administration sector agencies (59%) 531 (61%) 664 (67%) 718 (67%) 831 (65%) 855 (64%) 66 (10%) 67 (8%) 66 (7%) 70 (7%) 73 (5%) 84 (6%) 14 (2%) (28%) 256 (29%) 237 (24%) 257 (24%) 364 (28 %) 374 (28%) 661 (100%) 869 (100%) 983 (100%) 1064 (100%) 1280 (100%) 1335 (100%) Source: Modified from Thailand Health Profile , Bureau of Health Policy and Plan, MoPH Figure 4 Population-per-bed ratio by Region, Region Population-per-bed ratio Bangkok Central North South Northeast Bangkok: Northeast ,511 1 : ,167 1 : ,172 1: ,074 1: : :3.8 population-per -bed ratio Total 61,274 78,438 87,554 93, , ,303 Source: Thailand Health Profile, Bureau of Health Policy and Plan, MOPH

5 5 4. Quality assurance in hospitals For public hospitals under MOPH, the ministry set up standards for different levels of hospitals. They were mostly structural criteria, namely number of beds, number and specialties of physicians and medical equipments, for instance. In addition, the Nursing Division of the Office of Permanent Secretary who supports nursing administration and practices has developed guidelines for quality assurance in different areas of nursing, for example in-patient care, ICU, emergency & accident, operating room. For private hospitals, the MOPH develops rules and regulation for annual auditing. Most of the rules and regulations cover structure and manpower. Guideline for quality improvement was also given to private hospitals. Certain quality improvement programs have been tried in several public and private hospitals. Some of common programs include quality control circles (QCC) and 5-S program. However, the hospitals lost their interest in these activities after some time. In 1994, some public hospitals began to experiment implementing total quality improvement (TQM/CQI) with the support from the Provincial Hospital Division of MOPH. Recently, there were the Ministry s policies to encourage MOPH hospitals to install the ISO9000 quality system or the hospital accreditation (HA) programs. Some private hospitals also adopt ISO9000 to set their quality assurance system for marketing purposes. 5. Hospital accreditation (HA) in Thailand Policies The 1999 constitution states that Thai people have rights to access to standard healthcare, and that it is a mandate for the government to make it so. This is the mandate for the government, and results in increased policy interest in many aspects of the health system including quality of care. With inputs from healthcare academicians and health professionals, the politician focus has gradually changed from tangible aspects of quality e.g. smiling, structural surrounding to more comprehensive aspects of quality i.e. a quality management system. The Thai Medical Council was the first agency to set up a short list of hospital standards. After the enactment of the Social Security Act in 1991, a set of hospital standards were developed by the Social Security Office to approve and audit hospitals that participated in the social security program as contracted health care providers for the program beneficiaries. In 1995, the MOPH considered setting up a neutral agency to solve the conflict of quality and cost between healthcare providers and consumers. This initiative later developed into a research and development project on hospital accreditation in order to develop and implement a more comprehensive set of hospital standards, as well as to set up a system mechanism to accredit quality hospitals.

6 6 Organization The comprehensive Golden Jubilee version of hospital standards, which lay out foundation of the hospital s quality management system for the accreditation purpose, was completed in They were introduced and experimented by 35 public and private hospitals in a voluntary manner in During this phase, the advisory committee of the project recommended working as a partnership with all sector involved i.e. professional organizations, providers, payers, and consumers. Consequently, the Collaboration for Hospital Quality Improvement and Accreditation was set up. This body was a civic organization that works closely with the MOPH. It has 40 members composed of representatives from the MOPH, other relevant professional organizations, government agencies, credible individuals and experts. Some of the program s strategic partners include: Funding agencies: Thailand Research Fund, Health Systems Research Institute, and the World Health Organization (WHO) Professional bodies: The Thai Medical Council, The Thai nursing council, The Thai Dental council, The Thai Pharmaceutical Council, The Hospital Pharmaceutical Association of Thailand, The Medical Technologist Association of Thailand, The Private Hospital Association of Thailand and The Medical Section of Christ Church of Thailand Educational institutions: The Consortium of Royal Colleges of Thailand, The Consortium of Medication Education, Mahidol University, Chulalongkorn University and Prince Songkhla University. The Social Security Office. The international collaboration: Canadian Executive Service Organization, and Liverpool School of Tropical Medicine. After the research and development project ended in 1999, the collaboration was transformed into the Institute of Hospital Quality Improvement and Accreditation. At present, the institute is an independent agency under the supervision of the Health System Research Institute. The HA program itself has expanded beyond the 35 pilot hospitals to the country-wide scale. As of the year 2003, some 50 hospitals have been accredited while hundreds of public and private hospitals have voluntarily committed themselves to the program and are in process of installing the HA quality management systems. Regional networks have been set up to foster the improvement. Strategies The hospital accreditation (HA) in Thailand is not merely a certification or an accreditation program, but it is intended to be a mechanism to encourage total hospital quality improvement in a systematic way and in a proper direction. The Thai HA emphasizes the principles of self-assessment, quality assurance, customerfocused continuous quality improvement (CQI) and total quality management (TQM). The accreditation is meant to encourage hospitals to improve and confirm how well they are doing according to standards, not simply being an external quality audit or

7 7 inspection of compliance to a minimal set of standards. Being accredited, therefore, means that a hospital can demonstrate commitment to patient-centered quality improvement. It also indicates that the hospital has a good quality system to minimize risk and assure quality, that it has a system to look after appropriate professional practice and ethics, and that it has shown capability to continuously improve. In order to gain acceptance and expand the program for sustainability, the following strategies have been adopted to advance the HA program in Thailand: 1. Hospital accreditation is an education process, not an inspection. On a conceptual basis, accreditation as an inspection process by outsider may not make a success. No hospital wants external audits and evaluation. The strategy is, thus, to promote accreditation as an education process. People will learn while they do self assessment, conduct quality improvement activities, and exchange experiences during organizational surveys. The emphasis of the survey is primarily placed on improving quality rather that the accreditation. 2. Let s make it together. Beginning as the research and development project, everybody learned including an accrediting body, surveyors as well as the participated hospitals. The hospitals could make their own creative and make recommendations to shape the content and process of accreditation. They learned from one another in conferences and when they participated in surveys. At the same, feedback from these hospitals and research findings from researchers were applied in designing the process of giving consultancy and conducting hospital surveys. 3. Bring the professional organization into the field. Some hospital services have a lot of technical details, such as a hospital pharmacy and laboratory services. The Hospital Pharmaceutical Association of Thailand and the Medical Technologist Association of Thailand have been invited to visit the participating hospitals, give recommendations and follow up. These activities led to the setting up and improvement of professional standards and benchmarking in these areas. 4. Disperse the concept widely. A paradigm shift among health providers and others involved is needed for the HA program to succeed. Particularly, they have to change their ways of thought from Quality by inspection to Quality is a learning process, and from the old way of quality assurance to the TOM/CQI paradigm. Making these concepts understood and appreciated by the people at all levels as wide as possible is, therefore, important. Peer groups are critical. It should be noted, however, that the appreciation may come only after they change their practice and experience benefits from that change.

8 8 5. Rely upon knowledge, not authority Implementation through authority of the MOPH may be easy to start an HA program, but it may be difficult to gain acceptance by health professionals. For many times, relying upon authority compromises sustainability as political interests change frequently. By contrast, the work that is based on knowledge attracts more people to join with fewer doubts. Real outcomes can be demonstrated. Instead of being directed, program participants will be empowered. Activities The Thai experiences indicated that there were number of steps of activities to implement the national HA program. They can be briefly summarized as follows: 1. The research and development team was set up. A team of experts was formed to write the hospital standards for the program. The standards were, then, reviewed by various parties and published. 2. The Collaboration of Hospital Quality Improvement and Accreditation was formed. The project recruited a pilot group of hospitals. The HA consultant team assisted the pilot hospitals to implement quality improvement based on TQM philosophy and the hospital standards. Guidelines were developed and distributed to the hospitals through workshops as well as consultation visits. In addition, there were regular meetings of the hospital quality coordinators to gain better understanding of what they were doing, to share experience, and to report the progress. 3. The project encouraged various professional organizations and hospitals to develop professional standards and bring those standards into practice. They became valuable inputs. At the same time, support was gained through different offices in the Ministry of Public Health, such as the Division of Rural Hospitals. 4. The survey processes were developed and tested with the pilot hospitals. The processes were reviewed and revised as the project trained HA surveyors and hospital consultants. Relationships among peer groups and hospitals were enforced by exchange of experiences and observational visits. 5. Periodically, there were activities on public relation and information dissemination to professionals and other interested hospitals through newsletters, published articles and books, as well as annual conferences, called A National Forum on Hospital Accreditation. 6. There were also a few qualitative formative and summative studies on organizational behavior and the evaluation of the HA program itself to find lessons learned for future development. 7. After the pilot program was over, the national body, The Institute of Hospital Quality Improvement and Accreditation (HA-Thailand), was set up as an independent organization.

9 9 For a hospital, the quality improvement journey under the HA program typically involves: 1. Hospital quality improvement activities, which may be divided into the following phases: 1.1 Awareness phase: The hospital top management studies and decides to commit to the HA improvement program. They create awareness among middle management and those at the operational level. 1.2 Learning phase: The hospital supports education and training programs for its personnel on quality improvement. There usually are piloted improvement projects. 1.3 Quality assurance phase: There are activities related to assuring standardized care and work processes, as well as adequate resources. 1.4 CQI phase: Quality teams look for opportunities for improvement, and engage in the plan-do-check-act cycles. 1.5 Professional phase: A professional body is set up within a hospital to take care of professional practices and standards, as well as foster multi-disciplinary environment. 2. Assessment comparing with hospital standards 2.1 Self assessment by a hospital 2.2 Preparation survey (Intensive consultation visit, ICV) 2.3 External assessment by HA surveyors 3. Decision on accreditation status by the accreditation committee 6. Some practical issues in the hospital accreditation (HA) program Hospital standards The comprehensive edition of the HA hospital standards were written by a group of experts from different fields of expertise. It comprises 20 chapters organized into 6 major categories, including: Leadership commitment in quality improvement: [1] Governance and leadership, [2] Policy direction; Resources and Resources management: [3] Management of resources and service coordination, [4] Human resources management and development, [5] Environment and safety, [6] Medical equipment, and [7] Information system; Quality assurance and improvement: [8] General quality processes, [9] Clinical quality processes, and [10] Prevention and control of infection Professional standards: [11] Medical staff organization, and [12] Nursing administration

10 10 Patient rights and organizational ethics: [13] patient rights, and [14] organizational ethics Patient care processes: [15] Patient care teams, [16] Preparation of patients and relatives, [17] Patient assessment and treatment planning, [18] Care processes, [19] Recording of patient data, and [20] Discharge planning and continuous care. Selection and Training of Surveyors Standardization of surveyors under the accreditation program is critical for the program credibility. The surveyors of the HA-Thailand are recruited from: 1. The core expert group that initiate the project; 2. TQM/CQI instructors; 3. Hospital quality coordinators and administrators with quality improvement experiences; 4. Representatives from professional organizations; 5. Health care professionals with interests and experiences in quality improvement activities and attendance in HA training courses. The recruited enter intensive training and evaluation programs which include: 1. Surveyor training workshops; 2. Direct observations in the field; 3. Practicing in the field under close supervision. Voluntary consultants from Canada, along with some senior Thai surveyors, become the major trainers. Moreover, HA surveyors will be constantly evaluated by surveyed hospitals. Periodically, surveyors and consultants meet to exchange their ideas and experiences. Usually, as outputs of the meetings, there are suggestions for improving the HA program. Guidelines and Tools on HA Educational programs and training courses for hospital administrators, hospital quality facilitators, internal surveyors and external surveyors are critically needed. Development of guidelines and manuals on quality improvement techniques, as well as interpretation and implementation of the hospital standards, are necessary to support hospitals on their quality improvement processes. Examples of guidelines and manuals include: 1. Steps and tools for quality improvement; 2. Facilitator skills; 3. Self assessment tools; 4. Clinical practice guideline development;

11 11 5. Risk management; 6. Hospital quality indicators; 7. Simple HA implementation. In addition, there are consultation visits to hospitals, HA newsletters and websites with the question-and-answer section. To foster exchange of ideas and learning, the national forums on hospital accreditation were organized annually, having more than 2,000 participants each year. Moreover, evaluation studies of the HA program have been conducted by external researchers to provide feedback for system development. 7. Challenges and exercises 1. How can we ensure that people in a country will receive health care of good quality in an efficient manner? What alternatives do we have? 2. Based on the case study, is the accreditation program for hospitals essential? And why? 3. How vital is the national policy and political support on hospital accreditation? How can such support be gained? 4. What else seem to be critical success factors for implementing a hospital accreditation program in a health care system? 5. Given the complexity and the nature of the quality improvement program that needs to be continuous, how can the quality improvement program be sustained both within a hospital and at the system-wide level?

12 12 Bibliography Institute of Hospital Quality Improvement and Accreditation. Accessed August, 20 th, Office of the National Statistics, Office of the Prime Minister. Report of the 1999 household socio-economic survey. Bangkok: Text and Journal Publication Sriratanaban J. Quality assurance system for health care in Thailand. In: Pramualratana P. and Wibulpolprasert S. (eds.) Health Insurance System in Thailand. Nonthaburi: Health Systems Research Institute, 2002: Sriratanaban J., Supapong S., Kamolratanakul P., Tatiyakawee K., Srithamrongsawat S. Situational analysis of the health insurance market and related educational needs in the era of health care reform in Thailand. Journal of Medical Association of Thailand (12): Sriratanaban J, Ungsuroat Y. Evaluation of the Hospital Accreditation project. A study funded by the Hospital Accreditation Institute. Thailand (Unpublished paper) Supachutikul A. (Editor). Simplicity in a complex system: Concepts and experiences for hospitals. Nonthaburi: Institute of Hospital Quality Improvement and Accreditation (In Thai). Supachutikul A. and Sriratanaban J. Quality in the health system. The Health of Thais 2000 series. Bangkok: Health Systems Research Institute, (In Thai). Wibulpolprasert S. (Editor). Thailand Health Profile Bureau of Policy and Strategy, Ministry of Public Health. Bangkok: Express Transportation Organization Printing Press