DR.G.J. MIDIWO General Manager, Benefits & Quality Assurance

Transcription

1 DR.G.J. MIDIWO General Manager, Benefits & Quality Assurance

2 Background, Structure & Composition of the Fund and its mandate Established in July 1966 after the recommendations of the sessional paper no. 10 of 1965: African Socialism and its application to planning in Kenya. Transformed in to a state parastatal in1998 for autonomy of operation The Fund is managed by a board of Directors drawn from all stakeholder representative bodies (Trade Unions, Ministries of Health, Finance,public service,ngos, Health, Proffessional Bodies & Private Insurance, Association among others It is mandated to finance health Care, through formally accredited and contracted healthcare facilities, Revenue Collection from employers and members. Register members (Formal and Informal).Claims reimbursement to hospitals 2

3 THE FUND S MILESTONES Organizational restructuring Decentralization of systems Branch Expansion- 31 offices, 52 satellites, 30 windows Market surveys Upgrade of computer systems Adherence to International Standards (ISO) Monitoring & Evaluation of programs Growth in benefit payout ratio, Improved public Image 9/26/2013 3

4 Healthcare Financing in Kenya by NHIF The Fund covers up to 180 inpatient hospital days per member and his/her beneficiaries per year. It has a countrywide membership of approximately 3.8 million people and caters for over 12 million people.appoximatley25% of the population There are over 1200 accredited facilities countrywide offering benefits to members and their dependants. 9/26/2013 4

5 The Historical background of NHIF & Quality Management in Health care In the year 2000 the Government of Kenya developed the Kenya Quality Model for Health Care. In 2004,NHIF introduced the Department of Standards & Quality Assurance to spearhead Accreditation and Quality Assurance in Health provider facilities for the Fund. During the same year, Centre for Quality in Healthcare and the Ministry of Health piloted the Kenya Quality Model of Healthcare. NHIF adopted the KQM and introduced contracts for its implemented it in its accredited provider facilities in the year /26/2013 5

6 NHIF Benefit Package Inpatient Admission & nursing care, Diagnostic laboratory tests Operating theater charges Specialist consultations Prescribed drugs & dressings. NB: This is the minimum on offer Outpatient Consultation. Laboratory investigations Drugs administration & dispensing. Dental health care services. Radiological examinations. Nursing and midwifery services. Minor surgical services. Physiotherapy services. Occupational therapy services. Referrals 6

7 NHIF ACCREDITATION PROCESS Voluntary Application by a facility Quality Assurance, Auditing (KQM) Facility Assessment using NHIF standards Gazettement & Contracting Board ratification 9/26/2013 NHIF KENYA QUALITY ASSURANCE MODEL 7

8 Contracting & the KQM as a Model Vehicle for Quality in Healthcare The fund has three options on contract type for signing with accredited health service providers. Contract A, B and C Each is applicable at a time and has its own uniqueness given the providers orientation. Contracts are signed following the award of rebates that are tied to facility levels and performance following inspection surveys. Rebates are dependent on the scope and quality of care at the facility and therefore an incentive for improving health service provision. Therefore rebates are competitive. KQM Audits results are a determinant in review of rebates 9/26/2013 8

9 FIRST QUARTER 2010/2011 HOSPITAL SELF-ASSESSMENT COMPARISON BETWEEN AIC KIJABE HOSPITAL & COAST GENERAL HOSPITAL A.I.C KIJABE MEDICAL CENTRE COAST GENERAL HOSPITAL (MOMBASA) 0

10 KQM AUDIT PERFORMANCE ALL ACCREDITED HOSPITALS KQM SCORE 4 YEARS 60% 50% % SCORE 40% 30% 20% 10% 0% PHASE 2 PHASE 1 PHASE 2 PHASE / / / /2011 score 42% 42% 52% 55% FINANCIAL YEAR 9/26/

11 CHALLENGES Breach of contracts Frequent movement of skilled personnel high staff turn over in trained hospitals Quality assurance is not institutionalized Limited benefits as a result of low premiums. Recognition by international accreditation bodies Accreditation is one off Non specific KQM standards 9/26/

12 PARTNERSHIP

13 Safe-Care roll out in NHIF Network

14 Why Safe care? NHIF has used a the KQM model since Our capacity has come to a point that we need to move to another level Re-engineering the accreditation system International recognition and benchmarking 9/26/

15 Cont. Why Safe care? Improved clinical quality to better meet the needs of patients. Improved access to quality health services in Kenya Increased efficiency

16 Embedding SafeCare in NHIF Alignment to KQM Create new standards Use the stepwise methodology for accreditation and reimbursement Certification to improve quality assurance Hospitals to pay annual accreditation retention fee. 9/26/

17 Safecare Program Progress in NHIF? MOU signed Operational plan finalized Program staff appointed Secretariat and working group established Partnership Launched (25 Jun 2013)

18 CAPACITY BUILDING 25 NHIF quality assurance officers staff trained on SafeCare methodology 139 NHIF facilities sensitized through regional grouping (July & Aug 2013) NHIF facilities and staff sensitized included into safecare IT database (AfriDB).

19 SUPERVISED ASSESSMENTS Four facilities Assessed (26Aug 7Sept 2013) Four staff mentored and three qualified for certification Feedback to facilities and QIP development ongoing

20 WAY FORWARD More training of NHIF Quality Officers as Mentors, Surveyors and Assessors Bring on board more facilities on Safecare standards Alignment of KQM & Safe Care standards Assessment and set up of NHIF/ Safecare accreditation system

21 Thank You