Regulations and Standards for Health Establishments in Gauteng Province
I
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i
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l
–
User rights
–
Clinical governance and clinical care
–
Clinical support services
–
Facilities and Infrastructure
–
Governance and Human Resources
•
S
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4.
U
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I
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f
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m
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t
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n
:
services, costs, user experiences
5.
A
c
c
e
s
s
t
o
C
a
r
e
:
Emergency patients: triage, emergency transport, appropriate care (stabilisation)
Referrals
6.
H
e
a
l
t
h
R
e
c
o
r
d
s
:
Records management system including confidentiality
Biographical data
Documentation of care provided
Consent
Discharge report
7.
C
l
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n
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c
a
l
M
a
n
a
g
e
m
e
n
t
s
y
s
t
e
m
s
:
Clinical policies/guidelines available and communicated,
Clinical risk management systems
8.
I
P
C
:
Handwashing, isolation, linen, protective equipment and immunizations
9.
W
a
s
t
e
m
a
n
a
g
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m
e
n
t
:
Containers available; collection, handling, storage and disposal of waste
P
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d
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s
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d
S
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s
(
c
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1
)
10.
M
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s
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d
m
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d
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c
a
l
s
u
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s
:
Availability and stock control
11.
D
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12.
B
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d
S
e
r
v
i
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e
s
:
Cold chain maintenance
Hazardous waste management
Adverse blood reaction management
13.
M
e
d
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c
a
l
e
q
u
i
p
m
e
n
t
:
Licensing
All required medical equipment available in each unit
14.
M
a
n
a
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m
e
n
t
o
f
b
u
i
l
d
i
n
g
s
a
n
d
g
r
o
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d
s
:
Compliance certificates, maintenance plan, emergency access, ventilation
15.
E
n
g
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n
e
e
r
i
n
g
s
e
r
v
i
c
e
s
:
Electricity, lighting, medical gas, water, sewage system available and functional without interruption
16.
T
r
a
n
s
p
o
r
t
:
Vehicles licensed and maintained
Drivers have valid driver’s licenses
9
P
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m
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g
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e
d
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m
s
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n
d
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t
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d
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d
s
(
c
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t
.
2
)
17.
S
e
c
u
r
i
t
y
:
Security staff able to respond to incidents, threats and risks
18.
F
u
n
c
t
i
o
n
a
l
G
o
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r
n
a
n
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s
t
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t
u
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e
w
i
t
h
T
o
R
s
19.
H
R
M
:
HRM plan; Performance management, monitor registration of health care
professionals
20.
O
c
c
u
p
a
t
i
o
n
a
l
H
e
a
l
t
h
:
Comply with OHS Act
21.
A
d
v
e
r
s
e
E
v
e
n
t
s
:
Reporting systems in place, documentation and monitoring of events
22.
W
a
i
t
i
n
g
t
i
m
e
s
:
Monitoring of waiting times against targets
10
S
e
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p
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s
s
–
User rights
–
Clinical governance and clinical care
–
Clinical support services
–
Governance and Human Resources
–
Facilities and Infrastructure
I
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12
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13
S
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f
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5
(
1
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d
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i
o
n
,
C
r
i
t
e
r
i
o
n
5
.
(
2
)
(
a
)
A
h
e
a
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t
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t
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.
M
e
a
s
u
r
e
s
1
.
T
h
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g
u
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d
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.
D
o
c
,
E
Explanatory Note:
The document implemented must be approved by a relevant national body, such as the Emergency Medical Services of South Africa.
Not Applicable:
Never
2
.
T
h
e
p
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a
.
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In-service training documentation must include attendance registers and evidence of the topics discussed.
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The time the user was triaged should be compared with the time the user was seen to evaluated whether the user was seen within the agreed
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Regulation heading =
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Objects of the OHSC
In terms of Section 78 (A) of the Act, the objects of the
OHSC are to:
(a)
monitor and enforce compliance by health
establishments with norms and standards as
prescribed by the Minister of Health in relation to
the national health system; and
(b) ensure consideration, investigation and disposal of
complaints relating to non-compliance with
prescribed norms and standards in a procedurally
fair, economic and expeditious manner.
Compliance Monitoring
•
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prescribed Norms and Standards through
inspections and investigations;
•
The OHSC also receives incident
notifications (Early Warning System) and
complaints.
Inspections: Types of Inspections
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Notice of
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to the person in charge of a
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•
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determine the status of a health
establishment
(whether to issue a
certificate of compliance or enforce
compliance)
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The OHSC, and the future link to funding
(Policy: National Health Insurance for Universal Healthcare
Coverage)
25
Certification of compliance with norms and standards
as a pre-requisite for funding
xx
OHSC
NHI
fund
Service
provision
Certification
Contracting
Monitoring of
risk
Compliance
with standards &
norms
Services
to be
provided
Cost
/ price
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27
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28
T
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B
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!
!
29
The regulations and standards outlined in this framework pertain to different categories of health establishments in Gauteng Province, focusing on user rights, clinical governance, facilities, infrastructure, and human resources. Each regulation is summarized by a title to denote its content, covering aspects such as user information, access to care, health records, clinical management systems, infection prevention, waste management, and more.
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IDEAL HOSPITAL FRAMEWORK: PROVINCIAL VISITS GAUTENG PROVINCE 14 SEPTEMBER 2018 1
Outline of the Norms and Standards Regulations applicable to Different Categories of Health Establishments 2
Promulgated Norms and Standards Promulgated on 2 February 2018 Will come into operation 12 months after promulgation, February 2019
Chapters / Domains There are seven chapters in the regulations Chapter 1-definitions,purpose and scope Five Chapters(from chapter 2-6) in the regulations which will translate to Domains in the Inspection tool User rights Clinical governance and clinical care Clinical support services Facilities and Infrastructure Governance and Human Resources Seventh chapter General provisions does not relate to a clinical environment and will therefore not be used to create a domain in the inspection tools
Regulation title / Sub-domain Each regulation is given a title to summarise its content User Rights, Facilities and Infrastructure Each Regulation title will be used to create a sub- domain name User Information, Management of buildings and grounds
Promulgated Norms and Standards 4. User Information: services, costs, user experiences Access to Care: Emergency patients: triage, emergency transport, appropriate care (stabilisation) Referrals Health Records: Records management system including confidentiality Biographical data Documentation of care provided Consent Discharge report Clinical Management systems: Clinical policies/guidelines available and communicated, Clinical risk management systems IPC: Handwashing, isolation, linen, protective equipment and immunizations Waste management: Containers available; collection, handling, storage and disposal of waste 5. 6. 7. 8. 9.
Promulgated Norms and Standards (cont. 1) Medicines and medical supplies: Availability and stock control Diagnostic services: Accreditation by regulatory body Blood Services: Cold chain maintenance Hazardous waste management Adverse blood reaction management Medical equipment: Licensing All required medical equipment available in each unit Management of buildings and grounds: Compliance certificates, maintenance plan, emergency access, ventilation Engineering services: Electricity, lighting, medical gas, water, sewage system available and functional without interruption Transport: Vehicles licensed and maintained Drivers have valid driver s licenses 10. 11. 12. 13. 14. 15. 16. 9
Promulgated Norms and Standards (cont. 2) 17. Security: Functional Governance structure with ToRs HRM: HRM plan; Performance management, monitor registration of health care professionals Occupational Health: Comply with OHS Act Adverse Events: Reporting systems in place, documentation and monitoring of events Waiting times: Monitoring of waiting times against targets Security staff able to respond to incidents, threats and risks 18. 19. 20. 21. 22. 10
Sequencing Sequencing of the chapters has been adjusted to reflect the inspection process User rights Clinical governance and clinical care Clinical support services Governance and Human Resources Facilities and Infrastructure
Inspection Tools being developed for evaluation of compliance with Norms and Standards Public hospitals central, tertiary, regional, district Public CHCs Public Clinics TB Hospitals Mental Health Hospitals Private Hospitals Private clinics 12
Structure to retain hierarchy of the national core standards Domain - an aspect of service delivery where quality or safety can be at risk. Sub-Domain - further break down the domains into sub-sections or critical areas which combined describe the scope of that domain. Domain Sub Domain Standards - what is expected to be delivered in terms of quality care; reflect expected situation resulting from implementation of a policy, procedure or system. Criteria - elements setting out the requirements for measurable and achievable standard compliance. Measures - the means or evidence for determining whether the criteria have been met; examine aspects that can be seen, heard or felt by the assessors and give reasonable assurance that a standard is met. Standard Criteria Measures 13
Regulation heading = Subdomain SUB-DOMAIN Access to care Sub-regulation = standard statement Standard 5 (1) The health establishment must ensure that users are attended to in a manner which is consistent with the nature and severity of their health condition, Sub-regulation = criterion statement Criterion 5.(2)(a) A health establishment must implement a system of triage. Measures 1. The guideline or standard operating procedure for triaging is available. Doc, E Explanatory Note: The document implemented must be approved by a relevant national body, such as the Emergency Medical Services of South Africa. Not Applicable: Never Measure statement with methodology and risk rating 2. The procedure used for triage is visibly displayed in the triage area. Obs, E 3. Staff members responsible for triaging have received training on the triage process in the past 12 months. Doc, V Explanatory Note: In-service training documentation must include attendance registers and evidence of the topics discussed. Not Applicable: Never Explanatory note to clarify evidence required 4. Users are triaged in accordance with the documented procedure. PRA, V Explanatory Note: The user s triage status should be indicated on the emergency unit health record. Not Applicable: Never 5. Triaged users are seen within the target time frames. PRA, V Explanatory Note: The time the user was triaged should be compared with the time the user was seen to evaluated whether the user was seen within the agreed timeframe, as indicated in the triage poster. Not Applicable: Never
Objects of the OHSC In terms of Section 78 (A) of the Act, the objects of the OHSC are to: (a) monitor and enforce compliance by health establishments with norms and standards as prescribed by the Minister of Health in relation to the national health system; and (b) ensure consideration, investigation and disposal of complaints relating to non-compliance with prescribed norms and standards in a procedurally fair, economic and expeditious manner.
Compliance Monitoring The OHSC monitors compliance with the prescribed Norms and Standards through inspections and investigations; The notifications (Early Warning System) and complaints. OHSC also receives incident
Inspections: Types of Inspections conducted every four (4) years for certification purposes. Re-inspections where there was identified breaches. Routine (Planned) Inspections and Re-Inspection They are triggered by early warning system (e.g. Media Reports) There is always a re-inspection to ensure that the breach has been remedied. Risk based / Unplanned Inspections
Inspections Contd All inspections conducted by the OHSC are in accordance with the powers outlined in the Act as well as in the Inspection Strategy (e.g. questioning, requesting documents).
Inspections Contd Where there is identified breach of norms and standards, inspector shall immediately issue Compliance to the person in charge of a health establishment; The final inspection determine the status of a health establishment (whether to issue a certificate of compliance or enforce compliance) a Notice of report will
Required documents to be developed by the Office Inspection strategy Code of conduct of inspectors Procedures Enforcement policy 22
Certification All health establishments found to be compliant with the prescribed Norms and Standards shall be issued with a certificate of compliance; The certificate of compliance issued by the Office shall be valid for a period of four years and is subject to renewal; Health establishments shall apply for renewal of the certificate of compliance six months before the expiry date;
Certification Contd Certification/Compliance status for a health establishment which has applied for renewal may be extended for a period not more than one year; A compliance notice issued against a health establishment suspends the compliance status until the conditions set out in the compliance notice are fulfilled.
The OHSC, and the future link to funding (Policy: National Health Insurance for Universal Healthcare Coverage) Services to be provided Monitoring of risk Certification Contracting NHI fund Service provision OHSC xx Compliance with standards & norms Cost / price Certification of compliance with norms and standards as a pre-requisite for funding 25
Current Compliance Status Framework
Proposed Compliance Status Framework Score Grade NG&E Clinical Inspection outcomes frequency A <20% Excellent 4 Yearly 80% + B 21-30% Good 2 Yearly 70-79% C 31-40% Fair 1 Yearly 60-69% D >41% Poor 6 months <59% 27
Proposed Compliance Status Framework Contd Grade A: which means that no breaches to the norms and standards were identified during an inspection and the cycle for inspection for that health establishment is 4 years; Grade B: which means that minor breaches of the norms and standards were identified during an inspection and the cycle for inspection for that health establishment is 2 years; Grade C: which means that moderate breaches of the norms and standards were identified during an inspection and the cycle for inspection for that health establishment is 1 year; Grade D: which means that major breaches of the norms and standards were identified during an inspection and the cycle for inspection for that health establishment is 6 months and enforcement action should be taken against a health establishment. 28
THANK YOU!! REA LEBOGA!! 29
