Methods

COHSASA uses different methods to assist healthcare facilities to reach accreditation, depending on the needs of individual clients. All programmes are supported by the COHSASA Quality Information System (CoQIS) which helps clients to prioritise identified deficiencies and manage and monitor health quality improvement projects until substantial compliance with standards is reached.

There are two kinds of programmes.

 Self – Evaluation Programme

A self -evaluation programme using the COHSASA Quality Information System (CoQIS) is offered to clients who are reasonably well versed in quality assurance and quality improvement. Training is given at the beginning of the programme in continuous quality improvement methods (CQI) and evaluation techniques. Detailed training is provided on the use of the CoQIS system as a management tool and to appropriate personnel who will be doing the data capturing. All data entered by the facilities is validated by COHSASA personnel to ensure accuracy. An external survey is undertaken at an agreed point.

 Facilitated Programme

A Facilitated Accreditation Programme (FAP) is recommended for healthcare facilities that are unfamiliar with standards or the accreditation process. COHSASA’s experience is that these facilities usually need more time to reach compliance with standards. The FAP programme therefore includes a capacity-building element to assist staff to understand the standards and their intent and the fundamental principles on which they are based.  COHSASA Quality Advisors begin the process by introducing personnel to the standards and conducting practical exercises. Facility personnel are requested to conduct a self-assessment of compliance with standards and this information is validated by a full team from COHSASA.

The Quality Advisors then visit the facilities at agreed intervals to help implement the standards by ensuring that personnel understand the requirements of each standard and are able to identify deficiencies and act on them. They will also train teams in quality improvement methodology and direct the introduction of quality improvement projects in all departments and service areas of the facility.  COHSASA ensures that its Quality Advisor teams are kept apart from external survey teams in this programme.