COHSASA-HPCA Collaboration: a true success story 

By Marilyn Keegan and Esme Pudule


THE SEVEN-YEAR collaboration between member hospices of the Hospice Palliative Care Association (HPCA) and the Council for Health Service Accreditation of Southern Africa (COHSASA) has been a true success story. At present (February 2013) there are 27 hospices holding COHSASA accreditation awards and since 2006 when the quality improvement and accreditation programme was introduced, a total of 67 accreditation awards have been conferred to hospices over the years.
HPCA hospices have been providing palliative care to South African communities since 1979. Currently HPCA has 174 service sites providing palliative care services in nine provinces and reaching some tens of thousands of people each month. Another 10 000 orphans and vulnerable children are also reached by hospice programmes, with care provided mainly in the patients’ homes, through community home-based care, in hospice in-patient care units, in hospitals and frail care centres.
At successive COHSASA Technical Committee (TC) meetings, where decisions about accreditation are made, the results obtained by hospices have often drawn comments about hospice commitment to standards measuring quality of leadership and care. It is not unusual at a TC meeting for one or two of the hospices to have achieved scores of 99 against the standards. And it is not easy to meet these standards. They have been jointly developed by COHSASA, by HPCA, by leaders in the field of hospice care and by feedback from the hospices themselves. Furthermore, both editions of standards have been recognised as meeting the principles for standards set down by the International Society for Quality in Health Care (ISQua). The current set of palliative standards has been awarded accreditation by ISQua until 2014. This means that the 27 hospices currently accredited are providing services to South Africans that meet standards which are internationally recognised. A full picture of the hospices accreditation status is displayed in Table 1.

Table 1


Chief Surveyor of COHSASA, Dr Giel van Schalkwyk, trains hospice surveyors at Lentegeur Hospital, April 2004
The first HPCA Standards booklet Standards for the provision of Palliative Clinical Care in Hospices was distributed to member hospices by the National Patient Care committee in 1998. Initially the assessment of compliance with the clinical standards was done through a process of peer review but it became apparent that good clinical care was dependent upon good management and the Organisational Development sub-committee set to work, developing standards to address this.
The COHSASA-HPCA initiative was dramatically accelerated by a grant awarded by the President’s Emergency Plan for AIDS Relief (PEPFAR), which provided $15-billion to fight the HIV/AIDS pandemic in 14 of the world’s most affected countries. Since 2005 the availability of this PEPFAR funding was the key to the process which enabled the HPCA to actively collaborate with COHSASA. Together these two organisations began a journey to develop standards, train surveyors and get facilities ready for accreditation.
In 2004, COHSASA trained a group of 20 hospice and HPCA staff as surveyors and during the first year of the accreditation process, 47 baseline surveys were jointly conducted by an HPCA/COHSASA survey team. In order to achieve full accreditation, a hospice needs to score at least 80% in all the relevant service areas. 1
Hospice Surveyors were trained at Sungardens Hospice in Gauteng
From left to right: (back row) Dr Nelia Drenth, Mrs Fran Tong, Mrs Landi Bezuidenhout, Miss Rene Wienekus, Miss Ronel van Rooyen,
(front row) Mr Richard Perkins, Mrs Sue van Reijnsbergen, Mrs Colleen Dempers, Ms Maraliza Robbertze, Mrs Maria Demjan and Dr Giel van Schalkwyk, Chief Surveyor from COHSASA.
A total of 47 hospice members of the Association entered the accreditation programme in 2005 with Grahamstown Hospice being the first to be accredited on March 17, 2006 for two years with an external score of 89. Nine other hospices were accredited three months later (on May 19 2006) for two years.
Some of the Grahamstown Hospice staff who participated in the accreditation process
    were (from left): Sr Martha Mains, Sr Erica Botha, Ann Baxter, Janine Peinke,
   Sr Nomvuyu Pinini. Seated, Michele Barnard and Sr Gwen van Heerden.
Currently 27 of the 174 hospices of HPCA hold COHSASA accreditation awards. Many of these organisations have successfully maintained their standard compliance and have been awarded accreditation status for a period of three years.


The first edition of the comprehensive Hospice Palliative Care Standards was circulated to hospices in August 2005 and was linked to an HPCA/COHSASA accreditation process. The development of accredited palliative care standards was a first in South Africa. The set of standards was first piloted at various member hospices around the country in 2005 and then finalised for the first round of the HPCA/COHSASA accreditation process.
The hospices are rated on standards that include governance and leadership; human resource management, administrative support service; risk management, quality management and improvement; patient rights; access to care and admissions; interdisciplinary team, holistic patient care; medication management; support services, education and research and fund-raising. The full set of standards consists of the following twelve service elements:
In 2009 the second edition of the HPCA standards was published through a consultative process with member hospices, continued collaboration with COHSASA and input from the SA Pharmaceutical Council with regard to safe medication management in a hospice setting. On the preface page, the need for standards was emphasised: “A focus on quality is important to patients and families, clinical staff and volunteers, managers, donors and policy makers. There are many organisations offering home-based care in South Africa, mostly based on some alternative interpretations of palliative care. It was therefore imperative for the national association (HPCA) to take the lead in the process of pursuing quality, so that the credibility of member hospices could be enhanced in the eyes of the formal health care sector and existing and potential donors.” 2
In response to the escalating TB epidemic in SA and the increased number of patients with TB and co-infections admitted to hospice programmes it became crucial to integrate TB standards in the second edition.  This gave rise to a number of initiatives including the development of training programmes that focused on integrating TB and palliative care and standards that could measure the success of such integration.


The Hospice Palliative Care Association introduced an internal survey process through a structured mentorship programme for all the hospices to assess the required compliance score with the standards. This mentorship programme was further supported by the COHSASA surveyor training of the HPCA mentor coordinators who conduct internal and external surveys to assess the evidence of improved quality of care for patients and families in hospice programmes.
This internal process has helped to ensure the readiness of hospices before they are recommended for an external survey by COHSASA. As hospices develop their services in line with the standards, this improvement is recognised by the HPCA star-rating system. Hospices that score 80% on a Phase 1 assessment are awarded 1 star and as they progress in compliance with the standards they are awarded additional stars until full accreditation when they receive their HPCA 5-star certificate.
Providing this guidance and support to hospices has been vital in ensuring compliance with the standards, resulting in improved quality of care for patients and families.
Mrs Sheryl Wust, the Palliative Care Development Officer in KZN says: Complying with the HPCA standards to ensure good governance, leadership, management and clinical care and compliance with the laws and regulations is essential for any organisation to reduce the risk to patients, staff, volunteers, finance and property. The process is less about superficially impressing the surveyors, internal or external, but about developing and maintaining a level of quality palliative care that is pro-actively driven by the hospices themselves. I believe that the 5-star hospices take this seriously and have therefore developed a culture of quality management within the organisation.”
In their 2007 article in the Journal of Pain and Symptom Management, authors Kathleen Defilippi and Sue Cameron3 wrote: “The COHSASA accreditation process is now well established and survey results indicate a significant improvement in the quality of service delivery in all HPCA member hospices. To date, 114 South African hospices have been awarded full accreditation, for two years, by COHSASA. New hospices are committed to having a baseline survey within six months of being granted HPCA membership.
“There have also been significant beneficial effects on the national association. The development of the linked mentorship and accreditation programs has resulted in the acquisition of a wide range of additional skills by HPCA personnel. Competent HPCA surveyors are now able to conduct surveys independently and only refer to COHSASA for an external survey when hospices are assessed as likely to achieve full accreditation,” they wrote.
Kath Defilippi and Sue Cameron, Patient Care Services Co-ordinators for the Hospice Palliative Care Association say involvement in the accreditation programme provides a means to measure care and progress objectively. The quality initiative is linked to an extensive mentorship programme that supports member hospices as they work towards achieving full accreditation. This is in keeping with HPCA’s vision of equipping all hospices to serve as palliative care resources within the communities they serve.
CEO of the HPCA, Dr Liz Gwyther, says of the partnership: “HPCA member organizations have recognized the value of following an accreditation process to establish the credibility of their services which assists in accessing funding. To COHSASA and their support team, thank you for your valuable partnership, continued commitment and that we can share in the reward this ground breaking process has brought us all.”
Professor Stuart Whittaker, CEO of COHSASA: “The standards being used by hospices in South Africa meet international requirements. COHSASA, in association with the HPCA, has developed standards for palliative care that have been assessed by the International Society for Quality in Health Care and recognised as meeting principles for effective evaluation. We have had a rewarding and productive relationship with HPCA which we have found to be an organisation deeply committed to quality service provision and sound financial oversight and accountability. It is a relationship which we hope will continue well into the future.”
Palliative care focuses on promoting the best possible quality of life for patients and their families at all stages of a life-threatening illness and for many years South African hospices have been striving towards the delivery of quality palliative care to patients and families. Many of these hospices formed themselves into an association, the Hospice Palliative Care Association of South Africa in 1987. HPCA member hospices provide a range of services that include community-based home care, augmented by palliative day-care centres and in-patient units for terminal patients, bereavement counselling and education and training. HPCA hospices have been providing palliative care to South African communities since 1979. (
Cotlands (Western Cape) COHSASA survey Oct 2010. Their second survey is due in February 2013.
“Improving quality is an on-going process and any activities linked to monitoring standards need to be more about developing a culture of quality within each palliative care programme than meeting external requirements. Over the years I have watched our staff and hospice programmes grow with the quality improvement and accreditation programme. I think they benefit strongly from the fact that the HPCA has an internal programme to award a star rating to participating hospices for their progress towards achieving accreditation. The hospices that reach four-star levels are then recommended for COHSASA external surveys. It has been a pleasure to see these hospices move from strength to strength over time. Meeting these standards is no easy task. These standards have been developed over many years with input from COHSASA, the HPCA field staff, the carers and the International Society for Quality in Health Care which sets global benchmarks for quality” – Esme Pudule, the HPCA National Accreditation Officer.


1 Promoting the Integration of Quality Palliative Care – The South African Mentorship Programme, Kathleen M. Defilippi and Sue Cameron, Journal of Pain and Symptom Management (JPSM), Vol 33. No 5, May 2007, pp. 552-557.

2 Title Page 3 in 2nd Edition of Standards for Hospice and Palliative Care in South Africa – COHSASA and HPCA

3 Promoting the Integration of Quality Palliative Care – The South African Mentorship Programme, Kathleen M. Defilippi and Sue Cameron, Journal of Pain and Symptom Management (JPSM), Vol 33. No 5, May 2007, pp. 552-557.

4 That figure currently stands at 27.