One of the bulwarks against a deteriorating habitat and the spread of disease is an effective environmental health service. As the Minister of Health Dr Aaron Motsoaledi once put it: “I want to stop cholera at the river, not find it in a hospital.”
Section 24 in South Africa’s Bill of Rights stipulates that everyone has the right to an environment not harmful to their health and well-being. This includes the right of access to healthcare services, sufficient food and water and social security.
The infrastructure in Cape Town, like many cities, is groaning under massive inward migration and hence, the efficient management of environmental health become especially important.
It is thus heartening to know that the City of Cape Town’s Health Department has a long history of adherence to stringent standards for its Environmental Health Offices (EHOs) with a record 16 of these recently accredited by the Council for Health Service Accreditation of Southern Africa (COHSASA). This is without precedent in South Africa – or indeed, Africa.
Executive Director: Cape Town City Health, Dr Zandile Mahlangu speaks at the ceremony
Proud staff from 16 environmental health offices of the City of Cape Town hoist aloft their COHSASA accreditation award certificates.
From left: Ms Jacqui Stewart, COHSASA Interim CEO, Ashley Coller, Dr Paul Nkurunziza, Dr Hélène Visser, and Gerrit Mostert.
Speaking at the annual City Health Awards Ceremony, held at the Goodwood Civic Centre on Friday 20th March 2015, Interim CEO of COHSASA, Ms Jacqui Stewart said, “Cape Town City Health has demonstrated a long term commitment to quality. The first Environmental Health Offices and clinics were entered into the COHSASA quality improvement and accreditation programme back in 1999.
“Since then we have consistently worked together to update and further develop the Environmental Health Office standards and primary health care clinic standards, which have been accredited internationally by ISQua (The International Society for Quality in Health Care).
“This is the single biggest group of facilities to achieve accreditation at one time. A record 16 Environmental Health Offices have been accredited, with 15 of these having been accredited three times.
“Mitchells Plain EHO is one of only 13 facilities to have received a Four-Year Full Accreditation Award from COHSASA and is one of only 11 facilities that have been accredited 5 times by COHSASA. You can be very proud of this achievement. Congratulations!”
Quality Champion, Sigmund Badenhorst, Acting Principal Environmental Health Practitioner for the Maitland Environmental Health office, Western Sub District who has worked with the Cape Town Health Department for 34 years pictured with Bettie Leedo, Head of Environmental Health for the Western Sub District. In 2010, Sigmund received the Alfred Nzo Environmental Health Achievement Award from the National Department of Health.
A champion of the quality improvement process in Cape Town’s EHOs is Sigmund Badenhorst who, on the night before this interview, had been up until 1 am at the Cape Town stadium ensuring that people attending the Michael Bublé concert would not contract any kind of food poisoning. It was his drive and enthusiasm at the Green Point Environmental Health Office way back in 2000 that got the COHSASA quality improvement and accreditation process up and running. He initially drove his colleagues to distraction. He worked day and night to develop the systems required to implement quality. Nobody knew about COHSASA then and they weren’t all that happy about this extra load of paper either.
“In the beginning it was a bit overwhelming. People were very negative but as the years have gone by and the quality improvement process became embedded into everyday activities, it saves time! When people need policies or direction, it’s available and up-to-date and they feel safe operating in their profession”, he says
“One of the biggest benefits was that we could start making sense of the data. Before COHSASA we used to get complaints and there was no accounting of what happened to thosecomplaints. As a quality improvement project, we would determine how many complaints had been made, how many complaints had been resolved and what the complaints were about. This was powerful data that we could now do something with whereas before it just gathered dust. It shed light on our activities and guided us.
“It also helped us with stock control. Using the COHSASA programme we monitor our stocks and this is obviously extremely beneficial because we don’t run out of commodities we need and we are alerted to ordering them well in advance.”
Bettie Leedo, Head: Environmental Health for the Western Sub-district and an individual equally committed to quality improvement, says there is no question that the COHSASA accreditation process is beneficial.
“It seems like a lot of work to begin with but actually, it makes your life easier in the long run. It really and truly does.
“There is no question about the benefits, especially when you have a large structure like the City of Cape Town and you have eight different health sub-districts. Our structure – our organogram – is very flat. So without accreditation and everything that goes with it – the policies, the procedures, the rigorous guidelines – it would mean that we would probably have every sub-district managed very differently. The standards and overall guidelines generate standardisation across the entire organisation which is really very beneficial.
“Also from my personal point of view, what is important is the way that the systems are accepted across the organisation because if there isn’t buy-in from the top all the way down to the bottom you would have a ‘nice to have’ system but something that is not internalised. Now when we get queries or need an answer for ourselves, we immediately ask, ‘What’s in the policy?’ ‘Is the policy still up to date?’ ‘When last was it reviewed?’ ‘Is this external situation still the same?’ So we are constantly looking at quality. We have internalised the process and it has become part of the way we do things. We are not at the beginning stages of this process and so we see things through the lens of how we can constantly improve the services we provide.
“I do not see how any public health facility with a lack of funding, resources and staff, can get any kind of improvement in service without looking at some sort of quality improvement programme. I just do not see how one can face the community if you do not have some sort of system.
“I think it would be fantastic is the rest of the metropoles in South Africa adopted quality improvement and implemented COHSASA programmes. We are the eyes and ears of the health system and COHSASA makes one look at things differently. We could conduct best practice workshops and share knowledge with each other so that environmental health is delivered in the best possible way in South Africa.
“On a daily basis, we constantly have to look at how we can do something more efficiently and more cost-effectively with better outcomes. The demands on the public health system are increasing all the time.
“The COHSASA process may have been difficult to start with – with a few champions such as Sigie doing most of the work because nobody at that time understood the benefits of COHSASA – but with passing years, the whole team has come on board. They all see the importance of it and they all work and contribute equally and that is very heartening. Ultimately accreditation speaks for itself.”
The EHO Standards
COHSASA worked collaboratively with the City Health Specialised Health Management under the leadership of Dr Hélène Visser and former environmental health practitioners to develop standards and conduct surveys. Acknowledgment for their efforts must go to Mr J F du Toit, Mr J A du Plessis and Mr H Schrader.
The principles of the International Society for Quality in Health Care (ISQua) were applied in the development of the EHO standards and the standards are linked to an established assessment tool and information system. Areas that are evaluated and assigned scores in 43 different standards and 264 criteria with the following areas being measured:
- Management and leadership
- Human resource management
- Facilities and equipment
- Risk management
- Environmental health functions
Each environmental health office undergoes an external evaluation (lasting one and a half days) to assess compliance with standards. This is conducted by a team consisting of COHSASA surveyors and independent environmental health practitioners. In addition to the evaluation of the office the survey includes one or more site visits to observe the implementation of environmental health practices. These have included informal settlements, dairy farms, food factories, water management sites, informal food traders and formal food premises.
History of COHSASA awards for EHOs
What is COHSASA?
The acronym stands for the Council for Health Service Accreditation of Southern Africa.
COHSASA has been working in the field of quality improvement in South African healthcare facilities for two decades since it was registered as an association not-for-gain in the Republic of South Africa under Section 21 of the Companies Act on 12th September, 1995. It was later registered as a non-profit company in October 1999.
The Council has worked in over 600 facilities in both the public and private sector in South Africa and beyond our country’s borders to 9 other African countries: Swaziland, Lesotho, Namibia, Botswana, Malawi, Zambia, Rwanda, Nigeria, Uganda and Egypt. The Council works in hospitals, clinics, hospices, sub-acute facilities and environmental health offices.
Part of the proudly South African movement, COHSASA has achieved global recognition and is one of only 30 internationally accredited healthcare accrediting bodies recognised by the International Society for Quality in Health Care Ltd (ISQua). It has received four consecutive accreditation awards from this global body (the current award expires in 2018). In addition, two sets of COHSASA standards and its Surveyor Training programme have been accredited by ISQua and these accreditation awards are valid until 2018.
Since its inception, COHSASA has focused on providing local solutions for local problems. This has resulted in the development of strategies to assist facilities, particularly those in the public sector, that face significant challenges in providing quality healthcare.
These strategies include skills transfer through intense and ongoing training, facilitated accreditation processes, an information system that specifies areas of deficiency and a graded accreditation process where different levels of achievement are recognised through certificates and methods to sustain progress achieved. This has the effect of encouraging efforts towards full compliance with standards and institutionalising quality improvement.