Frequently Asked Questions

All areas of a healthcare facility need to reach compliance with standards (at least 80 out of 100) before accreditation can be awarded. The scores are weighted according to their importance in terms of legal requirements and how they impact on patient safety. If a standard contains criteria which have repercussions for patient safety and medico-legal implications, these so-called  critical criteria have to be compliant before an institution can be accredited.  

If an organisation is working according to standards that require excellent managerial and clinical policies, procedures and operations, risks to patients will be reduced and the quality of healthcare provided will be improved. Accreditation is a snapshot in time – that at a certain point in an organisation’s history, it has met published standards. The onus is on that organisation to maintain standards and to continue to improve. Strictly applied quality improvement methods can improve patient safety and quality of care by guiding interventions, monitoring progress and identifying improvements. COHSASA identifies impediments or blocks in the improvement process and assists hospital staff to overcome these in a process that eventually leads to a facility being accredited. The goal is accreditation, the means is quality improvement on a continuous basis.

Send an email to Jacqui Stewart at jacqui@cohsasa.co.za with a brief  summary of your research proposal and your contact details.

Board Members are appointed for their knowledge, skills and experience in a particular field of endeavour and they include doctors, nurses, administrators and entrepreneurs drawn from both public and private sectors who are considered leaders in their field.

In the healthcare field, according to the International Society for Quality in Healthcare External Evaluation Association (IEEA) it is:

• awarded based on achievement of quality standards and the independent external survey by peers of an organisation’s level of performance in relation to the standards;
• the longest established and most widely known process for the external evaluation of healthcare services;
• a formal process to ensure delivery of safe, high quality health care;
• based on standards and processes devised and developed by health care professionals for healthcare services;
• a developmental process using the skills of external peers trained and appointed as a team of assessors;
• public recognition of achievement by a healthcare organisation of requirements of national healthcare standards;
• generally available to public and private sectors;
• the coverage of a range of healthcare environments from local community-based care through to tertiary level providers and healthcare systems.

In the COHSASA programme, all areas of hospital and clinics have to meet standards. We help to improve systems that operate in clinical areas, clinical support areas (radiology, pharmacy and laboratory), technology, health and safety, infection control, administration and management and hotel areas.

These fees vary according to client needs, the size of the institution, the number of standards that need to be assessed and the location of the facility. For further information, email  queries@cohsasa.co.za.

This depends on the type of healthcare facility involved and how much compliance it has already achieved with professional standards. Where hospitals have continuously improved their quality and maintained standards, accreditation can be immediate. However, hospitals with poor resources and systems in place may take longer than those that are well managed and using resources optimally. The average time-frame for accrediting a public hospital is about 18 to 24 months. Once accreditation is achieved, quality needs to continue to improve and this is an ongoing, never-ending process. In our experience, once the quality improvement processes become embedded in normal hospital routine, accreditation surveys are less daunting.

To assist the many South African hospitals from disadvantaged backgrounds with poor resource bases that do not initially achieve accreditation but have made significant strides since their entry into the programme, COHSASA has developed two strategies to keep facilities focused on the long and winding road to quality service provision. These strategies are the Facilitated Accreditation Programme and the Graded Recognition Programme. The latter programme encourages a facility’s momentum towards accreditation by certifying specific, progressive levels of compliance with essential performance indicators calculated according to an algorithm. Criteria define the requirements of each of the three levels of Graded Recognition, “Progress”, “Entry Level” and “Intermediate Level”. Facilities achieving these levels are awarded certificates for a defined period and are encouraged and motivated to continue to higher levels and finally achieve accreditation. There are also individual certificates for services that achieve substantial compliance with standards.

It confers a certain amount of peace of mind to patients that the facility where they are receiving treatment is engaged in the process of continually improving the quality of service it provides. It assists doctors and nurses in that they feel safer working to streamlined systems; it helps administrative staff by providing checks and balances, by providing a system for accountability and the optimal use of resources. If a medical facility has passed through the stringent requirements of a COHSASA programme, it should become a preferred provider and should guide medical funders in their choice of facilities for their members. Accreditation helps to improve the image and delivery in public sector services: that they are endeavouring to provide quality service to their customers. According to IEEA, external evaluation is in demand in many countries by governments, healthcare managers, patients and communities wanting to know more about how scarce resources are being used to deliver safe, quality health care and with what results for external, independent assessment of the performance of services against formally established standards. COHSASA, as an African accreditor of health facilities, offers unique assets. Our home page has a paper on the benefits of accreditation.

COHSASA’s experience is that without management commitment to quality improvement and the accreditation programme, progress at any institution is – at best – limited and at worst severely impaired. Effective leaders – Quality Champions – at all levels of the organisation are required to emerge and commit to the concept of improving the quality of care provided to patients. Governing authorities responsible for healthcare facilities’ performance (at a provincial or at the private medical group HQ level) need to pay close attention to the information supplied by COHSASA, which identifies deficiencies and evaluates progress of compliance with standards.