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 monitor compliance with the standards and to prioritise identified deficiencies and manage quality improvement processes.
 

There are two kinds of programmes.

Self – Evaluation Programme

A self -evaluation programme (EVP) using the COHSASA Quality Information System (CoQIS) is offered to clients who are reasonably well versed in quality assurance and improvement principles. Training is given at the beginning of the programme on the interpretaion of the standards, evaluation techniques and in continuous quality improvement methods (CQI). 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 the standards or the accreditation process. COHSASA’s experience is that these facilities usually need more time to reach compliance with the standards. The FAP programme therefore includes a capacity-building element to assist personnel to understand the standards, their intent and the fundamental principles on which they are based.  COHSASA Quality Advisors begin the training process by introducing personnel to the standards and conducting practical exercises. They also train teams at the health facility in quality improvement methodology. 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.  To secure impartiality, COHSASA ensures that the external survey team will not be led by members of the quality advisor team.