Theme: “living the Vision through Evidence”

15th December 2016 

08:30 hrs

Mahalapye District Hospital


"Director of Ceremonies

Honourable Ministers and Members of Parliament 

Mahalapye District Commissioner,

Kgosi Tshipe Tshipe, and his Assistants

Honourable Councillors here present

Chairperson Hospital Advisory Committee

Chairperson of Umbrella Village Development Committee 

District Health Management Team

Representatives of Various Government Departments, 

Non- Governmental Organisations,


Members of the Media Fraternity, 

Invited Guests and the Public at Large 

Ladies and Gentlemen, 

Good Morning"

The Honourable Minister of Health and Wellness, the Hon. Dorcas Makgato, surrounded by jubilant hospital and clinic staff who received compliance certificates for their departments which help the hospital and clinic achieve full accreditation from COHSASA.

"Today marks one of the most important days in the health sector in which the Ministry of Health and Wellness joins Mahalapye community in a ceremony to recognize, appreciate and acknowledge the good work and significant achievement made by Mahalapye District Health Management Team in the accreditation programme with a theme “Living the vision through evidence”. Mahalapye District Hospital, Xhosa and Airstrip clinics have received Full Accreditation status from the Council for Health Services Accreditation of Southern Africa’s quality improvement and accreditation programme; commonly called by its acronym, COHSASA, by the facilities.

Let me point out that these are the first government facilities to be accredited, together with Scottish Livingstone Hospital and Phutadikobo Clinic in Molepolole. Enrollment into this programme has helped the hospital and the two clinics strive to provide patients with high-quality and safe healthcare services. I am greatly honoured to be standing here today to officiate at this important event. This event will take us through a journey undertaken by Mahalapye District Health Management Team as they walk and talk Accreditation.

Director of Ceremonies let me begin by highlighting that accreditation is one of the most powerful symbols of a healthcare organisation's commitment to provide high-quality and safe healthcare services, continuous improvement services across all aspects of patient care and patient safety, using the benchmarks associated with global best practices.

Accreditation is regarded as a basis of the safety and quality programmes of many healthcare systems. It is based on the application of nationally- and internationally-agreed standards for assessing and benchmarking the performance of the facilities, whether hospitals or clinics.

The benefits of accreditation processes are multiple and include among others: improved quality and safety of care; explicit, documented processes; effective teamwork; reduced costs and enhanced organisational cultures. In other words, accreditation is a process that drives the full scope of improvement which necessarily encompasses the structures, processes and outcomes of service delivery. Let me tell you that the award of full accreditation status reflects high individual and organisational performance.

Ladies and gentlemen, the Ministry of Health and Wellness accreditation project came about as a result of a baseline performance audit and gap analysis study that was conducted at four district hospitals and two referral hospitals during which several deficiencies in relation to the quality and safety of health services provided were identified. The programme started in March 2009 as a pilot project at Mahalapye District and Scottish Livingstone Hospitals, Xhosa, Airstrip, and Phutadikobo clinics. These facilities made significant progress that led to my Ministry taking a deliberate decision to introduce and implement uniform standards of healthcare throughout the system and to ensure the provision of consistent high quality and safe healthcare. The accreditation process incorporates the development of a quality improvement system which will ensure that continuous quality improvement becomes an essential part of the activities of all public health facilities.

When we first started this accreditation, we had an idea on the expected end results and the journey and the methodology was not what we had anticipated. It was not an easy journey as we did not know exactly what was required of us. We had many unstable turning points; there was lot of resistance from service providers. It was up to management to ensure that the journey continued. With ownership of the programme by management, change was gradually accepted and an understanding of the improvement process was gained by many. By then the hospital had 33 service areas commonly known as service elements and each was expected to produce evidence as to how they provide care to their customers. Policies and standard operating procedures had to be developed and continuous documentation as well as monitoring of their implementation and the outcomes. Everything was about quality and evidence of how one performed a particular procedure. The facilities did not just sit back; they took the project as a priority because they wanted their facility and services to be recognised by international health facilities.

Ladies and gentlemen, when this accreditation process started in 2009, the baseline survey results for Mahalapye hospital was 36 points with Airstrip and Xhosa clinics’ having baseline survey results of 37 and 40 respectively, all out of a possible score of 100. These facilities have worked tirelessly to the extent of adding extra hours to raise their performance results to 81 points for Mahalapye District Hospital with nineteen (19) out of thirty-three (33) achieving certification; while Airstrip Clinic has achieved a score of 77 and five (5) service areas certified; Xhosa Clinic has achieved a score of 79 points and four (4) service areas certified each out of eleven (11) service areas. These are the results of the external survey which was conducted in 2013. Today I am happy to announce that two (2) years down the line, Mahalapye District Hospital has scored 96 points, which gives them full accreditation status with all the 33 service elements being fully accredited. Airstrip and Xhosa has achieved a score of 96 and 97 points respectively.

These scores are a result of the dedication of every Wednesday afternoon as a time for the DHMT staff to meet to evaluate their performance against the standards and give support to each other as well as share assignments which needed to be done. Wednesday ended up being nicknamed “COHSASA’s day” but later on the staff owned the process and called it “Accreditation day”. This initiative helped them achieve a lot of things through their concerted effort. Each service area had to undertake quality improvement projects to address identified deficiencies. Directors of Ceremony, I wish to congratulate the management, leadership and staff of these facilities for a wonderful achievement of improving the level of compliance with internationally accredited standards. Your achievement has been reached through hard work coupled with commitment to excellence and continuous quality improvement.

Looking at how the staff had been committed towards improving their level of service delivery, I am confident that you will be able to maintain the full accreditation status. Please note that quality improvement is a continuous cycle that has no end and I urge you to keep on living your theme of “living the vision through evidence” and set performance trends for the Ministry. Let me also remind you that the full accreditation status will definitely put pressure on you since other facilities are now looking up to you for benchmarking. I have been told that since 2014, more than 10 facilities have already visited you for benchmarking. This is a sign of the good work that you have done.

The recognition and appreciation of your achievement by my Ministry and the community leadership should provide you with momentum to perform even better. This will result with increased utilisation of our services; increased community awareness on the performance of the hospital and clinics and a competitive edge where you will now become a health facility of choice.

Furthermore, this ceremony presents a challenge and you will continue to be tested in many different ways. The ways you respond to those challenges will have an impact on the reputation of the quality and safety of the health services you provide.

I therefore urge you to rejoice while at the same time keeping the commitment and collaborative team work to move to another level of excellence. We all know that healthcare is dynamic and you should continually be innovative to adapt new technologies and better modernised methods of providing care that is responsive to the health needs of the community we serve. There are no excuses for all of you for any substandard work, and it is up to the management and staff members of the Hospital and these two Clinics to uphold what they have achieved.

Looking at the journey you have travelled, I would like to point out that you are heroes; your achievement deserves praise.

I would like to take this opportunity to thank the DHMT management for their good leadership skills, it is through their dedication and perseverance that they managed to achieve what they have achieved today. Despite the challenges and setbacks, they did not despair but instead they encouraged their staff to hold on to the fort for the benefit of their facilities. They were fully aware that their effort would yield good results for their patients, the community as well as the country at large. This will indeed help our country to be recognised globally. I would also like to thank the staff for their hard work in realising their dreams; I have been told sometimes people had to put in extra hours just to ensure they scored good marks come internal or external assessments.

I would like to appreciate the team from the Ministry of Health and Wellness Headquarters, which from time to time visit such facilities to ascertain their challenges and come up with plans on how to assist them. To COHSASA, I would say thank you for teaching my staff good standards and taking them through the whole process until they understood what was needed of them.

Ladies and gentlemen, a lot can be said about the accreditation process. It is up to us now to ensure we keep up to the standards that we have set for ourselves. I trust that the full accreditation status will be maintained now that we are aware of the good results that came out of our hard work.

In conclusion, let me take this opportunity to encourage those facilities that have not yet enrolled in the accreditation programme to do so and take advantage of the existence of experience in implementing standards by benchmarking from Mahalapye District Hospital, Airstrip and Xhosa clinics."