The COHSASA accreditation programme can be tailored to meet the specific needs of the facility undergoing quality improvement and accreditation. We first assist the staff to understand the accreditation standards and then to use them to assess their own services. We also help them to appreciate quality improvement methods and to be able to implement quality improvement plans and programmes.
After the training and the self-assessment, a team from COHSASA will spend a week at the hospital (less for smaller facilities like clinics) and carry out a Baseline Survey. They look at every service in detail and assess each against the standards. Each standard is made up of a number of criteria – the measurable elements. These findings are put in a detailed report, which indicates how each department complies with the standards, criterion by criterion. It also guides the staff on what needs to be done to achieve compliance with the standards and what evidence is required to support this.
The results of the Baseline Survey guide the hospital team, with the assistance of COHSASA, to decide how long it will take to achieve compliance. For example, if there are major gaps in the physical facility and equipment, the management may decide that it will take longer as they need to budget for such capital investment. If the hospital is well maintained and there is good documentation to support all activities, such as SOPs, clinical protocols, staff records and maintenance records, and the staff are knowledgeable about quality improvement, the programme can be shorter.
We have a web-based information system, which we train the staff to use so they can carry out self-evaluation of their quality improvement activities to improve the compliance with the standards. They capture this data into the system and we are able to monitor the progress remotely. We offer support visits as required to meet the needs of the staff.
When the hospital is substantially compliant with the standards, we carry out the External Survey for the purposes of accreditation. The External Survey is carried out by a team of surveyors that have not been involved with supporting the quality improvement process. If the facility is compliant with standards, it is accredited.