Office of Health Standards Compliance on its 2014 Strategic Plan

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Health

19 August 2014
Chairperson: Ms M Dunjwa (ANC)
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Meeting Summary

The Office of Health Standard Compliance (OHSC) briefed the Committee on its strategic plan and annual performance plan for 2014/15.  The mandate of the Office dealt with the monitoring and enforcement of compliance by health establishments with the norms and standards prescribed by the Minister of Health for the national health system, and ensuring complaints relating to non-compliance were investigated and disposed of in a procedurally fair and economic manner.  The vision of the OHSC was for safe and quality health care for all South Africans.  Its mission was to act independently, impartially, fairly and fearlessly in guiding, monitoring and enforcing health care safety and quality standards in health establishments, to serve the people of South Africa.

The challenges facing the OHSC included the poor relationship with the private sector, shallow-based management, the public perception of sub-standard health care and gaps in resources and knowledge. The National Core Standards inspection of compliance had found poor accountability, with a lack of consequences for non-compliance, and multiple standards without objective measurements before the issuance of national core standards.

The OHSC strategies to meet these challenges involved providing guidance to the health system, which would be achieved through a single set of national health standards, such as setting out expectations for managers, and creating a framework and common understanding of what was actually expected.  Compliance would be measured through an objective external method, using a team of inspectors, and immediate feedback would be provided to all health establishments at the conclusion of inspections.

The strength of the OHSC included the fact that it was a new health sector public entity, a regulator with legislative authority, an independent board and an independent Ombud, and had gone through a significant period of development and awareness. Weaknesses included limited power to enforce compliance -- as the constitutional setup did not give a national body direct authority for enforcement powers – and a limited ability to correctly predict problems and intervene through an early warning system. There might also be a perceived lack of independence, as this process had been incubated within the Department of Health.

The key units of the Office were the inspectorates, the Ombud and critical support units. The roles of complaints management and the Ombud were to ensure the establishment of an accepted and accessible mechanism so that people could have access, and there had to be an efficient complaints management system.

The budget allocated for the 2014/15 financial year was R76 million, R90 million for 2015/16 and R97 million for 2016/17.

The Committee expressed concerns over the limited power of the office to enforce compliance because of a lack of consequences for non-compliance.  A lack of basic management skills was raised, as people should be employed for their expertise. The Basic Conditions of Employment Act was an issue, as some medical interns and nurses worked long hours at a stretch, which affected their efficiency. The Committee asked for the time frame required to fill all posts in the Office.  Clarification was sought on the position of the Ombud in the organizational structure.  Also discussed was how the OHSC would ensure that the patient’s perspective was woven into its assessments, perhaps by having a patient’s representative or patient advocacy on its board. 

Members raised queries about the budget allocation for the compensation of employees and corporate services, as it had no personnel, and suggested there should be targets for goods and services. Clarification was required on how the functions and roles of the OHSC would reach the farming and rural areas. Also discussed was how often quality checks would be conducted on institutions and the remedial actions to correct the situations for effective service delivery. 

The Committee expressed concern that there was insufficient independence from the Department of Health from the public perspective.  It also asked if National Health Insurance (NHI) pilot sites were meeting the required standards, as prescribed by the OHSC, and if systems were in place to ensure the National Service Delivery Agreement was implemented.

The minutes of the meeting held on 30 July 2014 were unanimously adopted.

Meeting report

Opening remarks

The Committee Chairperson welcomed everyone to the meeting and acknowledged the presence of the board members of the Office of Health Standards Compliance (OHSC).  Prof Lizo Mazwai, chairperson of the OHSC board, provided a brief introduction of members of the delegation.

Briefing by the Office of Health Standard Compliance

Dr Carol Marshall, CEO: OHSC, briefed the Committee on the strategic plan of the Office. The mandate came from the National Health Amendment Act that was debated in 2012/13, and promulgated by the President into law in September 2013.  It was about monitoring and enforcing compliance by health establishments with the norms and standards prescribed by the Minister in relation to the national health system, and ensuring the investigation and disposal of complaints relating to non-compliance with the prescribed norms and standards in a procedurally fair and economic manner.

The vision of the Office was for safe and quality health care for all South Africans, and its mission was to act independently, impartially, fairly and fearlessly in guiding, monitoring and enforcing health care safety and quality standards in health establishments to serve the people of South Africa.   Its values were informed by the South African constitution and enshrined human dignity, freedom and the achievement of equality.

Section 27 of the constitution guaranteed everyone the right of access to health care services, including reproductive health services and emergency medical treatment. It required that the state took reasonable measures within its available resources to achieve the progressive realisation of this right.  The Office took its mandate from the Constitution through regulating the quality of health services that would enable and require health establishments to comply with the minimum standards of care and priorities and contribute directly to the government’s realisation of its constitutional obligations.

Section 41 required all three tiers of Government to work cooperatively. The national government was responsible for developing and monitoring policies and regulations around norms and standards of the health sector.  The provincial governments remained responsible for the implementation of national policies and legislation.

Section 44 gave national government the authority to pass legislation with regard to functional areas and to prescribe minimum norms and standards.

A health establishment was defined as a facility, building or place that was operated or designed to provide in-patients’ or out-patients’ treatment, and diagnostic or therapeutic information on health services. All health establishments in relation to Section 47 must comply with the quality requirements and standards prescribed by the Minister after consultation with the Office. This may relate to human resources, health technology, and hygiene, including the manner in which users were treated. The Office must monitor and enforce compliance with the quality requirements and standards.  Section 90, as amended by the Act, provides for consultation by the Minister through the Office, in addition to consultation with the National Health Council, where the Minister makes regulations in terms of the Act. The Minister may prescribe different types of norms and standards for different types of health establishments after consultation with the relevant authority.

The two main roles of the Office were to protect and promote the health and safety of users.

Functions of the Office included: to advise the Minister on norms and standards; to inspect and certify health establishments; to investigate complaints; to monitor indicators of risk as an early warning system; to identify areas for interventions and make recommendations to various authorities in both the public and private health sectors, to ensure compliance with norms and standards; to publish information relating to norms and standards; to recommend improvements in quality assurance and management systems to the Minister and keep records; and to advise the Minister on any other matter.

Secondary functions included to issue guidelines on the implementation of norms and standards; collect and request any information from health establishments for users; liaise with other regulatory authorities on matters of common interests; and receive information from them and negotiate agreements with regulatory authorities.

The OHSC had within its ranks a health standard Ombud.  The functions of the Ombud included following written or verbal complaints and investigating and considering non-compliance with norms and standards. The Ombud may refer any complaint to any other relevant body. Patients had the rights to raise complaints with the Ombud.  The Ombud must provide findings and recommendations to the CEO, who must then take action.  The Ombud must then inform the complainant or respondent of its findings and recommendations.

The key powers of the Office to give effect to its mandate included the appointment of inspectors, the powers of the inspectors to enter an establishment, the powers of the Ombud to require information to be provided to him/her; the method of recommendation of the Ombud; the issuing of compliance notices and compliance certificates; and the use of progressive sanctions.

The National Health Development Plan (NHDP) had found a poor relationship existed with the private sector, shallow-based management, a public perception of sub-standard care and gaps in resources and knowledge. The national core standards authority had conducted inspection of compliance and found poor accountability, with lack of consequences for non-compliance, multiple standards without objective measurements before the issuance of national core standards, and gaps in basic knowledge and competence in management. These were the challenges that the strategic plan was designed to meet.

The strategies to meet these challenges were:

- Provide guidance to the system, which would be achieved through a single set of national health standards, such as setting out expectations for managers, creating a framework and common understanding of what was actually expected.

- Through measurement or benchmarking, involving a detailed assessment tool that measured compliance with the standards by a team of objective external inspectors.  Immediate feedback would be provided to all health establishments at the conclusion of inspections.

- Through ensuring improvement or correction of bottleneck situations in either the private or public health service delivery systems.

- Through regulations, in order to change behaviour, using the powers of the state.  The OHSC had been working on two sets of regulations to advise the Minister on what should be prescribed and how the board

The current environment under which the strategic plan operated, involved consistently strong political and senior management leadership.  The national core standard had been mainstreamed into the operation of the Department of Health (DOH), which would have impacts on budgets, job descriptions and performance agreements.  There was widespread support from role players and stakeholders for the plan, which would result in improved reliability and availability of health care and improved outcomes. with less preventable mortality (patient safety).

A preliminary SWOT analysis had been conducted in preparing a business case for establishing a public entity.  The strengths included a new health sector public entity, a regulator with legislative authority, an independent board and an independent Ombud.   The weaknesses were the limited power to enforce compliance -- as the constitutional setup of the country did not give a national body direct authority for enforcement powers – and a limited ability to correctly predict problems and intervene through an early warning system. There may be a perceived lack of independence, as this process was incubated within the Department of Health and was now in the process of moving out.  The opportunities were the strong political support and high public expectations, providing a favorable context for the body to start work now, and a clear expectation of its role within the national development plan.  However, there could be a perception of interference, which could influence the findings and decisions.

The establishment of the OHSC was listed in May 2014.  The board was inaugurated in January 2014.  A board constitutional code of conduct had been approved.  The CEO had been appointed on an interim basis from 1 April.   A formal memorandum of agreement had been signed between the DOH and the OHSC in order to enable the transition to take place, with system structures and policies already set up.

The Ombud was appointed by the Minister and reported to the Minister on the advice of the board, but did not report to the board. It was placed within the OHSC and used the staff of the Office. The management of complaints was one of the functions of the Office but the findings of Ombud were independent. The board reported to the Minister.  There were three executive committees represented on the board – finance, human resources and remuneration, and certification and enforcement. The board was the accounting authority in terms of the Act, with the roles of oversight in governance, approval of policies and plans, and the appointment of the CEO and approval of the executive management.

There was an organizational structure approved by the board and the Minister.

Partnerships in the strategic plan template were made up of primary stakeholders and secondary stakeholders.

The primary stakeholders included the health establishments, which were regulated entities made up of both managers and staff members, because they ensured compliance.  Head offices were important stakeholders but not regulated entities.  Users of health establishments were important stakeholders as their safety had to be ensured and protected by the Office.  Other partners included those interested in the regulation of health services, such as Parliament and other structures of accountability, other regulators and the national Department of Health.

Secondary stakeholders were those who had influence over, or interest in, the health service providers. These included professional associations, trade unions, associations of hospitals, academic and training institutes, certain NGOs that delivered services, and those entities that represented the interests of health care consumers, like the mass media and NGOs.

Strategic outcome oriented goals of the OHSC were reflections of what the state of change would be as a result of the work of the Office. The four strategic goals and their objectives were:

* That public health establishments should comply with norms and standards for health and safety and provision of quality, compassionate and responsive care.  The objectives were developing or reviving norms and standards for submission to the Minister; annual regulation of all health establishments obligated by these standards; provision of guidance on compliance; monitoring and inspection of compliance at least every four years; taking development action; and certifying health establishments found to be compliant, while those persistently non-compliant would be subject to enforcement action.

* That the public was protected through ensuring that poor care, and their situations of concern, were heard, responded to and corrected. The objectives included putting in place accessible mechanisms for lodging of complaints with the OHSC and making them widely known; ensuring complaints regarding non-compliance were rightly managed; issuing findings and recommendations within the agreed timeframe; recommendations made by the Ombud were monitored and enforced; the Office must monitor indicators of risks; and the publishing of information for the public to know what was going on.

* To ensure there was collaboration with other institutions in terms of sharing information and ensuring coordination of regulations.  This required that memorandums of agreement were signed with relevant regulations and organizations; ensuring there was a platform for information sharing; and ensuring coordinated activities and enforcement were implemented.

 * The Office needed to be fully functional and staffed.   This would require the implementation of staff training and development including accreditation of inspectorates; that financial management of the Public Finance Management Act (PFMA) was complied with; a standard IT system would be the heart of the organization; and public awareness.

The budget allocated for the 2014/15 financial year was R76 million, R90 million for 2015/16 and R97 million for 2016/17.

There had to be an efficient complaints management system, which meant the establishment of an accepted and accessible mechanism so that people could have access to the Ombud.   Importantly, the Ombud must provide its findings and recommendations to the CEO and the complainants directly, and would need to coordinate investigation with other bodies as well.

A complex unit of health standard design analysis and support would be responsible for developing the norms and standards for proposal to the Minister, or reviving them by using an expert Committee.  This would involve the registration of health establishments; informing inspectorates on what to inspect; providing guidance; and monitoring indicators of risk that would guide the prioritisation of inspection.

This was the first strategic plan of the newly established Office within a changing environment and context, as the regulations had not yet been published for comments.

Discussion

Dr P Maesela (ANC) requested for explanation for the lack of basic management skills mentioned in the presentation, as people should be employed for their expertise.  He added that the OHSC had alliances or signed agreements with NGOs, and asked if the press was involved in verifying operations.

Mr Bafana Msibi, Director-Inspections: OHSC commented that the Department and the OHSC needed to work together. Inspectors had been transferred from the DOH to the Office.  This was a tedious process, as the conditions of service of the employees had to be considered for them not to be disadvantaged and the entity did not have sufficient funds to strike the balance of employing highly skilled workers.

Dr Marshall commented that management weakness did not refer to the Office, but rather to the situation with the service providers. The Office was trying to address the challenges through its specific role. Two players were involved -- the regulator and the service provider.

Mr A Mahlalela (ANC) welcomed the new board and noted that OHSC had reflected in its goals and objectives the need to ensure efficient financial management to comply with PFMA requirements which were not mentioned in the legislations in the strategic plan.  Clarification was required on the position of the Ombud within the organizational structure of the OHSC.  He also commented that the bulk of the budget went to Programme 2 (Corporate) without the plans being stated.  There was a budget for the compensation of employees, even though it had no personnel or staff yet, but the OHSC might need to employ people who would be expected to perform certain duties which were not stated in the APP.  There should be targets for goods and services in the APP in order to have a better understanding, from an oversight perspective.  Public awareness was mentioned in the strategic plan, but was not mentioned in the APP -- would public awareness not be tackled in this current financial year?   He expressed concern about enforcement being one of OHSC’s responsibilities, and asked if it was disempowered by the current legislation to enforce.  Clarification was required on its targets, as they were meant to be reported quarterly, but had been highlighted as “not applicable” in the presentation. He suggested that the document be reviewed for better comprehension, as the grammatical constructions were rather confusing.

Prof Mazwai commented that the Ombud was appointed by the Minister, but housed within the OHSC, and would be appointed by January 2015.  It was difficult to build a structure for an Ombud who had not yet been appointed. As a board, the Office had targets as to when things should happen, but the budget was still held by DOH.  The OHSC had not yet appointed a chief financial officer, so it could not run its budget directly. It was still in a transition phase.  The Health Professions Council was extremely important, so labour relations and other items omitted in the document would be inserted.

Mr H Volmink (DA) thanked the board for an informative presentation. He asked how the OHSC would ensure that the patient’s perspective was woven into its assessment as a critical measure of patient rights, such as having a patient representative, or patient advocacy, on its board. He asked for the indicators of domains of leadership accountability, and the functions of hospital boards.  How would the challenges within the public health domains be managed?  What did the OHSC intend to do to alleviate concerns within the public mind?  As an independent assessor, if faced the challenge of not being at sufficient arm’s length from public perception as regards the management of complaints within the Department of Health.  He commented on the lack of the ability to enforce, and how to mitigate those challenges.

Prof Mazwai commented that independence from the Department of Health was a concern, as the board was in the transition process of finding new premises in order to move out physically from the DOH. The Minister was concerned about public reports of poor performance. There were inspectors currently working with the DOH which would be taken over by the OHSC, which was an important labour issue.  Within the board, there were committees that looked after human resources.  The issue of independence was problematic, as the Office was legislated into a complex South African environment where the responsibility for providing health services resided within the provinces, and OHSC worked from a national point.   Hence there was a need to look at the legislation existing in the National Health Council and to receive the input of the Portfolio Committee to assist with legislative issues.

Mr Martin Kuscus, Board Member: OHSC, commented that there was an expected standard of leadership that had to be inculcated, as leadership was of great importance.

Ms Vuyiseka Dubula, Board Member: OHSC commented that when the board was initially appointed, the main issues which had to be addressed were the primary health care provider of the services, and the voice of patients or service users.  Hence there were two members on the board  -- one to represent the health care workers, and the other to represent the patients.

Dr Ethelwynn Stellenberg, Board Member: OHSC, commented that the Enforcement and Certification Committee had been working on the regulations and addressing all aspects of patient care, such as professionalism.  Attitude was a problem to be addressed, and it was important to meet all the patient rights within the clinic environment.  Also, the issue of incompetence would be addressed by the board, as incompetent workers were being employed.  Patient safety and quality of care would be compromised if quality of health care was not enforced by the board.  It would take some time to put everything in place, such as the right of the disabled.  Other constitutional rights would be addressed in order to ensure that they were enforced in the health care system.

Dr Marshall commented that there was no staff establishment at the moment.  Expenses incurred included inspectorates that were being paid for outside of the budget.  There were posts that would be filled between now and the end of this financial yea,r hence the need for a budget for compensation of employees.

Mr I Mosala (ANC) congratulated the board on the presentation. He asked how often OHSC did quality checks at the institutions and suggested that the institutions that needed serious checkups following the previous inspections.  As the Office had identified the critical areas for effective service delivery of some institutions, what remedial actions had been put in place for them to correct the situations?  Had it received feedback regarding progress?  He asked if NHI pilot sites were meeting the required standards, as prescribed.  Had improvements been seen in the most critical areas of health care, such as patient-staff protection, reduction in waiting time of patients, tidiness of environment, and cross-infection?  He asked if the board was equal to the task with regard to the implementation and monitoring of the National Service Delivery Agreement (NSDA) between the President and the Minister. He asked what systems had been put in place to ensure that the agreements were implemented.

Mr Kuscus commented that the Act was clear in terms of the OHSC’s powers and jurisdiction. Some of the health care delivery systems in the country were not up to public expectation and the public had an expectation from the Office to start acting as if it had been long established. The Act, in section 79 (1) e, stated that the board could make recommendations based on its findings, and it was therefore useful to engage with Parliamentary bodies such as the Portfolio Committee on Health to appeal for enhancement of its oversight role.  There was also a need for a collaborative effort between the stakeholders, the legislature, the OHSC and others in order to work to the advantage of the people.  It took about six months to get approval for its structure, so attention should be given to the issues involving people, the processes and the tabling.

Dr Marshall commented that the Office did not have responsibility for monitoring the NSDA, but rather monitored health establishments hence, so it did not monitor higher level delivery, except for indirectly measuring how services were delivered on the ground and how users received services, as it did not directly monitor how services were set-up.

She commented that nearly 900 inspections had been done over the last three years as inspectors were being trained. In all provinces there were both excellent and weak institutions, which was an issue of individual management.  NHI pilot sites were selected on the basis of disadvantage, and not on the basis of the best, and not all NHI pilot sites were compliant.  Improvements in some areas were not as great as had been expected.  The Office only issued compliance notices, and did not fix the problems. The feedback response had been slow, but during the recent re-inspection it had noticed improvement and had also got qualitative feedback from individual institutions about how the national core standards were influencing how management went about their businesses. The number of improvements was small at the moment. 

Ms C Ndaba (ANC) commented that the 2014 proposed regulation development for submission to the Minister and the letter of the Minimum Qualifications Framework (MQF) of 6 May were incomplete.  She expressed her concern over the limited power of the OHSC to enforce compliance, as an Office should not be established without the power to enforce.  Clarification was required on the limited power to enforce compliance and the exact time frame to fill all the posts in the Office, starting with the CEO and the Ombud. She asked when the board would make a follow up on the signing of the final approval of the Act by the Minister. Explanations were required on the compensation of employees, and goods and services, as there were no targets.

Prof Mazwai commented that the board meeting was scheduled for 10-11 September, after which it would go ahead and advertise the top level posts.   The current organogram was not covered by the budget, so not all vacant posts could be filled, but the chief financial officer post would be filled.

Dr W James (DA) apologised for coming late and wished the OHSC good luck in carrying out its function of ensuring compliance with national health care standards.  He added that the weaknesses in the system were in the provinces, as no support came from the provincial ministries, and he asked how the OHSC as a national body intended to monitor compliance in a dysfunctional provincial system.

Mr A Shaik Emam (NFP) apologized for coming late and commented on the Basic Conditions of Employment Act, as it had been observed that medical interns worked up to 37 hours per shift at a time, and this could affect their efficiency.  He asked if there would be a survey to find out the mortality rate at night, compared to daytime, and asked if there was a lack of professional service at night. He also asked how competency was ensured in terms of peoples’ qualifications.  What time frame was needed to achieve the stated targets in the strategic plan in order to provide a better service?   What was OHSC’s role in ensuring control over the private institutions that were training medical staff?  Compliance was a problem at all levels, as there were no consequences for non-compliance.  How could Parliament step in to ensure compliance?  Consequences for non-compliance should be restricted to entities.

Dr Marshall commented that the OHSC could not fix the system, as it had no direct authority as a regulator to fix the system.   As a regulator, it had to remain independent and objective. The body needed to work with the Health Professions Council to deal with interns’ registration and the issue of incompetence, as this was not its direct responsibility.

The Chairperson asked how the Office intended to ensure its responsibilities and functions reached all rural communities and farm workers. Explanation was required on social contributions budgeted under the programmes.

Prof Mazwai commented that it was discussing with the Minister on how to reach everybody, as most complaints at the moment were routed through one calling centre. Hospitals in the provincial governments also had their complaints systems, hence the need to study how the current system was working.  This pointed to the need to discuss with the Minister about when the Ombud S offices would come in at the district level, which would have to be budgeted for and planned.

Ms Dubula commented that the board had planned engagement with stakeholders to disseminate information to the public about OHSC, as the public was desperate for the office to function. The stakeholder engagement would also serve as a medium of communication to reach rural communities. Priority was being given to vulnerable people, targeted NGOs, patient groups and other establishments outside the hospital and clinic boards.

Prof Mazwai commented that some challenges were slowing down the OHSC’s progress, and some limitations could affect its expectations. He asked if the Portfolio Committee was happy with the way the Office had interpreted the legislation, and if not, it should be corrected.

The Chairperson commented that as a new institution in its transition stage, she was happy with the presentation and response, which had included the voices of the health service providers and health service users. There had to be a balance between the health service providers and the administrative side, which included the general assistants and the clerks.   In playing its oversight role, the Committee would look into the Act to identify challenges and gaps.  The OHSC should be mindful of the layout of its documents, and a lot of cut and paste had been observed in the presentation document.  The OHSC had a responsibility to assist government in transforming the mindset of health workers.

Mr Maesela commented that the national government was responsible for developing and monitoring policies, legislation and norms and standards in the health sector, while the provincial governments could discharge their constitutional right by passing provincial legislation in the area of health sector but remain responsible for the implementation of national policies and functions.  Section 44 of the constitution gave the National Assembly the authority to pass the legislation with regard to the functional areas of concurrent competence and to prescribe minimum norms and standards.  Since the OHSC was not fixing the system but worked through norms and standards to ensure compliance, in the event of non-compliance, Parliament would introduce legislation and give “teeth” to enforcement for non-compliance.

The Chairperson thanked the representatives of the OHSC for their presentation.

Adoption of Minutes

Dr James moved the adoption of the minutes of the meeting held on 30 July 2014.   Mr Mosala seconded the adoption.  The minutes were unanimously adopted.

The meeting was adjourned.

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