External quality assessment of health facilities in South Africa: strengths appraised and gaps identified
Keywords: external quality assessment
time series analysis
south africa
systems thinking
quality assurance
health systems strengthening
healthcare accreditation

Background:
External Quality Assessment assesses the quality of the structures, processes and outcomes of health facilities using pre-determined standards. South Africa is introducing a national policy on External Quality Assessment, operationalised by a newly established External Quality Assessment agency: the Office of Health Standards Compliance. This thesis seeks to answer three research questions: What is the relationship between External Quality Assessment and patient outcomes (specifically Healthcare Associated Infections) at the specialist-care facility level in South Africa? What are the facilitators of and barriers to health facility performance (i.e. attainment of compliance with standards) in External Quality Assessment at the district hospital level in South Africa? What has been the experience of External Quality Assessment by frontline healthcare workers at the district hospital level in South Africa?
Methods:
Three systematic literature reviews are conducted that attempt to identify the existing evidence base for the above-mentioned research questions in the international literature. A convergent parallel mixed methods design is used to answer the research questions, comprising an Interrupted Time Series Analysis and a multiple embedded case study of two pairs of health facilities that had undergone External Quality Assessment by the Office of Health Standards Compliance. The Interrupted Time Series Analysis assesses whether an effectiveness relationship can be demonstrated between External Quality Assessment and the Healthcare Associated Infection Methicillin-resistant Staphylococcus Aureus (MRSA) in eight South African specialist-care hospitals using monthly MRSA data from 2004 to 2014. MRSA is used in this thesis as the proxy patient outcome indicator. In order to answer research questions two and three, I participated in a district hospital External Quality Assessment as a participant observer as well as conducted fifteen in-depth interviews with healthcare workers from two pairs of district hospitals and thirteen in-depth interviews with Office of Health Standards Compliance inspectors. These findings are triangulated with health facility External Quality Assessment reports.
Results:
No conclusive evidence is found of a relationship between implementation of External Quality Assessment and changes in MRSA. The major theoretical lenses drawn from in the analysis of the qualitative findings are systems thinking theory and regulatory theory. The qualitative research suggests that facilitators of performance in External Quality Assessment in South Africa include strong directional leadership within health facilities, a collaborative organisational culture, a whole systems approach, staff development, incentives, a robust information system and a supportive External Quality Assessment agency. The research also identifies poor alignment of External Quality Assessment standards, under-developed and limited human resources, inadequate decision-making space afforded to district hospital leadership, limited financial resources, the use of penalties and negative staff perceptions of External Quality Assessment as barriers to health facility performance in External Quality Assessment. In unpacking the experiences of South African healthcare workers of External Quality Assessment, this research finds that the work of the Office of Health Standards Compliance is valued by healthcare workers as a potential educational opportunity and is useful in providing the health system with a means to compare health facilities using a standardised tool. The implementation of the Office of Health Standards Compliance’s External Quality Assessments requires significant improvement and, in their current form, they have potential unintended negative consequences on healthcare worker motivation as well as potentially, inadvertently encouraging the gaming of External Quality Assessment.
Conclusion:
The Office of Health Standards Compliance is being set up in such a way that once fully established it will be the primary regulator of quality of care in the South African health system. This thesis attempts to identify some of the strengths and weaknesses of this largely under-researched health system intervention and to contribute to strengthening its implementation.