LCQ20: Hospital accreditation programmes
29.11.2023

Following is a question by the Hon Chan Hok-fung and a written reply by the Secretary for Health, Professor Lo Chung-mau, in the Legislative Council today (November 29): Question: The 2023 Policy Address has mentioned that the Hospital Authority (HA) will resume the "hospital accreditation programme" (accreditation programme) to ensure its management and services attaining international standards, and support the Shenzhen Hospital Accreditation Research Centre (the Research Centre) to set up an office in Hong Kong with a view to contributing to the internationalisation of the national hospital accreditation standards. In this connection, will the Government inform this Council: (1) given that the HA suspended the accreditation programme which had been implemented for nearly 10 years in 2017, whether it knows HA's reasons for resuming the programme; (2) whether it knows the details of the accreditation programmes (including pilot programmes) in which public and private hospitals are participating currently and participated in the past (including the names of the organisers and the countries to which they belong, and the number of accreditation programmes participating and participated), as well as the merits and demerits of the various programmes concerned; (3) whether it has assessed if resuming the accreditation programme will increase the amount of paperwork for healthcare personnel; if it will, whether the Government has corresponding plans to ensure that the quality of healthcare services will not be affected, such as having the senior management of hospitals lead the work of issuing relevant documents; (4) whether it knows the respective numbers of local healthcare personnel who are qualified for (i) becoming the surveyors of the relevant accreditation programmes and (ii) participating in the assessment of overseas hospital accreditation; of the future plans to train more such surveyors; and (5) as it is learnt that the Research Centre, which the University of Hong Kong-Shenzhen Hospital took the lead in setting up, has formulated a set of International Hospital Quality Accreditation Standards (2021 Version) which have integrated the international accreditation standards and the accreditation standards of national "Grade 3A" hospitals, and has obtained relevant international accreditation, in addition to such work, how the Government will contribute to the internationalisation of the national hospital accreditation standards in the future, and of Hong Kong's role and positioning in the relevant work? Reply: President, In consultation with the Hospital Authority (HA) and the Department of Health, the consolidated reply to the question raised by the Hon Chan Hok-fung is as follows: (1) and (2) With the advancement in medical technology and the increased healthcare needs brought about by demographic changes, hospital services have become increasingly complex. A sound risk and quality management system can provide an important basis on which the quality of healthcare services is raised. Hospital accreditation is a widely adopted tool in many parts of the world. Through the assistance of external and independent professional hospital accreditation organisations, various aspects of the performance of hospitals are assessed in an objective manner to determine if such performance is up to the expected standards, with a view to enhancing the quality of healthcare institutions and safeguarding patient safety. It also allows for an objective and systematic assessment for the risks and inadequacies in the management, facilities, operations and other areas of hospitals so as to continuously improve service quality. The HA commenced collaboration with the Australian Council on Healthcare Standards, an international accreditation organisation, in 2009 to implement the Hospital Accreditation Programme. As of 2017, a total of 20 hospitals under the HA had been awarded accreditation status. During the process of obtaining accreditation, based on self-evaluations and recommendations of independent surveyors, each hospital made continuous quality improvement in various areas and services, such as refinement of the management and performance review system, the standardisation of services and workflows, and reduction of duplicative work. The HA has been continuously exploring improvement and optimisation of the accreditation model having regard to the situation and characteristics of public hospitals, and commenced a review of the Hospital Accreditation Programme in 2017. The review concluded that the marginal benefits of continuing the programme in the same manner had gradually diminished and was not cost-effective overall. As a result, the HA officially ended its collaboration programme with the Australian Council on Healthcare Standards in 2019. Subsequently, the HA has been monitoring the situation and endeavouring to identify an accreditation system that is more suitable for adoption in the local public healthcare system and meets international standards and requirements, with a view to continuously improving the quality of hospital services. In December 2020, the Shenzhen Hospital Accreditation Research Center (Research Center) was established under the direction of the Shenzhen Municipal Health Commission. Based on the International Society for Quality in Health Care's standard-setting principles, and with incorporation of features from the national "Tier III Class A" hospital accreditation standards (such as multi-dimensional accreditation, quality assessment with healthcare indicators, case tracking, and system tracking), the Research Center has developed the China's International Hospital Accreditation Standards (2021 Version). These standards integrate both international and national standards and have successfully obtained accreditation from the International Society for Quality in Health Care. In line with the policy regarding hospital accreditation in the Chief Executive's Policy Addresses of 2022 and 2023, the HA will resume the Hospital Accreditation Programme by adopting the China's International Hospital Accreditation Standards (2021 Version) at Pamela Youde Nethersole Eastern Hospital and Prince of Wales Hospital in 2023-24, with a view to ensuring that the management and service levels as well as the healthcare quality of hospitals are on par with international standards, enhancing the uniformity of hospital accreditation standards as well as the quality and safety of healthcare in the Guangdong-Hong Kong-Macao Greater Bay Area (GBA), and aligning with the national healthcare system. In the private hospital sector, the Government implemented the Pilot Scheme on Hospital Accreditation (Pilot Scheme) in May 2009. At that time, three private hospitals participated in the Pilot Scheme and obtained accreditation from the Australian Council on Healthcare Standards in 2010 and 2011 respectively. As of October 2023, a total of 11 private hospitals have been awarded accreditation status, of which nine have been accredited by the Australian Council on Healthcare Standards and two have been accredited by the Joint Commission International. Both of these accreditation organisations are recognised by the International Society for Quality in Health Care. Meanwhile, some private hospitals have expressed their intention to adopt the China's International Hospital Accreditation Standards (2021 Version) in initiating their hospital accreditation work. (3) and (4) At present, the HA has set up a working group to guide public hospitals in the implementation of the Hospital Accreditation Programme based on the China's International Hospital Accreditation Standards (2021 Version). Drawing on the experience gained from the implementation of the accreditation programme in the past, the HA will ensure that healthcare staff are adequately supported in carrying out accreditation-related work. The HA will carefully plan the implementation timetable of the Hospital Accreditation Programme having regard to the readiness of hospitals, taking into full account the workload of frontline staff and giving priority to clinical work, so as to commencing the programme at a steady pace. With the objective of significantly reducing the administrative workload of frontline staff while achieving continuous improvement in the quality of hospital services and patient safety, the HA will carry out the Hospital Accreditation Programme with the following key directions: 1. focus on continuous improvement - not performance assessment; 2. eliminate duplication of work processes - integration into routine work; and 3. strengthen central co-ordination &ndash; allocating resources for improvement. To ensure the smooth implementation of the Hospital Accreditation Programme, healthcare staff from both the public and private healthcare institutions in Hong Kong have actively participated in the surveyor training organised by the Research Center. Training of the first batch of surveyors was held in January 2023 with the participation of 14 surveyors from Hong Kong, including eight HA staff. Training of the second batch of surveyors was held in July 2023. Among the seven surveyors and 18 observers from Hong Kong, three surveyors and 10 observers were HA staff. Surveyor training is the foundation for the commencement of the Hospital Accreditation Programme, and the HA will continue to encourage healthcare staff to actively participate in future surveyor training to be held by the Research Center. (5) Hong Kong's healthcare system is world-renowned, with experience in international hospital accreditation, and the development of healthcare policies and industry standards is aligned with international practices. The adoption and implementation of the China's International Hospital Accreditation Standards (2021 Version) and the resumption of the Hospital Accreditation Programme by the HA will not only ensure that the management and service standards as well as healthcare quality of hospitals are on par with international standard, but also complement the integration within the GBA and promote uniformity of the healthcare services in the GBA, as well as align with the national healthcare system. Relevant work will also enable the international community to have a better understanding of these hospital accreditation standards, thereby contributing to the internationalisation of the national hospital accreditation standards.