Quality Assurance of APCC service providers
THE APCC QUALITY IMPROVEMENT CYCLE
Quality Assurance of Association of Palliative Care Centres (APCC) Service Providers is at the heart of the work of the APCC. Given APCC’s Vision i.e. ‘quality Palliative Care for all’ and Mission i.e. ‘to promote quality in life, dignity in death and support in bereavement to all persons living with a life-threatening illness by supporting members and partner organisations’, APCC’s core Programmes aim to build the capacity of APCC Service Providers to provide quality Palliative Care. These Programmes are:
- Accreditation of Service Providers
- Mentorship of Service Providers
- Training of Service Providers
- Monitoring, Evaluating and Reporting on services
While each of these Programmes is separate in its own right, they are woven together into an integrated, complementary and systematic APCC Service Provider Quality Improvement Cycle (see below). With reference to the Quality Improvement Cycle, this page provides a brief description of each of the APCC Service Provider Quality Assurance Programmes.
The much publicized Life Healthcare Esidimeni tragedy (2018), involving the deaths of 143 patients, is a prime example of what could happen if patients are placed under the care of a Service Provider, that is not subject to a professional and comprehensive external accreditation. The National Health Amendment Act (Act No. 12 of 2013) requires that all healthcare Service Providers, including community-based Service Providers, be accredited by the Office of Health Standards Compliance (OHSC). The Office of Health Standards Compliance (OHSC) is an independent body established in terms of the National Health Amendment Act of 2013, to ensure that both public and private healthcare ‘establishments’ in South Africa comply with the required health standards.
To date, the focus of the OHSC has been on the development of standards for the accreditation of public health sector hospitals and primary health care clinics and conducting audits of these facilities against these standards. The OHSC has not yet developed standards for the accreditation of community-based healthcare Service Providers, let alone the accreditation of these providers.
The vision of APCC……. ‘quality palliative care for all’, both inspired and compelled APCC, to develop its own externally accredited Standards for Palliative Healthcare in collaboration with the Council for Health Services Accreditation of Southern Africa (COHSASA). The first Standards for Palliative Healthcare was released in 1998. These Standards focussed on clinical care. It was soon realised that it was difficult to implement clinical Standards in an organisation that did not comply with overarching organisational Standards. The first comprehensive Standards, including organisational Standards, were released in 2005 followed by a second (2010), third (2014) and fourth (2020) addition. All APCC Service Providers are audited and accredited against these Standards.
Aim of the APCC Accreditation Programme
The aim of the APCC Accreditation Programme is to ensure that all APCC Service Providers have the policies, systems, procedures, competencies and resources required to deliver quality Palliative Care.
The Accreditation Process
The APCC Service Provider accreditation process follows the steps below. All surveys are based on the Standards for Palliative Healthcare Services and are conducted by COHSASA-trained and approved Surveyors.
Step 1: Healthcare Service Providers that would like to become an APCC Service Provider must apply for APCC membership. Following application, a Baseline Survey is conducted with the applicant organisation to assess whether it complies with the minimum Standards required to become an APPC member. Based on the results of the Survey, an application may be deferred or recommended for approval to the APCC Board. On approval, the new member is assigned a Star rating depending on the results of the Baseline Survey. APCC members’ Star Rating indicates the level of compliance of the member with the Standards for Palliative Healthcare Services. All new members enter into a Memorandum of Understanding (MOU) with APCC, undertaking to work towards becoming a fully accredited 5-Star APCC Service Provider.
Step 2: All Star 1 to 3 Palliative Care Centres (PCC) are subject to ongoing Internal Follow-up Surveys to assess their progress towards full compliance with the Standards.
Step 3: Once a member complies with all the Standards required for a 4 Star APCC member, an Internal Pre-COHSASA Survey is undertaken to assess whether the organisation is ready for an External COHSASA Survey.
Step 4: If the APCC member is ready for an External COHSASA Survey, the survey is conducted by independent Surveyors appointed by COHSASA.
Step 5: On successful completion of an External COHSASA Survey, the APCC member receives a 5-star rating as a fully accredited APCC Service Provider. The accreditation is valid for 4 years.
APCC Service Provider Star Ratings
|APCC GRADED STAR RATING||APCC INTERNAL ASSESSMENT||COMPLIANCE REQUIREMENT ON APCC SELF-ASSESSMENT TOOL (SAT)|
APCC on-site new membership assessment
APCC online (SAT) Star 1 assessment
· Overall score of 80% on the membership assessment
· Full compliance with all critical criteria selected for HPCA membership assessment, Star 1 rating
|** Star 2||APCC online (SAT) Star 2 assessment|
· Overall average of at least 50% and not less than 30% on the full set of standards
· Full compliance maintained with all critical criteria in Star 1 membership assessment
|*** Star 3||APCC online (SAT) Star 3 assessment|
· >60% in SE 1, 2, 3, 5, 6, 7, 8, 9, 10
· Average of at least 50% and not less than 30% in SE 4
· Full compliance maintained with all critical criteria in line with membership assessment
|**** Star 4||APCC online (SAT) Star 4 assessment|
· >70% in SE 1, 2, 3, 5, 6, 7, 8, 9, 10
· At least 60% in SE 4
· Full compliance with all critical criteria of Standards
|***** Star 5||APCC online (SAT) evaluation and on-site APCC pre-COHSASA assessment|
· >90% in all applicable SEs
· Full compliance with all critical criteria of the full set of standards
Introduction to the APCC Mentorship Programme
While the National Health Amendment Act (Act No. 12 of 2013), and the resulting establishment of the Office of Health Standards Compliance (OHSC), is welcomed as an important step towards Quality Assurance (QA) in healthcare, its challenge is that it only represents one side of the Quality Improvement (QI) coin i.e. that of establishing Standards and auditing healthcare Service Providers against these Standards. It does not provide a mechanism for building the capacity of Service Providers to comply with these Standards. Quality Improvement (QI) is a two-sided coin, it must provide the Standards to be reached on the one side, and the mentorship required to enable Service Providers to reach these Standards on the other side. Without mentorship, the Standards only show Service Providers where they fall short, without providing them with the support required to address those shortcomings. One of the strategic priorities of APCC is “to build the capacity of its members to comply with the Palliative Healthcare Standards”.
Aim of the APCC Mentorship Programme
The aim of the APCC Mentorship Programme is to support APCC Service Providers to comply with the Standards for Palliative Healthcare Services.
APCC Service Provider Mentorship Tools
APCC Members Self-Assessment Tool (SAT)
During 2015 APCC developed an online cloud-based Self-Assessment Tool (SAT) based on the Standards for Palliative Healthcare Services. The SAT enables APCC Service Providers to assess themselves at any time against the Standards for Palliative Healthcare Services. APCC Service Providers can pace themselves through the SAT in preparation for Internal Follow-up Surveys or just to identify their strengths and challenges in being compliant with the Standards for Palliative Healthcare Services.
APCC Members Development Plan (MDP)
Based on the results from Internal Follow-up Surveys of APCC Service Providers in the APCC Accreditation Programme, an APCC Member’s Development Plan (MDP) is drafted and agreed to between the Member that was surveyed and the APCC. The Member’s Development Plan identifies the Palliative Healthcare Standards where the Service Provider needs to be strengthened, including the external expertise and timeframes required to do so, and the date for the next Internal Follow-up Survey. A Member may participate in several Internal Follow-up Surveys before it reaches a 4-star rating and can participate in a Pre-COHSASA Internal Survey.
Mentor Palliative Care Centers (PCC)
It is generally accepted that peer-to-peer learning is one of the most effective ways of learning. This is particularly true when it comes to building the capacity of APCC Service Providers since the expertise required to do so is generally not that of a ‘specialist expert’ but is more general in nature and is more related to systems, processes and procedures. In the APCC Mentorship Programme, fully accredited 5-Star Members are used as Mentors to other developing Members. Most of the mentorship received by 1 to 4 Star APCC Members is provided by accredited 5 4 or Star Members. If a 3 or a 4 Star Member has a particular strength in certain Standards, they may also be used as a Mentor for those Standards. Using Mentor Members to mentor other Members, benefits both the Member receiving the mentorship and the Member giving the Mentorship since the Mentor Member is remunerated through the APCC Member Mentorship Fund (MMF) for the mentorship it provides. Consequently, mentorship becomes an additional source of income for Mentor Members. The additional source of income also serves as an incentive for Star 1 to 4 Members to become fully accredited 5-Star Mentor Members.
APCC Member Mentorship Fund (MMF)
Given the importance that APCC Members provide the best possible Palliative Care, Mentorship of Service Providers is a key strategic priority of APCC. APCC plans to establish a Members Mentorship Fund (MMF) for mentorship that will be used to pay Mentor Members to mentor other APCC Members. The Members Development Plan (MDP), resulting from Internal Follow-up Surveys, will identify the areas in which a Member needs mentoring. The Mentor Member who provides the mentoring will be paid by the MMF to do the mentoring.
 Quality Assurance (QA) measures compliance against Standards
 Quality Improvement (QI) is a continuous improvement process focused on processes and systems
Introduction to the APCC Training Programme
The APCC Accreditation and Mentorship Programmes focus on strengthening the internal policies, systems, processes and procedures of APCC Service Providers to comply with the Standards for Palliative Healthcare Services. The APCC Training Programme further strengthens the capacity of APCC Service Providers by enhancing the knowledge, skills and attitudes of APCC Service Provider staff to deliver quality Palliative Care. The release of the National Department of Health, National Policy Framework and Strategy on Palliative Care (2017), has significantly increased the demand for Training in Palliative Care. Consequently, APCC offers its Training Courses not only to APCC Service Providers but also to health and welfare professionals in partner organisations such as the Department of Health, public and private hospitals, nursing agencies, homes for the elderly etc. etc.
Aim of the APCC Training Programme
The Aim of the Training Programme is to enhance the knowledge, skills and attitudes of patient care staff at APCC Service Providers and partner organisations to provide quality Palliative Care.
APCC Training Courses
All Training Courses were developed by APCC in collaboration with APCC Service Providers, and relevant stakeholders including academic institutions. During the COVID-19 pandemic, some of the listed courses were redeveloped for e-learning.
APCC Education & Training Courses
|NAME OF COURSE||DURATION||NQF LEVEL||ACCREDITATION BODY||TARGET AUDIENCE/FORMAT|
|1||Introduction to Palliative Care for Professionals||40 hours||Postgraduate level|
APCC / UCT
30 CPD points:
5 Ethics point
Healthcare Professionals /
Face to Face
|2||Certificate Course in Palliative Nursing||9 months||6||APCC|
Professional Nurses and Enrolled Nurses
Face to Face
|3||Psychosocial Palliative Care||5 days||Short Courses|
21 CPD points
Social Workers, Psychologists & spiritual counsellors
Face to Face
|4||Palliative Care for the Older Persons (Healthcare Professionals)||5 days||Short Courses|
20 CPD points
Face to Face
|5||Palliative Care for Older Person (Carers)||5 days||Short Courses|
Face to Face
|Home Based Personal Care Assistant||6 months||2|
Home Based Carers
Face to Face
|7||Home Based Personal Carer||11 months||3|
Home Based Carers
Face to Face
|8||Bereavement Support||5 days||Short Course|
18 CPD points
Anyone who wishes to support those bereaved
Face to Face
|10||Train the Trainer|
|Short Course||APCC||Palliative care trained and experienced practitioners|
APCC Service Providers, who comply with the relevant Standards in the Standards for Palliative Healthcare Services, may offer training in the above courses. To offer the two Home Based Care Courses (Course numbers 6 and 7), Service Providers have to be accredited by the Quality Council for Trades and Occupations (QCTO) as a Skills Development Provider (SDP). Currently, 11 APCC Service Providers are accredited by the QCTO to offer these courses.
Introduction to the APCC Accreditation, Mentorship and Training Programmes
The APCC Service Provider Accreditation, Mentorship and Training Programmes are designed to ensure that APCC Service Providers have all the policies, systems, processes and procedures required to comply with the Standards for Palliative Healthcare Services and that the APCC Service Provider staff are well trained in Palliative Care. While the above Programmes equip Service Providers to deliver quality Palliative Care, it does not guarantee the delivery of quality Palliative Care. Whether the Service Provider actually delivers quality Palliative Care, can only be assessed through monitoring, evaluation and reporting on the actual services delivered.
Aim of the APCC Monitoring, Evaluation & Reporting Programme
The aim of the APCC Monitoring, Evaluation & Reporting Programme is to report on the patient care services provided by APCC Service Providers and to use this information for Quality Improvement of patient care services and reporting to stakeholders including Medical Schemes.
The APCC Patient Data Management System (PDMS)
In 2011, APCC developed the Patient Care Management System (PDMS) in collaboration with Airborne Consulting. The purpose of the PDMS was to develop a national cloud-based patient care data management system that could be used by APCC Service Providers to capture and report on the actual delivery of Palliative Care services at an individual patient level; a patient group level (e.g. by diagnosis; age group; gender; population group; medical scheme; etc.); and at an organisational/geographic regional level (e.g. individual member); health sub-district; health district; provincial; and national). The PDMS was originally built on a Microsoft SQL Server 2008 platform and was upgraded to SQL Server 2016 in 2020. The PDMS is a highly sophisticated cloud-based patient care management system that can report on all patient care services provided to any patient at any point in time. The images below are two examples of data drawn from the PDMS.
 The HPCA HDMS was developed with a grant from First National Bank
 Airborne Consulting was created in 2004 and is a majority BEE-owned company that specializes in information technology and management consulting.
The African Palliative Care Association Patient Outcomes Scale
The African Palliative Care Association (APCA) Palliative Outcomes Scale (POS) (APCA-POS) is designed to assess patient outcomes based on the patient and family perception of selected components of Palliative Care. The APCA-POS contains 10 items, addressing the physical and psychological symptoms, spiritual, practical and emotional concerns, and psychosocial needs of the patient and family. The answers to all questions are scored using Likert scales from 0 to 5, with numerical and descriptive labels. Questions 1-7 are directed at patients; questions 8-10 are directed at family informal caregivers. The APCA-POS is a valid and reliable tool to measure patient outcomes as perceived by the patient and family.
Measuring the Quality of Care
APCC has developed and implemented three programmes designed to measure quality in one way or another. Below identifies each Programme and what each Programme measures.
The APCC Standards for Palliative Healthcare Services are essentially designed to ensure that an APCA Service Provider has the policies, systems, processes and procedures in place, that enable the Member to deliver quality Palliative care. However, there is no guarantee that a Service Provider that complies with the Standards will in fact provide quality Palliative Care even though its capacity to do so would be significantly enhanced through compliance with the Standards.
The African Palliative Care Association (APCA) Palliative Outcomes Scale (POS) (APCA-POS) is designed to assess patient outcomes based on the patient and family perception of selected components of Palliative Care. It does not however monitor, evaluate and report on the actual care given to the patient.
In addition to measuring the number of patients cared for collectively or in multiple categories (e.g. by age; diagnosis; gender; population group; category / level of illness; geographic distribution etc.), the PDMS measures the quality (intensity) of care actually given to a patient. The quality of care received by patients is measured in terms of the following 5 parameters:
- the frequency of care. How often and how many times does the patient receive care (visits)?
- the number of interventions received by the patient during the visit. Is the patient receiving the appropriate number of interventions given their level of illness?
- the range of interventions (i.e. physical; psychological; social; spiritual). Is the patient receiving the appropriate range of interventions commensurate with their level of illness?
- the human resource capacity (i.e. qualifications and experience) used to provide the interventions. Are the interventions provided by persons (e.g. Home Based Carer; Professional Nurse; Social Worker; Medical Doctor; Spiritual Counsellor etc.) who have the appropriate qualifications and experience given the level of illness of the patient?
- the supervision of interventions. How frequently are interventions for a given patient supervised by another healthcare professional?
The data generated against the above quality indicators are compared with (i) the average for the given APCC Service Provider; (ii) the average for APCC Service Providers in the Province; (iii) the average for APCC Service Providers throughout the country; and (iv) the minimum standard of care for a patient with this particular level of illness.
Combining the above 3 Measurement Programmes, APCC can produce evidence confirming:
(i) whether a particular APCC Services Provider has the capacity to deliver quality Palliative Care (Standards);
(ii) whether the patient and family are satisfied with the patient care services provided by a particular APCC Service Provider (APCA-POS); and
(iii) whether the APCC Service Provider actually delivered the services required in terms of national and international standards (PDMS).