PROGRAMMES
Programme 1: Administration
The Administration Programme provides the leadership and administrative support necessary for the OHSC to deliver on its mandate and comply with all relevant legislative requirements.
Corporate Services
Key Corporate Services functions are fulfilled through the following sub-programmes:
- Human Resources Management
- Information and Communication Technology
- Communication and Stakeholder Relations
Human Resources Management
Human Resources Management creates an enabling environment for employees to contribute towards the achievement of the organisations’ objectives and mandate. The unit enables the office to attract, develop and retain skilled people and ensure that funded vacancies are filled. In addition to this, the unit also deals with amongst others labour relations, performance management, and service benefits and oversees facility management. e.g. maintenance.
Information and Communications Technology
Information and Communication Technology (ICT) provides long-term planning and day-to-day support in respect of ICT needs, services, and systems.
Communication and Stakeholder Relations
The Communication and Stakeholder Relations sub-programme aims to enhance understanding of the role and powers of the OHSC and Office of the Health Ombud (OHO) amongst stakeholders and the general populace through effective communication, stakeholder engagement, and partnership development.
Office of the Chief Financial Officer
- Finance and Supply Chain Management
Finance and Supply Chain Management
The OHSC is a public entity with a regulatory mandate in the health sector, where accountability and transparency are of paramount importance. It is crucial for the OHSC to demonstrate accountability by obtaining an unqualified audit in order to promote public trust in the OHSC and the way the OHSC conducts its affairs, both in financial governance and performance reporting.
Office of the CEO
- Governance, Board Secretariat and Legal Services
- Strategy, Planning, Monitoring and Evaluation
Governance, Board Secretariat and Legal Services
The purpose of the Governance, Board Secretariat and Legal Services unit is to ensure that the OHSC Board and Committees function effectively and efficiently and that the OHSC operates in a legally compliant, transparent, and effective manner as well as to provide legal services to the CEO and the OHSC.
Strategy, Planning, Monitoring and Evaluation
The purpose of the Planning, Monitoring, and Evaluation unit is to coordinate the translation of policy priorities agreed upon by the Board into actionable strategic plans with clear outcomes, outputs, indicators, and resource commitments. The unit also monitors and evaluates the strategy articulated in the Annual Performance Plan and institutional Operational Plan to ensure that the OHSC delivers its impact statement and improves and sustains its performance and reporting.
The Planning, Monitoring, and Evaluation aim to determine the relevance and fulfillment of the OHSC’s priorities and the effectiveness of services delivered. Performance monitoring enables transparency and accountability, which allows the CEO and Board to step in when the organisation cannot fulfil its obligations.
Programme 2: Compliance Inspectorate
The Compliance Inspectorate programme manages the inspection of health establishments to assess compliance with the national health system norms and standards regulations, as prescribed by the Minister of Health. The programme is responsible for conducting routine and additional inspections. Routine inspections are planned inspections conducted as outlined in the OHSC Annual Inspection Strategy. Additional inspections comprise risk-based, re-inspections and pilot inspections. Risk-based inspections are ad hoc, triggered by the Early Warning System (EWS), while pilot inspections are conducted during the inspection tool development process in partnership with the Health Standards Design, Analysis, and Support (HSDAS) programme.
Re-inspections are conducted for all health establishments which were found to be non-compliant during routine inspections. Such an inspection is conducted to check whether non-compliance has been remedied. The outcomes of inspections are communicated to the Certification and Enforcement unit (Programme 5). All health establishments found to be compliant are recommended for certification, while those found to be non-compliant are issued with a compliance notice. Health establishments that are found to be non-compliant after a re-inspection, are recommended for enforcement.
Programme 3: Complaints Management and Office of the Health Ombud
Complaints Management and Office of the Health Ombud considers, investigates and dispose of complaints relating to non-compliance with prescribed norms and standards in a procedurally fair, economical, and expeditious manner.
The Complaints Management Programme comprises three distinct but inter-related programmes:
Complaints Call Centre (CCC)
OHSC employs Call centre operators to receive complaints from the public through calls, emails, and written letters. They register, record, and screen all complaints received and refer them to the next level as appropriate. All low-risk complaints are addressed at the call centre level.
Complaints Assessment Unit (CAU)
All complaints that receive a medium or high-risk rating are referred to the CAU. OHSC employs assessors to analyse and assess medium and high-risk complaints. Cases assessed as high are further escalated to the Investigation Unit for investigation.
Complaints Investigation Unit (CIU)
The CIU receives all complaints with a high and extreme risk rating. Investigators investigate these complaints, which mainly require on-site visits to the Health Establishments and robust analysis of evidentiary documents.
Programme 4: Health Standards Design, Analysis and Support (HSDAS)
The Health Standards Design, Analysis, and Support programme provides high-level technical support to the office through research, health systems analysis, development of data collection tools, training in the use of these tools, and analysis and interpretation of the data collected. The programme also drives the establishment of stakeholder networks for capacity building and the co-creation of information management systems. The programme has two units:
- Health Standards Development and Training.
- Health Systems, Data Analysis, and Research.
Health Standards Development and Training
The Health Standards Development and Training unit advises the Ministry of Health on the development and review of norms and standards incorporated into regulations against which health establishments will be inspected. It also develops inspection tools designed to enable inspectors to measure compliance with norms and standards promulgated by the Minister of Health.
The unit provides training to inspectors, complaints assessors, and investigators on the developed and approved inspection tools before the commencement of inspections of various categories of health establishments. The unit conducts workshops with relevant authorities to ensure that those responsible for implementing norms and standards regulations have a common understanding of the requirements, the intended benefits of compliance, and how this can be achieved sustainably to improve the quality of the health system and its outcomes.
Health Systems, Data Analysis, and Research
The Health Systems, Data Analysis, and Research unit monitors trends related to compliance with norms and standards regulations through health establishments’ submission of annual returns (facility profiles) and reporting on indicators of risk as part of the early warning system (EWS). The information contained in annual returns is used to plan compliance inspections and undertake contextual analysis of inspection results. By closely tracking key indicators, the EWS enables the OHSC to monitor serious breaches of norms and standards regulations and resulting risks to the health and safety of health service users.
The unit triangulates data from the annual returns, the EWS, and inspections to compile reports, analyse the health system and make recommendations to relevant authorities on areas of service that require improvement. The unit co-ordinates research activities that enable the OHSC to provide advice to the Minister of Health on norms and standards to be prescribed. The aim is to ensure that recommendations for the improvement of quality and other regulatory activities are supported by scientific evidence.
Programme 5: Certification and Enforcement
The Certification and Enforcement programme certifies compliant health establishments and take enforcement action against non-compliant health establishments.
The programme is also responsible to publish information relating to certificates of compliance issued and enforcement actions taken against health establishments, this includes convening of ad hoc hearing tribunals for the purposes of enforcing compliance.
Certification of Compliant Health Establishments
A Certificate of Compliance issued by the OHSC is valid for a period of four (4) years and is renewable upon application by health establishments. The validity of the certificate may be suspended if a health establishment is found to have contravened the norms and standards post-issuance of the certificate of compliance. The process of certifying compliant health establishments is explained through the diagram below.
Compliance Enforcement
Enforcement actions that the OHSC may take against a person in charge of a health establishment which fails to comply with regulated norms and standards are provided for in the act. The Act implores the OHSC to adopt a progressive approach in its enforcement of compliance and to consider the nature, extent, gravity and severity of the contravention. In accordance with the act, the following are listed as possible actions:
- issue a written warning to achieve compliance within a set period in the manner prescribed.
- require a written response from the health establishment regarding the continued non-compliance.
- recommend to the relevant authority any appropriate and suitable action to be undertaken, including the institution of disciplinary proceedings against persons responsible for the non-compliance or continued non-compliance.
- revoke the certificate of compliance and recommend to the Minister the temporary or permanent closure of the health establishment or part thereof that constitutes a serious risk to public health or health service users.
- impose upon that person or health establishment a fine as determined by the Minister in the Gazette from time to time; or
- refer the matter to the National Prosecuting Authority for prosecution.
The diagram below illustrates the compliance enforcement process of by the OHSC:
