Table 3

Qualitative exploration of the quality programme assessment

Participating service and intervieweeText referenceSubcategorySupporting quote
1. Western Cape
Director-level participant
1.1Leadership“We’re at the disadvantage where [the director] who normally drives this [quality] has been away for probably almost two years now and as a consequence, much of these questions where we had answered reasonably well before, realistically speaking we are nowhere near that because the person responsible for coordinating that has not been here”
1.2Mandate“I’m of the view that in the South African context, we are a logistics company, we are not a medical company…we are a transport system”
1.3Historical factors“Because of the nature of the South African services, because of the socio-political aspects of the way cities are structured in South Africa, particularly in Cape Town, response time performance had to be prioritised, due to spatial divide… our cities are racially designed which means in a post-democratic country, in a way to break that up, you have to put a transport system in place, so that the racial divide, the inequity isn’t perpetuated, and where you don’t have a public transport system, when it comes to healthcare, that’s the primary purpose of ambulance service”
1.4Safety“so, what has happened as a consequence of safety, as a consequence of all of these ambulance attacks, one of the things we’ve had to do, we’ve had to engage with the community more often, so what is happening relatively frequently, is we attend patient health forums. The district managers must attend or send a representative to every community health forum meeting or community safety forum meeting. So, at these sessions, a patient voice invariably comes through”
2. KwaZulu Natal
Deputy Director-level participant
2.1Structure“EMS in KwaZulu Natal has a provincial M&E (measurement and evaluation) manager and then one FIO (facility information officer) per district. We have eleven districts in total. Information and quality currently measured are focused on service delivery. The quality of medical care provided to patients is an area that is currently lacking. A set of indicators is reported on monthly by each district using an excel spreadsheet, this is a huge challenge as data is manually captured at each level from the source to final consolidation and reporting”
2.2“We do have a quality plan in place. This is reviewed annually. The plan takes into account available resources, available budget and timeframes. The plan contains mainly issues around service delivery and strategies to improve service delivery. The plan is reviewed by the EMS management team which includes the EMS provincial management team and EMS district managers.”
2.3Mandate“When we measure quality of services, we look at the national norms currently available together with the demand for services. Firstly, we look at available resources and how we compare to the 1 ambulance per 10 000 population national norm. Then we look at the demand for services—what the available resources had to attend to. And then we look at the percentage P1 cases responded to within the national norms. These are all viewed as a piece of the complete puzzle and should not be measured or reported on independently as the picture will be incomplete. The assumption is that, if you have 1 ambulance per 10 000 population then you should be able to achieve the response time norms to P1 cases taking into account your case load has not spiked due to any unforeseen circumstance”
2.4“This is the focus of our performance measured on a continuous basis where trends are monitored on a monthly, quarterly and annual basis. Other quality indicators are measured as and when required, particularly if we have a special project or intervention in place.”
2.5Engagement“performance results are presented at our EMS management team forum and distributed to districts by the provincial M&E manager. EMS district managers are encouraged to present their performance to staff at all levels within the districts, but this is not happening in all districts”
2.6“As EMS we do not have much public engagement regarding our performance however our performance reports are included in the departmental annual reports which are public documents. These are also discussed at public imbizo events where the public has an opportunity to pose questions, concerns, comments to the departments senior management where EMS is represented”
3. Limpopo
Director-level participant
3.1Strategic planning“The EMS plan fits into the broader department strategic plans, where we have a section that is focused on EMS… the strategic plans are updated and planned for over several years and then re-evaluated at the end of that period. Where we have failed to reach a target or goal, we re-incorporate those projects into future plans”
3.2Relationships“We form part of the (health) departments system as a whole and filter into the departments committees… for me the most important thing is the relationship we have with them. I would rather we have someone with an understanding of quality and quality systems and improve their understanding of EMS, than have someone from EMS and need to bring their understanding up to understand quality. But either way, for me the most important thing is still about the relationship we have with them”
3.3“We measure quality through response times targets, through the number of complaints, and from feedback from the facilities we take patients to. Their feedback about the interaction with our staff is very important to me.”
3.4Attitude“The attitude of the staff is very important to me, and that’s one of the biggest improvements we have planned for… It will be very difficult, but we want to involve organized labour, and invite them to be a part of the process… here they determine success or failure and that’s why I want to make sure they have buy-in to the process and provide feedback”
3.5Technology“Having systems in place such as CAD systems will allow us to monitor everything involving staff, vehicles, how they are used, all of which will allow us to monitor our performance more closely and to make the sure the staff are held responsible and accountable, because this will also allow us to provide extra information to the public as a measure of our performance as well”
4. North West
Director-level participant
4.1Structure“We’re not a provincialized service, we’re a totally decentralised service, each EMS station reports to the subdistrict they are in, so there’s no provincial structure. Currently we are the only province that is like that… Basically we’ve got like 19 different EMS services in the North West.”
4.2Staff capacity“we lost a lot of them to OSD (occupational specific dispensation) …the OSD has shot us in the foot. We’re losing a lot of staff because we can’t retain them, so we’re training, but we’re actually training for [other services)”
4.3Non-personal resources“I’m finding out from research that we don’t need such a high amount of ambulances, we need to be focusing more on planned patient transport, because 65% of our calls are actually P3, so we’re using a very expensive resource to transport something that we don’t need to transport”
4.4Technology“the unfortunate thing is all our stuff is paper-based, and we don’t have a digital system. So, we are moving towards a digital communication system, but currently it’s very easy to lie to your statistics, so I cannot trust the information given to me”
5. Private Service
Senior manager-level participant
5.1Leadership“We’re probably as good as a 5 as you can get, in my opinion. [Representatives] From the CEO, to the operational crews sit on a clinical committee, there’s a quality assurance manager that sits at an executive level, and all of this works through, it’s all auditable through minutes and committee meetings that report into the executive committee”
5.2Representation“we’ve got representatives from cross the organisation sitting on the clinical panel to discuss what the consumer wants, what training needs to be provided, what operations is currently doing and where the operations within operations is needed”
5.3Improvement focus“If we’re doing a quality improvement project, if it gets written down as a quality improvement project, and not just an intervention, then we do put the assurances in place, putting in the checks to monitor it over and time and then look at whether there’s a consistent change in behaviour or not”
5.4Fit for purpose“our biggest problems in terms of this are systems. We often review stuff, and we often see, and we might know what quality indicators to use, but the problem comes in that the system we currently have is, manual, and very hard to change any kind of quality indicators, because it’s an accounting system that we’re using for quality indicators essentially, and it’s still paper-based, and manually captured”
5.5Patient/community engagement“In terms of a structured patient satisfaction assessment, we do have that. In terms of having a point of entry into the business for patients concerns to be brought up, we do have that, that’s very well developed at [parent company]. I think the problem comes in when you start talking about patient or community engagement when it comes to patient centred events, and I don’t think we’re there yet.”
  • EMS, emergency medical services.