accreditation canada
TRANSCRIPT
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Accredited byAgéépar www.accreditation.cawww.accreditation.ca
Accreditation Canada’s
Qmentum Program:Rigorous, relevant & innovative
Accreditation Information SessionMississauga Halton and Central West LHINS
June 5th, 2009
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Presentation Outline
Accreditation Canada
Qmentum accreditation program
Framework
Self-assessment process Onsite survey
Reports
Looking forward
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Accreditation Canada’s Vision and Mission
Vision
The leader in raising the bar for health
quality
MissionDriving quality in health services through
accreditation Values
Excellence, integrity, respect, innovation
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Accreditation Program –
Facts and figures
Canadian accreditation program
incorporated in 1958
Not for profit organization
Funded by annual fees (min. $570) Cost-recovery for surveys
International program
Accredited by ISQua
Standards
Organization
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Accreditation Program –
Facts and figures
+550 peer surveyors
369 average surveys/year
+1000 client organizations - 3,000 sites
and facilities Recognized across the country and the
world
List of accredited organizations on ourwebsite
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Accreditation
Process that organizations use to
evaluate and to improve the quality of their services
Involves examining everyday activitiesand services against standards of excellence
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Benefits of accreditation
Increased organizational uptake of QI
initiatives
Enhanced use of indicators
Enabled change management Improved organizational learning
practices
Improved communication
Facilitated restructuring
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Standard format
Standard sectionStandard section
Standard subsectionStandard subsection
StandardStandard
GuidelinesGuidelines
CriteriaCriteria
Quality DimensionQuality Dimension
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Required Organizational Practices
A Required Organizational Practice (ROP)
is: an essential practice that organizations must
have in place to enhance patient/client safetyand minimize risk
a specific requirement for healthcareorganizations in the accreditation program
imbedded throughout the organizationincluding governance and service excellenceareas
Mental Health Specific – Suicide Prevention
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Qmentum Primer Program
Primer Report 2008
For new clients
A first step towards QI andaccreditation Identify basic elements of
safety and quality Establish supports, structures,
and processes required toachieve accreditation
Status good for 2 years
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More on primer…
Application process
$1,125 one time fee Quick and on-line
Deployment of 2 questionnaires
Client Staff
Primer survey visit
2 surveyors
Educational component
As early as 6 months post-approval
Report will provide next steps
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Accreditation Primer Organization staff and clientsrate service areas, and an on-site survey of basic qualityand safety elements isconducted, leading to an Accreditation Primer Award
EducationAccreditation Canadaintroduces Qmentumand addresses specificlearning needs
5 12 24 26 28 30 35 36MONTHS
Self-Assessment Process
Self-AssessmentOrganization staff assessservices against standards,and Accreditation Canadacategorizes the results usinggreen, yellow, and red flags.
Action PlanThe organization developsan action plan identifyingplanned qualityimprovement activities.
Data Collection•Indicator Data
Annually, the organization submits
data related to specific aspects of
patient / client safety and quality
care.
•Instrument DataOnce during the three year cycle,
the organization submits results
from the Governance Functioning
Tool, and thePatient Safety
Culture Tool and the Worklife Pulse
Tool.
Evidence of Action TakenThe organization submits updatedindicator data and evidence of actiontaken to address high priority issuesidentified in the self-assessment.
Customized Survey PlanA customized plan to guidethe on-site survey is jointlydeveloped.
Evidence of ActionTakenThe organization submitsupdated indicator dataand evidence of actiontaken to address highpriority issues.
On-site SurveySurveyors review andevaluate priority processesusing tracer activities.
Accreditation Reports•On-site Report
Summarizes the on-site
survey findings. The
organization has up to ten
days to respond.
•Forecast ReportContains the forecast
accreditation decision,
determined after a review of the
findings to date and the
organization’s response.
Final Report andAccreditation Decision
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The Self-Assessment questionnaires
What are they?
Tool for the organization’s use only Online questionnaires
Capture key areas of each standard section
content Tailored questionnaire for each standard section
Anonymous and time-sensitive
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Instruments and indicators
Instruments:
Patient Safety Culture Survey
Worklife Pulse
Board Functioning Tool Indicators:
Medication Reconciliation
MRSA and C. Difficile
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QPR –
Quality Performance Roadmap
Houses the results from:
Questionnaires
Indicators
Instruments Results displayed as flags
Priorities are assigned
Organization reviews the flagged itemsand set action plans
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Accreditation Primer Organization staff and clientsrate service areas, and an on-site survey of basic qualityand safety elements isconducted, leading to an Accreditation Primer Award
EducationAccreditation Canadaintroduces Qmentumand addresses specificlearning needs
5 12 24 26 28 30 35 36MONTHS
Self-Assessment Process
Self-AssessmentOrganization staff assessservices against standards,and Accreditation Canadacategorizes the results usinggreen, yellow, and red flags.
Action PlanThe organization developsan action plan identifyingplanned qualityimprovement activities.
Data Collection•Indicator Data
Annually, the organization submits
data related to specific aspects of
patient / client safety and quality
care.
•Instrument DataOnce during the three year cycle,
the organization submits results
from the Governance Functioning
Tool, and thePatient Safety
Culture Tool and the Worklife Pulse
Tool.
Evidence of Action TakenThe organization submits updatedindicator data and evidence of actiontaken to address high priority issuesidentified in the self-assessment.
Customized Survey PlanA customized plan to guidethe on-site survey is jointlydeveloped.
Evidence of ActionTakenThe organization submitsupdated indicator dataand evidence of actiontaken to address highpriority issues.
On-site SurveySurveyors review andevaluate priority processesusing tracer activities.
Accreditation Reports•On-site Report
Summarizes the on-sitesurvey findings. The
organization has up to ten
days to respond.
•Forecast ReportContains the forecast
accreditation decision,
determined after a review of the
findings to date and the
organization’s response.
Final Report andAccreditation Decision
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Survey Scheduling
Customized survey design tool is used
Organization Profile Information
Indicator Data
Draft Schedule
Revisions
Previous Survey Results
Business Rules
Data Source
Surveyor PortalFinal Schedule
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Priority Processes1. Planning and service
design
2. Emergency preparedness3. Communication4. Integrated quality
management5. Resource management
6. Human capital7. Principle-based care anddecision-making
8. Chronic diseasemanagement
9. Population health andwellness10. Patient flow11. Clinical leadership
12.Competency
13.Episode of care
14.Decision support
15.Impact on outcomes
16.Physical environment
17.Medical
devices/ equipment use18.Medication management
19.Infection prevention andcontrol
20. Diagnostic services
21. Blood services
22. Surgical procedures
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REVIEWclient files and
documents
Tracer Activities
TALK and LISTENindividual
interviews/discussions and
group discussions
OBSERVE
direct observationand tours
RECORDwhat is read,
heard and
seen
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Accreditation Primer Organization staff and clientsrate service areas, and an on-site survey of basic qualityand safety elements isconducted, leading to an Accreditation Primer Award
EducationAccreditation Canadaintroduces Qmentumand addresses specificlearning needs
5 12 24 26 28 30 35 36MONTHS
Self-Assessment Process
Self-AssessmentOrganization staff assessservices against standards,and Accreditation Canadacategorizes the results usinggreen, yellow, and red flags.
Action PlanThe organization developsan action plan identifyingplanned qualityimprovement activities.
Data Collection•Indicator Data
Annually, the organization submits
data related to specific aspects of
patient / client safety and quality
care.
•Instrument DataOnce during the three year cycle,
the organization submits results
from the Governance Functioning
Tool, and thePatient Safety
Culture Tool and the Worklife Pulse
Tool.
Evidence of Action TakenThe organization submits updatedindicator data and evidence of actiontaken to address high priority issuesidentified in the self-assessment.
Customized Survey PlanA customized plan to guidethe on-site survey is jointlydeveloped.
Evidence of ActionTakenThe organization submitsupdated indicator dataand evidence of actiontaken to address highpriority issues.
On-site SurveySurveyors review andevaluate priority processesusing tracer activities.
Accreditation Reports•On-site Report
Summarizes the on-sitesurvey findings. The
organization has up to ten
days to respond.
•Forecast ReportContains the forecast
accreditation decision,
determined after a review of the
findings to date and the
organization’s response.
Final Report andAccreditation Decision
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Issuing the Accreditation Reports
Accreditation Canada issuesreports which includes:
Surveyor commentary
List of unmet criteria
Organization commentary
Leading practices Award decision
Onsite report
Final report 6 months postsurvey visit showingprogress
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Accreditation decisions
Accreditation
Accreditation with conditions
Report
Focus visit Report and focus visit
Non-accreditation
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Accreditation Canada commitment
Accreditation Specialist support
throughout Resources
Educational sessions adapted to the sector DVDs, CDs and How-to Manuals
Web-based learning (webinars, webcasts)
IT technical support
Experienced surveyors
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Looking Forward
Customized portal for community-based
and smaller organizations Sector specific indicators and ROPs
Recognizing excellence Distinction
Leading practices
Client experience