accreditation canada

8/3/2019 Accreditation Canada

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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



© Accreditation Canada− Agrément Canada 2

Presentation Outline

Accreditation Canada

Qmentum accreditation program

Framework

Self-assessment process Onsite survey

Reports

Looking forward




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




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




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



Benefits of accreditation

Increased organizational uptake of QI

initiatives

Enhanced use of indicators

Enabled change management Improved organizational learning

practices

Improved communication

Facilitated restructuring



Standard format

Standard sectionStandard section

Standard subsectionStandard subsection

StandardStandard

GuidelinesGuidelines

CriteriaCriteria

Quality DimensionQuality Dimension



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



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



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



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



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



Instruments and indicators

Instruments:

Patient Safety Culture Survey

Worklife Pulse

Board Functioning Tool Indicators:

Medication Reconciliation

MRSA and C. Difficile



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





5 12 24 26 28 30 35 36MONTHS








care.






Tool.






Summarizes the on-sitesurvey findings. The


days to respond.









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




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




REVIEWclient files and

documents

Tracer Activities

TALK and LISTENindividual

interviews/discussions and

group discussions

OBSERVE

direct observationand tours

RECORDwhat is read,

heard and

seen






5 12 24 26 28 30 35 36MONTHS








care.






Tool.






Summarizes the on-sitesurvey findings. The


days to respond.










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




Accreditation decisions

Accreditation

Accreditation with conditions

Report

Focus visit Report and focus visit

Non-accreditation




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




Looking Forward

Customized portal for community-based

and smaller organizations Sector specific indicators and ROPs

Recognizing excellence Distinction

Leading practices

Client experience



The leader in raising the bar for health quality

www accreditation cawww accreditation ca

accreditation canada

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