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Prepared for GAMES Spring 2014 AttendeesBy
Mary Nicholas, MHAPresident / CEO
HQAA, Inc.
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Planning & PreparationFailure is not a desired outcome with
accreditationNo one proceeds with accreditation with
the goal of failureWhat then are some of the pitfalls you
run in to preventing your planning and preparing?
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Planning & PreparationDay to day responsibilities often take priority over maintaining accreditation compliance
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Planning & PreparationWhy important?
Our data indicates that in the past 8 months for renewal surveys:
An average of 58% of all surveys had repeated deficiencies
Lowest percentage in a month = 40%Highest percentage in a month = 77%
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Planning & Preparation Where to begin?
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ExecutionLet’s look at the areas with the highest frequencies of
cited deficiencies:Human Resources area claims three of the top 5
cited deficiency areas:Lack of demonstrated compliance to maintaining a
Competency Program = # 1Maintaining Personnel Files = # 2 Maintaining Annual Educational Programs = #3
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ExecutionEmployee Competency Create a process – assign responsibility
Start at the time of hire: observe person completing tasks they were hired to perform
Annually ensure the same checklist is evaluated; update it as tasks & skill levels change
Create opportunities for staff to observe each other; provide feedback and discussion
Ensure opportunities for learning are included in annual education calendar
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Execution
Personnel Files Use the standard(s) as your guide for what is required Ensure someone is responsible for upkeep
Maintain all files in consistent manner Place a checklist in each file and note when components
required are filed, updated, added Ensure secure storage
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ExecutionAnnual Education Program
Again, use the standard as your guide (mandatory vs. non) Designate someone to schedule, manage and implement
If using a 3rd Party Education Program, assign specific courses to each employee; track progress
Ask employees what types of courses interest them Bring experts in for all staff meetings Use sign in sheets for validation
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ExecutionThe next two highest cited deficiencies are:
Infection Control = 34% of surveys
Quality Management = 34% of surveys
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ExecutionInfection Control Thoroughly review expectations of the standard Maintaining a Clean, Safe & Organized Work Environment is where we’ve found the deficiencies
Know what your policy states you comply with Educate all on safety issues with the chemicals they
encounter Separation of clean & dirty items Involve several employees in maintaining items Complete a checklist daily/weekly/monthly – turn in
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ExecutionQuality MonitoringThe general concept of having, implementing, maintaining a QI program is inconsistent
Generally placing one person in charge to manage helps to keep it running
Break down requirements based upon standard• Define how each performance measurement is managed• Integrate actions across staff positions; include EVERYONE• Create a structure to keep on task
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Quality Management ProgramChart
QualityManagement
Program
PatientSatisfaction
FinancialPerformance
Targets
AdverseEvents
BusinessActivity
Timelinesswith
Customers
Other
Other
Other Other
Other
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Plan * Do * Study * Act
PLAN
DO
STUDY
ACT
Plot out the approach
Implement the plan
Analyze the results
Set the plan in motion; go back to thebeginning if needed
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For QI Quarterly Reports: Bring all P*D*S*A projects to meetings or offer written reports to central person
Speak to the progress being made How was the planning done? What happened when implemented? Improve? No
improvement? When analyzing, was it apparent what went wrong? What went
right? In implementing, has the process improved to your satisfaction?
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For QI Quarterly Reports: Use a specific format to the meetings / for the meeting minutes
Bring issues relating to processes Talk through what goes on before and what goes on after
each process: Input – Throughput – Output Report progress and recommendations if less than
expected Document * Document * Document
Who was at meeting ID the date / time Outline discussion items and action items File the “minutes” in same place always
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DiscussionWhat areas are you experiencing the most difficulty? What ideas can you share to help others? Resource Handout – FREE access to aids to help organize
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Thank you very much!
Mary Nicholas, MHAPresident / CEO
Healthcare Quality Association on Accreditation866.690.9851