Accreditation Canadas Qmentum Program: Rigorous, relevant & innovative

Accreditation Information Session Mississauga Halton and Central West LHINS June 5th, 2009
Accredited by Ag par

www.accreditation.ca

Presentation Outline
Accreditation Canada Qmentum accreditation program
Framework Self-assessment process Onsite survey Reports

Looking forward

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Accreditation Canadas Vision and Mission Vision

The leader in raising the bar for health quality

Mission
Driving quality in health services through accreditation

Values
Excellence, integrity, respect, innovation
Accreditation Canada Agrment Canada

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 Canada Agrment Canada

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 our website
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Accreditation Canada Agrment Canada

Accreditation
Process that organizations use to evaluate and to improve the quality of their services Involves examining everyday activities and services against standards of excellence

Accreditation Canada Agrment Canada

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 section Standard subsection

Quality Dimension

Standard Criteria

Guidelines
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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 safety and minimize risk a specific requirement for healthcare organizations in the accreditation program imbedded throughout the organization including governance and service excellence areas Mental Health Specific Suicide Prevention
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Accreditation Canada Agrment Canada

Qmentum Primer Program

For new clients A first step towards QI and accreditation Identify basic elements of safety and quality Establish supports, structures, and processes required to achieve accreditation Status good for 2 years

Primer Report 2008

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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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Organization staff assess services against standards, and Accreditation Canada categorizes the results using green, yellow, and red flags.

Self-Assessment

The organization develops an action plan identifying planned quality improvement activities.

Action Plan

A customized plan to guide the on-site survey is jointly developed.

Customized Survey Plan

Evidence of Action Taken

The organization submits updated indicator data and evidence of action taken to address high priority issues. Final Report and Accreditation Decision

Organization staff and clients rate service areas, and an onsite survey of basic quality and safety elements is conducted, leading to an Accreditation Primer Award

Accreditation Primer

Self-Assessment Process MONTHS

12

24

26

28

30

35

36

Accreditation Canada introduces Qmentum and addresses specific learning needs

Education

Data Collection
Indicator Data Annually, the organization submits data related to specific aspects of patient / client safety and quality care. Instrument Data Once during the three year cycle, the organization submits results from the Governance Functioning Tool, and the Patient Safety Culture Tool and the Worklife Pulse Tool.

Evidence of Action Taken

On-site Survey

The organization submits updated indicator data and evidence of action taken to address high priority issues identified in the self-assessment.

Surveyors review and evaluate priority processes using tracer activities.

Accreditation Reports
On-site Report

Summarizes the on-site survey findings. The organization has up to ten days to respond.
Forecast Report

Contains the forecast accreditation decision, determined after a review of the findings to date and the organizations response.

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The Self-Assessment questionnaires

What are they?
Tool for the organizations 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 items and set action plans
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Accreditation Canada Agrment Canada

Organization staff assess services against standards, and Accreditation Canada categorizes the results using green, yellow, and red flags.

Self-Assessment

The organization develops an action plan identifying planned quality improvement activities.

Action Plan

A customized plan to guide the on-site survey is jointly developed.

Customized Survey Plan

Evidence of Action Taken

The organization submits updated indicator data and evidence of action taken to address high priority issues. Final Report and Accreditation Decision

Organization staff and clients rate service areas, and an onsite survey of basic quality and safety elements is conducted, leading to an Accreditation Primer Award

Accreditation Primer

Self-Assessment Process MONTHS

12

24

26

28

30

35

36

Accreditation Canada introduces Qmentum and addresses specific learning needs

Education

Data Collection
Indicator Data Annually, the organization submits data related to specific aspects of patient / client safety and quality care. Instrument Data Once during the three year cycle, the organization submits results from the Governance Functioning Tool, and the Patient Safety Culture Tool and the Worklife Pulse Tool.

Evidence of Action Taken

On-site Survey

The organization submits updated indicator data and evidence of action taken to address high priority issues identified in the self-assessment.

Surveyors review and evaluate priority processes using tracer activities.

Accreditation Reports
On-site Report

Summarizes the on-site survey findings. The organization has up to ten days to respond.
Forecast Report

Contains the forecast accreditation decision, determined after a review of the findings to date and the organizations response.

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Survey Scheduling
Customized survey design tool is used
Data Source
Organization Profile Information Previous Survey Results Indicator Data

Business Rules Revisions Draft Schedule

Final Schedule

Surveyor Portal

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Priority Processes
1.
Planning and service design 2. Emergency preparedness 3. Communication 4. Integrated quality management 5. Resource management 6. Human capital 7. Principle-based care and decision-making 8. Chronic disease management 9. Population health and wellness 10. Patient flow 11. Clinical leadership

12.Competency 13.Episode of care 14.Decision support 15.Impact on outcomes 16.Physical environment 17.Medical

devices/equipment use 18.Medication management 19.Infection prevention and control 20. Diagnostic services 21. Blood services 22. Surgical procedures

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Tracer Activities
REVIEW client files and documents

RECORD what is read, heard and seen

TALK and LISTEN individual interviews/ discussions and group discussions

OBSERVE direct observation and tours

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Organization staff assess services against standards, and Accreditation Canada categorizes the results using green, yellow, and red flags.

Self-Assessment

The organization develops an action plan identifying planned quality improvement activities.

Action Plan

A customized plan to guide the on-site survey is jointly developed.

Customized Survey Plan

Evidence of Action Taken

The organization submits updated indicator data and evidence of action taken to address high priority issues. Final Report and Accreditation Decision

Organization staff and clients rate service areas, and an onsite survey of basic quality and safety elements is conducted, leading to an Accreditation Primer Award

Accreditation Primer

Self-Assessment Process MONTHS

12

24

26

28

30

35

36

Accreditation Canada introduces Qmentum and addresses specific learning needs

Education

Data Collection
Indicator Data Annually, the organization submits data related to specific aspects of patient / client safety and quality care. Instrument Data Once during the three year cycle, the organization submits results from the Governance Functioning Tool, and the Patient Safety Culture Tool and the Worklife Pulse Tool.

Evidence of Action Taken

On-site Survey

The organization submits updated indicator data and evidence of action taken to address high priority issues identified in the self-assessment.

Surveyors review and evaluate priority processes using tracer activities.

Accreditation Reports
On-site Report

Summarizes the on-site survey findings. The organization has up to ten days to respond.
Forecast Report

Contains the forecast accreditation decision, determined after a review of the findings to date and the organizations response.

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Issuing the Accreditation Reports

Accreditation Canada issues reports which includes:
Surveyor commentary List of unmet criteria Organization commentary Leading practices Award decision

Onsite report Final report 6 months post survey visit showing progress
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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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Accreditation Canada Agrment Canada

Looking Forward
Customized portal for community-based and smaller organizations Sector specific indicators and ROPs Recognizing excellence
Distinction Leading practices

Client experience

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The leader in raising the bar for health quality

www.accreditation.ca