Diagnostic Accreditation Program Accreditation Basics Helen Healey RN, BScN Director, Accreditation...

Diagnostic Accreditation Program

Accreditation Basics

Helen Healey RN, BScN

Director, Accreditation Services, DAP

Accreditation Basics

What is Accreditation?

What is DAP Accreditation?

Why be Accredited?

How does the DAP Accredit?

How to use Accreditation for Improvement


Process for the external evaluation of healthcare services

A formal process to ensure delivery of safe, high quality health care

Based on standards and processes devised and developed by health care professionals for health care services

A process using the skills of external peers trained and appointed as a team of assessors


Accreditation is one of a variety of strategies

that health care organizations adopt: in response to legislative requirements funding is contingent of them doing so to validate and continuously improve safety

and quality systems


Internationally models are evolving of external

assessment of health care services

Increasingly used to improve and promote health

care service to meet changing demands: public accountability clinical effectiveness improving the quality and safety of services

and their outcomes


Myth Buster

“Patient safety is much more important than

Accreditation”


History Started in 1971 as a Joint Program of the BC

Medical Association and College of Physicians and Surgeons of BC (CPSBC)

Became an independent Society operating under the Medical Practitioners Act, as a Program of the CPSBC


Authority DAP derives its authority from the Rules

Made Under the Medical Practitioners Act

No physician can work in, nor refer to a non accredited facility


Mandate Accrediting private and public diagnostic services

in BC Promoting excellence in diagnostic health care by:

Setting standards consistent with professional knowledge

Evaluating actual performance with peer review surveys, and proficiency testing

Providing education and consultation on improvement strategies and best practices


DAP Model Enabling health care organizations to review and

improve systems that support the delivery of safe,

high quality diagnostic health care

Accreditation evaluates: Quality Quality improvement Risk


Plan

Check

DoAct

Accreditation

(Evaluative Tool)

Mandatory Requirements

Opps For Improvement


Myth buster

“ My staff are very anxious about the Inspectors coming and what they will be asked. We are tying to get all our policies ready in time”

Why be Accredited?

Why be accredited?

Provides an independent external survey, by peers, of an organizations level of performance in relation to Provincial standards

Guides healthcare organizations to identify their strengths and also the limitations of the services they are providing

Why be accredited?

Strong motivational lever for organizations to review their operations and improve in areas where deficits exist

Articulate levels of expected performance through the establishment of standards and monitoring of compliance

Demonstrates an organizations commitment to achieving high quality and safe care for patients residents

Why be accredited?

Provides an award of accreditation which is intended to be an assurance that at a particular point in time a health care organization had instituted structure and was adhering to process designed to indentify, mitigate, and appropriately respond to risks, and achieving acceptable outcomes

Neither accreditation or any quality system can assure that an adverse event will not occur in a health care organization

Why be accredited?

Myth Buster

“Accreditation is not proven to improve quality”

Accreditation at a facility/departmental level

Standards & criteria directed at operations

Individuals involved responsible for operation of the service, and providers of service



Self Assessment Documentation

On-site Survey

Report & Recommendations

Mid-CycleAssessment

OrientationTraining, Education

3 Year Cycle


Planning Day Accreditation Specialist On-site, Teleconference, Telephone Orientation, Training and Education Facility profile developed Surveyor arrangements


Myth Buster

“It is all about the paperwork – policies,

guidelines and strategies that no one looks at”


Self assessment: Each diagnostic service completed a self

assessment

Diagnostic service rates criterion on a scale indicating achievement of goal (degree of compliance)

How does the DAP Accredit?Patients & Clients Served

MANAGEMENT STANDARDS

Leadership & Management Human ResourcesInformatics Suppliers & PartnersPatient & Client Focus SafetyQuality Improvement

Diagnostic ImagingRadiologyUltrasoundMammographyNuclear MedicineMRICTEchocardiographyBone Densitometry

Laboratory MedicineSample Collection, Transport, AccessioningChemistryMicrobiologyTransfusion MedicineHematologyAnatomic PathologyPoint of Care Testing

NeurodiagnosticsEEG & Evoked PotentialsEMG & Nerve Conduction Studies

Pulmonary Function

Polysomnography

DISCIPLINE/MODALITY STANDARDS


Two common approaches are:

Team approach – create groups of people to complete the self assessment by dividing areas of responsibility among each group

Individual(s) completes entire self-assessment


On-Site Survey Team of external peer surveyors that are in

active practice Team membership includes medical,

technical, and management surveyors Survey team conducts external assessment

by visiting facilities, observing processes, reviewing documentation, discussion with staff

Medical Surveyor observes from location where medical consultation/interpretation takes place


DAP prepares Report The Accreditation Award Summary of best practice and commendations

as identified by the surveyors Mandatory Requirements with accompanying

time frame for follow-up Opportunities for Improvement Facility Self Assessment Protocol sheets as completed by the surveyors

How does the DAP Accredit Facilities?

Myth Buster

“It is a cosy relationship between surveyor and

senior staff – no one wants to fail their peers”

Continuous Quality Improvement

Plan

Check

DoAct

What are we trying to accomplish?

How are we going to know that a change is an improvement?

What changes can we make that will result in improvement?

Nolan et al

Shewart

Diagnostic Accreditation Program Accreditation Basics Helen Healey RN, BScN Director, Accreditation...

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