The Danish National model for accreditation – how does it fit supervision Anne Mette Dons

The National Danish model for accreditation  Established in 2005  The long term aim is to include all Danish healthcare services and operate across the various sectors.  To be implemented in public hospital services in 2009  Pharmacies, municipalities and private hospitals will follow.

Organization  Refers to a board of directors, including the National Board of Health, the Ministry of Health and Prevention, the Danish Regions and Local Government in Denmark  The Director of the National Board of Health is also the director of the Board

The standards covers:  General areas such as medication, patient involvement, resuscitation and inter-sectorial transfer  The organizational area, with standards providing for management, data safety and technology  Several treatments of diseases such as gastric ulcers and diabetes  Four or more steps in each standard

5 Indicators Indicators, assessment points, are attached to each step. The indicators must ensure that the standard is implemented and used. ”The medical record contains documentation that the three initial prescriptions of medication during hospitalisation at the unit clearly sets out the dosage to be administered.” Guidance: The indicator is included in the semi-annual audit of records at the surgical, intensive care and other somatic care units as well as psychiatric units.

The proces of accreditation in DK  Self-evaluation  Mock-survey  Final survey  Final rapport/accreditation  Every 3 year:  Survey and accreditation is repeated  The standards are revised, and new standards are added

Supervisions role in accreditation  All mandatory requirements and guidelines from NBH are includes in the Standards  Role in the hearing process  Regular meetings with IKAS about patient safety issues  Focus areas from The Patient Safety Database in NBH can be taken into the model

Quality and supervision Good Quality Quality Bad Quality Supervision Acceptable medical standard

Problems?  Surveyors assess the level in which the organizations meet the standards.  Will this accreditation process find indicators of low patient safety?  Are Accredited hospitals a false safety?

More Differences Supervision  Focus on facts  Focus on exact result  Secure an acceptable medical standard  No assurances Accreditation  Focus on indicators  Focus on process  Quality Improvement  Stamp of accreditation

When is IKAS going to contact Supervision ?  When mandatory requirements are not met?  When accreditation demands are not met?  When unacceptable medical performance is documented?  What kind of remarks should lead to orientation of National Board of Health?  What kind of remarks should lead to investigation from National Board of health?  Will the organizations audits give useful information?

Will accreditation provide information on health personnel  Seldom, in case:  Identification of health care professionels with malpractice or lack of fittness to practice – identified during examining patients records durng the survey  Failure to fullfill a standard is caused by ONE person’s preformance Report to the local NBH