1. CCHSA Accreditation: New Standards for Managing Medications
Jessica Peters
Lead, Research & Product Development
CCHSA

2. Presentation Outline Vision, Mission and Values
The Accreditation Program
Program Enhancements
The New Standards for Managing Medications
Next Steps

3. CCHSA’s Vision and Mission
The leader in raising the bar for health quality
Mission
Driving quality in health services through accreditation

4. CCHSA’s Values
Within an environment focused on clients and committed to quality of worklife, partnerships, and personal growth, our values are:
Excellence
Integrity
Respect
Innovation

5. CCHSA’s Accreditation Program
Canadian accreditation program - incorporated in 1958
Not-for-profit
High participation rates; continued growth
Surveyors (approx. 400) are senior health care professionals
Surveys may be regional, institution specific, national or market specific (i.e. First Nations, Corrections, Canadian Forces)
Average 400+ surveys per year
Three year cycle
Both public and private organizations participate

7. Role of Accreditation
Quality Improvement – at the organization level and at the system level
Change management
Standards of excellence – raising the bar on health care
Standards of clinical practice
Governance
Leadership

8. CCHSA Standards Standards of excellence
‘Raise the bar’ for health care practice
Enable an organization/team to stretch to improve care, to reach or raise the bar
Developed with the input and guidance of experts in the field and updated on a regular basis to ensure relevance and value
Are applicable to different regions and service delivery settings
Will continue to be used by organizations, but in a new way
Describe that CCHSA standards continue to be…..
Standards are still the benchmarks but you will no longer use them to guide you through every step of the self-assessment. Physically, they will be more of a reference tool but the content will be embedded throughout the process. For example, the self-assessment will be partly administered through online questionnaires which are essentially a roll-up of the standards. The questionnaires use wording directly from the standards. But, that’s a topic for another day…
Draft target areas based on literature review, evidence, CCHSA experience
Input from experts, key informants
Draft standards
Extensive consultation with stakeholders
Revision process
Pilot testing
Standards finalized
* Ideas in and direction of standards are decided largely by those who will use them

9. Evolution of CCHSA Program
Speak to why/rationale for ever-evolving programs… i.e. changing environment, accountability, etc.

10. The New Accreditation Program
Benefits:
1. Standards that:
Capture the most recent governance/managerial and clinical best practices
Reflect the emerging trends or disease (and wellness) patterns in healthcare
Have an increased level of specificity
Can be used or integrated into the daily work of organizations
2. Streamlined and more flexible process that:
Supports and aligns better to an organizations’ quality improvement initiatives
Is adaptable no matter how small or how complex the organization may be
The design and development of the new accreditation program has been guided by the desire to realize the following benefits for client organizations

11. The New Accreditation Program
Benefits:
3. Greater focus on the provision of safe quality care and service in a variety of health care settings
4. Planned and predictable accreditation activities with a on-site survey that is customized to the organizations’ needs
5. Automated measurement tools that allow:
Greater and faster data exchange
Improved standardization and objectivity
The design and development of the new accreditation program has been guided by the desire to realize the following benefits for client organizations

12. The standards have a brand new structure…
Structure or configuration ?
New standards for laboratory, pharmacy, diagnostic imaging, operating room procedures, and other therapeutic -technologies are being developed — areas prone to significant risk and associated with the largest volume of adverse events. This new content will strengthen the way these elements are reviewed in the -accreditation program.
Ongoing and increased emphasis on population health
Increased attention to primary care, including emergency medical services, teletriage, and primary care networks
Enhanced outcome-related content
Focus on integrated quality management

13. Standards Areas EFFECTIVE AND SUSTAINABLE GOVERNANCE
PROACTIVE AND SUPPORTIVE ORGANIZATION
SERVICE EXCELLENCE
CCHSA standards are still organized into areas . Let us look at this a little more closely. This table outlines the new standards model.
Four (4) main standards areas are envisioned. These areas are:
Responsible and sustainable governance
Proactive and supportive Organization
Service Excellence (these are the revised Client Services/Care standards) –and include population-based standards, sector/service based standards, and new specific standards in some areas, i.e. infection prevention and control, managing medications, diagnostic imaging.
Positive Client Experience
POSITIVE CLIENT EXPERIENCE

14. Managing Medications: Background
The development of the new standards for managing medications was driven by:
Importance of safe medication management processes in protecting client safety
Feedback from client organizations and surveyors
Changing health care environment
Development began in 2004
Expert working group including representatives from organizations and ISMP-Canada
Standards circulated for consultation in late 2005 to approximately 15 organization

15. The New Standards for Managing Medications…
Standards target medication processes in an institutional setting, i.e. hospital, long term care
Focus on the safe use of medications from selection and procurement through administration
Address a number of key themes:
Working Together to Promote Medication Safety
Carefully Selecting and Procuring Medications
Properly Labelling and Storing Medications
Appropriately Ordering and Transcribing Medications
Accurately Preparing and Dispensing Medications
Safely Administering Medications to Clients
Monitoring Quality and Achieving Positive Results
CCHSA is currently exploring/testing the application of the standards in a wider range of organizations.

16. Working Together to Promote Medication Safety
Recognizing pharmacists and pharmacy staff as integral members of the interdisciplinary team
Actively involving the pharmacy staff in designing the organization’s medication use and medication management processes
Providing access to accurate medication-related information, formally approved drug information tools and education about safe medication use
Evaluating the competency of all service providers who participate in the medication use process

17. Carefully Selecting and Procuring Medications
Maintaining an up-to-date and evidence-based list of available medications
Minimizing the number of procured and available medications
Minimizing the medications available – includes the REQUIRED ORGANIZATIONAL PRACTICE: The organization standardizes and limits the number of drug concentrations available.

18. Properly Labeling And Storing Medications
Reducing the possibility of errors with drug product nomenclature, labeling, and packaging
Labeling all drug concentrations clearly and legibly
Providing suitable space for drug storage in pharmacies and client/unit medication areas
Carefully selecting stock drugs for each client area
Storing hazardous chemicals away from clients, service providers, and drug preparation areas
Selecting stock drugs – includes ROP: The organization has removed all concentrated electrolytes from client areas/units.

19. Ordering and Transcribing Medications Appropriately
Maintaining accessible and up-to-date client information
Communicating drug orders and other drug information in a standardized way
Reviewing all prescriptions or medication orders for accuracy and appropriateness

20. Accurately Preparing and Dispensing Medications
Preventing contamination when preparing medications
Dispensing medications in a safe, accurate, and timely way
Having a system to safely dispense medications where there is no internal pharmacy or when the pharmacy is closed
Transporting medication in a safe, secure, and timely manner way

21. Safely Administering Medications To Clients
Educating clients about their medications and delivery devices, and ways to prevent errors
Following a process to allow and monitor clients’ self-administration of their medications
Safely and accurately administers medications
Reducing the risk of error through careful procurement, maintenance, use, and standardization of medication delivery devices
Monitoring clients following medication administration
Medication administration: REQUIRED ORGANIZATIONAL PRACTICE: Service providers use at least two identifiers before administering medications.
Medication delivery devices: REQUIRED ORGANIZATIONAL PRACTICE: The organization provides all staff and service providers with ongoing, effective training on all infusion pumps.

22. Monitoring Quality And Achieving Positive Outcomes
Having a coordinated risk management program to reduce medication-related errors and sentinel events
Regularly monitoring and evaluating the quality of the medication management and pharmacy system

23. Current Status of the New Program
13 pilot sites will test various elements of the program starting March to December 2007
National consultation on standards
Customized transition plan for each client in 2008
Pan Canadian information sessions in major cities to support transition
Ongoing communication
CCHSA web site
teleconferences

24. The leader in raising the bar for health quality
Canadian Council on Health Services Accreditation
The leader in raising the bar for health quality