1. Diagnostic Accreditation Program Accreditation Basics Helen Healey RN, BScN Director, Accreditation Services, DAP

2. Accreditation Basics  What is Accreditation?  What is DAP Accreditation?  Why be Accredited?  How does the DAP Accredit?  How to use Accreditation for Improvement

3. What is Accreditation?

4.  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

5. What is Accreditation? 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

6. What is Accreditation? 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

7. What is Accreditation? Myth Buster “Patient safety is much more important than Accreditation”

8. What is DAP Accreditation?

9. 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

10. What is DAP Accreditation? 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

11. What is DAP Accreditation? 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

12. What is DAP Accreditation? 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

13. What is DAP Accreditation? Plan Check DoAct Accreditation (Evaluative Tool) Mandatory Requirements Opps For Improvement

14. What is DAP Accreditation? 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”

15. Why be Accredited?

16. 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

17. 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

18. 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

19. Why be accredited? Myth Buster “Accreditation is not proven to improve quality”

20. How does the DAP Accredit?

21.  Accreditation at a facility/departmental level  Standards & criteria directed at operations  Individuals involved responsible for operation of the service, and providers of service How does the DAP Accredit?

22. 3 Year Cycle

23. How does the DAP Accredit? Planning Day  Accreditation Specialist  On-site, Teleconference, Telephone  Orientation, Training and Education  Facility profile developed  Surveyor arrangements

24. How does the DAP Accredit? Myth Buster “It is all about the paperwork – policies, guidelines and strategies that no one looks at”

25. How does the DAP Accredit? Self assessment:  Each diagnostic service completed a self assessment  Diagnostic service rates criterion on a scale indicating achievement of goal (degree of compliance)

26. How does the DAP Accredit? Patients & Clients Served MANAGEMENT STANDARDS Leadership & ManagementHuman Resources InformaticsSuppliers & Partners Patient & Client FocusSafety Quality Improvement Diagnostic Imaging  Radiology  Ultrasound  Mammography  Nuclear Medicine  MRI  CT  Echocardiography  Bone Densitometry Laboratory Medicine  Sample Collection, Transport, Accessioning  Chemistry  Microbiology  Transfusion Medicine  Hematology  Anatomic Pathology  Point of Care Testing Neurodiagnostics  EEG & Evoked Potentials  EMG & Nerve Conduction Studies Pulmonary Function Polysomnography DISCIPLINE/MODALITY STANDARDS

27. How does the DAP Accredit? 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

28. How does the DAP Accredit? 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

29. How does the DAP Accredit? 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

30. 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”

31. 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