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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
What is Accreditation?
What is Accreditation?
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
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
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
What is Accreditation?
Myth Buster
“Patient safety is much more important than
Accreditation”
What is DAP Accreditation?
What is DAP 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
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
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
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
What is DAP Accreditation?
Plan
Check
DoAct
Accreditation
(Evaluative Tool)
Mandatory Requirements
Opps For Improvement
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”
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”
How does the DAP Accredit?
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?
How does the DAP Accredit?
Self Assessment Documentation
On-site Survey
Report & Recommendations
Mid-CycleAssessment
OrientationTraining, Education
3 Year Cycle
How does the DAP Accredit?
Planning Day Accreditation Specialist On-site, Teleconference, Telephone Orientation, Training and Education Facility profile developed Surveyor arrangements
How does the DAP Accredit?
Myth Buster
“It is all about the paperwork – policies,
guidelines and strategies that no one looks at”
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)
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
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
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
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
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