LEADING THE ACCREDITATION PRIMER PROCESS
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TM MC LEADING THE ACCREDITATION PRIMER PROCESS A How-to Manual for Accreditation Coordinators and Accreditation Primer Teams
Transcript of LEADING THE ACCREDITATION PRIMER PROCESS
TM
MC
LEADING THE ACCREDITATION PRIMER PROCESS
A How-to Manual for Accreditation Coordinators and Accreditation Primer Teams
Leading the Accreditation Primer Process
A How-to Manual for Accreditation Coordinators and Accreditation Primer TeamsPublished by Accreditation Canada.
All rights reserved.
No part of this publication may be reproduced, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without proper written permission from Accreditation Canada.
© Accreditation Canada, 2009 (Revised version November 2010)
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www.accreditation.ca
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CONTENTS
SECTION 1 OVERVIEW OF THE ACCREDITATION PRIMER ............................................ 1
SECTION 2 GETTING READY FOR THE ACCREDITATION PRIMER ............................... 32.1 Designate an Accreditation Coordinator ........................................................ 32.2 Access the Organization Portal ...................................................................... 32.3 Convene an Accreditation Primer Team ........................................................ 3
SECTION 3 COORDINATING THE CLIENT AND ORGANIZATION QUESTIONNAIRES .............................................................................................. 53.1 Coordinating the Client Questionnaires ........................................................ 53.2 Coordinating the Organization Questionnaires ............................................. 73.3 Receiving the results through the Quality Performance Roadmap ................ 8
SECTION 4 BUILDING THE ACTION PLAN ....................................................................... 104.1 Analyze results from the Quality Performance Roadmap .......................... 104.2 Establish an action plan ............................................................................... 104.3 Submit evidence of action taken .................................................................. 10
SECTION 5 DEVELOPING THE CUSTOMIZED ON-SITE SURVEY PLAN ...................... 125.1 Update the organization profi le .................................................................... 125.2 Ensure accurate data ................................................................................... 125.3 Review draft on-site survey plan ................................................................. 125.4 Participate in the pre-survey teleconference ................................................ 13
SECTION 6 ORGANIZING THE ON-SITE SURVEY (LOGISTICS) .................................... 146.1 Reserve space and equipment for surveyors and debriefi ngs ...................... 146.2 Arrange meetings ......................................................................................... 146.3 Collect advance documentation ................................................................... 146.4 Educate staff and clients about the on-site survey ...................................... 156.5 Identify key staff members ......................................................................... 16
SECTION 7 HAVING THE ON-SITE SURVEY ..................................................................... 177.1 Surveyor planning session ........................................................................... 217.2 Introductory meeting ......................................................................... 217.3 Priority processes and tracers ...................................................................... 217.4 Surveyor information exchange ................................................................... 237.5 Daily review with Accreditation Coordinator .............................................. 237.6 Surveyors: completion of the on-site survey ............................................... 247.7 Debriefi ng sessions (leadership and general) .............................................. 24
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SECTION 8 THE PROGRESS DECISION .............................................................................. 268.1 Receive the Progress Decision .................................................................... 26
SECTION 9 EVALUATION, ONGOING SUPPORT AND RESOURCES ............................. 28
GLOSSARY ............................................................................................................................... 29
APPENDIX A ACCREDITATION PRIMER ORGANIZATION CHECKLIST......................... 31
APPENDIX B DOCUMENTATION LIST .................................................................................. 33
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SECTION 1 OVERVIEW OF THE ACCREDITATION PRIMER
The Accreditation Primer is the fi rst step in the accreditation journey for a new client organization. It is an opportunity for the organization and Accreditation Canada to work together to establish the supports, structures, and processes necessary for accreditation, with a particular focus on fundamental elements of quality and safety.
All of Accreditation Canada’s programs focus on the development and use of national standards of excellence to assist organizations to improve the quality and safety of their services. During the Accreditation Primer, organization staff and a representative sample of clients answer questionnaires related to quality and safety. The staff questionnaire is done online, while the client questionnaire is paper-based. Results are used to identify areas for improvement and determine priorities for action.
Subsequently, an on-site survey is conducted by two surveyors. The surveyors validate questionnaire results and assist with action planning.
Organizations that successfully complete the Accreditation Primer are issued an Accreditation Primer Award and move into the next phase of Qmentum. Some of these organizations proceed directly to preparing for their Qmentum on-site survey while others are required to take action on issues identifi ed in the Primer before beginning to plan for their Qmentum on-site survey. Organizations that successfully complete the Primer are accredited and are eligible to receive the Accreditation Canada banner and seal. Those that do not successfully complete the Accreditation Primer are required to address identifi ed issues and repeat the Primer.
Timing• The Accreditation Primer can only be repeated once; after an unsuccessful
second attempt, the organization loses its Candidate for Accreditation status.
• Organizations that are accredited under the Primer must complete their Qmentum on-site survey within two years of completing the Primer.
The Primer Arrow
The Primer Arrow on the following page shows timelines and activities.
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SECTION 2 GETTING READY FOR THE ACCREDITATION PRIMER
2.1 Designate an Accreditation Coordinator
The fi rst step in preparing for the Accreditation Primer is for the organization to designate an Accreditation Coordinator who oversees the Primer process and serves as the primary contact between Accreditation Canada and the organization.
The Accreditation Coordinator is responsible for accessing the Organization Portal (see below), entering information on the Portal, and ensuring organizational information is accurate and up-to-date. The Accreditation Coordinator also helps coordinate the questionnaires and organize logistics for the on-site survey.
2.2 Access the Organization Portal
The Accreditation Coordinator uses an organization code and password provided by Accreditation Canada during the application process to access the online, secure Organization Portal. Much of the work done during the Accreditation Primer is facilitated through the Portal. Accreditation Canada has a team of technical support advisors available to help with questions or problems.
Once the Organization Portal has been accessed, the Accreditation Coordinator completes the organization profi le which asks for key information about the organization, including structure, size, number of locations, planning and service design and type of services offered.
2.3 Convene an Accreditation Primer Team
The Accreditation Coordinator convenes an Accreditation Primer team that may include quality improvement staff, organization leaders or managers, or others. The team should include those who will act as “champions” for the accreditation process in the organization. The team works with the Accreditation Coordinator to coordinate completion of the client and staff questionnaires, analyze the results, and prepare and carry out action plans.
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Once the Accreditation Primer team is identifi ed, the Coordinator enters team member names into the Organization Portal.
RECAP GETTING READY FOR THE ACCREDITATION PRIMER
What steps should have been completed by now?
A Primer Coordinator has been designated to manage the accreditation Primer process.
The Primer Coordinator has accessed the Organization Portal, and understands its various components and how to navigate through them.
An Accreditation Primer team has been formed.
Organization profile information and team member names have been entered into the Organization Portal.
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SECTION 3 COORDINATING THE CLIENT AND ORGANIZATION QUESTIONNAIRES
Accreditation Canada knows the value of obtaining numerous perspectives when assessing quality in health care organizations. To this end, both clients and staff are asked to respond to questionnaires that collect information about the organization’s basic elements of safety and quality.
As part of the structured accreditation process, the organization and staff questionnaires help the organization assess its current performance against standards and determine which areas require review and follow-up. The organization can then begin to develop action plans to address these areas.
3.1 Coordinating the Client Questionnaires
Most Accreditation Canada questionnaires are completed online. The Primer client questionnaire is an exception. It is an anonymous, paper-based questionnaire that asks for clients’ perspectives on access to services, client-centred care, infection control, the physical environment, provider competency, and medication management. To coordinate completion of the questionnaires, the Coordinator:
1. Chooses a sampling group and decides on a time period
A representative sample of current clients, patients or residents is chosen to fi ll out the questionnaire. The larger the sample, the more information will be available about how clients perceive the quality of the care and services they receive. A time period for distribution and collection is established.
2. Downloads and prints one copy of the questionnaire per respondent
Each print-out has a code, so one copy per respondent must be printed. Photocopies cannot be used or the Accreditation Canada system will not tabulate the responses accurately.
3. Shares the task If the sample size is large, several team members may be tasked
with printing out and distributing the questionnaires.
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4. Collects the sealed questionnaires and forwards them to Accreditation Canada
One way to collect the questionnaires is to set up drop boxes where clients can leave their sealed questionnaires. The sealed questionnaires can then be forwarded to Accreditation Canada for scanning and tabulation. The results are posted on the Organization Portal.
A sample client questionnaire:
Topic Area and Question Yes No N/A
Access to Services
1. I am able to access the care or services I need, when I need them.
2. When there are delays in receiving care or services, I am told how long I would have to wait.
3. When I need other health services, I am told about what’s available and who to contact.
Client Centred Care
4. The people who provide my services are respectful and caring.
5. The people who provide my care and services help me understand my condition and my options for care or treatment .
6. The people who provide my care or services answer my questions and provide information when I need it.
7. When I need help to understand language or other information about care or services, it is given to me.
8. The people who provide my care or services involve me to make decisions about my care or services.
9. The people who provide my care or services make sure I agree before starting any treatments or medical procedures.
10. The people who provide my care or services help me learn how to safely care for myself.
Provider Competency
11. I feel confi dent in the abilities of the people who provide my care or services.
12. I feel well-cared for by the people who provide my care or services.
Medication Management
13. The people who provide my care or services ask what medications I am taking.
Physical Environment
14. The place where I receive care and services is clean and comfortable [If services provided at home, check ‘not applicable’]
15. I feel safe at the place where I receive care or services [If services provided at home, check ‘not applicable’]
Infection Prevention and Control
16. People who provide my care or services wash their hands or wear gloves before giving me medical care or treatments.
17. People who provide my care or services talk to me about preventing infections, such as hand washing and coughing into my sleeve.
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3.2 Coordinating the Organization Questionnaires
The organization questionnaire is an anonymous online questionnaire that asks staff for their perspective on a variety of topics such as experience with and knowledge of accreditation and organizational resources and capacity, as well as fundamental issues such patient safety, infection control, emergency preparedness, and provider competency. Staff members from across the organization complete the questionnaire individually and anonymously. This usually takes less than 30 minutes.
The Accreditation Coordinator, with the Accreditation Primer team, determines when and for how long the organization questionnaires will be available. Questionnaires are generally made available for about two or three weeks – if the timeframe is too long, momentum for the Primer process may be lost.
Part of the Accreditation Primer team’s role is to decide how to educate staff about the questionnaires, and how to facilitate the process in order to obtain a good response rate. Staff needs to know the timeframe during which they can complete the questionnaires, along with instructions on how to access and answer them.
The questionnaire starts with basic demographic questions, and then lists a number of questions with a choice of answers. Additional questions may be added depending on the services the organization offers (e.g. Home care, Emergency Medical Services, etc.).
A sample organization questionnaire:
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3.3 Receiving the results through the Quality Performance Roadmap
Accreditation Canada posts the aggregate results from the staff and client questionnaires on the organization’s Quality Performance Roadmap, available on the Portal. Results are categorized using green, yellow, or red fl ags to show areas that are in need of improvement as well as areas of strength. Surveyors do not have access to the Roadmap.
The Accreditation Primer team uses the fl agged results to develop and prioritize action plans to address the issues identifi ed by the fl ags. Green fl agged items indicate areas where the organization excels. Red or yellow fl ags show areas where the organization needs to focus attention and discussion, and develop action plans. The organization submits evidence of the action(s) it has taken to show that these gaps have been addressed.
RECAP COORDINATING THE CLIENT AND ORGANIZATION QUESTIONNAIRES
What steps should have been completed by now?
Client Questionnaires
A sample of clients/residents/patients has been identified to fill out the client questionnaires, and a time period has been defined for administering and collecting these questionnaires.
Separate copies of the questionnaire for each client identified in the sample have been downloaded and printed. (NO PHOTOCOPIES!)
A system has been developed (such as drop boxes) to collect and send the completed client questionnaires to Accreditation Canada.
The client questionnaires have been completed, collected, and sent.
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RECAP COORDINATING THE CLIENT AND ORGANIZATION QUESTIONNAIRES
What steps should have been completed by now?
Organization Questionnaires
Dates have been set for when the organization questionnaires will be available.
Staff members have been notified of the dates and they know how to access the questionnaires.
Staff members understand how to complete the questionnaires (i.e. selecting the description that best describes their experience).
The organization questionnaires have been completed by staff.
The Quality Performance Roadmap showing aggregate questionnaire results and the coloured flags is available.
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SECTION 4 BUILDING THE ACTION PLAN
4.1 Analyze results from the Quality Performance Roadmap
Once the Roadmap is available, the Accreditation Primer team analyzes the results in detail, paying particular attention to the results marked with a yellow or a red fl ag. Red and yellow fl ags provide opportunities for discussion about what should be included in the action plan. In the Roadmap, the team can click on that item to see the related standard, as well as guidelines on how the standard requirements can be addressed in action plans.
Through this process, the team is able to establish where it needs to focus its improvement efforts, and decide how to prioritize them.
4.2 Establish an action plan
Once the Roadmap results have been analyzed, the Accreditation Primer team develops and prioritizes action planning activities to address the gaps. The action plans should take into account previous organizational priorities that have been established, as well as the priorities identifi ed in the Roadmap.
The action plan needs to indicate how success will be measured for each item, and show specifi c timelines for when each action is to be completed.
Once the action plan has been established, the Accreditation Primer team implements the action plan, or monitors the progress of those who are responsible for the various elements of the plan.
4.3 Submit evidence of action taken
Evidence of action taken for each area identifi ed for improvement may be submitted prior to the on-site survey. Consultation with the Accreditation Specialist at Accreditation Canada is recommended for help in this area.
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For example, let’s imagine an organization identifi es “ethics” as an area needing attention. Its action plan could involve ensuring that a policy and procedure for ethical decision-making be implemented by December 31. The organization may submit this information as evidence of action taken by updating the Roadmap to that effect.
While it is not necessary to include backup documentation when submitting evidence of action taken, Accreditation Specialists or surveyors may ask to see such documentation. For instance, in this case, surveyors could ask to review the ethical decision-making policy and the board minutes of when the policy was approved.
RECAP BUILDING THE ACTION PLAN
What steps should have been completed by now?
The Primer team has analyzed the Quality Performance Roadmap, paying particular attention to results marked with red and yellow flags.
For results marked with red and yellow flags, the Primer team has reviewed the associated standards in detail, identified gaps, identified areas for improvement, and developed action plans to address these areas.
Evidence of action taken to address the gaps has been submitted through the Quality Performance Roadmap.
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SECTION 5 DEVELOPING THE CUSTOMIZED ON-SITE SURVEY PLAN
Once the questionnaire results have been reviewed by the Accreditation Primer team and an action plan established, a customized on-site survey plan is drafted by Accreditation Canada.
5.1 Update the organization profile
To develop the customized on-site survey plan, Accreditation Canada needs to have the most up-to-date information possible. The Accreditation Coordinator adds the following information to the organization profi le:
• governance and organization structure • populations served (demographics) • location-specifi c information including all locations owned and
operated, location description, number of staff, types of services, and age of facilities
• research or academic centres• high and low volume services. This information is requested
because of the increased risk of error in these areas. Single site organizations are asked to rank their service volumes against each other (e.g., top 5 services offered, bottom 2 offered). Multi-site organizations are asked to rank highest and lowest volume sites (e.g., site with highest volume, another site with lowest volume)
5.2 Ensure accurate data
The Accreditaton Coordinator and the Accreditation Primer team review information on the Organization Portal to ensure that the organization profi le and evidence of action taken are accurate and current.
5.3 Review draft on-site survey plan
The draft on-site survey plan, which outlines a detailed schedule of on-site survey activities, is developed about two months prior to the on-site survey. After discussion with the Accreditation Coordinator,
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the Accreditation Specialist, and the surveyors, the plan is fi nalized a few weeks before the on-site survey takes place.
Accreditation Canada’s automated on-site survey design program uses information from the organization to develop a customized on-site survey plan, tailored to the needs and structure of the organization.
The program takes into account the organization profi le (structure, size, number of locations, planning and service design, type of services offered), preferences, and evidence of action taken. This is used to build an on-site survey plan.
The Accreditation Specialist reviews the on-site survey plan before sending it to the Accreditation Coordinator. They work together to negotiate amendments.
5.4 Participate in the pre-survey teleconference
The pre-survey teleconference is organized by the Accreditation Specialist. It is an opportunity for the Accreditation Coordinator, the Accreditation Specialist, and the on-site survey team to:
• review and fi nalize the on-site survey plan • fi nalize details related to the on-site survey
This teleconference occurs about 6 weeks prior to the on-site survey.
RECAP DEVELOPING THE CUSTOMIZED SURVEY PLAN
What steps should have been completed by now?
Detailed information about the organization (sites, programs, service volumes, strengths) has been added to the organization profile.
A draft on-site survey plan has been developed by Accreditation Canada and changes have been negotiated.
The pre-survey teleconference has been held.
The on-site survey plan has been finalized.
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SECTION 6 ORGANIZING THE ON-SITE SURVEY (LOGISTICS)
This section outlines the logistical activities that need to be completed prior to the surveyors’ arrival. These activities are summarized in APPENDIX A: ACCREDITATION PRIMER ORGANIZATION CHECKLIST.
Section 7 provides more detail on specifi c components of the on-site survey (tracers, debriefi ng sessions), some of which are referenced here.
6.1 Reserve space and equipment for surveyors and debriefings
• Reserve private working space for the surveyors to meet and work during the survey, with access to phone, internet, shredder, printer and paper
• Reserve space for the introductory meeting, and the leadership and general debriefi ng sessions separate from the surveyors’ workspace
• Arrange for a projector and screen, if required • For the general debriefi ng, arrange video or teleconferencing for
remote sites, if necessary• Make hospitality arrangements (beverages, lunch) for on-site
surveyors
6.2 Arrange meetings• Notify senior management about the introductory meeting and
brief them on the overview and other information they may want to provide during this meeting
• If requested by the surveyors, arrange for specifi c people to be available to meet with the surveyors
• Invite staff, board members, volunteers, clients, family members, community partners, and others to the general debriefi ng
• Arrange transportation between sites if necessary
6.3 Collect advance documentation
Accreditation Canada provides surveyors with the organization profi le, evidence of action taken, and the customized survey plan before the on-site survey begins. They do not have access to the Quality Performance Roadmap.
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Documents and information that the Accreditation Coordinator should have available for the surveyors for their initial planning session (to be provided either at the hotel or at the organization, wherever the session is held) include:
• organization chart • strategic plan • annual report (if applicable) • service and program descriptions• a list of committee or program meetings occurring at the time of
the on-site survey; (be sure to inform staff that surveyors may observe these meetings)
• contact information for the Accreditation Coordinator throughout the on-site survey
Other documents: Surveyors may ask to review any of the documents listed in Appendix B: Documentation List. These documents do not need to be gathered into a central location for the surveyors. Rather, surveyors will want to access these in the location where they are normally kept, in the same way that staff use the documents during their normal course of business. Staff need to be aware of where these documents are kept and how to access them.
6.4 Educate staff and clients about the on-site survey
Staff and clients need to be aware of how the on-site survey works if they are to participate effectively. At minimum, they need to know:
• that surveyors use observation, discussion, and document review to rate the organization’s basic elements of safety and quality
• that surveyors will be moving throughout the organization, talking to them and possibly asking for clarifi cation about work processes
• when surveyors will be on their unit, area, or accompanying them in the community, as per the on-site survey plan
They also need to know that this is not an individual performance review and that they are not expected to know everything, or to have all the answers. If they don't have an answer, they should feel comfortable sharing what they know and then referring surveyors to someone else who may be able to provide more information.
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6.5 Identify key staff members
The Accreditation Coordinator chooses a key staff member for each of the surveyors to accompany them during the tracers. (Tracers are one method surveyors use to assess the organization; they are discussed in more detail later in this manual.)
The key staff member is ideally a frontline staff member, or a team leader or supervisor who is knowledgeable about the service area(s) and who can navigate through the various locations and program linkages. This person does not participate in interviews with clients and staff unless the surveyor requests it, but supports the surveyor by answering general questions about the service area(s), and guides the surveyor to the appropriate units, locations, staff, or clients during the tracer.
RECAP ORGANIZING THE ON-SITE SURVEY (LOGISTICS)
What steps should have been completed by now?
Meeting space and equipment have been booked, and people have been notified about potential discussions with surveyors.
Meeting invitations have been issued.
Senior management has been informed of the overview required for the introductory meeting. This is a 10 to 15 minute presentation of major accomplishments and factors affecting the organization.
Advance documentation has been prepared.
Staff and clients have been informed what to expect during the on-site survey.
Key staff members have been identified and they understand their roles. The number of key staff members that you identify depends on the size of the organization.
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SECTION 7 HAVING THE ON-SITE SURVEY
Surveyors are health care or social services professionals from outside the organization who observe and evaluate the basic elements of safety and quality in the organization. The on-site survey is an opportunity for surveyors to discuss the organization’s progress in addressing self-identifi ed areas for improvement, and to share their expertise with organization staff.
The surveyors will usually be at the organization for about three days.
During the on-site survey, surveyors validate the results of the questionnaires, assist the organization in determining next steps and action plans, and make suggestions about improvements to quality and safety.
Throughout the on-site survey, the Accreditation Coordinator needs to be easily and quickly available to the on-site survey team to provide feedback about the survey activities, to answer questions, or to provide additional documentation.
Below are excerpts from a sample on-site survey plan, listing activities that usually occur during an on-site survey. The rest of this section provides details on each activity.
Surveyor 1 Surveyor 2
Topics of focus 1. Planning and service design
2. Integrated quality management
3. Emergency preparedness
4. Physical environment
5. Medical devices, equipment use, and supplies
6. Episode of care
7. Decision support
8. Principle-based care and decision-making
9. Infection prevention and control
10. etc. (13 priority processes in total, see page 22)
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Day 1
Surveyor 1 Surveyor 2
1300-1700 ½ day Surveyor planning time (surveyors only)
Day 2
Surveyor 1 Surveyor 2
8:00 to 8:30 Introductory meeting
Meeting with senior management, Chair of the Board, Chief and Council and a few board members
Organization overview, scope of services, successes and challenges, factors affecting Accreditation Primer, on-site survey activities.
8:30 to 9:30 Discussion group
Meeting with Leadership team members
Topics for discussion
Strategic and operational plans.
Overview re the monitoring/evaluation of strategic and operational goals.
Experience with and knowledge of Accreditation.
9:30 to 10:00 Surveyor information exchange
10:00 to12:00 Topic: Physical environment
Tour of facility
Discussion with staff responsible for maintenance, repair, mechanical systems, risk areas; with staff responsible for security and access
Discussion with residents/families re: clean, safe, organized environment
Topic: Medical devices, equipment use, and supplies
Review of preventative maintenance process, documentation and the equipment on unit
Discussions with staff on unit re: training on equipment and devices, maintenance
Topic: Episode of care/service
Client record review and selection for tracer activities
Discussion with staff on unit, physicians, clients, families re:
Care plans
Interdisciplinary teams
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Day 2 (continued)
Surveyor 1 Surveyor 2
12:00-13:00 Lunch
13:00-14:30 Topic: Integrated quality management
Review of organization’s quality, safety, risk management processes
Discussion with quality committee regarding quality, safety, risk monitoring, reporting and improvements, culture of safety
Discussion with staff on unit regarding a quality improvement initiative that has been implemented
Topic: Episode of care/service (continued)
Medication
Proper identification of clients
Communication with clients/families
Assessment tools for pain etc
Roles and responsibilities clear
Client rights explained and documented, consents
14:30 to15:00 Surveyor information exchange
15:00 to 16:00 Topic: Integrated quality management (continued)
Topic: Principle-based care and decision-making
Interview with clinical leader and discussion with staff on unit about identifying and decision-making regarding ethical dilemmas and related problems that may arise
16:00 to 16:30 Surveyor information exchange
16:30 to 16:45 Daily review with Accreditation Coordinator
Day 3
Surveyor 1 Surveyor 2
8:30 to 9:30 Topics: Planning & service design and decision support
Review of strategic and operational plans. Overview re: the monitoring/evaluation of strategic and operational goals.
Experience with and knowledge of accreditation.
Discussion with IM – IT regarding technology supports, training and education, and challenges
Decision support
Review of information related to confidentiality
Discussion with IM – IT regarding technology supports, training and education, and challenges
Decisions around client information
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Day 3 (continued)
Surveyor 1 Surveyor 2
9:30 to 10:00 Surveyor information exchange
10:00 to 11:30 Topic: Emergency preparedness
Review of emergency preparedness plan, fire safety plans, tracking and debriefing
Discussion with staff on unit regarding fire drills, emergency exercises, training and debriefing
Discussion with staff responsible for emergency preparedness and planning
Topic: Infection control
Discussion with housekeeping staff and manager about linen process
Discussion with staff responsible for coordinating infection prevention and control
Review policy on vaccination
Review hand washing policy
11:30 to 13:00 Lunch
13:00 to 14:00 Discussion Group with an existing working team (regarding the use of information, research and best practice information in clinical decision making)
Other discussions with staff may also take place during this time
14:00 to 14:30 Surveyor information exchange
14:30 to 15:45 Documentation review and report writing
15:45 to 16:00 Daily review with Accreditation Coordinator
Day 4
Surveyor 1 Surveyor 2
8:00 to 10:00 Report and debrief preparation
10:00 to 11:00 Senior Leadership debriefing
11:00 to 12:00 General debriefing
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7.1 Surveyor planning session
At the beginning of the survey, surveyors meet to plan the on-site survey activities. This meeting may take place at the organization or at the hotel where the surveyors are staying. The location is determined by the surveyors and discussed during the pre-survey teleconference.
If the meeting is held at the organization, the Accreditation Coordinator greets the surveyors, shows them to the working room, and leaves them to review the advance materials provided by Accreditation Canada and the organization, and to coordinate the survey activities.
7.2 Introductory meeting
Before the on-site survey begins, an introductory meeting is held with the surveyors and the organization’s senior management. This is an opportunity for the organization to provide an overview of its structure, programs, and services, and to discuss the survey plan.
The overview usually consists of a 10 to 15 minute presentation of major accomplishments and factors affecting the organization. It could address gains in or impediments to achieving the strategic goals, and other factors affecting strategic and quality improvement goals such as changes to boundaries or scope of service, population health trends, new programming, organization-wide initiatives, major funding changes, or divestments.
This session provides surveyors with an appreciation for the structural, environmental, and political context in which the organization operates.
7.3 Priority processes and tracers
Priority processes are critical areas and systems known to have a signifi cant impact on the quality and safety of care and services. Priority processes are used to focus the on-site survey. In the Qmentum program, they are the key areas that surveyors evaluate to assess and validate compliance with the standards as they relate to the various priority processes. Each priority process draws from a number of different standard sections. During the Primer on-site survey, the surveyors use fewer priority processes to assess whether the fundamental elements of quality and safety are in place.
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To evaluate priority processes, surveyors use an interactive method known as a tracer to gather information and begin the process of validation and assessment. Surveyors conduct tracers on their own, rather than with a partner.
During a tracer, surveyors use direct observation and interaction with a wide variety of people to gather evidence about a sector or service area’s quality and safety of care and services. Tracers are used to evaluate both clinical (direct client care) and administrative (governance, leadership, management) processes.
Tracer activities include:
• fi le and document review; • discussions with clients, staff, senior management,
board members, community partners, or others; • direct observation of service delivery; and• record information pertaining to the above.
If someone is not available in person, surveyors may conduct an interview over the phone. Some meetings may be planned in advance, while others will occur as the tracer progresses. The beauty of the tracer method is that it is fl exible and responsive, allowing surveyors to observe and interact directly with frontline staff in their working environment.
During a tracer, surveyors are not evaluating individual performance. They are observing processes and procedures to assess compliance with the standards.
Review of client records: When the surveyors arrive at the organization, they request a list of current clients and access to the client records, and sign confi dentiality forms, unless a global confi dentiality form was signed at the beginning of the survey. Client consent should already have been obtained, and these signed consent forms should be available with the records.
As they review client records, surveyors look for a variety of factors, including number of medications, age, services provided, the complexity of the case, and the interaction of multiple service areas. They also want to be sure the fi les they choose are representative of the clients served and the services provided.
Surveyors then choose the client records for the tracer they are conducting.
Good to know!Priority processes for Primer
1. Planning and service design 2. Integrated quality management3. Emergency preparedness4. Physical environment5. Medical devices, equipment
use, and supplies6. Episode of care/service 7. Decision support8. Principle-based care and
decision-making9. Infection prevention and control10. Client and provider safety11. Medication Management12. Human capital13. Communication
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Review of human resource records: The Accreditation Coordinator should have a selection of human resources records ready, with consent forms signed by the staff members. The records should be a cross representation of full- and part-time staff, from various disciplines and departments, and with varying lengths of service.
7.4 Surveyor information exchange
As the on-site survey proceeds, the surveyors may meet several times during the day to:
• share observations about organization performance,• discuss the priority processes and tracers, including
client and staff interviews, documentation reviews and tour observations
• obtain information from other surveyors to inform their own ratings
• develop and share question lines for their fellow surveyors to use during tracers
• plan or revise the next tracer
Surveyor information exchanges may take place in person, via phone or teleconference when surveyors are at different sites. The Accreditation Coordinator is asked to facilitate teleconference arrangements if necessary.
After a surveyor information exchange, the surveyors may ask the Accreditation Coordinator for further information or clarifi cation on an issue, or they may request a meeting be set up with other staff or clients.
7.5 Daily review with Accreditation Coordinator
This 15 to 30 minute meeting is held at the end of each survey day between the surveyors and the Accreditation Coordinator. It is an opportunity for the Accreditation Coordinator to provide feedback on the surveyors’ approach and interactions with clients and staff, and to offer suggestions for more effective interactions with staff if necessary.
During these meetings, surveyors do not share specifi c observations about the on-site survey fi ndings. Rather, the review is an opportunity to receive feedback that may enhance the next day’s survey activities
Good to know!
Tracers are made up of four main components:
• File and document review: For a clinical tracer, surveyors review client files and choose the clients whose “path” they wish to trace.
• Talk and listen: As they move through the organization, surveyors talk to staff, clients, families or others who may be relevant to the tracer.
• Observe: Surveyors observe the processes, procedures, and direct care activities in the service areas.
• Record: Surveyors record their perceptions and important points about what they see, hear, and read.
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and to ask for additional documentation or follow-up if necessary, or to resolve logistics issues.
For example, if surveyors need to adjust the next day’s schedule to follow-up on a specifi c part of a tracer, this is arranged with the Accreditation Coordinator at this time.
7.6 Surveyors: completion of the on-site survey
On the fi nal day of the on-site survey, surveyors work together to rate each of the question items (they use the same question items as appear on the client and the organization questionnaires), and to develop the commentary on their fi ndings. The Accreditation Coordinator provides access to a printer, paper, and a shredder.
Using the surveyor software system, surveyors rate each of the question items as “in place”, “in development” or “not in place”. A report is produced and left with the CEO at the end of the on-site survey.
7.7 Debriefing sessions (leadership and general)
At the end of the on-site survey, surveyors prepare two debriefi ng presentations for the organization – one for senior leadership, and a more general one for staff, board members, and other interested parties.
Leadership debriefi ng: During this meeting of approximately one hour, surveyors present a summary of their fi ndings and observations, highlighting strengths and areas for improvement. Their presentation provides the leadership team with a solid understanding of the main fi ndings (45 minutes).
Following the presentation, the leadership team and the surveyors discuss the fi ndings and clarify next steps. The leadership team is encouraged to ask questions to clearly understand the fi ndings and the next steps (15 minutes).
General debriefi ng: During this approximately one hour meeting, surveyors summarize their fi ndings, identify strengths and areas for improvement, and outline key messages.
The organization may choose to invite board members, staff, volunteers, clients, family members, and community partners, or any other interested parties.
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RECAP HAVING THE ON-SITE SURVEY
What steps should have been completed by now?
Senior leadership has presented an overview of the organization during the introductory meeting.
Tracers have been conducted. Discussions have been held. Documents have been reviewed.
Debriefing sessions (leadership and general) have taken place.
The report has been reviewed.
Next steps are being considered.
Achievements are being celebrated!
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SECTION 8 THE PROGRESS DECISION
8.1 Receive the Progress Decision
After the on-site survey, the surveyors submit their data to Accreditation Canada. This information and the results from the client and organization questionnaires are used to determine one of three possible progress decisions, as follows:
Proceed
The organization has earned its Accreditation Primer Award and is ready to move into the next phase of Qmentum. This includes reviewing and addressing the red and yellow fl agged topics, and contacting the Accreditation Specialist to discuss the next Qmentum steps.
Take Action and Proceed
The organization has earned its Accreditation Primer Award. As part of the decision, your organization is required to address the items identifi ed as red and yellow fl ags. Evidence of the action taken on these items must be submitted to Accreditation Canada before you can move into the next phase of Qmentum. Contact your Accreditation Specialist for more information.
Further Development Required
The organization has not successfully completed the Primer. To strengthen key aspects of quality and safety, items identifi ed with red and yellow fl ags must be addressed, and evidence of the action taken submitted through the Organization Portal. We will schedule a subsequent Primer on-site survey.
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RECAP THE PROGRESS DECISION
What steps should have been completed by now?
Surveyors have submitted their data to Accreditation Canada.
Accreditation Canada has issued the Accreditation Primer Decision.
Action plans have been developed and implemented to address areas for improvement identified (for “Take Action and Proceed” or “Further Development Required” decisions).
Evidence of action taken has been submitted to address areas for improvement.
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SECTION 9 EVALUATION, ONGOING SUPPORT AND RESOURCES
Accreditation Canada ensures that its client organizations have the support and resources they need to implement the accreditation programs easily and effectively. Some of the options for resource and support are listed below.
Accreditation Specialists: Accreditation Specialists are the fi rst point of contact for information, advice, and support. The Specialist helps guide Accreditation Coordinators through the process in any way possible. This includes interpretation of standards, advice on navigating through the Organization Portal or other tools, and information on Qmentum processes and procedures.
Education materials: Accreditation Canada offers regional education sessions across Canada which can be attended by representatives of any health or social services organization. Additionally, on-site education sessions can be booked, for a fee, through Accreditation Specialists. There are also webcasts available on the Organization Portal, and a tracer DVD available for purchase.
Technical support: To access Accreditation Canada’s technical support team, call toll-free at 1-866-333-3346, locally in Ottawa at 613-247-3056, or e-mail [email protected].
Website: Accreditation Canada’s website, at www.accreditation-canada.ca, is an excellent source of information about the Qmentum program and accreditation in general. It also has a searchable database of leading practices including contact information so organizations can contact their peers and discuss the innovative practices they have implemented.
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GLOSSARY
Accreditation Primer Arrow: an overview of timelines and activities for the Accreditation Primer cycle, from the Candidate for Accreditation status to the Accreditation Primer Award. There is also a Qmentum arrow.
Client Questionnaire: A paper-based questionnaire that clients/patients or residents complete as part of the Primer to assess the basic elements of safety and quality within the organization and to indicate strengths and areas for improvement.
Customized Survey Plan: a detailed plan of all on-site survey activities, tailored to each organization’s needs and structure.
Evidence of Action Taken: information submitted by the organization to show how it has addressed areas identifi ed as needing improvement.
On-site Survey: an opportunity for organizations to demonstrate to a team of peer surveyors their commitment to quality care and for surveyors to share their knowledge and expertise. Surveyors assess the organization in terms of basic elements of quality and safety.
Organization Portal: an electronic record of most accreditation activities and results, providing the organization with easy access to accreditation information and straight-forward management of the accreditation process.
Organization Questionnaire: An online questionnaire that staff complete as part of the Primer to assess the basic elements of safety and quality within the organization and to indicate strengths and areas for improvement.
Performance Measures: methods by which the degree of success a program has had in achieving its stated objectives, goals, and planned activities can be objectively measured. Qmentum performance measures include both indicators and instruments.
Primer: The Qmentum Primer is the fi rst step in an organization’s accreditation journey. It is an opportunity for the organization and Accreditation Canada to work together to establish the supports, structures, and processes necessary for accreditation. The Primer focuses on ensuring that basic quality and safety elements are in place.
Priority Processes: critical areas and systems known to have a signifi cant impact on the quality and safety of care and services. During the on-site survey, surveyors assess priority processes using tracers.
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Quality Dimensions: eight elements used to defi ne quality and that serve as the foundation for all Accreditation Canada standards.
Quality Performance Roadmap (the Roadmap): a tool to help organizations plan their accreditation journey. Available on the Organization Portal, it is a comprehensive record of accreditation activities and results.
Tracer: a method used by surveyors during an on-site survey to evaluate priority processes, involving review, discussion, observation, and recording.
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APPENDIX A ACCREDITATION PRIMER ORGANIZATION CHECKLIST
Getting Ready to your On-site Survey
Steps Tasks
Organization Profile
(At time of application)
Complete the online organization profile information on the Organization Portal
Questionnaire submission
(Within a month after application)
Launch and complete client and organization questionnaires
Submit sealed client questionnaires to Accreditation Canada for analysis
Logistics
(2-3 months prior to survey)
Provide meeting space for surveyors’ initial planning session, including access to printer, paper, shredder, extension cords for laptops, accreditation coordinator’s contact info while on-site, etc.
Provide meeting space, telephone and/or teleconference access for surveyors to conduct information exchanges during the day, according to the schedule
Arrange for large meeting space for the General Debriefing
Provide access to an LCD projector and screen for the general debriefing
Invite staff, board members, management and all interested stakeholders to the General Debriefing
Arrange for surveyors to have refreshments and a light lunch throughout the day
Ensure that transportation arrangements between sites have been made for surveyors (if multiple sites will be surveyed)
Advance staff preparation
(1-2 months prior to survey; ongoing until survey week)
Inform staff and clients of when on-site survey will take place, the services and locations to be surveyed, as well as the surveyor activities
Inform board members and community partners of when on-site survey will take place and confirm their participation as per the schedule activities
For the duration of the on-site survey, assign a staff person to “buddy” with the surveyor. The buddy assists the surveyor in navigating and travelling throughout the organization and, in each service area, connects the surveyor to the key frontline staff member.
For each service area, prepare client records as discussed during the pre-survey teleconference.
Provide surveyors with a list of committee/program meetings that will occur at the time of the on-site visit; inform staff that surveyors may observe these meetings
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Steps Tasks
Ensure that organization’s operational documentation is available on-site in its natural or regular location (e.g. strategic plans, operational plans, policies and procedures, etc.). See Primer: Advance On-site Documentation List for more information.
Arrange for senior leaders to prepare a 10-15 minute organization overview for the introductory meeting.
On-site survey schedule preparation
Discuss and confirm the list of service(s) and location(s), draft schedule and associated survey activities with your Accreditation Specialist
Finalize schedule
Organize tours, staff meetings as appropriate, based on the survey schedule
Preparation for pre on-site survey teleconference
(2-3 months prior to survey)
Contact the Accreditation Specialist to do the following:
Discuss pre on-site visit preparation
Confirm the buddy assignments
Discuss and confirm agenda items for pre on-site visit teleconference
Address any particular issues if necessary
Participate in pre on-site visit teleconference with accreditation specialist and surveyors
Pre on-site survey teleconference
(6 weeks prior to survey)
Discuss final on-site visit schedule with surveyors
Receive and respond to questions surveyors may have regarding the questionnaire results or information from the organization profile
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APPENDIX B DOCUMENTATION LIST
The following list is intended to assist organizations in preparing for the on-site survey. As much as possible, the organization should make these documents easily accessible to surveyors while they are on site. This list is a guide only, and does not exclusively represent materials reviewed by surveyors during the onsite visit. Organizations may not have all of the materials listed below.
Plans and Policies
Strategic plan
Quality improvement plan
Risk management plan
Human resources plan
Emergency preparedness plan
Ethics policy and procedures
Consent policy and procedures
Incident report trends and action taken
Reporting policy and process for actual and potential adverse events
Evacuation exercise and debriefi ng documentation
Fire drill and debriefi ng documentation
Confi dentiality/release of information policy
Safety/protection/destruction of information
Privacy policy according to legislation
Infection control policies and guidelines
Policy and protocol for administration of the infl uenza vaccine
Policy on Medication Management
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General Documentation
Incident report tracking and trending
List of other accreditation awards, including dates granted
Access to organization’s administrative and clinical policies
Mission and vision statements
Orientation package
Preventive maintenance program, details in service contracts
Hand hygiene guidelines and training material
Minutes of committees
Organization chart
Personnel fi les selected with written comments
Selected client fi les
11/2010
Ottawa, Ontario K1www.accreditation.ca
