Accreditation Canada International

Defining Health Excellence

Sébastien Audette, CEO

Accreditation Canada International
 Today’s goal

To walk you through:

 Introduction to the Accreditation Canada International
and the Qmentum International Program
 Overview of the accreditation standards
 Tour of the new client portal
 Accreditation Canada’s experience with quality
improvement globally

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 Accreditation Canada - A World Leader

Vision
The leader in raising the bar for health quality.
Mission
Driving quality in health services through
accreditation.
Values
Excellence Integrity Respect Innovation

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 Accreditation: Early Beginnings (1917)

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 The Past (cont’d.)

1951 CMA and RCPSC joined with AMA and AHA

and ACP to form the Joint Commission on the
Accreditation of Hospitals (JCAHO)
1953 Canadian Commission on Hospital
Accreditation (CCHA) formed
1980 CCHSA Accredits its first international
organization, the Bermuda Hospitals Board
2008 CCHSA became Accreditation Canada

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 The Past (cont’d.)

2010 Accreditation Canada launches its

Qmentum International program in English
2010 Accreditation Canada achieved its fourth
ISQua accreditation for standards and
organization

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 Accreditation Canada –
World Leader in Accreditation

 Fifty years of experience in standard setting

 Non-governmental, non-profit, private
 Accreditation across the full continuum of care
 Internationally proven standards
 Credibility and support in Canadian and
International health systems and global experts

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 Accreditation Canada –
a World Leader in Accreditation (cont’d.)

In 2010…
 Over 500 surveyors who are senior health care
professionals recruited and qualified from
accredited organizations
 Close to 400 on-site assessments and surveys a
year, in private and public organizations
 More than 1,000 organizations or 4,400 sites
accredited in Canada and internationally

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 On the International front...

Caribbean Middle East Europe Latin Other

and North America regions
Anguilla Africa Italy
Brazil Bermuda
St. Lucia Iran France Costa Rica Philippines
Trinidad & UAE Ireland Columbia
Kazakhstan
Tobago Saudi
Arabia
Turks &
Kuwait
Caicos
Bahrain
Lebanon
Egypt
Tunisia

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 International Recognition
 Founding member of ISQua (International
Society for Quality in Health Care)
 Host for international research portal on
accreditation
 Accreditation Canada achieved ISQua
international accreditation in 1998, 2002, 2006
and 2010 for its:
 Standards
 Organization
 Education Programs
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 One third of all new
accreditation programs and
standards developed
worldwide have taken the
lead from Accreditation
Canada.
(International Society for Quality in Health Care)

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 International Pograms

 Accreditation and Certifications

 Distinctions
 Advisory and Education

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 Health Care Accreditation

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 Patient Safety Challenges

Patient Safety Incident Types

Non Preventable
Incidents

Preventable
Incidents

Source: Analysing potential harm in Australian general practice: an

incident-monitoring study, Bhasale et al. 1998

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 Preventing Patient Safety Incidents

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 Identifying Best Practices

Source: What are the Critical Attributes and benefits of a High-Quality

Primary Healthcare System?
Canadian Health Services Research Foundation, 2009

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 Identifying Best Practices

Source: What are the Critical Attributes and benefits of a High-

Quality Primary Healthcare System?
Canadian Health Services Research Foundation, 2009
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 Accreditation: From Research to Patients

 Development of standards and criteria adapted to a given health

care environment
 Education and training of staff
 Measure of the achievement of standards by organizations,
through:
 Self-assessment
 Peer reviews
 Patient and staff surveys
 Clinical outcome indicators
 Scoring system to recognize the level of achievement made by the
organization
 Recognition and celebration of successes

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 What is Accreditation at Accreditation
Canada?

 Strategic change and risk management tool

 Proactive and continuous
 Transparent and rigorous analysis of service provision
 Addresses current and future client needs
facilitated by:
 Independent third party

 Quality Improvement focus

 Objectivity

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 Changing behaviors for patients

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 Quality , Momentum , QMENTUM

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 Qmentum International

 Organization wide development and sustainability

 Empowering the organization to “map” their quality
journey
 Focus on quality improvement, patient safety, risk
management
 Performance measures and accountability
 Step by step approach

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 Qmentum International:
A step by step approach to accreditation

Striving for Excellence

Advancing Client-centered
Care and Quality Improvement

Setting the Foundation for

Quality and Safety

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 Qmentum International
Accreditation Program
Three-year Cycle

ON-SITE SURVEY
SIMULATED Surveyors assess services
SELF-ASSESSMENT
SURVEY and report findings
• Client organization
completes
questionnaires and
submits instrument
and indicator data
• Organization
updates on-line
profile

ACCREDITATION
EDUCATION DECISION and
Core and REPORT
comprehensive Client
sessions available Organization

PROGRESS REVIEW
Accreditation Canada reviews
evidence of action taken and
amends
READINESS ASSESSMENT and REPORT accreditation decision if
• Organization completes applicable. Annual update of
on-line profile indicators required
• Assessment of fundamental elements of
quality and safety using questionnaires
and initial visit
www.accreditation.ca

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 The Standards

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© Accreditation Canada International
 Qmentum International Standards

SERVICE EXCELLENCE STANDARDS

Service/Sector Specific

Primary Health Acute / Ambulatory Care Laboratories

STANDARD SECTIONS
• Primary Care •Ambulatory Care •Biomedical Laboratory
SUSTAINABLE GOVERNANCE •Critical Care Services
•Diagnostic Imaging •Blood Bank and
•Emergency and Transfusion Services
EFFECTIVE ORGANIZATION Disaster Preparedness •Laboratory and Blood
•Emergency Department Services
•Medicine
SERVICE EXCELLENCE
•Obstetrics/Perinatal
•Operating Rooms
•Reprocessing &
Sterilization
•Surgical Care
•Global Healthcare
Standards

Medication Management – Infection Prevention and Control

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 2011 Standards Release

Health systems Acute Care/Ambulatory

 Public Health  Global Health
 Developmental Disabilities  Rehabilitation
Services  Cancer Care and Oncology
 Home Care
 Mental Health
 Senior Care
 Substance Abuse
 Animal Health and Food
Safety

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 Required Organizational Practices
(ROPs)
 An essential practice that client organizations must have in place to
enhance patient/client safety and minimize risk.
Client Safety Area ROP
Communication Client verification
Transfer of client information at transition points

Medication reconciliation

Safe surgical practices

Medication Use Control of concentrated electrolytes
Worklife Training on patient safety

Infection Prevention and Control Hand hygiene

Timely administration of prophylactic antibiotics

Safe injection practices

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 Organization
Portal
Overview
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 Self-assessment

 Questionnaires

 Indicators

 Instruments

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 Self Assesment

 Self Assessment Questionnaires are tailored to

the organization
 For each standard section there is a
corresponding Self Assessment Questionnaire

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© Accreditation Canada International
 Quality Performance Roadmap

√ ∆ X

 Set priorities based on flagged results and priority ratings

 Establish action plans

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 Action Plans

 Determine priorities and areas for action considering:

 Team’s priorities for action
 Accreditation Canada’s priorities based on areas of risk
 Develop concrete action plan for each standard
including:
 Key success factors
 Detailed timelines for completion

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 Indicators used in Qmentum International

 Time to 3rd next available appointment

 In-date blood product wastage
 Timely follow-up of abnormal test results
 Medication Reconciliation at Admission
 Pressure ulcers
 Turn-around time of a critical test
 Transfusion reactions

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 On-site Survey

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 Accreditation Decision

 Accreditation
 Accreditation with Condition
 Report and/or Focused visit
 Non-accreditation

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 Recap

What is involved in the process?

 Standards of Excellence
 Self Assessment
 Collecting indicators
 Identifying areas for improvement
 Developing action plans
 On-Site Survey with Tracers

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 Patient Safety Culture: Strengths
2008 – 2010 Q1 Trends

Ranking Areas of strength Rating scale Canada overall

(n=170,008)

Mean Std Dev

If I make a mistake that has significant consequences and no body notices, I do not 1=strongly agree to 5=strongly
1 4.43 0.97
tell anyone about it disagree

1=strongly agree to 5=strongly

2 Asking for help is a sign of incompetence 4.39 0.94
disagree

1=strongly agree to 5=strongly

3 I will suffer negative consequences if I report a patient safety problem 4.04 1.07
disagree

1=strongly agree to 5=strongly

4 I am less effective at work when I am fatigued 3.88 1.13
disagree

1=strongly disagree to 5=strongly

5 I work in an environment where patient safety is a high priority 3.85 1.25
agree

1=strongly disagree to 5=strongly

6 My unit does a good job managing risks to ensure patient safety 3.83 1.29
agree

Reporting a patient safety problem will result in negative repercussions for the 1=strongly agree to 5=strongly
7 3.82 1.17
person reporting it disagree

1=strongly disagree to 5=strongly

8 Patient safety decisions are made at the proper level by the most qualified people 3.78 1.15
agree

I have made significant error constitutes a real and significant risk to patients that we 1=strongly agree to 5=strongly
9 3.77 1.42
treat disagree

1=strongly disagree to 5=strongly

10 My unit takes the time to identify and assess risks to patients 3.71 1.34
agree

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 Education and Capacity-building

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 International Health Care Education

 Five areas of specialty offered via face-to-face sessions

or webinars:
 Leadership and Governance (E.g. Strategic Planning
in Health Care Organizations)
 Management (E.g. Effective Human Resources
Management)
 Quality and Accreditation (E.g. Policies and
Procedures in Health Care Organizations)
 Specialty Series (E.g. Medical Device Sterilization)

 Certified Accreditation Specialist Course and Certified

Healthcare Surveyor Course

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 The future of accreditation

 Better involve medical practitioners in the quality agenda

 Recognize the evolution of factors promoting changes
 Develop innovative tools and educational products
 Provide comparative data on indicators, accreditation
results and measurement tools
 Maintain a high level of proficiency and consistency
among surveyors

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 In conclusion…

Accreditation Canada:
 Is a well established organization with more than 50
years of experience
 Offers internationally recognized standards covering the
full continuum of care and medical specialties
 Has extensive presence in Brazilian, European, Middle
Eastern and Asian health care institutions
 Can rely on a network of over 500 surveyors and 1000
organizations who are looking to share their expertise
and contribute to continuous quality improvement in peer
health care organizations
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The leader in raising the bar for health quality

www.accreditation.ca