Healthy Work Environment: Using Accreditation to Move Us Forward

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Healthy Work Environment Using Accreditation
to Move Us Forward

• 3rd Annual RNAO Creating Healthy Work
  Environments Summer Institute
• August 11, 2008
• Wendy Nicklin
• President CEO, Accreditation Canada

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Outline

• Accreditation Canadas accreditation program
• The role and value of accreditation
• Standards
• The new program Qmentum
• Accreditation Canada and Quality of Worklife
• Organizational commitment
• Quality definition
• Standards
• Patient Safety - worklife
• Quality Worklife Quality Healthcare Collaborative
• Performance Indicators
• Leading practices

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Accreditation Canadas Accreditation Program

• Canadian accreditation program - incorporated in
  1958
• High participation rates continued growth
• Surveyors (over 500) are senior health care
  professionals
• Surveys may be regional, institution specific,
  national or market specific (i.e. Aboriginal,
  Corrections, Canadian Forces)
• Average 400 surveys per year
• Three year cycle
• Both public and private organizations participate
• Not-for-profit, funded by
• Client annual fees
• Cost recovery for survey

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Evolution of Accreditation Canadas Program
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Role of Accreditation

• Quality Improvement at the organization level
  and at the system level
• Risk Mitigation
• Effectiveness and efficiency improvement (e.g.
  IPC worklife)
• Change management supports system
  transformation and transitions
• Education -- tool and process
• Independent 3rd party review

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The Value of AccreditationDoes Accreditation
Make A Difference?

• Research shows accreditation leads to
• Increased organizational uptake of CQI
  initiatives
• Enhanced use of indicators
• Enabled change management
• Improved organizational learning practices
• Improved communication among teams
• Facilitated organization and regional
  restructuring

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Accreditation Canada Partnerships

• Canadian Stroke Network
• Correctional Services of Canada
• Health Canada First Nations Inuit Health Branch
  
• Health Canada Secretariat on Palliative and
  End-of-Life Care
• Health Canada Worklife Strategy
• Trauma Association of Canada
• Trillium Gift of Life
• University of Montreal

• Canadian College of Health Service Executives
• Canadian Council for Donation and Transplantation
• Canadian Forces Health Services
• Canadian Institute for Health Information
• Canadian Medical Biomedical Engineering Society
• Canadian Patient Safety Institute
• Canadian Standards Association

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Why develop and add new standards to the program?

• Extensive ongoing feedback sought from all
  stakeholders (surveyors, client organizations,
  national organizations)
• Environmental scan of health care issues and
  trends nationally and internationally
  
• Approached by groups to consider development of
  standards / program (e.g. Canadian Stroke
  Network, Canadian Trauma Association, Organ
  Donation and Transplantation)

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Accreditation Canada Standards

• As standards of excellence they set the bar
  for health care practice enable an
  organization/team to improve care, to reach or
  raise the bar
• Organizations/team assess themselves against
  these standards, identify where they are doing
  well and where they can improve
• The standards are developed with the input and
  guidance of experts in the field and updated on a
  regular basis to ensure relevance and value

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Responding to RealitiesProactive vs Reactive

• Standards
• Governance
• Infection Prevention and Control
• Chronic Disease Management
• Sterilization and Reprocessing
• Primary Health Public Health
• Aligning accreditation with quality improvement
  programs streamline

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Accreditation Canada Standards Development Process

• Expert Advisory Committees
• Literature Reviews
• Principles for Standards Development
• national in scale
• applicable to all health organizations
• throughout the continuum of care
• public and private

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Client Services Standards Sections

• Aboriginal Health Services (Addictions
  Community Health)
• Acquired Brain Injury
• Ambulatory Care
• Assisted Reproductive Technology (Clinical
  Laboratory)
• Biomedical Laboratories and Blood Banks
• Canadian Forces Health Services
• Cancer Care (Services Populations)
• Child/Youth Populations
• Child Welfare
• Community Health
• Correctional Services
• Critical Care/ICU
• Diagnostic Imaging
• Emergency Departments
• Home Care
• Hospice, Palliative End-of-life Care
• Infection Prevention Control
• Long Term Care

• Mental Health (Services Populations)
• Operating Room
• Obstetrics Perinatal
• Populations with Chronic Conditions
• Public Health
• Rehabilitation
• Substance Abuse Problem Gambling
• Surgical Care
• Telehealth
• Under Development
• Aboriginal Health Services (Remote Health
  Public Health)
• Case Management
• Developmental Disabilities
• Emergency Medical Services
• Organ and Tissue Donor and Transplantation
• Point of Care testing
• Primary Care
• Staffing Agencies

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Qmentum New Accreditation Program

• Concept approval January 2004
• Development 2004 present
• Pilot testing and feedback 2007
• Release 2008

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The New Accreditation ProgramQmentum

• Why Change?
• While annual program improvements are made as
  necessary (e.g. software upgrades, standards
  content), the time arrives when a comprehensive
  program upgrade is necessary.
• Factors
• Changing health services environment
• e.g. Increasing emphasis on accountability,
  performance measurement and governance
• Feedback from our surveyors, clients, staff,
  CCHSA Board of Directors
• e.g. Strengthen the alignment of the relevance of
  the program with regional health care delivery
  structures as well as small standalone facilities

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The New Accreditation Program Elements

• Standards
• New Structure
• Governance
• 32 item Governance Functioning Tool
• Leadership/Operations
• Service Excellence
• New standards
• laboratory, diagnostic imaging, medication
  management, infection prevention and control
• All standards updated

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The New Accreditation Program Elements

• Streamlined and more flexible process
• Supports and aligns better to an organizations
  quality improvement initiatives
• Accreditation integrates with QI program
• Is adaptable no matter how small or how complex
  the organization may be
• Planned and predictable accreditation activities
  during the 3 year cycle

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The New Accreditation Program Elements

• Customized to the organizations needs
• Automated measurement tools that allow
• Greater and faster data exchange
• Improved standardization and objectivity

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New Self-Assessment Process

• Realigned to be mid-cycle
• A questionnaire is provided to all employees
  within that program
• This questionnaire obtains feedback from staff as
  to the meeting of that standard
• The core team focuses on questionnaire results,
  streamlining the standards review process

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Priority Processesdrive the tracer methodology

• Physical environment
• Principle-based care and decision-making
• Patient flow
• Episode of care
• Decision support
• Diagnostic services
• Blood services
• Medical devices/equipment
• Medication management
• Infection prevention and control

• Community assessment
• Planning and service design
• Emergency Preparedness
• Client and provider safety
• Human capital
• Communication
• Integrated quality management
• Resource management
• Population health and wellness
• Chronic disease management

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Performance Measures

• Integrate into the accreditation program in order
  to increase objectivity and rigor
• Pan-Canadian review
• Outcomes summarized on Accreditation Canadas
  website
• Detailed information being published within next
  few months

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Performance Measures

• Initial performance measures include
• patient safety culture survey, medication
  reconciliation admission, MRSA/C Diff, surgical
  site infection
• worklife pulse survey
• governance functioning tool
• Client experience tool under discussion
• within each province/territory

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Performance Measures

• Next steps
• Assess and improve process based on the first
  phase of performance measure experience
• Next, focus on operations and key service
  delivery/clinical indicators (combination of
  process and outcome) e.g. home care, mental
  health, long term care

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Accreditation Primer

• Progressive approach to accreditation
• Available for new clients
• A preparatory step to moving into the full
  accreditation program within a 2 year timeframe

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Accreditation Report

• Concise and action oriented
• Based on on-site results, indicators and
  instruments
• Onsite report left on site at conclusion of
  survey visit
• Forecast report issued following feedback (3-4
  weeks)
• Final report issued 6 months following survey

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Whats No Longer Required?

• No more frequent team meetings pre-survey to
  identify strengths and areas for improvement team
  against the standards
• No more rating of team performance on 1- 7 rating
  scale
• No more preparation of self-assessment documents
  and sending them to surveyors
• No more preparation of evidence binders for each
  team
• No more assembling of documentation in one room
  for surveyors review
• No more multiple team meetings with surveyors at
  the time of survey
• No more environment, information management,
  human resources dedicated standard sets and team
  interviews

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What did Accreditation Canada hear?What is
realized in Qmentum?

• Aligns accreditation with the organizations
  quality improvement program
• Encourages and enables the standards to be
  utilized on an ongoing basis not only at time
  of survey
• Indicators and performance measures are of direct
  value to the organization and aligned with the
  standards
• Surveyor assessment approach and tools have
  greater rigor and enable greater consistency

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What did Accreditation Canada hear?What is
realized in Qmentum?

• Recognizes that organizations vary e.g. in
  size, complexity, access to computers. (Ensure
  that the program is user friendly to all.)
• Focuses less on areas for improvement and more on
  actions taken
• Enables more predictable times of communication
  with Accreditation Canada
• Reduces preparation work for the on-site survey
• Reflects the increasing emphasis on governance

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What did Accreditation Canada hear?What is
realized in Qmentum?

• Increases the emphasis on primary care
• Recognizes the integration of quality, risk and
  patient safety
• Integrates ROPs into the standards
• Increases specificity in areas such as
  laboratory, medications and diagnostic imaging
• Uses natural teams
• Improved final report shorter, more concise,
  message simplified

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Accreditation Canada Commitments

• Minimize duplication optimize collaboration
  with other organizations e.g. CIHI, vendors of
  health care tools, colleges
• Streamline workload accreditation better
  aligned with your QI programs and process
  minimize/optimize impact on workload
• Move towards alignment with other accreditation
  groups and national organizations (e.g. CIHI,
  CPSI, CHICA) where appropriate
• Dialogue with all provincial and territorial
  Ministries of Health to understand
  accreditation changes, commitment to no
  duplication, alignment of indicators where
  feasible

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Accreditation Canada and Quality of Worklife

• Organizational commitment
• Quality definition
• Standards
• Patient Safety - worklife
• Quality Worklife Quality Healthcare Collaborative
• Performance Indicators

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Accreditation Canada and Quality of
WorklifeOrganizational Commitment

• Accreditation Canada Vision
• The leader in raising the bar for health quality
• Accreditation Canada Mission
• Driving quality in health services through
  accreditation
• Accreditation Canada Values
• With an environment focused on clients and
  committed to quality of worklife, partnerships
  and personal growth, our values are excellence,
  integrity, respect and innovation

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Accreditation Canada Worklife StrategyQuality
Definition

• 1999
• worklife introduced into the definition of
  Quality and worklife standards added to the
  program

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Accreditation Canada Quality DefinitionAIM
Program

• Four dimensions
• Responsiveness
• Client/Community Focus
• System Competency
• Worklife
• The organization provides a work environment that
  enables optimal individual, client and
  organizational health and outcomes

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Accreditation Canada Worklife Strategy

• 2003 - review of all 2002 surveys
• - 6 worklife seminars conducted
• Outcomes
• provided keys for success
• provided action plans to improve worklife in
  organizations
• included worklife in more standards sections
• kept worklife outcomes people focused
• provided education
• developed/provided indicators (preferably
  mandatory)

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Accreditation Canada Worklife Advisory Committee
- 2003

• Formed to advise Accreditation Canada on future
  directions about worklife
• 17 experts included researchers, policy
  advisors, senior managers
• Guided the development of the worklife model
  focuses on the impact on staff, the organization
  and patient outcomes of
• Organizational factors,
• Care and service processes
• Staff characteristics
• Patient characteristics

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Accreditation Canada Quality Definition Qmentum
Program

• Worklife a key part of how Accreditation Canada
  defines quality

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• Standards

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3.0 The governing body defines values for the
organization that are used to guide
decision-making and for determining how services
are delivered

• 3.1
• The governing body seeks input from staff and
  service providers to define or update the
  organizations values statement
• Quality Dimension Worklife
• (Sustainable Governance)

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9.0 The governing body works effectively with the
CEO, senior management, and clinical leadership
to achieve the strategic goals and objectives and
improve the organizations performance

• 9.6
• The governing body, with the CEO, communicates
  with staff and the rest of the organization
• Quality Dimension Worklife
• (Sustainable Governance)

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16.0 The governing body fosters and supports a
culture of safety throughout the organization

• 16.3
• The governing body approves policies and
  initiatives that encourage open communication,
  blame-free dialogue, and full disclosure about
  client safety issues, incidents, and potential
  problems
• Quality Dimension Worklife
• (Sustainable Governance)

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4.0 The organizations leaders develop and
implement the operational plans, infrastructure,
and management systems to meet the scope of
services and achieve the strategic goals and
objectives

• 4.3
• When developing the operational plans, the
  organizations leaders seek input from staff,
  service providers, volunteers, and other
  stakeholders, and communicate the plans
  throughout the organization
• Quality Dimension Worklife
• (Effective Organization)

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5.0 The organizations leaders deliver services
and make decisions according to the
organizations values and ethics

• 5.1
• The organizations leaders provide input in
  defining or updating the organizations values
  statement
• 5.2
• The organizations leaders communicate the values
  statement throughout the organization and educate
  staff, service providers, and clients and
  families about it
• 5.4
• The ethics framework defines formal processes for
  managing ethics-related issues and concerns
• 5.7
• The organizations leaders assign responsibility
  for monitoring the ethics framework and the
  processes to address ethics-related issues
• 5.8
• The organizations leaders build the
  organizations capacity to apply the ethics
  framework by encouraging the governing body,
  leaders, staff, and service providers to develop
  and enhance their ethics-related knowledge
• (Effective Organization)

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7.0 The organizations leaders foster a quality
improvement culture throughout the organization

• 7.3
• The organizations leaders are involved in
  quality improvement initiatives
• 7.5
• The organizations leaders, staff, service
  providers, volunteers, and students receive
  recognition for their quality improvement work
• (Effective Organization)

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8.0 The organizations leaders promote a positive
worklife culture and supports worklife balance

• 8.1
• The organization has a positive worklife culture
  as a strategic priority
• 8.2
• The organizations leaders promote worklife
  balance
• 8.3
• The organization has healthy workplace strategies
  to help staff and service providers manage their
  health
• 8.5
• The organization has a confidential process for
  staff, service providers, and volunteers to bring
  forward complaints, concerns, and grievances
• 8.6
• The organizations leaders identify and monitor
  process and outcome measures related to worklife
  and the working environment
• 8.7
• Accreditation Canada REQUIRED INSTRUMENT The
  organization monitors the quality of its worklife
  culture using the Worklife Pulse Tool
• (Effective Organization)

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12.0 The organization invests in its people and
in the development of competencies among its
senior leaders, staff, service providers, and
volunteers

• 12.2
• The organizations leaders implement staff
  retention strategies for managers, staff, service
  providers, and volunteers
• 12.3
• The organizations leaders use a staffing process
  that is evidence-based and makes appropriate use
  of individual skills, education, and knowledge
• 12.4
• The organizations leaders define reporting
  relationships for staff, service providers, and
  volunteers
• 12.8
• The organizations leaders regularly evaluate
  reporting relationships and managers span of
  control
• 12.9
• The organizations leaders implement policies and
  procedures to monitor performance
• 12.11
• The organizations leaders conduct exit
  interviews with individuals and use this
  information to improve staffing and retention
  strategies
• (Effective Organization)

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5.0 The team promotes the well-being and worklife
balance of each of its members

• 5.1
• The organization has defined criteria that are
  used to assign team members to clients and other
  responsibilities in a fair and equitable manner
• 5.2
• Team members have input on work and job design,
  including the definition of roles and
  responsibilities, and case assignments, where
  appropriate
• 5.5
• The team has a fair and objective process to
  recognize team members for their contributions
• (Sector and Service-based Template)

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• Patient Safety - worklife

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Patient Safety - worklife

• Accreditation Canada Patient Safety Advisory
  Committee
• 2006 - Established 5 goals and 21 Required
  Organizational Practices (ROPs)
• Since then, additional 10 ROPs
• Goal 5 Create a worklife and physical
  environment that supports the safe delivery of
  care/service

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• Accreditation Canada was the secretariat for this
  national coalition and currently hosts the
  collaborative
• National Health Partners
• Accreditation Canada CHA
• CPSI CNA
• CHSRF CMA
• ACAHO ACEN
• CFNU NQI
• Health Canada (ONP) VON

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QWQHC Mandate

• All recognize the value of working together on
  this issue need to see more action, urgently
• The Pan-Canadian Action Strategy focuses on
• National standard indicators
• Priority action strategies
• Knowledge exchange vehicles
• Engagement activities

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• Quality Worklife Performance Indicators

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Quality Worklife Performance Indicators

• QWQHC Performance Indicators Working Group
  created to guide further development of
  performance indicators and database
• Working Group includes representatives from
• Accreditation Canada
• CIHI
• Health Canada
• NAHO
• CHA

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Quality Worklife Performance Indicators

• Key part of Accreditation Canada and QWQHC
  strategy is promoting wide adoption of standard
  Worklife performance indicators

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QWQHC

• QWQHC Within Our Grasp (2007) outlined vision
  and strategy for healthier healthcare work
  environment, including set of quality of worklife
  performance indicators
• Performance indicators were selected based on
• Evidence of connection to key outcomes (for
  staff, organization and patients)
• Input from content experts
• Feasibility to collect

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Quality Worklife Performance Indicators Next
Steps

• Detailed review to identify common
• Practices
• Definitions
• Data sources
• Identify performance indicators for pilot testing
  
• Database requirements
• Accreditation Canada to pilot test and evaluate
  performance indicators for accreditation program

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Quality Worklife Performance Indicators
(identified by QWQHC)

• Accreditation Canada Worklife Pulse Tool Survey
• Turnover rate
• Vacancy rate
• Training and professional development
  opportunities
• Overtime
• Absenteeism
• Workers compensation lost time injury rate

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Accreditation Canada and Next Steps

• Will continue to be strongly informed by the
  outcome of the Quality Worklife-Quality
  Healthcare Collaborative
• Review feedback from surveyors, clients and
  survey results

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Leading Practices

• Leading practices are identified during survey by
  the surveyors
• With the permission of the organization, leading
  practices are placed on the Accreditation
  Canadas website
• Searchable by word or category, organizations can
  access these leading practices enabling sharing
  of knowledge and expertise across the country
• Launched Nov 07, development and improvement
  continuing

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Summary

• Accreditation Canadas accreditation program
• The role and value of accreditation
• Standards
• The new program Qmentum
• Accreditation Canada and Quality of Worklife
• Organizational commitment
• Quality definition
• Standards
• Patient Safety - worklife
• Quality Worklife Quality Healthcare Collaborative
• Performance Indicators
• Leading practices

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www.accreditation-canada.ca
The leader in raising the bar for health quality