Accreditation a Powerful Tool for Healthcare Quality and Safety part 2

1
Accreditation a Powerful Tool for Healthcare
Quality and Safetypart 2

• Some Australian Examples
• New directions
• ISQuas International Accreditation Program
• Bruce Barraclough

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The Australian Council on Healthcare Standards
Evaluation and Quality Improvement Program (EQuIP)

• EQuIP cycle a 4 year program with at least one
  activity per year
• Phase 1 self assessment against criteria
• Phase 2 organisation wide survey
• ACHS Accreditation
• Phase 3 self assessment of mandatory criteria
  and review of progress on recommendations
• Phase 4 periodic review self assessment
  survey of mandatory criteria review of progress
  on recommendations
• In surveyed hospitals there has been a dramatic
  shift towards outstanding achievement rating
  levels over 5 years

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EQuIP 4, Clinical mandatory criteria

• The assessment system ensures current and ongoing
  needs of the consumer / patient are identified
• Care is planned and delivered in partnership with
  the consumer / patient and when relevant, the
  carer, to achieve the best possible outcomes
• Consumer / patients are informed of the consent
  process, understand and provide consent for their
  healthcare
• Care is evaluated by healthcare providers and
  when appropriate, the consumer / patient and
  carer
• Processes for discharge / transfer address the
  needs of the consumer / patient for ongoing care
• The health record ensures comprehensive and
  accurate information is recorded and used in care
  delivery
• The infection control system supports safe
  practice and ensures a safe environment for
  consumer / patients and healthcare workers

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EQuIP mandatory criteria

• Mandatory criteria are those where a rating of
  Moderate Achievement (MA) or higher is required
  to gain or maintain ACHS accreditation. A
  mandatory criterion is one where it is considered
  that without evaluation, the quality of care or
  the safety of people within the organisation
  could be at risk

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Australian Council on Healthcare
StandardsClinical Indicators Performance
Outcomes Service

• What are the benefits?
• Accessing regular and current information on
  processes and outcomes of healthcare
• Trending data over time and benchmarking with
  peers
• Utilising comparative reports in conjunction with
  a quality improvement program to provide evidence
  of how an organisation is monitoring and
  evaluating patient care
• Accessing documented evidence of improved
  management and examples of improved patient
  outcomes
• Utilising indicators to support change and
  movement

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What areas do the current clinical indicator sets
cover?

• Adverse drug reaction
• Anaesthetics
• Day surgery
• Dermatology
• Emergency medicine
• Gastrointestinal endoscopy
• Gynaecology
• Hospital in the home
• Hospital wide clinical
• Infection control
• Intensive care
• Internal medicine

• Mental health inpatient
• Mental health community
• Obstetrics
• Ophthalmology
• Oral health
• Paediatrics
• Pathology
• Radiation oncology
• Radiology
• Rehabilitation medicine
• Surgery

Australian Council on Healthcare Standards
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Improving clinical indicator results

• Anaesthetic review and records
• Day surgery unplanned overnight admission,
  delay in discharge and failure to arrive
• Mental health assault and discharge summary
• Catch up immunisation
• Radiographic report availability
• Rehabilitation assessment and rehab plans

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Deteriorating clinical indicator results

• Delays in Emergency Department triage category
  2, 3, 4 and 5
• Access block from Emergency Department to ward
• Turn around time for pathology reports
• Waiting time for radiotherapy for cancer
• Warfarin associated adverse reactions
• Documented assessment for geriatric patients

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Accreditation is only part of the answer

• Also needed is
• Credentialling of individuals with a defined
  scope of practice
• Reporting systems
• Production and implementation of evidence based
  guidelines

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Credentialling defining scope of clinical
practice

• Mutual obligations of clinicians and health care
  organisations to ensure safe, high quality health
  care

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New South Wales Clinical Excellence Commission

• Incident information management system
• 128,000 incidents in past year
• 500 high level adverse events submitted to root
  cause analysis
• Voluntary reporting anonymous by choice

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TOP 10 Clinical Principal Incident Types Jul 05
Mar 06
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Risks associated with clinical management
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Risks associated with Communication
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Elements of accreditation systems

• A governance and stewardship function
• A standards setting process
• A process of external evaluation of compliance
  against those standards
• Action on the outcomes of that evaluation
• Promotion of continuous quality improvement

A Core Strategy for Cancer Care Accreditation of
Cancer Services a Discussion Paper Australian
Cancer Network National Breast Cancer Centre
2005
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What is needed for quality cancer care?

• Safety
• Appropriateness
• Access
• Consumer centredness
• Effectiveness
• Efficiency
• Health professionals with competencies to
  support this agenda

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Accreditation of cancer services

• What did our stakeholders want?
• The system ensuring that the program proposed
  is appropriately integrated with the broader
  system of accreditation to deliver quality cancer
  services across the continuum of care.
• The process developing a clear process that
  minimises duplication of resource use and effort
  in obtaining and maintaining accredited
  standing.
• The standards the need for a set of obligatory
  core standards, generic service standards and
  potentially, tumour stream specific standards.
• All agree, review and feedback of service
  activity leads to improvement

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Whats new in accreditation?

• A move away from the high resource levels
  required if large teams of surveyors used towards
  -
• Initial internal assessment
• Web based self lodgement of activity statement
• Surveyor assessment by desk audit
• Focussed review of outliers and high risk or
  targeted areas
• Ask not only what was done? but how it was
  done?

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The New South Wales Clinical Excellence
Commissions Quality Systems Assessment Program

• Objectives
• Provide assurance of compliance with
• Policies
• Standards
• guidelines
• Support improvement at local unit, facility and
  systems level
• Provide assessment of the level of development of
• Patient safety system
• Clinical quality improvement
• Identify future risks to patient safety

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The assessment process

• Will occur at three tiers
• Area Health Service
• Facility / clinical stream
• Clinical unit
• Targeted focus on specific aspects on an annual
  basis
• Thematic approach to targeting
• Customised for specific issues identified in
  previous quality system assessment

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What is the QSAP assessing?

• Quality framework
• Policies and procedures
• Incident management
• Complaint management
• Medical record review
• Peer review
• Clinical audits

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QSA Evaluation of pilot program

• Data on value and burden of self assessment
  criteria (47 questions)
• Data on source documents for desk top
  verification
• Results All agreed
• Self assessment addresses 7 key patient safety
  quality policies
• Identified inconsistent performance in
• death review,
• peer review,
• medical record review
• Showed incident management system well
  implemented

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ISQuas International Accreditation Program
ISQua
Executive Board
Accreditation Federation Council

National accreditation organizations also
representatives of IHF, World Bank, WHO, WONCA
International accreditation process for
healthcare standards, also training programs
International accreditation of performance
of healthcare accreditors other external
evaluators of healthcare
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ISQua International Accreditation

• A four year cycle of
• Assessment tools and guidance
• Supported development, education and training
• Self-assessment and documentation review
• On-site pre-survey review
• Independent peer assessment or on-site survey
• Full report and recommendations for improvement
• Accreditation as a formal recognition of
  achievement

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ISQua Accreditation Output

• The standards of 19 organisations in Australia,
  Canada, England Wales, France, Ireland, Japan,
  Joint Commission International, New Zealand,
  South Africa successfully accredited
• Also in process of assessment are standards in
  transitional and developing countries in Eastern
  Europe, Eastern Mediterranean and Asia

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Research and evaluation of accreditation
improving quality of care

• ISQuas Accreditation Council website forum will
  provide opportunities to
• Share and post research on accreditation and on
  the effectiveness of accreditation
• Identify gaps in research and areas for further
  study
• Host an open discussion forum (community of
  practice)
• Transfer knowledge among researchers, policy
  makers, practitioners and other stakeholders and
  post individual and organisational expertise and
  experience related to research on accreditation
• Be trilingual English, French, Spanish
• Website to be hosted by the Canadian Council on
  Health services Accreditation available within 3
  months

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Contact ISQua

• The International Society for Quality in Health
  Care
• Tel [phone]
• Fax [phone]
• Web www.isqua.org
• E-Mail isqua_at_isqua.org