Across Canada and internationally, the public and governments at all levels have increasing expectations for quality of care, value for healthcare dollars and accountability. Within this reality, there is increasing recognition of the value of accreditation as a barometer of quality and as a tool to assess and improve accountability and efficiency in healthcare delivery. In this commentary, we show how three key attributes of the Accreditation Canada Qmentum accreditation program – measurement, scalability and currency – promote accountability in healthcare.
Worldwide, health services accreditation is viewed as external evaluation, an external third-party review aimed at validating the achievement of healthcare standards (Accreditation Canada 2014). Accreditation Canada is a not-for-profit independent organization that provides national and international health services organizations with quality-focused, comprehensive accreditation services. Accredited by the International Society for Quality in Health Care, Accreditation Canada has supported organizations in improving healthcare quality since 1958. Accreditation is voluntary in some sectors and jurisdictions and mandatory in others. Within this reality, in total over 1,200 organizations (located on over 6,000 sites) throughout the continuum of care participate in Accreditation Canada programs. In 2008, Accreditation Canada launched the Qmentum accreditation program, a major refocusing of the preceding program.
Tailored Measurement for Individual Healthcare Organizations within a National Context
The Qmentum program provides a framework to guide measurement, known as the Accreditation Canada Quality Framework. Eight dimensions are used to define quality and guide the focus of the standards: population focus, accessibility, safety, work life, client-centred services, continuity of services, effectiveness and efficiency. The Accreditation Canada program promotes accountability through measurement by providing benchmarking – across teams in an organization, across time and in comparison to other peer comparators within the appropriate jurisdiction or sector of care. Performance in each quality dimension is reported back to each organization. Leaders at all levels of an organization can use this dimension benchmarking to diagnose strengths and opportunities for improvement (Mitchell et al. 2012).
During the on-site survey, surveyors – senior healthcare professionals from Canadian healthcare organizations accredited by Accreditation Canada – observe and evaluate the extent to which the standards are met. Surveyors interact directly with a wide variety of staff, clients and stakeholders in their work environments to gather evidence about the quality and safety of care and services provided. The independent on-site peer review and the standards criteria rated by surveyors serve as an accountability tool by enabling the staff of healthcare organizations to identify strengths and opportunities for improvement.
Surveyors assess what is evident and presented to them; what is not evident or presented cannot be assessed. The interaction of direct care providers with surveyors enhances the information obtained during the on-site survey. In the Qmentum program, information is also collected through survey instruments that complement the on-site survey. These questionnaires – focusing on work life, patient safety culture and governance – provide data across the organization, different groups of staff/service providers and programs. The survey instruments are applied, at minimum, once per accreditation cycle; however, they can be utilized as often as the organization chooses.
Accreditation Canada produces organization-specific, sector-specific, national and jurisdictional reports, as well as joint reports with other national healthcare organizations on emerging trends, quality and safety risks, and best practices (Accreditation Canada 2013; Accreditation Canada et al. 2012). This analysis of accreditation data/results promotes accountability in organizations by allowing for the comparison of organization-specific results to sector, jurisdictional and national results and by sharing quality improvement practices across Canada.
Scalability: Customizing the Accreditation Program to Individual Organizations' Needs
The size and structure of healthcare organizations across Canada varies, with regional health systems in the western and eastern provinces and health networks in the central provinces. Consequently, the healthcare organizations that participate in the Accreditation Canada program differ greatly in size, scope and context. An organization participating in accreditation may be an entire provincial health system, made up of many sites providing a wide range of services, or a single-site independent organization providing a narrower scope of services, such as a primary care practice. In addition, Accreditation Canada accredits several healthcare delivery systems under the jurisdiction of the federal government – Aboriginal Health Services, Corrections and the Canadian Forces.
In many jurisdictions, Accreditation Canada accredits organizations as an entire system, further promoting accountability and integration across an entire organization as opposed to accrediting particular program areas. Close to one hundred different standard sets have been developed by Accreditation Canada to cover the continuum of care that a patient/client experiences; these standards are developed to be sensitive to variances in sectors of care and cultures (e.g., First Nations and Inuit health). In consultation with Accreditation Canada, each client organization selects those standards sets that reflect the care and services that the organization provides to its clients.
Maintaining Currency and Looking Forward
What are some of the key findings from the Canadian healthcare organizations surveyed over the past years? Processes for the standardization and storage of medications and the implementation of policies for infection control continue to be identified as strengths (Accreditation Canada 2012, 2013). (See the Canadian Health Accreditation Reports at www.accreditation.ca for additional information.) While the accreditation program has primarily focused on structure and process measures of performance, outcome-focused content will continue to be added to the program in order to obtain a more comprehensive view of organizational performance. In identifying outcome measures, key quality and safety elements will be examined such as patient flow, access to services and patient experience.
Accreditation Canada continues to work in partnership to shift the focus away from data reporting requirements to supporting healthcare organizations in using their own data for quality improvement. Data that organizations are already using for quality improvement purposes can be used for their accreditation process. For example, results of patient, client, and resident experience surveys and the action plans that are developed and applied place the emphasis on quality improvement rather than simply reporting data and results to Accreditation Canada.
How is the information in the accreditation program kept current? The Accreditation Canada database is updated continually owing to the ongoing accreditation surveys across the country, ensuring that data are current and relevant. Feedback from client organizations, surveyors and stakeholders, as well as research and best practice, are used to update the content of the program. The standards and other key components of the program are adjusted to ensure their relevance and value and therefore provide access to a wealth of information for users' knowledge and practice to "keep pace." Accreditation Canada continues to partner with researchers, academics, medical and policy experts as well as ministries and organizations across Canada and internationally to understand the emerging area of risks to quality and safety and to develop tools to guard against these risks.
The pace of change within the healthcare environment is rapid. Within this reality, accreditation represents a valuable "neutral" yet complementary accountability mechanism to assess and improve the quality of healthcare and healthcare delivery through ongoing surveys, the timely reporting of results and data reporting.
Le programme d'Agrément Canada: outil complémentaire pour la promotion de l'obligation de rendre compte dans les services de santé canadiens
Au Canada et à l'étranger, la population et tous les paliers de gouvernement ont des attentes de plus en plus grandes pour ce qui est de la qualité des soins, du rendement de chaque dollar dépensé pour la santé et de l'obligation de rendre compte. Dans ce contexte, on reconnaît de plus en plus la valeur de l'agrément à titre de baromètre de la qualité et comme outil pour évaluer et améliorer l'obligation de rendre compte et l'efficacité dans la prestation des services de santé. Dans ce commentaire, nous montrons comment trois caractéristiques clés du Programme d'agrément Qmentum d'Agrément Canada – évaluation, adaptabilité et fiabilité – favorisent l'obligation de rendre compte dans les services de santé.
About the Author
Jonathan I. Mitchell, MSc, Manager, Policy and Research, Accreditation Canada, Ottawa, ON
Wendy Nicklin, BN, MSc(A), President and Chief Executive Officer, Accreditation Canada, Ottawa, ON
Bernadette MacDonald, MScN, Vice President, Innovation and Development, Accreditation Canada, Ottawa, ON
Correspondence may be directed to: Jonathan I. Mitchell, Manager, Policy and Research, Accreditation Canada, 1150 Cyrville Rd., Ottawa, ON K1J 7S9; tel.: 613-738-3800; e-mail: firstname.lastname@example.org.
Accreditation Canada. 2012. Required Organizational Practices: Emerging Risks, Focused Improvements. Retrieved March 30, 2014. <http://www.accreditation.ca/sites/default/files/char-2012-en.pdf>.
Accreditation Canada. 2013. Safety in Canadian Health Care Organizations: A Focus on Transitions in Care and Required Organizational Practices. Retrieved March 30, 2014. <http://www.accreditation.ca/sites/default/files/char-2013-en.pdf>.
Accreditation Canada. 2014. The Value and Impact of Health Care Accreditation: A Literature Review. Retrieved March 30, 2014. <http://www.accreditation.ca/sites/default/files/value-and-impact-en.pdf>.
Accreditation Canada, Canadian Institute for Health Information, Canadian Patient Safety Institute and Institute for Safe Medication Practices Canada. 2012. Medication Reconciliation in Canada: Raising the Bar – Progress to Date and the Course Ahead. Retrieved March 30, 2014. <http://www.accreditation.ca/sites/default/files/med-rec-en.pdf>.
Mitchell, J.I., W. Nicklin and B. MacDonald. 2012. "The Determinants of Quality Healthcare: Implications for Canadian Health Leaders." Healthcare Management Forum 25: 138–41.
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