The Surveyor’s Journey

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The Surveyors Journey

• The Onsite Survey and Practical Tips for You

Presented by Nathalie Beaulieu Cheryl
Harrison, Accreditation Canada Surveyors February
26, 2009
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Accreditation Process
Accreditation Primer Organization staff and
clients rate service areas, and Accreditation
surveyors conduct an on-site survey to evaluate
basic quality and safety elements. On
completion, an Accreditation Primer Award is
issued.
Self-Assessment Organization staff complete
questionnaires assessing services against
standards. Accreditation canada categorizes the
results using green, yellow, and red flags which
become part of the Quality Performance Roadmap
(QPR).
Organization Action Plan The organization
develops an action plan identifying the steps it
will take in its quality improvement activities.
Customized Survey Plan The Accreditation
Specialist, the organization, and surveyors
develop a customized plan to guide the on-site
survey.
Evidence of Action Taken The organization submits
updated indicator data and evidence of action
taken since the on-site survey.
S e l f - A s s e s s m e n t P r o c e s s
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MONTHS

• D a t a C o l l e c t i o n
• Indicator Data
• Annually, the organization submits data related
  to a core set of patient / client safety
  indicators.
• Instrument Data
• Once during the three year accreditation cycle,
  the organization submits results from a variety
  of tools such as the Governance Functioning Tool,
  the Patient Safety Culture Tool, and the
  Worklife Pulse Tool.

Education CCHSA provides education materials to
introduce Qmentum to the organization and to
address specific learning needs.
On-site Survey CCHSA surveyors review and
evaluate priority processes using tracer
activities.
Final Report and Accreditation Decision

• Accreditation Reports
• On-site Report summarizes the on-site survey
  findings. The organization has five to ten days
  to respond.
• Forecast Report CCHSA reviews the
  organizations response and findings to date and
  issues the forecast accreditation decision.

Most information and templates (questionnaires,
survey instruments, QPR) can be accessed and
updated through the on-line Organization Portal.
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• Roles Responsibilities of Surveyors

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Survey Team Leader

• Coordinates, facilitate and sets agenda for
  planning session
• Confirms roles and responsibilities for each
  member
• Reviews standards, criteria and protocols related
  to tracer activities
• Ensures completion of all survey activities and
  requirements
• Finalizes the report and print copy of the
  on-site report
• Team leader writes and submits commentary

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Survey Team Members

• Review organization information prior to
  teleconference
• Confirms priority processes and service area
  assignments with team leader
• Reviews standards, criteria and protocols related
  to tracer activities
• Independently completes tracer activities and
  ratings
• Transfers survey data to team leader
• Participates in and prepare for debriefing with
  organization

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• The On-site Survey Process

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Purpose of the On Site Survey

• To directly observe and evaluate whether
  standards and criteria are met
• To provide a forum to give advice on how to
  address areas of concern to recognize successes
• To discuss the organizations progress in
  addressing self-identified opportunities for
  improvement

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Main Steps of the On-site Survey

• 1.Organization introductory meeting
• 2.Priority processes and tracer activities
• 3.Surveyor information exchange daily review
• 4.Surveyor ratings and on-site report completion
• 5.Debriefings

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1.Organization Introductory Meeting

• 30-40 minute exchange with the surveyors
• Senior management and select members of the
  governing body
• Can include
• Two way conversation between surveyors and senior
  management
• Scope of services
• Strengths and impediments that have affected the
  organization
• Areas of focus during the survey

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2.Priority Processes Tracer Activities

• Priority Processes
• Reflect critical areas and systems within an
  organization that are known to have a significant
  impact on the quality and safety of care and
  services
• Priority Processes will be assessed using the
  tracer activities

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Priority Processes

• System-Wide Processes Infrastructure
• Integrated quality management
• Planning and service design
• Emergency preparedness
• Patient Flow
• Physical environment
• Human capital
• Principle-based care decision-making
• Communication
• Medical devices equipment use
• Resource management

• Site-Specific Services
• Clinical leadership
• Competency
• Episode of care and service
• Decision support
• Diagnostic services (Imaging)
• Diagnostic services (Laboratory)
• Blood services
• Medication Management
• Infection prevention control
• Impact on outcomes
• Surgical procedures
• Impact on Population served
• 22. Chronic Disease Management
• 23. Population health and wellness

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Tracer Activities

• What is a tracer?
• Following the path of either a client or an
  administrative process

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Tracer Activities
REVIEWclient files and documents
TALK and LISTEN individual interviews/
discussions and group discussions
RECORDwhat you read, hear and see
OBSERVE direct observation and tours
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Tracer Activities Selecting Review Client Files

• Surveyors select client files based on
• Diagnosis, number of medications, age, procedure,
  services
• Complexity and interaction of multiple factors or
  service areas
• Tip..Patient with approx. 3-4 day LOS, not too
  complex and familys input welcomed.

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Tracer Activities Talk and Listen

• Surveyors will
• approach and speak to any staff member
• speak freely to clients and families
• return to a service area if has a follow-up
  questions
• May ask to pull together a small group
• Tipanticipate the need for the presence of key
  individuals e.g. Physicians, Community Providers
  etc. and let surveyor know they available

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Tracer Activities Observe

• Directly observe whats going on in the service
  area processes, procedures, direct care
• May attend normal scheduled meetings
• Tips
• Requires flexibility since the service activities
  can be unpredictable
• Provide schedule of meetings relevant to the area
  being traced

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Tracer Activities Record

• Record
• Observations, notes and issues
• Information that may be relevant to other
  processes

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Clinical Tracer
Driving Dimension Client-centred services
Priority Process Episode of care and service
Choose a client file detailing their care plan

• Talk to clients (both clients and their families)
  about the development and execution of plan
• Did they participate in planning their own care?

Talk to staff who are accountable with care
planning for a given client (presented in
emergency)
Dimension Client-centred services Process
Episode of care and service

• Nurse
• What are the policies and procedures on
  developing and implementing care plans?
• What are the components of a care plan?

Look at the links in the plan and how the plan
was managed across disciplines and departments
(transferred to surgery, followed by medicine and
rehab services, discharged to CareWest)
Evaluate the accreditation requirement using a
software tool
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Administrative Tracer
Driving Dimension Safety Priority Process
Medical Devices Equipment Use
Choose file detailing equipment purchased or to
be purchased

• Talk to staff and clients who
• are using equipment
• Was training provided?
• Who is responsible for arranging cleaning and
  sterilization of equipment and devices?

Ask capital planning committee about the
guidelines they followed
Dimension Safety Process Medical Devices
Equipment Use

• Director, Purchasing Supply Management
• What was the acquisition process for the
  recently purchased MRI?

• Look at equipment
• Has preventative maintenance been conducted?

Evaluate the accreditation requirement using a
software tool
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3. Surveyor Information Exchange and Daily Review

• Surveyor Information Exchange
• Exchange information with surveyors
• Daily Review
• Accreditation Coordinator and Surveyor team meet
  at the end of each day
• 10-15 minute meeting where the accreditation
  coordinator shares feedback on the days
  activities and interactions
• Surveyors will not share specific observations
  about the survey activities

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4. Surveyor Ratings and Preliminary Report
Completion

• When rating, surveyor checks off the items
  (criterion) that are in place
• Survey team synchronizes findings
• Team members support the team leader to complete
  the commentary
• Preliminary report is generated and shared with
  organization

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5. Debriefings

• Leadership debriefing
• General debriefing

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Debriefing Leadership

• One hour session to
• Highlight successes and areas that require more
  evidence of action
• Outline key observations
• Leadership will be given a brief preliminary
  report that
• Provides results from the surveyors evaluation

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General Debriefing

• One hour session for staff, board members,
  volunteers, clients and family members
• Summary will provide
• Key findings and messages
• Solid understanding of the results, including
  strengths and areas for improvement
• Tips....
• If process is transparent, leaders are already
  aware of areas for improvement
• There should be no surprises so listen carefully
• Does not indicate if accreditation will be given

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