Using the Accreditation Report for Implementing System Wide Improvements

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Using the Accreditation Reportfor Implementing
System WideImprovements

• Improving Quality of Care and Patient Safety
  Through Accreditation
• Ms. Terry Brent, RT, OHSA Lab Manager
• Dr. Kirk Ready, Clinical Director OHSA Labs
• Monday, May 12th, 2008

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Using the Accreditation Report for Implementing
System Wide Improvements

• Introduction
• Pre-Accreditation
• On-Site
• Review Report
• Implementation
• Conclusions
• Recommendations

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Introduction Accreditation ? System Wide
Improvement

• Kirk Terry Co-Management
• OHSA Labs
• VJH - 125, KGH 325 , PRH 134 - beds
• OLSC
• OHSA Working Groups
• IH LSC
• IH SET

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Pre-Accreditation Accreditation ? System Wide
Improvement

• Self Assessment
• By Site
• Then together
• Terry and Kirk
• Preparation in relation to overall strategic plan
• 3 5 year Mission DAP or other
• Vision Mission Values
• Nothing
• Snap shot
• On a mission course set

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On-Site Accreditation ? System Wide Improvement

• 3 consecutive days
• 2 teams
• If it is Tuesday,
• this must be Vernon

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On-Site Accreditation ? System Wide Improvement

• 3 consecutive days
• 2 teams
• If it is Tuesday, it must be Vernon

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Review Report Accreditation ? System Wide
Improvement

• 3 separate reports
• Presentation to IH Board Quality Committee
• Hosp MAC
• Electronic
• Converted to Table
• Merged tables
• OLSC
• OHSA Discipline WG review sections

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Implementation Accreditation ? System Wide
Improvement

• OHSA Discipline WG
• Involvement of IH Lab Discipline WG
• Implementation of instruments
• Method Validation
• General Operations Manual
• QS Manual

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Conclusions Accreditation ? System Wide
Improvement

• Done in one day
• Snap shot of three sites
• Define standards (previously none)
• Long time between assessment and receipt of
  report
• Short time to respond (lead time taken up in
  delay of receipt of report)
• Variations in the reports but overall showed
  almost all issues were in similar / common
• Opportunity for prioritization helpful
• Opportunity to really bring together the lab
  staff from all three sites for each of the
  various disciplines (team building)
• Overall rating system - good

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Recommendations Accreditation ? System Wide
Improvement

• Electronic Reports with ability to insert and
  edit action plan
• More regional approach especially for general
  areas, including human resources, information
  management, suppliers and partners
• For each bullet need Y / N / Na

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