The Infection Prevention and Control Accreditation Process

1
The Infection Prevention and Control
Accreditation Process

• CHICA Conference
• June 4th, 2008

2
Itinerary

• 2008 CCHSA Program
• New IPAC Standards
• Required Organizational Practices
• Capital Health Edmonton and Area Accreditation
  Preparation Experience

3
Overview of Process
Self-Assessment Questionnaire
Indicators Instruments
Quality Performance Roadmap (QPR)
Action Plans
On-site Survey
Accreditation Decision
4
Comparisons Past and New CCHSA Programs

• Past Program
• Standards used as basis for accreditation survey
  identifying strengths areas of improvement,
  assigning ratings
• Quality framework included four dimensions
• Self-assessment paper based and time consuming

• New Program
• Standards integrated with ROPs quality
  improvement tool to be used on ongoing basis to
  measure compliance
• Quality framework includes eight dimensions
• Self-assessment electronic and shorter

5
CCHSA Standards
6
CCHSA Standards for IPAC

• Promote assessment of compliance with standards,
  ROPs and indicators
• Incorporate best practice and research
• Include client perspective in preventing and
  controlling infections
• Address IPAC issues affecting all staff,
  volunteers, clients and families,
• Include structure, process, and outcome
  performance measurement

7
Themes of IPAC Standards

• Investing in IPAC
• Keeping people safe from infection
• Providing a safe and suitable environment
• Being prepared for outbreaks and pandemics

8
Included in IPAC Standards

• 6 Required Organizational Practices
• Test(s) for Compliance
• IPAC specific Indicators
• Rates of Health Care-Associated MRSA /or C
  difficile
• Rates of Surgical Site Infection

9
Self Assessment Questionnaire

• Example Infection Prevention and Control

10
Self Assessment Questionnaire Portal
11
Quality Performance Roadmap

• The Quality Performance Roadmap based on
  self-assessment
• Priorities are identified by red, yellow and
  green flags

12
ROP Definition Five Safety Areas

• An essential practice that organizations must
  have in place to enhance patient/ client safety
  and minimize risk

Based on CCHSA Patient/Client Safety Goals
ROPs, v.2.1 for use with 2007 Standards
12
13
Albertas Health Regions

• Health regions are responsible for all hospitals,
  continuing care, community health services,
  public health programs, and mental health

Capital Health
14
Capital Health Geography
15
Population Served

• Capital Health provides many specialized services
  for western and northern Canada
• Capital Health serves a diverse population with
  higher healthcare needs than other health regions
  in Alberta

16
Regional Accreditation Preparation
Accreditation Launch November 2, 2007
17
Accreditation 12 Month Time Line
Identify people and numbers to complete
web-based self-assessment
Develop Customized Plan for On-Site Survey April
- June
Convene Accreditation Teams
Complete web-based self-assessment 2 4 weeks
Oct Nov Dec Jan Feb
Mar Apr May Jun Jul
Aug Sep Oct
Review Results from CCHSA (Quality Performance
Road Map) Develop and Implement Action
Plan Report to Regional Quality Council February
- April
Submit Indicator and Instrument Data On-Line
Participate in On-Site Survey Review CCHSA Brief
Report 5- days Post Survey
18
Team Development

• New process
• Team membership identification
• Support provided
• Team expanded and contracted as required

19
Self Assessment Questionnaire
20
Questionnaire Completion

• Portal open for 2 weeks
• Anonymous
• Questions quite broad
• Cant rate option

21
And the Survey Says?
22
The Benefits of Accreditation

• Opportunity to improve quality and patient safety
• Team building, collaboration, communication and a
  shared vision
• Strengthens relationships and partnerships with
  staff, clients, external care providers,
  community partners and the public
• Identification of new opportunities to further
  integrate service delivery along the continuum of
  care in all sectors

23
Action Plan Development

• Adherence to Standards Guidelines
• Cleaning, Disinfection Sterilization
• Infection Rate Monitoring
• Hand Hygiene
• Immunization P P
• Compliance Monitoring

24
Action Plan Development

• Compliance
• Gap Analysis
• Partnering with Public Health for the Influenza
  and Pneumococcal ROPs

25
On-Site Survey

• Trace a client and/or process throughout the
  region
• Focus on critical areas
• Systems and processes known to have
  significant impact on patient safety/and quality
  care/service
• Preliminary report will be provided

26
Accreditation Decision

• Response Process
• CCHSA will issue final report
• Capital Health will continue to work on
  identified high priority areas

27
New Accreditation Program

• Standards easier to integrate and apply, quality
  improvement tool can be used on ongoing basis
• Quality framework includes eight dimensions
• Accreditation Process Self-assessment shorter

28
Questions