Elaine O’Connor

Head of International Accreditation & Regulation

19th EPSO Conference Oslo, Norway

April 2015

About ISQua

IAP Awards to Date

115 sets of standards 22 surveyor training programmes 58 organisations

Haute Autorité de Santé – DAQSS Accreditation Canada Joint Commission of Taiwan – JCT Council for Health Service Accreditation of

Southern Africa - COHSASA Danish Institute for Quality and Accreditation

in Health Care - IKAS Diagnostic Accreditation Programme, British

Columbia Health and Disability Auditing Australia Pty

Ltd - HDAA Joint Commission International - JCI Malaysian Society for Quality in Health -

MSQH Quality Improvement Council, Australia - QIC National Accreditation Board for Hospitals &

Health Care Providers, India - NABH DAA Group Limited, New Zealand AABB, USA Netherlands Institute for Accreditation in

Healthcare - NIAZ ICONTEC Health Accreditation Service,

Columbia

5

CHKS Accreditation Unit, UK Canadian Accreditation Council of Human

Services - CAC Global-Mark Pty Ltd, Australia Health and Disability Auditing New

Zealand - HDANZ Australian Aged Care Quality Agency -

AACQA The Healthcare Accreditation Institute

(Public Organization), Thailand - HAI Australian General Practice Accreditation

Ltd / Quality in Practice Pty Ltd – AGPAL/QIP

Japan Council for Quality Health Care - JCQHC

The Australian Council on Health Care Standards - ACHS

Health Care Accreditation Council, Jordan - HCAC

DNV GL Business Assurance, Norway Associacao Brasileira de Acreditacao De

Sistemas e Servicos de Saude, Brazil – CBA

Accredited Organisations

International Accreditation Programme

6

20062007

20082009

20102011

20122013

20142015

20160

5

10

15

20

25

30

35

40

IAP Programmes by Year

Surveys Cancelled/RescheduledFUTURE DATES ConfirmedAMOUNT Completed

IAP- 4 year cycle

Critical path issued Technical review Final Submission of Self Assessment Surveyor Assessment (survey) Factual Review Report Validated by Panel Accreditation Decision Award Pack to Organisation Continuous Assessment – 12 and 30 months post survey

7

New Zealand

Health and Disability Services (Safety) Act 2002

Introduced health and disability standards for hospitals, rest homes and residential disability services aimed at improving safety and quality of care – became mandatory in 2004

Director General of Health approves designated audit agencies (DAAs) whose role is to audit services against the standards

2009 – Ministry required 3rd party accreditation of DAAs 2010 – MOU between ISQua and NZ Ministry of Health

8

Standards

Guidelines and Principles for the Development of Health and Social Care Standards, 4th Edition 2014

Surveyor Training Programme, 2nd Edition 2009

Guidelines and Standards for External Evaluation Organisations, 4th Edition 2014

9

Rating Scale

4 = excellent achievement Evidence exceeds the criteria

3 = good achievement (60%) Evidence meets the intent of the criteria

2 = fair achievement (31 – 59 %) Partially in place and evidence of working towards

implementation – risk rated

1 = poor achievement (under 30 %) Nothing properly in place and no evidence of working

towards implementation – risk rated

10

Risk rating

11

Risk Matrix

Moderate (4)

High (5)

Critical (6)

Low (3)

Moderate (4)

High (5)

Low (2)

Low (3)

Moderate (4)

Low (1) Moderate (2) High (3)

Impact Risk = Likelihood + Impact

Lik

elih

ood

High (3)

Moderate (2)

Low (1)

Achieving Accreditation

All core criteria must achieve a rating of 3 or more, a rating of 2 may be accepted, if the risk associated with the criterion is rated low or moderate;

There should be no more than two criteria within each standard rated as 2, if the risk associated with the criterion is rated low or moderate; and

The 70% compliance rate can still be achieved even if there are a minimal number of criteria rated 1, the risk associated with each can only be low or moderate.

12

Guidelines and Principles for the Development of Health and Social Care Organisations 4th Edition, 2014

6 Principles Standards Development Standards Measurement Organisational role,

planning and performance Safety and risk Patient / service user focus Quality Performance

13

Guidelines and Standards for External Evaluation Organisations 4th Edition, 2014

8 Standards Governance Strategic, operational and

financial management Risk management and

performance Human resources management Information management Surveyor management Survey and client management Accreditation or certification

awards

14

Core Criteria

26 in total financial loss to the organisation or their clients;

loss of reputation to the organisation;

inability to perform surveys;

suitable workforce, including surveyors; and

accreditation decision-making.

15

Example of Standard

Standard 1 Governance

The external evaluation organisation is responsibly governed to meet its defined purposes and objectives.

16

Criteria

1.1 Mission & Vision

1.2 Values

1.7 Code of conduct

1.8 Documented governance arrangements

Stakeholders involved

Evidence of implementation across all departments

Code of conduct

Constitution of the governing body, terms of reference for governing body, meeting papers, agendas, documented lines of accountability, supporting committees terms of reference

17

Example of Core Criteria

1.10 The governing body defines and documents overall authority and responsibility for:

1.11 The governing body defines and documents overall authority and responsibility for financial activities including:

Annual plan Strategic documents Job descriptions

Terms of reference Budget approval Financial reports Job description

18

Self Assessment

1.10

Core

The governing body defines and documents overall authority and responsibility for:a) overseeing the strategic planning

process,b) developing and approving

accreditation/certification standards used by the organisation,

c) ensuring the organisation meets legal and regulatory requirements as well as reporting, monitoring, and accountability obligations,

d) approving the organisation's corporate policies and ensuring the policies are followed,

e) ensuring appropriate communications plans and strategies are in place,

f) monitoring the organisation's performance including the achievement of the strategic goals and objectives

 

Self - Rating   Surveyor Rating     

 

 

19

Guidance

These may be included in the annual plan, strategic documents or operational documents. Other areas may include:

i. overseeing the business development and marketing process;ii. ensuring research plans and strategies are in place as appropriate in view of the overall mission and vision of the external evaluation organisation

 Evidence Annual plan Strategic documents Job descriptions

Language

8.0 The processes for determination, awarding and maintenance of accreditation or certification are objective, consistent and meet the external evaluation organisation’s objectives.

8.1

Core

The external evaluation organisation states who is responsible for determining the outcome of the survey; that the award of accreditation or certification is made in accordance with criteria, set by the governing body; and on the basis of the findings in the survey report. The process is transparent, consistent, and impartial and is determined within a set timescale.

Guidance

This could include accreditation and certification decisions being:

i. confined to matters relevant to the scope of the accreditation or certification being considered

 

The set timescale in which all activities have to be met be included in the criteria set by the governing body.

Suggested Evidence

Defined process and criteria for making accreditation decisions

8.2 The certificate awarded to the participating organisation details the name of the organisation, the scope and effective date of the accreditation or certification and the term for which it is valid.

20

Board Accreditation Committee Tracey Cooper (Chairperson)

Chief Executive, Public Health Wales, UK

Wendy NicklinPresident & CEO, Accreditation Canada, Canada

B.K Rana Joint Director, NABH, India

Janne Lehmann Knudsen Director of Quality, Danish Cancer Society, Denmark

Cliff HughesCEO, Clinical Excellence Commission, Australia

Triona Fortune Deputy CEO, ISQua

21

Accreditation Status

Approval Process Validation Panel

Recommend to award accreditation with or without comments BAC approve or may ask for further information Award for 4 years, continuing accreditation maintained

through continuous assessment

Appeals process

22

Thank you

Any Questions…

23