Presentation on theme: "CCHSA Accreditation: New Standards for Managing Medications"— Presentation transcript:
1 CCHSA Accreditation: New Standards for Managing Medications Jessica PetersLead, Research & Product DevelopmentCCHSA
2 Presentation Outline Vision, Mission and Values The Accreditation ProgramProgram EnhancementsThe New Standards for Managing MedicationsNext Steps
3 CCHSA’s Vision and Mission The leader in raising the bar for health qualityMissionDriving quality in health services through accreditation
4 CCHSA’s ValuesWithin an environment focused on clients and committed to quality of worklife, partnerships, and personal growth, our values are:ExcellenceIntegrityRespectInnovation
5 CCHSA’s Accreditation Program Canadian accreditation program - incorporated in 1958Not-for-profitHigh participation rates; continued growthSurveyors (approx. 400) are senior health care professionalsSurveys may be regional, institution specific, national or market specific (i.e. First Nations, Corrections, Canadian Forces)Average 400+ surveys per yearThree year cycleBoth public and private organizations participate
7 Role of AccreditationQuality Improvement – at the organization level and at the system levelChange managementStandards of excellence – raising the bar on health careStandards of clinical practiceGovernanceLeadership
8 CCHSA Standards Standards of excellence ‘Raise the bar’ for health care practiceEnable an organization/team to stretch to improve care, to reach or raise the barDeveloped with the input and guidance of experts in the field and updated on a regular basis to ensure relevance and valueAre applicable to different regions and service delivery settingsWill continue to be used by organizations, but in a new wayDescribe that CCHSA standards continue to be…..Standards are still the benchmarks but you will no longer use them to guide you through every step of the self-assessment. Physically, they will be more of a reference tool but the content will be embedded throughout the process. For example, the self-assessment will be partly administered through online questionnaires which are essentially a roll-up of the standards. The questionnaires use wording directly from the standards. But, that’s a topic for another day…Draft target areas based on literature review, evidence, CCHSA experienceInput from experts, key informantsDraft standardsExtensive consultation with stakeholdersRevision processPilot testingStandards finalized* Ideas in and direction of standards are decided largely by those who will use them
9 Evolution of CCHSA Program Speak to why/rationale for ever-evolving programs… i.e. changing environment, accountability, etc.
10 The New Accreditation Program Benefits:1. Standards that:Capture the most recent governance/managerial and clinical best practicesReflect the emerging trends or disease (and wellness) patterns in healthcareHave an increased level of specificityCan be used or integrated into the daily work of organizations2. Streamlined and more flexible process that:Supports and aligns better to an organizations’ quality improvement initiativesIs adaptable no matter how small or how complex the organization may beThe design and development of the new accreditation program has been guided by the desire to realize the following benefits for client organizations
11 The New Accreditation Program Benefits:3. Greater focus on the provision of safe quality care and service in a variety of health care settings4. Planned and predictable accreditation activities with a on-site survey that is customized to the organizations’ needs5. Automated measurement tools that allow:Greater and faster data exchangeImproved standardization and objectivityThe design and development of the new accreditation program has been guided by the desire to realize the following benefits for client organizations
12 The standards have a brand new structure… Structure or configuration ?New standards for laboratory, pharmacy, diagnostic imaging, operating room procedures, and other therapeutic -technologies are being developed — areas prone to significant risk and associated with the largest volume of adverse events. This new content will strengthen the way these elements are reviewed in the -accreditation program.Ongoing and increased emphasis on population healthIncreased attention to primary care, including emergency medical services, teletriage, and primary care networksEnhanced outcome-related contentFocus on integrated quality management
13 Standards Areas EFFECTIVE AND SUSTAINABLE GOVERNANCE PROACTIVE AND SUPPORTIVE ORGANIZATIONSERVICE EXCELLENCECCHSA standards are still organized into areas . Let us look at this a little more closely. This table outlines the new standards model.Four (4) main standards areas are envisioned. These areas are:Responsible and sustainable governanceProactive and supportive OrganizationService Excellence (these are the revised Client Services/Care standards) –and include population-based standards, sector/service based standards, and new specific standards in some areas, i.e. infection prevention and control, managing medications, diagnostic imaging.Positive Client ExperiencePOSITIVE CLIENT EXPERIENCE
14 Managing Medications: Background The development of the new standards for managing medications was driven by:Importance of safe medication management processes in protecting client safetyFeedback from client organizations and surveyorsChanging health care environmentDevelopment began in 2004Expert working group including representatives from organizations and ISMP-CanadaStandards circulated for consultation in late 2005 to approximately 15 organization
15 The New Standards for Managing Medications… Standards target medication processes in an institutional setting, i.e. hospital, long term careFocus on the safe use of medications from selection and procurement through administrationAddress a number of key themes:Working Together to Promote Medication SafetyCarefully Selecting and Procuring MedicationsProperly Labelling and Storing MedicationsAppropriately Ordering and Transcribing MedicationsAccurately Preparing and Dispensing MedicationsSafely Administering Medications to ClientsMonitoring Quality and Achieving Positive ResultsCCHSA is currently exploring/testing the application of the standards in a wider range of organizations.
16 Working Together to Promote Medication Safety Recognizing pharmacists and pharmacy staff as integral members of the interdisciplinary teamActively involving the pharmacy staff in designing the organization’s medication use and medication management processesProviding access to accurate medication-related information, formally approved drug information tools and education about safe medication useEvaluating the competency of all service providers who participate in the medication use process
17 Carefully Selecting and Procuring Medications Maintaining an up-to-date and evidence-based list of available medicationsMinimizing the number of procured and available medicationsMinimizing the medications available – includes the REQUIRED ORGANIZATIONAL PRACTICE: The organization standardizes and limits the number of drug concentrations available.
18 Properly Labeling And Storing Medications Reducing the possibility of errors with drug product nomenclature, labeling, and packagingLabeling all drug concentrations clearly and legiblyProviding suitable space for drug storage in pharmacies and client/unit medication areasCarefully selecting stock drugs for each client areaStoring hazardous chemicals away from clients, service providers, and drug preparation areasSelecting stock drugs – includes ROP: The organization has removed all concentrated electrolytes from client areas/units.
19 Ordering and Transcribing Medications Appropriately Maintaining accessible and up-to-date client informationCommunicating drug orders and other drug information in a standardized wayReviewing all prescriptions or medication orders for accuracy and appropriateness
20 Accurately Preparing and Dispensing Medications Preventing contamination when preparing medicationsDispensing medications in a safe, accurate, and timely wayHaving a system to safely dispense medications where there is no internal pharmacy or when the pharmacy is closedTransporting medication in a safe, secure, and timely manner way
21 Safely Administering Medications To Clients Educating clients about their medications and delivery devices, and ways to prevent errorsFollowing a process to allow and monitor clients’ self-administration of their medicationsSafely and accurately administers medicationsReducing the risk of error through careful procurement, maintenance, use, and standardization of medication delivery devicesMonitoring clients following medication administrationMedication administration: REQUIRED ORGANIZATIONAL PRACTICE: Service providers use at least two identifiers before administering medications.Medication delivery devices: REQUIRED ORGANIZATIONAL PRACTICE: The organization provides all staff and service providers with ongoing, effective training on all infusion pumps.
22 Monitoring Quality And Achieving Positive Outcomes Having a coordinated risk management program to reduce medication-related errors and sentinel eventsRegularly monitoring and evaluating the quality of the medication management and pharmacy system
23 Current Status of the New Program 13 pilot sites will test various elements of the program starting March to December 2007National consultation on standardsCustomized transition plan for each client in 2008Pan Canadian information sessions in major cities to support transitionOngoing communicationCCHSA web siteteleconferences
24 The leader in raising the bar for health quality Canadian Council on Health Services AccreditationThe leader in raising the bar for health quality