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Accredited by /Agréé par ISQua CCHSA Accreditation: New Standards for Managing Medications Jessica Peters Lead, Research & Product Development CCHSA
© CCHSA / CCASS 2 Presentation Outline Vision, Mission and Values The Accreditation Program Program Enhancements The New Standards for Managing Medications Next Steps
© CCHSA / CCASS 3 CCHSAs Vision and Mission Vision The leader in raising the bar for health quality Mission Driving quality in health services through accreditation
© CCHSA / CCASS 4 CCHSAs Values Within an environment focused on clients and committed to quality of worklife, partnerships, and personal growth, our values are: Excellence Integrity Respect Innovation
© CCHSA / CCASS 5 CCHSAs Accreditation Program Canadian accreditation program - incorporated in 1958 Not-for-profit High participation rates; continued growth Surveyors (approx. 400) are senior health care professionals Surveys may be regional, institution specific, national or market specific (i.e. First Nations, Corrections, Canadian Forces) Average 400+ surveys per year Three year cycle Both public and private organizations participate
© CCHSA / CCASS 6
7 Role of Accreditation Quality Improvement – at the organization level and at the system level Change management Standards of excellence – raising the bar on health care Standards of clinical practice Governance Leadership
© CCHSA / CCASS 8 CCHSA Standards Standards of excellence Raise the bar for health care practice Enable an organization/team to stretch to improve care, to reach or raise the bar Developed with the input and guidance of experts in the field and updated on a regular basis to ensure relevance and value Are applicable to different regions and service delivery settings Will continue to be used by organizations, but in a new way
© CCHSA / CCASS 9 Evolution of CCHSA Program
© CCHSA / CCASS 10 The New Accreditation Program Benefits: 1. Standards that: Capture the most recent governance/managerial and clinical best practices Reflect the emerging trends or disease (and wellness) patterns in healthcare Have an increased level of specificity Can be used or integrated into the daily work of organizations 2. Streamlined and more flexible process that: Supports and aligns better to an organizations quality improvement initiatives Is adaptable no matter how small or how complex the organization may be
© CCHSA / CCASS 11 The New Accreditation Program Benefits: 3. Greater focus on the provision of safe quality care and service in a variety of health care settings 4. Planned and predictable accreditation activities with a on-site survey that is customized to the organizations needs 5. Automated measurement tools that allow: Greater and faster data exchange Improved standardization and objectivity
© CCHSA / CCASS 12 The standards have a brand new structure…
© CCHSA / CCASS 13 Standards Areas POSITIVE CLIENT EXPERIENCE SERVICE EXCELLENCE PROACTIVE AND SUPPORTIVE ORGANIZATION EFFECTIVE AND SUSTAINABLE GOVERNANCE
© CCHSA / CCASS 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 safety Feedback from client organizations and surveyors Changing health care environment Development began in 2004 Expert working group including representatives from organizations and ISMP-Canada Standards circulated for consultation in late 2005 to approximately 15 organization
© CCHSA / CCASS 15 The New Standards for Managing Medications… Standards target medication processes in an institutional setting, i.e. hospital, long term care Focus on the safe use of medications from selection and procurement through administration Address a number of key themes: Working Together to Promote Medication Safety Carefully Selecting and Procuring Medications Properly Labelling and Storing Medications Appropriately Ordering and Transcribing Medications Accurately Preparing and Dispensing Medications Safely Administering Medications to Clients Monitoring Quality and Achieving Positive Results
© CCHSA / CCASS 16 Working Together to Promote Medication Safety Recognizing pharmacists and pharmacy staff as integral members of the interdisciplinary team Actively involving the pharmacy staff in designing the organizations medication use and medication management processes Providing access to accurate medication-related information, formally approved drug information tools and education about safe medication use Evaluating the competency of all service providers who participate in the medication use process
© CCHSA / CCASS 17 Carefully Selecting and Procuring Medications Maintaining an up-to-date and evidence- based list of available medications Minimizing the number of procured and available medications
© CCHSA / CCASS 18 Properly Labeling And Storing Medications Reducing the possibility of errors with drug product nomenclature, labeling, and packaging Labeling all drug concentrations clearly and legibly Providing suitable space for drug storage in pharmacies and client/unit medication areas Carefully selecting stock drugs for each client area Storing hazardous chemicals away from clients, service providers, and drug preparation areas
© CCHSA / CCASS 19 Ordering and Transcribing Medications Appropriately Maintaining accessible and up-to-date client information Communicating drug orders and other drug information in a standardized way Reviewing all prescriptions or medication orders for accuracy and appropriateness
© CCHSA / CCASS 20 Accurately Preparing and Dispensing Medications Preventing contamination when preparing medications Dispensing medications in a safe, accurate, and timely way Having a system to safely dispense medications where there is no internal pharmacy or when the pharmacy is closed Transporting medication in a safe, secure, and timely manner way
© CCHSA / CCASS 21 Safely Administering Medications To Clients Educating clients about their medications and delivery devices, and ways to prevent errors Following a process to allow and monitor clients self-administration of their medications Safely and accurately administers medications Reducing the risk of error through careful procurement, maintenance, use, and standardization of medication delivery devices Monitoring clients following medication administration
© CCHSA / CCASS 22 Monitoring Quality And Achieving Positive Outcomes Having a coordinated risk management program to reduce medication-related errors and sentinel events Regularly monitoring and evaluating the quality of the medication management and pharmacy system
© CCHSA / CCASS 23 Current Status of the New Program 13 pilot sites will test various elements of the program starting March to December 2007 National consultation on standards Customized transition plan for each client in 2008 Pan Canadian information sessions in major cities to support transition Ongoing communication CCHSA web site teleconferences
© CCHSA / CCASS 24 Canadian Council on Health Services Accreditation The leader in raising the bar for health quality
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