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Elaine O’Connor Head of International Accreditation & Regulation 19 th EPSO Conference Oslo, Norway April 2015
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About ISQua
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IAP Awards to Date 115 sets of standards 22 surveyor training programmes 58 organisations
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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
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International Accreditation Programme 6
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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
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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 3 rd party accreditation of DAAs 2010 – MOU between ISQua and NZ Ministry of Health 8
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Standards Guidelines and Principles for the Development of Health and Social Care Standards, 4 th Edition 2014 Surveyor Training Programme, 2 nd Edition 2009 Guidelines and Standards for External Evaluation Organisations, 4 th Edition 2014 9
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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
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Risk rating 11
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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
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Guidelines and Principles for the Development of Health and Social Care Organisations 4 th Edition, 2014 6 Principles Standards Development Standards Measurement Organisational role, planning and performance Safety and risk Patient / service user focus Quality Performance 13
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Guidelines and Standards for External Evaluation Organisations 4 th 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
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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
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Example of Standard Standard 1 Governance The external evaluation organisation is responsibly governed to meet its defined purposes and objectives. 16
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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
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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
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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
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Language 8.0The 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. SuggestedEvidence Defined process and criteria for making accreditation decisions 8.2The 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
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Board Accreditation Committee Tracey Cooper (Chairperson) Chief Executive, Public Health Wales, UK Wendy Nicklin President & CEO, Accreditation Canada, Canada B.K Rana Joint Director, NABH, India Janne Lehmann Knudsen Director of Quality, Danish Cancer Society, Denmark Cliff Hughes CEO, Clinical Excellence Commission, Australia Triona Fortune Deputy CEO, ISQua 21
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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
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Thank you Any Questions… 23
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