1. Accreditation; Self Assessment Viki Massey, Quality Coordinator A Joint Venture of London Health Sciences Centre and St. Joseph’s Health Care London

2. Two Phases of Accreditation Peer review assessment Self-assessment

3. Purpose of Self-assessments All laboratories starting the OLA process at the same time Assist laboratories in: – Setting priorities – Planning for peer visits – Looking at big picture – Snap shot of “where we are” – How do we measure up?

4. Self-assessment Facts An audit or gap analysis Once roll-out completed – once every 5 years Requires a physical walk about – not a desk audit!

5. Three Phases I. Preparatory: 1. Create timelines (report due in 120 days) 2. Breakdown tasks 3. Assign responsibilities II. Audit: 4. Fill out checklist

6. Three Phases III. Review/Analyze/ Prioritize (RAP) 5. Compile non-conformances 6. Categorize – major /minor 7. Develop reasonable action plans 8. Complete exception report for submission

7. Phase One - Prepare 1. Create timelines audits conducted by end of June action plans due 2 weeks post audit exceptions reports complete by August 20 2. Schedule self-assessments by campus 3. Assign responsibilities by discipline OLA trained assessors- team leaders, team members Volunteer assistants

8. Phase Two - The Audit 4. Fill out the checklist by: Interviewing staff Tracing processes (policies to evidence) Observing staff at work Making notes on checklists

9. Phase Three - RAP 5.Compile information gathered and look for: similar issues in multiple areas trends isolated incidents 6.Categorize non-conformances to Major/Minor use to set priorities

10. Phase Three - RAP 7. Develop an action plan to correct every non-conformance: – Achievable, Reasonable, Effective

11. Phase Three - RAP 8. Prepare and submit report to OLA within 120 days of notification Sample for detail levels required Getting signatures - allow enough time Fax, E-mail, Mail

12. Potential Follow-up OLA requests compiled checklist for QA purposes OLA requests compiled checklists to review, submission to scientific or advisory panel Completed checklists reviewed at your next peer assessment Initiate peer assessment

13. Acknowledgement I would like to acknowledge and thank OLA for the use of some of their slides contained in this presentation