Elaine O’Connor Head of International Accreditation & Regulation 19 th 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

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 3 rd 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, 4 th Edition 2014  Surveyor Training Programme, 2 nd Edition 2009  Guidelines and Standards for External Evaluation Organisations, 4 th Edition

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

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 4 th Edition, 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 4 th Edition, 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 8.0The 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

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

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