Qmentum Accreditation All what you need to know By: Abdalla Ibrahim
Jul 01, 2015
Qmentum Accreditation All what you need to know
By: Abdalla Ibrahim
By
Abdalla Ibrahim
Accreditation Specialist, Healthcare Surveyor
Email: [email protected]
Qmentum Accreditation All what you need to know
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Qmentum (Quality + Momentum) literally referred to Quality Process in energetic and continuous motion.
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* It is a Comprehensive Accreditation Program to help
health organizations improve quality of care and
patient safety.
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*The program brings accreditation standards into
every day service operations.
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*It focuses on what matters most to
Organizations and Patients.
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Standards Evidence-based standards of excellence
Online portal Comprehensive automated self-assessment
Roadmap Quality performance roadmap
Indicators Performance Indicators
Survey Customized Survey Plan and Survey Process
Tracer Interactive Tracer Technique
Support Ongoing support through account manager
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Qumentum Standards
Governance
Leadership
Medication Management
Qmentum Service
Excellence
Infection Prevention and Control
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*The Standards are goal statements, written in bold and numbered 1.0, 2.0, 3.0, etc.
*Each standard is followed by a number of Criteria that are the activities required to achieve the standard.
*By complying with the criteria, an organization can achieve the standard.
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The criteria contain additional information and
linked to one of eight quality dimensions:
Accessibility
Client-centred Services
Continuity of Services
Effectiveness
Efficiency
Population Focus
Safety
Worklife
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* Some of the criteria are identified as a Required
Organizational Practice (ROP).
*An ROP is as an essential practice that organizations
should have in place to enhance patient/client safety and
minimize risk.
*To reflect the step-by-step approach of the program, each
ROP is assigned a level of Gold, Platinum, or Diamond.
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All criteria are assigned a level of Gold, Platinum, or Diamond to reflect the tailored nature of the accreditation program (see above).
*Gold criteria would apply to organizations in the Gold cycle of accreditation.
*Gold and Platinum criteria would apply to organizations in the Platinum cycle of accreditation.
*All criteria would apply to organizations in the Diamond cycle of accreditation.
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*The Qmentum International Accreditation
Program has three levels of accreditation:
Diamond
Platinum
Gold
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*The Qmentum International Accreditation
Program has three levels of accreditation:
Gold addresses basic structures and processes linked to the foundational elements of safety and quality improvement.
Platinum • emphasizes on
client-centred care.
• creating consistency in delivery of services through standardized processes.
• involving clients and staff in decision-making.
Diamond • focuses on
monitoring outcomes
• using evidence and best practice
• benchmarking with peer organizations to drive system-level improvements.
*Cycle of Accreditation Services
*Accreditation Life Cycle
Readiness Assessment
Self-Assessment
Simulated Survey
Accreditation Survey
Report
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*New organizations to accreditation starts the process with a
clear understanding of where they stand in comparison to
accreditation standards.
*It is conducted by surveyors using Tracer Methodology.
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Initial Assessment
Action Plan
Risk Profile
Indicator
Culture of Quality
Education
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*Initial Assessment of existing processes and systems against
standards and a baseline for future work.
*Action Plan for getting started
*Risk Profile: Organization’s compliance with Required
Organization Practices (ROPs),
*Indicators: Readiness to collect performance measures
*Capacity to transition to a Culture of quality improvement
*Education about the accreditation process, quality
improvement, and safety.
* Surveyors
uses:
Focus Group
Discussion Group
One-to-On
Group Interview
Tours to trace priority processes
Observation
By observing and interacting directly with frontline
staff in their working environment, surveyors able to
assess the health care organization’s:
*Readiness for accreditation
*Compliance with Qmentum International™ standards
and levels.
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The outcome of the RA is
a Comprehensive REPORT providing:
Analysis
• Analysis of organization’s capacity to achieve accreditation
Recommendation
• To assist the in achieving accreditation goals and objective.
Action Plan
• To ensure that organization continues to provide the highest quality of service and care.
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Orientation sessions allow surveyors to:
* Introduce the Qmentum International™
accreditation program to leaders and staff of
the organization
*Provide a refresher, especially with those
experiencing higher staff turnover.
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These sessions are meant to:
*Reduce the anxiety associated with
accreditation
*Frame the process according to philosophy of
continuous quality improvement.
* Introduction to Qmentum International:
for all levels of staff, introduces the key elements of the
Qmentum International accreditation process
Qmentum International™ for Leaders:
overview of the new accreditation program including tools,
team formation, and team work required by the organization’s
team leaders and senior leadership to manage the process
Qmentum International™ for Self-Assessment Teams:
introducing the Qmentum International accreditation program
to the organization’s leadership and senior management team.
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Introduction to Qmentum International:
for all levels of staff, introduces key elements of Qmentum International accreditation process
Qmentum International for Leaders:
(Team leaders, senior leadership to management)
overview of new accreditation program including tools, team formation, and team work
Qmentum International™ for Self-Assessment Teams:
(leadership and senior management team).
Introducing Qmentum International accreditation program
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*A web-based tool that allow all staff to evaluate the level of compliance against Qmentum International™ standards
*And aggregate this data by Functional Teams and reported within a Management Dashboard.
*The self-assessment tool includes a Client Portal and the Quality Performance Roadmap™.
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*In this secure portal, the health care organization completes its self-assessment at its convenience.
*Once the self-assessment is complete, the health care organization can obtain its Results automatically, and also generate reports.
*Report includes findings related to performance measures and indicators.
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*Comprehensive picture of organization’s status
performance against standards and measures.
*Identifies quality and safety areas for follow-up and
improvement.
*Consolidate and present information in a secure database.
*Enable policy-makers and leaders to identify system-wide
quality and safety issues and strengths.
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*Creates, coordinates and ensures execution of a
critical path of key events leading up to
accreditation
*Guides, mentors and coaches the organization in
its accreditation-related activities, for example
standards interpretation and knowledge transfer
regarding quality improvement plans
*Ascertains the organization’s educational needs
and may also be part of delivering client education
and capacity building programs
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*Assists the organization in developing and
implementing quality improvement action plans
*Provides access to resources, examples of policies
and procedures, best practices and contacts
available within its network of over a thousand
accredited organizations
*Provides access to all national and international
health care accreditation and distinction standards
available
*Reviews and provides advice on the
implementation of accreditation recommendations
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* The surveyors conduct both clinical and administrative tracers for a sample of priority processes which are critical areas and systems known to have a significant impact on the quality and safety of care and services.
*Normally occurs 4 - 6 months prior to the final survey
The Simulated Survey provides the staff with:
*Opportunity to experience the Tracer Methodology
*Understand the questions surveyors may ask during this activity.
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*A comprehensive onsite review that evaluates
the organization’s level of performance against
Qmentum International™ standards.
*The onsite visit is conducted by a team of
external peer surveyors using tracer
methodology.
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*Tracer Methodology is used to assess levels of care, treatment, and services by following an actual client or patient experience through the care continuum.
Tracers are used to evaluate both:
* clinical process(direct client care).
* administrative processes (governance, leadership, management).
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*The tracer is an interactive process whereby
surveyors use direct observation and interaction
with a wide variety of staff and patients/clients to
gather evidence about the quality and safety of care
and services in a particular service area.
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Professionals with:
* credentials
* healthcare and leadership experience
* analytical and communication skills.
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*The PHC Centers will be chosen based on a high
volume & high risk basis.
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*Timing: 10-20 days after the survey
*It provides specific information on key findings, strengths,
and areas for improvement, and highlights areas that will
minimize risk and improve overall performance.
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*Accreditation: the organization may be accredited
at a Gold, Platinum or Diamond level depending on
their performance at the time of the survey.
*Accreditation with Condition: the organization
achieves compliance with standards at a certain
level, but conditions must be met to maintain
accreditation.
*Non-Accreditation: Unsuccessful in achieving
accreditation.
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*The Accreditation Decision is provided with the
Accreditation Report.
*Upon achieving successful accreditation, the
organization will receive an award letter, a certificate
of accreditation for each location.
*In the event that the decision specifies conditions, the
organization will have five months to one year to meet
the required conditions by providing evidence of
improvement initiatives and outcomes.
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*Following the receipt of the Accreditation report, the
organization must address any conditions, and continue to
work on the areas identified for improvement.
*Accreditation Canada International will review whether
the conditions are met based on the information received
including evidence of action taken.