Diagnostic Accreditation Program
Accreditation Basics
Helen Healey RN, BScN
Director, Accreditation Services, DAP
Accreditation Basics

What is Accreditation?

What is DAP Accreditation?

Why be Accredited?

How does the DAP Accredit?

How to use Accreditation for Improvement
What is Accreditation?
What is Accreditation?




Process for the external evaluation of healthcare
services
A formal process to ensure delivery of safe, high
quality health care
Based on standards and processes devised and
developed by health care professionals for
health care services
A process using the skills of external peers
trained and appointed as a team of assessors
What is Accreditation?
Accreditation is one of a variety of strategies
that health care organizations adopt:
 in response to legislative requirements
 funding is contingent of them doing so
 to validate and continuously improve safety
and quality systems
What is Accreditation?
Internationally models are evolving of external
assessment of health care services
Increasingly used to improve and promote health
care service to meet changing demands:
 public accountability
 clinical effectiveness
 improving the quality and safety of services
and their outcomes
What is Accreditation?
Myth Buster
“Patient safety is much more important than
Accreditation”
What is DAP Accreditation?
What is DAP Accreditation?
History
 Started in 1971 as a Joint Program of the BC
Medical Association and College of Physicians
and Surgeons of BC (CPSBC)

Became an independent Society operating
under the Medical Practitioners Act, as a
Program of the CPSBC
What is DAP Accreditation?
Authority
 DAP derives its authority from the Rules
Made Under the Medical Practitioners Act

No physician can work in, nor refer to a non
accredited facility
What is DAP Accreditation?
Mandate
 Accrediting
private and public diagnostic
services in BC
 Promoting excellence in diagnostic health care
by:
 Setting standards consistent with professional
knowledge
 Evaluating actual performance with peer
review surveys, and proficiency testing
 Providing education and consultation on
improvement strategies and best practices
What is DAP Accreditation?
DAP Model
Enabling health care organizations to review and
improve systems that support the delivery of safe,
high quality diagnostic health care
Accreditation evaluates:
 Quality
 Quality improvement
 Risk
What is DAP Accreditation?
Accreditation
(Evaluative Tool)
Mandatory Requirements
Opps For Improvement
Plan
Act
Do
Check
What is DAP Accreditation?
Myth buster
“ My staff are very anxious about the Inspectors coming
and what they will be asked. We are tying to get all our
policies ready in time”
Why be Accredited?
Why be accredited?

Provides an independent external survey, by
peers, of an organizations level of
performance in relation to Provincial
standards

Guides healthcare organizations to identify
their strengths and also the limitations of the
services they are providing
Why be accredited?

Strong motivational lever for organizations to
review their operations and improve in areas
where deficits exist

Articulate levels of expected performance
through the establishment of standards and
monitoring of compliance

Demonstrates an organizations commitment to
achieving high quality and safe care for patients
residents
Why be accredited?

Provides an award of accreditation which is
intended to be an assurance that at a particular
point in time a health care organization had
instituted structure and was adhering to process
designed to indentify, mitigate, and appropriately
respond to risks, and achieving acceptable
outcomes

Neither accreditation or any quality system can
assure that an adverse event will not occur in a
health care organization
Why be accredited?
Myth Buster
“Accreditation is not proven to improve quality”
How does the DAP Accredit?
How does the DAP Accredit?

Accreditation at a facility/departmental level

Standards & criteria directed at operations

Individuals involved responsible for operation of
the service, and providers of service
How does the DAP Accredit?
Orientation
Training, Education
Self Assessment
Documentation
3 Year
Cycle
Mid-Cycle
Assessment
On-site Survey
Report
& Recommendations
How does the DAP Accredit?
Planning Day



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
Accreditation Specialist
On-site, Teleconference, Telephone
Orientation, Training and Education
Facility profile developed
Surveyor arrangements
How does the DAP Accredit?
Myth Buster
“It is all about the paperwork – policies,
guidelines and strategies that no one looks at”
How does the DAP Accredit?
Self assessment:

Each diagnostic
assessment
service
completed
a
self

Diagnostic service rates criterion on a scale
indicating achievement of goal (degree of
compliance)
How does the DAP Accredit?
Patients & Clients Served
MANAGEMENT STANDARDS
Leadership & Management
Informatics
Patient & Client Focus
Quality Improvement
Human Resources
Suppliers & Partners
Safety
DISCIPLINE/MODALITY STANDARDS
Diagnostic Imaging
Laboratory Medicine
Radiology
Sample
Ultrasound
Mammography
Nuclear
Medicine
MRI
CT
Echocardiography
Bone
Densitometry
Neurodiagnostics
EEG
& Evoked Potentials
EMG & Nerve Conduction Studies
Collection, Transport,
Accessioning
Chemistry
Microbiology
Transfusion Medicine
Hematology
Anatomic Pathology
Point of Care Testing
Pulmonary Function
Polysomnography
How does the DAP Accredit?
Two common approaches are:

Team approach – create groups of people to
complete the self assessment by dividing
areas of responsibility among each group

Individual(s) completes entire selfassessment
How does the DAP Accredit?
On-Site Survey
 Team of external peer surveyors that are in
active practice
 Team membership includes medical,
technical, and management surveyors
 Survey team conducts external assessment
by visiting facilities, observing processes,
reviewing documentation, discussion with
staff
 Medical Surveyor observes from location
where medical consultation/interpretation
takes place
How does the DAP Accredit?
DAP prepares Report
 The Accreditation Award
 Summary
of
best
practice
and
commendations as identified by the surveyors
 Mandatory Requirements with accompanying
time frame for follow-up
 Opportunities for Improvement
 Facility Self Assessment
 Protocol
sheets as completed by the
surveyors
How does the DAP Accredit Facilities?
Myth Buster
“It is a cosy relationship between surveyor and
senior staff – no one wants to fail their peers”
Continuous Quality Improvement
What are we trying to accomplish?
How are we going to know that a change is an improvement?
What changes can we make that will result in improvement?
Plan
Act
Nolan et al
Shewart
Do
Check