Transcript powerpoint - Diagnostic Accreditation Program

Diagnostic Accreditation Program
Annual Report: Trends in Facility Performance
Sharmen Vigouret Lee, Executive Director
May 12, 2008
New Accreditation Standards
Laboratory Medicine – 2007
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Sample Collection, Transport & Accessioning
Chemistry
Hematology
Microbiology
Transfusion Medicine
Anatomic Pathology
Laboratory Informatics
Point of Care Testing – Field Testing
Cytology – in development
Cytogenetics – in development
New Accreditation Standards
Diagnostic Imaging – 2007
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Radiology
Ultrasound
Echocardiography
Mammography
CT
MRI
Nuclear Medicine
Bone Densitometry
Imaging Informatics
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Digital Mammography – field testing
PET/CT – development to start Summer 2008
New Accreditation Standards
Neurodiagnostic Services – 2007
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EEG
Evoked Potentials
EMG & Nerve Conduction Studies
Pulmonary Function – Field Testing June 2008
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Hospital Based Services
Polysomnography
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Development to start Summer 2008
Advisory Committees
Advisory Committees
 Laboratory Medicine – 7
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Diagnostic Imaging – 10
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Cytology
Cytogenetics
PET/CT
Hospital Based Neurodiagnostic Services – 2
Hospital Based Pulmonary Function
Polysomnography
Accreditation Assessments
On-site Surveys, Focused Visits, Initial Assessment
Number of Facilities Number of Modalities
Laboratory Medicine
51
191
Diagnostic Imaging
60
148
Neurodiagnostic
Services
2
6
Pulmonary Function
2
2
118
347
Total
Accreditation Assessments
Accreditation Status – 2006 and 2007
Laboratory Medicine
73 Accreditation with Report
5 Full Accreditation
Diagnostic Imaging
76 Accreditation with Report
10 Full Accreditation
Trends in Performance:
Most frequently cited by Surveyors
Leadership & Management
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Lack of position descriptions for medical and
administrative leadership
Management of adverse events and critical incidents
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Lack of definitions, policies & procedures, investigation process,
monitoring changes implemented, staff communication & training
Reporting process in place, but no feedback or trend analysis
Litigation preparation focus instead of continuous improvement
Trends in Performance:
Most frequently cited by Surveyors
Human Resources
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Significant recruitment challenges: medical, technical
and administrative staff
Outdated job descriptions
Continuing education challenges – funding & backfilling
Performance reviews and competency assessments
not occurring
Outdated or no contract in place between the facility
and the medical professionals
Trends in Performance:
Most frequently cited by Surveyors
Patient & Client Focus
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Excellent knowledge of the patient populations served
Demonstrated commitment to patients and providing
the best possible care with the resources availalble
Well defined knowledge of who referring physicians are
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Effective communication and established relationships
Performance based contracts with 3rd party payers
Trends in Performance:
Most frequently cited by Surveyors
Suppliers & Partners
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Health authorities – centralized process for capital and
consumable purchasing
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Diagnostic service has significant input into selection process
Capital planning processes regionally based
Community based services – more informal purchasing
practices
Trends in Performance:
Most frequently cited by Surveyors
Quality Improvement
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Lack of a comprehensive approach to quality
management and quality improvement
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No linkage between specific quality activities
Use of indicators for monitoring – very limited
Lack of available & knowledgeable staff to develop
quality programs
Trends in Performance:
Most Frequently Cited Mandatory Requirements
Safety – Laboratory Medicine
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Eyewash stations are conveniently located and regularly flushed
Emergency lighting is available
Safety manual is readily available to staff
Items for patient consumption are stored separately from sample,
reagents and supplies
Safe and effective cleaning and disinfection
Chemical and biological spill kits and procedures are available
Personal protective and other safety equipment (e.g. splashguards)
Sufficient, well marked “clean” sinks for hand washing
Trends in Performance:
Most Frequently Cited Mandatory Requirements
Safety – Diagnostic Imaging
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Safety program in place including documentation and staff
education
Ongoing staff education to prevent and control infections
Policies in place for dealing with emergency procedures
(cardiopulmonary arrest)
Policy for staff working alone
Action plan for emergency evacuation has been developed and
communicated to staff
MSDS are posted where toxic and corrosive agents are used
Radiation safety
Eyewash stations conveniently located
Laboratory Medicine
Most Frequently Cited Mandatory Requirements
Sample Collection:
Sample rejection criteria established
Acceptable time limits between collection and processing of
standards are established and monitored
Policies and procedures to deal with unlabeled, mislabeled, lost or
compromised samples
Proficiency Testing/QC:
When mandated PT is not available, alternative PT is used to
validate performance
QC policies and procedures are documented and maintained
Laboratory Medicine
Most Frequently Cited Mandatory Requirements
Document Control:
All procedures are documented, communicated to and available to
staff performing the analysis
Invalid or obsolete documents are promptly removed from all points
of use
Master index of all laboratory documents identifying current version
and distribution is in place
Documents are reviewed and approved by the medical leader or
designate prior to use
Instrumentation and Equipment:
Process for correction action when temperatures deviate from the
acceptable ranges
Diagnostic Imaging
Most Frequently Cited Mandatory Requirements
Patient and Staff Needs:
Patient information cannot be viewed by other patients or visitors
Secure and private location for storage of personal belongings
Information Management:
Processes to ensure confidentiality, security and integrity of data
are provided at the beginning of employment as well as on an
ongoing basis
Data stored on-site is accessible, but protected from unauthorized
access and safeguarded from harm
Downtime procedures are documented and readily available
Policy for the use and disclosure of personal information
Diagnostic Imaging
Most Frequently Cited Mandatory Requirements
Radiology:
Radiation safety policies & procedures
Mammography:
Appropriate consenting process prior to invasive procedures indications, risks, alternatives
Equipment performance is evaluated and monitored and
quantitative dose determination conducted by a qualified medical
physicist
Diagnostic Imaging
Most Frequently Cited Mandatory Requirements
Ultrasound/Echocardiography:
MSDS are posted where toxic and corrosive agents are used
Policy of appropriate use of gel as per Health Canada
Computed Tomography:
Policies and procedures are in place where Transfer of Function
duties are performed
MRI Safety Policies:
Policies/procedures in the event of an inadvertent magnet quench
Controlling access to MRI environment with appropriate signage
Diagnostic Imaging
Most Frequently Cited Mandatory Requirements
Nuclear Medicine:
Radiopharmaceutical agent is identified including dosage, time,
route of administration and individual administering
Policies and procedures are in place where Transfer of Function
duties are performed
Routine performance of documented schedule for QC procedures
Radiation warning labels/signage are posted at entrance of rooms
that may contain a source of ionizing radiation
Education regarding hazards of radiation and reducing exposure
for nursing and ancillary staff
Bone Densitometry :
Precision determinations are done in-house according to standard
protocol
Best Practices
Laboratory Medicine
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Document control program
Occurrence management
Diagnostic Imaging
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Random daily audit of general procedures by
supervisor
Retrospective review using electronic medical record
and images to identify process errors
Conclusions
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Prior to 2006 on-site surveying of facilities was
sporadic
“First” accreditation on-site survey provides a baseline
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expect several mandatory requirements and opportunities for
improvement to be noted
Accreditation standards are far more comprehensive
Surveyors use detailed survey protocols using
“tracers”– more comprehensive assessment of the
diagnostic care process
Accreditation needs to be incorporated into the facility’s
overall quality management program
Quality improvement is a process and takes time