Hardwiring accreditation for high reliability

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By Mike Heenan

Most of us who work in hospitals know the feeling you get when you’re reminded the next scheduled Accreditation Survey is just around the corner, and you’re not quite sure how truly ready your organization is to meet the standards and achieve Exemplary Standing.

That looming survey can create feelings of uncertainty, anxiety and even panic among senior leaders, quality staff and frontline providers.

Hospital leaders often set off a surge of activity designed to make sure we not only meet the standards but achieve the highest award. Our “Accreditation” activities include staff surveys using the self-assessment questionnaire, meetings for leaders to assess their programs’ compliance to Required Organizational Practices (ROPs), new staff training forums, and the sudden renewal of numerous new policies, procedures and clinical practice guidelines.

It’s a lot of work and stress in a complex health environment that’s already at capacity.

So why do we react like this? Why do we do this to our physicians, staff and volunteers every four years like clockwork?

Perhaps it’s because we treat Accreditation like an event, and not a process. An event is defined as “something that happens – especially something important or noteworthy.” A process is “a series of actions that produce something or lead to a particular result” or “a series of changes that happen naturally.”

At St. Joseph’s Health Centre, Toronto we are beginning a journey aimed at transforming Accreditation into a process – a series of planned actions that lead to the results we want and, over time, start to happen naturally.

To do this we are reviewing our organization’s plans, policies, procedures and practices to identify exactly where they line up with the principles and standards of Accreditation Canada. We’re looking for ways to achieve Accreditation while simultaneously doing what we need and want to do as an organization.

It turns out there are plenty of opportunities.

The first thing we are doing is being clear that the founding principles of Accreditation are the same as those of our organization. Both Accreditation Canada and St. Joe’s share a mission to deliver safe, high quality care to our patients every day.  As a result we are seeing Accreditation Canada as a true partner in care instead of an organization that audits us every four years.

Second, we are incorporating Accreditation into our leadership and quality management frameworks. St. Joe’s is working with Studer Group Canada and has deployed many of the Must Haves® that are part of Studer Group’s Evidence-Based Leadership℠ framework. We are linking the Accreditation Standards and ROPs to tools and tactics such Rounding for Outcomes, Stop Light Reports, Leadership Evaluation Manager®, 90 Day Planning and Goal Setting, and even using Key Words at Key Times to build a culture that supports Accreditation and the mission it sets out for us all.

We are also adopting a regular review of policies and procedures and building a new corporate learning model that constantly evolves to meet new standards. Our Board’s Quality Committee plays an important role as it requires senior leaders to report annually on how we approach Accreditation – not just in the last year of the cycle.

The third part of our approach to embedding Accreditation as a process focuses on our new Integrated Risk Management (IRM) framework, launched in 2015. Senior leaders use the IRM framework to report to the Board quarterly on emerging risks in areas such as strategy, patient care, resources and compliance. We also assess a specific area of our organization each quarter using the relevant Accreditation Standards and ROPs. In the last three quarters we examined performance and risks in human resources, privacy, and medical affairs. Reviewing our Accreditation compliance routinely allows us to continually identify opportunities to improve.

In short, changing Accreditation from an event to a process means integrating the standards and ROPs into all operations – from strategic planning to daily routines. Of course all of this doesn’t happen overnight, and each organization’s journey is unique. But as Quint Studer stresses in his book Hardwiring Excellence, improving quality and safety cannot be seen as an event. This must be grounded in our mission, vision and values and be lived every day from the top of the organization to the point of care. St. Joe’s leaders, physicians, staff and volunteers are dedicated to advancing the health of our community and delivering high quality care. Like all of us in healthcare, we know it’s a journey that’s never complete. But it is a journey that can be enhanced by embedding Accreditation into what we do each and every day.

Mike Heenan is Vice President, Strategy Communications and Organizational Effectiveness at St. Joseph’s Health Centre, Toronto.

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