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Diagnostic Accreditation Program. Annual Report: Trends in Facility Performance Sharmen Vigouret Lee, Executive Director May 12, 2008. New Accreditation Standards. Laboratory Medicine – 2007 Sample Collection, Transport & Accessioning Chemistry Hematology Microbiology

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diagnostic accreditation program

Diagnostic Accreditation Program

Annual Report: Trends in Facility Performance

Sharmen Vigouret Lee, Executive Director

May 12, 2008

new accreditation standards
New Accreditation Standards

Laboratory Medicine – 2007

  • 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 standards3
New Accreditation Standards

Diagnostic Imaging – 2007

  • Radiology
  • Ultrasound
  • Echocardiography
  • Mammography
  • CT
  • MRI
  • Nuclear Medicine
  • Bone Densitometry
  • Imaging Informatics
    • Digital Mammography – field testing
  • PET/CT– development to start Summer 2008
new accreditation standards4
New Accreditation Standards

Neurodiagnostic Services – 2007

  • EEG
  • Evoked Potentials
  • EMG & Nerve Conduction Studies

Pulmonary Function – Field Testing June 2008

  • Hospital Based Services

Polysomnography

  • Development to start Summer 2008
advisory committees
Advisory Committees

Advisory Committees

  • Laboratory Medicine – 7
    • Cytology
    • Cytogenetics
  • Diagnostic Imaging – 10
    • PET/CT
  • Hospital Based Neurodiagnostic Services – 2
  • Hospital Based Pulmonary Function
  • Polysomnography
accreditation assessments7
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
Trends in Performance:Most frequently cited by Surveyors

Leadership & Management

  • Lack of position descriptions for medical and administrative leadership
  • Management of adverse events and critical incidents
    • 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 surveyors9
Trends in Performance:Most frequently cited by Surveyors

Human Resources

  • 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 surveyors10
Trends in Performance:Most frequently cited by Surveyors

Patient & Client Focus

  • 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
    • Effective communication and established relationships
  • Performance based contracts with 3rd party payers
trends in performance most frequently cited by surveyors11
Trends in Performance:Most frequently cited by Surveyors

Suppliers & Partners

  • Health authorities – centralized process for capital and consumable purchasing
    • 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 surveyors12
Trends in Performance:Most frequently cited by Surveyors

Quality Improvement

  • Lack of a comprehensive approach to quality management and quality improvement
    • 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
Trends in Performance:Most Frequently Cited Mandatory Requirements

Safety – Laboratory Medicine

  • 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 requirements14
Trends in Performance:Most Frequently Cited Mandatory Requirements

Safety – Diagnostic Imaging

  • 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
Laboratory MedicineMost 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 requirements16
Laboratory MedicineMost 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
Diagnostic ImagingMost 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 requirements18
Diagnostic ImagingMost 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 requirements19
Diagnostic ImagingMost 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 requirements20
Diagnostic ImagingMost 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
Best Practices

Laboratory Medicine

  • Document control program
  • Occurrence management

Diagnostic Imaging

  • Random daily audit of general procedures by supervisor
  • Retrospective review using electronic medical record and images to identify process errors
conclusions
Conclusions
  • Prior to 2006 on-site surveying of facilities was sporadic
  • “First” accreditation on-site survey provides a baseline
    • 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