Accreditation In Long Term Care Organizations A Commitment To Quality Improvement

By Angele MacRae, Conny Menger, Gabriela Prada

Introduction

Accreditation is a process that focuses on continuous quality improvement. Health organizations use this process to evaluate their services by identifying their strengths and areas to improve, and developing plans for the quality improvement of services. Accreditation is a dynamic process that is fundamental to creating and maintaining a culture of quality.

Long term care organizations, like many organizations seeking quality, find that the accreditation process gives them the opportunity to examine and improve their day-to-day care and services. It also tells their residents and the general public that they are open to the idea of a peer review and willing to work towards standards of excellence.

Accreditation and CCHSA

The Canadian Council on Health Services Accreditation (CCHSA) is the major national accrediting body for health services across all sectors in the country. More than one thousand long term care organizations in Canada are accredited by CCHSA. CCHSA’s accreditation program is built on a three-year cycle (see Figure 1). The program defines quality by means of quality dimensions and descriptors, which enable CCHSA to measure and track quality within an organization. CCHSA’s accreditation standards incorporate concepts such as population health, client and community focus, evidence-based decisionmaking, and the continuum of care and integration of services. These standards challenge long term care organizations to increase their potential to achieve excellence in the quality of care and services.

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CCHSA’s accreditation program helps long term care organizations understand the concept of quality improvement and its methodologies. Accreditation promotes a culture that embraces learning opportunities and engages its participants in improvement discussions.

How accreditation differs from licensure

Accreditation is distinct from compliance reviews carried out by regulatory bodies and is a process undertaken to raise the level of care and services, regardless of how good those services may already be. (See Figure 2 for a comparison between licensure and accreditation.) The arrival of CCHSA surveyors is a valuable opportunity to seek and exchange information with peers from the field.

The difference between licensure and accreditation is important for staff and stakeholders to understand. Accreditation provides the organization with the opportunity to involve its members in examining current processes and outcomes with the goal of continuously seeking to improve care and striving for excellence. The self-assessment and subsequent accreditation report is incorporated into the organization’s ongoing quality journey.

Key Elements for Success

Gaining support, organizing for accreditation and maintaining enthusiasm

Obtaining support is an important first step in ensuring that the accreditation process begins and proceeds smoothly. Leadership, including senior management and boards/owners, need to understand and support the rationale for undertaking the accreditation process. They also need to stay involved throughout the process to ensure that barriers encountered by the teams working on the accreditation self-assessment are overcome.

Appointing an accreditation coordinator is also a key step. This person will acquire knowledge and experience to properly support the accreditation process. Organizations that are part of a larger chain can explore ways of designating one person to help sister homes through the process. An accreditation coordinator will be instrumental in ensuring that the accreditation process is a positive and worthwhile experience for all participants.

The identification of accreditation champions in the organization will assist in gaining support from all involved in the process. Champions are people who understand the benefits of accreditation and provide positive reinforcement to staff and teams to keep them motivated. While champions are usually staff members, they may also include residents and family members.

Once initial support from stakeholders is confirmed, it is important to keep momentum going. Keep staff and other stakeholders abreast of new and exciting developments in the accreditation process through informal communication tools such as the Web site, e-mail, newsletters and bulletin boards. Other ideas include updates at committee meetings, regular poster presentations to illustrate progress and the involvement of the local media to feature a story. Organize town hall meetings to increase awareness about accreditation and its benefits and to generate interest. These sessions can serve as ways to motivate staff and residents and encourage their participation in quality improvement activities.

Organizations form teams to complete the self-assessment part of the accreditation process. Many of these teams continue to meet after the accreditation survey takes place to followup on recommendations and continue working towards quality improvement. These “Continuous Quality Improvement” (CQI) teams ensure that the accreditation process is ongoing rather than an event that occurs every three years. These teams can be responsible for certain components of the CQI program, such as indicator monitoring.

They promote commitment and create a desire to make quality improvement part of the fabric of the organization. It is important to incorporate community partners, clients, and families in these CQI teams, even as ad hoc members. Community partners may include representatives from access centres, educational institutions, municipal offices, public health offices, other health care organizations, fire departments, supplier organizations, pastoral affiliations and ambulance services.

Maintaining staff enthusiasm is critical. Even when staff members support accreditation, it can be difficult to keep their enthusiasm since accreditation requires dedicated time. However, since staff members possess the knowledge and experience required for quality improvement initiatives, and often have ideas about how to decrease errors and improve processes, it is fundamental to foster and seek out this knowledge.

Some examples of how to increase and maintain enthusiasm include recognizing the efforts of the individuals and teams by organizing peer recognition events and contests for the bestorganized team, the best self-assessment, and overall participation; organizing fun competitions and games that test knowledge; supporting participating staff by arranging transportation if overtime is needed; and supplying food and catering for meetings. Remember to make the process enjoyable for all participants.

Considering education needs and optimizing learning opportunities

Leaders have a fundamental role not only in articulating the importance of accreditation and promoting a “quality” culture, but also in supporting education. Staff members might have a limited understanding of quality improvement (QI), its methodologies and how it relates to the Achieving Improved Measurement (AIM) accreditation program. Many teams lack the necessary tools for a successful journey, and in some instances, the organization may lack a culture that embraces learning opportunities and engages in improvement discussions.

Education sessions help organizations understand and participate more fully in the accreditation process. These sessions ensure that the overall accreditation experience is fully optimized, that the facility has the tools needed to put the accreditation process in motion, and that the facility has the resources to begin the CQI journey, including knowledge on indicator development and monitoring. Some suggestions to facilitate education for long term care organizations include:

Formal education sessions provide the facility with knowledge from experienced CCHSA accreditation specialists or surveyors, who are health care professionals who survey organizations on behalf of CCHSA. Formal education sessions are usually full-day interactive workshops delivered on site that provide participants with the foundation of accreditation, including fundamentals such as how to plan and conduct a survey. The formal education session is often viewed as the “kick off” event that fosters staff motivation and builds support for accreditation.

An organization also has the option of sending the appointed accreditation coordinator, as well as other key staff members, to participate in sessions off-site. This is a great opportunity for the accreditation coordinator to learn about the accreditation process and meet and network with individuals going through the same process.

Overcoming Challenges

Limited resources, financial and human, are key challenges. Constrained human resources and the intensity of the daily work may hinder quality improvement activities. Lack of personnel may result in fewer resources to draw from to complete the self-assessment, which then becomes a large task particularly if these individuals must work on a volunteer basis. Financial constraints may be responsible for limited technology such as hardware, software and e-mail capabilities, technology that facilitates the accreditation process. Limited funding constraints also reduce opportunities to attend educational sessions.

High staff turnover, which occurs at some long term care facilities, contributes to a lack of continuity and consistency between accreditation surveys. In some instances, interpretation and understanding of the accreditation standards may be a challenge as well. The result is a continuous, steep learning curve for the organization regarding quality improvement and accreditation.

Strategies to overcome limited resources

Seek out the assistance of accreditation specialists at CCHSA to obtain support and guidance along the way.

Embrace the culture of continuous quality improvement and incorporate it into daily activities. When an organization incorporates accreditation activities into its work environment on an ongoing basis, the accreditation process successfully moves forward.

Use pre-existing committees as teams for accreditation. This will reduce the amount of time required for building teams and establishing working rules. These teams could be made up of “core” members as well as “ad hoc” members who would need to be present to respond only to certain standards. “Ad hoc” members could be invited to attend a minimum of one or two meetings.

Establish a plan and set guidelines for the completion of the self-assessment. Some teams complete the self-assessment together by addressing a specific number of standards per month or per meeting. Other teams distribute the standards among their members and make it every individual’s responsibility to complete the assigned standards; teams then come back together to discuss the results.

Increase volunteer involvement in the process. Volunteers can coordinate, participate and input information into the computer software.

Develop a critical path detailing all the activities related to the accreditation process with realistic timelines. This critical path should begin at least 18 months prior to the survey. It should also include planning activities and document submission deadlines.

Conclusion

The benefits of accreditation for a long term care organization and for our health care system in general are numerous. The time, commitment and resources that are devoted to the accreditation process are certainly worthwhile to any organization that wants to assess itself against standards of excellence, seek valuable advice from peers in the field and demonstrate to its community and residents that it is committed to quality improvement.

Support from leaders, team commitment and a planned course of education will result in a successful survey process and will produce a roadmap for the organization to continue its quality improvement efforts for the ultimate purpose of providing excellent resident care and services. Accreditation can help organizations to embrace a culture of continuous quality improvement and incorporate it into daily activities.