QEH Accreditation with Condition at Gold Level

For the first time in the more than five decades of its existence, the Queen Elizabeth Hospital has pursued and has been awarded an International Accreditation at the Gold level by Accreditation Canada, an international credentialing body.

Chief Executive Officer of the Queen Elizabeth Hospital, Dr. Dexter James remarked that “we were assessed during the week of February 19-23 by a team of surveyors from Accreditation Canada and just 20 days after the survey visit, we received correspondence from the credentialing body stating, ‘Accreditation Canada has reviewed the results from your on-site survey and is pleased to inform you that the decision awarded to your organization is Accreditation with Condition – Gold‘.”

Dr. James indicated that many teams comprising various categories of staff worked exceedingly hard over the past 2 years to achieve this strategic development and as such must be lauded for their tireless effort. However, he noted that “the accreditation process is a journey, not a destination; and that the hospital is required to submit an action plan on areas of operations referred to as system-wide and service excellence standards by August 22, 2018.”

The QEH’s journey to the Gold level accreditation occurred in three phases. Phase one commenced with a review of the methodology and approach to accreditation of a number of credentialing bodies and after this evaluation, it was in March 2016 that the Board of Management accepted the recommendation to pursue the accreditation journey with the Canadian body.

This paved the way for the appointment of the CEO as the Accreditation Coordinator with responsibility for leading and overseeing the accreditation process. Dr. James was supported by a team comprised of three Accreditation Support Specialists and team leaders drawn from among existing staff. These teams were responsible responsible for working through the requirements of the many standards which included critical care, disaster management, sterilization, governance and medicine services, to name a few.

Phase 2 entailed the myriad of activities required for the formal process. This phase commenced with the assignment of a Project Officer by Accreditation Canada to support and clarify concerns with the accreditation process and the interpretation of standards. A team of surveyors from Accreditation Canada then conducted an Orientation Session and Readiness Assessment in April 2016. The objectives of these activities were to present the broad framework of their Qmentum International Programme of accreditation, introduce the various methodologies used in the conduct of the survey and conduct comparative assessments of the policies and procedures utilized to effectively manage the hospital’s clinical, diagnostic and general operations against a set of international standards.

The results from this assessment confirmed that the hospital had the basic structures and processes for the Gold standard of accreditation and the QEH was deemed to be 66 percent compliant on the foundational elements of safety and quality management with work still to be accomplished by teams. This assessment was followed by a mock audit conducted by the same body in March 2017. The audit revealed that significant progress was noted by surveyors, with the hospital achieving an improvement rating of 76 percent compliance with standards relevant to the Gold Level.

The improvement gap comprising non-conformances and unmet criteria informed the basis for further work on what were referred to as Required Organizational Practices (ROPS) and High Priority Criteria and a number of plans and other criteria, which required completion before the formal survey. To attain the Gold Standard of accreditation, it is Accreditation Canada’s policy that the hospital must comply with 100 percent of all ROPS, meet at least 90 percent of High Priority Criteria, meet at least 81 percent of all regular criteria and conduct a staff patient safety culture survey.

Phase 3 was the formal survey which was conducted during the week of February 19 -23, 2018. This was an independent assessment of the QEH’s organizational practices against the above international Gold standard requirements, conducted by a team of Accreditation Canada surveyors. Assessments were conducted on resource management for increased efficiency, improved quality and patient safety utilizing a number of approaches which included the review of various types of documentation, audits, focus groups meetings, interviews with staff and other stakeholders and tracer studies.

The survey concluded with debriefing sessions for the QEH’s management team and general staff during which surveyors indicated that the QEH had achieved an average compliance rate of 80 percent across various quality dimensions and commended staff for their dedication to patient care and exceptional work ethic. However, receipt of the final survey result revealed that the hospital had obtained a 90 percent compliance rate with Accreditation Canada’s standards at the Gold level, and on this basis the QEH was awarded International Accreditation.

An official ceremony will be held this month to commemorate the hospital’s successful attainment of this international recognition and the formal hand-over of the Award by Accreditation Canada.

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