Qmentum Accreditation All what you need to know

By: Abdalla Ibrahim

By

Abdalla Ibrahim

Accreditation Specialist, Healthcare Surveyor

Email: abdallaibrahim@hotmail.com

Qmentum Accreditation All what you need to know

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Qmentum (Quality + Momentum) literally referred to Quality Process in energetic and continuous motion.

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* It is a Comprehensive Accreditation Program to help

health organizations improve quality of care and

patient safety.

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*The program brings accreditation standards into

every day service operations.

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*It focuses on what matters most to

Organizations and Patients.

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Standards Evidence-based standards of excellence

Online portal Comprehensive automated self-assessment

Roadmap Quality performance roadmap

Indicators Performance Indicators

Survey Customized Survey Plan and Survey Process

Tracer Interactive Tracer Technique

Support Ongoing support through account manager

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Qumentum Standards

Governance

Leadership

Medication Management

Qmentum Service

Excellence

Infection Prevention and Control

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*The Standards are goal statements, written in bold and numbered 1.0, 2.0, 3.0, etc.

*Each standard is followed by a number of Criteria that are the activities required to achieve the standard.

*By complying with the criteria, an organization can achieve the standard.

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The criteria contain additional information and

linked to one of eight quality dimensions:

Accessibility

Client-centred Services

Continuity of Services

Effectiveness

Efficiency

Population Focus

Safety

Worklife

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* Some of the criteria are identified as a Required

Organizational Practice (ROP).

*An ROP is as an essential practice that organizations

should have in place to enhance patient/client safety and

minimize risk.

*To reflect the step-by-step approach of the program, each

ROP is assigned a level of Gold, Platinum, or Diamond.

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All criteria are assigned a level of Gold, Platinum, or Diamond to reflect the tailored nature of the accreditation program (see above).

*Gold criteria would apply to organizations in the Gold cycle of accreditation.

*Gold and Platinum criteria would apply to organizations in the Platinum cycle of accreditation.

*All criteria would apply to organizations in the Diamond cycle of accreditation.

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*The Qmentum International Accreditation

Program has three levels of accreditation:

Diamond

Platinum

Gold

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*The Qmentum International Accreditation

Program has three levels of accreditation:

Gold addresses basic structures and processes linked to the foundational elements of safety and quality improvement.

Platinum • emphasizes on

client-centred care.

• creating consistency in delivery of services through standardized processes.

• involving clients and staff in decision-making.

Diamond • focuses on

monitoring outcomes

• using evidence and best practice

• benchmarking with peer organizations to drive system-level improvements.

*Cycle of Accreditation Services

*Accreditation Life Cycle

Readiness Assessment

Self-Assessment

Simulated Survey

Accreditation Survey

Report

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*New organizations to accreditation starts the process with a

clear understanding of where they stand in comparison to

accreditation standards.

*It is conducted by surveyors using Tracer Methodology.

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Initial Assessment

Action Plan

Risk Profile

Indicator

Culture of Quality

Education

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*Initial Assessment of existing processes and systems against

standards and a baseline for future work.

*Action Plan for getting started

*Risk Profile: Organization’s compliance with Required

Organization Practices (ROPs),

*Indicators: Readiness to collect performance measures

*Capacity to transition to a Culture of quality improvement

*Education about the accreditation process, quality

improvement, and safety.

* Surveyors

uses:

Focus Group

Discussion Group

One-to-On

Group Interview

Tours to trace priority processes

Observation

By observing and interacting directly with frontline

staff in their working environment, surveyors able to

assess the health care organization’s:

*Readiness for accreditation

*Compliance with Qmentum International™ standards

and levels.

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The outcome of the RA is

a Comprehensive REPORT providing:

Analysis

• Analysis of organization’s capacity to achieve accreditation

Recommendation

• To assist the in achieving accreditation goals and objective.

Action Plan

• To ensure that organization continues to provide the highest quality of service and care.

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Orientation sessions allow surveyors to:

* Introduce the Qmentum International™

accreditation program to leaders and staff of

the organization

*Provide a refresher, especially with those

experiencing higher staff turnover.

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These sessions are meant to:

*Reduce the anxiety associated with

accreditation

*Frame the process according to philosophy of

continuous quality improvement.

* Introduction to Qmentum International:

for all levels of staff, introduces the key elements of the

Qmentum International accreditation process

Qmentum International™ for Leaders:

overview of the new accreditation program including tools,

team formation, and team work required by the organization’s

team leaders and senior leadership to manage the process

Qmentum International™ for Self-Assessment Teams:

introducing the Qmentum International accreditation program

to the organization’s leadership and senior management team.

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Introduction to Qmentum International:

for all levels of staff, introduces key elements of Qmentum International accreditation process

Qmentum International for Leaders:

(Team leaders, senior leadership to management)

overview of new accreditation program including tools, team formation, and team work

Qmentum International™ for Self-Assessment Teams:

(leadership and senior management team).

Introducing Qmentum International accreditation program

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*A web-based tool that allow all staff to evaluate the level of compliance against Qmentum International™ standards

*And aggregate this data by Functional Teams and reported within a Management Dashboard.

*The self-assessment tool includes a Client Portal and the Quality Performance Roadmap™.

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*In this secure portal, the health care organization completes its self-assessment at its convenience.

*Once the self-assessment is complete, the health care organization can obtain its Results automatically, and also generate reports.

*Report includes findings related to performance measures and indicators.

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*Comprehensive picture of organization’s status

performance against standards and measures.

*Identifies quality and safety areas for follow-up and

improvement.

*Consolidate and present information in a secure database.

*Enable policy-makers and leaders to identify system-wide

quality and safety issues and strengths.

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*Creates, coordinates and ensures execution of a

critical path of key events leading up to

accreditation

*Guides, mentors and coaches the organization in

its accreditation-related activities, for example

standards interpretation and knowledge transfer

regarding quality improvement plans

*Ascertains the organization’s educational needs

and may also be part of delivering client education

and capacity building programs

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*Assists the organization in developing and

implementing quality improvement action plans

*Provides access to resources, examples of policies

and procedures, best practices and contacts

available within its network of over a thousand

accredited organizations

*Provides access to all national and international

health care accreditation and distinction standards

available

*Reviews and provides advice on the

implementation of accreditation recommendations

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* The surveyors conduct both clinical and administrative tracers for a sample of priority processes which are critical areas and systems known to have a significant impact on the quality and safety of care and services.

*Normally occurs 4 - 6 months prior to the final survey

The Simulated Survey provides the staff with:

*Opportunity to experience the Tracer Methodology

*Understand the questions surveyors may ask during this activity.

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*A comprehensive onsite review that evaluates

the organization’s level of performance against

Qmentum International™ standards.

*The onsite visit is conducted by a team of

external peer surveyors using tracer

methodology.

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*Tracer Methodology is used to assess levels of care, treatment, and services by following an actual client or patient experience through the care continuum.

Tracers are used to evaluate both:

* clinical process(direct client care).

* administrative processes (governance, leadership, management).

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*The tracer is an interactive process whereby

surveyors use direct observation and interaction

with a wide variety of staff and patients/clients to

gather evidence about the quality and safety of care

and services in a particular service area.

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Professionals with:

* credentials

* healthcare and leadership experience

* analytical and communication skills.

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*The PHC Centers will be chosen based on a high

volume & high risk basis.

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*Timing: 10-20 days after the survey

*It provides specific information on key findings, strengths,

and areas for improvement, and highlights areas that will

minimize risk and improve overall performance.

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*Accreditation: the organization may be accredited

at a Gold, Platinum or Diamond level depending on

their performance at the time of the survey.

*Accreditation with Condition: the organization

achieves compliance with standards at a certain

level, but conditions must be met to maintain

accreditation.

*Non-Accreditation: Unsuccessful in achieving

accreditation.

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*The Accreditation Decision is provided with the

Accreditation Report.

*Upon achieving successful accreditation, the

organization will receive an award letter, a certificate

of accreditation for each location.

*In the event that the decision specifies conditions, the

organization will have five months to one year to meet

the required conditions by providing evidence of

improvement initiatives and outcomes.

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*Following the receipt of the Accreditation report, the

organization must address any conditions, and continue to

work on the areas identified for improvement.

*Accreditation Canada International will review whether

the conditions are met based on the information received

including evidence of action taken.