Abstract:

Context/Aim: The BC Cancer Agency aimed to strategically implement a successful and

sustainable Accreditation, with strong Executive and staff engagement, to meet all Required

Organizational Practices (ROPs) and standards. This project is consistent with the forum objectives

of showcasing successes and sharing effective strategies.

Problem/Issue: Accreditation requirements have become more challenging since the

introduction of the Accreditation Canada’s Qmentum process, including the addition of new Required

Organizational Practices (ROPs) and standards. In addition to cancer centres, the BCCA has

governance and oversight for cancer therapy in BC. Although the number of programs are limited,

the geographically separate centres make standardization of approaches, policies and procedures

challenging.

Interventions:• ROPs and standards were re-categorized, timelines were set, expectations for leaders and staff were

communicated and evidence of education and tests of compliance was collected and communicated

to staff. Key success strategies included:

• Focus on education of front-line staff

• Agency Executive Participation

• Creation of a Steering Committee

• Implemention of clear guidelines and expectations of leaders and staff constantly throughout the

process

• Implemention of an aggressive communication plan including fact sheets, Question and Answer

sheets and posters

• Execution of multiple mock surveys leading up to the survey

• Facilitating Accreditation Fairs

• Implemenation of specific strategies to address physicians, volunteers and researchers

• Paying specific attention to problematic Required Organizational Practices

Measurement/Results: BCCA met all ROPs and had only three unmet standards. Mock

Surveys have been conducted and ROP test of compliance data collected every six months since

Accreditation with close to 100% compliance. Lessons learned from this process are being realized

now as the BCCA prepares for its next Accreditation. All ROPs continue to be in place so time and

energy is spent moving forward with new improvements

Description of the Context/ Aim Statement:

Achieving Accreditation without conditions is a challenging yet achievable accomplishment as long

as an organization has the right formula. British Columbia Cancer Agency’s (BCCA) experience with

the Qmentum Accreditation was unique to the organization and cannot suggest that by using its

tactical strategies would ensure a condition-free Accreditation for another organization. However,

there are a number of key strategies that made a significant difference in the BCCA’s outcome for

Accreditation and have continued to sustain the gains.

The BCCA is an agency of the Provincial Health Services Authority, comprised of 5 cancer centres

and geographically dispersed throughout the province. In addition to cancer centres, the BCCA has

governance and oversight for cancer therapy in BC. Although the number of programs are limited,

the geographically separate centres make standardization of approaches, policies and procedures

challenging.

The BC Cancer Agency had three main objectives:

1. Ensure that the agency implemented and had sufficient documentation to show the Accreditation

Surveyors to meet all Required Organizational Practices (ROPs) and standards.

2. To ensure that staff were aware of all of the ROPs and standards and were articulate about the

changes.

3. To ensure that ROPs and standards were sustained and upgraded in the years in between

Accreditation Surveys.

Description of the Problem/Issue:

All organizations strive for a successful Accreditation. Accreditation requirements have become more

challenging since the introduction of the Accreditation Canada’s Qmentum process, including the

addition of new Required Organizational Practices (ROPs) and standards. Accreditation is a

mandatory requirement for all Canadian Hospitals and only those Accredited organizations are able

to conduct teaching and research activities. Through researching best practices, Accreditation

Canada has identified the key processes that organizations need to have in place to ensure safe and

standardized practices. The BCCA has a number of programs and services that are geographically

separate in the province but are required to standard all of the processes. The challenge was to

utilize staff and resources effectively to ensure that all ROPs and standards were implemented

consistently across the province without duplication or rework.

Identification of the Intervention/Strategy for Change:

The Qmentum Accreditation process is focused on not only ensuring that the standards and policies

are in place but also, that the patient care teams are aware of and follow these standards. It was

apparent that the key to a successful Accreditation this time was going to be ensuring that staff were

fully aware of the ROPs and key standards. This tactic drove our planning and communication

strategies as follows for both the 2009 and 2013 Accreditation Planning Processes:

BCCA’s 2009 and 2013 Intervention/Strategy:

1.Agency Executive Engagement and Participation:The Chief Operating Officer was identified as the Executive Sponsor for Accreditation and played an

integral part of the Core Accreditation Team. A second Executive member, the Chief Nursing Officer,

now VP, Quality & Safety, was also part of the Core Accreditation Team. All Executive team members

were assigned one or two cancer centres and were responsible for participating in kick-off sessions,

Mock Surveys and Accreditation Fairs in each centre. The President assigned 20 – 60 minutes for

Accreditation on each Executive meeting agenda.

2. Creation of Core Accreditation Task Force: A core Accreditation Task Force was

created with a purpose of providing direction to the Director, Quality, Safety and Accreditation and to

assist with Accreditation planning.

3. Strategic Action Plans for the BC Cancer Agency:PHSA’s Strategic Plan, BCCA’s Strategic Action Plans and PHSA’s Quality & Safety Framework were

compared to the Accreditation Canada standards to ensure compliance and information sharing with

leaders and staff.

PHSA Strategic Plan/PHSA Quality & Safety Framework:

4.Strategic organization of Accreditation Work Teams:As we began to divide up the work with each Quality Performance Roadmap team, it became apparent

that there would be duplication at each centre especially with the Cancer Care and Oncology Services

standards and ROPs if we organized our work according to the Accreditation Standard teams. In order

to satisfy our underlying principles, we needed to organize the work differently.

The ROPs and standards were re-categorized into six categories or Quality and Safety Goals similar to

the ROP bundles identified by Accreditation Canada which are shown in the following diagram

5. Create a project plan and Provide Clear Direction and Guidelines for Completion of Quality & Safety Theme Work:

a)Guidelines for the completion of the Accreditation work was clearly articulated

and distributed including:

b) Review BCCA policy, patient education pamphlets, website information, poster information,

orientation guidelines, procedures and processes. If no policy/process, create one. ROPs should

all have a policy and procedure. Timelines: February 14, 2009

c) Review all tests of compliance for ROPs. Identify evidence of compliance through the use of

audits/documentation of education sessions, copies of results of the review for each centre.

All ROPs require audits. Timelines: Februrary 14, 2009

Create and implement actions to bring ROP or standards into compliance and evaluate action plans.

March 31, 2009.

6. Create and Implement a Detailed Communication Plan:

a) Communication Fact Sheets per Quality & Safety Theme:

b) Presentations, Mock Surveys and Accreditation Fairs: Mock Surveys were

conducted prior to each Accreditation Survey to ascertain compliance with ROPs and standards.

7. Sustainability of compliance/Measurement:

Mock Surveys are conducted by the Director, Quality, Safety & Accreditation and centre leaders every

six months to ascertain compliance with the ROPS and other key standards. New ROPs are

introduced and staff education occurs as part of the survey. Results are brought to Quality Council

and the Executive after every visit and any shortcoming are addressed through re-education or

creation of a task force. Bi-annual distribution of Accreditation Fact Sheets to staff is done to ensure

that staff are aware of new ROPs and also to remind staff of established procedures.

ROP education was built into Accreditation prior to the last Accreditation.

Results:

The BC Cancer Agency received full Accreditation with no conditions. Out of 508relevant standards,

there were only 3 standards that required further work. All of the ROPs were met. Bi-annual Mock

Survey results reveal sustainability of the ROPs with close to 100% compliance. Mock Surveys

include conducting audits of the ROPS, collection of evidence during or prior to the survey and

ascertaining knowledge from staff through discussions at the bedside with each centre.

Effects of the Changes/Lessons Learned:

Staff include Accreditation into daily activity rather than a once every 4 year cycle. It is easier to keep

the education and awareness of the Accreditation ROPs and Standards rather than re-educating staff

only every 4 years.

Sustainability:

Sustainability of the Accreditation is built into the process and includes leaders and staff throughout

the entire process. Mock Surveys tests the compliance with ROPs and standards and results are

shared with staff to assist with creating mitigating strategies if required.

BC Cancer Agency’s Accreditation FormulaSue Fuller Blamey, RN, BScN, MBACorporate Director, Quality & Safety, PHSA/BCCA

PartnershipsOrganizational Capacity

Promoting Healthier

Populations

Improving Quality Outcomes and Better Value for

Patients

Contributing to a Sustainable Health Care

System

Better Health

LearningResearch

Quality and Safety

Strategic Directions

Cross-cutting Themes

EnablersPolicy

PartnershipsOrganizational Capacity

Provincial Policy

Quality &SafetyGoals

Cancer Populations

Lead: Sandra

Broughton

Work lifeWorkforce

Lead:Noorjean Hassam

Culture of Safety

Lead:Fiona Walks

Infection Prevention & Control

Lead: Anne

Burgess

MedicationManagement

Lead:Susan

WalisserKaren Janes

Communi-cationsLead:

IvoOlivotto

DentistryAccreditationMay 27 - 29Dentistry

Lead:Allan Hovan

Quality &SafetyGoals

Cancer Populations

Lead: Sandra

Broughton

Work lifeWorkforce

Lead:Noorjean Hassam

Culture of Safety

Lead:Fiona Walks

Infection Prevention & Control

Lead: Anne

Burgess

MedicationManagement

Lead:Susan

WalisserKaren Janes

Communi-cationsLead:

IvoOlivotto

DentistryAccreditationMay 27 - 29Dentistry

Lead:Allan Hovan

BC Cancer AgencyAccreditation 2013

All StaffEducation & Expectations

Sam AbrahamSue Fuller Blamey