Guideline to the Accreditation Process for Primary Care Accreditation in Lebanon (for organizations)

July 2011

Overview
The following document provides a detailed description of the accreditation process that Accreditation Canada has developed for primary care in Lebanon.

Completing the Self-Assessment

Prior to beginning the self-assessment process, all of the primary care clinics that participate in the assessments had the opportunity to attend education sessions, held in Lebanon. The education sessions focused on the accreditation process including information on how to complete the self-assessment, the content of the standards for primary care as well as quality improvement in general. After the education sessions, the clinics will be able to work on their self-assessments. The self-assessment process includes the following steps: 1. The clinic identifies an Accreditation Coordinator. The Accreditation Coordinator is responsible for preparing the clinic for the onsite visit and supporting clinic staff to participate in the self-assessment process. 2. The clinic assembles a Self-Assessment Team. To ensure that all areas are appropriately represented, it is recommended that staffs from different areas of the clinic are invited to be part of this team. Team membership usually consists of 6 to 8 members. Ad-hoc members may be invited to meetings as required. With the help of the Accreditation Coordinator, the Self-Assessment Team is responsible for gathering information from across the clinic to complete the self-assessment. 3. The Self-Assessment Team meets regularly to discuss their compliance with the standards and complete the selfassessment. 4. The Accreditation Coordinator submits the completed self-assessment, containing the clinics strengths and areas for improvement, to Accreditation Canada through email. 5. Accreditation Canada provides surveyors with the completed self-assessment of the clinics strengths and areas for improvement as part of the pre-survey information package.

The Accreditation Process for Primary Care Accreditation in Lebanon

Preparing for the Visit

Prior to the onsite visit surveyors are provided with an information package. In order for surveyors to fully prepare, this package should contain specific information about the clinic, organizational documents and the survey schedule. The documents will provide evidence for the surveyors when they are completing their ratings of the standards. The list below captures which documents surveyors will require onsite and those that will be useful during their planning day. A copy of the checklist needs to be forwarded to the survey team prior to the visit or on the planning day. The list is also a guide to assist organizations in their preparation for the onsite visit. The information surveyors will require access to includes the following: Name of the Accreditation Coordinator and a summary of the clinics self-identified strengths and areas for improvement The type of clinic and which primary care services are offered by the clinic and number of days per week that the clinic is open The number of sites and number of physicians, non-physician health care providers, and administrative staff The number of patients that are served by the clinic and characteristics of the client population (for example, urban, rural, primary languages, age groups) Whether or not the clinic conducts client experience surveys and whether or not they offer group meetings (for example for clients with specific chronic conditions) What health information systems the clinic uses as well as whether the systems are electronic or paper-based

The documentation surveyors will require access to includes the following: Organizational chart Vision and mission statements Where available, the strategic plan, operational plan, human resources plan, quality improvement plan, a recent annual report, and budget List of other accreditation/certification activities and awards, including dates granted Sample of client records and personnel files for staff (including evidence of credentials and job descriptions) Samples of the following materials: information provided to clients about services available, evidence of community participation, health promotion activity reports or materials, and preventative maintenance reports Copies of completed questionnaires (as well as evidence of analysis) on client accessibility, client experience, behavioural change as a result of interventions, and staff exit interviews/questionnaires Policies and procedures on equitable access, client rights, responding to complaints, intake systems, preventative maintenance, and fire safety Minutes from meetings between management and staff Performance or quality improvement reports, including initiatives or responses Data collected on the catchment area or client population or performance measures (process and outcome)

Prior to the survey, a teleconference will be scheduled with the primary care centres Accreditation Coordinator, the surveyors, and Accreditation Canadas International Accounts Manager. The purpose of this teleconference is to discuss and confirm the final survey schedule, discuss the information received from the clinics profile, and confirm logistical arrangements for the surveyors (travel, accommodations, directions, and local transportation). ____________________________________________________________________________________ Accreditation Process

The Accreditation Process for Primary Care Accreditation in Lebanon

The Onsite Visit

Two experienced surveyors will visit the primary care clinic for two days. The onsite visit includes the following activities (See Appendix A for a sample schedule). Introductory Leadership Meeting Surveyors will meet with the clinics managers and leaders the first morning of the visit to get an overview of the primary care centre, including its structural, environmental and political contexts. The primary care centre will provide an overview of its major accomplishments, major impediments to achieving its strategic goals, and factors affecting its quality improvement goals. During this meeting surveyors and primary care centre leaders establish a rapport, review and agree on the centres quality improvement objectives, and review the evaluation strategies and schedule. Priority Processes and Tracer Activities For the majority of the visit, surveyors trace priority processes throughout the clinic to assess compliance with the standards. A priority process is a key process within an organization that reflects critical areas and systems known to have a significant impact on the quality and safety of care and services. There are nine (9) priority processes for the primary care onsite visit: Planning and Service Design Human Capital Physical Environment Medical Devices and Equipment Infection Prevention and Control Medication Management Clinical Encounter Decision Support Integrated Quality Management

Surveyors use a technique called tracers to follow and evaluate priority processes. Depending on the priority process, tracer activities may include focus groups, discussion groups, one-on-one and group interviews, and tours. The tracer method is flexible and responsive, allowing surveyors to observe and interact directly with frontline staff in their working environment. While conducting a tracer, the surveyor looks for evidence that demonstrates compliance with the required criteria. It is important to note that surveyors are not evaluating individual performance they are observing processes and procedures to assess compliance with the standards. Each priority process is conducted by one surveyor, according to a detailed protocol to guide their activities and questions. Surveyor Information Exchange Following each tracer, and in preparation for report completion and debriefing, surveyors will meet to: Share their observations about the primary care centres performance Confirm their evaluation of priority processes Obtain information from each other to facilitate rating compliance Develop consensus regarding the overall performance of the clinic

Daily Review with the Accreditation Coordinator At the end of each day, surveyors meet briefly with the clinics Accreditation Coordinator to: Gather feedback on their approach and interactions with staff and clients Address concerns or suggestions for more effective interactions Request additional documentation / clarify information
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The Accreditation Process for Primary Care Accreditation in Lebanon

Request follow-up on some of the days activities Confirm logistics for the next days activities

Assessing Compliance During the visit, surveyors evaluate compliance with each of the measures of quality within the standards. Surveyors collect information during the tracer activities and then use the surveyor software to check the appropriate response for each measure of quality, for which there are four possible rating options: Not in place (N), In development (D), In place (I) and Leading practice (L). For each measure of quality rating, there is a comment field where surveyors can enter additional information related to the rating. If Not in place (N) or In development (D) is selected, surveyors will be prompted to provide a rationale for the ratings and recommendations and suggestions for improvements. If In place (I) or Leading practice (L) is selected, the surveyors will be prompted to provide observations and comments to support the rating. Additionally, if Leading Practices are identified, surveyors will be prompted to describe the Leading Practice. Leading Practices are defined as: Creative and innovative; Demonstrate efficiency in practice; Linked to the primary care standards; Adaptable by other organizations. Debriefing Following completion of the ratings, surveyors will prepare to debrief the clinic. The surveyor software includes a debriefing template to assist surveyors with organizing the debriefing session. The template covers key observations and suggestions, balancing areas of strength and areas for improvement. Surveyors provide two sessions: a leadership debriefing for the centres managers and leaders and a general debriefing for all staff (and clients, families, or community partners, at the discretion of each clinic). The Assessment Report The Assessment Report (see Appendix C for a sample report) will be sent to the primary care centres through the Lebanon Ministry of Public Health. The report will address the following: Overview of the onsite survey including dates Distribution of the overall results of the onsite visit (% not in place; % in place; % in development; % leading practice; % not applicable) A summary of the surveyors assessment of compliance: Overall distribution of the ratings by subsection (% not in place; % in place; % in development; % leading practice; % not applicable) Under each subsection, summary of the ratings with measures of quality listed, organized by standard Surveyor commentary including strengths and areas for improvement Comparison of the centres self-assessment rating and surveyor rating Overall distribution of the ratings by level (basic, advanced, excellence)

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The Accreditation Process for Primary Care Accreditation in Lebanon

Next Steps
Once the clinic receives their debriefing session and pilot report, they may then use the feedback for their ongoing quality improvement activities.

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The Accreditation Process for Primary Care Accreditation in Lebanon Appendix A: Sample Survey Schedule Lebanon Primary Care Sample Survey Schedule (2 surveyors x 2 days)
Day One Activity
Surveyor planning session (Half day)

Participants
Surveyors

Function
Discuss/review pre-survey accreditation documents and diagnostics Develop/review surveyor tracer responsibilities Develop/review/finalize schedule Establish rapport Organizational overview (scope of services, successes/challenges) Review survey schedule and self-assessment summary (strengths and priorities for improvement) Review evaluation strategies and schedule Priority Process: Planning and Service Design

Tool
List of predetermined required documents Tracer guideline package

Introductory leadership meeting

Surveyors, manager/director or lead physician

Tour of premises

Surveyors, manager/director or Surveyors become familiarized with practice set up and lead physician observation of facilities/reception/waiting areas Priority Process: Physical Environment

Tracer guideline package

Priority Processes

Surveyors Medical staff Non medical staff Patients (preselected charts)

Priority Process: Clinical Encounter, including impact on client Tracer guideline package outcomes and Decision Support Review of pulled client charts Discussions regarding the primary care clinical encounter (access, encounter, completion, and integration and coordination of services) Discussions with staff regarding how they use information, research, and best practice information in clinical decision making Priority Process: Integrated Quality Management Review of organizations quality and safety policies, plans and processes Discussions with individuals responsible for leading quality and safety initiatives Administrative tracer- organization-wide quality improvement initiative (one-to-one discussions with staff regarding a quality improvement initiative that has been implemented and discussions with patients regarding this initiative) Administrative tracer- recent safety incident (near miss, adverse event, sentinel event)

Surveyor knowledge exchange Priority Processes

Surveyors Surveyors Medical staff Non medical staff Patients (preselected charts)

Individual assigned ratings Priority Process: Infection Prevention and Control Review of infection control policies and/or strategy Discussion with individual responsible for cleaning and contracts with external service providers Discussions with staff responsible for coordinating infection prevention and control Discussions with clinical staff Tracer guideline package

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The Accreditation Process for Primary Care Accreditation in Lebanon

Priority Process: Medical Devices and Equipment and Physical Environment Review of the preventative maintenance process, documentation and equipment Discussions with staff regarding training on equipment, devices, maintenance Discussions with patients in waiting room Surveyor knowledge exchange Daily review Surveyors Patients Surveyors Surveyors, Accreditation coordinator Gain feedback on patient experience (accessing services, being assessed, receiving care and referrals or follow up) Individual assigned ratings Daily review with accreditation coordinator

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The Accreditation Process for Primary Care Accreditation in Lebanon

Lebanon Primary Care Sample Survey Schedule (2 surveyors x 2 days)

Day Two
Activity Priority Processes Participants Surveyors Medical staff Non medical staff Patients (preselected charts)

Function
Priority Process: Medication Management Tour of the medication storage areas, including sample medications Review of client files and one-on-one discussions with clients regarding the information provided to them about their medications and safety One-on-one discussions with staff regarding the medication management process Discussions with community partners (via phone or in person) regarding partnerships for promoting health and preventing disease, community engagement and coordination and continuity of services Prepare for debriefing Debrief and summarize survey visit.

Tool

Community Partners Focus Group

Surveyors Relevant community partners, stakeholders and partner organizations Surveyors Surveyors Manager/director or lead physician Nurses Nonmedical staff

Complete debriefing template Debriefing

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