CCA ACCREDITATION AND QUALITY IMPROVEMENT 101 Presentation for Community–Based Primary Health Care organizations Presenters: Siu Mee Cheng, Executive Director, Canadian Centre for Accreditation Jackeline Barragan, Accreditation Manager Presented to: AOHC 2018 Conference Date: June 13, 2018
CCA OVERVIEW
What is & isn’t Accreditation?
• Focuses on both strengths and areas for further organizational & service delivery improvement.
• “Witch Hunt”
• Provides a 360 of organizational performance.
• Audit
• Provides insights into sector targets and standards.
• Paperexercise
• Compliance
•Provides objective opinion that is informed by evidence on whether your organization is meeting accepted performance standards
A New Partnership for Accreditation •
Responding to growing interest in Canadian accreditation program tailored to community-based health and social services
•
Five associations serving community-based service providers combining over 100 years of accreditation experience - Association of Ontario Health Centres (Community Organizational Health), Children’s Mental Health Ontario, Ontario and Canadian Associations of Credit Counselling Services, Family Service Ontario, Ontario Association of Children’s Aid Societies
•
Combined and revised accreditation programs - creating new independent third-party organization (supported by Trillium Foundation grant )
•
Significant input from CHCs and AHACs into development of the Community-Based Primary Health Care Module
•
April 2013 Program launched (after piloting in previous year)
4
Continued Growth & Recognition • ISQua accreditation - CCA’s Standards are accredited by the International Society for Quality in Healthcare, a widely respected body that offers the only international accreditation for national accrediting bodies like CCA • CCA is an approved accreditation provider of: – Ontario Local Health Integration Networks that require accreditation – Family Service Canada’s network of employee assistance program providers – Catholic Charities Toronto region – the Ontario Federation of Indigenous Friendship Centres
Benefits of CCA Accreditation “Return on Investment” •
In post-accreditation evaluations organizations tell us that participating in accreditation: – Enhances their culture of learning, quality improvement and accountability – Supports learning about leading practices – Strengthens their systems and processes in order to improve organizational effectiveness – Motivates board and staff to work towards common goals – Demonstrates to the community, people served and funders the organization’s commitment to ongoing quality improvement, risk management and accountability – Provides third party recognition for achievements of their organization
6
CCA Vision and Mission Vision: Effective organizations strengthen healthy and resilient communities. Mission: We assure quality and continuous improvement through the provision of excellence and leadership in accreditation services.
CCA Values • Continuous Learning and Improvement - We pursue continuous learning and improvement towards excellence and innovation; We recognize and celebrate key milestones achieved. • Meaningful Collaboration - We inclusively engage the diverse organizations we serve, as well as other CCA stakeholders, in dialogue to shape our mission, goals and services. • Inclusion and Equity - We value the diverse contributions of our stakeholders and strive to promote inclusive environments and elimination of systemic barriers to equity. • Responsible Stewardship - We manage CCA resources ethically, transparently and responsibly, in order to ensure its sustainability. • Accountability - We hold ourselves accountable for the quality of our work and the achievement of established outcomes that are aligned with our values.
Overview: The CCA Program •
CCA accredits organization as a whole
•
Using tailored, modular set of organizational and program/service standards; developed with sector input
•
Process includes: – Organizational self-assessment & planning; web-based tool – Organizational documentation presented ahead of time – CCA Surveys: community partners, staff, other stakeholders – Site visit: interviews, observations, file review – Preliminary Report: Opportunity for additional input before accreditation decision
•
Reviewers are staff, board, volunteers involved with organizations that participate in CCA; from mix of community-based sectors
•
Accredited for four years
9
Principles of CCA Approach •
Focus on both fostering quality improvement and risk management
•
Standards challenging and achievable by diverse organization types and sizes
•
Clear and transparent expectations
•
Consistent practices applied with sufficient flexibility to recognize unique circumstances and challenges of organizations being reviewed
•
Supportive of organizations achieving and maintaining accreditation
•
Recognition of strengths/successes of organizations
•
Value-added experience for community organizations
10
Alignment Between QI & Accreditation Quality Improvement
Accreditation
Assessing Needs – where are the gaps in quality
Accreditation Standards provide a baseline of minimum performance / requirements to support quality (what is “quality”) Assessing existing practices, processes, policies and structures against this
Engage in QI activities / initiatives to improve quality to desired target / outcome
Once assessment done, time is given to clients to address and improve upon the gaps during accreditation:
Training & Building Capacity Supports Benchmarks (other clients / policies, etc.,) *** (i.e., before submission of evidence required & site visit)
Evaluate QI solutions & Revise
Final Accreditation Decision & Recommendations: provides affirmation and/or objective opinion on QI areas
CCA Accreditation Drives Quality A. Standards (Organizational and Services Delivery modules) •
Evidence-based and sector driven
•
Comprehensive (all organizational components/functions and services delivery)
•
Demands consideration of external partners / community
•
Value: • Self assessment requires full engagement of organization (from Board, management and front-line) • Benchmark with rest of sector on best practices • Accreditation program permits time for entire organization to address variance from existing practice to standards requirement
CCA Accreditation cont’d… B. Accreditation Evidence Requirement • Demand for evidence as proof that indicators have been satisfied requires full engagement of the organization – survey, interviews, policies and procedures, minutes and other documents. • Staff
• Management • Board • Community partners
C. CCA Support with Client Organization
• Orientation to organization • Access to CCA supports by all staff in organization
CCA Accreditation cont’d… D. Community of Service Providers • Given CCA’s history with its association members; • Majority of Association members’ membership are CCA clients (60%-100%); • Reviewers from among the sectors; and • Inventory of client policies and procedures for shared access. E. Accreditation Site Visit • Preparation for site visit requires full engagement of organization: • Board, management and staff
CCA STANDARDS
Foundations of CCA Standards: Excellence in Service Provision •
A focus on people and communities served; respect for their dignity and diversity
•
A strength-based approach to service delivery, recognizing the social and physical environments that impact people’s well-being and health
•
A commitment to equity and to actively addressing barriers to service
•
A drive to improve outcomes for people and communities served
•
Integration of continuous learning, improvement and innovation
•
Decision making that is evidence-based
•
Safe services and work settings
•
The most efficient use of resources to achieve outcomes
•
Social and ethical responsibility
•
Accountability and transparency
Modular Framework of Standards •
Organizational Standards Module – Cover governance, leadership, management, core service areas – Apply to all reviews
•
Program Modules matched to organization current: – Community-Based Primary Health Care – Community-Based Support and Social Services – Community Mental Health and Addiction Services – Child and Youth Mental Health Services – Credit Counselling Services – Child Welfare Services – Family Services including Employee Assistance Programs – Youth Justice Services
Standards for Community-Based Primary Health Care CCA Organizational Standards Module
Governance Stewardship Risk and Safety Organizational Planning and Performance Programs and Services Community Learning Environment Human Resources Human Resources – Volunteers Systems and Structure Aboriginal Organizations
CCA Community-Based Primary Health Care Module
• Community-Based Approach • Delivery of Quality Programs and Services • Risk and Safety
Organizational Standards: 11 Components •
Governance – Focuses on key elements for effective functioning of the organization’s governing body – Includes orientation and development, code of conduct, clarity of roles
•
Stewardship – Covers important aspects of managing financial and other resources
•
Risk and Safety – Addresses management of risks (for example through incident reporting systems and insurance), safety of the workplace, general client safety and management of complaints
Organizational Standards: 11 Components • Organizational Planning and Performance – Addresses key elements of planning at the organizational level including leadership through the strategic plan, and the organization’s engagement in quality monitoring and improvement
• Programs and Services – Covers key common elements of service provision including person-centered services, strength-based approach, client rights, accessibility of services, information and referral; includes standards for organizations serving Aboriginal persons re culturally safe services
Organizational Standards: 11 Components • Community – Explores the organization’s communication with and responsiveness to its community, including consultation with Aboriginal organizations if serving this population
• Learning Environment - Student placements and research, if applicable • Human Resources – Covers important elements of managing paid staff resources
• Human Resources – Volunteers – Covers key aspects of managing volunteers
Organizational Standards: 11 Components • Systems and Structure –
Addresses management of information and privacy requirements among other
• Aboriginal Organizations – Addresses elements of unique concern to serving Aboriginal people including, creating an environment that supports indigenous cultural safety for clients and staff, functioning of the governing body, community engagement, working with traditional practitioners.
CBPHC Module Components • Community-Based Approach – Addresses health equity, social determinants of health, community engagement, health promotion, community capacity building, client surveys
• Delivery of Quality Programs and Services – Addresses client-centred services, client advocacy, assessment, timely access, inter-professional teams, continuity and coordination of service, client records
• Risk and Safety – Focuses on taking a pro-active approach to client safety, managing service-related risks (eg. re: infection control, medication dispensing and reconciliation)
How CCA Standards are Structured • Standards and Indicators – Mandatory (M) Standards address • Legislated requirements • Significant safety or risk issues • Crucial elements of good practice • All must be met
– Leading Practice (LP) Standards address • Quality improvement and excellence • About 80% must be met
• Each Standard assessed based on concrete, measurable Indicators • Flexible in how apply to small, medium, large organizations
Example - Mandatory Module:
CCA Organizational Standards (ORG)
Component:
Human Resources (HR)
Standard:
ORG HR 4. The organization has clear lines of accountability and communication. (M)
Indicators:
4.1 The organizational structure is clearly defined and documented.
4.2 The roles, responsibilities and accountability of all personnel are outlined. 4.3 There is a clearly defined process for delegating responsibility and authority, including for coverage of key positions during anticipated and unexpected leaves. 4.4 Staff, volunteers and students understand the lines of accountability and communication.
Example – Leading Practice Module:
CCA Organizational Standards (ORG)
Component:
Organizational Planning and Performance (OPP)
Standard:
ORG OPP 6. The organization’s culture supports ongoing learning, improvement and innovation. (LP 2 out of 3)
Indicators:
6.1 Staff and other stakeholders, as appropriate, are encouraged to reflect and identify opportunities for innovation and improvement in the organization’s work. 6.2 Individuals at all levels of the organization are given opportunities for ongoing learning and to exchange ideas and experiences. 6.3. Staff are encouraged to test new approaches as a means of fostering quality.
THE CCA ACCREDITATION PROCESS
Overview: The CCA Program •
CCA accredits organization as a whole
•
Using tailored, modular set of organizational and program/service standards; developed with sector input
•
Process includes: – Organizational self-assessment & planning; web-based tool – Organizational documentation presented ahead of time – CCA Surveys: community partners, staff, other stakeholders
– Site visit: interviews, observations, file review – Preliminary Report: Opportunity for additional input before accreditation decision
•
Reviewers are staff, board, volunteers involved with organizations that participate in CCA; from mix of community-based sectors
•
Accredited for four years with annual quality updates
The CCA Accreditation Process
29
Getting Ready Beginning at least 18 months prior to site visit • Sign agreement with CCA • Plan dates for site visit • Self-assess and plan; confirm which standards apply – Initial review of standards, assess strengths and areas for development – Assign leadership/organize work groups for accreditation preparation – Create accreditation work plan with assigned tasks, time lines – Access tools and resources in Go CCA section of Web site
Supports to Accreditation • Resources available on CCA Website – Incl. sample policies and procedures, guide to preparing
• Support provided by CCA Accreditation Managers • Web-based tool to manage the process – your own password-protected hub – Use to self-assess against the standards
– Review schedule, deadlines, manage milestones – Respond to standards and indicators • Attach documents, answer with narratives
– Access preliminary and final reports
Keys to Successful Preparation 1. Understand CCA Framework and Requirements 2. Understand the Timelines and Process
3. Know Where to Go for Help/Answers 4. Complete a self-assessment/gap analysis -
Identify lead staff (or board, for governance related areas) to complete self-assessment/gap analysis
-
Develop a workplan with key milestones
5. Create Systems –
To manage collection of organizational documentation in advance; loading into MyCCA portal
6. Prepare Staff, Board, community partners – for lead up, CCA surveys and Site Visit
… Pre-Site Evidence Beginning about four months before the site visit • Logistics fall into place – Review team assigned after conflict of interest check – Review first draft site visit schedule
• CCA surveys organization’s stakeholders including: – All governing body members • CCA looks for 80% or better response rate
– All full- and part-time staff • CCA looks for 80% or better response rate
– All volunteers – Between 12 and 30 community partners – Depending on sector: EAP customers, youth involved in youth engagement, foster parents/foster kin, children in care
Site Visit by CCA Review Team •
•
Orient the team to the organization –
Make brief presentation on organization
–
Give tour
–
Orient team to file system as required
Participate in interviews: –
Group interviews •
–
Individual and small-group interviews •
•
Governing body, managers, staff Staff, chief executive, volunteers, clients, others as relevant
Provide access for team to: –
Observe facilities, programs in action
–
Reviews files/documents
•
Provide additional evidence as requested by team
•
Participate in verbal wrap-up presentation by team
The CCA Preliminary Report •
Preliminary Accreditation Report of results includes: – Overview of review process and results to date – Strengths and areas for further quality improvement in each module – Any standards still to be met for accreditation – Response Form outlining evidence required to meet outstanding standards if any – Compiled summary of responses to CCA surveys
•
Prepared by Team Leader and Accreditation Manager
•
Posted to Web tool for organization two weeks after site visit
•
Opportunity for organization to respond – Including with additional evidence to satisfy outstanding accreditation requirements if any • 30 working days to respond
The Accreditation Decision •
Accreditation Manager reviews response to Preliminary Report
•
Makes recommendation on accreditation status
•
Possible outcomes: – Accreditation – Accreditation denied – Accreditation conditional • For conditional, follow up (additional evidence, site visit)
•
Final Accreditation Report and Certificate
•
Opportunity for reviewers and organization to give anonymous feedback on their experience
Advantages of Accreditation with CCA for Community Service Organizations • • • • • • • •
Independent third-party process Bilingual Canadian program Geared to community-based service providers Review teams made up of individuals from related community-based sectors Four-year accreditation cycle Fees are competitive One stop for multi-service organizations Sector association could become partner in CCA governance
Thank-you Visit us at the CCA booth, get a swag, and enter your caca prize! name for a fabulous Com Suite 500A – 970 Lawrence Ave W Toronto, Ontario M6A 3B6 Ph: 416-239-2448
www.canadiancentreforaccreditation.caca ed@canadiancentreforaccreditation.ca jbarragan@canadiancentreforaccreditation.ca