Transcript Danish model for accreditation and regulation

The Danish National model for accreditation –
how does it fit supervision
Anne Mette Dons
The National Danish model for accreditation
 Established in 2005
 The long term aim is to include all Danish
healthcare services and operate across the
various sectors.
 To be implemented in public hospital services in
2009
 Pharmacies, municipalities and private hospitals
will follow.
Organization
 Refers to a board of directors, including the
National Board of Health, the Ministry of
Health and Prevention, the Danish Regions
and Local Government in Denmark
 The Director of the National Board of Health is
also the director of the Board
The standards covers:
 General areas such as medication, patient
involvement, resuscitation and inter-sectorial
transfer
 The organizational area, with standards
providing for management, data safety and
technology
 Several treatments of diseases such as gastric
ulcers and diabetes
 Four or more steps in each standard
5
Indicators
Indicators, assessment
points, are attached to
each step.
The indicators must
ensure that the
standard is
implemented and used.
”The medical record
contains documentation
that the three initial
prescriptions of medication
during hospitalisation at the
unit clearly sets out the
dosage to be administered.”
Guidance:
The indicator is included in
the semi-annual audit of
records at the surgical,
intensive care and other
somatic care units as well
as psychiatric units.
The proces of accreditation in DK

Self-evaluation

Mock-survey

Final survey

Final rapport/accreditation

Every 3 year:
Survey and accreditation is repeated
 The standards are revised, and new standards are added

Supervisions role in accreditation
 All mandatory requirements and guidelines from
NBH are includes in the Standards
 Role in the hearing process
 Regular meetings with IKAS about patient safety
issues
 Focus areas from The Patient Safety Database in
NBH can be taken into the model
Quality and supervision
Quality
Good Quality
Acceptable medical standard
Bad Quality
Supervision
Problems?
 Surveyors assess the level in which the
organizations meet the standards.
 Will this accreditation process find
indicators of low patient safety?
 Are Accredited hospitals a false safety?
More Differences
Supervision
 Focus on facts
 Focus on exact result
 Secure an acceptable
medical standard
 No assurances
Accreditation
 Focus on indicators
 Focus on process
 Quality Improvement
 Stamp of accreditation
When is IKAS going to contact Supervision ?
 When mandatory requirements are not met?
 When accreditation demands are not met?
 When unacceptable medical performance is
documented?
 What kind of remarks should lead to orientation
of National Board of Health?
 What kind of remarks should lead to
investigation from National Board of health?
 Will the organizations audits give useful
information?
Will accreditation provide information on
health personnel
 Seldom, in case:
 Identification of health care professionels with
malpractice or lack of fittness to practice – identified
during examining patients records durng the survey
 Failure to fullfill a standard is caused by ONE person’s
preformance
Report to the local NBH