CCHSA Accreditation: New Standards for Managing Medications Jessica Peters Lead, Research & Product Development CCHSA Accredited by /Agréé par ISQua.
Download ReportTranscript CCHSA Accreditation: New Standards for Managing Medications Jessica Peters Lead, Research & Product Development CCHSA Accredited by /Agréé par ISQua.
Slide 1
CCHSA Accreditation: New Standards
for Managing Medications
Jessica Peters
Lead, Research & Product Development
CCHSA
Accredited by /Agréé par ISQua
Slide 2
Presentation Outline
Vision, Mission and Values
The Accreditation Program
Program Enhancements
The New Standards for Managing
Medications
Next Steps
© CCHSA / CCASS
2
Slide 3
CCHSA’s Vision and Mission
Vision
The leader in raising the bar for
health quality
Mission
Driving quality in health services
through accreditation
© CCHSA / CCASS
3
Slide 4
CCHSA’s Values
Within an environment focused on clients
and committed to quality of worklife,
partnerships, and personal growth, our
values are:
Excellence
Integrity
Respect
Innovation
© CCHSA / CCASS
4
Slide 5
CCHSA’s Accreditation Program
Canadian accreditation program - incorporated in 1958
Not-for-profit
High participation rates; continued growth
Surveyors (approx. 400) are senior health care
professionals
Surveys may be regional, institution specific, national or
market specific (i.e. First Nations, Corrections, Canadian Forces)
Average 400+ surveys per year
Three year cycle
Both public and private organizations participate
© CCHSA / CCASS
5
Slide 6
© CCHSA / CCASS
6
Slide 7
Role of Accreditation
Quality Improvement – at the organization
level and at the system level
Change management
Standards of excellence – raising the bar on
health care
Standards of clinical practice
Governance
Leadership
© CCHSA / CCASS
7
Slide 8
CCHSA Standards
Standards of excellence
‘Raise the bar’ for health care practice
Enable an organization/team to stretch to improve care, to
reach or raise the bar
Developed with the input and guidance of experts in the
field and updated on a regular basis to ensure relevance
and value
Are applicable to different regions and service delivery
settings
Will continue to be used by organizations, but in a new
way
© CCHSA / CCASS
8
Slide 9
Evolution of CCHSA Program
© CCHSA / CCASS
9
Slide 10
The New Accreditation Program
Benefits:
1. Standards that:
Capture the most recent governance/managerial and
clinical best practices
Reflect the emerging trends or disease (and wellness)
patterns in healthcare
Have an increased level of specificity
Can be used or integrated into the daily work of
organizations
2. Streamlined and more flexible process that:
Supports and aligns better to an organizations’ quality
improvement initiatives
Is adaptable no matter how small or how complex the
organization may be
© CCHSA / CCASS
10
Slide 11
The New Accreditation Program
Benefits:
3. Greater focus on the provision of safe quality
care and service in a variety of health care
settings
4. Planned and predictable accreditation activities
with a on-site survey that is customized to the
organizations’ needs
5. Automated measurement tools that allow:
Greater and faster data exchange
Improved standardization and objectivity
© CCHSA / CCASS
11
Slide 12
The standards have a
brand new structure…
© CCHSA / CCASS
12
Slide 13
Standards Areas
EFFECTIVE AND SUSTAINABLE GOVERNANCE
PROACTIVE AND SUPPORTIVE ORGANIZATION
SERVICE EXCELLENCE
POSITIVE CLIENT EXPERIENCE
© CCHSA / CCASS
13
Slide 14
Managing Medications: Background
The development of the new standards for
managing medications was driven by:
Importance of safe medication management processes in
protecting client safety
Feedback from client organizations and surveyors
Changing health care environment
Development began in 2004
Expert working group including representatives from
organizations and ISMP-Canada
Standards circulated for consultation in late 2005 to
approximately 15 organization
© CCHSA / CCASS
14
Slide 15
The New Standards for Managing
Medications…
Standards target medication processes in an institutional
setting, i.e. hospital, long term care
Focus on the safe use of medications from selection and
procurement through administration
Address a number of key themes:
Working Together to Promote Medication Safety
Carefully Selecting and Procuring Medications
Properly Labelling and Storing Medications
Appropriately Ordering and Transcribing Medications
Accurately Preparing and Dispensing Medications
Safely Administering Medications to Clients
Monitoring Quality and Achieving Positive Results
© CCHSA / CCASS
15
Slide 16
Working Together to Promote
Medication Safety
Recognizing pharmacists and pharmacy staff as
integral members of the interdisciplinary team
Actively involving the pharmacy staff in designing
the organization’s medication use and medication
management processes
Providing access to accurate medication-related
information, formally approved drug information
tools and education about safe medication use
Evaluating the competency of all service providers
who participate in the medication use process
© CCHSA / CCASS
16
Slide 17
Carefully Selecting and Procuring
Medications
Maintaining an up-to-date and evidencebased list of available medications
Minimizing the number of procured and
available medications
© CCHSA / CCASS
17
Slide 18
Properly Labeling And Storing
Medications
Reducing the possibility of errors with drug
product nomenclature, labeling, and packaging
Labeling all drug concentrations clearly and
legibly
Providing suitable space for drug storage in
pharmacies and client/unit medication areas
Carefully selecting stock drugs for each client
area
Storing hazardous chemicals away from clients,
service providers, and drug preparation areas
© CCHSA / CCASS
18
Slide 19
Ordering and Transcribing Medications
Appropriately
Maintaining accessible and up-to-date client
information
Communicating drug orders and other drug
information in a standardized way
Reviewing all prescriptions or medication
orders for accuracy and appropriateness
© CCHSA / CCASS
19
Slide 20
Accurately Preparing and Dispensing
Medications
Preventing contamination when preparing
medications
Dispensing medications in a safe, accurate, and
timely way
Having a system to safely dispense medications
where there is no internal pharmacy or when the
pharmacy is closed
Transporting medication in a safe, secure, and
timely manner way
© CCHSA / CCASS
20
Slide 21
Safely Administering Medications To
Clients
Educating clients about their medications and
delivery devices, and ways to prevent errors
Following a process to allow and monitor clients’
self-administration of their medications
Safely and accurately administers medications
Reducing the risk of error through careful
procurement, maintenance, use, and
standardization of medication delivery devices
Monitoring clients following medication
administration
© CCHSA / CCASS
21
Slide 22
Monitoring Quality And Achieving
Positive Outcomes
Having a coordinated risk management
program to reduce medication-related
errors and sentinel events
Regularly monitoring and evaluating the
quality of the medication management and
pharmacy system
© CCHSA / CCASS
22
Slide 23
Current Status of the New Program
13 pilot sites will test various elements of the program
starting March to December 2007
National consultation on standards
Customized transition plan for each client in 2008
Pan Canadian information sessions in major cities to support
transition
Ongoing communication
CCHSA web site
teleconferences
© CCHSA / CCASS
23
Slide 24
Canadian Council on Health Services Accreditation
The leader in raising the
bar for health quality
© CCHSA / CCASS
24
CCHSA Accreditation: New Standards
for Managing Medications
Jessica Peters
Lead, Research & Product Development
CCHSA
Accredited by /Agréé par ISQua
Slide 2
Presentation Outline
Vision, Mission and Values
The Accreditation Program
Program Enhancements
The New Standards for Managing
Medications
Next Steps
© CCHSA / CCASS
2
Slide 3
CCHSA’s Vision and Mission
Vision
The leader in raising the bar for
health quality
Mission
Driving quality in health services
through accreditation
© CCHSA / CCASS
3
Slide 4
CCHSA’s Values
Within an environment focused on clients
and committed to quality of worklife,
partnerships, and personal growth, our
values are:
Excellence
Integrity
Respect
Innovation
© CCHSA / CCASS
4
Slide 5
CCHSA’s Accreditation Program
Canadian accreditation program - incorporated in 1958
Not-for-profit
High participation rates; continued growth
Surveyors (approx. 400) are senior health care
professionals
Surveys may be regional, institution specific, national or
market specific (i.e. First Nations, Corrections, Canadian Forces)
Average 400+ surveys per year
Three year cycle
Both public and private organizations participate
© CCHSA / CCASS
5
Slide 6
© CCHSA / CCASS
6
Slide 7
Role of Accreditation
Quality Improvement – at the organization
level and at the system level
Change management
Standards of excellence – raising the bar on
health care
Standards of clinical practice
Governance
Leadership
© CCHSA / CCASS
7
Slide 8
CCHSA Standards
Standards of excellence
‘Raise the bar’ for health care practice
Enable an organization/team to stretch to improve care, to
reach or raise the bar
Developed with the input and guidance of experts in the
field and updated on a regular basis to ensure relevance
and value
Are applicable to different regions and service delivery
settings
Will continue to be used by organizations, but in a new
way
© CCHSA / CCASS
8
Slide 9
Evolution of CCHSA Program
© CCHSA / CCASS
9
Slide 10
The New Accreditation Program
Benefits:
1. Standards that:
Capture the most recent governance/managerial and
clinical best practices
Reflect the emerging trends or disease (and wellness)
patterns in healthcare
Have an increased level of specificity
Can be used or integrated into the daily work of
organizations
2. Streamlined and more flexible process that:
Supports and aligns better to an organizations’ quality
improvement initiatives
Is adaptable no matter how small or how complex the
organization may be
© CCHSA / CCASS
10
Slide 11
The New Accreditation Program
Benefits:
3. Greater focus on the provision of safe quality
care and service in a variety of health care
settings
4. Planned and predictable accreditation activities
with a on-site survey that is customized to the
organizations’ needs
5. Automated measurement tools that allow:
Greater and faster data exchange
Improved standardization and objectivity
© CCHSA / CCASS
11
Slide 12
The standards have a
brand new structure…
© CCHSA / CCASS
12
Slide 13
Standards Areas
EFFECTIVE AND SUSTAINABLE GOVERNANCE
PROACTIVE AND SUPPORTIVE ORGANIZATION
SERVICE EXCELLENCE
POSITIVE CLIENT EXPERIENCE
© CCHSA / CCASS
13
Slide 14
Managing Medications: Background
The development of the new standards for
managing medications was driven by:
Importance of safe medication management processes in
protecting client safety
Feedback from client organizations and surveyors
Changing health care environment
Development began in 2004
Expert working group including representatives from
organizations and ISMP-Canada
Standards circulated for consultation in late 2005 to
approximately 15 organization
© CCHSA / CCASS
14
Slide 15
The New Standards for Managing
Medications…
Standards target medication processes in an institutional
setting, i.e. hospital, long term care
Focus on the safe use of medications from selection and
procurement through administration
Address a number of key themes:
Working Together to Promote Medication Safety
Carefully Selecting and Procuring Medications
Properly Labelling and Storing Medications
Appropriately Ordering and Transcribing Medications
Accurately Preparing and Dispensing Medications
Safely Administering Medications to Clients
Monitoring Quality and Achieving Positive Results
© CCHSA / CCASS
15
Slide 16
Working Together to Promote
Medication Safety
Recognizing pharmacists and pharmacy staff as
integral members of the interdisciplinary team
Actively involving the pharmacy staff in designing
the organization’s medication use and medication
management processes
Providing access to accurate medication-related
information, formally approved drug information
tools and education about safe medication use
Evaluating the competency of all service providers
who participate in the medication use process
© CCHSA / CCASS
16
Slide 17
Carefully Selecting and Procuring
Medications
Maintaining an up-to-date and evidencebased list of available medications
Minimizing the number of procured and
available medications
© CCHSA / CCASS
17
Slide 18
Properly Labeling And Storing
Medications
Reducing the possibility of errors with drug
product nomenclature, labeling, and packaging
Labeling all drug concentrations clearly and
legibly
Providing suitable space for drug storage in
pharmacies and client/unit medication areas
Carefully selecting stock drugs for each client
area
Storing hazardous chemicals away from clients,
service providers, and drug preparation areas
© CCHSA / CCASS
18
Slide 19
Ordering and Transcribing Medications
Appropriately
Maintaining accessible and up-to-date client
information
Communicating drug orders and other drug
information in a standardized way
Reviewing all prescriptions or medication
orders for accuracy and appropriateness
© CCHSA / CCASS
19
Slide 20
Accurately Preparing and Dispensing
Medications
Preventing contamination when preparing
medications
Dispensing medications in a safe, accurate, and
timely way
Having a system to safely dispense medications
where there is no internal pharmacy or when the
pharmacy is closed
Transporting medication in a safe, secure, and
timely manner way
© CCHSA / CCASS
20
Slide 21
Safely Administering Medications To
Clients
Educating clients about their medications and
delivery devices, and ways to prevent errors
Following a process to allow and monitor clients’
self-administration of their medications
Safely and accurately administers medications
Reducing the risk of error through careful
procurement, maintenance, use, and
standardization of medication delivery devices
Monitoring clients following medication
administration
© CCHSA / CCASS
21
Slide 22
Monitoring Quality And Achieving
Positive Outcomes
Having a coordinated risk management
program to reduce medication-related
errors and sentinel events
Regularly monitoring and evaluating the
quality of the medication management and
pharmacy system
© CCHSA / CCASS
22
Slide 23
Current Status of the New Program
13 pilot sites will test various elements of the program
starting March to December 2007
National consultation on standards
Customized transition plan for each client in 2008
Pan Canadian information sessions in major cities to support
transition
Ongoing communication
CCHSA web site
teleconferences
© CCHSA / CCASS
23
Slide 24
Canadian Council on Health Services Accreditation
The leader in raising the
bar for health quality
© CCHSA / CCASS
24