Accreditation more
outcomes-based than prescriptive: CCHSA
Monday, November 22, 2004 - Roderick Benns
According to the Canadian Council on Health Services Accreditation (CCHSA), the Ministry of Health and Long-Term Care would recognize accreditation as a constructive and positive exercise for any health-based organization.

Lisa Nowlan, team leader, communications, for CCHSA, says the Ministry "sees it as a favourable undertaking."

"An organization, I’m sure, would be encouraged to undergo accreditation," she says, noting it is a voluntary approach that has national standards, as opposed to provincial standards.

Open to all health care sectors, accreditation is quite different from the process of provincial level compliance advisors coming into long-term care homes to check Ministry standards.

"We’re looking for some of the same things, but our standards are more outcomes-based. We’re looking for what works and what doesn’t, what’s effective and what’s not – it’s a guide to quality improvement. I don’t think our standards are quite as prescriptive" as the Ministry’s, she says.

Within OMNI, Garden Terrace recently went through a highly successful three-year accreditation in June. But in a recent issue of the Ottawa Citizen, an article was written based on the raw data from the Ministry of Health and Long-Term Care's new public website, pointing out the Kanata home has 25 so-called "unmet standards." Two other facilities in the region are also mentioned.

As Samuelson mentions in an earlier OMNIway story, the things the Kanata home was cited for have no context behind them. "We didn't deliver a newspaper quickly enough for a short-stay resident, we were cited for some people not wearing name tags and we were cited because a resident lit an aromatherapy candle for a few minutes before she was discovered," says Karl. None of this contextual information is available to the public on the website.

All unmet standards were dealt with immediately, says the administrator

Accreditation evaluates an organization according to national standards of excellence, as defined by health care providers across the country. It requires that participating organizations complete a process of self-assessment and allows management to develop a road map outlining current challenges and setting future goals, according to information from the CCHSA. This framework can then be clearly communicated, encouraging continual progress and growth.

"The accreditation experience was a very positive one," recalls Samuelson.

"The survey team studied our home with precision. They made recommendations to assist us in our continued improvement efforts and commended us in so many areas," he says.

Nowlan points out accreditation is mandatory for acute care teaching hospitals, which suggests something about the level of credibility the organization has within the health services field, she notes.

Four key areas are assessed in the accreditation process; they are, environment, human resources, information management and leadership and partnerships. There are also care standards on top of this and all categories are broken down into more minute pieces.

But Nowlan says just because an organization is accredited, it doesn’t mean there are not recommendations. Garden Terrace, for instance, was asked to test, document and evaluate their emergency plan and to review its policies on aggressive behaviour, and to educate staff on the management of aggressive clients.

According to Samuelson, these are common recommendations in the long-term care industry. The home must prepare a progress report within one year on these two "high urgency" recommendations.