Having been in hospital management and leadership positions
in both the United States and Canada, it is my experience that surveys by
Accreditation Canada are considerably less than thorough; that they do not
ensure that hospitals are committed to providing safe, quality healthcare; and
that many hospitals in Canada would not
pass the more rigid accreditation surveys conducted by The Joint Commission in
the United States.
What is Accreditation Canada?
Accreditation Canada is an independent organization
responsible for accrediting hospitals and other healthcare organizations across
Canada.
As per Accreditation Canada, their accreditation is supposed
to assure you that the accredited organizations are committed to the ongoing
delivery of safe, quality healthcare; risk-reduction; and accountability.
How do they accomplish this?
Accreditation Canada completes a survey (assessment) of the
organization and its operating practices during a pre-arranged time period
of 2-5 days.
Accreditation occurs every 4 years.
What do they look at?
Accreditation primarily looks at the organization’s
compliance with what are referred to as “Required Organizational Practices”
(ROPs). (http://www.accreditation.ca/sites/default/files/rop-handbook-2014-en.pdf
)
Is Accreditation Canada the same as The Joint Commission
that accredits hospitals in the United States?
The Joint Commission in the United States is also an
independent organization responsible for accrediting hospitals and other
healthcare organizations.
Besides jurisdiction, there are several important
distinctions and differences.
-
Joint Commission surveys are unannounced.
-
Accreditation is for a three year period.
-
The number and detail of standards that are assessed.
-
The breadth and thoroughness of the survey.
How does The Joint Commission accomplish this?
The Joint Commission completes a rigorous and unannounced survey (assessment) of a
wide range of standards.
The standards-based performance areas for hospitals are:
- Environment of Care
- Life Safety
- Provision of Care, Treatment,
and Services
- Emergency Management
- Medication Management
- Record of Care, Treatment, and
Services
- Human Resource
- Medical Staff
- Rights and Responsibilities of
the Individual
- Infection Prevention and
Control
- National Patient Safety Goals
- Transplant Safety
- Information Management
- Nursing
- Waived Testing
- Leadership
- Performance Improvement
Also examined are “Accountability Measures” (formerly “Core
Measures”) - which are condition-based best practice measures.
Where does Accreditation
Canada fall behind The Joint Commission?
- Example: Infection
Control and Prevention
Accreditation Canada only looks at following:
- Hand Hygiene Compliance
- Hand Hygiene Education &
Training
- Infection Rates – how the
hospital tracks common infections (at the hospital’s discretion), reportable
diseases, and antibiotic-resistant organisms – and what is done with that
information
- Administration of the
Pneumococcal vaccine to high-risk populations
- Reprocessing of medical
equipment.
The Joint Commission surveyors would look at all the above,
but also at:
-
The minutes of every Infection Control and Prevention (IPAC) Committee
meeting for the survey period.
-
If and how IPAC Committee reviews all hospital policies and procedures.
-
If and how the IPAC Department in involved in the review of all
equipment and supplies used in the hospital.
-
How the hospital ensures that it is following best-practices to prevent
healthcare-associated infections – including, but not limited to, central
line-associated bloodstream infections (CLABSI), surgical site infections
(SSI), ventilator-associated pneumonia (VAP), and catheter-associated urinary
tract infections (CAUTI).
-
Rates for healthcare-associated infections and strategies to address
them.
-
Collaboration of the IPAC Department with Occupational Health to ensure
employee health and safety – and strategies to prevent the spread of infections
between patients and staff (or visa-versa).
-
Evaluation of the Occupational Health Department with respect to the
employee immunization program, fit testing, etc.
-
If the IPAC Department has a seat on, and active role in, the Employee
Safety Committee.
-
What strategies are in place to prevent the spread of multi-drug
resistant organisms between patients, or to employees.
-
Collaboration between the IPAC Department and Emergency Preparedness to
mitigate the risk to the hospital population from incidents involving
potentially infectious agents.
-
If the IPAC Department has a seat on, and active role in, the
“Environment of Care” Committee (U.S. term for the committee responsible for
review of all safety concerns involving the physical facilities, and which
conducts monthly surveys of the facility.)
-
Hand-on thorough examination of the reprocessing of reusable medical
equipment in the central reprocessing area and any point-of-care reprocessing.
-
Special attention is paid to the reprocessing of endoscopes - a device
with a camera (and sometimes instruments) to examine various internal body
parts.
-
The process for hospital staff and physicians to report any Infection
Control concerns – and how these are handled by the IPAC Department.
[Note: This is a not an
exhaustive list by any means.]
While a surveyor for Accreditation Canada could choose look
at these additional items, they are not part of the ROPs and therefore have
essentially no bearing on the accreditation process.
Examples of
significant omissions in recent Accreditation Canada surveys in Ontario:
1) Accreditation Canada completed a survey of a
hospital in the Toronto area.
- Within a month, the local
Public Health Department ordered the hospital to immediately cease using all
endoscopes and cited serious breaches in reprocessing and storage (specifically
related to scopes used for examining the digestive tract, colon, and
respiratory tract).
-
The hospital was cited for breaches in the central reprocessing area,
and for reprocessing done at the point-of-care.
-
How did Accreditation Canada miss that?!?
-
The Centers for Disease Control and Prevention (CDC) and the Ontario
Ministry of Health both consider adherence to best practices in the
reprocessing of endoscopes so importance that they created separate and
specific guidelines to address it – yet Accreditation Canada does not mention
it in their ROPs – nor apparently is it part of their surveys.
-
An out-patient centre in Ottawa was also cited by Ottawa Public Health
the previous year. This received
extensive coverage in the news – so it should have been fresh in the minds of
the Accreditation Canada surveyors at this Toronto area hospital.
(- This should make you wonder what else Accreditation Canada will miss
when they survey your local hospital.)
2) Elsewhere in Ontario, Accreditation Canada
completed a hospital survey and failed to note that bedpans and commode buckets
were being washed/reprocessed in soiled utility rooms at the point-of-care, and
without employees being provided or wearing proper personal protective
equipment (PPE).
-
Best practices for reprocessing of equipment that involves the potential
for aerosolization of blood, body fluids or other potentially infectious
material – state that the employee should wear appropriate gloves, full face
protection, and an impermeable gown or waterproof apron. Gloves must be long enough to cover their
wrists and forearms, and the rest of their arms also need to be covered by PPE.
-
Reusable bedpans and commode buckets should be reprocessed in a central
reprocessing area. (Disposable liners
are available for bedpans and commode buckets – so they do not have to be
reprocessed with each use for the same
patient.)
3) Why does Accreditation Canada not look at if
and how the hospital ensures that it is following best-practices to prevent
healthcare-associated infections – including, but not limited to, central
line-associated bloodstream infections (CLABSI), surgical site infections
(SSI), ventilator-associated pneumonia (VAP), and catheter-associated urinary
tract infections (CAUTI)?
-
Why are Safer Healthcare Now! best practices not listed as “Reference
Material” anywhere in the ROPs?
-
This topic was discussed at length
in the first post on this blog.
4) Accreditation Canada fails to review the
reprocessing procedures for commode chairs (as
discussed in the December 02, 2014 post on this blog) – and the storage of
clean commode chairs in soiled utility rooms – as these breaches occur in
numerous hospitals.
5) I have seen Accreditation Canada surveyors
walk under damaged and water-stained ceiling tiles without noticing.
-
Water damage has been linked to the spread of infection in healthcare
settings.
-
Hospitals should not only be replacing the tiles – but addressing the
problem that caused the damage.
-
Accreditation Canada should be noticing these tiles.
-
Accreditation Canada should be asking hospitals what their process is
for assessing for and dealing with this and other types of water damage.
-
Hospitals in Canada need to adopt the “Environment of Care” committees
used it hospitals in the United States and surveyed by the Joint Commission –
and Accreditation Canada needs to ensure that hospitals examine issues that
would be looked at by an “Environment of Care” committee (whether the hospital
chooses to create one by that name or
not).
6) Accreditation Canada ROPs requires at least
two patient identifiers before providing any service or procedure – yet some
hospitals have not changed the default setting on a commonly used ECG machine
which only asks for the patient’s name and age as patient identifiers. Age is not an acceptable patient-specific
identifier. Date-of-birth is. (I recall working in an Emergency Department
and having two patients who had the same name and were both born less than 12
months apart – so they would be the same age for part of the year.) Accreditation Canada has failed to notice
this.
-
Even though most ECG machines ask for the patient’s name and medical
record number, it is important to enter the date of birth in case the name is misspelled
or the medical number is entered incorrectly (which occurs often).
-
Some hospitals put a patient label or stamp the ECG with this
information, but it should be entered into the machine in case a label or stamp
is not applied (which also happens).
7) The Ontario Ministry of Health PIDAC best
practice guidelines (and those of other provinces) have specific requirements
for soiled utility room and clean equipment/supply rooms.
- Hospitals frequently have clean
supplies or equipment stored in soiled utility rooms.
-
Items are stored in cupboards under sinks (in clean or soilded utility rooms).
-
Clean supplies are placed on the floor in supply rooms. (Even boxes/cases need to be stored off the
floor).
-
These are common problems in hospitals, yet Accreditation Canada fails
to notice.
8) Accreditation Canada does not randomly audit,
nor do they ensure that hospitals audit, compliance with the “Do Not Use List”
of dangerous abbreviations as per their own ROP on the issue.
-
The Institute for Safe Medication Practices – Canada (ISMP – Canada)
publishes the list of Dangerous Abbreviations.
-
Many nurses, physicians, and allied health professionals routinely use
dangerous abbreviations in their orders and documentation.
-
[More on the ISMP Canada’s
Dangerous Abbreviations list in a later blog post.]
9) Some hospitals do not have a policy, nor make
it a practice to disinfect equipment before it is sent to the Maintenance
Department or Biomedical Engineering for repairs – thus contaminating those
areas and placing those employees at risk.
Accreditation Canada does not look at this.
10) All of the issues mentioned in the previous
two blog posts on this blog routinely go unnoticed by Accreditation Canada.
Where do we go
from here?
1) Accreditation Canada surveys need to be unannounced.
-
Since hospitals know in advance when the survey occurs, they coach their
staff, paint the walls, and effectively manage to temporarily change and/or hide
many of the aforementioned issues from the surveyors – yet these problems go
unaddressed for the remainder of the 4 year period in-between accreditation
visits.
-
Some of the aforementioned problems (and many others) would be noticed
by Accreditation Canada if the surveys were unannounced.
-
[Sidebar: Sadly, here in Ontario Public Health Department inspections (i.e.
commercial kitchens, Day Care centres, etc.) and Fire Marshall inspections are
also pre-scheduled.]
-
How can an Accreditation Canada survey (or any other inspection) be an
accurate reflection of the safe operating practices of an organization if that
organization knows in advance when to hide their poor practices?
-
In the United States, hospitals remain “Accreditation Ready” at all
times – as they do not know when The Joint Commission will walk through the
door.
2) I can already hear the calls of “We are not
the United States”.
-
Correct, we are not. But that
should not be an excuse of why we can be less diligent, but rather why we should
strive to be even better. Look at The
Joint Commission standards and rigorous surveys as something to aspire to – and then exceed!
3) Perhaps there needs to be the opportunity (or requirement) for
surveyors (and staff) at Accreditation Canada to accompany Joint Commission
surveyors on a survey.
4) Accreditation Canada needs to take more
control over the accreditation process and surveys – as hospitals are very skilled at
steering the process in the direction they want to go, and away from their
failures.
What can we do?
-
Write or e-mail Accreditation Canada and discuss the concerns mentioned
in this blog post.
-
Write or e-mail your Member or Parliament (MP). Member of Provincial
Parliament (MPP), and the federal and provincial Ministers of Health and
discuss the concerns mentioned in this blog post.
- Hospitals that are deficient in any of the areas mentioned in this
blog post need to address them - despite not being cited by Accreditation
Canada.
Links:
Accreditation Canada - http://www.accreditation.ca/
Accreditation Canada ROPs - http://www.accreditation.ca/sites/default/files/rop-handbook-2014-en.pdf
The Joint Commission - http://www.jointcommission.org/
The Joint Commission’s National Patient Safety Goals - http://www.jointcommission.org/assets/1/6/2015_NPSG_HAP.pdfThe Joint Commission’s Accountability Measures - http://www.jointcommission.org/assets/1/18/ACCOUNTABILITY_MEASURES_List_2014.pdf
The Joint Commission’s “Central Line-Associated Bloodstream Infection Toolkit and Monograph” - http://www.jointcommission.org/Topics/Clabsi_toolkit.aspx and
http://www.jointcommission.org/assets/1/18/CLABSI_Monograph.pdf
Government
of Ontario - Provincial Infectious Disease Advisory Committee (PIDAC): http://www.publichealthontario.ca/en/BrowseByTopic/InfectiousDiseases/PIDAC/Pages/PIDAC_Documents.aspx (Best Practice Documents.)
Public Health Agency of Canada’s “Routine Practices and
Additional Precautions for Preventing the Transmission of Infection in
Healthcare Settings” - http://publications.gc.ca/collections/collection_2013/aspc-phac/HP40-83-2013-eng.pdf
and
http://www.phac-aspc.gc.ca/nois-sinp/guide/summary-sommaire/tihs-tims-eng.php
Institute for Safe Medication Practices – Canada (ISMP – Canada) - http://www.ismp-canada.org/index.htm
ISMP- Canada’s Dangerous Abbreviations list - http://www.ismp-canada.org/download/ISMPCanadaListOfDangerousAbbreviations.pdf
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