ne Accreditation Survey Preparation And Preparedness Copyrights© Productivity & Quality Institute DR.MAGDY YOUSSEFProper planning is essential Knowing that the compliance with the standards will impose more : -— » Documentation, wl at a > Alot of communication with patients, > Reporting adverse events, > Introducing quality activities, » Changes in the practice, AGOAL WITHOUT A PLAN IS JUST A WISH All are additions to the routine work of the staff, which already is overwhelming, you need to plan carefully the implementation process. 2 Copyrights© Productivity & Quality Institute DR.MAGDY YOUSSEF1- Involve the leaders in the process oO Itis very important to gain the leadership commitment to the accreditation process. o Asuccessful way is making them members of the quality council that oversees the work of all committees. o Identify key leaders and managers to coordinate and oversee ongoing compliance and survey planning efforts. Copyrights© Productivity & Quality Institute DR.MAGDY YOUSSEF2- Plan to overcome Resistance Remember change brings with it resistance, and resistance is mostly due to fear, fear of the unknown. 2.1 Offer Support How to make the staff overcome their fear????? co Be with them in each and every activity they do to provide support and guidance. a In fact, usually the quality coordinators make most of the work at the beginning of the accreditation journey. oc Later, all the staff become active in the process. 4 Copyrights® Productivity & Quality Institute DR.MAGDY YOUSSEF2.2 Align staff objectives with hospital's objective a To overcome the huge resistance to change, make ita point to align their personal objectives with hospital's objective of accreditation. co Focus on awareness of staff personal benefits, what they will gain from the accreditation process. How much they will grow in knowledge, reaching in their practice the level of international standards, adding to their resume their experience in practicing in an accredited hospital etc. Copyrights© Productivity & Quality Institute DR.MAGDY YOUSSEF3- Educate, Educate, Educate 3.1 Educate your self to be able to lead the change To be able to support the staff through the accreditation process, you need to become an expert in the field, so start learning as much as you can about standards and the accreditation requirements. ay DUCATING OURSEL? Copyrights© Productivity & Quality Institute DR.MAGDY YOUSSEF3.2 Seek help and guidance- Do networking Make it a point to know as many people as possible who are experts in the field, as well as hospitals that were accredited . > Ask them for guidance and support > Ask them for some documents that the hospital’s committees find difficult to develop. Copyrights© Productivity & Quality Institute DR.MAGDY YOUSSEF3.3 Educate your staff a Provide Intensive training to the quality staff and some of the staff that volunteer to become quality coordinators/facilitators in their departments. a Then allocate them as secretaries for the committees working on standards’ implementation. This helps to facilitate the work of the teams and to follow the implementation. Copyrights© Productivity & Quality Institute DR.MAGDY YOUSSEF3.4 Educate all staff « Start with the leadership. Leadership is prime. Then go down to the supervisory level + Then involve all staff through continuous intensive training on quality improvement principles and tools, the compliance with the standards, and the tracer methodology. Copyrights© Productivity & Quality Institute DR.MAGDY YOUSSEF10 4- Involve as many of the staff as possible in the process Start by assigning each chapter to a committee to develop the required policies and processes and oversee the implementation of that chapter. The committees need to be interdisciplinary, with a quality coordinator attached to each committee for guidance and follow up. Involve a medical/professional staff, or medical group team of clinical leaders who will be in authority at the time of the survey or will be required to participate as medical directors, department chairs Copyrights© Productivity & Quality Institute DR.MAGDY YOUSSEF5- Monitor the implementation process a Perform audits and clinical reviews and introduce indicators to monitor the implementation process. a Provide feedback on continuous basis to the departments and teams. Gap Analysis A a2 O es factor tr ee Garrent ‘Sore 11 Copyrights© Productivity & Quality Institute DR.MAGDY YOUSSEF6- Encourage competition = Make sure to publish successes, achievements, and improvement projects on continuous basis no matter how small they are. = Publish the results on the intranet, in the quality bulletin, in the general staff meetings, etc. Present them in graphs that compare the achievements of the different departments = Reward Teams and individuals in public such as in the general staff meetings. = Identify best practices in your hospital and request the concerned 12 teams to share their experience with the rest of the departments. Copyrights© Productivity & Quality Institute DR.MAGDY YOUSSEF13 7- Perform self Assessment Oo Developed your own tracers, this is an excellent tool for educating the staff on the requirements and monitoring the hospital progress in relation to standards’ compliance. 0 Try to involve as many staff as possible, from different disciplines, in the preparation of the tracers as well as the execution. c Provide a feedback on the findings to the concerned departments. Copyrights© Productivity & Quality Institute DR.MAGDY YOUSSEF8- Mock survey = The mock survey six months prior to accreditation survey and may serve as the final checkpoint in readiness. = Simulation of the actual survey process and identify gaps in standards compliance. = This intensive exercise is an ideal opportunity to engage senior leaders and prepare staff for the actual survey I 14 Copyrights© Productivity & Quality Institute DR.MAGDY YOUSSEF15 9- Be ready and organized for the survey Oo Read Hospital Survey Process Guide. Prepare all the required policies in a file. Keep all the required plans in another file. This is important for the document review sessions. Organize your staff so that each knows his role in this process Copyrights© Productivity & Quality Institute DR.MAGDY YOUSSEF16 Can you do it??? Yes, Yes, Yes, You Can! If others could do it, you canlll Good Luck Copyrights© Productivity & Quality Institute DR.MAGDY YOUSSEF