| Mapping to ‘knowledge to action cycle’ . | Accreditation body program elements . | Description of client actions and rationale . |
|---|---|---|
| Knowledge/standards creation | ||
| ‘Knowledge/standards’ KT goal: to identify the knowledge to be implemented to optimize quality of care and patient safety. | Standards synthesize the best available evidence and expert opinion to offer guidance on how to enable quality improvement, mitigate safety risks and improve quality. These standards are reviewed regularly to ensure they are reflective of the current evidence. | The client organization implements or attempts to implement these standards on a regular basis, at minimum 1 year prior to the on-site survey visit. The currency and evidence-informed nature of the standards support the client organization in achieving their goal of keeping practices and decision-making current. |
| ‘Knowledge tools/products’ KT goal: to provide resources to facilitate meeting accreditation requirements and to encourage engagement with phases of the action cycle. | Specific assessment tools such as a staff engagement survey and/or a patient safety culture survey may be required which are utilized by the client organization on a cyclic basis. The results contribute toward identifying achievement of a particular standard criterion. These tools are often embedded in the accreditation body’s software that is made available to all client organizations. | The survey tools are of value to the client organization in that the results can be used, even in isolation from the standards assessment, to identify areas of strength or deficiency requiring an action plan. The tools could be reapplied at an appropriate interval to determine if change has occurred in the desired direction. |
| Action Phases | ||
| ‘Determine the standards/practice–achievement gap’ KT goal: to determine gaps between the standards and current practice–achievement so as to quantify the need for improvement. This information can be used to promote organizational consensus on the need to act to reduce the gap. | The accreditation body encourages the client organization to conduct a self-assessment against the standards. The purpose of this exercise is to enable identification of areas of strength and areas for improvement. The survey tools facilitate in identifying areas of strength and areas for improvement further strengthening the assessment of performance against a particular standard. The accreditation body organizes an on-site survey visit, conducted by surveyors carefully selected for their expertise and training, which is a vital component of their third-party external review process. The surveyors use different methodologies depending on the accreditation body’s program. At minimum it includes that surveyors visit the client organization in person to gather evidence of current practice which they can compare to the practice described in the standards. During the on-site visit, surveyors may interview the board, leadership, staff, patients, their families and key stakeholders in the community. The surveyors observe the environment, staff interactions and review documentation in the health record and policies. During discussion with individuals, the surveyors may provide feedback and evidence back to each team to encourage their practice going forward, reinforce those areas requiring improvement and share their own expertise. | The client organization conducts the self-assessment to determine the degree to which they achieve a particular standard and the specific criteria within the standard. This process enables their identification of performance relative to the standard and areas in which there are opportunities for improvement, as well as organizational readiness for change. The identified areas for improvement then become the focus of the client organization’s quality improvement action plan to address areas needing improvement. It is the decision of the client organization as to how the self-assessment process is conducted—whether an entire team collectively completes the assessment or whether a designated person does this on behalf of the team. Depending on the information technology resources of the client organization, the exercise may be conducted ‘online’ or manually on paper and then entered into the accreditation body’s software program. The survey instruments (e.g. staff engagement, patient safety culture) generally require involvement of staff, individually or as a team. In addition to providing useful results in identifying areas of strength and areas of improvement, the process contributes to team building. The client organization prepares for the on-site visit to ensure all necessary information is available for the surveyors, including availability of teams to be interviewed and preparation to enable observation of care/service being provided (e.g. surgery in the OR, a clinic as patients receive treatment). The recipients of care are available to speak with a surveyor when required while at all times maintaining anonymity and confidentiality to the degree necessary. Copies of health records are made available as appropriate. |
| ‘Customize operationalization of standards to local context’ KT goal: to adapt and customize the operationalization of the standard to foster organizational buy-in and contribute to optimal implementation of standards tailored to organizational needs. | While the standards are set and somewhat prescriptive, the accreditation body encourages the client organizations to review and develop an implementation strategy that is relevant to their own context. While standards outline a particular desired practice or result, the means by which this is achieved, the “how”, is the decision of the client organization. | The client organization has the responsibility to carefully assess each standard and determine how best to implement/achieve the standards within their own context. Every client organization’s structure, patient population, staffing arrangement and resource availability is different. There are unique elements in every client organization’s milieu. |
| ‘Assess barriers/facilitators to standards use’ KT goal: to identify potential barriers (and facilitators) to implementing the standards. This information can be used to more strategically to select implementation strategies explicitly targeting the barriers, thereby improving implementation success. | The self-assessment process enables the identification of the degree to which a standard is being achieved, identification of gaps or areas for improvement and in some cases identification of barriers to uptake of the particular standards. Furthermore, during the site visit, the surveyors may further identify barriers and offer suggestions for effective strategies for overcoming the identified barriers. These suggestions may be included in the final accreditation report. For example, a standard may require that a hand-washing procedure is in place, with evidence of its effectiveness. How that procedure is designed and implemented is the decision of the client organization. Throughout this design period and then assessment of its effectiveness after implementation, barriers and facilitators to the process are identified and adjustments made in order to obtain the optimum result for the client organization, their patients and staff. | Carefully reviewing each standard and then adapting the implementation to apply to their context are critical components from the beginning of the self-assessment process to the development of the quality improvement action plan. The client organization identifies those factors that are barriers and facilitators and indicates how they will be addressed in the action or implementation plan. Thus, if the standard requires an annual board evaluation, the type of tool utilized, the content, the means of administration, steps taken to analyze and actions taken to address the results lie with the client organization. Barriers to undertaking this exercise must be considered as well as those factors that will facilitate achieving this standard. Once the strategy is implemented, monitoring its effectiveness is important as is making corrections to the strategy as necessary to enable buy-in and achievement of the goal. |
| ‘Select, tailor and activate implementation strategies (the action plan)’ KT goal: to tailor implementation strategies to the identified barriers so as to increase implementation success. | The implementation strategy or quality improvement action plan that is developed by teams during the self-assessment process is the responsibility of the client organization—both to implement and monitor progress. Most accreditation bodies require that progress on this plan is provided back to them on a regular basis, e.g. every 6 months or annually. The accreditation report that is given to the organization post the on-site visit reinforces the actions that are required and assists in the determination of priorities for action. Other implementation strategies supported by accreditation bodies include providing education and training based on the learning needs of the client organization. Given the wealth of information that is obtained both online and during the on-site visit, many accreditation bodies are creating a ‘library’ of best or leading implementation practices that is accessible to all client organizations. The accreditation body develops eligibility criteria against which to assess if a strategy indeed qualifies as a best or leading practice (e.g. clinical, service, governance/leadership). | The quality improvement action plan is unique to each client organization and should ideally consider identified barriers to implementing the standards and identify how selected implementation strategies will address the barriers. There are many different implementation strategies to achieve uptake of a particular standard/criterion. Client organizations are encouraged to identify those strategies most relevant to them, optimizing buy-ins and results. Teams together develop these plans. The accreditation report is a useful tool for the client organization, confirming areas important to focus actions. Within the specified timeframes as to when reports should be provided to the accreditation body, the client organization’s implementation strategies are developed, monitored and assessed accordingly. The sharing of ‘leading or best practices’ between organizations is a major benefit for all client organizations. Rather than ‘reinventing the wheel’ to identify a strategy to meet a particular standard, reviewing what other client organizations have considered is very helpful. The client organization may then contact the ‘owner’ of that leading practice, seek advice and then consider and/or adapt that practice to their own setting, or choose to reject it. |
| ‘Monitor use of the standards’ KT goal: to determine the extent to which the organization is adhering to the standards so that the organization can assess its performance against the desired practice (the standard). The monitoring of indicators serves as a mechanism to ensure/facilitate that users’ knowledge and practice are ‘keeping pace’. | The standards may identify specific indicators that should be monitored to allow assessment of performance toward meeting the standards. Monitoring of strategic and operational indicators/performance measures occurs in all organizations. Utilizing the specific indicators that may be identified by the accreditation body provides further direction to confirm priority areas for monitoring. The accreditation bodies establish a mechanism with the client organizations to have regular contact throughout the accreditation cycle. Generally, following the receipt of the accreditation report, it is required that there be a 6-month report, an annual report or something similar. This ongoing monitoring of compliance and ongoing assessment of implementation of the action plan are critical components of the accreditation process. The goal is that accreditation is not a onetime event but an ongoing cycle, with an expectation of ongoing assessment of compliance with the standards, implementation of action plans, ongoing monitoring and continuing to improve care and services. At minimum, there is an expectation to receive a report, online or hard copy, at regular intervals of progress with the action plans. | The client organization has a responsibility to follow through on the implementation of the quality improvement action plan that results from the survey process. A sincere commitment by the organization to value this process is fundamental to its success and to having maximum impact on quality of care. Monitoring of strategic and operational indicators/performance measures occurs in all organizations. Utilizing specific indicators identified by the accreditation body provides further direction to confirm priority areas for monitoring and are used to determine adherence to the standards. The client organization recognizes that accreditation is a major quality improvement tool that complements other quality improvement strategies within their organization, e.g. LEAN, Six Sigma, etc. The client organization’s overall quality improvement plan at a strategic level acknowledges how these initiatives comprehensively integrate to enable improvement of care and services, from the governance level to the point of care. |
| ‘Evaluate outcome/impact’ KT goal: to determine the extent to which adherence to the standards translate into improved health outcomes or health system outcomes. This information can further motivate maintaining adherence to the standards and to celebrate organizational achievements. | As the primary goal of accreditation is to improve quality and safety, requirements to report on specific outcomes or specific clinical indicators may not be required by accreditation bodies. However, one of the key goals of accreditation is to provide an organization with tools that enable resilience. The content of the standards focuses on quality improvement and the prevention or mitigation of risk. If an adverse event arises, the organization knows how to learn from the event, recover and continue improving. Thus, accreditation does not guarantee quality of care but demonstrates accountability that the organization is focused on improvement and meeting evidence-based standards. | If outcomes of adherence to standards are collected, client organizations can use this information to justify implementing the standards, demonstrate to the community how they improve patient health outcomes and better demonstrate the value of money invested in healthcare. The challenge, however, is that the standard alone does not directly improve outcomes. Factors such as the knowledge and expertise of the ‘user’, patient behaviors and resource availability combine to enable the desired outcome. |
| ‘Sustain use of standards’ KT goal: to continue to focus the organization on maintaining adherence to the standard and maintaining quality and patient safety. If declines in adherence are observed, the organization can double efforts to identify barriers to ongoing use of the standards and institute more/different implementation strategies (starting the knowledge to action cycle over again). | If the accreditation body becomes concerned about the performance of the client organization, i.e. that insufficient attention is being paid to areas of concerns/deficiencies, or perhaps significant complaints from the public have been received by the accreditation body, mechanisms are in place to send a surveyor to the organization mid-cycle. Similar strategies can also be undertaken to identify problems and suggest improvements. This relationship is critical and an important part of the accreditation process. It provides support and assists with quality improvement and the implementation of recommendations. From one on-site visit to the next, the ongoing relationship with the client organization is sustained. Additional education and training are provided as appropriate to the client organization and its needs. Ongoing monitoring of performance is critical to sustaining standards use. | Client organizations are encouraged to use the standards in an ongoing way, perhaps to annually review the relevant standards. For example, the Emergency Department team should review the standards for emergency care annually, conduct a self-assessment and continuously monitor adherence to the standards. Are any new deficiencies identified? If the standard has been updated since previously utilized, there may be new important knowledge/practices to consider and be included in the quality improvement plan, including mechanisms to monitor progress. |
| Mapping to ‘knowledge to action cycle’ . | Accreditation body program elements . | Description of client actions and rationale . |
|---|---|---|
| Knowledge/standards creation | ||
| ‘Knowledge/standards’ KT goal: to identify the knowledge to be implemented to optimize quality of care and patient safety. | Standards synthesize the best available evidence and expert opinion to offer guidance on how to enable quality improvement, mitigate safety risks and improve quality. These standards are reviewed regularly to ensure they are reflective of the current evidence. | The client organization implements or attempts to implement these standards on a regular basis, at minimum 1 year prior to the on-site survey visit. The currency and evidence-informed nature of the standards support the client organization in achieving their goal of keeping practices and decision-making current. |
| ‘Knowledge tools/products’ KT goal: to provide resources to facilitate meeting accreditation requirements and to encourage engagement with phases of the action cycle. | Specific assessment tools such as a staff engagement survey and/or a patient safety culture survey may be required which are utilized by the client organization on a cyclic basis. The results contribute toward identifying achievement of a particular standard criterion. These tools are often embedded in the accreditation body’s software that is made available to all client organizations. | The survey tools are of value to the client organization in that the results can be used, even in isolation from the standards assessment, to identify areas of strength or deficiency requiring an action plan. The tools could be reapplied at an appropriate interval to determine if change has occurred in the desired direction. |
| Action Phases | ||
| ‘Determine the standards/practice–achievement gap’ KT goal: to determine gaps between the standards and current practice–achievement so as to quantify the need for improvement. This information can be used to promote organizational consensus on the need to act to reduce the gap. | The accreditation body encourages the client organization to conduct a self-assessment against the standards. The purpose of this exercise is to enable identification of areas of strength and areas for improvement. The survey tools facilitate in identifying areas of strength and areas for improvement further strengthening the assessment of performance against a particular standard. The accreditation body organizes an on-site survey visit, conducted by surveyors carefully selected for their expertise and training, which is a vital component of their third-party external review process. The surveyors use different methodologies depending on the accreditation body’s program. At minimum it includes that surveyors visit the client organization in person to gather evidence of current practice which they can compare to the practice described in the standards. During the on-site visit, surveyors may interview the board, leadership, staff, patients, their families and key stakeholders in the community. The surveyors observe the environment, staff interactions and review documentation in the health record and policies. During discussion with individuals, the surveyors may provide feedback and evidence back to each team to encourage their practice going forward, reinforce those areas requiring improvement and share their own expertise. | The client organization conducts the self-assessment to determine the degree to which they achieve a particular standard and the specific criteria within the standard. This process enables their identification of performance relative to the standard and areas in which there are opportunities for improvement, as well as organizational readiness for change. The identified areas for improvement then become the focus of the client organization’s quality improvement action plan to address areas needing improvement. It is the decision of the client organization as to how the self-assessment process is conducted—whether an entire team collectively completes the assessment or whether a designated person does this on behalf of the team. Depending on the information technology resources of the client organization, the exercise may be conducted ‘online’ or manually on paper and then entered into the accreditation body’s software program. The survey instruments (e.g. staff engagement, patient safety culture) generally require involvement of staff, individually or as a team. In addition to providing useful results in identifying areas of strength and areas of improvement, the process contributes to team building. The client organization prepares for the on-site visit to ensure all necessary information is available for the surveyors, including availability of teams to be interviewed and preparation to enable observation of care/service being provided (e.g. surgery in the OR, a clinic as patients receive treatment). The recipients of care are available to speak with a surveyor when required while at all times maintaining anonymity and confidentiality to the degree necessary. Copies of health records are made available as appropriate. |
| ‘Customize operationalization of standards to local context’ KT goal: to adapt and customize the operationalization of the standard to foster organizational buy-in and contribute to optimal implementation of standards tailored to organizational needs. | While the standards are set and somewhat prescriptive, the accreditation body encourages the client organizations to review and develop an implementation strategy that is relevant to their own context. While standards outline a particular desired practice or result, the means by which this is achieved, the “how”, is the decision of the client organization. | The client organization has the responsibility to carefully assess each standard and determine how best to implement/achieve the standards within their own context. Every client organization’s structure, patient population, staffing arrangement and resource availability is different. There are unique elements in every client organization’s milieu. |
| ‘Assess barriers/facilitators to standards use’ KT goal: to identify potential barriers (and facilitators) to implementing the standards. This information can be used to more strategically to select implementation strategies explicitly targeting the barriers, thereby improving implementation success. | The self-assessment process enables the identification of the degree to which a standard is being achieved, identification of gaps or areas for improvement and in some cases identification of barriers to uptake of the particular standards. Furthermore, during the site visit, the surveyors may further identify barriers and offer suggestions for effective strategies for overcoming the identified barriers. These suggestions may be included in the final accreditation report. For example, a standard may require that a hand-washing procedure is in place, with evidence of its effectiveness. How that procedure is designed and implemented is the decision of the client organization. Throughout this design period and then assessment of its effectiveness after implementation, barriers and facilitators to the process are identified and adjustments made in order to obtain the optimum result for the client organization, their patients and staff. | Carefully reviewing each standard and then adapting the implementation to apply to their context are critical components from the beginning of the self-assessment process to the development of the quality improvement action plan. The client organization identifies those factors that are barriers and facilitators and indicates how they will be addressed in the action or implementation plan. Thus, if the standard requires an annual board evaluation, the type of tool utilized, the content, the means of administration, steps taken to analyze and actions taken to address the results lie with the client organization. Barriers to undertaking this exercise must be considered as well as those factors that will facilitate achieving this standard. Once the strategy is implemented, monitoring its effectiveness is important as is making corrections to the strategy as necessary to enable buy-in and achievement of the goal. |
| ‘Select, tailor and activate implementation strategies (the action plan)’ KT goal: to tailor implementation strategies to the identified barriers so as to increase implementation success. | The implementation strategy or quality improvement action plan that is developed by teams during the self-assessment process is the responsibility of the client organization—both to implement and monitor progress. Most accreditation bodies require that progress on this plan is provided back to them on a regular basis, e.g. every 6 months or annually. The accreditation report that is given to the organization post the on-site visit reinforces the actions that are required and assists in the determination of priorities for action. Other implementation strategies supported by accreditation bodies include providing education and training based on the learning needs of the client organization. Given the wealth of information that is obtained both online and during the on-site visit, many accreditation bodies are creating a ‘library’ of best or leading implementation practices that is accessible to all client organizations. The accreditation body develops eligibility criteria against which to assess if a strategy indeed qualifies as a best or leading practice (e.g. clinical, service, governance/leadership). | The quality improvement action plan is unique to each client organization and should ideally consider identified barriers to implementing the standards and identify how selected implementation strategies will address the barriers. There are many different implementation strategies to achieve uptake of a particular standard/criterion. Client organizations are encouraged to identify those strategies most relevant to them, optimizing buy-ins and results. Teams together develop these plans. The accreditation report is a useful tool for the client organization, confirming areas important to focus actions. Within the specified timeframes as to when reports should be provided to the accreditation body, the client organization’s implementation strategies are developed, monitored and assessed accordingly. The sharing of ‘leading or best practices’ between organizations is a major benefit for all client organizations. Rather than ‘reinventing the wheel’ to identify a strategy to meet a particular standard, reviewing what other client organizations have considered is very helpful. The client organization may then contact the ‘owner’ of that leading practice, seek advice and then consider and/or adapt that practice to their own setting, or choose to reject it. |
| ‘Monitor use of the standards’ KT goal: to determine the extent to which the organization is adhering to the standards so that the organization can assess its performance against the desired practice (the standard). The monitoring of indicators serves as a mechanism to ensure/facilitate that users’ knowledge and practice are ‘keeping pace’. | The standards may identify specific indicators that should be monitored to allow assessment of performance toward meeting the standards. Monitoring of strategic and operational indicators/performance measures occurs in all organizations. Utilizing the specific indicators that may be identified by the accreditation body provides further direction to confirm priority areas for monitoring. The accreditation bodies establish a mechanism with the client organizations to have regular contact throughout the accreditation cycle. Generally, following the receipt of the accreditation report, it is required that there be a 6-month report, an annual report or something similar. This ongoing monitoring of compliance and ongoing assessment of implementation of the action plan are critical components of the accreditation process. The goal is that accreditation is not a onetime event but an ongoing cycle, with an expectation of ongoing assessment of compliance with the standards, implementation of action plans, ongoing monitoring and continuing to improve care and services. At minimum, there is an expectation to receive a report, online or hard copy, at regular intervals of progress with the action plans. | The client organization has a responsibility to follow through on the implementation of the quality improvement action plan that results from the survey process. A sincere commitment by the organization to value this process is fundamental to its success and to having maximum impact on quality of care. Monitoring of strategic and operational indicators/performance measures occurs in all organizations. Utilizing specific indicators identified by the accreditation body provides further direction to confirm priority areas for monitoring and are used to determine adherence to the standards. The client organization recognizes that accreditation is a major quality improvement tool that complements other quality improvement strategies within their organization, e.g. LEAN, Six Sigma, etc. The client organization’s overall quality improvement plan at a strategic level acknowledges how these initiatives comprehensively integrate to enable improvement of care and services, from the governance level to the point of care. |
| ‘Evaluate outcome/impact’ KT goal: to determine the extent to which adherence to the standards translate into improved health outcomes or health system outcomes. This information can further motivate maintaining adherence to the standards and to celebrate organizational achievements. | As the primary goal of accreditation is to improve quality and safety, requirements to report on specific outcomes or specific clinical indicators may not be required by accreditation bodies. However, one of the key goals of accreditation is to provide an organization with tools that enable resilience. The content of the standards focuses on quality improvement and the prevention or mitigation of risk. If an adverse event arises, the organization knows how to learn from the event, recover and continue improving. Thus, accreditation does not guarantee quality of care but demonstrates accountability that the organization is focused on improvement and meeting evidence-based standards. | If outcomes of adherence to standards are collected, client organizations can use this information to justify implementing the standards, demonstrate to the community how they improve patient health outcomes and better demonstrate the value of money invested in healthcare. The challenge, however, is that the standard alone does not directly improve outcomes. Factors such as the knowledge and expertise of the ‘user’, patient behaviors and resource availability combine to enable the desired outcome. |
| ‘Sustain use of standards’ KT goal: to continue to focus the organization on maintaining adherence to the standard and maintaining quality and patient safety. If declines in adherence are observed, the organization can double efforts to identify barriers to ongoing use of the standards and institute more/different implementation strategies (starting the knowledge to action cycle over again). | If the accreditation body becomes concerned about the performance of the client organization, i.e. that insufficient attention is being paid to areas of concerns/deficiencies, or perhaps significant complaints from the public have been received by the accreditation body, mechanisms are in place to send a surveyor to the organization mid-cycle. Similar strategies can also be undertaken to identify problems and suggest improvements. This relationship is critical and an important part of the accreditation process. It provides support and assists with quality improvement and the implementation of recommendations. From one on-site visit to the next, the ongoing relationship with the client organization is sustained. Additional education and training are provided as appropriate to the client organization and its needs. Ongoing monitoring of performance is critical to sustaining standards use. | Client organizations are encouraged to use the standards in an ongoing way, perhaps to annually review the relevant standards. For example, the Emergency Department team should review the standards for emergency care annually, conduct a self-assessment and continuously monitor adherence to the standards. Are any new deficiencies identified? If the standard has been updated since previously utilized, there may be new important knowledge/practices to consider and be included in the quality improvement plan, including mechanisms to monitor progress. |
| Mapping to ‘knowledge to action cycle’ . | Accreditation body program elements . | Description of client actions and rationale . |
|---|---|---|
| Knowledge/standards creation | ||
| ‘Knowledge/standards’ KT goal: to identify the knowledge to be implemented to optimize quality of care and patient safety. | Standards synthesize the best available evidence and expert opinion to offer guidance on how to enable quality improvement, mitigate safety risks and improve quality. These standards are reviewed regularly to ensure they are reflective of the current evidence. | The client organization implements or attempts to implement these standards on a regular basis, at minimum 1 year prior to the on-site survey visit. The currency and evidence-informed nature of the standards support the client organization in achieving their goal of keeping practices and decision-making current. |
| ‘Knowledge tools/products’ KT goal: to provide resources to facilitate meeting accreditation requirements and to encourage engagement with phases of the action cycle. | Specific assessment tools such as a staff engagement survey and/or a patient safety culture survey may be required which are utilized by the client organization on a cyclic basis. The results contribute toward identifying achievement of a particular standard criterion. These tools are often embedded in the accreditation body’s software that is made available to all client organizations. | The survey tools are of value to the client organization in that the results can be used, even in isolation from the standards assessment, to identify areas of strength or deficiency requiring an action plan. The tools could be reapplied at an appropriate interval to determine if change has occurred in the desired direction. |
| Action Phases | ||
| ‘Determine the standards/practice–achievement gap’ KT goal: to determine gaps between the standards and current practice–achievement so as to quantify the need for improvement. This information can be used to promote organizational consensus on the need to act to reduce the gap. | The accreditation body encourages the client organization to conduct a self-assessment against the standards. The purpose of this exercise is to enable identification of areas of strength and areas for improvement. The survey tools facilitate in identifying areas of strength and areas for improvement further strengthening the assessment of performance against a particular standard. The accreditation body organizes an on-site survey visit, conducted by surveyors carefully selected for their expertise and training, which is a vital component of their third-party external review process. The surveyors use different methodologies depending on the accreditation body’s program. At minimum it includes that surveyors visit the client organization in person to gather evidence of current practice which they can compare to the practice described in the standards. During the on-site visit, surveyors may interview the board, leadership, staff, patients, their families and key stakeholders in the community. The surveyors observe the environment, staff interactions and review documentation in the health record and policies. During discussion with individuals, the surveyors may provide feedback and evidence back to each team to encourage their practice going forward, reinforce those areas requiring improvement and share their own expertise. | The client organization conducts the self-assessment to determine the degree to which they achieve a particular standard and the specific criteria within the standard. This process enables their identification of performance relative to the standard and areas in which there are opportunities for improvement, as well as organizational readiness for change. The identified areas for improvement then become the focus of the client organization’s quality improvement action plan to address areas needing improvement. It is the decision of the client organization as to how the self-assessment process is conducted—whether an entire team collectively completes the assessment or whether a designated person does this on behalf of the team. Depending on the information technology resources of the client organization, the exercise may be conducted ‘online’ or manually on paper and then entered into the accreditation body’s software program. The survey instruments (e.g. staff engagement, patient safety culture) generally require involvement of staff, individually or as a team. In addition to providing useful results in identifying areas of strength and areas of improvement, the process contributes to team building. The client organization prepares for the on-site visit to ensure all necessary information is available for the surveyors, including availability of teams to be interviewed and preparation to enable observation of care/service being provided (e.g. surgery in the OR, a clinic as patients receive treatment). The recipients of care are available to speak with a surveyor when required while at all times maintaining anonymity and confidentiality to the degree necessary. Copies of health records are made available as appropriate. |
| ‘Customize operationalization of standards to local context’ KT goal: to adapt and customize the operationalization of the standard to foster organizational buy-in and contribute to optimal implementation of standards tailored to organizational needs. | While the standards are set and somewhat prescriptive, the accreditation body encourages the client organizations to review and develop an implementation strategy that is relevant to their own context. While standards outline a particular desired practice or result, the means by which this is achieved, the “how”, is the decision of the client organization. | The client organization has the responsibility to carefully assess each standard and determine how best to implement/achieve the standards within their own context. Every client organization’s structure, patient population, staffing arrangement and resource availability is different. There are unique elements in every client organization’s milieu. |
| ‘Assess barriers/facilitators to standards use’ KT goal: to identify potential barriers (and facilitators) to implementing the standards. This information can be used to more strategically to select implementation strategies explicitly targeting the barriers, thereby improving implementation success. | The self-assessment process enables the identification of the degree to which a standard is being achieved, identification of gaps or areas for improvement and in some cases identification of barriers to uptake of the particular standards. Furthermore, during the site visit, the surveyors may further identify barriers and offer suggestions for effective strategies for overcoming the identified barriers. These suggestions may be included in the final accreditation report. For example, a standard may require that a hand-washing procedure is in place, with evidence of its effectiveness. How that procedure is designed and implemented is the decision of the client organization. Throughout this design period and then assessment of its effectiveness after implementation, barriers and facilitators to the process are identified and adjustments made in order to obtain the optimum result for the client organization, their patients and staff. | Carefully reviewing each standard and then adapting the implementation to apply to their context are critical components from the beginning of the self-assessment process to the development of the quality improvement action plan. The client organization identifies those factors that are barriers and facilitators and indicates how they will be addressed in the action or implementation plan. Thus, if the standard requires an annual board evaluation, the type of tool utilized, the content, the means of administration, steps taken to analyze and actions taken to address the results lie with the client organization. Barriers to undertaking this exercise must be considered as well as those factors that will facilitate achieving this standard. Once the strategy is implemented, monitoring its effectiveness is important as is making corrections to the strategy as necessary to enable buy-in and achievement of the goal. |
| ‘Select, tailor and activate implementation strategies (the action plan)’ KT goal: to tailor implementation strategies to the identified barriers so as to increase implementation success. | The implementation strategy or quality improvement action plan that is developed by teams during the self-assessment process is the responsibility of the client organization—both to implement and monitor progress. Most accreditation bodies require that progress on this plan is provided back to them on a regular basis, e.g. every 6 months or annually. The accreditation report that is given to the organization post the on-site visit reinforces the actions that are required and assists in the determination of priorities for action. Other implementation strategies supported by accreditation bodies include providing education and training based on the learning needs of the client organization. Given the wealth of information that is obtained both online and during the on-site visit, many accreditation bodies are creating a ‘library’ of best or leading implementation practices that is accessible to all client organizations. The accreditation body develops eligibility criteria against which to assess if a strategy indeed qualifies as a best or leading practice (e.g. clinical, service, governance/leadership). | The quality improvement action plan is unique to each client organization and should ideally consider identified barriers to implementing the standards and identify how selected implementation strategies will address the barriers. There are many different implementation strategies to achieve uptake of a particular standard/criterion. Client organizations are encouraged to identify those strategies most relevant to them, optimizing buy-ins and results. Teams together develop these plans. The accreditation report is a useful tool for the client organization, confirming areas important to focus actions. Within the specified timeframes as to when reports should be provided to the accreditation body, the client organization’s implementation strategies are developed, monitored and assessed accordingly. The sharing of ‘leading or best practices’ between organizations is a major benefit for all client organizations. Rather than ‘reinventing the wheel’ to identify a strategy to meet a particular standard, reviewing what other client organizations have considered is very helpful. The client organization may then contact the ‘owner’ of that leading practice, seek advice and then consider and/or adapt that practice to their own setting, or choose to reject it. |
| ‘Monitor use of the standards’ KT goal: to determine the extent to which the organization is adhering to the standards so that the organization can assess its performance against the desired practice (the standard). The monitoring of indicators serves as a mechanism to ensure/facilitate that users’ knowledge and practice are ‘keeping pace’. | The standards may identify specific indicators that should be monitored to allow assessment of performance toward meeting the standards. Monitoring of strategic and operational indicators/performance measures occurs in all organizations. Utilizing the specific indicators that may be identified by the accreditation body provides further direction to confirm priority areas for monitoring. The accreditation bodies establish a mechanism with the client organizations to have regular contact throughout the accreditation cycle. Generally, following the receipt of the accreditation report, it is required that there be a 6-month report, an annual report or something similar. This ongoing monitoring of compliance and ongoing assessment of implementation of the action plan are critical components of the accreditation process. The goal is that accreditation is not a onetime event but an ongoing cycle, with an expectation of ongoing assessment of compliance with the standards, implementation of action plans, ongoing monitoring and continuing to improve care and services. At minimum, there is an expectation to receive a report, online or hard copy, at regular intervals of progress with the action plans. | The client organization has a responsibility to follow through on the implementation of the quality improvement action plan that results from the survey process. A sincere commitment by the organization to value this process is fundamental to its success and to having maximum impact on quality of care. Monitoring of strategic and operational indicators/performance measures occurs in all organizations. Utilizing specific indicators identified by the accreditation body provides further direction to confirm priority areas for monitoring and are used to determine adherence to the standards. The client organization recognizes that accreditation is a major quality improvement tool that complements other quality improvement strategies within their organization, e.g. LEAN, Six Sigma, etc. The client organization’s overall quality improvement plan at a strategic level acknowledges how these initiatives comprehensively integrate to enable improvement of care and services, from the governance level to the point of care. |
| ‘Evaluate outcome/impact’ KT goal: to determine the extent to which adherence to the standards translate into improved health outcomes or health system outcomes. This information can further motivate maintaining adherence to the standards and to celebrate organizational achievements. | As the primary goal of accreditation is to improve quality and safety, requirements to report on specific outcomes or specific clinical indicators may not be required by accreditation bodies. However, one of the key goals of accreditation is to provide an organization with tools that enable resilience. The content of the standards focuses on quality improvement and the prevention or mitigation of risk. If an adverse event arises, the organization knows how to learn from the event, recover and continue improving. Thus, accreditation does not guarantee quality of care but demonstrates accountability that the organization is focused on improvement and meeting evidence-based standards. | If outcomes of adherence to standards are collected, client organizations can use this information to justify implementing the standards, demonstrate to the community how they improve patient health outcomes and better demonstrate the value of money invested in healthcare. The challenge, however, is that the standard alone does not directly improve outcomes. Factors such as the knowledge and expertise of the ‘user’, patient behaviors and resource availability combine to enable the desired outcome. |
| ‘Sustain use of standards’ KT goal: to continue to focus the organization on maintaining adherence to the standard and maintaining quality and patient safety. If declines in adherence are observed, the organization can double efforts to identify barriers to ongoing use of the standards and institute more/different implementation strategies (starting the knowledge to action cycle over again). | If the accreditation body becomes concerned about the performance of the client organization, i.e. that insufficient attention is being paid to areas of concerns/deficiencies, or perhaps significant complaints from the public have been received by the accreditation body, mechanisms are in place to send a surveyor to the organization mid-cycle. Similar strategies can also be undertaken to identify problems and suggest improvements. This relationship is critical and an important part of the accreditation process. It provides support and assists with quality improvement and the implementation of recommendations. From one on-site visit to the next, the ongoing relationship with the client organization is sustained. Additional education and training are provided as appropriate to the client organization and its needs. Ongoing monitoring of performance is critical to sustaining standards use. | Client organizations are encouraged to use the standards in an ongoing way, perhaps to annually review the relevant standards. For example, the Emergency Department team should review the standards for emergency care annually, conduct a self-assessment and continuously monitor adherence to the standards. Are any new deficiencies identified? If the standard has been updated since previously utilized, there may be new important knowledge/practices to consider and be included in the quality improvement plan, including mechanisms to monitor progress. |
| Mapping to ‘knowledge to action cycle’ . | Accreditation body program elements . | Description of client actions and rationale . |
|---|---|---|
| Knowledge/standards creation | ||
| ‘Knowledge/standards’ KT goal: to identify the knowledge to be implemented to optimize quality of care and patient safety. | Standards synthesize the best available evidence and expert opinion to offer guidance on how to enable quality improvement, mitigate safety risks and improve quality. These standards are reviewed regularly to ensure they are reflective of the current evidence. | The client organization implements or attempts to implement these standards on a regular basis, at minimum 1 year prior to the on-site survey visit. The currency and evidence-informed nature of the standards support the client organization in achieving their goal of keeping practices and decision-making current. |
| ‘Knowledge tools/products’ KT goal: to provide resources to facilitate meeting accreditation requirements and to encourage engagement with phases of the action cycle. | Specific assessment tools such as a staff engagement survey and/or a patient safety culture survey may be required which are utilized by the client organization on a cyclic basis. The results contribute toward identifying achievement of a particular standard criterion. These tools are often embedded in the accreditation body’s software that is made available to all client organizations. | The survey tools are of value to the client organization in that the results can be used, even in isolation from the standards assessment, to identify areas of strength or deficiency requiring an action plan. The tools could be reapplied at an appropriate interval to determine if change has occurred in the desired direction. |
| Action Phases | ||
| ‘Determine the standards/practice–achievement gap’ KT goal: to determine gaps between the standards and current practice–achievement so as to quantify the need for improvement. This information can be used to promote organizational consensus on the need to act to reduce the gap. | The accreditation body encourages the client organization to conduct a self-assessment against the standards. The purpose of this exercise is to enable identification of areas of strength and areas for improvement. The survey tools facilitate in identifying areas of strength and areas for improvement further strengthening the assessment of performance against a particular standard. The accreditation body organizes an on-site survey visit, conducted by surveyors carefully selected for their expertise and training, which is a vital component of their third-party external review process. The surveyors use different methodologies depending on the accreditation body’s program. At minimum it includes that surveyors visit the client organization in person to gather evidence of current practice which they can compare to the practice described in the standards. During the on-site visit, surveyors may interview the board, leadership, staff, patients, their families and key stakeholders in the community. The surveyors observe the environment, staff interactions and review documentation in the health record and policies. During discussion with individuals, the surveyors may provide feedback and evidence back to each team to encourage their practice going forward, reinforce those areas requiring improvement and share their own expertise. | The client organization conducts the self-assessment to determine the degree to which they achieve a particular standard and the specific criteria within the standard. This process enables their identification of performance relative to the standard and areas in which there are opportunities for improvement, as well as organizational readiness for change. The identified areas for improvement then become the focus of the client organization’s quality improvement action plan to address areas needing improvement. It is the decision of the client organization as to how the self-assessment process is conducted—whether an entire team collectively completes the assessment or whether a designated person does this on behalf of the team. Depending on the information technology resources of the client organization, the exercise may be conducted ‘online’ or manually on paper and then entered into the accreditation body’s software program. The survey instruments (e.g. staff engagement, patient safety culture) generally require involvement of staff, individually or as a team. In addition to providing useful results in identifying areas of strength and areas of improvement, the process contributes to team building. The client organization prepares for the on-site visit to ensure all necessary information is available for the surveyors, including availability of teams to be interviewed and preparation to enable observation of care/service being provided (e.g. surgery in the OR, a clinic as patients receive treatment). The recipients of care are available to speak with a surveyor when required while at all times maintaining anonymity and confidentiality to the degree necessary. Copies of health records are made available as appropriate. |
| ‘Customize operationalization of standards to local context’ KT goal: to adapt and customize the operationalization of the standard to foster organizational buy-in and contribute to optimal implementation of standards tailored to organizational needs. | While the standards are set and somewhat prescriptive, the accreditation body encourages the client organizations to review and develop an implementation strategy that is relevant to their own context. While standards outline a particular desired practice or result, the means by which this is achieved, the “how”, is the decision of the client organization. | The client organization has the responsibility to carefully assess each standard and determine how best to implement/achieve the standards within their own context. Every client organization’s structure, patient population, staffing arrangement and resource availability is different. There are unique elements in every client organization’s milieu. |
| ‘Assess barriers/facilitators to standards use’ KT goal: to identify potential barriers (and facilitators) to implementing the standards. This information can be used to more strategically to select implementation strategies explicitly targeting the barriers, thereby improving implementation success. | The self-assessment process enables the identification of the degree to which a standard is being achieved, identification of gaps or areas for improvement and in some cases identification of barriers to uptake of the particular standards. Furthermore, during the site visit, the surveyors may further identify barriers and offer suggestions for effective strategies for overcoming the identified barriers. These suggestions may be included in the final accreditation report. For example, a standard may require that a hand-washing procedure is in place, with evidence of its effectiveness. How that procedure is designed and implemented is the decision of the client organization. Throughout this design period and then assessment of its effectiveness after implementation, barriers and facilitators to the process are identified and adjustments made in order to obtain the optimum result for the client organization, their patients and staff. | Carefully reviewing each standard and then adapting the implementation to apply to their context are critical components from the beginning of the self-assessment process to the development of the quality improvement action plan. The client organization identifies those factors that are barriers and facilitators and indicates how they will be addressed in the action or implementation plan. Thus, if the standard requires an annual board evaluation, the type of tool utilized, the content, the means of administration, steps taken to analyze and actions taken to address the results lie with the client organization. Barriers to undertaking this exercise must be considered as well as those factors that will facilitate achieving this standard. Once the strategy is implemented, monitoring its effectiveness is important as is making corrections to the strategy as necessary to enable buy-in and achievement of the goal. |
| ‘Select, tailor and activate implementation strategies (the action plan)’ KT goal: to tailor implementation strategies to the identified barriers so as to increase implementation success. | The implementation strategy or quality improvement action plan that is developed by teams during the self-assessment process is the responsibility of the client organization—both to implement and monitor progress. Most accreditation bodies require that progress on this plan is provided back to them on a regular basis, e.g. every 6 months or annually. The accreditation report that is given to the organization post the on-site visit reinforces the actions that are required and assists in the determination of priorities for action. Other implementation strategies supported by accreditation bodies include providing education and training based on the learning needs of the client organization. Given the wealth of information that is obtained both online and during the on-site visit, many accreditation bodies are creating a ‘library’ of best or leading implementation practices that is accessible to all client organizations. The accreditation body develops eligibility criteria against which to assess if a strategy indeed qualifies as a best or leading practice (e.g. clinical, service, governance/leadership). | The quality improvement action plan is unique to each client organization and should ideally consider identified barriers to implementing the standards and identify how selected implementation strategies will address the barriers. There are many different implementation strategies to achieve uptake of a particular standard/criterion. Client organizations are encouraged to identify those strategies most relevant to them, optimizing buy-ins and results. Teams together develop these plans. The accreditation report is a useful tool for the client organization, confirming areas important to focus actions. Within the specified timeframes as to when reports should be provided to the accreditation body, the client organization’s implementation strategies are developed, monitored and assessed accordingly. The sharing of ‘leading or best practices’ between organizations is a major benefit for all client organizations. Rather than ‘reinventing the wheel’ to identify a strategy to meet a particular standard, reviewing what other client organizations have considered is very helpful. The client organization may then contact the ‘owner’ of that leading practice, seek advice and then consider and/or adapt that practice to their own setting, or choose to reject it. |
| ‘Monitor use of the standards’ KT goal: to determine the extent to which the organization is adhering to the standards so that the organization can assess its performance against the desired practice (the standard). The monitoring of indicators serves as a mechanism to ensure/facilitate that users’ knowledge and practice are ‘keeping pace’. | The standards may identify specific indicators that should be monitored to allow assessment of performance toward meeting the standards. Monitoring of strategic and operational indicators/performance measures occurs in all organizations. Utilizing the specific indicators that may be identified by the accreditation body provides further direction to confirm priority areas for monitoring. The accreditation bodies establish a mechanism with the client organizations to have regular contact throughout the accreditation cycle. Generally, following the receipt of the accreditation report, it is required that there be a 6-month report, an annual report or something similar. This ongoing monitoring of compliance and ongoing assessment of implementation of the action plan are critical components of the accreditation process. The goal is that accreditation is not a onetime event but an ongoing cycle, with an expectation of ongoing assessment of compliance with the standards, implementation of action plans, ongoing monitoring and continuing to improve care and services. At minimum, there is an expectation to receive a report, online or hard copy, at regular intervals of progress with the action plans. | The client organization has a responsibility to follow through on the implementation of the quality improvement action plan that results from the survey process. A sincere commitment by the organization to value this process is fundamental to its success and to having maximum impact on quality of care. Monitoring of strategic and operational indicators/performance measures occurs in all organizations. Utilizing specific indicators identified by the accreditation body provides further direction to confirm priority areas for monitoring and are used to determine adherence to the standards. The client organization recognizes that accreditation is a major quality improvement tool that complements other quality improvement strategies within their organization, e.g. LEAN, Six Sigma, etc. The client organization’s overall quality improvement plan at a strategic level acknowledges how these initiatives comprehensively integrate to enable improvement of care and services, from the governance level to the point of care. |
| ‘Evaluate outcome/impact’ KT goal: to determine the extent to which adherence to the standards translate into improved health outcomes or health system outcomes. This information can further motivate maintaining adherence to the standards and to celebrate organizational achievements. | As the primary goal of accreditation is to improve quality and safety, requirements to report on specific outcomes or specific clinical indicators may not be required by accreditation bodies. However, one of the key goals of accreditation is to provide an organization with tools that enable resilience. The content of the standards focuses on quality improvement and the prevention or mitigation of risk. If an adverse event arises, the organization knows how to learn from the event, recover and continue improving. Thus, accreditation does not guarantee quality of care but demonstrates accountability that the organization is focused on improvement and meeting evidence-based standards. | If outcomes of adherence to standards are collected, client organizations can use this information to justify implementing the standards, demonstrate to the community how they improve patient health outcomes and better demonstrate the value of money invested in healthcare. The challenge, however, is that the standard alone does not directly improve outcomes. Factors such as the knowledge and expertise of the ‘user’, patient behaviors and resource availability combine to enable the desired outcome. |
| ‘Sustain use of standards’ KT goal: to continue to focus the organization on maintaining adherence to the standard and maintaining quality and patient safety. If declines in adherence are observed, the organization can double efforts to identify barriers to ongoing use of the standards and institute more/different implementation strategies (starting the knowledge to action cycle over again). | If the accreditation body becomes concerned about the performance of the client organization, i.e. that insufficient attention is being paid to areas of concerns/deficiencies, or perhaps significant complaints from the public have been received by the accreditation body, mechanisms are in place to send a surveyor to the organization mid-cycle. Similar strategies can also be undertaken to identify problems and suggest improvements. This relationship is critical and an important part of the accreditation process. It provides support and assists with quality improvement and the implementation of recommendations. From one on-site visit to the next, the ongoing relationship with the client organization is sustained. Additional education and training are provided as appropriate to the client organization and its needs. Ongoing monitoring of performance is critical to sustaining standards use. | Client organizations are encouraged to use the standards in an ongoing way, perhaps to annually review the relevant standards. For example, the Emergency Department team should review the standards for emergency care annually, conduct a self-assessment and continuously monitor adherence to the standards. Are any new deficiencies identified? If the standard has been updated since previously utilized, there may be new important knowledge/practices to consider and be included in the quality improvement plan, including mechanisms to monitor progress. |
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