Accredited by /Agréé par ISQuaAccredited by /Agréé par ISQua

CCHSA Accreditation: New Standards for Managing Medications

Jessica Peters

Lead, Research & Product Development

CCHSA

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Presentation Outline

Vision, Mission and Values

The Accreditation Program

Program Enhancements

The New Standards for Managing Medications

Next Steps

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CCHSA’s Vision and Mission

VisionThe leader in raising the bar for health quality

MissionDriving quality in health services through accreditation

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CCHSA’s Values

Within an environment focused on clients and committed to quality of worklife, partnerships, and personal growth, our values are:

Excellence Integrity Respect Innovation

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CCHSA’s Accreditation Program

Canadian accreditation program - incorporated in 1958 Not-for-profit High participation rates; continued growth Surveyors (approx. 400) are senior health care

professionals Surveys may be regional, institution specific, national or

market specific (i.e. First Nations, Corrections, Canadian Forces)

Average 400+ surveys per year Three year cycle Both public and private organizations participate

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Role of Accreditation

Quality Improvement – at the organization level and at the system level

Change management

Standards of excellence – raising the bar on health care Standards of clinical practice Governance Leadership

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CCHSA Standards

Standards of excellence

‘Raise the bar’ for health care practice

Enable an organization/team to stretch to improve care, to reach or raise the bar

Developed with the input and guidance of experts in the field and updated on a regular basis to ensure relevance and value

Are applicable to different regions and service delivery settings

Will continue to be used by organizations, but in a new way

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Evolution of CCHSA Program

1958 -1976Hospital Based

1958-1980Acute Care

Long Term Care Institutions

1980 - 1995

1980 - 1992Mental HealthRehabilitation

Cancer

1995 - 2000

1995 - 1997Home Care

Community HealthServices

Health SystemsAcquired Brain

Injury

2000 - 2006

2001 - 2006HPCAHSCF

ARTChild Welfare

TelehealthLabs

1980 - 2006Diversification of Markets

2001AIM Introduction 2007

NewAccreditation

Program(Development & Pilot)

2001- 2006V2-V5

1959Accreditation

Program

New Sector New Sector

New Sector

New Sector

LEGEND

HPC: Hospice Palliative CareAHS: Aboriginal Health ServicesCF: Canadian ForcesART: Assisted Reproduction TechnologyEHS: Emergency Health Services

1995CCAP

2006Under Development

Public HealthEHS

TeletriageAHS Nursing StationsInfection Prevention &

Control

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The New Accreditation Program

Benefits:

1. Standards that: Capture the most recent governance/managerial and

clinical best practices Reflect the emerging trends or disease (and wellness)

patterns in healthcare Have an increased level of specificity Can be used or integrated into the daily work of

organizations

2. Streamlined and more flexible process that: Supports and aligns better to an organizations’ quality

improvement initiatives Is adaptable no matter how small or how complex the

organization may be

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The New Accreditation Program

Benefits:

3. Greater focus on the provision of safe quality care and service in a variety of health care settings

4. Planned and predictable accreditation activities with a on-site survey that is customized to the organizations’ needs

5. Automated measurement tools that allow: Greater and faster data exchange Improved standardization and objectivity

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The standards have a brand new structure…

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Standards Areas

POSITIVE CLIENT EXPERIENCE

SERVICE EXCELLENCE

PROACTIVE AND SUPPORTIVE ORGANIZATION

EFFECTIVE AND SUSTAINABLE GOVERNANCE

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Managing Medications: Background

The development of the new standards for managing medications was driven by: Importance of safe medication management processes in

protecting client safety Feedback from client organizations and surveyors Changing health care environment

Development began in 2004 Expert working group including representatives from

organizations and ISMP-Canada Standards circulated for consultation in late 2005 to

approximately 15 organization

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The New Standards for Managing Medications…

Standards target medication processes in an institutional setting, i.e. hospital, long term care

Focus on the safe use of medications from selection and procurement through administration

Address a number of key themes: Working Together to Promote Medication Safety Carefully Selecting and Procuring Medications Properly Labelling and Storing Medications Appropriately Ordering and Transcribing Medications Accurately Preparing and Dispensing Medications Safely Administering Medications to Clients Monitoring Quality and Achieving Positive Results

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Working Together to Promote Medication Safety

Recognizing pharmacists and pharmacy staff as integral members of the interdisciplinary team

Actively involving the pharmacy staff in designing the organization’s medication use and medication management processes

Providing access to accurate medication-related information, formally approved drug information tools and education about safe medication use

Evaluating the competency of all service providers who participate in the medication use process

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Carefully Selecting and Procuring Medications

Maintaining an up-to-date and evidence-based list of available medications

Minimizing the number of procured and available medications

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Properly Labeling And Storing Medications

Reducing the possibility of errors with drug product nomenclature, labeling, and packaging

Labeling all drug concentrations clearly and legibly

Providing suitable space for drug storage in pharmacies and client/unit medication areas

Carefully selecting stock drugs for each client area

Storing hazardous chemicals away from clients, service providers, and drug preparation areas

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Ordering and Transcribing Medications Appropriately

Maintaining accessible and up-to-date client information

Communicating drug orders and other drug information in a standardized way

Reviewing all prescriptions or medication orders for accuracy and appropriateness

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Accurately Preparing and Dispensing Medications

Preventing contamination when preparing medications

Dispensing medications in a safe, accurate, and timely way

Having a system to safely dispense medications where there is no internal pharmacy or when the pharmacy is closed

Transporting medication in a safe, secure, and timely manner way

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Safely Administering Medications To Clients

Educating clients about their medications and delivery devices, and ways to prevent errors

Following a process to allow and monitor clients’ self-administration of their medications

Safely and accurately administers medications Reducing the risk of error through careful

procurement, maintenance, use, and standardization of medication delivery devices

Monitoring clients following medication administration

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Monitoring Quality And Achieving Positive Outcomes

Having a coordinated risk management program to reduce medication-related errors and sentinel events

Regularly monitoring and evaluating the quality of the medication management and pharmacy system

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Current Status of the New Program

13 pilot sites will test various elements of the program starting March to December 2007

National consultation on standards Customized transition plan for each client in 2008 Pan Canadian information sessions in major cities to support

transition Ongoing communication

CCHSA web site teleconferences

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Canadian Council on Health Services Accreditation

The leader in raising the bar for health quality