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Published by ชมพูนุท บุษกรเรืองรัตน์, 2023-04-27 05:14:17

(1) AACI_Overview_25APR2023

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(1) AACI_Overview_25APR2023

© 2023 American Accreditation Commission International (AACI) All Right Reserved Swiss Chesse Model (โมเดลชีส) Ini$a$ng Event/Hazard หลีกเลี่ยง เพื่อไม่ให้เกิดความเสี่ยง มาตรการป้องกัน ความเสี่ยง หลุมพราง (Weakness) เกิดเหตุการณ์ (มักเกิดขึ้นเมื่อเกิดรอยรั่ว ของชั้นการป้องกัน) ผลสุดท้าย รุนแรงน้อย เนื่องจากการบรรเทา การควบคุมโดยระบบ วิศวกรรม การควบคุมโดยการ บริหารจัดการ การควบคุมโดย มนุษย์ มาตรการบรรเทา ความรุนแรงหลงจาก เกิดเหตุการณ์

© 2023 American Accreditation Commission International (AACI) All Right Reserved Responsible Person/Committee มีผู้รับผิดชอบ/คณะกรรมการ Staff Qualification Credential & Privilege /ทําJD & JS /HR Profile Staff Education ฝึกอบรม/training record Staffing & Equipment & Resource บุคลากร/อุปกรณ์เครืVองมือ/ทรัพยากร Law & Regulation กฎหมายและกฎระเบียบ Plan & Program มีแผน/ แผนงาน P &P/Criteria/List/Guideline/Measure/Org st/ Doc จัดทํานโยบาย&ขัaนตอนการทํางาน,จัดทําเกณฑ์/รายชืVอหรือรายการ/ แนวทาง/มาตรการ Process Designed/Standardized & Implemented/Action กระบวนการทีVทําจริงอยู่ให้เป็นมาตรฐาน/ออกแบบกระบวนการ/นําสู่ ปฏิบัติ Medical record/Form ความสมบูรณ์ของบันทึกเวชระเบียน/แบบฟอร์ม Monitoring เครืVองชีaวัดทีVต้องทํา Review การทบทวน

© 2023 American Accreditation Commission International (AACI) All Right Reserved Survey Findings Conformity Minor Non-Conformity Major Non-conformity Critical Non-conformity Situation in which conformity to all aspects of a requirement are fulfilled Critical nonconformity is interpreted as a situation in which the health and safety of individual(s) are at risk. The absence of one or more required system elements or a situation which raises significant doubt that products or services will meet specified requirements. A lapse of either discipline or control during the implementation of system/procedural requirements For an organisation to achieve AACI accreditation, an overall compliance rate of 70% of the maximum score must be achieved.

© 2023 American Accreditation Commission International (AACI) All Right Reserved Swiss Chesse Model (โมเดลชีส) Initiating Event/Hazard หลีกเลี่ยง เพื่อไม่ให้เกิดความเสี่ยง มาตรการป้องกัน ความเสี่ยง หลุมพราง (Weakness) เกิดเหตุการณ์ (มักเกิดขึ้นเมื่อเกิดรอยรั่ว ของชั้นการป้องกัน) ผลสุดท้าย รุนแรงน้อย เนื่องจากการบรรเทา การควบคุมโดยระบบ วิศวกรรม การควบคุมโดยการ บริหารจัดการ การควบคุมโดย มนุษย์ มาตรการบรรเทา ความรุนแรงหลงจาก เกิดเหตุการณ์

© 2023 American Accreditation Commission International (AACI) All Right Reserved Review of CAP Identify Identify the performance measure(s) and/or other supporting evidence that will be monitored to ensure the effectiveness of the corrective action(s) taken Identify Identify the person responsible for implementing the corrective action measure(s); and, Identify Identify the timeframe for the implementation of the corrective action measure(s); Identify Identify the process or system changes that will be made to ensure that the nonconformity does not recur; Identify Identify other areas and/or processes (if applicable) that have the potential to be affected by the same nonconformity; Identify Identify the actions taken to correct the nonconformity in the affected areas and/or processes; Identify Identify the root cause that led to the nonconformity;

© 2023 American Accreditation Commission International (AACI) All Right Reserved CAP Timelines Conformity Minor Non-Conformity Major Non-conformity Critical Non-conformity Situation in which conformity to all aspects of a requirement are fulfilled Closing NC Critical The risk related to the Critical NC must be mitigated within seven (7) days. The final resolution must be completed within thirty (30) days. A follow-up survey prior to the next annual survey will be required Closing NC Major Within sixty (60) days of CAP acceptance A desk follow-up survey prior to the next annual survey will be required Closing NC Minor will take place at the next annual survey The organization shall submit performance measure(s) data, findings, results of internal reviews (internal surveys), or other supporting documentation, including timelines to verify implementation of the corrective action measure(s). All Critical and Major nonconformities must be removed prior to the awarding of accreditation.

© 2023 American Accreditation Commission International (AACI) All Right Reserved AACI Accreditation Surveyor Clinical Surveyors Patient Care Unit Visits (Clinical Setings) Surgery, ICU, CCU, Obstetrics, Emergency Department High acuity units Medical Staff Governance Surveyor Quality Management Review Pharmaceutical Services Human Resources Review Utilization Review Interview Patient Rights Ancillary / Support Services Review (e.g. Lab, Medical Imaging, etc) Physical Environment / Life Safety Surveyor All Physical Environment aspects and Management Plans Physical Environment / Comprehensive Building Tour Calibration of Equipment Information Security System

© 2023 American Accreditation Commission International (AACI) All Right Reserved Surveyor Competency Clinical, Generalist, and Physical Environment expertise Complete the ISO 9001 Lead surveyor Course Complete the AACI Accreditation Implementation Course Physical Environment Specialists completed Fire Safety Mentored surveys Technical reviews and calibration surveys All must atend annual surveyor training & complete 24 hours every 3 years

© 2023 American Accreditation Commission International (AACI) All Right Reserved Evidence Collection and Analysis Procedures A. Observation B. Document review C: Interview D. Analysis E. Technical verification Evidence collection procedures

© 2023 American Accreditation Commission International (AACI) All Right Reserved A. survey Procedure: Observation • Direct observation is one where the surveyor observes a phenomenon based on his senses without wanting to modify them with appropriate procedures. • For example, the surveyor observes: Buildings Work environment Employee performances Medical Equipment Presence of a fire prevention device

© 2023 American Accreditation Commission International (AACI) All Right Reserved Documenting the Observations • The surveyor must document his observations • This can be done in various ways: Taking notes Photocopying documents Taking photos or audio/video recordings (usually to be avoided)

© 2023 American Accreditation Commission International (AACI) All Right Reserved B. survey Procedure: Document Review • The document review consists of a systematic and methodical review of text documents • The surveyor must evaluate the conformity of the documents in terms of: Content Format Document management procedure

© 2023 American Accreditation Commission International (AACI) All Right Reserved Document review General understanding of the operation of the accreditation system Evaluation of the design of the management system as well as the related processes and requirements Verification that internal surveys and management reviews have been conducted

© 2023 American Accreditation Commission International (AACI) All Right Reserved Required documents 1. Contract 2. Organisation application form • Names of top leadership team • A description of the organisation location(s) • Identification of services provided • Number of in-patient beds ( if hospital) • Number of staff employed (FTE) • Average daily census • Any additional information available about the facility (e.g., the hospital’s web site, any media information about the hospital, etc) if applicable 3. List of documentation

© 2023 American Accreditation Commission International (AACI) All Right Reserved Document list 1. Organizational chart 2. Organizational chart for nursing services 3. A map/floor plan, indicating locations for patient care and treatment areas 4. A list of current inpatients with each patient’s room number, age, primary diagnosis, attending physician, admission date, and other significant information as it applies to that patient. 5. Current Surgical Schedule 6. Most recent ISO certification report unless provided by AACI 7. Most recent local healthcare accreditation report (if applicable)

© 2023 American Accreditation Commission International (AACI) All Right Reserved Document list Minutes of the Quality Oversight/Management Review Committee – including Performance Improvement data for the previous 12 months Minutes from Environment of Care/Safety Committee Management plans for the physical environment and annual evaluations List of contracted services, companies and individualsSurveyors will select a sample for review

© 2023 American Accreditation Commission International (AACI) All Right Reserved Document list Nursing service plan of administrative authority/delineation of responsibilities for delivery of pt. care Infection Control Plan with risk assessment/hazard vulnerability analysis List of employees including name, title, unit, and hire date List of current patients who have had restraint or seclusion used during hospitalization List of patients discharged with the past 6 months who had restraint or seclusion used violent or self-destructive behavior during their hospitalization

© 2023 American Accreditation Commission International (AACI) All Right Reserved Document list - Policies & Procedures 1. Autopsies; 2. Blood & Blood Product Administration; 3. History and Physical Examination; 4. Informed Consent; 5. Medication Security; 6. Moderate Sedation; 7. Patient Assessment (Nursing, respiratory, nutritional services, etc.); 8. Pain Management; 9. Patient Care Planning/Interdisciplinary Treatment Plan; 10. Patient Grievance; 11. Procedural Verification Process (Practices ensuring the correct patient, site & procedure); 12. Restraint or Seclusion; 13. Verbal/Telephone Orders

© 2023 American Accreditation Commission International (AACI) All Right Reserved Survey Agenda Plan sent to healthcare organization • Survey location • Date of survey • Survey type • Lead surveyor • Team of surveyors • Locations to be surveyed • Departments to be surveyed •People to met •Time

© 2023 American Accreditation Commission International (AACI) All Right Reserved Before survey Planner shall prepare survey packs and submit to team leader Survey packs will include: • Application form F-001 • Previous survey reports • Previous corrective action plan submissions • Complaints against the healthcare organization • External Market information if available Team leader responsible: • To prepare draft survey agenda and send to hospital with a list of documents that might be requested (with CC to survey team) • To coordinate with operational support and translators

© 2023 American Accreditation Commission International (AACI) All Right Reserved During the survey Opening Meeting Document review Building visits Clinical record review Patient care review Staff and patient interviews Closing meeting

© 2023 American Accreditation Commission International (AACI) All Right Reserved Opening Meeting Agenda 1. Introduction of participants 2. Survey objectives, scope, and criteria 3. Confirmation of the survey plan and logistics 4. Introduction of survey methods and procedures to be used 5. Formal communication channels between the survey team and the surveyee 6. Availability of resources 7. Summarize survey methods to be employed including how patient information and data will be managed 8. Confidentiality, information security, health and safety matters 9. Information about how to deal with possible findings during the survey and about the closing meeting 10. Information about feedback on the findings or conclusions of the survey, including complaints or appeals The following subjects are usually included in the agenda:

© 2023 American Accreditation Commission International (AACI) All Right Reserved Process from collecting information to reaching survey conclusions Sources of information Collecting by appropriate sampling and verifying Evaluating against survey criteria Reviewing Survey conclusions Survey evidence Survey findings Show me! TAKE NOTES! Methods to collect informa$on including interviews observa$on of ac$vi$es review of documents

© 2023 American Accreditation Commission International (AACI) All Right Reserved Tracer Methodology A key part of AACI’s on-site survey process Uses information from an organization to follow the experience of care, treatment or services for a number of patients through the organization’s entire health care delivery process Tracers allow surveyors to identify performance issues in one or more steps of the process, or interfaces between processes.

© 2023 American Accreditation Commission International (AACI) All Right Reserved Individual tracer activity These tracers are designed to “trace” the care experiences that a patient had while at an organization. It is a way to analyze the organization’s system of providing care, treatment or services using actual patients as the framework for assessing standards compliance. Patients selected for these tracers will likely be those in high-risk areas or whose diagnosis, age or type of services received may enable the best in-depth evaluation of the organization’s processes and practices.

© 2023 American Accreditation Commission International (AACI) All Right Reserved System tracer activity Includes an interactive session with a surveyor and relevant staff members in tracing one specific “system” or process within the organization, based on information from individual tracers. While individual tracers follow a patient through his or her course of care, the system tracer evaluates the system or process, including the integration of related processes, and the coordination and communication among disciplines and departments in those processes. The three topics evaluated by system tracers are : Data management Infection control Medication management.

© 2023 American Accreditation Commission International (AACI) All Right Reserved Interviews and building visits The survey will include a series of activities that will include: • Review of previous survey results and implementation of associated corrective action plans; • Interviews with leadership, management staff, physicians, and board members; • Interviews with patients; • Building tour (4-12 hours, dependent on Applicant organization size); • Interviews with individuals who oversee core processes (e.g. patient safety, infection control, etc.); • Human Resources interview to verify compliance with staff requirements; • Medical Staff credentialing session to verify compliance with Medical Staff requirements; • Additional document review if deemed necessary by survey findings.

© 2023 American Accreditation Commission International (AACI) All Right Reserved Interview Types General interview ▪ Allows to validate strategic and tac2cal aspects as well as the type of process ▪ Example: Interview with the Human Resources manager to understand HR management processes Detailed interview ▪ Allows to reach an increased level of informa2on to evaluate and determine if the implemented processes operate without visible error and effec2vely in a repe2Ave and con2nuous way ▪ Example: Interview with an HR administra2ve assistant to understand and validate how employee files are kept

© 2023 American Accreditation Commission International (AACI) All Right Reserved Individual and Group Interview Individual Interview Group Individual interviews are preferred because the surveyor can concentrate his efforts on a single person and in general obtain more detailed informa=on Use of group interviews must be limited, unless the surveyor wants to validate the interac8on and dynamics between the various members of the group

© 2023 American Accreditation Commission International (AACI) All Right Reserved Preparing an Interview 1. Define the objec=ves to be reached during the interview 2. List the themes/topics to be addressed 3. Write an interview plan with a checklist or a ques=onnaire 4. Determine the persons with the appropriate competencies and du=es 5. Make an appointment 6. Prepare the working documents Prepara&on is the key to a successful interview in a professional manner and ensure the adequate coverage of all the defined items

© 2023 American Accreditation Commission International (AACI) All Right Reserved Sampling Why What How Because a surveyor cannot verify everything Selection of a sample Using an adequate sampling method

© 2023 American Accreditation Commission International (AACI) All Right Reserved Systematic Sampling Example Define Define the population •Number of all patients present at the hospital •Example: 300 patients at the time of survey Determine Determine the size of the sample •Observed frequency: 10% therefore the sample of 25 Execute Execute the sampling plan •Choose one patient from each relevant department (after the 1st one is chosen randomly)

© 2023 American Accreditation Commission International (AACI) All Right Reserved Examples of Frequent Analysis The following is a list of elements often validated using sampling during an accreditation survey: • Control of documented information (4.5.) • Medical staff (8.4. & 8.10) • Orientation (7.5.) • Medical Records (23.3. & 23.4. & 23.5) • Medical Equipment Process (27.6.)

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