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Using the Accreditation Report for Implementing System Wide Improvements

Using the Accreditation Report for Implementing System Wide Improvements. Improving Quality of Care and Patient Safety Through Accreditation Ms. Terry Brent, RT, OHSA Lab Manager Dr. Kirk Ready, Clinical Director OHSA Labs Monday, May 12th, 2008.

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Using the Accreditation Report for Implementing System Wide Improvements

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  1. Using the Accreditation Reportfor Implementing System WideImprovements Improving Quality of Care and Patient Safety Through Accreditation Ms. Terry Brent, RT, OHSA Lab Manager Dr. Kirk Ready, Clinical Director OHSA Labs Monday, May 12th, 2008

  2. Using the Accreditation Report for Implementing System Wide Improvements • Introduction • Pre-Accreditation • On-Site • Review Report • Implementation • Conclusions • Recommendations

  3. Introduction Accreditation  System Wide Improvement Kirk & Terry Co-Management OHSA Labs VJH - 125, KGH 325 , PRH 134 - beds OLSC OHSA Working Groups IH LSC IH SET

  4. Pre-Accreditation Accreditation  System Wide Improvement Self Assessment By Site Then together Terry and Kirk Preparation in relation to overall strategic plan 3 – 5 year Mission – DAP or other Vision Mission Values Nothing Snap shot On a mission course set

  5. On-Site Accreditation  System Wide Improvement 3 consecutive days 2 teams If it is Tuesday, this must be Vernon

  6. On-Site Accreditation  System Wide Improvement 3 consecutive days 2 teams If it is Tuesday, it must be Vernon

  7. Review Report Accreditation  System Wide Improvement 3 separate reports Presentation to IH Board Quality Committee Hosp MAC Electronic Converted to Table Merged tables OLSC OHSA Discipline WG – review sections

  8. ImplementationAccreditation  System Wide Improvement OHSA Discipline WG Involvement of IH Lab Discipline WG Implementation of instruments Method Validation General Operations Manual QS Manual

  9. ConclusionsAccreditation  System Wide Improvement Done in one day Snap shot of three sites Define standards (previously none) Long time between assessment and receipt of report Short time to respond (lead time taken up in delay of receipt of report) Variations in the reports but overall showed almost all issues were in similar / common Opportunity for prioritization – helpful Opportunity to really bring together the lab staff from all three sites for each of the various disciplines (team building) Overall rating system - good

  10. RecommendationsAccreditation  System Wide Improvement Electronic Reports with ability to insert and edit action plan More regional approach – especially for general areas, including human resources, information management, suppliers and partners For each bullet need Y / N / Na

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