Diagnostic Accreditation Program

Annual Report: Trends in Facility Performance

Sharmen Vigouret Lee, Executive Director

May 12, 2008

New Accreditation Standards

Laboratory Medicine – 2007 Sample Collection, Transport & Accessioning Chemistry Hematology Microbiology Transfusion Medicine Anatomic Pathology Laboratory Informatics Point of Care Testing – Field Testing Cytology – in development Cytogenetics – in development

New Accreditation Standards

Diagnostic Imaging – 2007 Radiology Ultrasound Echocardiography Mammography CT MRI Nuclear Medicine Bone Densitometry Imaging Informatics

Digital Mammography – field testing PET/CT – development to start Summer 2008

New Accreditation Standards

Neurodiagnostic Services – 2007 EEG Evoked Potentials EMG & Nerve Conduction Studies

Pulmonary Function – Field Testing June 2008

Hospital Based Services

Polysomnography Development to start Summer 2008

Advisory Committees

Advisory Committees Laboratory Medicine – 7

Cytology Cytogenetics

Diagnostic Imaging – 10 PET/CT

Hospital Based Neurodiagnostic Services – 2 Hospital Based Pulmonary Function Polysomnography

Accreditation Assessments

On-site Surveys, Focused Visits, Initial Assessment

Number of Facilities Number of Modalities

Laboratory Medicine 51 191

Diagnostic Imaging 60 148

Neurodiagnostic Services

2 6

Pulmonary Function 2 2Total 118 347

Accreditation Assessments

Accreditation Status – 2006 and 2007

Laboratory Medicine73 Accreditation with Report

5 Full Accreditation

Diagnostic Imaging76 Accreditation with Report

10 Full Accreditation

Trends in Performance:Most frequently cited by Surveyors

Leadership & Management Lack of position descriptions for medical and

administrative leadership Management of adverse events and critical incidents

Lack of definitions, policies & procedures, investigation process, monitoring changes implemented, staff communication & training

Reporting process in place, but no feedback or trend analysis Litigation preparation focus instead of continuous improvement

Trends in Performance:Most frequently cited by Surveyors

Human Resources Significant recruitment challenges: medical, technical

and administrative staff Outdated job descriptions Continuing education challenges – funding & backfilling Performance reviews and competency assessments

not occurring Outdated or no contract in place between the facility

and the medical professionals

Trends in Performance:Most frequently cited by Surveyors

Patient & Client Focus Excellent knowledge of the patient populations served Demonstrated commitment to patients and providing

the best possible care with the resources availalble Well defined knowledge of who referring physicians are

Effective communication and established relationships

Performance based contracts with 3rd party payers

Trends in Performance:Most frequently cited by Surveyors

Suppliers & Partners Health authorities – centralized process for capital and

consumable purchasing Diagnostic service has significant input into selection process Capital planning processes regionally based

Community based services – more informal purchasing practices

Trends in Performance:Most frequently cited by Surveyors

Quality Improvement Lack of a comprehensive approach to quality

management and quality improvement No linkage between specific quality activities

Use of indicators for monitoring – very limited Lack of available & knowledgeable staff to develop

quality programs

Trends in Performance: Most Frequently Cited Mandatory Requirements

Safety – Laboratory Medicine

Eyewash stations are conveniently located and regularly flushed Emergency lighting is available Safety manual is readily available to staff Items for patient consumption are stored separately from sample,

reagents and supplies Safe and effective cleaning and disinfection Chemical and biological spill kits and procedures are available Personal protective and other safety equipment (e.g. splashguards) Sufficient, well marked “clean” sinks for hand washing

Trends in Performance: Most Frequently Cited Mandatory Requirements

Safety – Diagnostic Imaging

Safety program in place including documentation and staff education

Ongoing staff education to prevent and control infections Policies in place for dealing with emergency procedures

(cardiopulmonary arrest) Policy for staff working alone Action plan for emergency evacuation has been developed and

communicated to staff MSDS are posted where toxic and corrosive agents are used Radiation safety Eyewash stations conveniently located

Laboratory Medicine Most Frequently Cited Mandatory Requirements

Sample Collection:Sample rejection criteria established

Acceptable time limits between collection and processing of standards are established and monitored

Policies and procedures to deal with unlabeled, mislabeled, lost or compromised samples

Proficiency Testing/QC:When mandated PT is not available, alternative PT is used to

validate performance

QC policies and procedures are documented and maintained

Laboratory Medicine Most Frequently Cited Mandatory Requirements

Document Control:All procedures are documented, communicated to and available to

staff performing the analysisInvalid or obsolete documents are promptly removed from all points

of useMaster index of all laboratory documents identifying current version

and distribution is in placeDocuments are reviewed and approved by the medical leader or

designate prior to use

Instrumentation and Equipment:Process for correction action when temperatures deviate from the

acceptable ranges

Diagnostic Imaging Most Frequently Cited Mandatory Requirements

Patient and Staff Needs:Patient information cannot be viewed by other patients or visitors

Secure and private location for storage of personal belongings

Information Management:Processes to ensure confidentiality, security and integrity of data

are provided at the beginning of employment as well as on an ongoing basis

Data stored on-site is accessible, but protected from unauthorized access and safeguarded from harm

Downtime procedures are documented and readily available

Policy for the use and disclosure of personal information

Diagnostic Imaging Most Frequently Cited Mandatory Requirements

Radiology:Radiation safety policies & procedures

Mammography:Appropriate consenting process prior to invasive procedures -

indications, risks, alternatives

Equipment performance is evaluated and monitored and quantitative dose determination conducted by a qualified medical physicist

Diagnostic Imaging Most Frequently Cited Mandatory Requirements

Ultrasound/Echocardiography:MSDS are posted where toxic and corrosive agents are usedPolicy of appropriate use of gel as per Health Canada

Computed Tomography:Policies and procedures are in place where Transfer of Function

duties are performed

MRI Safety Policies:Policies/procedures in the event of an inadvertent magnet quenchControlling access to MRI environment with appropriate signage

Diagnostic Imaging Most Frequently Cited Mandatory Requirements

Nuclear Medicine:Radiopharmaceutical agent is identified including dosage, time,

route of administration and individual administeringPolicies and procedures are in place where Transfer of Function

duties are performedRoutine performance of documented schedule for QC proceduresRadiation warning labels/signage are posted at entrance of rooms

that may contain a source of ionizing radiationEducation regarding hazards of radiation and reducing exposure

for nursing and ancillary staff

Bone Densitometry :Precision determinations are done in-house according to standard

protocol

Best Practices

Laboratory Medicine Document control program Occurrence management

Diagnostic Imaging Random daily audit of general procedures by

supervisor Retrospective review using electronic medical record

and images to identify process errors

Conclusions

Prior to 2006 on-site surveying of facilities was sporadic

“First” accreditation on-site survey provides a baseline expect several mandatory requirements and opportunities for

improvement to be noted Accreditation standards are far more comprehensive Surveyors use detailed survey protocols using

“tracers”– more comprehensive assessment of the diagnostic care process

Accreditation needs to be incorporated into the facility’s overall quality management program

Quality improvement is a process and takes time