Accreditation

by Lindi Rule, Quality Kaiwhakahaere (Quality Manager)

Lindi.jpg

Tēnā koutou katoa

Ko Ngāti Kahungunu ki te Wairarapa toku iwi, Ko Tumapuhia Arangi toku hapu, Ko Te Ore Ore toku marae, Ko Takitimu toku waka, Ko Te Maipi toku maunga, Ko Kawhata toku awa, Ko Okautete toku turangawaewae.                           

Ko Lindi Rule ahau, Ko Te Waiharakeke toku kainga tuturu, Kei konei tonu au e noho ana, Ko Quality Kaiwhakahaere taku mahi o Te Piki Oranga.

I have been with Te Piki Oranga since before its opening in July 2014. I was seconded from Maataa Waka Ki Te Tau Ihu Trust to help Anne Hobby with establishment of HR records. My role was Kaiawhi Tumuaki which involved all administrative tasks/ Board/Tumuaki support/HR processes/Financial data entry. 

As of 1 March, I will change to the full-time role of Quality Kaiwhakahaere.  The key areas of this role include Quality, Health and Safety and Risk Management. My first project is to attain accreditation using the DAA Group’s Evaluation and Quality Improvement Program (EQuIP).

What is accreditation?

Healthcare accreditation is an external review of the quality of care and services. It is “an internationally recognised evaluation process used to assess and improve the quality, efficiency, and effectiveness of healthcare organisations; it is also a way to publicly recognise that a healthcare organisation has met national quality standards.

EQuIP6 is structured in a hierarchy, as follows:

1. Function: A function is a group of standards.
2. Standard: The standard describes the overall goal; for example, Standard 1.1, Consumers / patients are provided with safe, high quality care throughout the care delivery process.
3. Criteria: The criteria describe key components of the goal, which are necessary for meeting the goal; for example, Criterion 1.1.1, Assessment ensures current and ongoing needs of the consumer / patient are identified.
4. Elements: For each criterion, there is a series of elements which explains the criterion:

  • describes some important practices for each level of achievement
  • should not limit practices; organisations are encouraged to undertake and present additional activities that respond to the criterion statement
  • should be regarded as a framework for total quality rather than a checklist of compliance
  • provides direction for improvement activities and for achieving better practice.
    Each element identifies what should be in place to at least fulfil the requirements of the criterion at a certain rating level.

5. Guidelines: The guidelines give definitions and provide more information and guidance on demonstrating achievement against the standards at the criterion level.

EQuIP6 has 3 functions, 13 standards, and 47 criteria. Each of the 47 EQuIP6 criteria has five possible levels of achievement: Little Achievement (LA), Some Achievement (SA), Marked Achievement (MA), Extensive Achievement (EA) and Outstanding Achievement (OA).

EQuIP accreditation cycle

Accreditation against the EQuIP standards requires organisations to participate in a four-year cycle of events, with one activity to be completed during each year of the cycle.

Phase 1 - Self assessment - New members provide a self-assessment against all criteria. Existing members  provide progress on action taken towards addressing the recommendations from the previous survey. Members submit their register of key organisational risks (risk register). Members submit their Quality Improvement Plan.
Phase 2 - Organisation-Wide Survey (OWS) - 6 weeks prior to OWS, members provide ACHS with a self assessment against all criteria and progress on action taken towards addressing the recommendations from the previous survey.
Phase 3 - Self assessment - Members provide progress on action taken towards addressing the recommendations from the previous survey. Members submit their register of key organisational risks (risk register). Members submit their Quality Improvement Plan.
Phase 4 - Periodic Review (PR) - 6 weeks prior to PR, members provide ACHS with a self-assessment against all mandatory criteria and progress on action taken towards addressing the recommendations from the previous survey. The Quality Improvement Plan is uploaded to EAT. The full risk register is provided to the surveyors at survey. Mandatory criteria are surveyed and progress on recommendations from the previous survey is reviewed.

This will be the focus of my mahi over the next 18 months. I have worked in Maori Health since 2002 and have successfully worked with previous providers to achieve accreditation so I look forward to the challenge. 

Nō reira, Tēnā koutou, Tēnā koutou, Tēnā koutou katoa.