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Accreditation; Self Assessment

Accreditation; Self Assessment. Viki Massey, Quality Coordinator. A Joint Venture of London Health Sciences Centre and St. Joseph’s Health Care London. Two Phases of Accreditation. Peer review assessment Self-assessment. Purpose of Self-assessments .

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Accreditation; Self Assessment

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  1. Accreditation; Self Assessment VikiMassey, Quality Coordinator A Joint Venture of London Health Sciences Centre and St. Joseph’s Health Care London

  2. Two Phases of Accreditation • Peer review assessment • Self-assessment

  3. Purpose of Self-assessments • All laboratories starting the OLA process at the same time • Assist laboratories in: • Setting priorities • Planning for peer visits • Looking at big picture • Snap shot of “where we are” • How do we measure up?

  4. Self-assessment Facts • An audit or gap analysis • Once roll-out completed – once every 5 years • Requires a physical walk about – not a desk audit!

  5. Three Phases • Preparatory: • Create timelines (report due in 120 days) • Breakdown tasks • Assign responsibilities • Audit: • Fill out checklist

  6. Three Phases • Review/Analyze/ Prioritize (RAP) • Compile non-conformances • Categorize – major /minor • Develop reasonable action plans • Complete exception report for submission

  7. Phase One - Prepare 1. Create timelines • audits conducted by end of June • action plans due 2 weeks post audit • exceptions reports complete by August 20 2. Schedule self-assessments by campus 3. Assign responsibilities by discipline • OLA trained assessors- team leaders, team members • Volunteer assistants

  8. Phase Two - The Audit 4. Fill out the checklist by: • Interviewing staff • Tracing processes (policies to evidence) • Observing staff at work • Making notes on checklists

  9. Phase Three - RAP 5.Compile information gathered and look for: • similar issues in multiple areas • trends • isolated incidents 6.Categorize non-conformances to Major/Minor • use to set priorities

  10. Phase Three - RAP 7. Develop an action plan to correct every non-conformance: • Achievable, Reasonable, Effective

  11. Phase Three - RAP 8. Prepare and submit report to OLA within 120 days of notification • Sample for detail levels required • Getting signatures - allow enough time • Fax, E-mail, Mail

  12. Potential Follow-up • OLA requests compiled checklist for QA purposes • OLA requests compiled checklists to review, submission to scientific or advisory panel • Completed checklists reviewed at your next peer assessment • Initiate peer assessment

  13. Acknowledgement I would like to acknowledge and thank OLA for the use of some of their slides contained in this presentation

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