Accreditation Audit Report by eDgFkO

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									Accreditation Audit Report



         Quality Council
       January 23rd, 2007
Objectives of Accreditation
Audit Report
   Evaluate the effective implementation of
    the QM / PI plan ;
         Follow on Findings and recommendations of
          2003Survey report
   Present 2006 Survey Report;
         Identify main quality strategic initiatives
   Framework for QM/PI Plans and Future
    steps.
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CCHSA Survey Report 2006

   Survey Summary
   Survey Details
   Overall Recommendations
   Focus Group Feedback
   Team Details
         Overall Findings
         Strengths
         Area For Improvement
         Recommendations
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Survey Summary

    This is the second accreditation survey for
     Security Forces Hospital Program. The
     hospital is commended for enabling and
     supporting the ongoing functioning of the
     accreditation teams...
 As a result, the teams have been able to
     implement quality improvements in their
     various areas which have contributed to the
     hospital’s overall growth and development in
     its quest for quality.
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SURVEY DETAILS
Accreditation Decision Details


          As granted by the Board of
          Directors of CCHSA, Security
          Forces Hospital Program has
             achieved the following
            accreditation recognition
                    decision:
                 Accreditation
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Overall Recommendations

   A Total of 30 Recommendations as
    follows:
   Total 10 Recommendations for
    Management areas
   Total 12 Recommendations for clinical
    teams
   8 recommendations for all clinical areas
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Focus Group Feedback

   Community Partners Focus Group.
   Staff Focus Group.
   Client Focus Group




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Team Details

   They have instituted a process to identify
    the best employee at regular intervals.
    The patients and their families are invited
    to provide input about whom they believe
    is the best employee. The person that is
    selected is recognized and this is
    communicated and publicized in the
    department and within the hospital

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Measurement and Outcomes


   Performance measurement is monitored
    through selected indicators. The team has
    selected them based on risk and frequency.
    They cover areas such as sedation protocol,
    delinquency of medical record complexion,
    patient falls, and readmission rates.
   The team analyzes the results regularly and
    appropriate action is taken when necessary.

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   Minutes of meetings are recorded and shared.
    This ensures good communication and
    maintains documented evidence of the work and
    the decisions made.
   The results are communicated. The team
    showed creativity, and an excellent poster was
    visible in the meeting in which performance
    results were presented.

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Today’s Situation

   Summary of the current situation
   Use brief bullets, discuss details verbally




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How Did We Get Here?

   Any relevant historical information
   Original assumptions that are no longer
    valid




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Available Options

   State the alternative strategies
   List advantages & disadvantages of each
   State cost of each option




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Recommendation

   Recommend one or more of the
    strategies
   Summarize the results if things go as
    proposed
   What to do next
   Identify action items


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