Case Study: Hospital Quality Accreditation

Introduction:

Upon assuming the role of Accreditation and Compliance Manager, Claire McDevitt, now the founder and principal of Healthcare Solutions, was entrusted with the task of implementing the Accreditation Canada Qmentum Program to enhance patient safety initiatives across Bermuda Hospitals Board (BHB). Over a span of 18 months, Claire led the hospital staff to full engagement, culminating in a monumental achievement in 2011 – Bermuda Hospitals Board attained the prestigious ‘Accredited with Exemplary Standing’, Accreditation, Canada’s highest level of accreditation, a feat achieved by only 20% of Canadian hospitals.

Challenge:

The challenge was to lead the hospital in a comprehensive implementation of the rigorous Accreditation Canada Qmentum Program. The mandate was not solely confined to the C-suite; the new continuous model required integration at every level, placing staff and patients at the core. The goal was to nurture a culture of excellence that thrived on continuous improvement, ensuring that quality and safety remained priority.

Approach:

Claire’s approach hinged on fostering hospital-wide buy-in and using clinical audits with quantifiable targets. She worked for four years on quality and safety improvements, culminating in a week-long onsite visit by four independent surveyors assessing BHB against 26 sets of healthcare standards, 35 priority processes and 30 required organisational practices. They assessed King Edward VII Memorial Hospital, Mid-Atlantic Wellness Institute, Lamb Foggo Urgent Care Centre and visited BHB’s group homes, reviewing documentation and policies, and interviewing staff, patients, and community partners.

Outcomes:

Accredited hospitals offer higher quality of care to their patients. 

Accreditation also:

• provides a competitive advantage in the healthcare industry
• strengthens community confidence in the quality and safety of care, treatment, and services at the hospitals. 
• helps healthcare facilities consistently deliver the best quality care and exhibit a culture of excellence that inspires them to continually improve their performance. 

Qmentum’s new continuous model means that accreditation cannot be achieved from the C suite alone and ensures staff and patients are at the forefront. It helps staff measure and improve on an ongoing basis and it keeps quality and safety at the forefront throughout the entire accreditation cycle.

By introducing clinical audits with measurable targets, the translation of utilisation data into meaningful information was transformational. This supported quality improvement, cost effectiveness and decision-making, all managed at the front line with managers and leaders taking accountability. Frontline staff emerged as pivotal contributors, participating in the development of patient safety initiatives and engaging in Root Cause Analysis (RCA) and Failure Mode and Effects Analysis (FMEA).

Conclusion:

The journey of accreditation highlighted the collaborative networking skills and Claire’s vision, the founder and CEO of Healthcare Solutions who led this programme from start to finish. High level vision and persuasion to draw others into the program, as well as the attention to detail, was required to implement the changes that such a stringent accreditation calls for.

The success of the program saw leaders from other departments seek and achieve more specialised accreditation, such as Laboratory Services, Joint Commission International (JCI); Mammography Services, American College of Radiography; Outpatients Rehabilitation and Outpatient Detoxification Services, Commission Accreditation of Rehabilitation Facilities (CARF).