Accreditation Criteria

Definitions

Accreditation

‘Accreditation is a self-assessment and external review process used by healthcare organisations to accurately assess their level of performance in relation to established standards and to implement ways to continually improve.’ (Rooney & Van Ostenberg 1999)

FULL ACCREDITATION

All services should score at least 80/100. There should not be any non-compliant standards or criteria that could result in serious harm or injury to patients or staff; contravention of critical laws and regulations or serious administration, organisational and/or managerial problems.

Compliance requirements for Full Accreditation:

All services must score at least 80/100; remaining non-compliant (NC) and partially compliant (PC) criteria must not pose a risk to patient and staff safety and must not contravene legal requirements (that is, services must achieve substantial compliance with standards and have no non-compliant or partially-compliant critical criteria)

External survey score > or = 85

  • All area indicator scores > or = 80 – (Management, Clinical and Clinical Support, Domestic and Technical, Allied Health Professionals)
  • All Service Element scores > or = 80
  • There may be no non-compliant or partially compliant critical criteria

GRADED RECOGNITION (PRE-ACCREDITATION)

For facilities that do not initially achieve accreditation, but have made significant strides since the baseline survey and are close to substantially complying with the standards, the Council has introduced a Graded Recognition Programme. There are four levels of Graded Recognition namely, “Progress”, “Entry” and “Intermediate” levels. Facilities achieving these levels are awarded recognition, in the form of certification, for a defined period and are encouraged and motivated to proceed to higher levels. The Graded Recognition Programme has been introduced to assist facilities that operate from a poor resource base.

REQUIREMENTS

Intermediate with a Focus Survey This award is given to facilities that, it is estimated, are able to address remaining deficiencies in the form of NC or PC criteria in three to six months.

External Survey score >85
All area indicator scores (Management, Clinical and Clinical Support, Domestic and Technical and Allied Health Professionals) >  or = 80
Not more than 3 Service Elements < or = 75 but > or = 70 and the remaining > or = 75.

The Focus Survey, which will normally be carried out over one day on-site at the facility, must take place within six (6) months of the External Survey.

Intermediate (no Focus Survey)
External Survey score > or = 80
All but one indicator score > or = 80 and the remaining area indicator score > or = 70 (Management, Clinical and Clinical Support, Domestic and Technical, Allied Health Professionals)

If only one area indicator is scored, then it must be > or = 80
Not more than three Service Elements < or =75 but > or = 65
Not more than two Service Elements < or = 65 but > or = 60 and the remaining > or = 75

Entry
External Survey score > or =75
At least half the area indicator scores (Management, Clinical and Clinical Support, Domestic and Technical and Allied Health Professionals) > or = 80 and the remaining area indicator score > or = 60
If only once scored, then it must be > or = 60
Not more than three Service Elements < or = 40
All the remaining Service Elements > 40.

Compliance requirements for Progress Status

  • If the baseline score is 50 or less, the facility must improve by at least 20
  • If baseline score is 60 or less, facility must improve by at least 15
  • If baseline score is 70 or less, facility must improve by at least 10
  • If the facility is a re-entry into the programme, it is not eligible for a Progress Certificate.

 If a facility has made little progress and is unlikely to do so unless there are significant increases in available manpower and physical resources, the facility will be encouraged to re-enter the programme to continue to improve the quality and standards of care within the facility.

Lapse
The time between the expiry of the accreditation certificate and the date of re-entry (see below).

Re-entry date
The date of re-entry is defined as the date on which the new contract is signed and a deposit paid.

  • CRITERIA THAT DETERMINE THE ACCREDITATION PERIOD

1. On first entry into the Council’s facilitated accreditation programme, a facility that substantially complies with the accreditation requirements will be awarded a two-year accreditation.

2. Should the facility re-enter the Council’s accreditation programme as part of a continuous self-evaluation using CoQIS, and remain in the continuous self-evaluation programme using CoQIS, it will be awarded a three-year accreditation.

3. A facility that re-enters the programme within one year after the expiry of its accreditation certificate will be awarded a three-year accreditation on condition that:

  • there is cogent evidence that the facility’s quality improvement programmes have not only been sustained but improved since the previous accreditation award;
  • the facility agrees to undergo an interim survey by the Council at the midpoint of the accreditation period to ensure that standards are being maintained or to enter the Council’s continuous self-evaluation programme using CoQIS for the duration of the accreditation period.
3.1 Should the facility substantially comply with the standards, but not meet the above requirements, a two-year accreditation will be awarded, with the option of undergoing a validation visit by the Council within 15 to 18 months after accreditation in order to identify any deficiencies:
  • monitor on-going compliance with standards;
  • extend the accreditation award by another year to three years if appropriate.
3.2. Should any deficiencies indeed be identified, the facility would then have the opportunity to rectify these and to apply for another validation visit, which might result in the extension of the award for another year to three years.
4. A facility that re-enters the programme four times and sustains unbroken accreditation awards will be awarded a four-year accreditation on condition that:
  • It achieved an initial two-year accreditation award with no Focus Survey;
  • The initial award is followed by two successive, three-year accreditation awards with no Focus Surveys;
  • there is substantive evidence that the facility’s quality improvement programmes have not only been sustained but improved since the previous accreditation award;
  • The facility agrees to undergo an interim survey by the Council within 24 months of accreditation to ensure that standards are being maintained or to enter the Council’s continuous self-evaluation programme using CoQIS.

CRITERIA FOR INTERIM SURVEYS:

1. All facilities that receive a four-year full accreditation award will be required to undergo an on-site Interim Survey.

2. A facility that receives a two-year full accreditation award shall be required to submit a report at the midpoint of the accreditation award period, containing documented evidence of compliance with selected standards. The continued use of CoQIS in a self-evaluation programme will assist facilities to maintain a continuous quality improvement programme.

3. A facility that receives a three-year full accreditation award and enters into an agreement to use CoQIS for a continuous quality improvement programme for the full duration of the accreditation award period, will be required to submit a report containing documented evidence of compliance with selected standards, at the midpoint of the accreditation award period. They will not be required to undergo an on-site Interim Survey.

4. A facility that receives a three-year full accreditation award and does not enter into an agreement to use CoQIS for a continuous quality improvement programme, will be required to have an on-site Interim Survey at the midpoint of the accreditation award period.