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).

Focus survey  –  When a facility has made good progress, but there remain a number of non-conforming criteria that have the potential to impact negatively on patient and staff safety, legality or patient care, it is judged that the facility will be capable of addressing these non-conforming criteria within six (6) months of the External Survey. This survey (paid for by the facility) determines whether these deficiencies that are incompatible with accreditation, which remained at the External Survey, have been addressed prior to the award of accreditation.

 Remote Interim survey –  A survey (paid for by the facility) carried out at the mid-point of the accreditation award period to ensure that standards are being maintained in high-risk and selected areas.

Lapse –  The time between the expiry of the accreditation certificate and the date of the next re-accreditation (external) survey.

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

CATEGORIES OF THE COUNCIL’S ACCREDITATION AWARDS 

There are two categories of accreditation awarded by the Council, namely:

Full Accreditation and Graded Recognition.

FULL ACCREDITATION

This is an award given to facilities that substantially comply with the majority of the standards and criteria. Those criteria not complied with are considered not to seriously affect patient and staff safety, legality or patient care.

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

Criteria for determining the Accreditation period:

  1. On first entry into the Council’s accreditation programme, a facility that substantially complies with the accreditation requirements will be awarded a two-year accreditation on condition that:
  • the facility agrees to undergo a Remote Interim Survey by the Council at the midpoint of the accreditation award to ensure that standards are being maintained.

2. A facility that re-enters the programme within 12 months 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 a Remote Interim Survey by the Council at the midpoint of the accreditation award to ensure that standards are being maintained.

3. A facility that enters the programme four times and receives continuous accreditation 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 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 a Remote Interim Survey by the Council at the midpoint of the accreditation award to ensure that standards are being maintained.

Criteria for Remote Interim Surveys: 

  1. All facilities that receive a full accreditation award, regardless of the validity period of accreditation, will be required to undergo a Remote Interim Survey at the midpoint of the accreditation award period to demonstrate that compliance with the standards has been maintained.
  2. This requires the client to upload the relevant documentation for review a month ahead of the survey.  All the documentation is reviewed by two surveyors.  Any shortcomings are noted and if required, additional documentation may be requested.  A virtual meeting is scheduled with the client facility with the relevant team members.  A report on the findings is submitted to the client for factual accuracy and then to the Technical Committee to confirm that the standards have been maintained.

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, ‘Intermediate Level with a Focus Survey’, ‘Intermediate Level’, ‘Entry Level’ and ‘Progress Level’. 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, 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
At least two Service Elements > or = 65
Not more than three Service Elements < or = 40
All the remaining Service Elements > 40.

Progress 

  • 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.