HAS Evaluation strategy

• CODIR – Evaluation HAS is a preparation strategy for HAS evaluation.
• It was created on 20250121, by Feron-Vrau ST FRANÇOIS DE SALES and Université Catholique de Lille 1875

Agenda

• Démarche d'évaluation HAS presentation
• Key concepts by chapter
• Retroplanning
• Core actions
• Projects
• Turnkey

HAS Evaluation

• Replaces both the internal and external establishment evaluation systems.
• Takes place every 5 years.
• It responds to three issues:
  • Allowing the person to be an actor in their journey.
  • Reinforcing quality dynamics.
  • Promoting a meaningful approach for professionals.
• It is based on 4 core values:
  • The power to act of the person.
  • Respect for fundamental rights.
  • The inclusive approach of support.
  • Ethical reflection of professionals.

Characteristics of the HAS Evaluation

• Aims to propose a unique, homogeneous and common national framework.
• Aims to promote a continuous improvement approach.
• Fosters better support.
• Gives meaning to daily work.
• Involves a cross-examination of activities.
• Raises questions.
• It is not a control device or a search for a fault or inspection.

Key Figures of the Approach

• There is a single repository with 3 chapters, 9 themes, and 42 objectives.
• This repository contains 157 criteria and 18 imperative criteria.
• With specificities by type of establishment (= fields of application)
  • Target sectors include all ESSMS, Social, and Medico-social.
  • Structure type includes all structures, establishments, and services.
  • Public Type includes all public, elderly, PHE/PHA, PDS, AHI, PE/PJJ.

The 3 main chapters

• The accompanied person (Ch1)
• The professionals (Ch2)
• The establishment (governance) (Ch3)
• There are 9 investigational themes total.
• There are 139 standard criteria and 18 imperative criteria.

The 9 investigational themes

• Bientraitance and ethics
• Rights of the accompanied person
• Expression and participation of the person
• Co-construction and personalization of their support project
• Support for autonomy
• Support for health
• Continuity and fluidity of people's journey
• HR policy for ESSMS
• Quality approach and risk management

Evaluation Tools

• Validated evaluation tools aim to include input regarding citizenship, consent, activities, CVS, co-construction, and expression and participation.
• It also considers support project, evaluation waiting, staff awareness, autonomy and health
• It explores the end of life, resources, pain, HR, QVT, and quality approach

Evaluation process includes

• Consideration into prevention of breakage, staffing, professional risks, maltreatment, complaints, claims and risk management
• Also looks into the expression of person, personal awareness, ethics, freedom of opinion , and spirituality
• Looks into the private life, rights, dignity, liberty to come and go, with confidentiality and data protection is considered

HAS Evaluation Methods

• There are 3 assessment methods.
  • Referential which includes Chapter 1, Chapter 2, and Chapter 3
  • Methods which is accompanied tracer, targeted tracer, and audit system
  • Means which are interviews, observations, and documentary review

HAS imperative criteria focus

• There are 18 imperative criteria of HAS
• If it is < 4/4 a PAQ must be transmitted to the ARS in the 2nd month following the visit.

Some of the 18 criteria

• Professionals support the freedom to come and go of the accompanied person
• Professionals respect the dignity and integrity of the accompanied person
• Professionals respect the privacy and intimacy of the accompanied person
• ESSMS defines, with professionals, a plan for preventing and managing risks of maltreatment to the benefit of people accompanied
• ESSMS organises the collection and processing of complaints and claims

Intervenants

• Professionals in the field who are trained and competent
• Principles: Integrity/objectivity/confidentiality/skill
• Values: kindness and listening
• Consideration of difficulties.

Evaluation Visit process

1. Opening meeting
2. Meeting with residents/professionals/governance/CVS.
3. Observations/document review.
4. Closing meeting.

Cotation Legend

• Each criterion is rated by the intervener
• 1: The expected level is not at all satisfactory
• 2: The expected level is rather unsatisfactory
• 3: The expected level is rather satisfactory
• 4: The expected level is completely satisfactory
• *: The level achieved is optimized
• NC: The ESSMS is not concerned by the assessment element(s) of a criterion
• RI: The accompanied person gives an inappropriate response to the assessor (Chapter 1)

HAS Evaluation Updates

• Decree n°2024-1138 of December 4, 2024 setting the terms for publishing the results of quality assessments of services provided by social and medico-social establishments and services.
• Harmonisation and reinforcement of the rating system.

2023 key figures

• Quality of the ESSMS indicates that 3028 establishments and services were reviewed.
• A need for better prevention of risks is indicated
• A need for better management of complaints and the crisis

Implications / Challenges

• The implication of a maximum of employees and preparation of teams
• Capitalization based on the experience of other EHPADs in the association
• Preparation Logic integrated into daily practices
• Actions

Essentials by Chapter 1

• Bientraitance and ethics includes Perception and daily practices
• PA rights includes information, identification, rights and duties, trusted person, and access to information
• Expression and participation of the PA includes joint bodies and tracking requests
• PAP co-construction includes expectations and co-construction
• Support for autonomy includes expectations and assessment of needs
• Health support includes prevention, education and assessment of needs
• Continuity and fluidity of journeys includes transition and rupture.

Accompanying tracer

• In the framework of HAS evaluation, accompanied tracer corresponds to one of the 3 methods used to assess practices and organizations. -"Accompanying Tracer" is a method to assess professional practices with the experience of the accompanied Person. Identifies Key elements in the patient journey.

Aspects of the journey that are assessed

• "What works."
• "What could be improved."
• Examination of the completed records.
• Choice of an accompanied person by the team to participate in the process.

Aspects of The process

• Gather information and consent from the person and or their family.
• Meeting with the person and or their family and the questions posed won't deal with the relevant care.
• The views coming from points of view between different meetings and the audit the records.
• Identification of Strong and weak parts of the journey.

Essentials of Chapter 1

• Absence of IDEC / MED CO
• Identify professionals with the exercise
• The elements of proof include reception booklet, operating rules, DSI NETSOINS, FE awareness, training plan etc

Essentials of Chapter 2

• Bientraitance and ethics are ethical questioning
• Rights of the PA includes freedom to come and go, dignity and integrity, private life and intimacy, freedom of opinion, belief and spiritual life
• Respect and promote rights and freedoms along with sharing information
• PAP coconstruction includes adapting risks, trouble swallowing, dénutrition, sexuality, harassment, radicalization

Traced targets

• The traced targets in the framework of HAS evaluation relates to one of 3 methods used to evaluate the processes.
• The method evaluate if there are problems and seeks to ensure what is needed daily by the professional
• Targets themes are bientraitance and ethics, rights the person has etc

Essentials of chapter 3

• The quality indicators must be assessed include RH policy, violence, the way the clients are treated and quality
• There are different kinds of assistance that includes health and well being assistance
• There has to be quality indicators that should have been assessed

Retropical planning consists of

• Setting up a institutional meeting to exchange on different quality indicators
• Make sure everyone has an understanding
• Then schedule a follow up meeting and share the info

Other action plans

• Communication and overall plan of action
• Recruitment and centralisation of evidence
• Internal formation
• Administrative

Chantiers

• This process has to be displayed in the facility with organisation and the location needs to be set up for ease of access
• These programs need to have personalised assistance.
• Also needs to include promotional tools and risks in relation to clients.

Key Takeaways

• Procedures in different languages
• Guide to assist the gouvernance
• Complétantion of different key points