Accreditation and People Management PDF

Accreditation People Management Mohamed Eldeeb CPHQ,CPHRM,LSSBB,TQM,SCRUM Master ,TOT , Team STEPPS master training, TEMOS approved consultant  Accreditation concept Voluntary survey process used by non governmental ,...

Accreditation People Management Mohamed Eldeeb CPHQ,CPHRM,LSSBB,TQM,SCRUM Master ,TOT , Team STEPPS master training, TEMOS approved consultant  Accreditation concept Voluntary survey process used by non governmental , independent external agencies to assess extent of healthcare organization’s compliance with applicable pre-established performance standards set by the agency Accreditation involves both self assessment and external review (Accreditation surveys) focusing on organizational performance  Purpose of Accreditation True commitment to improve the quality of care Willingness to be compared to like organizations Enhance confidence to the public. Requirement for contracting with health plans and receive reimbursements. Condition of payment for U.S federal programs. To improve system , process of patient care and outcome  Standards and performance measures 1. Assessing actual performance rather than capacity to perform. 2. Processes and outcome not simply structure 3. Patient care issues related to quality and safety. 4. The organization’s efforts to manage care and to support process improvement.  JCI accreditation programs 1. 3 year cycle 2. it shifted the focus from survey preparation to continuous improvement. 3. Periodic performance review PPR (Annual self assessment) 4. Priority focus process PFP (pre-survey review of organization specific data 5. Quality reports revision 6. Active engagement of physician and healthcare givers in the accreditation process  survey preparations Just-in-time- JIT 1. Required ramp-up activities in the months prior to the survey to ensure success 2. During unplanned surveys crisis management cycle begins 3. Compliance is not sustained, but fluctuates in response to known survey cycles 4. Additional resources in order to be successful, such as extra time, energy, and people; as well as extra meetings for policy revision approvals and education on standards, roles, and survey process 5. Difficult to get leadership attention for identified compliance after survey  Continuous readiness: Goal of continuous readiness programs is to break crisis management cycles and just-in-time cultures to provide continuous safe quality patient care and sustained compliance with evidence-based practices, professional standards, and regulations. Key components of successful readiness programs: leadership commitment and manager Accountability. routine self-assessment. survey preparation processes. unannounced visit or survey plans  PERIODIC SELF-ASSESSMENT/PRE-SURVEY PREP 1. Establish focus groups for each important function of standards 2. Focus on correcting any non-compliance issues 3. Delegate any recommendations to the appropriate manager including person(s) responsible and time frames or actual deadlines 4. Educate all who should know about each pertinent improvement impacting their role 5. Review credentials process and files for (LIPs) for timeliness, completeness, and current competency status 6. Review human resource process and files for documentation of timely orientation and completion and maintenance of current competencies 7. Educate all staff concerning survey process, its importance, staff roles, policy & procedures 8. Walk around inspection. 9. Make Corrective Action Plans 10. These plans often are written in response to a survey, inspection, or gap analyses from that define. observations as well as recommendations for actions to achieve compliance for a given standard  PERIODIC SELF-ASSESSMENT/PRE-SURVEY PREP 11. Review the previous two full survey reports, as well as any random survey reports, looking for patterns in the organization 12. Previous recommendations will be focus areas for surveyors in future surveys. 13. Review credentials process and files for licensed independent practitioners (LIPs) ,peer review reports and human resources process. 14. Review and revise all polices and procedures associated with the standards (I couldn’t control this item during the surveys). 15. Identify any changes in survey process such as increased emphasis on patient safety will be addressed in any required pre survey documentation and on site  Leadership support/commitment: 1. Leaders must be willing to change their organization’s culture to one of readiness. 2. leaders must understand the business case for compliance and understand the costs of noncompliance. 3. Leaders must include continuous readiness within organizational strategic priorities in order to change the culture. 4. Identify an administrative team of key leaders and managers to coordinate and oversee ongoing compliance and survey planning efforts. These team members must have decision- making authority in the organization. 1. In some organizations, the Quality Council assumes this role. In other organizations, 2. it may be the administrative council or a leadership team made up of key QM/PI team leaders and sponsors.  Communications and Information: organization-wide information/communication improvements that make compliance easier e.g: Putting policy and procedure manuals and forms online. Providing an organization-wide compliance calendar with review dates, plan/report due dates, etc.. Computer sign-on screen. QI/PI or survey tips, reminders. Frequent emails to staff concerning relevant standards, Progress reports. Compliance needs. Get the network rolling  Education: Education programs can be designed around survey cycles over 2 or 3 years Pre-survey (1 year): focus of this year could be to keep staff and leadership aware of key standards and regulations and any anticipated changes as: sentinel event policies patient safety goals patient rights and responsibilities topics medication management infection control practices Survey year (year two): Educate staff about: The purpose of the survey. The value of the survey to the organization Expected timelines for the survey (dates) Expectations during the survey process. Survey etiquette. Post Survey (Year three): The focus of this year could be very similar to the focus of the first year, with the addition of programs that highlight survey results and next steps associated with opportunities identified for improvement, as well as new programs associated with these opportunities or findings.  Unannounced Visits 1. Healthcare quality professionals should develop plans with leadership for how the organization will respond when an unannounced surveyor arrives. 2. These plans facilitate a smooth survey regardless of who is present or available to assist the surveyor, as roles and expectations are understood in advance. 3. After welcoming the surveyor, request to see a photo identification card from the represented agency or organization and obtain a business card from the surveyor. 4. The survey should not proceed without proper surveyor identification.  The role of the quality professional in accreditation ❑ Healthcare quality professionals in leadership roles cannot be the lone voices requiring compliance in complex organizations so he must ask the governing board to identify an administrative team and clinical leaders who will assume the responsibility for continuous readiness. Provide the program structure and education to help managers understand their accountabilities and be successful. Check with the agencies and organizations that survey their facilities to understand changes in standards and regulations. Develop an effective and efficient education plan that targets defined levels within the organization also must develop an effective education plan that targets defined departments within an organization.  Exam Tips Seeking for accreditation: 1. Leadership commitment. 2. Becomes familiar with the appropriate standards. 3. Assign team for accreditation management and standard education 4. Standards education. 5. Communicate accreditation process to all staff. (Through the accreditation team.). 6. Educate all staff members the FAQs by the surveyors. And check compliance to standards.  People management ❖ Customer satisfaction begins with employee satisfaction. 1-That is why we strongly adhere to our people , service and profit philosophy. 2-If we put our employee first , They will deliver impeccable service and ‫خدمه خاليه من العيوب‬profit will be the natural outcome. Leader as motivator: 1- Motivation: 1- Encourage all to examine their own strengths and weaknesses. 2- Care OF all. 3- Listen actively and Discover others' strengths. 4- Remove barriers (dissatisfies) as much as possible and Obtain involvement 5- Lead by example. 6- Provide positive reinforcement and Ensure rewards. 7- Use the Pareto Rule: 20% of activities, if well prioritized, bring 80% of the results  2-Situational management: 1. Forces in groups and individuals need different response. ‫استجابته يتعامل مع كل واحد عل حسب‬ 2. It is wise to respond based on a solid assessment rather than fixed bias. ‫ان يكون حكيم وعادل بعيد عن التحيز‬ 69% of the responses related to desire for empowerment, recognition and acknowledgement of value, not for more money. Participative management ❖ Management puts people first and believe that employees are active participants in the organization so they should contribute ideas towards identifying and setting organizational goals , solve problems and other decisions that may directly affect them and information must be shared among all members of the organization. The negative impact of fear on employee: 1-Lack of extra efforts. 2-Making and hiding mistakes. 3-Loss of effective problem solving. 4-Loss of creativity , innovation and risk tracking. Participative management components: 1-Empowerment 2-conflict management 3-Problem solving and decision-making 4-Teamwork and education 5-Communication  1- Empowerment: ❖ Giving employees greater responsibility and authority and information they need to make wise recommendations or decisions and solve problems. Empowered staff are : 1-Properly trained. 2-Informed about and aligned with organizational strategies. 3-Authorized to act within parameters and feel secured no fear Empowerment enables people to: 1-Take ownership of their jobs and make decision concerning their department. 2-Take responsibility for their decisions. 3-Add value to their jobs. (the result)  2- Negotiation: Conflict resolution Negotiation is the art of conferring ‫ التشاور‬bargaining ‫ المساومة‬to reach agreement Types of negotiation 1-Hard negotiation: Out for "the kill” ‫بيدى أوامر‬ 2-Soft negotiation: Must be liked by the other side, giving in to ensure a good feeling ‫يكون مرغوب من‬ ‫الجانب االخر‬ Principled or interest-based negotiation: win-win. 1-Focus on the problem, not role as friends or enemies. 2-Separate issues from people; ‫افصل القضايا عن الناس‬ 3-Search for mutual gain based on each person's real interests. ‫الربح المتبادل‬  Stages of negotiation: 1. Prepare: Document your objectives, anticipate outcomes that might differ from your own expectations. 2. Determine: each other's stated interests/goals. 3. Search: for compromise or options for mutual benefit )‫(حل وسط‬. Philosophy of negotiation: ❖ Placing all relevant facts before the disputants, discussing the basis of disagreement, and finding some alternative solution that is best for the total organization. ‫ ناقش البدايل المفيدة للمؤسسة‬/‫ناقش نقط الخالف‬/‫وضح الحقايق‬ ❖ What course of action is likely to produce the best effect for all involved (WIN-WIN) Conflict Resolution Strategies: 1- Conflict is natural, neither positive nor negative. 2- Assume conflict can be healthy. 3- Focus on ideas, not people 4- Acknowledge the merits of every idea. ‫مزايا كل فكرة‬ 5- Use smoothing statements, such as, "Maybe there's another interpretation…." or "What about the possibility that…". If the group cannot reach consensus: 1-Step back and analyze the situation. 2-Review members' thinking ,Regroup the group, raise questions, suggest revisions.  3- Decision making: 1- It is choosing one decision from alternatives to determine a course of action. 2- There must be at least 2 choices or there is no decision , only forced choice. Steps in decision making and problem solving: 1)Define the problem / issue. 2)Set objectives and gather data. 3)Establish responsibility for decision making ( group or individual ) and delegate appropriate authority. 4)Search for alternatives (all possible way of reaching the objectives) (brainstorming). 5)Evaluate alternatives. 6)Make the decision. 7)Implement (action plan – resources – time frame – individuals).  Decision by consensus 1-Consensus is a group discussion where everyone’s opinions are heard and understood, and a solution is created that respects that opinions. 2- Consensus is not what everyone agrees to.(not unanimous agree) But, an acceptable resolution , one that can be supported by everyone, even if not the favorite of each one. 3-Consensus occurs when the majority agrees on a certain course of action and everyone else in the group is willing to proceed for the sake of the group ‫مصلحة الجروب‬, even some may not have chosen that course of action and would prefer another.  4- Problem solving: Problem : A deviation from an expected occurrence that cannot be justified as appropriate under the given circumstances. The key of problem solving is: involve people closest to the problem in both defining it and discovering the solution.(process owner) 1.Identification of the problem through : through Implementation of a well designed quality management program with clearly define performance measure. 2.Know the causes of the problems: a. Inadequate system or process ( 85% of causes ). process special cause variation. Wasteful unnecessary steps b. Lack of skills. c. Inappropriate persons behaviour ( not more than 15% )  5- Change management 1-Organizational change : any change occur in the environment of work. More important than changing processes and technologies is preparing people for change in behaviour. Causes of change resistance 1-Social network : relationships with co-workers. 2-Economics : salary , career, job security. 3-Inconvenience : ‫عدم االرتياح‬extra duties, transfer , learning new ways. 4-Fear of the unknown Organization’s ability to change dependent upon : A- individuals including leaders. B- Resiliency of individuals. C- Role of leaders in establishment of the culture of change. D- Behaviours needed to adapt to change. Change strategies: 1)The Value of Guiding Ideas "Guiding ideas" include at least the organization's mission, vision, core values, and strategic direction, and perhaps strategic initiatives with reasons for change. 2) Effective Change Management 1-A key managerial skill: on participatory management techniques. educating the entire organization on the anticipated impact of the change. 2-The change agent( CPHQ specialist): Makes change occur or facilitates group to effect change. 3-Group participation 4-Communication:  Resistance to change Focus on decreasing resistance to change, not necessarily increasing desire to change. How?????? 1. Explaining the need in advance. 2. Explaining the benefits of the change to the individual and group. 3. Establishing a receptive frame of mind. ‫االقناع باالدله‬ 4. Changing systems rather than people. 5. Provide a vision of the future. ‫اضع رؤيه‬ 6. Listen , use data to gain support; focus on the process. 7. Confusion ("We need to change, but how?"): Provide a plan and process. 8. Engaging people in appreciating this improvement and in assisting in other improvement efforts. Kotter's 8 step lewin's change model  palmer's change model Assess readiness first