Millcroft Hospital Pharmacy Leadership Conference - June 1 - 3, 2007

Theme: Hospital Pharmacy Practice Today - Just How Good are We?

CCHSA Accreditation: New Standards for Managing Medications

Jessica Peters, MPA
Senior Research and Product Development Specialist
Canadian Council on Health Services Accreditation
Ottawa, ON

Jessica Peters prefaced her remarks with an overview of CCHSA and its history. The role of accreditation is to promote quality improvement at the organizational and systems level, she said. The key elements in the program are the sets of standards. The current program sets out leadership and practice standards. The new program, which comes into effect in 2008, will see standards on governance, leadership, and clinical practice. These are high-level standards of excellence, not minimum standards, and are based on expert advice.

The new accreditation program is based on standards that:

•	Capture the most recent governance and clinical best practices
•	Reflect emerging trends in disease and wellness
•	Are more specific than current standards
•	Are easier to integrate into daily practice

The process has been streamlined and is more flexible so that it should be more adaptable for organizations of various sizes and complexities, Peters explained. There is also a greater focus on safety.

The standards also have a new structure. Four main standards areas have been envisioned:

•	Responsible and sustainable governance
•	Proactive and supportive organization
•	Service excellence (which includes population and sector-based standards, as well as specific standards for some areas, such as infection prevention, medication management, and diagnostic imaging)
•	Positive client experience

The importance of appropriate and evaluated medication processes is obvious in the current context, she said. After receiving extensive feedback from surveyors and client organizations, an expert working group with representatives of client organizations and the Institute for Safe Medication Practices Canada began developing the standards in 2004. In 2005, they were circulated for consultation to 15 key groups. Most of the content has remained the same, although there have been some subtle changes.

The introduction of Required Organizational Practices (ROPs) in 2005 was a new focus for CCHSA, Peters said. Experience has suggested that the standards are sometimes “pitted against” the ROPs, so the new ROPs are embedded within the standards. Some of the ROPs, like medication reconciliation, are beyond current common practice in the field, but they are important targets that raise the bar for continual improvement of patient care and safety.

The new standards for managing medication target institutional settings and focus on the safe use of medications, from selection and procurement through administration, Peters explained. A number of key themes are addressed:

•	Working together to promote medication safety
•	Carefully selecting and procuring medications
•	Properly labelling and storing medications
•	Appropriately ordering and transcribing medication
•	Accurately preparing and dispensing medications
•	Safely administering medications to clients
•	Monitoring quality and achieving positive outcomes

Importantly, the new standards recognize that pharmacists and pharmacy staff are integral members of the interdisciplinary team and should be actively involved in designing the organization’s medication use and medication management process, she said.

Peters reviewed the status of the process, timelines, and the role of pharmacy leaders in its development. The new standards and process are currently being piloted at 13 sites. A national consultation on the standards opened on May 14 and will be active until mid-June. She encouraged participants to “tell CCHSA what you think, because we rely exclusively on your feedback.”

Organizations involved in the 2008 process are being helped with customized transition plans into the new program, she said. Information sessions are being offered across the country to support the transition, and information is continually available on the CCHSA website.

Another important piece in the process is the ongoing and increased use of performance measures and indicators. Organizations have expressed confusion about which performance measures they should use, Peters said. In response, four performance indicators regarding patient safety have been developed. She cited this as a concrete example of how all organizations participate in the accreditation process. “As we move forward, the goal is to identify specific indicators in each process area, by involving as many organizations as possible in this ongoing broad consultative process,” she concluded.