Hospital Pharmacy Leadership Conference - June 1 - 3, 2007
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
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:
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
the most recent governance and clinical best practices
emerging trends in disease and wellness
more specific than current standards
Are easier to integrate into daily practice
The standards also have a new structure. Four main standards areas
have been envisioned:
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.
and sustainable governance
and supportive organization
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 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
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.
together to promote medication safety
selecting and procuring medications
labelling and storing medications
ordering and transcribing medication
preparing and dispensing medications
administering medications to clients
Monitoring quality and achieving positive outcomes
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.