Organisation self-assessment: The first accreditation challenge

By Dr. Abdalla Ibrahim, M.B.B.CH, MSc, MBA, Managing Director of Smart Management Consultancy, Bahrain and Adjunct Business Faculty, Geneva Business School

According to the International Society for Quality in Health Care (ISQua), accreditation is a self-assessment and external peer review process used by health and social care organisations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve the health or social care system.

Healthcare accreditation is currently a national mandatory requirement in some countries and optional choice reflecting performance excellence in other countries. The Quality Accreditation Life Cycle includes multiple steps and among them, there is an essential one that we call self-assessment.

Self-assessment is a process where an organisation compares its activities and performance against pre-set standards of excellence developed by an accrediting organisation or national authority. The purpose of self-assessment is to identify the organisation’s quality gaps, and consequently, find opportunities for future enhancement in terms of quality performance, safety practices and positive patient experience.

Because self-assessment step starts early in the accreditation life cycle, it is usually conducted by team members who demonstrate, at this phase, little understanding of benefits of accreditation and are confused with the accreditation terms. At this moment of the accreditation life cycle, the staff reflect an actual chaotic phase and continuously debate on questions like, “Why do we put extra load on the busy managers and staff?” “What’s in it for us?” And finally, “Why do we do such work?” This stage of rejecting versus accepting accreditation proves a true challenge to the organisation.

It is important to admire that self-assessment is not an easy task, as it seems on paper. It takes multiple sessions and some of them might not be related to the process itself but related to conflict consequences. As self-assessment is a teamwork task, therefore, all obstacles and challenges of teamwork will sound as struggle and competition; engagement and detachment; idea generation; acceptance and rejection, humble leadership support and reluctance of team involvement.

In the beginning, team participation, feedback, and input are expressed in terms of frustration, aggressive response, and dissatisfaction. Chaos and hard talk are a common impression after the early session. To overcome those challenges, it requires an effective leader who can manage the session to be organised, direct the hard talk to be productive, complete efficiently the self-assessment on due time and effectively, as it ought to be written. That leader will coach the team and work hard to facilitate the team transition from the low productive Forming Stage, and peacefully passing the staff to Storming Stage, then to the Norming Stage and finally reaching the highly productive Performing Stage of team development.

Nevertheless, it is essentially to know which team members should present the team. Self-assessment should be done with the involvement of staff who work within the discussed service chapter/element of accreditation standard manual. The self-assessment team should ideally consist of a group of motivated and committed staff of diverse backgrounds. Principally, the team should include a member who is quality/ accreditation oriented with good teaching skills to clarify the standards. It is equally important to have a member with extensive experience and knowledge of the organisation structure, committees, people in authority and people with talents. Likewise, a positive add is to include a knowledgeable member who can relate standard criterion to available organisational legislation, policy, manuals, practices, audits, circulars and other indicators. Additionally, there is a need for a mid-senior and new generation staff for their drive, ambition and enthusiastic power to meet accreditation challenges and confront other staff frustration and resistance for change.

Different models have been deployed to do self-assessment and currently they are electronically available on the portal of the accrediting organisation. The self-assessment portal has the following domains: Standard Met; Partial Met, Not Met, Not Applicable and finally a place for the evidence.

The problem is that, in some instances, the staff are requested to fill the self-assessment electronically and then to upload the response to the system without receiving training or clarification of the standards. This process may lead to improper input that results in doubtful assessment of the organisation.

Preferred method
There are many models to overcome such problems and the one I prefer the most and find easy to apply on the ground is when the team comes together in one single room and starts the process all together in the following sequences.

First, the leader of the self-assessment team reads and clarifies the requirement of a standard. To clarify a standard, identify how many verbs are in the standard phrase. The standard will be met whenever the organisation responds to the available verbs. For example: If the standard states “The organisation should develop and implement a process to improve …” this means there should be two activities: initially, develop the process. Next, implement the developed process.

Once the leader explains the standard, then, the team separately responds in a ‘Check List Style’ with an answer. The answer could be Met, Partially Met, Not Met or Not Applicable. If the answer is met or even Partially Met, the staff ought to mention evidences that might be a policy, manual, circular, meeting minutes, observation, outcome of process, interview findings, etc. Finally, the team members discuss their feedback and come in common agreement that the standard is met or partially met or not met and available evidences are true ones that actually meet the standard requirements.

To wrap it up, self-assessment is the first and true challenge for an organisation going through the accreditation cycle. It requires an effective and efficient leader to coach and navigate the ship through the early stage of chaos and team brainstorming and to achieve harmony between the accreditation team members to complete the self-assessment process and identify the organisation’s quality gaps.

Dr. Ibrahim will be speaking on “Communication safety in healthcare services” on October 25, day two of the Patient Safety conference, at Patient Safety Middle East.