1. What is Qmentum?
Qmentum is Accreditation Canada’s latest accreditation program, introduced in 2008. It replaced our AIM (Achieving Improved Measurement) accreditation program.
As part of our ongoing commitment to quality improvement, Accreditation Canada regularly reviews its programs and services to ensure we continue to meet the needs of our client organizations and provide leadership in the health services field. Qmentum features new and updated standards, innovative ways to assess services and submit data online, and an improved on-site survey process. Between on-site surveys, Accreditation Canada works with client organizations to identify follow-up activities and implement a roadmap for quality improvement. Qmentum also strengthens the consistency of evaluation across health service organizations.
The fundamental aspects of Qmentum are the same for all client organizations. For Aboriginal Health Services (AHS), the program has been customized to include culturally responsive practices, traditions, and to take into account the service delivery context in Canadian aboriginal communities.
As with all of Accreditation Canada’s programs and services, Qmentum will be regularly reviewed and refined to ensure its ongoing relevance, rigour, and applicability.
2. What is the Accreditation Primer, and who is it for?
The Qmentum Accreditation Primer is the first step on a health service organization’s journey to quality through accreditation. It is for client organizations that are new to Accreditation Canada. Organizations already accredited under AIM or Qmentum do not need to complete the Primer.
The Accreditation Primer helps an organization determine its readiness to proceed with accreditation. The Primer self-assessment and on-site survey form the foundation for ongoing quality improvement efforts that continue throughout the three-year accreditation cycle.
Accreditation Specialists guide the client organization through the Primer process, providing education and information, and helping the organization prepare for the Primer on-site survey. This usually takes place within six months of enrollment with Accreditation Canada.
During the Primer on-site survey, surveyors assess the organization’s programs and services. Surveyors also offer advice and insight and organizations find this is very useful in their quality improvement efforts. Following the Primer on-site survey, the client organization receives a report outlining areas of strength and areas for improvement; these areas become the basis for preparation for Qmentum accreditation.
Organizations that complete the Primer successfully receive an Accreditation Primer award and are able to proceed with the Qmentum accreditation process.
Accreditation Canada is pilot testing the Qmentum Accreditation Primer with three Aboriginal health service organizations in the fall of 2009. After information gathered from the pilot is incorporated, the Primer will be made available to Aboriginal health service client organizations in 2010.
3. What are the key differences between AIM and Qmentum?
AIM focused on improved measurement, evaluation, system integration, and automation. Qmentum builds on the success of AIM by incorporating these components and also introducing new elements. Qmentum involves more interaction between the Accreditation Specialist and the organization, as well as an accreditation survey schedule that is customized to each organization’s needs and priorities.
The core AIM standards have been reorganized and re-named in Qmentum:
| AIM core standards |
Qmentum core standards |
| Leadership and Partnerships |
Sustainable Governance |
| Environment |
Effective Organization |
| Human Resources |
|
| Information Management |
|
Tracers have been introduced as part of the on-site survey. A tracer is an assessment method that involves a variety of activities including document review, observation of service delivery, tours of the facility, and discussions with staff, clients, families, board members, partner organizations, and others as applicable. During a tracer surveyors, accompanied by a staff person from the organization, “trace” the path of a client (clinical tracer) or an administrative process (administrative tracer) to gather information about how the organization delivers service and manages its operations,
Performance measurement plays a more prominent role in Qmentum. As applicable to the activities of the health service organization, indicator data related to patient safety (for example, medication reconciliation and infection rates), and instrument data related to organizational processes (for example, governance, patient safety, and worklife culture) must be collected and submitted.
Required Organizational Practices (ROPs) remain an important part of Qmentum. An ROP is an essential practice that organizations must have in place to enhance patient or client safety and minimize risk. Consultation with Accreditation Canada’s Patient Safety Advisory Committee and a review of the evidence led to the first ROPs which came into effect in January 2005.
ROPs are now incorporated into each standards section rather than being assessed separately as they were under AIM. This approach allows us to select and tailor the ROPs to the specific services being assessed.
4. How are Aboriginal health organizations being moved into Qmentum?
Following the launch of Qmentum in February 2008, Accreditation Canada consulted with stakeholders in Aboriginal health services about the transition of AHS clients from AIM to Qmentum. A Transition Planning Committee for Aboriginal Health Services was established to develop a plan and a schedule for the change. The transition plan is now in place, with the objective of having all Aboriginal health service organizations using Qmentum by 2010.
The timing of an organization’s transition to Qmentum is dependant on where the organization is in its current accreditation cycle. Organizations due for their on-site survey in 2010 will start using Qmentum standards and materials in 2009. Organizations due for their on-site survey in 2011 will start using Qmentum standards and materials in 2010. Accreditation Specialists are available to help all our Aboriginal organizations plan their move to Qmentum.
5. How are Qmentum standards and accreditation processes for Aboriginal Health Services developed?
Qmentum standards and accreditation processes for Aboriginal Health Services are developed in close consultation with client organizations, content experts, and key stakeholders. The work is guided by Accreditation Canada’s Aboriginal Health Services Strategic Advisory Committee (AHS-SAC), consisting of representatives from diverse Aboriginal health services who have experience with and well-developed knowledge of issues related to Aboriginal health and wellness, and accreditation.
AHS-SAC was established in October 2008 to guide Accreditation Canada on the accreditation processes, tools and resources for Aboriginal health services. The AHS-SAC has been meeting regularly since that time and will continue to work with Accreditation Canada throughout the development and implementation of Qmentum for AHS.
6. When will our Organization Portal be available?
When organizations have their Qmentum education session, they are provided with online access to the standards and login information for their Portal. A customized education and training session called Introduction to Qmentum is delivered by Accreditation Specialists. The cost of this session is included in the new equalized fee structure, with additional education on a wide range of topics available on request.
Education sessions usually occur about a year prior to the on-site survey, with the precise timing determined in consultation with the Accreditation Specialist.
Organizations that have on-site surveys scheduled in 2010 will be provided with access to the Organizational Portal for Qmentum when they receive their Qmentum education session.
Organizations that have on-site surveys scheduled in 2011 and 2012 will be provided with access to the Portal in the year prior to their on-site survey.
Organizations scheduled for Primer assessment in 2010 will be provided with access to the Portal in 2009.
7. What Qmentum standards are available for Aboriginal Health Services?
As recommended by the AHS Advisory Committee, the Qmentum standards section for addictions treatment services is called Aboriginal Substance Misuse Services (ASMS). The associated standards sections are Infection Prevention and Control and Managing Medications within substance misuse services.
The Qmentum standards section for Aboriginal community health services is called Aboriginal Community Health and Wellness (ACHW). Where applicable, this set of standards is used in conjunction with Aboriginal Integrated Primary Care (AIPC) standards which address the primary care functions of health service delivery in Aboriginal community health services. In addition, organizations providing community health services also use standards that address infection prevention and control and managing medications within their services.
Additional standards are being developed to cover other services and functions offered by Aboriginal health centres and authorities, including services typically provided in remote nursing stations.
8. Does Qmentum have a self-assessment component?
Yes. Self-assessment is an important component of Qmentum and is completed in the months leading up to the on-site survey. All staff in a given service area are asked to participate in the self-assessment by completing anonymous on-line questionnaires that are linked to the standards. The results are summarized by Accreditation Canada and posted on the Organization Portal as part of the organization’s Quality Performance Roadmap.
The Roadmap is an electronic tool that helps organization leaders and teams easily identify strengths and areas for improvement, and begin action planning.
9. When can we start giving out self-assessment questionnaires?
Access to the self-assessment questionnaires is provided at the same time organizations are given access to the Organization Portal. Accreditation Specialists can help determine the best time to start setting up the self-assessment questionnaires.
10. How many self-assessment questionnaires need to be administered?
The standards sections under which an organization is assessed and the corresponding self-assessment questionnaires associated with those standards sections are determined by the scope and type of services provided by the organization. All organizations complete the Effective Organization self-assessment questionnaire; depending on their circumstances, they may also need to complete the Sustainable Governance questionnaire.
Accreditation Specialists work closely with each organization to determine the self-assessment process and requirements for that organization.
11. How is the Qmentum on-site survey conducted?
The on-site peer review by surveyors continues to be a key component of the accreditation process in both the Primer for new organizations and in the Qmentum process which follows successful completion of the Primer.
High-risk areas of service delivery are an important focus of Qmentum on-site surveys. There is particular attention paid to systems known to have a significant impact on patient/client safety and the overall quality of the care and services provided. In Qmentum, these systems are called priority processes, and are assessed during the survey using tracers.
Client organizations are provided with a summary report of the on-site survey findings immediately following the on-site survey. The report is a valuable tool to facilitate ongoing quality improvement activities, and manage the accreditation process.
12. We have been preparing for an on-site survey under AIM. Will Qmentum make our current efforts under the AIM program redundant?
Not at all. Qmentum builds on the strengths of AIM and current accreditation initiatives are simply carried over into the Qmentum process and accreditation cycle. Organizations should continue to focus their efforts on the current program requirements and work on recommendations from their AIM on-site survey. During the Qmentum on-site survey, surveyors review evidence of action and progress related to previously received recommendations under AIM.
13. We are a small organization with limited resources. How will Qmentum change our accreditation-related activities?
Qmentum streamlines the accreditation process for small and large organizations by focusing on priority processes and high-risk service areas, and by making it easy to integrate accreditation into your ongoing, everyday operations rather than concentrating primarily on the on-site survey.
That said, preparing for and achieving accreditation always requires organizational leadership, effort, commitment, and resources. To support your efforts, Accreditation Canada offers an efficient and flexible accreditation process that can be adapted to the needs of many types and sizes of health organizations, as well as ongoing communication and liaison with Accreditation Specialists who guide you on your accreditation journey. Accreditation Canada will continue to develop its information technology and other tools to further simplify the accreditation process and reduce the workload for client organizations, with ongoing attention directed to the needs of smaller organizations.
14. How can we stay informed about Qmentum program developments for Aboriginal health services?
Throughout 2009, Accreditation Canada has been communicating with Aboriginal health service organizations and key stakeholders about Qmentum. We host on-site education sessions to introduce and explain the program. We also publish information about Qmentum in In Touch, our newsletter for surveyors, in The Accreditation Standard, our newsletter for client organizations and Accreditation Coordinators, and on our website at www.accreditation.ca.
We continue to communicate directly with our client organizations through our AHS Accreditation Specialists who are available by phone and e-mail to answer questions and provide advice.
Accreditation Canada is committed to ongoing, open communication with our client organizations, our surveyors, and other stakeholders, and we welcome your ongoing interest and input in building accreditation services for Aboriginal communities and populations in Canada.
Accreditation in Aboriginal Health Service Organizations
Frequently Asked Questions
September 2009