Heading into their accreditation survey earlier this year, staff at Vancouver Island’s health authority were anxious. The organization was putting on a series of mock “tracers,” in which evaluators visit clinical settings and question front-line providers about care delivery. This in itself was a nerve-wracking prospect; the fact that a patient would be among the evaluators only upped the ante. “What will they ask? What can we say in front of them?” were some of the questions that Marlene Montgomery, a quality consultant at Island Health, remembers hearing from staff. In the end, though, the experience was very positive, and when Island Health was asked whether they would like a patient to be part of the actual accreditation process, they were “over the moon,” says Montgomery.
In 2017, Accreditation Canada (the organization that accredited Island Health) began introducing patients to their survey teams, teams that previously consisted only of “peer surveyors”—fellow physicians, nurses, social workers, managers and even CEOs. So far, AC has trained 14 patient surveyors, and a number of organizations, including Island Health, have been evaluated by teams that include them.
How will the inclusion of patient surveyors change the accreditation process? And how does this change fit within the broader shift in Canada toward patient-centred care?
How accreditation works
Though not mandatory in all provinces, accreditation is a process almost all major health care organizations across Canada undergo (all teaching hospitals are required to be accredited). It is typically conducted by independent, non-profit organizations (Accreditation Canada is primary among these, with more than 1,000 client organizations both nationally and internationally), and takes place once every four years. It often begins with an organization undergoing a self-assessment and several months of preparation, and culminates with an on-site visit by a team which can include as many as 30 surveyors. The team evaluates the organization against a series of standards specific to relevant services—diagnostic imaging, cancer care, the emergency department, for example—and issues a written report with its decision on whether or not to accredit, as well as any recommendations.
Previous patient involvement in accreditation
Five years ago, Accreditation Canada began a process of updating its standards to be client- and family-centred, which included “extensive involvement and engagement of patients,” says AC CEO, Leslee Thompson. Today, about 30 percent of the standards relate directly to the inclusion of patients and families, says Thompson, and 25 percent of each of the committees responsible for the ongoing development of standards at AC’s affiliate Health Standards Organization are comprised of patients and families.
To our knowledge, AC is the only accreditation body in Canada that officially includes patients on their survey teams. On its website, the Canadian Centre for Accreditation, which works primarily with social service agencies in Ontario, explains that it sometimes includes a youth reviewer on surveys of child and youth mental health organizations to assess standards related to youth engagement. The Canadian Accreditation Council, which works with social service and health organizations primarily in the Prairies, includes “consumers” on committees for developing standards, says Calvin Wood, the organization’s CEO. They do not have a formal process for including consumers on review teams, though Wood says his organization is considering moving in this direction. “There are certain things that, as a service provider, you have blinders on,” he says.
Wood thinks it’s important that there be clear screening and training processes if patients or consumers are to be included as reviewers. “We don’t want to put them into a situation if there are anxiety issues, where they are triggered through that process,” he says, adding that “they [must] understand that their role on the team is not to be carrying a particular agenda which they may have because of their experiences and that they have to be objective and evaluate the evidence as they are observing and as the process dictates.”
How do patient surveyors change the accreditation process?
In terms of logistics, there are few differences between Accreditation Canada’s peer and patient surveyors. The organization has adapted its surveyor competency framework, and now uses the same one when assessing potential patient surveyors that they do when assessing potential peer surveyors. They train both patients and peers together, and compensate both groups the same way, covering their survey expenses: travel, hotel and a per diem for food.
The key difference that patient surveyors make is the perspective they bring to the table. For example, during one of Island Health’s practice tracers at a dialysis clinic, the patient surveyor asked where the nurses did their hand hygiene—out in the hall or in front of the patient? She explained that while on an extended stay in the critical care unit, she had been very fearful of contracting infection and was always watching to see whether the staff who came to talk to her had washed their hands. She suggested that other patients would similarly appreciate being able to see clinicians wash their hands right there in the room before starting a conversation.
Then, when Island Health went through its real survey several months later, the patient surveyor was very interested in talking to the organization’s patient advisory board, asking questions like, “Do you feel the things that you have contributed have actually made a difference? Do you feel heard at quality council meetings?” “She really wanted to know how real the process was,” says Marlene Montgomery. “And I think our patients really appreciated that patient-to-patient connection, instead of having someone who they perceived as a surveyor with power.”
The patient surveyor pointed out some gaps in service, says Montgomery, referring to a standard that calls for a patient to be consulted when there are conflicting guidelines related to patient care. “We don’t do that at all,” says Montgomery. “[The patient surveyor] brought that out and thought it was a good opportunity [for change].”
What are the challenges with having patient surveyors on accreditation teams?
At a 2016 conference, AC’s CEO, Leslee Thompson, asked peer surveyors whether they thought bringing patients onto the survey teams was a good idea. “To a person, every one of the 350 hands went up,” says Thompson.
In spite of this enthusiasm, there are still growing pains. Some peer surveyors, says Thompson, “may not have the experience to feel as comfortable with the patient on the survey team,” depending on where their own organizations are in terms of patient inclusion. And of course, the same is true for organizations. “When we began the conversation in preparation [for accreditation], there was a lot of anxiety,” says Montgomery. People were uncertain generally about the new “paradigm” of including patients—managers wondered how they could talk about safety incidents in front of patients, for example, while nursing staff were concerned that the expectation to engage patients in care decisions would limit their time and impede their ability to get their work done. Helping staff feel comfortable with patient inclusiveness is “an ongoing thing,” says Montgomery.
Presently, it is up to an organization whether it wants a patient surveyor on its team, though Thompson says the goal is to eventually embed patients on every team. This will require significant growth, given that AC now only has 14 patient surveyors compared to their 500 peer surveyors. “How are we going to scale this on a very big level?” says Thompson. “We’re figuring that out now. We don’t have an answer to that. We’re taking it slowly and methodically, and using external evaluation to help us learn and adapt along the way.”