The DAP accreditation processes reflect modern accreditation methodology and best practice. For new facilities and services, an Initial Assessment Process has been developed that requires completion of documentation and an initial on-site visit by the DAP prior to services being provided to patients.
Previously accredited facilities and services participate continuously in assessment activities throughout a three (3) year accreditation cycle.
Orientation & Education
All diagnostic services undergoing accreditation are provided with on-site orientation and education by an assigned DAP Accreditation Specialist. This two hour orientation session covers topics such as:
» Principles of quality improvement, accreditation, and the quality framework
» Accreditation Process and Methodology
» On-site Survey
» Standards organization
» Rating Scale
» Working through examples
Self Assessment
The Self Assessment is completed once in the 3 year cycle and precedes the On-site Survey. Conducting a Self Assessment enables the diagnostic service to evaluate their performance relative to stated standards and best practice. Assessing the diagnostic service's practices provides a profile of strengths, risks, and opportunities for improvement. This is both a valuable process and tool to enable the management to focus continuous quality improvement efforts toward specific activities and take action with the creation of a quality improvement plan.
On-site Survey
The On-site Survey is completed once in the Three Year Cycle and is conducted by a team of external peers comprised of medical, technical and management surveyors. During the On-site Survey, the surveyor will assess the performance of the diagnostic service using a patient/sample tracer methodology. This enables the surveyor to assess the performance of the diagnostic service as staff are conducting patient examinations, studies and/or analysis. Detailed survey protocols provide direction to the surveyor outlining what to ask, observe, and assess. The use of protocols also assists with increasing the objectivity and consistency amongst surveyors. The tracer methodology has been used successfully by the Joint Commission (JCAHO) and the DAP approach is based upon their experience.
Mid-cycle Assessment
In the two years that a full Self Assessment and On-site Survey is not being conducted, the diagnostic service will complete a site specific Mid-cycle Assessment. This self assessment is an abbreviated version of the DAP Standards and focuses on the critical aspects of providing effective and safe patient care. Screening criteria have been developed for use by DAP staff reviewing Mid-cycle Assessments that flag real or potential problems. Should the DAP identify an area of concern, the diagnostic service will be contacted directly for clarification. For issues requiring further analysis the diagnostic service will be required to complete a more detailed assessment. Based on this response, the DAP may conduct an On-site visit.
Proficiency Testing & Quality Control
Participation in DAP mandated Proficiency Testing and Quality Control programs remains a requirement for accreditation. Throughout the Three Year Cycle, the DAP will continue to monitor Proficiency Testing and Quality Control performance of facilities. Currently, facilities providing Laboratory Medicine and Pulmonary Function services provide performance data to the DAP for monitoring and follow-up. A priority for 2007 and 2008 will be to determine if participation in Proficiency Testing and/or Quality Control programs by Diagnostic Imaging, Polysomnography, and Neurodiagnostic services would be recommended.