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Accreditation Process

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 four (4) year accreditation cycle.  

 

Orientation & Education

All diagnostic services undergoing accreditation can be provided with orientation and education. Some topics that can be covered are:

 

» 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 Four (4) 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 Assessment

The On-site Assessment is completed once in the Four (4) Year Cycle and is conducted by either DAP Accreditation Assessment Officers and medical assessor and/or external peer assessor. During the On-site Assessment, the assessor will assess the performance of the diagnostic service using a patient/sample tracer methodology. This enables the assessor 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 assessors. The tracer methodology has been used successfully by the Joint Commission (JCAHO) and the DAP approach is based upon their experience.

 

Proficiency Testing & Quality Control

Participation in DAP mandated Proficiency Testing and Quality Control programs remains a requirement for accreditation. Throughout the Four (4) 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.