Why we accredit facilities
Accreditation ensures quality, competence and safety through conformance to an acknowledged standard. Accreditation can lead to improved quality of service. It also provides formal recognition that the facility meets industry best practices.
Regulatory accreditation body
The DAP is the regulatory accreditation body for pulmonary function services in BC. We ensure availability of accreditation services to all diagnostic facilities and apply all policies and procedures in a non-discriminatory manner.
The DAP does not:
- provide competing services
- offer consultancy services
The accreditation scheme employs program specific standards developed by the DAP using international best practices and expert consensus through the program’s advisory committees. Staff and peer assessors with appropriate knowledge of the scope of accreditation are chosen to assess the diagnostic facility to the DAP standards.
Diagnostic facilities may not operate without an accreditation award
An accreditation agreement stating the terms of accreditation must be signed by the diagnostic service medical director as part of each assessment and when there is a change of diagnostic service medical director. The accreditation agreement explicitly states the College’s expectations of the medical director within the College Bylaws.
Facilities require provisional accreditation prior to opening and operating in BC. The provisional accreditation certificate is valid for up to two years. The DAP will reassess the diagnostic service to the full set of applicable standards within one year of the initial assessment.
Diagnostic facilities accredited by the DAP will have an on-site assessment conducted every four years.
Accreditation is only valid for the location (physical address) assessed. Relocation of a facility requires application for a relocation assessment. The existing accreditation award is transferred to the new physical address when the assessment standards are successfully met.
Hybrid (peer and staff-based) assessment methodology
What assessors do
The use of system and patient tracers allows the diagnostic service’s performance to be assessed as staff conducts their daily work.
The assessors are required to observe and assess the full scope of service that occurs at the facility, including all modalities.
The assessors follow specific assessment protocols that direct their assessment activities. The protocols provide direction to the assessors by outlining what to ask, observe and assess. The use of protocols also assists to increase the objectivity and consistency among assessors. It allows for comments, observations and recommendations to be recorded.
Collaborative assessment model
A collaborative assessment model will be used where facilities have common medical and administrative leadership, including:
- oversight of the quality manual
- safety program, human resource management
- quality management system
Collaborative assessments are used to reduce the duplication of work when multiple facilities under the same medical and administrative leadership are required to provide the same evidence.
Where a collaborative assessment is conducted, a comprehensive assessment to the DAP organizational standards will be conducted at a primary site. Site leaders will attend the assessment to confirm conformance to regional standards in each related facility.
Pulmonary function quality control program
Pulmonary function testing is a useful diagnostic test; however, accurate results are dependent on careful technique, proper equipment calibration, and maintenance. The American Thoracic Society (ATS) and European Respiratory Society (ERS) have recommended procedures to reduce variability.
Under the DAP pulmonary function quality control program, facility personnel at each site perform quality control (QC) procedures and pulmonary function measurements on BioQC subjects according to the DAP protocol.
The PF QC worksheets are submitted to the DAP twice each year, and they give an indication of any areas of concern with the equipment or performance of the tests. Where unsuccessful QC performance is observed, facilities must provide the DAP with evidence of corrective actions taken to improve performance.
During the on-site assessments every four years the QC performance history will be reviewed and considered when determining the overall accreditation award.