DDKM - the method

Getting started

When an institution, a company or an organisation is going to be accredited according to DDKM, collaboration with IKAS is initiated. IKAS offers courses for the employee(s) who are going to be project coordinators in relation to the process.

In addition, the management and project coordinator acquaint themselves with the relevant version of DDKM, i.e. the accreditation standards which apply for the specific institution.
Then the accreditation standards have to be distributed to the relevant areas or units. Some standards are relevant for all while other standards only are relevant for limited functions. One example is the hospital standard regarding use of coercion in psychiatry and which therefore is irrelevant for e.g. the maternity ward.

IKAS recommends a baseline assessment when the standards have been distributed. It is possible to see how many standards are met and how much work is needed. When the baseline assessment has provided you with an overview and you have prioritised the effort, you can start preparing guidelines for the areas which need guidelines, introduce new routines, teach staff etc.

Survey

When DDKM isimplemented, typically after approx. one year, an on-site survey should be carried out.

This implies a visit from a survey team consisting of professionals who ordinarily work in the healthcare system but who are also trained to handle this task.

The survey team does not make an unannounced visit. The time is agreed beforehand. The surveyors interview staff and patients or customers, observe procedures and review guidelines and other documents.

Subsequently, the survey team writes a report on how the institution or the company meets the accreditation standards in DDKM. This report is forwarded to the institution or company within five to six working days after the on-site survey, so the institution or company can change errors of facts and raise objections. The institution has five days to raise objections and there is only one opportunity to raise objections.

The report is discussed in akkrediteringsnævnet, which is an independent body responsible for the final decision regarding award of accreditation.

Accreditation status

The accreditation award committee awards three types of accreditation status:

• Accredited
• Accredited with comments
• Not accredited

There may be several stages before the final status. Some hospitals, community pharmacies, etc. are awarded status as accredited already by the first case handling while others are told that there are circumstances to put right before the final status can be awarded.

If an institution cannot be awarded accreditation, it can apply for a new process.

The decision of the accreditation award committee can be appealed.
 

Publication

When the institution's or the company's case has been decided in the accreditation award committee, the institution or company is informed.

Accreditation status and report are published at sundhed.dk and on this website irrespective of the result.

When accreditation has been awarded, i.e. status as "accredited" or "accredited with comments", the institution gets a certificate and the opportunity for using an electronic logo which shows that the institution has been accredited.

Validity period

An accreditation cycle lasts three years. New accreditation standards are prepared every three years and all institutions which are included by DDKM also have to undergo survey every three years.