- Introduction to DDKM
- Accreditation standards
-
Survey and rating of compliance
- Award of accreditation and publication of award decisions
- Appeals
- Resources
Survey and rating of compliance
A survey implies a visit from a surveyor team consisting of healthcare professionals who have received specific training to handle this task. Some surveyors in the practice sectors are IKAS employees, but all survey teams will include surveyor(s) who are peers, working most of their time in healthcare.
Survey has a dual purpose: To assess compliance with minimal requirements and to identify opportunities for improvement, even when the threshold for obtaining accreditation has been reached. A client needs to comply with the minimal requirements in order to obtain accreditation. But the survey should also give the client a feedback on his or her efforts to meet the purpose of the standards, and give this in a way that inspires and supports quality improvement work.
Compliance assessment is governed by defined rating principles. The fundamentals are the same for all programmes:
Met: the client in all essentials complies with the requirements in the indicator.
Largely Met: there are opportunities for improvement, but accreditation can be awarded; no further action is required.
Partially Met: there are opportunities for improvement, and action is required, unless accreditation be awarded with comments, or - in case of critical non-compliances - be denied.
Not Met: there is no evidence for compliance or only plans to achieve compliance.
For each programme, a guidance is available to clients and surveyors, assisting in the use of the principles in the specific context of that programme. The guidance also includes any supplementary rules pertinent to the programme.
After completion of the survey, the surveyor team submits a report to IKAS. IKAS provides a quality check of the report, which includes checking ratings for consistency with the principles and similar previous situations, but the final responsibility for the report lies with the leader of the surveyor team. The report includes the rating of all indicators, including reasons for the rating, if an indicator is not rated as Met, and a summary of the findings of the surveyor team. The surveyor team makes recommendations on follow up, if indicators are Partially Met or Not Met, but it does not make any recommendations on award of accreditation status. The client has an opportunity to review the report and to object to any factual inaccuracies, before it is forwarded to the Accreditation Award Committee, who will decide on the award of accreditation status (link til næste sektion).
As a rule, surveys are announced well ahead of the planned time. By special agreement, IKAS can provide unannounced surveys as part of an accreditation programme.
Some accreditation programmes require submission of a self-assessment before survey. This is not the case in DDKM.
Sidst redigeret : 22. januar 2016