4 key points to accreditation success

1. Link data clearly to your main accreditation hot spots

• Each “main measure” must have a clear line of sight to your accreditation requirements. Data collected at your front line (“sub measures” or “process measures”) can then be linked back to your main measures.

2. Allocate a sponsor

• “Main measures” need a sponsor to make sure it is reported and used for the benefit of reaching the accreditation goal.

3. Spell it out

• All measures need to be clearly defined to bring them to life.
• “Sub measures” and “process measures” must be tracked regularly to check if improvement efforts are working.

4. Inspire the right behaviour

• Involve staff in designing the “sub measures” and “process measures” so they understand how the actions they take impact accreditation performance.

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Main measures

Main measures are the highest-level measure and must be linked to your accreditation hot spots. These measures are usually lag indicators. If possible, keep the number of main measures to between four and ten. Our active short-term memory can only pay attention to, and manipulate, three to four things at once. 


Sub measures

Each main measure needs a set of sub measures. These could be lag or lead measures. Sub measures need a sponsor. Sub measures should be allocated to functional managers, or a key individual, to act as a sponsor for performance. The sponsor oversees performance but may not be performing required actions day to day.

Process measures

Each sub measure should have a set of short-term process measures used to track improvement activities. These should be measured daily, or at least weekly. Process measures describe the important behaviours or actions that contribute to the achievement of accreditation outcomes. 


Examples of process indicators include:

• Attendees at training
• Performance reviews completed
• Compliance with mandatory fields in medication history chart 


Data on display

Find a wall space to display your data in an area that is easily visited by your target audience. This could be in your work area, in a corridor or even in the staff tearoom.

For further advice on how you can best utilise the vast array of available data to ensure you prepare for accreditation, contact Michelle McDade on 03 8612 9313. Michelle is a lead consultant in PPC Health & Care industry practice, with extensive experience in public and private health.

Read: 5 things your organisation should know and do something about to improve clinical governance