Accreditation Report
Prepared for:
Health PEI
Charlottetown, PE
On-site Survey Dates:
September 26, 2010 - October 1, 2010
October 18, 2010
Accredited by ISQua
Accreditation Report
About this Report
The results of this accreditation survey are documented in the attached report, which was prepared by
Accreditation Canada at the request of Health PEI.
This report is based on information obtained from the organization. Accreditation Canada relies on the accuracy
of this information to conduct the survey and to prepare the report. The contents of this report is subject to
review by Accreditation Canada. Any alteration of this report would compromise the integrity of the accreditation
process and is strictly prohibited.
Confidentiality
This Report is confidential and is provided by Accreditation Canada to Health PEI only. Accreditation Canada does
not release the Report to any other parties.
In the interests of transparency, Accreditation Canada encourages the dissemination of the information in this
Report to staff, board members, clients, the community, and other stakeholders.
© Accreditation Canada, 2010
QMENTUM PROGRAM
Table of Contents
About the Accreditation Report.................................................................................................................
ii
Accreditation Summary...........................................................................................................................
1
Surveyor’s Commentary..........................................................................................................................
3
Organization's Commentary......................................................................................................................
5
Overview by Quality Dimension.................................................................................................................
7
Overview by Standard Section...................................................................................................................
8
Overview by Required Organizational Practices (ROPs).....................................................................................
9
Detailed Accreditation Results..................................................................................................................
12
Performance Measure Results...................................................................................................................
97
Instrument Results.............................................................................................................................
97
Indicator Results...............................................................................................................................
102
Next Steps..........................................................................................................................................
119
Appendix A – Accreditation Decision Guidelines..............................................................................................
120
Table of Contents
i
Accreditation Report
About the Accreditation Report
The accreditation report describes the findings of the organization's accreditation survey. It is Accreditation
Canada's intention that the comments and identified areas for improvement in this report will support the
organization to continue to improve quality of care and services it provides to its clients and community.
Legend
A number of symbols are used throughout the report. Please refer to the legend below for a description
of these symbols.
Items marked with a GREEN flag reflect areas that have not been flagged for
improvements. Evidence of action taken is not required for these areas.
Items marked with a YELLOW flag indicate areas where some improvement is required. The
team is required to submit evidence of action taken for each item with a yellow flag.
Items marked with a RED flag indicate areas where substantial improvement is required.
The team is required to submit evidence of action taken for each item with a red flag.
­
Leading Practices are noteworthy practices carried out by the organization and tied to the
standards. Whereas strengths are recognized for what they contribute to the organization,
leading practices are notable for what they could contribute to the field.
Items marked with an arrow indicate a high risk criterion.
ii
About the Accreditation Report
QMENTUM PROGRAM
Accreditation Summary
Health PEI
This section of the report provides a summary of the survey visit and the status of the accreditation decision.
On-site survey dates
September 26 to October 1, 2010
Report Issue Date:
October 18, 2010
Accreditation Decision
Accreditation with Condition (Report)
Locations
The following locations were visited during this survey visit:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
Addiction Services Lacey House
Addiction Services Provincial Addictions Treatment Facility
Addiction Services Talbot House
Beach Grove Home
Central Queens Family Health Centre
Community Hospital O'Leary(CHO)
Harbourside Family Health Centre
Hillsborough Hospital
Home Care East-Montague
Home Care Queens County
Home Care West-Community Hospital O'Leary
Kings County Memorial Hospital
Margaret Stewart Ellis Home
Mental Health & Addictions East-Montague
Mental Health & Addictions Services West Alberton
Mental Health & Addictions West-PCH
Mental Health-McGill
O'Leary Health Centre
Primary Health Care-Sherwood Business Centre
Prince County Hospital (PCH)
Prince Edward Home
Queen Elizabeth Hospital (QEH)
Riverview Manor
Souris Hospital
Accreditation Summary
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Accreditation Report
25
26
27
Stewart Memorial Hospital
Wedgewood Manor
Western Hospital
Service areas
The following service areas were visited during this survey visit:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
2
Addictions/Gambling
Ambulatory Care
Blood and Transfusion Services
Cancer Care
Community Health Services
Diagnostic Imaging
Emergency Department
Home Care
Intensive Care Unit/Critical Care
Laboratory
Long Term Care
Maternal/Perinatal
Medicine
Mental Health
Operating Room
Rehabilitation
Sterilization and Reprocessing of Medical Equipment
Surgical Care
Accreditation Summary
QMENTUM PROGRAM
Surveyor’s Commentary
The following global comments regarding the survey visit are provided:
Surveyor Comments
The Health PEI organization is in the process of transitioning from a health system with direct oversight
by the ministry to a provincial health care organization, with a chief executive officer (CEO) and a board
of directors. The organization is commended for it's courage to participate in a full accreditation survey
in the midst of such change. The organization's intent is to use this report, along with areas for
improvement identified at the time of survey as a key strategy to improve the quality and safety of the
services provided to the population of Prince Edward Island. As this organization moves toward it' vision:
"One Island Future, One Island Community and One Island Health System', a key enabler will be the CEO's
leadership and a very capable board of directors. The board, which was appointed by the minister, has
been in place since July of this year, and it has just begun to develop a committee structure to support
its role in this organization. The board has created two sub committees namely, the quality and safety
committee as well as the compliance and monitoring committee in addition to one task group entitled:
"Public Engagement Task Force". The board has developed a strategic plan with four goals for the
organization. These include quality, equity, efficiency, and sustainability. Another key enabler to
achieve the vision for Health PEI is the new approach to a provision of service called Model of Care. This
initiative is intended to engage both patients/clients and families in self care and to support providers
to work within their full scope of practice.
Several exemplary initiatives to guide the future work of Health PEI have occurred. Diagnostic imaging
has demonstrated significant success and realized measurable benefits in wait times and turnaround
times, benefiting the entire organization as well as the public at large. The initial plans and strategies
to implement a provincial palliative care program are commendable. Efforts to negotiate a provincially
funded medication program for palliative care have been piloted and should be considered for ongoing
support. The organization has also implemented a Provincial Stroke Program to meet the needs of stroke
patients across the island. This is truly a collaborative effort including emergency services (ED)
medicine, intensive care (ICU) and emergency medical services (EMS).
Continuing Care and Home Based Care staff have embraced the Model of Care to expand the role of the
licensed practice nurse (LPN). This work could be used to advance the further development of the
Model of Care across the continuum. These examples should be celebrated and used to guide future
initiatives. Commendation is given to Health PEI for its efforts at implementing the Model of Care, which
does need to be expanded to include disciplines beyond nursing. There is also a need for a strategic,
broad communication plan to ensure that staff feel included in this process and understand the future
vision.
Based upon this survey, there are a number of areas that the organization is encouraged to focus on to
support the solid commitment to quality and safety in patient care. The organization needs to develop
province wide policies and procedures for infection prevention and control (IPAC) and ensure these are
well communicated and readily available for all staff at all sites.
The organization has developed and implemented clinical ethics and organizational ethical decision
making guidelines. This tool has been implemented to support a matrix, values based process for
decision making across the organization.
The organization is experiencing an incredible amount of change in all areas and would benefit from a
significant period of stability in order to focus on its stated objectives and strategic directions.
The organization needs to manage competing priorities within available resources to effectively achieve
overall goals and maintain momentum for providing quality care to the people across the island. A
significant risk to the organization is the lack of clarity around lines of reporting and accountability, in
Surveyor’s Commentary
addition to the many interim positions in the organization. The organization needs to pursue strategies
and opportunities to clarify roles and enhance integration between services and programs. The
organization also needs to pursue a province wide approach to planning and leadership for key clinical
services.
3
Accreditation Report
The organization needs to manage competing priorities within available resources to effectively achieve
overall goals and maintain momentum for providing quality care to the people across the island. A
significant risk to the organization is the lack of clarity around lines of reporting and accountability, in
addition to the many interim positions in the organization. The organization needs to pursue strategies
and opportunities to clarify roles and enhance integration between services and programs. The
organization also needs to pursue a province wide approach to planning and leadership for key clinical
services.
Communication across this organization continues to be a challenge. While much good communication
has occurred, the organization could benefit from a more proactive and strategically driven
communication strategy, which will profile the strengths and successes of the organization. Continued
attention needs to be paid to customized communication strategies to meet the information needs of
key stakeholders, including the public.
Community Advisory Committees (CACs) are in place at some sites to provide input from the community
on service needs. This is an effective way to obtain community input and feedback on organizational
plans. The community is very supportive of the organization, with financial contributions to the local
Foundation.
The organization has many positive initiatives and accomplishments that could be strategically
communicated to the public. There is much to be proud of and the organization could benefit from a
proactive approach to getting the message out to key stakeholders across the province.
4
Surveyor’s Commentary
QMENTUM PROGRAM
Organization's Commentary
The following comments were provided to Accreditation Canada post survey.
2010 Accreditation Health PEI Commentary
At the time of the last survey in 2007, all health services on Prince Edward Island were delivered within
the Department of Health. In addition, there were five boards providing some oversight to the
operations of the five community hospitals. When the surveyors arrived in P.E.I. in September 2010, all
health services in the province were being delivered by a separate entity, named Health P.E.I., under
the oversight of an eleven person board whose appointments were based on identified competencies.
The scope of the Department of Health and Wellness was expanded to bring a renewed focus on
wellness, as reflected in the new name, while providing policy direction to and monitoring of the
activities of Health P.E.I.
Authority was transferred to the Board on July 6, 2010; consequently they will not be covered by the
current survey.
The most recent transformation of the P.E.I. health system began shortly after the departure of the
surveyors in 2007 and is significantly broader than merely changes to the governance model. The
changes are designed to address, as much as any jurisdiction can, the significant issues impacting the
sustainability of the Island’s health system, most significantly being health human resource shortages,
the impacts of an aging population, and the introduction of modern technologies creating increased
demand for new services and treatments.
The creation of Health P.E.I. as a separate entity provides for a single, province-wide administrative
structure which will facilitate the development of provincial standards and practices, improve service
integration, and allow more active oversight as a result of the introduction of the competency-based
board. Other strategic initiatives include:
• introduction of a new collaborative service delivery model across all services which will
maximize the contribution of all staff in the system to the effective delivery of services;
• significant investments in primary health care and home-based care to shift the emphasis from
an over-reliance on bed-based care, provide improved access to health services closer to home, and
reduced admissions to hospitals and manors;
• introduction of a new medical leadership model supported by a single set of medical staff
bylaws for the province;
• implementation of comprehensive drug and clinical information systems which establish PEI as
one of the leaders in moving toward an interoperable health record;
• significant increase in focus and support for improved quality and safety across all service
sectors, including legislative changes, new disclosure policies and training, acquisition of a robust
electronic reporting system, and increased support for the provincial quality and safety council;
• increased focus on utilization and patient flow;
• enhanced support for staff and leadership development, including the creation of a provincial
human resources committee and a Chief Nursing Officer and Director of Clinical Practice position;
• the implementation of comprehensive accountability structure ranging from an integrated
strategic, business, and operational planning process, the introduction of accountability agreements, the
use of key performance indicators and associated dashboards, and project management and process
re-engineering techniques.
Our main objective as an organization through this period is improving patient safety and the quality of
our care.
Organization's Commentary
5
Accreditation Report
The new Board has confirmed their commitment to the same objective and have clearly stated that
quality and patient safety come first. We used the standards and principles embedded in the Accreditation
Standards as a key resource in supporting our work over the last two years. This survey provides an
excellent opportunity to see if we have been able to balance the many competing interests over the last
few years. The observations of the surveyors, their contact with our staff, and the information contained
in the final report will be a valuable resource for the new Board and for this new organization. This external
review, which compares our services to national benchmarks, reinforces our commitment to using evidence
and best practice as the basis for decision-making and prioritizing our work.
Thanks to everyone who was involved in the preparations leading up to and during the survey visit including
many staff and physicians who have worked hard on our quality teams. We believe that through each
improvement we make we can better support our staff and physicians in the work they do everyday
delivering quality, safe health services to Islanders.
6
Organization's Commentary
QMENTUM PROGRAM
Overview by Quality Dimension
The following table provides an overview of the organization’s results by quality dimension. The first column lists
the quality dimensions used. The second, third and fourth columns indicate the number of criteria rated as met,
unmet or not applicable. The final column lists the total number of criteria for each quality dimension.
Quality Dimension
Met
Unmet
N/A
Total
Population Focus (Working with communities to anticipate
and meet needs)
60
22
0
82
Accessibility (Providing timely and equitable services)
133
13
0
146
Safety (Keeping people safe)
541
82
54
677
Worklife (Supporting wellness in the work environment)
163
16
5
184
Client-centred Services (Putting clients and families first)
196
20
9
225
Continuity of Services (Experiencing coordinated and
seamless services)
80
2
3
85
Effectiveness (Doing the right thing to achieve the best
possible results)
698
168
65
931
Efficiency (Making the best use of resources)
72
7
2
81
1943
330
138
2411
Total
Overview by Quality Dimension
7
Accreditation Report
Overview by Standard Section
The following table provides an overview of the organization by standard section. The first column lists the
standard section used. The second, third and fourth columns indicate the number of criteria rated as met, unmet
or not applicable. The final column lists the total number of criteria for that standard section.
Standard Section
Met
Unmet
N/A
Total
Effective Organization
94
9
2
105
Infection Prevention and Control
90
9
4
103
Ambulatory Care Services
86
28
6
120
Biomedical Laboratory Services
32
19
1
52
Blood Bank and Transfusion Services
75
3
86
164
Cancer Care and Oncology Services
100
10
0
110
Community Health Services
64
4
0
68
Critical Care
80
26
3
109
Diagnostic Imaging Services
96
6
2
104
Emergency Department
91
13
3
107
Home Care Services
93
1
1
95
Laboratory and Blood Services
106
62
8
176
Long Term Care Services
112
5
4
121
Managing Medications
91
39
5
135
Medicine Services
88
15
1
104
Mental Health Services
101
8
2
111
Obstetrics/Perinatal Care Services
97
22
0
119
Operating Rooms
92
8
2
102
Rehabilitation Services
91
12
0
103
Reprocessing and Sterilization of Reusable Medical Devices
93
2
4
99
Substance Abuse and Problem Gambling Services
84
15
4
103
Surgical Care Services
87
14
0
101
1943
330
138
2411
Total
8
Overview by Standard Section
QMENTUM PROGRAM
Overview by Required Organizational Practices (ROPs)
Based on the accreditation review, the table highlights each ROP that requires attention and its location in the
standards.
Criteria
Effective Organization 6.9
Effective Organization 10.5
Infection Prevention and Control 1.2
Ambulatory Care Services 8.3
Ambulatory Care Services 12.2
Cancer Care and Oncology Services 7.5
Cancer Care and Oncology Services 11.3
Cancer Care and Oncology Services 11.4
Diagnostic Imaging Services 14.6
Emergency Department 8.3
Emergency Department 11.5
Long Term Care Services 8.4
Managing Medications 3.4
Managing Medications 3.5
Required Organizational Practices
The organization’s leaders provide the governing body with quarterly
reports on client safety, and include recommendations arising out of
adverse incident investigation and follow-up, and improvements made.
The organization’s leaders implement an effective preventive
maintenance program for medical devices, equipment, and
technology.
The organization tracks infection rates, analyzes the information to
identify clusters, outbreaks, and trends, and shares this information
throughout the organization.
The team reconciles the client’s medications with the involvement of
the client, family or caregiver at each visit if medications have been
discontinued, altered or changed.
The team reconciles medications with the client at referral or transfer,
and communicates information about the client’s medications to the
next provider of service at referral or transfer to another setting,
service, service provider, or level of care within or outside the
organization.
The team reconciles the client’s medications upon admission to the
organization, with the involvement of the client, family or caregiver.
The team reconciles medications with the client at referral or transfer,
and communicates information about the client’s medications to the
next provider of service at referral or transfer to another setting,
service, service provider, or level of care within or outside the
organization.
The team transfers information effectively among providers at
transition points.
The team informs and educates its clients and families in writing and
verbally about the client and family’s role in promoting safety.
The team reconciles medications for clients with a decision to admit,
with the involvement of the client, family or caregiver.
The team reconciles medications with the client at referral or transfer
and communicates information about the client’s medications to the
next provider of service at referral or transfer to another setting,
service, service provider, or level of care within or outside the
organization.
The organization assesses each client’s risk for developing a pressure
ulcer and implements interventions to prevent pressure ulcer
development.
The organization standardizes and limits the number of medication
concentrations available.
The organization evaluates and limits the availability of heparin
products and has removed high-dose formats.
Overview by Required Organizational Practices (ROPs)
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Accreditation Report
Criteria
Managing Medications 3.6
Managing Medications 7.2
Managing Medications 10.2
Medicine Services 7.5
Medicine Services 11.3
Medicine Services 15.4
Medicine Services 15.5
Mental Health Services 4.4
Mental Health Services 11.3
Obstetrics/Perinatal Care Services 11.3
Obstetrics/Perinatal Care Services 16.5
Rehabilitation Services 7.4
Rehabilitation Services 11.3
Rehabilitation Services 15.4
Substance Abuse and Problem Gambling
Services 7.5
10
Required Organizational Practices
The organization evaluates and limits the availability of narcotic
(opioid) products and removes high-dose, high-potency formats from
patient care areas.
The organization removes concentrated electrolytes (including, but not
limited to, potassium chloride, potassium phosphate, sodium chloride
>0.9%) from client service areas.
The organization has identified and implemented a list of
abbreviations, symbols, and dose designations that are not to be used
in the organization.
The team reconciles the client’s medications upon admission to the
organization, with the involvement of the client, family or caregiver.
The team reconciles medications with the client at referral or transfer,
and communicates information about the client’s medications to the
next provider of service at referral or transfer to another setting,
service, service provider, or level of care within or outside the
organization.
The team informs and educates its clients and families in writing and
verbally about the client and family’s role in promoting safety.
The team implements verification processes and other checking
systems for high-risk activities.
Staff and service providers receive ongoing, effective training on
infusion pumps.
The team reconciles medications with the client at referral or transfer,
and communicates information about the client’s medications to the
next provider of service at referral or transfer to another setting,
service, service provider, or level of care within or outside the
organization.
The team reconciles medications with the client at referral or transfer,
and communicates information about the client’s medications to the
next provider of service at referral or transfer to another setting,
service, service provider, or level of care within or outside the
organization.
The team implements verification processes and other checking
systems for high risk activities.
The team reconciles the client’s medications upon admission to the
organization, with the involvement of the client, family or caregiver.
The team reconciles medications with the client at referral or transfer,
and communicates information about the client’s medications to the
next provider of service at referral or transfer to another setting,
service, service provider, or level of care within or outside the
organization.
The team informs and educates its clients and families in writing and
verbally about the client's and family’s role in promoting safety.
The team reconciles the client’s medications upon admission to the
organization, with the involvement of the client, family or caregiver.
Overview by Required Organizational Practices (ROPs)
QMENTUM PROGRAM
Criteria
Substance Abuse and Problem Gambling
Services 11.3
Surgical Care Services 11.4
Required Organizational Practices
The team reconciles medications with the client at referral or transfer,
and communicates information about the client’s medications to the
next provider of service at referral or transfer to another setting,
service, service provider, or level of care within or outside the
organization.
The team reconciles medications with the client at referral or transfer,
and communicates information about the client’s medications to the
next provider of service at referral or transfer to another setting,
service, service provider, or level of care within or outside the
organization.
Overview by Required Organizational Practices (ROPs)
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Accreditation Report
Detailed Accreditation Results
System-Wide Processes and Infrastructure
This part of the report speaks to the processes and infrastructure needed to support service delivery. In the
regional context, this part of the report also highlights the consistency of the implementation and coordination of
these processes across the entire system. Some specific areas that are evaluated include: integrated quality
management, planning and service design, resource allocation, and communication across the organization.
Findings
Following the survey, once the organization has the opportunity to address the unresolved criteria and provide
evidence of action taken, the results will be updated to show that they have been addressed.
Planning and Service Design
Developing and implementing the infrastructure, programs and service to meet the needs of the
community and populations served.
Surveyor Comments
This organization has recently moved from being governed by the ministry to a model with a CEO
and board of directors. The leadership team has a good understanding of the needs of the people
it serves and uses this knowledge to plan services. Leadership team members have good
relationships with community partners such as the local community college and university to
support learning opportunities for students and as a recruitment strategy for the organization.
The organization has a very clear vision of: "One Island Community, One Island Future, One
Island Health System", which is how it frames the future of Health PEI, as well as the scope of the
services provided. There were value statements developed in consultation with staff and
stakeholders via a survey and focus groups. The values identified to guide the work of the
organization include: caring, excellence and stewardship. The strategic plan is based upon four
goals including quality, equity, efficiency, and sustainability. Objectives and corresponding
measures have been identified from which a series of key performance indicators (KPIs) were
defined, and are tracked and monitored in a regular basis.
In light of the many changes this organization is experiencing, a comprehensive educational plan
is being presented specifically around change management. This includes tools and strategies to
navigate change successfully and to support staff in the process as well. The organization is also
investing strongly in developing the nurse managers that will be leading and supporting much of
the change related to scope of practice for the many staff employed in Health PEI. All of these
initiatives indicate a strong commitment to not only leadership development during times of
change, but also support to all levels of staff.
There is an organized approach to quality and risk management, with long term goals that
include a comprehensive risk assessment for the organization and an education strategy to
support the implementation. This has yet to be put in place but the organization has identified
and implemented strategies to identify and mitigate risks through conducting proactive analysis
of high risk processes and implementing a disclosure policy across the province.
No Unmet Criteria for this Priority Process.
12
Detailed Accreditation Results
QMENTUM PROGRAM
Resource Management
Monitoring, administration, and integration of activities involved with the appropriate allocation
and use of resources.
Surveyor Comments
There is a centralized finance service that provides financial support to all sites and programs in
the province. The budgeting process is integrated into the planning process and the strategic
plan for the province guides the decision making around introduction of new spending. The
organization has operated with a balanced budget up until the last year when it incurred a
deficit. This was covered by the provincial treasury, and the goal is still a balanced budget. The
finance department has staff in each of the sites to work with local managers in the reporting
and monitoring of budgets. The chief financial officer (CFO) attends board meetings and is part
of the compliance and monitoring sub committee of the board to over see the financial status of
the Health PEI organization.
The staff of the finance department are very well qualified to manage the finances of this
organization and are not only committed to financial sustainability for Health PEI but also to
ensuring health services are available to meet the needs of the population served by this
organization. These staff have implemented processes to ensure accountability for the resources
they receive as well as compliance with all applicable legislation of the province. They have an
external audit conducted each year and all recommendations are addressed in a timely manner.
This department uses utilization data to identify opportunities for cost savings without
compromising care. One example concerns the high cost of island residents going to New
Brunswick (NB) and Nova Scotia (NS) for services not available in this province such as cardiac
surgery. Health PEI has reduced these costs by hiring two nurses to work in Halifax and one in NB
to coordinate the timely repatriation of patients post operatively for recovery back in PEI. This
has resulted in a significant cost reduction, reducing the length of stay (LOS) in a tertiary surgical
site before returning to a local facility. This department has implemented a number of innovative
approaches to reducing costs without compromising the quality or safety of the services
provided.
The organization does need to review utilization data to identify opportunities for more efficient
use of resources available. Please refer to the examples under patient flow documentation.
No Unmet Criteria for this Priority Process.
Human Capital
Developing the human resource capacity to deliver safe and high quality services to clients.
Surveyor Comments
The team has developed a comprehensive Human Resources (HR) plan and identified three
drivers which include leadership capacity, workforce capacity and work environment. They have
identified specific goals with objectives with strategies to achieve the goals and measures to
track progress. The organization has identified a clear need for leadership development for
managers who are dealing with an ever changing work environment. There has been a very
comprehensive training program developed for these managers which is just being implemented.
In addition to this training initiative a program to support change management is being
implemented as well.
within a provincial structure. Bylaws are under development and are in the process of being
approved.
Detailedcompetent
Accreditation
Results
The HR team represents a broad range of services to support a healthy,
work force.
The team has a specific unit called Recruitment and Retention Services to support a long range
strategy to ensure the right people are in place to fulfil the roles of the organization. Many
effective strategies have been employed to improve recruitment. Strategies include partnering
with the local colleges and university and working with community groups to support new
13
Accreditation Report
There has been significant planning to meet physician manpower needs well into the future
within a provincial structure. Bylaws are under development and are in the process of being
approved.
The HR team represents a broad range of services to support a healthy, competent work force.
The team has a specific unit called Recruitment and Retention Services to support a long range
strategy to ensure the right people are in place to fulfil the roles of the organization. Many
effective strategies have been employed to improve recruitment. Strategies include partnering
with the local colleges and university and working with community groups to support new
immigrants to the province. The organization has also implemented a bursary program to fund
the education of individuals being educated to fill difficult to recruit to positions. This funding is
provided via a return for service agreement.
Numerous efforts have occurred to support the health and wellness of employees. Wellness
committees are in place at many sites and there are many local initiatives to recognize staff for
quality work provided to the organization. There is also support for fitness club memberships,
walking groups, and support for staff that wish to stop smoking.
There is a clear focus on and commitment to staff development in this organization. There are
many educational offerings to support patient as well as staff safety. Sometimes, there are
difficulties in getting time to attend professional development due to limited replacement staff.
Staff have access to financial support for education through their unions and limited funds from
the organization. There exists some concern that access to these resources is not equally
distributed.
The organization conducted a staff satisfaction survey last year, and the top areas for
improvement were communication and performance reviews. The HR team has increased efforts
to ensure information is communicated to all levels of staff in the most effective way. This
continues to be an issue for front line staff at many sites. The team has also just developed a
policy on performance reviews, which it will be implementing and monitoring. Staff at some sites
did have performance reviews done on a regular basis however, with the exception of Prince
County Hospital, these were not done in acute care. Staff in community care, home care and
many long term care (LTC) facilities did have regular reviews done. The organization needs to
ensure managers are supported to complete this important work. The HR team does conduct exit
surveys for all staff that leave the organization and it monitors the results for opportunities for
improvement.
Staff files are maintained in a confidential area and are accessible only to appropriate staff.
There is a process to ensure that staff are appropriately licensed for the work they do.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Criteria
Location
Effective Organization
The organization’s leaders implement policies and procedures to
monitor performance.
14
Detailed Accreditation Results
12.9
Priority for
Action
QMENTUM PROGRAM
Integrated Quality Management
Continuous, proactive and systematic process to understand, manage and communicate quality
from a system-wide perspective to achieve goals and objectives.
Surveyor Comments
As part of an overall risk management program, the organization conducted their first
prospective analysis using failure modes effects analysis (FMEA) earlier this year following an
increase in the number of patients coming into hospital on methadone. There was also an
increase in newborns affected by methadone. The quality and risk staff identified this as a need
and are trained to lead and support this process. There have been changes in practice, based on
the findings of this work.
The organization has implemented the Patient Safety Culture instrument. While all areas of
concern have been addressed, it will take some time to see evidence of improvement. One area
of concern was follow up from incidents reported. Some strategies have been implemented but
they feel that a new electronic incident reporting will do much to help with the feedback loop on
these reports.
The governing body has had a presentation on quality and safety and has started to receive
reports on key performance indicators related to quality and safety, but as this body is very new
as a board, it has not had the opportunity to act on any recommendations. That is however, the
intent as the governance progresses with the quality and safety sub committee of the board.
The organization has a review process for all sentinel events that occur in the organization.
These reviews are lead by staff that have received formal training in the process, and
recommendations that come from those reviews are tracked and monitored by the quality and
patient safety council. Action plans are developed for the recommendations and accountability is
assigned at the executive senior leadership team to oversee compliance with those
recommendations.
The organization has dedicated significant resources to quality and patient safety as well as risk
management. This structure needs to become more integrated with all levels of the organization
to maximize the effects on front line care and services. As part of the risk management program,
the organization plans to do a comprehensive risk assessment across programs and services. This
has not been completed due to competing priorities. The organization needs to continue its
efforts to complete this work to ensure risks are identified and plans are developed to mitigate
these risks.
Numerous quality initiatives that have been done in response to a review of utilization data. One
example is in response to triage information, which reflected a tendency for inaccurate triage
levels to be assigned. Data were reviewed and audits were done that confirmed this assumption.
Education sessions for all triage nurses at the Queen Elizabeth Hospital (QEH) were implemented
and ongoing audits indicate an improvement in accuracy of triage levels assigned to patients
presenting to the emergency department at the QEH.
The leadership of this organization has made a clear commitment to providing safe, high quality
care to the patients they serve. There is a need for better communication to staff about this
infrastructure and a need for better integration of this program across all sites and levels of the
organization.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Detailed Accreditation Results
15
Accreditation Report
Criteria
Location
Priority for
Action
Effective Organization
The organization’s leaders provide the governing body with
quarterly reports on client safety, and include recommendations
arising out of adverse incident investigation and follow-up, and
improvements made.
There is evidence of the governing body’s involvement in
supporting the activities and accomplishments, and acting
on the recommendations in the quarterly reports.
6.9
6.9.3
The organization’s leaders, staff, service providers, volunteers,
and students receive recognition for their quality improvement
work.
7.5
The organization’s leaders implement an integrated risk
management approach to identify, report, assess, and manage
risk.
14.2
The organization’s leaders communicate the results of risk
management and quality improvement activities to everyone in
the organization.
14.9
Principle Based Care and Decision Making
Identifying and decision making regarding ethical dilemmas and problems.
Surveyor Comments
There are two committees responsible for ethics review. These are the Provincial Research Ethics
Board and the Provincial Clinical Ethics Committee. The first committee, the Provincial Research
Ethics Board, reviews research proposals regarding participant consent, data collection processes
and research methodology. Once this board has reviewed and assured compliance of these
items, it is sent to risk management, legal and contracts for review. This process can be quite
lengthy and delays occur at each step of the sign off process. The process can take up to six
months, which results in frustration and at times cessation of the research project. There is
evidence of reciprocal approval processes for some projects but not others
Area for Improvement:
It is suggested that a prospective analysis of the review process be initiated so that a new and
more streamlined process can be developed. The new process needs to encompass each required
step so that the review may be facilitated in a timely manner and a coordinated process
established to expedite and support researchers in their research attempts.
the strategic goals of the organization.
16
The
addition of clerical
support may assist in the timely management of the review processes and
Detailed
Accreditation
Results
the coordination of the steps required for supporting timely completion of the research review.
The Provincial Clinical Ethics Committee has been established to educate staff, physician and
client education on ethics, complete case consultation, review policies that have ethical
QMENTUM PROGRAM
It is further suggested that research questions be identified to support the direction of the
organization and facilitate knowledge exchange to build research capacity that may also benefit
the strategic goals of the organization.
The addition of clerical support may assist in the timely management of the review processes and
the coordination of the steps required for supporting timely completion of the research review.
The Provincial Clinical Ethics Committee has been established to educate staff, physician and
client education on ethics, complete case consultation, review policies that have ethical
considerations and promote an ethical culture where values of the organization are reflected in
decision making. This committee provides a report of its activities to the quality council and
holds in service sessions to share information about its process and conclusions to staff. This
committee has developed a comprehensive binder of information outlining the clinical and
organizational ethical decision making guidelines including a decision matrix and consultation
request process. This information has been distributed to the organization's staff. A workshop
was held in June 2009 to launch the guidelines. In addition to this introductory workshop, four
educational sessions were held across the province to inform attendees of the application of the
guidelines to everyday work processes. Issues discussed this year include: end of life decisions,
law enforcement disclosure, input to policies for management of critical care triage and first
available bed processes. A workshop directed at promoting a culture of patient safety through an
ethical lens was held for June 2010.
Areas for Improvement:
The committee is encouraged to pursue developing a feedback form for staff who have received
decisions from the Ethics Committee as to what was done with the information provided.
Further, the committee is encouraged to track the response time for consultation.
It is suggested that the committee proactively deliberate issues that may present ethical
concerns to support the implementation of new initiatives and to facilitate comprehensive policy
development.
It is suggested that the committee develop a communication strategy to inform staff of decisions
that have been made and consultation that has been completed so that all staff may learn from
and incorporate suggestions that may be relevant to their own practice.
It is also suggested that the guidelines be incorporated into the orientation program to acquaint
all new staff with the process.
It is suggested that the committee develop presentations to inform staff as to the use of the
ethical decision making criteria matrix in their practice and to facilitate this use at the clinical
and administrative level.
No Unmet Criteria for this Priority Process.
Communication
Communication among various layers of the organization, and with external stakeholders.
Surveyor Comments
The organization has a communications team that works hard to facilitate a positive relationship
with the media.
have implemented a forum for open communications with all levels of staff. This forum called:
"Straight Talk" has been quite well received and attended by employees. There continues to be a
need to focus a comprehensive communication plan targeted to all front line staff about key
Accreditation
Results
initiatives happening within Health PEI. This needs to be a multiDetailed
modal strategy
to reach the
maximum number of staff and physicians in all sites. The quality and safety plan for the
organization is an example of a large initiative that could impact the practice of all staff in the
organization but lacks a clear understanding by staff in some sites. There is a well developed
strategic communication plan for Health PEI. This plan will be critical to ensuring the right
17
Accreditation Report
These efforts are supported by the CEO and the board chair who have had open discussions with
the public at large. The team also works with various initiatives to ensure that have implemented
a forum for open communications with all levels of staff. This forum called: "Straight Talk" has
been quite well received and attended by employees. There continues to be a need to focus a
comprehensive communication plan targeted to all front line staff about key initiatives happening
within Health PEI. This needs to be a multi modal strategy to reach the maximum number of staff
and physicians in all sites. The quality and safety plan for the organization is an example of a large
initiative that could impact the practice of all staff in the organization but lacks a clear
understanding by staff in some sites. There is a well developed strategic communication plan for
Health PEI. This plan will be critical to ensuring the right message reaches the right people at the
right time. Many managers acknowledged the assistance they received from the communications
team to identify key messages in ensuring effective communication for various initiatives. There
are certainly challenges in reaching all staff and physicians of all sites across the province but
many strategies are being used to reach the target audiences.
The organization has also developed a strategic information management/information technology
(IM/IT) plan that aligns with the vision and goals of Health PEI. The organization has identified
IM/IT priorities and timelines for implementation. This has been a consultative process, with end
users engaged in each step of the process. This work and the plan is part of the long term
commitment to establish an integrated electronic health record (EHR) for the province of PEI. At
this time, a hybrid chart is in use which in some sites, has created some potential issues of safety
with different and inconsistent uptake for electronic chart entry. The organization is urged to
ensure that patient safety is a key consideration as the EHR is implemented across this province.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Criteria
Location
Priority for
Action
Effective Organization
The organization’s leaders seek input from stakeholders to
evaluate the effectiveness of their relationships with them.
3.4
Physical Environment
Providing appropriate and safe structures and facilities to successfully carry out the mission,
vision, and goals.
Surveyor Comments
Physical space planning is carried out in consideration of future needs. For example, the new
Emergency Department (ED) and sterile processing (SPD) at the QEH are designed based on a
formal assessment of the future projected requirements.
The Canadian Standards Association (CSA) standards and building code are followed for all
construction projects. All new areas are designed to be accessible for people with disabilities.
For example, the new ED at the QEH has wheelchair accessible entrances to all rooms, as well as
electronically controlled water taps for those with manual dexterity disabilities.
18
asset management) and put them in place across Health PEI. A Co-Joint Provincial Physical
Environment and Infection Prevention Committee has also been established in order to
incorporate infection prevention and control (IPAC) and environmental occupational health and
Detailed
Accreditation Results
safety best practices across the provincial physical environment including housekeeping.
All negative pressure rooms are maintained according to infection control requirements for
containment of airborne infections with alarms that simultaneously alert the unit and engineering
department any time the pressure changes.
QMENTUM PROGRAM
A Provincial Physical Environment Committee has been established to align the major
environmental standards and processes (i.e. preventative maintenance, security and equipment
asset management) and put them in place across Health PEI. A Co-Joint Provincial Physical
Environment and Infection Prevention Committee has also been established in order to
incorporate infection prevention and control (IPAC) and environmental occupational health and
safety best practices across the provincial physical environment including housekeeping.
All negative pressure rooms are maintained according to infection control requirements for
containment of airborne infections with alarms that simultaneously alert the unit and engineering
department any time the pressure changes.
The organization has generator back up for electricity. There is a back up data repository in
place at the provincial government offices.
The QEH site uses the steam from the local waste disposal incineration plant as a conservation
initiative.
Areas for Improvement:
Some more flexibility in standardization of equipment is needed as newer, improved solutions
come to the market.
The use of prospective risk assessment tools such as failure modes effect analysis (FMEA) is
encouraged. These tools can be used to identify and proactively address any major risk and
safety issues associated with the introduction of new equipment such as patient lifts, beds,
infusion pumps, and so on.
The organization is encouraged to develop a corporate construction/renovations policy and
procedure and have it easily accessible to all Health PEI sites. It is noted the organization has a
well developed process for protection of clients and staff during construction and renovation.
The safety requirements are incorporated into the building plans for all major projects. The CSA
Code # Z317.13 is followed for all internal renovation and construction projects. Infection
prevention and control and occupational health are routinely consulted. The construction site is
isolated and sealed off.
The organization is encouraged to ensure the hospital commissionaires receive the same training
as security guards, including for de-escalation.
The organization is encouraged to expand the designated areas for storage of patient equipment
when it is not in use in order to decrease clutter in the hallways on the medical and paediatric
units at the QEH site.
No Unmet Criteria for this Priority Process.
Emergency Preparedness
Dealing with emergencies and other aspects of public safety.
Surveyor Comments
Health PEI has adopted the Incident Management System (IMS) as the framework to prepare plans
to address the risk of disasters. A tabletop exercise was done in November 2007, and the
framework has been deployed to every facility on the island. A provincial incident manager and
site incident manager have been assigned as well as supporting roles to manage the response to
the disaster.
codes into the IMS framework. In the meantime, each of the sites has emergency response plans,
which are readily available on every unit. All staff are required to review and sign off on the
emergency codes each year.
Detailed Accreditation Results
Manager levels at every site have been trained on the IMS system. All staff have received a half
day training on IMS at the Community Hospital O'Leary site. Training is scheduled to be
completed as the site specific IMS is implemented in other sites.
19
Accreditation Report
Currently, work is underway to incorporate the current site specific emergency codes into the
IMS framework. In the meantime, each of the sites has emergency response plans, which are
readily available on every unit. All staff are required to review and sign off on the emergency
codes each year.
Manager levels at every site have been trained on the IMS system. All staff have received a half
day training on IMS at the Community Hospital O'Leary site. Training is scheduled to be
completed as the site specific IMS is implemented in other sites.
Health PEI is working closely to align with the Provincial Incident Command Structure (ICS) in
order to explore synergies and determine sustainability.
Health PEI has successfully enacted the IMS in response to three external disasters, since it was
adopted in 2007. The external disasters involved an anticipated major strike of essential
healthcare workers in the next province, a serious bus accident resulting in a significant increase
in incoming casualties, and the H1N1 pandemic in 2009. All sites reported the IMS enabled them
to respond more effectively, which was mainly due to increased role clarity and efficiency of
work flow and more effective communication.
System wide debriefs were completed after the H1N1, and a schedule of upgrades is being
reviewed.
Areas for Improvement:
A sustainable IMS training plan is required for new hires.
The IMS plan and assigned roles need to be assessed following the recent leadership realignment.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Criteria
Location
Priority for
Action
Effective Organization
The organization’s leaders regularly test the organization’s
disaster and emergency plans with drills and exercises.
11.8
Patient Flow
Smooth and timely movement of clients and their families through appropriate service and care
settings.
Surveyor Comments
The organization has experienced significant bottlenecks in patient flow owing to a lack of
discharge options for clients leaving acute care services. There are a number of strategic
initiatives to help relieve the pressure on the system. Many of these are longer range and will
need to be monitored to ensure they are making a difference. Health PEI has engaged discharge
planners as well as patient flow staff to help with appropriate timely discharge or transfer of
patients. There are many utilization issues that result in extended lengths of stay (LOS).
20
reveal significant opportunities for improvement. Some examples would be extended LOS for
normal vaginal deliveries, convalescing hip replacement patients, admission of day surgery
patients normally discharged home and reduction of Intensive Care Unit (ICU) days usage if
Detailed
Accreditation Results
epidural anaesthesia was managed on the unit care areas.
There are some areas of concern with over census on many units in the QEH and staff are feeling
significant 'change fatigue'. This needs to be monitored, as well to ensure that care is safe. There
are consistently off service patients on many units especially paediatrics, obstetrics, surgery and
QMENTUM PROGRAM
A more extensive review of bed utilization using LOS benchmarks and best practice would be expected
to reveal significant opportunities for improvement. Some examples would be extended LOS for
normal vaginal deliveries, convalescing hip replacement patients, admission of day surgery
patients normally discharged home and reduction of Intensive Care Unit (ICU) days usage if
epidural anaesthesia was managed on the unit care areas.
There are some areas of concern with over census on many units in the QEH and staff are feeling
significant 'change fatigue'. This needs to be monitored, as well to ensure that care is safe. There
are consistently off service patients on many units especially paediatrics, obstetrics, surgery and
rehabilitation. This can prolong wait times for elective procedures if beds are not available when
needed. This also presents a challenge to staffs' skill set who may be caring for a broad range of
patients with very differing care needs. The organization needs to make sure specific criteria are
used for placement of these patients as well.
The wait times for diagnostic reports has improved markedly with the redesign of work patterns
and addition of more equipment. This has benefited the organization as well as the public it
serves. There has been a policy and a process developed to manage increased work load for surge
capacity in ED, as well as ambulance diversion. There is a good process to identify critical
diagnostic values and reports are available to support timely client care. The ED at the QEH has a
process to inform clients and community about wait times for access to services in other sites.
Surgical services has implemented strategies to optimize flow of patients awaiting surgery.
However, the service does not have a process for follow up with clients discharged following
surgery, nor does it have a process to contact other service providers to evaluate the
effectiveness of services provided.
The introduction of a Crisis Response Team has improved the patient flow in mental health
services by limiting admissions, as a result of putting services in place in the community.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Criteria
Location
Priority for
Action
Operating Rooms
The operating room team contacts clients or follow-up service
providers to help evaluate the effectiveness of the procedure
and the post-surgical transition, and makes improvements to its
services as appropriate.
11.5
Medical Devices and Equipment
Machinery and technologies designed to aid in the diagnosis and treatment of healthcare
problems.
Surveyor Comments
An evidence based approach was adopted in the design for the support services including the
Sterilization, Processing and Distribution (SPD) department at the QEH site. An evaluation was
done for every department. The newly opened SPD meets best practice standards and has
capacity to meet future needs.
A robust education and skills development program is in place for all reprocessing staff at all the
sites involved in reprocessing. All staff are expected to complete the Vancouver Community
Detailed Accreditation Results
College Sterilization Program. Ongoing education is provided using a variety of approaches
including seminars, literature review and skills testing. The level of professionalism, cohesive
team based approach and commitment to excellence demonstrated by the SPD staff is
noteworthy. Staff are knowledgeable, motivated and take a great deal of pride in their work.
This was evident at all sites.
21
Accreditation Report
A robust education and skills development program is in place for all reprocessing staff at all the
sites involved in reprocessing. All staff are expected to complete the Vancouver Community
College Sterilization Program. Ongoing education is provided using a variety of approaches
including seminars, literature review and skills testing. The level of professionalism, cohesive
team based approach and commitment to excellence demonstrated by the SPD staff is
noteworthy. Staff are knowledgeable, motivated and take a great deal of pride in their work.
This was evident at all sites.
A skills based competency tool for the reprocessing staff has been developed and it will be
incorporated into the annual staff performance review at the QEH site.
Areas for Improvement:
There is an opportunity for the sites/centres to serve as a resource to one another and share best
practices across the island to include the community care and primary care. The designation of
one person that has overall responsibility for reprocessing and sterilization will assist with this.
The organization is adopting an asset management tool for maintenance and biomedical which
will eventually be used across all sites.
The organization is encouraged to ensure the physical separation of cleaning and reprocessing of
endoscopes, consistent with CSA Standard Z314.3-09.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Criteria
Location
Effective Organization
22
The organization’s leaders follow a plan for maintaining,
upgrading, and replacing medical devices and equipment.
10.4
The organization’s leaders implement an effective preventive
maintenance program for medical devices, equipment, and
technology.
10.5
There is a preventive maintenance (PM) program in place
for all medical devices, equipment, and technology.
10.5.1
The organization’s leaders have a process to evaluate the
effectiveness of the organization’s PM program.
10.5.3
Detailed Accreditation Results
Priority for
Action
QMENTUM PROGRAM
Reprocessing and Sterilization of Reusable Medical Devices
The organization designates a trained and competent individual
with the accountability for coordinating all reprocessing and
sterilization activities across the organization, including those
performed outside the medical device reprocessing department.
1.4
The designated person reports directly to the organization’s
senior management or the executive office.
1.5
Direct Service Provision
This part of the report provides information on the delivery of high quality, safe services. Some specific areas
that are evaluated include: the episode of care, medication management, infection control, and medical devices
and equipment.
Findings
Following the survey, once the organization has the opportunity to address the unresolved criteria and provide
evidence of action taken, the results will be updated to show that they have been addressed.
Ambulatory Care Services
Clinical Leadership
Providing leadership and overall goals and direction to the team of people providing services.
Surveyor Comments
Leadership efforts at the QEH site have been busy planning the new facility. This has contributed
to the lack of measurable objectives and goals at a time when understanding the current needs
of the community would enhance the design and function of the new facility.
The ambulatory care service at the Prince County Hospital (PCH) site is a hub of activity. The
essentially unrelated services are grouped together in a wing of the hospital and these manage to
function extremely well. The QEH ambulatory service also functions very well despite the space
and location challenges it currently faces.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Criteria
Location
The team uses the information it collects about clients and the
community to define the scope of its services and set priorities
when multiple service needs are identified.
1.2
The team’s scope of services is aligned with the organization’s
strategic direction.
1.3
Priority for
Action
Detailed Accreditation Results
23
Accreditation Report
The team regularly reviews its services and makes changes as
needed.
1.6
The team works together to develop goals and objectives.
2.1
The team’s goals and objectives for ambulatory care services are
measurable and specific.
2.2
The team has access to designated, private treatment or service
areas.
10.1
Competency
Developing a highly competent interdisciplinary team with the knowledge, skills and abilities to
develop, manage, and deliver effective and efficient programs, services, and care.
Surveyor Comments
The essentially unrelated services manage to function very well together. Education
requirements for staff are up to date and routinely reviewed and opportunities exist for
professional development. The "model of care" could be used to enhance the efficient use of
professional staff.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Criteria
24
Location
The interdisciplinary team follows a formal process to regularly
evaluate its functioning, identify priorities for action, and make
improvements.
3.7
The team monitors and meets each team member’s ongoing
education, training, and development needs.
4.8
Team leaders regularly evaluate and document each team
member’s performance in an objective, interactive, and positive
way.
4.9
Team leaders regularly evaluate the effectiveness of staffing
and use the information to make improvements.
5.3
The team has a fair and objective process to recognize team
members for their contributions.
5.5
Detailed Accreditation Results
Priority for
Action
QMENTUM PROGRAM
Episode of Care
Healthcare services provided for a health problem from the first encounter with a health care
provider through the completion of the last encounter related to that problem.
Surveyor Comments
Bedside care is very good. The team has a good client focus and routinely ensures clients receive
timely service.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Location
Criteria
The team receives clients at the service area in a manner that
respects their privacy and confidentiality.
6.2
The team monitors and works to reduce the length of time
clients wait for services beyond the time the appointment was
scheduled to begin.
7.5
The team regularly reviews the needs of clients who are waiting
for services and responds quickly to those who are in an
emergency or crisis situation.
7.6
The team reconciles the client’s medications with the
involvement of the client, family or caregiver at each visit if
medications have been discontinued, altered or changed.
8.3
There is a demonstrated, formal process to reconcile
client medications at each visit if medications have been
discontinued, altered or changed.
The team generates or updates a comprehensive list of
medications the client has been taking prior to the visit
(Best Possible Medication History).
The team documents that if medications have been
discontinued, altered, or prescribed during the visit, that
appropriate modifications have been made to the new
medications list; and clients have been provided with clear
information about the changes.
The new medications list is retained for the next client
visit.
The process is a shared responsibility involving the client
and one or more health care practitioner(s), such as
nursing staff, medical staff, pharmacists, and pharmacy
technicians, as appropriate.
Priority for
Action
8.3.1
8.3.2
8.3.3
8.3.4
8.3.5
Detailed Accreditation Results
25
Accreditation Report
Medication reconciliation at each visit if medications have been
discontinued, altered, or changed.
The team follows Accreditation Canada’s protocols and
definitions to collect and submit data on medication
reconciliation.
The team does not have any unaddressed priority for
action flags based on their medication reconciliation
indicator results.
8.4.1
8.4.2
The team uses standardized clinical measures to evaluate the
client’s pain.
8.6
The team provides clients and families with access to emotional
support and counselling.
9.6
The team follows the organization’s process to identify, address,
and record all ethics-related issues.
9.8
The team follows up with clients and service providers to
determine whether the ambulatory services provided
contributed to the achievement of the client’s service goals and
expected results, and uses this information to identify and
address barriers that are preventing clients from achieving their
goals.
10.9
The team documents all incidents involving administering, using,
storing, and disposing of medications, and uses this information
to make improvements.
11.8
The team reconciles medications with the client at referral or
transfer, and communicates information about the client’s
medications to the next provider of service at referral or
transfer to another setting, service, service provider, or level of
care within or outside the organization.
12.2
There is a demonstrated, formal process to reconcile
client medications at referral or transfer.
The process includes generating a comprehensive list of
all medications the client has been taking prior to referral
or transfer.
The process includes a timely comparison of the
prior-to-referral or prior-to-transfer medication list with the
list of new medications ordered at referral or transfer.
The process requires documentation that the two lists
have been compared; differences have been identified,
discussed, and resolved; and appropriate modifications to
the new medications have been made.
26
8.4
Detailed Accreditation Results
12.2.1
12.2.2
12.2.3
12.2.4
QMENTUM PROGRAM
The process makes it clear that medication reconciliation
is a shared responsibility involving the client, nursing staff,
medical staff and pharmacists, as appropriate.
The organization has a documented plan to implement
throughout the organization, and before the next
accreditation survey, a medication reconciliation process
at referral and transfer.
Following transition or end of service, the team contacts clients,
families, or referral organizations to evaluate the effectiveness
of the transition, and uses this information to improve its
transition and end of service planning.
12.2.5
12.2.6
12.6
Decision Support
Information, research and evidence, data, and technologies that support and facilitate
management and clinical decision-making.
Surveyor Comments
The team routinely tries to schedule visits to different services together, which makes the best
use of the client's time. When possible, privacy and confidentiality are maintained but some
space issues make this difficult to achieve.
No Unmet Criteria for this Priority Process.
Impact on Outcomes
The identification and monitoring of process and outcome measures to evaluate and improve the
quality of services to clients and the impact on client outcomes.
Surveyor Comments
The team needs to ensure that measurable goals are available, routinely measured and analyzed
to determine quality.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Location
Criteria
The team identifies the resources needed to achieve its goals
and objectives.
2.3
Staff and service providers participate in regular safety briefings
to share information about potential safety problems, reduce
the risk of error, and improve the quality of service.
17.3
The team identifies and monitors process and outcome measures
for its ambulatory care services.
18.1
Priority for
Action
Detailed Accreditation Results
27
Accreditation Report
The team compares its results with other similar interventions,
programs, or organizations.
18.3
The team uses the information it collects about the quality of its
services to identify successes and opportunities for
improvement, and makes improvements in a timely way.
18.4
Biomedical Laboratory Services
Diagnostic Services - Laboratory
Availability of laboratory services to provide health care practitioners with information about
the presence, severity, and causes of health problems, and the procedures and processes used by
these services.
Surveyor Comments
The standardized requisition is available to all clinicians across the health system.
The implementation of order entry on nursing units will be challenging and will require a full
training program.
Establishing a Point of Care program should be a priority for the organization to ensure the
accuracy of results obtained.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Criteria
28
Location
The laboratory has a written procedure for responding to verbal
requests for procedures.
CSA Reference: Z15189-03, 5.4.13
1.2
The laboratory follows a policy for identifying and handling
urgent requests.
CSA Reference: Z15189-03, 5.4.11
1.5
The laboratory has a manual or instructions available that
describes how to collect primary samples.
CSA Reference: Z15189-03, 5.4.2
2.1
The manual includes procedures for preparing the client,
identifying the primary sample needed, collecting the sample,
and safely disposing of the materials used to collect the sample.
CSA Reference: Z15189-03, 5.4.3
2.2
Detailed Accreditation Results
Priority for
Action
QMENTUM PROGRAM
The laboratory has a policy that describes acceptance and
rejection criteria for a primary sample.
CSA Reference: Z15189-03, 5.4.5, 5.4.8
2.5
The laboratory makes available standardized operating
procedures (SOPs) for processing samples and specimens.
CSA Reference: Z15189-03, 5.4.2, 5.5.1, 5.5.3
4.1
Authorized laboratory staff decides on examinations that are
needed and the SOPs to be followed.
CSA Reference: Z15189-03, 5.4.2, 5.5.3
4.2
The SOP includes examination procedures that have been
validated and confirmed for their intended use.
CSA Reference: Z15189-03, 5.5.2
4.3
Laboratory staff who are responsible for specific procedures
have access to the relevant SOPs.
CSA Reference: Z15189-03, 5.4.2, 5.5.3
4.4
If tests are performed outside the laboratory, the appropriate
individual applies the same processes and procedures as used in
the laboratory.
4.7
The organization has defined those situations in which testing
and analysis may occur outside the laboratory.
6.1
The laboratory has designated staff members to perform or
monitor point-of-care testing.
6.2
When monitoring point-of-care testing, the laboratory performs
quality control checks on each analysis.
6.3
The laboratory makes corrections to reports only in authorized
circumstances.
CSA Reference: Z15189-03, 5.8.15
7.9
The laboratory has a detailed policy on the release of
examination results.
CSA Reference: Z15189-03, 5.8.13
7.10
The laboratory is able to pull indicators of quality from the
overall results of analyses.
8.1
Detailed Accreditation Results
29
Accreditation Report
The laboratory informs individual requesters of analyses of their
utilization patterns.
8.2
The laboratory monitors results and analyzes trends.
8.3
The laboratory uses this information as part of its quality
management system to make improvements to future services.
8.4
Blood Bank and Transfusion Services
Blood Services
Safe processes to handle blood and blood components, from donor selection and blood collection
through to providing transfusions.
Surveyor Comments
Transfusion Services has effective processes and procedures to ensure patient safety.
There is a need for education training at the rural sites in the proper handling of blood products.
The Pre-Operative Clinic should revise information given to clients to include information on
possible transfusion risks and benefits.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Criteria
Location
The team keeps blood and blood components separate from
donor and recipient samples, tissues for transplantation, or
blood centre reagents.
CSA Reference: Z902-04, 9.4.3
11.6
The organization provides the recipient with information that
includes a description of the whole blood or blood component,
the risks and benefits associated with transfusion, and any
alternatives including their risks and benefits.
CSA Reference: Z902-04, 11.2.1, 11.2.2
18.2
The organization provides its staff with the most recent
information about the risks associated with transfusion.
CSA Reference: Z902-04, 11.2.3
18.3
Priority for
Action
Cancer Care and Oncology Services
Clinical Leadership
Providing leadership and overall goals and direction to the team of people providing services.
30
Detailed Accreditation Results
QMENTUM PROGRAM
Surveyor Comments
The team uses the services of a provincial epidemiologist that provides a population analysis
every six or seven years. The registry provides retrospective data regarding cancer patients.
There does not appear to be data compiled or analyzed, which would serve to inform planners
and decision makers regarding population trends upon which decisions as to changes in cancer
treatment programs can be made. Population demographics indicate that PEI has the highest rate
of female colorectal cancer in Canada. Staff however, are not aware of a program being
considered to address this issue or investigate its cause. The staff feel that the cancer program
no longer functions as an agency and as such, it is fragmented and no longer provides an over
arching cancer service in the province.
The team has identified two issues to be addressed namely, staffing and wait times. In addition,
the areas identified as red flags and Required Organizational Practice (ROP) deficiencies serve as
a basis for the team's action plans for the next year. Areas to be addressed include transition
processes, medication reconciliation at transfer of service, and medication utilization reviews. A
medication management program for palliative patients has been piloted with good results and
the staff are hoping that financial support for ongoing management will be forthcoming.
The cancer program utilizes the ARIA system for scheduling, for LINAC management and for
pre-printed protocol forms. The hope is that this program will be accommodated by the new
Clinical Information System (CIS). A professional interdisciplinary collaborative education (PICE)
has been organized to provide in services for staff. An integrated palliative care team exists and
provides comprehensive palliative care in the province.
The program/centre adheres to an eight week wait time target for radiation therapy.
There is an excellent individualized package of information, including for computerized
tomography (CT) scans, treatment plans and discharge instructions, which is prepared for every
patient.
Areas for Improvement:
Consider that both staff and family members indicate that there is a greater need for emotional
support of both patients and family members in the cancer program.
Families also request that waiting time for appointments in outpatients be posted so that
patients and families know the expected wait time. Although a pain scale is on the medication
administration record (MAR), its use is variable. Pain as a vital sign is not recorded consistently.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Criteria
The team uses the information it collects about clients and the
community to define the scope of its services and set priorities
when multiple service needs are identified.
Location
Priority for
Action
1.2
Detailed Accreditation Results
31
Accreditation Report
Competency
Developing a highly competent interdisciplinary team with the knowledge, skills and abilities to
develop, manage, and deliver effective and efficient programs, services, and care.
Surveyor Comments
The staff are all Registered Nurses (RNs) with the Canadian Association of Nurses in Oncology
(CANO) certification in oncology. Orientation is provided with ongoing in servicing for equipment,
new protocols and clinical trials.
The chemotherapy administration area is crowded and as such, compromises confidentiality of
information. However, a new ambulatory care centre is being built to address some of these
issues.
Multidisciplinary rounds are held weekly to discuss the progress of patients.
No Unmet Criteria for this Priority Process.
Episode of Care
Healthcare services provided for a health problem from the first encounter with a health care
provider through the completion of the last encounter related to that problem.
Surveyor Comments
The family and patient is actively involved in the plan of care. Contact information is provided
for after hours coverage and patients indicate that response to calls is timely and effective.
Extensive information is provided regarding treatment protocols, medication information and
appointment scheduling, and services available at the cancer centre. Individualized treatment
plan information is provided for patients, including person diagnostics, pre and post treatment
management and Canadian Cancer Society brochures about diet, chemotherapy, emergency
assistance program and living with cancer.
Areas for improvement:
There is inconsistent application of the Best Possible Medication History (BPMH) template. The
organization is encouraged to monitor compliance and admission reconciliation of medications for
all patients.
Although staging information is collected and serves as the basis for protocol identification and
implementation, there is a lack of consistency in recording the staging in a consistent location in
the patient chart for easy access.
It is evident that the Clinical Information System (CIS) will provide the support for an electronic
patient record. In the interim however, documentation of client's pain management, staging and
response to treatment is not consistently recorded in the paper chart and this needs to be
addressed
It is recommended that the organization inform clients of resources to provide emotional support
in terms of tumour specific support groups, as well as to access emotional support from
professionals as appropriate.
It is recommended that the use of medications and other therapeutic technologies be monitored
through ongoing utilization reviews.
32
It is recommended that medication reconciliation be consistently completed on referral or
transfer. It is also recommended that the team consistently provide transfer information at
transition points and at end of service. A document is provided to the client. However, complete
information
is not Results
consistently provided to the referral physicians.
Detailed
Accreditation
Patients and their families indicate that there is room for improvement in emotional support
services. One on one intervention is sometimes available and the team is actively encouraged to
promote the group interventions that are available.
QMENTUM PROGRAM
It is recommended that medication reconciliation be consistently completed on referral or
transfer. It is also recommended that the team consistently provide transfer information at
transition points and at end of service. A document is provided to the client. However, complete
information is not consistently provided to the referral physicians.
Patients and their families indicate that there is room for improvement in emotional support
services. One on one intervention is sometimes available and the team is actively encouraged to
promote the group interventions that are available.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Location
Criteria
The team reconciles the client’s medications upon admission to
the organization, with the involvement of the client, family or
caregiver.
The team documents that the BPMH and admission
medication orders have been reconciled; and appropriate
modifications to medications have been made where
necessary.
Medication Reconciliation at Admission
Priority for
Action
7.5
7.5.4
7.6
The team does not have any unaddressed priority for
action flags based on their medication reconciliation at
admission indicator results.
7.6.2
The team uses standardized clinical measures to evaluate the
client’s pain.
7.9
The team helps clients with moderate to high levels of distress
access education and supports services.
7.11
The team provides clients and families with access to emotional
support and counselling.
8.6
The team monitors and reports its use of medications and other
therapeutic technologies through ongoing utilization reviews.
10.9
Detailed Accreditation Results
33
Accreditation Report
The team reconciles medications with the client at referral or
transfer, and communicates information about the client’s
medications to the next provider of service at referral or
transfer to another setting, service, service provider, or level of
care within or outside the organization.
There is a demonstrated, formal process to reconcile
client medications at referral or transfer.
The process includes generating a comprehensive list of
all medications the client has been taking prior to referral
or transfer.
The process includes a timely comparison of the
prior-to-referral or prior-to-transfer medication list with the
list of new medications ordered at referral or transfer.
The process requires documentation that the two lists
have been compared; differences have been identified,
discussed, and resolved; and appropriate modifications to
the new medications have been made.
The team transfers information effectively among providers at
transition points.
11.3
11.3.1
11.3.2
11.3.3
11.3.4
11.4
The team uses mechanisms for timely transfer of
information at transition points (e.g. transfer forms,
checklists) that result in proper information transfer.
11.4.1
There is documented evidence that timely transfer of
information occurs.
11.4.3
Following transition or end of service, the team contacts clients,
families, or referral organizations to evaluate the effectiveness
of the transition, and uses this information to improve its
transition and end of service planning.
11.5
Decision Support
Information, research and evidence, data, and technologies that support and facilitate
management and clinical decision-making.
Surveyor Comments
The team is in transition regarding implementing the electronic chart for documentation of
patient progress. As a result, there are two charts: one electronic and one paper based. This
appears to present the opportunity for documentation to be inconsistent on each form of the
record.
No Unmet Criteria for this Priority Process.
Impact on Outcomes
The identification and monitoring of process and outcome measures to evaluate and improve the
quality of services to clients and the impact on client outcomes.
34
Detailed Accreditation Results
QMENTUM PROGRAM
Surveyor Comments
A risk assessment process is in place to identify and address risk to clients and staff.
No Unmet Criteria for this Priority Process.
Community Health Services
Clinical Leadership
Providing leadership and overall goals and direction to the team of people providing services.
Surveyor Comments
The provincial Primary Health Care Initiative has energized the primary care agenda in PEI. This
includes space, equipment, human resources, models of care, and chronic disease management.
The newly built O'Leary Health Centre opened this summer. Community service needs and
evidence supported practice were considered in the development of the physical space and
programs. Utilization of services is monitored with the goal of maximizing client access to
services.
Existing work design and job descriptions are being revised. Some staff have expressed concern
that they have not had input to this process.
The medical directors interviewed at both the Harbourside Family Health Centre and O'Leary
Health Centre sites are active participants in the planning of services and improvement
initiatives.
Staff express their passion for working with clients that have chronic disease to assist them in
self management of their condition. A good example of this is the pilot congestive obstructive
pulmonary disease (COPD) program in place at Harbourside Family Health Centre. The pilot
demonstrates what can be achieved via collaborative relationships with health system partners.
In the case of the COPD pilot project, there is a skilled respiratory professional from acute care
providing leadership to the project.
Also, services focus on illness prevention and health promotion as well as access to family
physicians in a collaborative model of care.
Areas for Improvement:
There are committed, multidisciplinary teams in all the health centres surveyed. Planning for a
consolidated, multidisciplinary client record is underway. Policy requires mental health (MH)
services to have a client's informed consent prior to sharing the client's health information with
the team. This will be a barrier to a single client record. It is recommended that the mental
health policy requiring client consent prior to sharing client information with other health
professionals for the purpose of providing comprehensive care be reviewed.
It is recommended that the process of developing and revising work and job design include staff
input.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Detailed Accreditation Results
35
Accreditation Report
Criteria
Team members have input on work and job design, including the
definition of roles and responsibilities, and case assignments..
Location
Priority for
Action
5.2
Competency
Developing a highly competent interdisciplinary team with the knowledge, skills and abilities to
develop, manage, and deliver effective and efficient programs, services, and care.
Surveyor Comments
The O'Leary Health Centre has excellent space and equipment for service delivery and
interdisciplinary team functioning. Staff meetings are held regularly, as are meetings with an
interdisciplinary clinical focus.
This fall, it is intended that a team development resource will be made available to work with
interdisciplinary staff. Orientation packages are being developed and new staff will be "buddied".
The licensed practical nurses (LPNs) will begin to have medical administration updates if
required, as per established parameters.
Students are welcomed in this environment, it is excellent exposure to an interdisciplinary work
environment. Partnership and interdisciplinary collaboration is well developed in the health
centres. Regular staff meetings are held and collaborative problem solving is usual.
Plans for human resources include the addition of nurse practitioners (NPs) to the
multidisciplinary team.
There is a committee structure which is used for developing the Primary Care Networks . The
committees are populated with managers and front line staff across the sites. Communication
about the work of the committees is proving a challenge to filter to front line staff.
Staff indicated that they receive adequate opportunity to attend educational events that support
evidence based program development. However, there was no evidence of an educational plan
for staff, and consistency in regular performance reviews is lacking. It is recommended that
regular performance reviews inclusive of an educational plan for staff be done regularly.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Criteria
36
Location
The team monitors and meets each team member’s ongoing
education, training, and development needs.
4.6
Team leaders regularly evaluate and document each team
member’s performance in an objective, interactive, and positive
way.
4.7
Detailed Accreditation Results
Priority for
Action
QMENTUM PROGRAM
Episode of Care
Healthcare services provided for a health problem from the first encounter with a health care
provider through the completion of the last encounter related to that problem.
Surveyor Comments
Clients that were interviewed value the service provided. They have all noted the excellent
access to service, which is respectful and professional. A post partum patient emphasized the
value of support and teaching from a lactation nurse and in fact, cited that as making her
successful in breast feeding.
Areas for Improvement:
Access to services is monitored and results inform changes to improve access where needed.
There is one area of long term difficulty in access to service. Access to speech language therapy
remains a concern as wait times vary between one to twelve months. It is recommended that
access to speech language therapy be reviewed and an action plan to reduce wait times be
implemented.
A client satisfaction survey has been done in the past year but results have not been
communicated to staff or clients. It is recommended that the client satisfaction survey results be
communicated to staff and shared with clients.
No Unmet Criteria for this Priority Process.
Decision Support
Information, research and evidence, data, and technologies that support and facilitate
management and clinical decision-making.
Surveyor Comments
There has been some involvement in research projects with partners. An example is the
pre-diabetes national project with the Public Health Agency and validating a screening tool.
No Unmet Criteria for this Priority Process.
Impact on Outcomes
The identification and monitoring of process and outcome measures to evaluate and improve the
quality of services to clients and the impact on client outcomes.
Surveyor Comments
In O'Leary, there has been communication with the community about the role and services of the
new health centre. Ongoing communication will be required before there is to be sufficient
community understanding. Management and staff at the O'Leary Health Centre are conscious of
staff and client safety.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Detailed Accreditation Results
37
Accreditation Report
Criteria
The team shares evaluation results with staff and the
community.
Location
Priority for
Action
11.10
Critical Care
Clinical Leadership
Providing leadership and overall goals and direction to the team of people providing services.
Surveyor Comments
The setting of clear written goals and objectives that are measurable and for which the
department is held accountable, is an important vehicle for implementing quality improvement
projects.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Criteria
38
Location
The team collects information about its clients and the
community.
1.1
The team uses the information it collects about clients and the
community to define the scope of its services and set priorities
when multiple service needs are identified.
1.2
The team’s scope of services is aligned with the organization’s
strategic direction.
1.3
The team regularly reviews its services and makes changes as
needed.
1.5
The team works together to develop goals and objectives.
2.1
The team’s goals and objectives for its critical care services are
measurable and specific.
2.2
The team works with its leaders and other organizational teams
to plan for surge capacity in units dedicated to critical care
services, particularly during predictable periods of high client
volume (e.g. flu season), or during pandemics or other
large-scale emergencies.
2.8
Detailed Accreditation Results
Priority for
Action
QMENTUM PROGRAM
Competency
Developing a highly competent interdisciplinary team with the knowledge, skills and abilities to
develop, manage, and deliver effective and efficient programs, services, and care.
Surveyor Comments
Areas for Improvement:
Closing the critical care unit would allow for a smaller number of clinicians to gain expertise to
manage ICU patients and also, would enable the physicians to make rounds with the
interdisciplinary team. Additionally, closing the ICU would permit standardization of treatment
and likely reduce the need to transfer critically ill patients off the island.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Location
Criteria
The interdisciplinary team follows a formal process to regularly
evaluate its functioning, identify priorities for action, and make
improvements.
3.10
Team leaders regularly evaluate and document each team
member’s performance in an objective, interactive, and positive
way.
4.6
Team members have access to a quiet space to reflect, rest, and
relax.
5.6
The team has a fair and objective process to recognize team
members for their contributions.
5.7
The interdisciplinary team conducts daily rounds.
10.2
Priority for
Action
Episode of Care
Healthcare services provided for a health problem from the first encounter with a health care
provider through the completion of the last encounter related to that problem.
Surveyor Comments
Medical outreach teams would reduce the rates of admission to ICU, reduced code blues and
provided educational and professional support to unit nurses. The QEH site is advised to endorse
and resource such a team.
The QEH and PCH sites should promote or mandate use of standardized admission order sets. This
will standardize treatment using evidence based guidelines and improve patient safety by
increasing the percentage of patients receiving deep vein thrombosis (DVT) prophylaxis.
A review of nursing practice and appropriateness of admission to intensive care (ICU) may result
in lowering the occupancy of ICU beds and therefore, free up capacity.
Detailed Accreditation Results
39
Accreditation Report
Managing patients on the unit with epidural anaesthesia would reduce the pressure on ICU beds.
A review of nursing practice and appropriateness of admission to intensive care (ICU) may result
in lowering the occupancy of ICU beds and therefore, free up capacity.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Criteria
Location
If the team offers outreach services in the form of a rapid
response or medical emergency team, it defines the role of this
team and communicates it to other teams in the organization.
3.2
The team develops standardized processes and procedures to
improve teamwork and minimize duplication.
3.7
The team uses standardized criteria to determine whether
potential clients require critical care services.
6.2
Medication Reconciliation at Admission
7.7
The team follows Accreditation Canada’s protocols and
definitions to collect and submit data on medication
reconciliation at admission.
The team meets Accreditation Canada’s recommended
target for medication reconciliation at admission.
Following transition or end of service, the team contacts clients,
families, or referral organizations to evaluate the effectiveness
of the transition, and uses this information to improve its
transition and end of service planning.
Priority for
Action
7.7.1
7.7.2
12.7
Decision Support
Information, research and evidence, data, and technologies that support and facilitate
management and clinical decision-making.
Surveyor Comments
The management of critically ill patients has become increasingly complex. The recruitment of
an intensivist to intensive care units would be expected to improve the quality of care by
introducing and standardizing best practice.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
40
Detailed Accreditation Results
QMENTUM PROGRAM
Location
Criteria
An intensivist or critical care specialist is available daily to
consult with admitting physicians in open ICUs.
3.5
The organization has a process to select evidence-based
guidelines for critical care services.
15.1
The team reviews its guidelines to make sure they are
up-to-date and reflect current research and best practice
information.
15.2
Priority for
Action
Impact on Outcomes
The identification and monitoring of process and outcome measures to evaluate and improve the
quality of services to clients and the impact on client outcomes.
Surveyor Comments
The team needs to be encouraged to move forward with the introduction of more
SaferHealthCareNow! initiatives. It is imperative that the organization then measure the effects
of and impact on the process changes that are made.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Location
Criteria
The team shares benchmark and best practice information with
its partners and other organizations.
15.4
The team implements the Safer Healthcare Now Central Line
(CLI) bundle for all clients requiring a central line.
16.5
The team identifies and monitors process and outcome measures
for its critical care services.
17.1
The team monitors clients’ perspectives on the quality of its
critical care services.
17.2
The team compares its results with other similar interventions,
programs, or organizations.
17.3
The team shares evaluation results with staff, clients, and
families.
17.5
Priority for
Action
Detailed Accreditation Results
41
Accreditation Report
Diagnostic Imaging Services
Impact on Outcomes
The identification and monitoring of process and outcome measures to evaluate and improve the
quality of services to clients and the impact on client outcomes.
Surveyor Comments
The team routinely uses two client identifiers on registration to DI services and prior to delivering
service via any modality. The team identifies and reports adverse events via the Health PEI
incident reporting system on a regular basis. However, there is very little feedback from the
system on incident trends or analysis that may have been undertaken. There is an investigation
that is undertaken in the department and also provided to a higher authority; but this is
essentially the limit of usefulness for future mitigating action.
No Unmet Criteria for this Priority Process.
Diagnostic Services - Diagnostic Imaging
Availability of diagnostic imaging to provide health care practitioners with information about the
presence, severity, and causes of health problems, and the procedures and processes used by
these services.
Surveyor Comments
Diagnostic imaging (DI) is the one fully integrated service in Health PEI and as such, it is showing
other areas the value that can be had from this approach. Diagnostic Imaging Services has
recently benefited from a resource infusion for equipment, space and staff, which has given rise
to a dramatic shift in wait times and turnaround times, all for the positive. As examples, wait
times for breast mammography have dropped from fourteen months to five weeks, and wait
times for levels 1 and 2 computerized tomography (CT) and magnetic resonance (MR) are
essentially within the guidelines. Previous issues of wait times and turnaround times raised by
referring services and individual physicians have been largely put to rest.
A recent survey of user physicians obtained a forty five percent response rate and is a
fundamental piece for planning consideration going forward. Utilization reviews are routinely
undertaken and the radiologists take the opportunity to address issues such as appropriateness
with their colleagues in emergency (ED). With the basics of service delivery now in place, the
radiologists are looking forward to expanding on the service offering. The administrative function
is looking to deal with succession planning. There is a program being undertaken to keep 'rolling'
summary documentation of total radiation dose for all clients.
Areas for improvement:
There are several issues that require correction. The medical director has to sign off on the
policy manual. The reprocessing process requires a thorough review. Documentation must
include, explicitly and directly, the name and ID of every client/patient to facilitate tracking
should any adverse event occur, and this is a CSA requirement. The separation of clean and
decontamination areas from other functions at the QEH site is needed. The planned client
satisfaction survey needs to be done as part of the planning process. Additionally, the
department needs to develop a specific safety program that includes consideration of client
involvement.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
42
Detailed Accreditation Results
QMENTUM PROGRAM
Criteria
Location
The team has a policy and procedures manual for using
diagnostic equipment, and the manual is signed by the medical
director.
6.1
All DI reprocessing areas are equipped with separate clean and
decontamination work areas as well as separate storage,
dedicated plumbing and drains, and proper air ventilation.
7.6
The record of reprocessing includes the identification number
and type of device or piece of equipment, the identification of
the automated device reprocessor if applicable, date and time
of the clinical procedure, the name or unique identifier of the
client, and the name of the person responsible for reprocessing.
7.15
The team appoints a safety officer, a safety committee, or both
to lead its safety program.
14.2
The team informs and educates its clients and families in writing
and verbally about the client and family’s role in promoting
safety.
14.6
Written and verbal information is provided to clients and
families about their role in promoting safety.
Staff uses written and verbal approaches to inform and
educate clients about their role in promoting safety.
Clients indicate that they have received written and verbal
communication about their role in promoting safety.
14.6.1
The team involves clients, families, and other organizations
when evaluating its diagnostic imaging services.
Priority for
Action
14.6.2
14.6.3
16.2
Emergency Department
Clinical Leadership
Providing leadership and overall goals and direction to the team of people providing services.
Surveyor Comments
At the QEH site, the newly built and opened Emergency Department (ED) has more than ample
space to meet current population needs and is well equipped. The general radiology unit in the
ED provides excellent access to general radiology procedures. Radiology technologists staff the
area during the day Monday to Friday, and this includes nights. Space for CT has been developed
for future installation. Space is also developed to accommodate radiologists should that resource
become available in the future.
more acute patient care areas over time and with further training and education. Adequate
space is provided for allied health providers and community partners to work with patients and
families in privacy. Medical leadership has been identified for the
ED and Accreditation
will soon be formalized,
Detailed
Results
which will provide consistency in medical staff leadership.
Areas for Improvement:
43
Accreditation Report
New registered nursing (RN) graduates work in the fast track area for one year and progress to
more acute patient care areas over time and with further training and education. Adequate
space is provided for allied health providers and community partners to work with patients and
families in privacy. Medical leadership has been identified for the ED and will soon be formalized,
which will provide consistency in medical staff leadership.
Areas for Improvement:
There is a lack of consistency between the ED units across the province as they are resourced
differently with regard to support for clinical staff education and in relation to access to acute
care beds.
It is recommended that the ED service be one provincial program and that quality, safety,
education, service planning, delivery and evaluation for example, proceed from that premise.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Criteria
Location
The team works together to develop goals and objectives.
2.1
The team’s goals and objectives are linked to benchmarking of
bed availability in the Emergency Department, time to
admission, client diversion to other facilities, and wait times.
2.2
Team members have input on work and job design, including the
definition of roles and responsibilities, and case assignments,
where appropriate.
5.4
Priority for
Action
Competency
Developing a highly competent interdisciplinary team with the knowledge, skills and abilities to
develop, manage, and deliver effective and efficient programs, services, and care.
Surveyor Comments
At the QEH site, the process of developing the functional plan, resulting in the existing new ED
was inclusive of interdisciplinary team members and partners. Although a regular staff meeting
is held, attendance is sporadic. This makes communication between managers and front line staff
a challenge. A communication book is kept current and made available to staff in an easily
accessible area. There is also a "gripe" board for staff to communicate concerns.
At the QEH, a dedicated clinical nurse coordinator tracks annual education and certification
status. This responsibility is attended to at other sites by other categories of staff. The clinical
nurse coordinator position is available only at the QEH. There is an opportunity to improve
support for clinical nursing practice education in the rural emergency departments.
The definition of an interdisciplinary team differs from site to site, in accordance with available
human resources.
For all sites, staff reported feeling safe working in the ED.
44
Areas for Improvement:
Detailed Accreditation Results
There was no evidence of either an education plan for staff or of performance reviews being
done regularly.
It is recommended that regular performance reviews inclusive of an educational plan for staff be
QMENTUM PROGRAM
For all sites, staff reported feeling safe working in the ED.
Areas for Improvement:
There was no evidence of either an education plan for staff or of performance reviews being
done regularly.
It is recommended that regular performance reviews inclusive of an educational plan for staff be
done regularly.
It is recommended that clinical education support for rural ED staff be reviewed.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Location
Criteria
The interdisciplinary team follows a formal process to regularly
evaluate its functioning, identify priorities for action, and make
improvements.
3.5
Team leaders regularly evaluate and document each team
member’s performance in an objective, interactive, and positive
way.
4.12
Priority for
Action
Episode of Care
Healthcare services provided for a health problem from the first encounter with a health care
provider through the completion of the last encounter related to that problem.
Surveyor Comments
At the QEH site, patients with triage categories of three and more are advised to return to the
triage area at a specified time for reassessment. However, this is not the protocol at all other
sites. For all sites, pain assessment is done on a scale of 1-10 and documented accordingly.
At the QEH site, transfer of patients to inpatient units is done by verbal reports. There is
planning underway to implement a documented process to use in facilitation of transferring
patients and their information.
The electronic triage system is planned for implementation at the QEH this fall. All other EDs
have already implemented this system.
Transfer of information at transition points is currently a verbal process. Plans for development
and implementation of a written transfer of information process are underway.
Areas for Improvement:
It is recommended that the ED service be considered to be a provincial program and that
planning for process and program development proceed from that premise.
Detailed Accreditation Results
45
Accreditation Report
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Criteria
The team informs clients in the waiting area of wait times for
assessment and treatment.
7.5
The team monitors possible progression of illness for clients
waiting in the Emergency Department.
7.7
The team reconciles medications for clients with a decision to
admit, with the involvement of the client, family or caregiver.
8.3
There is a demonstrated, formal process to reconcile
client medications for clients with a decision to admit.
The team generates a Best Possible Medication History
(BPMH) for clients with a decision to admit.
Depending on the model, the prescriber uses the BPMH
to create admission medication orders (proactive), OR, the
team makes a timely comparison of the BPMH against the
admission medication orders (retroactive).
The team documents that the BPMH and admission
medication orders have been reconciled; and appropriate
modifications to medications have been made where
necessary.
The process is a shared responsibility involving the client
and one or more health care practitioner(s), such as
nursing staff, medical staff, pharmacists, and pharmacy
technicians, as appropriate.
Medication reconciliation for clients with a decision to admit.
The team follows Accreditation Canada’s protocols and
definitions to collect and submit data on medication
reconciliation.
The team does not have any unaddressed priority for
action flags based on their medication reconciliation
indicator results.
The team reconciles medications with the client at referral or
transfer and communicates information about the client’s
medications to the next provider of service at referral or
transfer to another setting, service, service provider, or level of
care within or outside the organization.
There is a demonstrated, formal process to reconcile
client medications at referral or transfer.
46
Location
Detailed Accreditation Results
8.3.1
8.3.2
8.3.3
8.3.4
8.3.5
8.4
8.4.1
8.4.2
11.5
11.5.1
Priority for
Action
QMENTUM PROGRAM
The process includes generating a comprehensive list of
all medications the client has been taking prior to referral
or transfer.
The process includes a timely comparison of the
prior-to-referral or prior-to-transfer medication list with the
list of new medications ordered at referral or transfer.
The process requires documentation that differences
between the two lists have been identified, discussed, and
resolved, and that appropriate modifications to the new
medications have been made.
The process makes it clear that medication reconciliation
is a shared responsibility involving the client, nursing staff,
medical staff and pharmacists, as appropriate.
The organization has a documented plan to implement
throughout the organization, and before the next
accreditation survey, a medication reconciliation process
at referral and transfer.
11.5.2
11.5.3
11.5.4
11.5.5
11.5.6
Decision Support
Information, research and evidence, data, and technologies that support and facilitate
management and clinical decision-making.
Surveyor Comments
Overall, the QEH ED has space that facilitates patient privacy. There is the need for privacy
curtains around patient beds in the coronary care area. Requests to attend to this have been
made.
Health record documentation is manual. Triage documentation will be electronic this fall. The
EDIS system will be replaced by a first net clinical system, which is a component of the Clinical
Information System (CIS) used across Health PEI.
No Unmet Criteria for this Priority Process.
Impact on Outcomes
The identification and monitoring of process and outcome measures to evaluate and improve the
quality of services to clients and the impact on client outcomes.
Surveyor Comments
At the QEH, patients routinely experience long waits for admission to inpatient units. At the time
of the survey visit, there were two patients in the ED in excess of sixty hours. There is a protocol
for moving patients to inpatient units when there are more than five patients awaiting transfer to
inpatient units. However, there is uncertainty amongst staff about the applicability and use of
this protocol.
There may be a gap in post operative infection data, as primarily rural patients who are
readmitted to a facility different than their surgical facility within the thirty day time frame may
not be reported as having a post operative infection. This gap was observed at the Western
Hospital ED.
there was no available bed on the inpatient unit. When the ED closes nightly at 2200 hours,
patients are moved into the closed beds on the inpatient unit. Then, in the morning these same
patients are moved back to the ED. At the QEH, two patients had been in the ED in excess of
Detailed Accreditation Results
sixty hours owing to lack of access to a bed.
A surveyor encountered a medico-legal risk issue during a visit to the QEH's ED. The issue pertains
to displaying a sign warning physicians that they are at risk if they choose to use unopened, un
staffed ED rooms to provide patient care. The manager agreed that this question would be
47
Accreditation Report
At the Kings County Hospital, there was a patient who had been in ED for seven days because
there was no available bed on the inpatient unit. When the ED closes nightly at 2200 hours,
patients are moved into the closed beds on the inpatient unit. Then, in the morning these same
patients are moved back to the ED. At the QEH, two patients had been in the ED in excess of
sixty hours owing to lack of access to a bed.
A surveyor encountered a medico-legal risk issue during a visit to the QEH's ED. The issue pertains
to displaying a sign warning physicians that they are at risk if they choose to use unopened, un
staffed ED rooms to provide patient care. The manager agreed that this question would be
followed up.
While there is a provincial ED quality improvement team/committee, information on its work and
objectives are not routinely shared with staff.
Areas for Improvement:
It is recommended that the policy for transferring patients to inpatient beds in a timely manner
be reviewed and communicated to all ED staff.
It is recommended that the ED quality improvement committee communicate its priorities and
process to ED staff.
It is recommended that the QEH ED clarify the safety risk to patients and the organization's risk
exposure if physicians use unopened, un staffed rooms to provide patient care.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Criteria
Location
Staff and service providers participate in regular safety briefings
to share information about potential safety problems, reduce
the risk of error, and improve the quality of service.
15.3
The team identifies and monitors process and outcome measures
for its Emergency Department services.
16.1
The team shares evaluation results with staff, clients, and
families.
16.5
Priority for
Action
Home Care Services
Clinical Leadership
Providing leadership and overall goals and direction to the team of people providing services.
Surveyor Comments
The following comments relate to the Montague Home Care service. Where comments are related
to different units, a notation has been made accordingly.
48
The issues that Home Care (HC) service is addressing include provision of evening services
particularly in palliative care. There is also a concern regarding transportation of the senior
population and the lack of emotional support for patients and families because of the absence of
a social
worker in the
HC service. Staff training is evident and an HC orientation and new
Detailed
Accreditation
Results
employee handbook provides the information for staff as to policies, procedures and performance
reviews. Weekly staff meetings provide opportunities to share observations, adjust care plans
and address ethical issues. Client information pamphlets address reducing risk of falls in the
home, and self responsibility for safety. A falls risk assessment tool is being introduced and a
QMENTUM PROGRAM
The issues that Home Care (HC) service is addressing include provision of evening services
particularly in palliative care. There is also a concern regarding transportation of the senior
population and the lack of emotional support for patients and families because of the absence of
a social worker in the HC service. Staff training is evident and an HC orientation and new
employee handbook provides the information for staff as to policies, procedures and performance
reviews. Weekly staff meetings provide opportunities to share observations, adjust care plans
and address ethical issues. Client information pamphlets address reducing risk of falls in the
home, and self responsibility for safety. A falls risk assessment tool is being introduced and a
study to determine if exercise has positive implications for reducing falls is being initiated. A
service agreement is signed by the patient/client, which outlines the client's responsibility for
self care. Also, a consent for treatment is signed by the client. A home care assessment is
completed for all new clients and serves as the basis for the care plan. Medication reconciliation
is done on admission. Incident reports are completed for occurrences as well as near misses.
These are analyzed and reported to the staff.
No Unmet Criteria for this Priority Process.
Competency
Developing a highly competent interdisciplinary team with the knowledge, skills and abilities to
develop, manage, and deliver effective and efficient programs, services, and care.
Surveyor Comments
Staff are encouraged to participate in conferences and inter agency meetings regarding Home
Care.
A very comprehensive HC orientation and employee handbook is used to prepare and support
staff members. Staff note personal goals and have regular performance reviews.
A falls assessment guide is used to identify risk of falls and a program of intervention is
implemented.
No Unmet Criteria for this Priority Process.
Episode of Care
Healthcare services provided for a health problem from the first encounter with a health care
provider through the completion of the last encounter related to that problem.
Surveyor Comments
The shortage of transportation options is a barrier to care in HC in this community. A day
program is offered but attendance may be compromised because of a lack of transportation. The
staff also identify the lack of social services support in the program and the lack of 24/7
palliative care coverage. In order to compensate, staff provide clients and their families with
their cell phone numbers and spend extra non paid hours with clients in their last hours.
After hours requests for information are handled via the Emergency Department or frequently,
the nurses will provide their cell phone number to the client
issues are discussed in the team and resolved at this level. Client satisfaction surveys are done
every two years.
It is recommended that services be established to provide emotional
support
and counselling
for
Detailed
Accreditation
Results
clients and their families.
49
Accreditation Report
Areas for improvement:
The staff provide emotional support to families and clients but a social worker is needed. Ethical
issues are discussed in the team and resolved at this level. Client satisfaction surveys are done
every two years.
It is recommended that services be established to provide emotional support and counselling for
clients and their families.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Criteria
The organization facilitates access to emotional support and
counselling for clients and families.
Location
Priority for
Action
7.6
Decision Support
Information, research and evidence, data, and technologies that support and facilitate
management and clinical decision-making.
Surveyor Comments
The Home Care (HC) service is introducing a central intake position to coordinate all services
required.
Home Care O’Leary site: HC operates from 0800 hours to 1600 hours seven days a week. New
funding last year has allowed HC to extend service to the weekends. The manager is responsible
for six communities, which includes renal dialysis in Alberton and Summerside. The program has
both Registered Nurses (RN) and Home Support Worker (HSW) students. The RN student said that
this is her second rotation at the O’Leary HC support program, and chose to return because of
such a cohesive interdisciplinary team and good experience. The interdisciplinary team includes
RN, HSW, Occupational Therapy (OT), Physiotherapy (PT), Social Work (SW) and an Adult
Protection Worker. The team has access to a nutritionist that works in the primary care program.
Services include blood collection, intravenous (IV) antibiotic infusion, peritoneal dialysis, wound
care, palliative care, and B12 injections. Policy requires that a nurse stay with the client for
twenty minutes after the administration of any medication. The interdisciplinary team has
meetings every two months and these meetings have an education component. Team members
express their ability to work collaboratively and resolve conflict as it arises. The program works
well with a large variety of partners including community physicians, the hospital, mental health,
geriatrics, hospice, veteran affairs, long term care, and meals on wheels. Access to service is
good except for some inability to provide prompt OT service at times. More OT resources will be
recruited and shared between the hospital and the HC program. Performance appraisals are to
be done every two years and staff report that they are done regularly. A new process began this
year, which ensures that new staff have a performance review at two months, six months, at one
year of service and then at two years. There is low staff turnover and staff report high
satisfaction with their place of work.
50
Staff are just beginning to deal with medication reconciliation, using the SaferHealthCareNow!
model. They are just beginning the education sessions to prepare for this process. The program
had an innovative tele-home care component which commenced in the 90s. This technology
allowed for the monitoring of chronic HC patients/clients and was effective in reducing frequent
ED visits for the clients.
Though there have been requests for funding of new equipment to allow for the continuance of
the program, Health PEI organization has made implementation and expansion of the CIS a
priority so there is no funding for buying new tele-home equipment. The nursing staff are sad to
Detailed
Accreditation
Resultsand effective use of technology lost to them and their clients.
see
an area of innovation
Services are planned by evaluating utilization and referrals. There is documented protocol for
discharging clients from the programs based on clients having met their goals. There are no
formal care plans beyond a stated goal for the client An out patient home care clinic occurs
QMENTUM PROGRAM
The technology is now old and the majority of units do not function.Though there have been
requests for funding of new equipment to allow for the continuance of the program,
Health PEI organization has made implementation and expansion of the CIS a
priority so there is no funding for buying new tele-home equipment. The nursing staff are sad to
see an area of innovation and effective use of technology lost to them and their clients.
Services are planned by evaluating utilization and referrals. There is documented protocol for
discharging clients from the programs based on clients having met their goals. There are no
formal care plans beyond a stated goal for the client An out patient home care clinic occurs
once a month for clients able to attend the clinic. Staff feel safe in their work environment. If
any staff member feels unsafe in a client's home, an assessment of safety is done. The nurse can
request that a second staff member attend the home with her and this request is supported. An
Adult Protection Worker always attends the first home assessment, with a second staff member.
Health PEI has established a “working alone” telephone in service whereby a staff member can
inform the call in centre that she is going to see a client when there is no one in the office to
notice her safe return from the client. If the worker does not call back to say she has completed
the home visit and is safe, then the call centre is to alert a program manager that the staff
member has not been heard from. This process does not always work as intended as the call
centre may fail to note that the staff member has not reported that she has completed the client
visit.
There is a barrier between sharing client information between child and adult protection as child
protection is reluctant to share client information on the grounds of patient confidentiality. This
issue was a previous Accreditation Canada recommendation and the situation has not improved
despite home care program efforts. Currently, there are service agreements signed by clients
which serve as consent. Health PEI is working on a new consent form.
Written information on MRSA and VRE is provided to clients. Other written material is available
such as precautions around infection control for chemotherapy patients. Clients receive a
“welcome letter” providing information on hours of service, their responsibility requirements
such as no smoking for an hour prior to a home visit, keeping the sidewalk shovelled, keeping
dogs restrained and so on. There is no formal falls risk assessment in place. There is a pilot
underway in another home care program in PEI. Incident reports are completed as per policy.
There is no feedback to the staff on risk data, trending and such. The manager does not receive
such reports either. The program participates in research projects for example, a wound
management evaluation in partnership with a hospital in Toronto, and evaluation of support
required by care givers in partnership with the University of PEI (UPEI). The manager is aware of
requirements of research approval by the research ethics committee The staff have never
referred an ethics issue to the ethics service. They work things out amongst themselves and call
an interdisciplinary/family case conference as needed. Documentation is done by each health
professional on a separate chart and filed in a separate folder, which means there is not one
comprehensive health record for every client.
No Unmet Criteria for this Priority Process.
Impact on Outcomes
The identification and monitoring of process and outcome measures to evaluate and improve the
quality of services to clients and the impact on client outcomes.
Surveyor Comments
The palliative program monitors the number of deaths at home and currently, the rate is over
forty percent. The team also monitors staff injuries.
Hillsborough Hospital HC services: This service appears to be well integrated within home care
services across the province. A UPEI consultant was contracted to create an orientation program
Detailed
Accreditation
plan for new staff. The plan includes a follow up, which involves
regular review
periods Results
throughout the first year of service. This orientation plan is now being adapted to long term care
(LTC) and it may be something that can also be adapted to other programs. Staff are quite
pleased with the orientation process and assessments.
51
Accreditation Report
Hillsborough Hospital HC services: This service appears to be well integrated within home care
services across the province. A UPEI consultant was contracted to create an orientation program
plan for new staff. The plan includes a follow up, which involves regular review periods
throughout the first year of service. This orientation plan is now being adapted to long term care
(LTC) and it may be something that can also be adapted to other programs. Staff are quite
pleased with the orientation process and assessments.
Performance reviews are routinely completed every two years. They include self assessment and
a staff component for planning performance improvement, this appears to be well received.
The LPNs are working to full scope and do medication administration. The LPN role has been
integrated well with the nursing complement however, the term ‘nurse’ is only used to include
registered professional nurses.
Home Care has a liaison nurse at the QEH site to ensure continuity of care and to gather/process
referrals. As with other programs, identifying goals and objectives and then monitoring outcomes
is variable or non existent. Clients are assisted in accessing other services and insurers to aid
them in obtaining needed care as often as possible.
There exist well integrated teams of many different professional services, ranging from
hemodialysis to OT, PT, SW, Dietician, RN, LPN, and HSW. As well, there is integrated palliative
home care with input from both community and hospital physicians and pharmacists. There is a
well established check in/call in for home visit workers to ensure their safety. The original
assessment is always done in pairs. Two identifiers are used for patient identification (ID), and
are most typically name and address however, this is not included formally as a part of
orientation.
The same incident form used at the QEH is used here and while it is discussed with staff involved,
it is not used to educate all staff. Trending information is not distributed.
Lifts and repositioning (TLR) is firmly in place and is adapted from the Saskatchewan program.
This includes ensuring proper equipment is available in the client homes before service can be
provided. All staff appear well informed and compliant. The different disciplines work well
together and are comfortable consulting one another as client needs arise. Care plans and orders
are reviewed annually and/or when service needs change. A process is in place to ensure that
orders are sent to physicians prior to their expiration date, and annual review is done.
No Unmet Criteria for this Priority Process.
Infection Prevention and Control
Infection Prevention and Control
Measures practiced by healthcare personnel in healthcare facilities to decrease transmission and
acquisition of infectious agents.
52
Detailed Accreditation Results
QMENTUM PROGRAM
Surveyor Comments
Strengths:
Health PEI has made good progress in establishing the foundation for an effective integrated
infection prevention and control (IPAC) program, which will serve to provide governance
oversight for the control of infection across all programs and services in the health care system.
In response to the recommendations from the previous accreditation survey, the position of a
In responseIPAC
to the
recommendations
fromestablished
the previous
accreditation
position
of a
provincial
strategy
coordinator was
and
the Infectionsurvey,
Controlthe
(IC)
practitioner
provincial
IPAC strategy
coordinator
and the
Infection(FTEs).
Control (IC) practitioner
staff
complement
was increased
formwas
2.6established
to 5.2 full time
equivalents
staff complement was increased form 2.6 to 5.2 full time equivalents (FTEs).
A service model, including a provincial committee structure was established. The new strategy
A service
including
a provincial
committee
was established.
Thethe
new
strategy
was
rolledmodel,
out within
an eighteen
month
work plan.structure
Early achievements
include
development
was implementation
rolled out withinofana eighteen
month
plan. information
Early achievements
include the
development
and
surveillance
andwork
reporting
system including
case
definition
and data
implementation
of a surveillance
reporting information
system including
case definition
and
submission guidelines
for theand
IC practitioners.
The organization
is encouraged
to
and data to
submission
guidelines
for the
practitioners.
The organization
encouraged
to
continue
incorporate
other areas
of IC
surveillance
including
surgical siteisinfections
(SSI),
continue
to
incorporate
other
areas
of
surveillance
including
surgical
site
infections
(SSI),
ventilator associated pneumonia (VAP) and central line infections (CLIs).
ventilator associated pneumonia (VAP) and central line infections (CLIs).
Provincial reports on the major epidemiological infections are being generated and the plan for
Provincial
reports onofthe
major wide
epidemiological
infections
areisbeing
generated
the plan
regular
distribution
province
and site specific
reports
currently
being and
decided.
Thefor
regular distribution
of province feedback
wide and and
site reporting
specific reports
currently
decided.
The
establishment
of a transparent
processisfor
hospitalbeing
acquired
infection
establishment
ofand
a transparent
feedback
for hospital
acquired
infectionin
rates
at the site
program level
will beand
an reporting
effective process
way of engaging
staff
and leadership
ratescontrol
at theof
site
and program level will be an effective way of engaging staff and leadership in
the
infection.
the control of infection.
A framework is in place and work has commenced to develop province wide infection control
A framework
is in place
and work has
commenced
develop province
wide
infection
control
standards,
policies
and procedures.
Evidence
basedtoguidelines
have been
rolled
out across
the
standards,
policies
and
procedures. Evidence based guidelines have been rolled out across the
system
for MRSA
and
VRE.
system for MRSA and VRE.
Areas for Improvement:
Areas for Improvement:
There is considerable variation in the availability, format and consistency in the site specific
There is considerable
variation
in the availability,
and
consistency
in the siteshould
specific
infection
control policies
and procedures.
Infectionformat
control
policies
and procedures
be
infection control
and procedures.
and procedures should be
standardized
and policies
readily available
to staff Infection
across thecontrol
healthpolicies
care system.
standardized and readily available to staff across the health care system.
Medical leadership is not in place for IPAC. The addition of a physician specialist in infection
Medical isleadership
place
forthe
IPAC.
The addition
of a physician
specialistinfection
in infection
control
essential is
tonot
notin
only
meet
established
guidelines
for an effective
control
control
is
essential
to
not
only
meet
the
established
guidelines
for
an
effective
infection
control
program but to also support the IC practitioners and to further engage the medical staff in
the
program but to also support the IC practitioners and to further engage the medical staff in the
program.
program.
The provincial infection control office has established capacity to build a statistical database for
The provincial
infection
control
office
capacity
to buildThe
a statistical
database
for
surveillance
and
reporting
infection
to has
the established
front lines and
community.
organization
is
surveillance
and
reporting
infection
to
the
front
lines
and
community.
The
organization
is
encouraged to establish a reporting process to staff and the community across the province.
encouraged to establish a reporting process to staff and the community across the province.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Location
Criteria
The organization tracks infection rates, analyzes the information
to identify clusters, outbreaks, and trends, and shares this
information throughout the organization.
Staff and service providers know the infection rates and
recommendations from outbreak reviews.
Priority for
Action
1.2
1.2.3
Detailed Accreditation Results
53
Accreditation Report
The organization shares trends in infections and significant
findings with other organizations, public health agencies, and
the community.
1.6
The organization develops policies and procedures to address
infection prevention and control issues.
4.1
Each policy and procedure includes up-to-date references to
research and best practice in infection prevention and control.
4.3
Staff, service providers and volunteers have access to the
organization’s policies and procedures in an infection prevention
and control manual.
4.6
The organization reviews and updates its policies and procedures
at least every three years, and as new information becomes
available.
4.7
The organization monitors compliance with its infection
prevention and control policies and procedures.
5.7
Information provided to clients and families is documented in
the client record.
7.3
All endoscope reprocessing areas are equipped with separate
clean and decontamination work areas as well as storage,
dedicated plumbing and drains, and proper air ventilation.
13.4
Laboratory and Blood Services
Diagnostic Services - Laboratory
Availability of laboratory services to provide health care practitioners with information about
the presence, severity, and causes of health problems, and the procedures and processes used by
these services.
Surveyor Comments
The staff are patient focused and willing to endorse change.
The implementation of a quality management system is needed to ensure standardization and
quality of results.
Implementation of a formal safety program needs to include education of staff, coordinated and
revised policies and safety manuals and the implementation of a safety officer.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
54
Detailed Accreditation Results
QMENTUM PROGRAM
Location
Criteria
The laboratory collects and reviews information at least annually
about service volumes, client perspectives on services, and
patterns of requests from service providers and other
organizations.
CSA Reference: Z15189-03, 4.1.2
1.1
The laboratory considers current best practice knowledge and
results of quality improvement activities, including up-to-date
information on errors and adverse events.
1.3
The laboratory follows established processes for communicating
within the laboratory and with other clinicians.
5.2
Laboratory staff attends regular meetings with clinicians.
CSA Reference: Z15189-03, 4.7
5.3
The laboratory recruits and assigns staff based on education and
professional qualifications, training and experience, and
evidence of competency.
CSA Reference: Z15189-03, 5.1.2
6.1
The laboratory considers the size of the laboratory, volume of
services, and the complexity of procedures when assigning staff.
CSA Reference: Z902-04, 4.3.1.1, 4.3.1.2
6.2
The laboratory defines each staff member’s qualifications,
duties, and level(s) of authority in detailed position profiles.
CSA Reference: Z15189-03, 4.1.4, 5.1.1, 5.1.7, 5.1.8, 5.1.12;
Z902-04, 4.3.1.2, 4.3.1.4
6.4
The laboratory has a designated technical director or supervisor
who provides leadership and coordination functions within and
outside the laboratory.
CSA Reference: Z15189-03, 5.1.3, 5.1.4; Z902-04, 4.3.1.3
6.5
The laboratory uses an organizational chart to outline
responsibilities and reporting relationships.
CSA Reference: Z15189-03, 5.1.1; Z902-04, 4.3.1.4
6.6
The laboratory annually reviews staff roles and responsibilities,
and monitors adherence to position profiles.
6.7
Priority for
Action
Detailed Accreditation Results
55
Accreditation Report
56
The laboratory identifies staff orientation and ongoing training
needs.
CSA Reference: Z15189-03, 4.12.5, 5.1.9; Z902-04, 4.3.2.1
7.1
The laboratory provides training to staff on quality control,
preventing errors or adverse events, and quality improvement.
CSA Reference: Z15189-03, 5.1.6, 5.1.10; Z902-04, 4.3.2.2
7.3
The laboratory has a formal program to assess competence.
CSA Reference: Z902-04, 4.3.3.1
7.4
The program regularly evaluates staff’s theoretical and practical
knowledge using a variety of techniques.
CSA Reference: Z902-04, 4.3.3.1
7.5
The laboratory documents the results of staff assessments and
reassessments.
CSA Reference: Z902-04, 4.3.3.1
7.6
The laboratory provides additional training when gaps in training
or competency are identified, and reassesses competency
following training.
CSA Reference: Z15189-03, 5.1.11; Z902-04, 4.3.3.4
7.7
The laboratory annually evaluates the effectiveness of its
education, training, and competency assessment activities and
records the results.
CSA Reference: Z902-04, 4.3.2.3, 4.3.3.1
7.8
The laboratory maintains complete and up-to-date records on
qualifications, training, and competence for each staff member.
CSA Reference: Z15189-03, 5.1.2; Z902-04, 4.3.4
7.9
The laboratory keeps staff records for a minimum of 10 years
after the individual has left the employ of the laboratory.
CSA Reference: Z902-04, 4.3.4, 19.6.4.3
7.10
The laboratory has processes to address complaints and respond
to feedback from clinicians, clients, and others.
CSA Reference: Z15189-03, 4.8
9.5
The laboratory maintains a record of complaints, investigations
of those complaints, and corrective action taken.
CSA Reference: Z15189-03, 4.8
9.6
Detailed Accreditation Results
QMENTUM PROGRAM
The laboratory has a process for establishing and maintaining
SOPs.
CSA Reference: Z902-04, 4.2.2.1
10.1
The laboratory writes its SOPs clearly, concisely, and
consistently.
CSA Reference: Z15189-03, 4.3.3; Z902-04, 4.2.2.2
10.2
The laboratory maintains an SOP manual.
CSA Reference: Z902-04, 4.2.1.4
10.3
The laboratory’s SOP manual is available to all staff, at all
times, in all locations.
CSA Reference: Z902-04, 4.2.2.3
10.4
The laboratory reviews and updates the SOPs annually or more
often if needed.
CSA Reference: Z902-04, 4.6.1.4
10.5
The laboratory tracks changes to SOPs using a document control
procedure.
CSA Reference: Z15189-03, 4.3.1, 4.3.2; Z902-04, 4.2.2.4, 4.2.3,
4.2.4
10.6
The laboratory’s senior managers approve new or revised SOPs.
CSA Reference: Z15189-03, 4.3.2; Z902-04, 4.2.1.2
10.7
The laboratory trains staff before implementing a new or revised
SOP.
CSA Reference: Z902-04, 4.2.2.5
10.8
The laboratory regularly evaluates the effectiveness of its SOPs
and makes necessary changes.
10.9
The laboratory reviews data entered into the LIS for accuracy
and completeness.
CSA Reference: Z15189-03, Annex B.4-B.6; Z902-04, 20.6.2
12.5
The laboratory conducts and documents initial and regular
testing of the LIS.
CSA Reference: Z15189-03, Annex B.7.6-7.7, Z902-04, 20.2.3,
20.3; Z15189-03, Annex B.7.4, Z902-04. 20.4
12.6
Detailed Accreditation Results
57
Accreditation Report
58
The laboratory has enough space and resources to perform its
activities.
CSA Reference: Z15189-03, 5.2.1, 5.2.9; Z902-04, 4.5.1.4,
21.1.1, 21.1.5
13.1
The laboratory considers ergonomics when designing working
areas.
13.2
The laboratory’s collection areas ensure client comfort and
privacy, and accommodate disabilities.
CSA Reference: Z15189-03, 5.2.3; Z902-04, 21.4.2
13.3
The laboratory communication system facilitates efficient
transfer of messages.
CSA Reference: Z15189-03, 5.2.8
13.5
The laboratory monitors and controls utilities and environmental
conditions.
CSA Reference: Z15189-03, 5.2.4, 5.2.5
13.7
The laboratory controls access to and use of areas affecting the
quality of activities.
CSA Reference: Z15189-03, 5.2.7; Z902-04, 21.1.2
13.10
The laboratory has separate space for record keeping, data
entry, and other administrative activities.
13.11
The laboratory evaluates its physical space and environment to
verify that they do not adversely affect collection or analysis.
CSA Reference: Z15189-03, 5.2.4
13.12
The laboratory has a sanitation and housekeeping program, and
it follows documented standard operating procedures (SOPs) for
cleaning.
CSA Reference: Z15189-03, 5.2.10; Z902-04, 21.3, 21.3.2, 21.3.3
14.1
The layout of the laboratory makes it easy to wash, clean, and
disinfect work areas, equipment, and floors.
CSA Reference: Z902-04, 21.2.1, 21.2.2
14.2
The laboratory is secure, with access limited to authorized
personnel.
CSA Reference: Z15189-03, 5.2.7
14.8
Detailed Accreditation Results
QMENTUM PROGRAM
The laboratory annually reviews and updates as appropriate its
processes for maintaining, inspecting, and calibrating
instruments and equipment.
CSA Reference: Z902-04, 22.1.1
16.5
The laboratory carries out and records regular checks of
temperature, humidity levels, and any other critical factors.
CSA Reference: Z902-04, 9.4.6, 9.4.7
17.2
The laboratory prevents the use of inappropriate, expired,
deteriorated, and substandard supplies, reagents, and media.
18.5
The laboratory has a safety officer who develops, maintains, and
monitors the program.
21.1
The safety officer is authorized to stop any laboratory activities
deemed unsafe.
21.2
The safety program includes orientation and training, education
programs, and monitoring and evaluation.
21.3
The safety officer audits the program annually and makes
revisions as needed.
21.5
The laboratory labels work area entrances and exits according to
hazards or risks present within.
22.2
The laboratory regularly evaluates staff compliance with its
safety program and safe personal behaviour directives.
CSA Reference: Z902-04, 4.5.1.3
23.1
Staff wears protective clothing and personal protective
equipment (PPE) as necessary.
23.2
The laboratory monitors compliance with safe work practices.
CSA Reference: Z902-04, 4.5.1.2
23.5
The laboratory has a formal quality management system.
CSA Reference: Z15189-03, 4.1.5, 4.12.4, 4.15.1, 4.15.3, 4.15.4
25.1
The laboratory defines the elements of the quality management
system in a quality policy statement and makes it available in a
quality manual.
CSA Reference: Z15189-03, 4.2.3, 4.2.4
25.2
Detailed Accreditation Results
59
Accreditation Report
The laboratory management delegates the key functions of the
quality management system, and communicates quality
management policies to staff.
CSA Reference: Z15189-03, 4.1.5, 4.2.1, 4.2.4
25.3
As part of the quality management system, the laboratory
evaluates outcomes using formal internal audits, proficiency
testing, and inter-laboratory comparisons.
CSA Reference: Z15189-03, 4.2.2, 4.14.1, 4.14.2, 4.14.3;
Z902-04, 4.3.3.2, 4.3.3.3, 4.3.3.4
25.4
The laboratory identifies potential sources of nonconformities
and their root causes, and implements and monitors action plans
to prevent nonconformities.
CSA Reference: Z15189-03, 4.9, 4.9.1, 4.9.2, 4.10.1, 4.10.2,
4.10.3, 4.11.1, 4.11.2
25.5
The laboratory implements and monitors quality indicators to
evaluate its contribution to patient service and shares the
results with staff and other programs, services, or organizations.
CSA Reference: Z15189-03, 4.9
25.6
The laboratory’s senior managers use indicator and evaluation
information to guide decision-making and to make ongoing and
timely improvements to its procedures and quality management
system.
CSA Reference: Z15189-03, 4.12, 4.14.3
25.7
The laboratory participates in external quality control programs.
27.2
Long Term Care Services
Clinical Leadership
Providing leadership and overall goals and direction to the team of people providing services.
Surveyor Comments
The Long Term Care (LTC) team demonstrated the best example of goals and objectives, which
are measurable and tracked.
At the Riverview Manor site, the objective is to institute medication reconciliation.
No Unmet Criteria for this Priority Process.
Competency
Developing a highly competent interdisciplinary team with the knowledge, skills and abilities to
develop, manage, and deliver effective and efficient programs, services, and care.
60
Detailed Accreditation Results
QMENTUM PROGRAM
Surveyor Comments
The Wedgewood Manor site has been very successful in the implementation of the new model of
care with LPNs administering medications.
At the Riverview Manor site there is a need for a social worker to provide support and income
assistance applications.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Location
Criteria
The interdisciplinary team follows a formal process to regularly
evaluate its functioning, identify priorities for action, and make
improvements.
Priority for
Action
3.7
Episode of Care
Healthcare services provided for a health problem from the first encounter with a health care
provider through the completion of the last encounter related to that problem.
Surveyor Comments
The model of care transformation has proceeded very well, with LPNs successfully administering
medications and working collaboratively with RNs.
Areas for Improvement:
The Provincial Pharmacy is a barrier to patients accessing LTC beds, as it can take days for the
medications to arrive for a patient who is left waiting either at home or in an acute care bed.
The absence of pharmacy support in the hospital delays transfers to LTC, as medications
prescribed in the hospital are often are not covered by the provincial program. This results either
in delays in transfer until the doctor either agrees to change the medication to one covered by
the Provincial Pharmacy, or Provincial Pharmacy agrees to pick up the cost, or the family agrees
to pay for the drug.
At the Riverview Manor site, and due to staffing constraints, the closed unit is left unlocked at
night, which can result in residents wandering and an increased incidence of falls.
At Prince Edward Home, concerns were raised about maintenance and the ability to keep the
building operating (e.g. elevators) until the building, which is approximately 90 years old, can be
replaced. While very old, it was clean and space appeared to be appropriate.
At Prince Edward Home, there is no on site support from the Provincial Pharmacy. The Provincial
Pharmacy provides a monthly computer printed MAR but there are concerns that medications are
sometimes not present or missed. At Wedgewood Manor, staff raised concerns about the
Provincial Pharmacy and the lack of response to their safety concerns. In particular, the lack of
unit dosing, the time to receive medications, and the need to cut medications in half at the
Manor increases the risk that they would give an overdose. The labels on the blister packs were
very small and therefore, hard to read and the labels were on the bottom of the blister packs
which makes them difficult to identify the client.
Detailed Accreditation Results
61
Accreditation Report
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Criteria
Location
The organization assesses each client’s risk for developing a
pressure ulcer and implements interventions to prevent pressure
ulcer development.
Priority for
Action
8.4
The organization monitors its success in preventing the
development of pressure ulcers and makes improvements
to its prevention strategies and processes.
8.4.5
The team responds to client and family complaints in an open,
fair, and timely way.
10.14
Decision Support
Information, research and evidence, data, and technologies that support and facilitate
management and clinical decision-making.
Surveyor Comments
The long term care team would benefit from having access to the Clinical Information System
(CIS).
No Unmet Criteria for this Priority Process.
Impact on Outcomes
The identification and monitoring of process and outcome measures to evaluate and improve the
quality of services to clients and the impact on client outcomes.
Surveyor Comments
The falls identification and prevention program is particularly strong.
At the Wedgewood Manor site, the goals and objectives and the outcome measures are posted.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Criteria
The team shares benchmark and best practice information with
its partners and other organizations.
62
Detailed Accreditation Results
Location
15.5
Priority for
Action
QMENTUM PROGRAM
The team compares its results with other similar interventions,
programs, or organizations.
17.3
Managing Medications
Medication Management
Interdisciplinary provision of medication to clients.
Surveyor Comments
Medication reconciliation on admission is well done in a number of locations and there appears to
be awareness at most of the rest of sites. Evaluation of the program is required. Those sites
now doing medication reconciliation on admission can look to begin developing the process for
transfer and/or discharge.
Previous pharmacy consultant reports can be leveraged to enhance the quality and safety of
medication management. A Provincial Pharmacy department with a single leadership structure is
required to move quality and safe service forward.
Safe medication management would be enhanced by way of a single pharmacy and therapeutics
(P&T) entity approving a provincial formulary. Currently, the use of the Provincial Pharmacy as
part of medication management adds complexity to the medication system, including fostering
delays in therapy while waiting for cost approvals.
Long term care facilities would benefit from clinical pharmacist services being available in
patient/resident care areas to assist with medication reviews, to monitor use of Beer’s list
medications, to reduce the number of medications every resident receives and enhance
medication reconciliation at the admission process. Medication administration records (MARs) in
LTC would be improved with a seven day MAR, rather than monthly to reduce the number of
handwritten items on the MAR. Bringing Provincial Pharmacy into the structure of the pharmacy
department may facilitate transfers between acute and long term care.
Clinical services provided by pharmacists are inconsistent between sites. The pharmacy
department needs to develop measurable goals and objectives provincially for clinical pharmacist
services. Pharmacists are needed more routinely in patient care areas to provide education to
patients and participate in evidence informed medication ordering.
There is need to increase the use of "tech check tech" to enhance the availability of pharmacists
for clinical services. Additional potential areas for 'tech check tech' include first dose and
missing medication checking, as well as intravenous (IV) preparation checking. Further gains may
be realized if packaging can be centralized, along with the services provided by Provincial
Pharmacy.
Enhanced CIVA services from pharmacy would reduce the number of injectables prepared in
patient care areas. Removal of concentrated electrolytes (e.g. KCI) is required. The CIVA system
would be able to create patient specific infusions when required. Use of the CIVA will
standardize the quality of sterile products being prepared for patients and also, will return time
to nurses for patient centred activities.
The model of care should be enhanced to include allied health professionals such as pharmacists.
Pharmacists can be integrated into the care teams on the units for a number of medication
management concerns including medication reconciliation, use of evidence informed order sets
and patient and family education.
Detailed Accreditation Results
63
Accreditation Report
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Criteria
The organization provides access to current protocols,
guidelines, dosing recommendations, checklists, and/or
pre-printed order forms for high risk/high alert drugs.
1.5
The organization educates staff and service providers about
adverse drug events (ADEs).
1.8
The organization investigates a medication’s benefits and risks
before adding it to the formulary.
2.3
The organization educates staff and service providers about new
medications prior to their use.
2.6
The organization educates staff and service providers about new
uses for existing medications.
2.7
The organization has a process to systematically and regularly
review the formulary and update safety or efficacy information
accordingly.
2.8
The organization standardizes and limits the number of
medication concentrations available.
3.4
Medication concentrations are standardized and limited
across the organization.
The organization evaluates and limits the availability of heparin
products and has removed high-dose formats.
The organization has completed an audit of unfractionated
and low molecular weight heparin storage in the pharmacy
and in all patient care areas.
The audit includes a review of products and quantities
stored; assessment of the intended use for each heparin
product stored (alignment with evidence-based
guidelines); and identification of unnecessary products to
be removed.
64
Location
Detailed Accreditation Results
3.4.1
3.5
3.5.1
3.5.2
Priority for
Action
QMENTUM PROGRAM
The organization has reviewed and reduced, where
possible, availability of the following unfractionated
heparin products in patient care areas, ie. 10,000 units/mL
in 1 mL vials and 1,000 units/mL in 10 mL vials.
3.5.4
The organization evaluates and limits the availability of narcotic
(opioid) products and removes high-dose, high-potency formats
from patient care areas.
3.6
The organization has removed the following products:
hydromorphone ampoules or vials with concentration
greater than 2 mg/ml (exceptions include palliative care);
and morphine ampoules or vials with concentration
greater than 15 mg/ml.
3.6.2
The organization uses alerts to inform staff and service providers
about problematic labelling, packaging, and nomenclature.
4.2
The organization reports drug labelling, packaging, and
nomenclature problems.
4.4
The organization positions intraveneous infusion containers so
the manufacturer’s label is clearly visible.
5.2
The organization separates or isolates look-alike, sound-alike
medications; different concentrations of the same medication;
high-risk/high-alert medications; and discontinued, expired,
damaged, and contaminated medications pending removal.
6.5
When selecting stock drugs for client areas, the needs of the
client service area, staff and service provider expertise with
specific drugs, the risk of adverse events, and the typical age
and diagnosis of clients treated in that area are taken into
consideration.
7.1
The organization removes concentrated electrolytes (including,
but not limited to, potassium chloride, potassium phosphate,
sodium chloride >0.9%) from client service areas.
7.2
There are no concentrated electrolytes stored in client
service areas.
7.2.1
The organization has identified and implemented a list of
abbreviations, symbols, and dose designations that are not to be
used in the organization.
10.2
The organization implements the Do Not Use List and
applies this to all medication-related documentation when
hand written or entered as free text into a computer.
10.2.2
Detailed Accreditation Results
65
Accreditation Report
The organization updates the list and implements
necessary changes to the organization’s processes.
The organization audits compliance with the Do Not Use
List and implements process changes based on identified
issues.
66
10.2.6
10.2.7
The organization develops and follows a policy to maintain
accurate allergy information in each client medication history.
10.6
The organization develops and follows a policy or procedure to
maintain clinically accurate, known adverse drug reactions for
each client in the ongoing medication profile.
10.7
The pharmacy and other service providers accept telephone
orders for medication only in emergencies.
10.10
The organization monitors compliance with its policies and
processes for prescribing medications.
10.13
The pharmacy sets and follows policies for dispensing
emergency, urgent, and routine medications.
13.4
The organization has medication delivery turn-around times for
emergency, urgent, and routine medications.
15.2
At the start of service, service providers educate clients and
families about how to take an active role in ensuring medication
prescribed for them is administered safely.
16.1
Service providers ensure clients know who to contact, and how
to reach that person, if they have concerns or questions about
their medication, both while receiving care/service and at end
of service or transfer of service.
16.3
Service providers record in the client record verbal or written
information that is provided to the client.
16.5
The organization has explicit selection criteria for establishing
which clients are permitted to self-administer medications.
17.1
The organization educates and supervises clients who
self-administer medications.
17.2
The policy for self-administration of medications includes
documenting in the client record that the medication was taken
by the client, and when.
17.3
Detailed Accreditation Results
QMENTUM PROGRAM
Service providers seek an independent double check before
administering high-alert/high-risk medications.
18.5
Staff and service providers monitor and document the effects of
medication on progress towards the client’s treatment goals.
20.1
The organization has a quality control process to monitor
adherence to its policies related to medications with heightened
potential for adverse events.
21.3
The organization has a policy and process for reporting adverse
drug events, near misses, and hazardous situations in a timely
way.
21.4
The organization establishes an interdisciplinary group to
investigate adverse drug events and review adverse event
summary reports to support learning within the organization.
21.5
The organization has a policy and process about the adverse
drug event review process including which staff and service
providers to involve in the review.
21.6
The organization uses the findings of adverse drug event
investigations to identify and implement improvements.
21.8
The organization provides staff and service providers with
regular feedback about adverse drug events, hazardous
situations, and risk reduction strategies that are being
implemented.
21.9
The organization selects and monitors process and outcome
indicators for medication use and medication management.
22.1
The organization monitors medication use with an ongoing
medication utilization review.
22.2
Based on the data collected and analyzed, the organization
identifies and addresses areas for improvement.
22.4
Medicine Services
Clinical Leadership
Providing leadership and overall goals and direction to the team of people providing services.
Detailed Accreditation Results
67
Accreditation Report
Surveyor Comments
Community
Community Hospital
Hospital has
has done
done a
a review
review of
of community
community needs
needs and
and patient
patient admissions
admissions to
to determine
determine
an
appropriate
scope
of
service
and
has
concluded
that
a
palliative,
convalescence
and
an appropriate scope of service and has concluded that a palliative, convalescence and
rehabilitation
rehabilitation focus
focus would
would be
be appropriate.
appropriate. The
The QEH
QEH had
had previously
previously identified
identified the
the need
need for
for a
a
Provincial
Provincial Stroke
Stroke Program.
Program. It
It has
has implemented
implemented that
that program
program across
across the
the province
province and
and in
in ten
ten
dedicated
dedicated beds
beds on
on unit
unit 8.
8. This
This was
was achieved
achieved in
in collaboration
collaboration with
with a
a variety
variety of
of partners
partners including
including
the
Heart
and
Stroke
Foundation.
The
Stewart
Memorial
Hospital
medical
unit
the Heart and Stroke Foundation. The Stewart Memorial Hospital medical unit provides
provides a
a valuable
valuable
resource
for
patients
that
are
deemed
alternate
level
of
care
(ALC)
and
who
are
transferred
resource for patients that are deemed alternate level of care (ALC) and who are transferred to
to
Stewart
Stewart Memorial
Memorial Hospital
Hospital while
while awaiting
awaiting a
a placement.
placement. It
It is
is clear
clear that
that services
services are
are reviewed
reviewed and
and
revised
revised when
when circumstances
circumstances call
call for
for a
a review
review though
though not
not on
on a
a regular
regular basis.
basis. There
There are
are no
no formal,
formal,
measurable
measurable goals
goals and
and objectives
objectives evident.
evident.
With
With regard
regard to
to access
access to
to medical
medical care
care beds,
beds, there
there are
are issues
issues with
with access
access to
to beds
beds for
for admitted
admitted ED
ED
patients
at
the
QEH
site.
Also,
at
the
Kings
County
Memorial
Hospital,
there
is
concern
patients at the QEH site. Also, at the Kings County Memorial Hospital, there is concern that
that the
the
beds
beds are
are not
not being
being appropriately
appropriately used,
used, and
and that
that inappropriate
inappropriate utilization
utilization is
is contributing
contributing to
to
backlog
backlog and
and blocking
blocking of
of beds.
beds.
The
The chief
chief of
of pediatrics
pediatrics reported
reported that
that the
the use
use of
of pediatric
pediatric beds
beds for
for adult
adult patients
patients results
results in
in delays
delays
in
admitting
pediatric
patients
from
the
ED
and
can
impact
on
elective
surgery
for
children.
in admitting pediatric patients from the ED and can impact on elective surgery for children. The
The
unit
unit is
is currently
currently recruiting
recruiting five
five RNs.
RNs. Experienced
Experienced pediatric
pediatric nurses
nurses are
are difficult
difficult to
to recruit.
recruit. The
The
education
education of
of parents
parents is
is done
done well,
well, especially
especially upon
upon discharge.
discharge. The
The discharge
discharge documentation
documentation tool
tool
for
for same
same day
day surgery
surgery is
is noteworthy.
noteworthy. Statistics
Statistics are
are reviewed
reviewed monthly
monthly as
as a
a team.
team. The
The team
team is
is
working
working to
to develop
develop more
more robust
robust clinical
clinical indicators.
indicators. Physicians
Physicians sign
sign off
off on
on incident
incident reports
reports but
but the
the
feedback
loop
is
not
closed.
feedback loop is not closed.
Community
Community Hospital
Hospital staff
staff have
have been
been involved
involved in
in the
the model
model of
of care
care project.
project. The
The staff
staff are
are
enthusiastic
about
providing
palliative
care
services
for
the
surrounding
community.
enthusiastic about providing palliative care services for the surrounding community.
Areas
Areas for
for Improvement:
Improvement:
It
It is
is recommended
recommended that
that the
the team
team develop
develop measurable
measurable goals
goals and
and objectives
objectives for
for the
the services
services
provided.
provided.
It
It is
is recommended
recommended that
that admission
admission criteria
criteria to
to acute
acute care
care medical
medical beds
beds be
be developed
developed where
where
needed
needed and
and reviewed
reviewed on
on an
an ongoing
ongoing basis
basis in
in collaboration
collaboration with
with referring
referring physicians.
physicians.
It
It is
is recommended
recommended that
that a
a utilization
utilization management
management process
process for
for acute
acute care
care medical
medical beds
beds be
be
developed
and
implemented.
developed and implemented.
It
It is
is recommended
recommended that
that the
the utilization
utilization of
of pediatric
pediatric beds
beds by
by adult
adult patients
patients be
be reviewed.
reviewed.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Criteria
68
Location
The team regularly reviews its services and makes changes as
needed.
1.5
The team works together to develop goals and objectives.
2.1
Detailed Accreditation Results
Priority for
Action
QMENTUM PROGRAM
The team’s goals and objectives for its medicine services are
measurable and specific.
2.2
Competency
Developing a highly competent interdisciplinary team with the knowledge, skills and abilities to
develop, manage, and deliver effective and efficient programs, services, and care.
Surveyor Comments
Although there is an orientation process, it does not incorporate goals and objectives, as these
are not developed. There is consistent, diligent tracking of annual education requirements on the
medical unit surveyed.
Community Hospital and Kings County Memorial Hospital nursing staff communicated their
concern about a lack of funding to support their ongoing learning needs. Several staff stated that
there is no money to support education. In Souris and Stewart Memorial Hospitals, there are
opportunities for continuing education beyond the prescribed annual refreshers. There seems to
be inconsistency in availability of education opportunities. There was no evidence of an
educational plan for staff and performance reviews are not done regularly.
It is recommended that regular performance reviews, inclusive of an educational plan for staff,
be done regularly.
It is recommended that access to educational opportunities for nursing staff be reviewed.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Criteria
Location
The interdisciplinary team follows a formal process to regularly
evaluate its functioning, identify priorities for action, and make
improvements.
3.7
Team leaders regularly evaluate and document each team
member’s performance in an objective, interactive, and positive
way.
4.8
Priority for
Action
Episode of Care
Healthcare services provided for a health problem from the first encounter with a health care
provider through the completion of the last encounter related to that problem.
Surveyor Comments
The Provincial Stroke Program provides leadership in the care of stroke patients across the
province. Patient pathways, standardized order sets and teaching plans are well developed and
intended to be used for stroke patients across the province. Documentation on forms provided is
inconsistent.
Patients interviewed in all of the medical care areas surveyed, were consistently appreciative of
the care they or their loved ones received. They acknowledged being cared for in a respectful,
professional manner. Access to diagnostic procedures was noted to be readily available. Transfer
forms were consistently used to document patient information.Detailed
DischargeAccreditation
planning is a Results
significant care planning activity.
There was a variety of printed material available to patients. It might be useful to review all of
the medical services printed material to standardize what is available and to identify gaps in
69
Accreditation Report
Patients interviewed in all of the medical care areas surveyed, were consistently appreciative of
the care they or their loved ones received. They acknowledged being cared for in a respectful,
professional manner. Access to diagnostic procedures was noted to be readily available. Transfer
forms were consistently used to document patient information. Discharge planning is a
significant care planning activity.
There was a variety of printed material available to patients. It might be useful to review all of
the medical services printed material to standardize what is available and to identify gaps in
information.
There is part time on site clinical pharmacist support in the smaller medical facilities. The
clinical pharmacists encountered were very committed partners in patient care.
If an ED patient is awaiting a bed on a medical unit, that patient remains in ED for the duration.
Access to placement for ALC patients in medical care beds can be problematic. In those cases,
the patients have long length of stays in the acute care beds.
When staff identify an ethical issue, they tend to work amongst themselves to resolve the issue.
Seldom is the organizational ethics service utilized for guidance.
Areas for Improvement:
It is recommended that a brochure informing patients of the complaint process be developed and
provided to patients.
It is recommended that the Provincial Stroke Program undertake a provincial documentation
audit.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Criteria
The team reconciles the client’s medications upon admission to
the organization, with the involvement of the client, family or
caregiver.
There is a demonstrated, formal process to reconcile
client medications upon admission.
The team generates a Best Possible Medication History
(BPMH) for the client upon admission.
Depending on the model, the prescriber uses the BPMH
to create admission medication orders (proactive), OR, the
team makes a timely comparison of the BPMH against the
admission medication orders (retroactive).
The team documents that the BPMH and admission
medication orders have been reconciled; and appropriate
modifications to medications have been made where
necessary.
70
Detailed Accreditation Results
Location
7.5
7.5.1
7.5.2
7.5.3
7.5.4
Priority for
Action
QMENTUM PROGRAM
The process is a shared responsibility involving the client
and one or more health care practitioner(s), such as
nursing staff, medical staff, pharmacists, and pharmacy
technicians, as appropriate.
Medication Reconciliation at Admission
7.5.5
7.6
The team follows Accreditation Canada’s protocols and
definitions to collect and submit data on medication
reconciliation at admission.
The team does not have any unaddressed priority for
action flags based on their medication reconciliation at
admission indicator results.
7.6.1
7.6.2
The team educates clients and families about their rights, and
investigates and resolves any claims that these rights have been
violated.
8.7
The team develops an integrated and comprehensive service
plan for each client.
9.2
The team reconciles medications with the client at referral or
transfer, and communicates information about the client’s
medications to the next provider of service at referral or
transfer to another setting, service, service provider, or level of
care within or outside the organization.
11.3
There is a demonstrated, formal process to reconcile
client medications at referral or transfer.
The process includes generating a comprehensive list of
all medications the client has been taking prior to referral
or transfer.
The process includes a timely comparison of the
prior-to-referral or prior-to-transfer medication list with the
list of new medications ordered at referral or transfer.
The process requires documentation that the two lists
have been compared; differences have been identified,
discussed, and resolved; and appropriate modifications to
the new medications have been made.
The process makes it clear that medication reconciliation
is a shared responsibility involving the client, nursing staff,
medical staff and pharmacists, as appropriate.
The organization has a documented plan to implement
throughout the organization, and before the next
accreditation survey, a medication reconciliation process
at referral and transfer.
11.3.1
11.3.2
11.3.3
11.3.4
11.3.5
11.3.6
Detailed Accreditation Results
71
Accreditation Report
Following transition or end of service, the team contacts clients,
families, or referral organizations to evaluate the effectiveness
of the transition, and uses this information to improve its
transition and end of service planning.
11.6
Decision Support
Information, research and evidence, data, and technologies that support and facilitate
management and clinical decision-making.
Surveyor Comments
Charting is done by exception and there was evidence of regular charting on patient progress and
care. There is a hybrid chart with some information in hard copy and electronic assessments and
progress notes. A Conley Falls Risk Assessment is used to identify patients at risk for falls.
At the Stewart Memorial Hospital, when asked about evidence based guidelines, the staff
indicated that they had computer access to look up protocols and guidelines and that most of
their guidelines related to their ambulatory care patients, and used the example of myocardial
infarction (MI) guidelines. In the Provincial Stroke Program, evidence based guidelines are the
foundation of care maps. In Community Hospital, evidence based guidelines are being used to
develop the palliative care service.
No Unmet Criteria for this Priority Process.
Impact on Outcomes
The identification and monitoring of process and outcome measures to evaluate and improve the
quality of services to clients and the impact on client outcomes.
Surveyor Comments
Managers develop and submit operating and capital budgets for their units.
Quality/performance indicators are collected provincially for ALOS, readmission rates and
infection rates. The front line staff are unaware of what indicators are collected. Quality
improvement (QI) initiatives are not consistently communicated to the front line staff.
Staff address patient concerns on an ongoing basis. Quality and safety issues are dealt with case
by case. Different components of the medical service identify and address opportunities for
improvement in a variety of ways. What is lacking is a comprehensive, standardized way to
identify quality indicators, measure them, evaluate effectiveness of change and then
communicate with the organization and patients.
Patient satisfaction surveys were conducted last year. Results have been communicated to some
parts of the medicine services but not to all areas.
Of the sites surveyed, there has been one referral for ethical consultation in recent memory. This
involved a do not resuscitate (DNR) request by a diabetes client at Souris Hospital.
Areas for Improvement:
It is recommended that a comprehensive QI program and process be developed for medicine
services.
72
Detailed Accreditation Results
QMENTUM PROGRAM
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Location
Criteria
Staff and service providers participate in regular safety briefings
to share information about potential safety problems, reduce
the risk of error, and improve the quality of service.
15.3
The team informs and educates its clients and families in writing
and verbally about the client and family’s role in promoting
safety.
15.4
Written and verbal information is provided to clients and
families about their role in promoting safety.
Staff uses written and verbal approaches to inform and
educate clients about their role in promoting safety.
Clients indicate that they have received written and verbal
communication about their role in promoting safety.
15.4.1
The team implements verification processes and other checking
systems for high-risk activities.
The team identifies high-risk activities.
The team develops and implements verification processes
for high-risk activities.
The team evaluates the verification processes and uses
information to make improvements.
The team shares evaluation results with staff, clients, and
families.
Priority for
Action
15.4.2
15.4.3
15.5
15.5.1
15.5.2
15.5.3
16.5
Mental Health Services
Clinical Leadership
Providing leadership and overall goals and direction to the team of people providing services.
Surveyor Comments
In August 2009 strategy entitled: "The Path Forward: a PEI Mental Health Services Strategy" was
developed with key strategic directions to improve the integration of a quality, person centred,
recovery oriented service in mental health (MH) province wide.
The MH services appear to be well on its way to providing integrated services between acute care
inpatient and community services across the province. This is reflected in quality MH services
across the continuum of care. There is evidence of two way communication between community
teams, emergency and inpatient units to provide for ongoing care of these clients and to
facilitate discharge back into the community.
continuum of care by alerting the team to potential client problems in the community and by
following up on clients discharged from inpatient units to the community. The representation of
staff from the community programs at regular rounds in acute care, facilitates a good exchange
of information and coordinated client care planning across the continuum of care.
Detailed Accreditation Results
The introduction of the Crisis Response Team in emergency at the QEH and PCH sites has made a
positive impact on patient flow within the MH program. During the tracer, it was easy to see how
well the Crisis Response Team in emergency worked with the psychiatrists and community
partners to assess and make decisions on patient care. The Crisis Response Team has improved
73
Accreditation Report
The community's liaison nurse attends rounds and provides information that facilitates a
continuum of care by alerting the team to potential client problems in the community and by
following up on clients discharged from inpatient units to the community. The representation of
staff from the community programs at regular rounds in acute care, facilitates a good exchange
of information and coordinated client care planning across the continuum of care.
The introduction of the Crisis Response Team in emergency at the QEH and PCH sites has made a
positive impact on patient flow within the MH program. During the tracer, it was easy to see how
well the Crisis Response Team in emergency worked with the psychiatrists and community
partners to assess and make decisions on patient care. The Crisis Response Team has improved
patient flow by preventing acute care admissions wherever possible by setting up community
resources for clients. Emergency department physicians also expressed how well the system
works to manage patient flow and quality client care.
Although there is a wait time in Summerside for admission to Adult Community Mental Health
Services; each client on the wait list is sent a letter giving them instructions on whom to
telephone if they run into difficulty. These clients are provided with a comprehensive list of
resources available in the community with information to access the resources.
Areas for Improvement:
There is some evidence of team goal setting at some sites but it is not consistently applied across
the province. All teams are encouraged to develop team goals and objectives to improve team
functioning.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Criteria
Location
The team works together to develop goals and objectives.
2.1
The team’s goals and objectives for its mental health services
are measurable and specific.
2.2
Priority for
Action
Competency
Developing a highly competent interdisciplinary team with the knowledge, skills and abilities to
develop, manage, and deliver effective and efficient programs, services, and care.
Surveyor Comments
The Mental Health (MH) program at the sites consists of inpatient units, crisis intervention beds,
community mental health and in some cases, addictions. The inpatient team meets daily with
community MH as part of an interdisciplinary team to discuss client care. These meetings can
include psychiatrists, family physicians, social workers, unit and outreach nursing staff, OT,
psychologist, adult program staff, and reflect the interdisciplinary team at each respective site.
This is one of the vehicles used to ensure the continuum of care for MH clients. It is noted that
students are invited to these rounds and that there is often an educational component as part of
the discussion.
74
Staff stated that they have access to educational opportunities that cover non violent crisis
intervention (NVCI) sessions, cardiopulmonary resuscitation (CPR), fire, workplace hazardous
management information system (WHIMIS), and lifts and repositioning (TLR). Staff also indicated
that
they have access
to other courses but that funding was limited. A potentially helpful
Detailed
Accreditation
Results
suggestion from a clinical staff is to obtain a Health PEI wide subscription access to internet
based, health care knowledge sites.
The team felt that there are informal discussions about patient safety issues at rounds and shift
QMENTUM PROGRAM
Staff stated that they have access to educational opportunities that cover non violent crisis
intervention (NVCI) sessions, cardiopulmonary resuscitation (CPR), fire, workplace hazardous
management information system (WHIMIS), and lifts and repositioning (TLR). Staff also indicated
that they have access to other courses but that funding was limited. A potentially helpful
suggestion from a clinical staff is to obtain a Health PEI wide subscription access to internet
based, health care knowledge sites.
The team felt that there are informal discussions about patient safety issues at rounds and shift
change over report. The team is also encouraged to include patient safety and quality as a
standing agenda item at staff meetings.
Managers ensure that all staff are licensed to practice annually.
There is an annual award for mental health nursing as well as recognition of professional weeks
with internal celebrations that offer coffee and donuts, flowers, and so on. Once or twice per
year the organization will combine an educational half day with a team building activity such as a
barbecue. Morale appears good, and the team is close knit.
There was mixed response from staff when asked if they received regular performance reviews.
The answers ranged from one year, to some long term staff that had never received a
performance review. It is recommended that the team managers consistently do regular
performance reviews for staff that includes development plans .
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Location
Criteria
The interdisciplinary team follows a formal process to regularly
evaluate its functioning, identify priorities for action, and make
improvements.
3.7
Staff and service providers receive ongoing, effective training on
infusion pumps.
4.4
There is documented evidence of ongoing, effective
training on infusion pumps.
Priority for
Action
4.4.1
Team leaders regularly evaluate and document each team
member’s performance in an objective, interactive, and positive
way.
4.10
Episode of Care
Healthcare services provided for a health problem from the first encounter with a health care
provider through the completion of the last encounter related to that problem.
Detailed Accreditation Results
75
Accreditation Report
Surveyor Comments
Clinical care is well coordinated with referrals from the emergency crisis intervention beds,
community, inpatient units and from psychiatrists, with the majority of referrals coming from the
emergency department (ED).
The development of the Crisis Response Team in emergency, the central children's intake and the
introduction of complex cases are examples of where the MH services have addressed
organizational strategic directions.
The continuum of care includes emergency crisis response, inpatient, outpatient and community
services.
The team evaluates its service by collecting data on readmission rates and feels that the new
Crisis Response Team has been able to keep clients out of hospital and in their communities
where ever possible. The team also measures the average length of stay and monitors mandatory
educational sessions.
The clinical care is well done with appropriate intake, assessment, and progress notes being
maintained. The Integrated Services Management Program (IMS) is used for charting and is
efficient. There is cross over to the newer Clinical Information System (CIS) on the part of the
nursing staff so that they can appropriately access pertinent medical information on their MH
clients. This access is not readily available to the staff on the addictions side.
There seems to be little awareness of formal policies/mechanisms such as ethics consultation at
some sites, with providers using their own sources to find solutions to such issues. The teams are
encouraged to become familiar with the ethics framework and to gain an understanding of how
to refer ethical issues to the committee when necessary.
Suicide screening is a fundamental intake focus at all sites, and a regular consideration in
following clients.
The implementation of medication reconciliation on admission varies across acute care sites from
full implementation to partial. There are plans for a full roll out and the teams in mental health
are encouraged to implement the process at all sites.
The organization has created an orientation program for new staff. The plan includes follow up
with regular review periods during the first year of service. Staff are quite pleased with the
orientation process and assessments.
The LPNs have been integrated into the nursing complement and staff report that the staffing
model is working well.
There is well established check in for community workers to ensure their safety. Arrangements
are made to work in pairs whenever they assess that they are at risk with a specific client.
All inpatients are assessed for risk of falls and a falls prevention strategy and TLR are firmly in
place.
The different disciplines work well together and are comfortable consulting one another as client
needs arise. Care plans and orders are reviewed regularly.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
76
Detailed Accreditation Results
QMENTUM PROGRAM
Location
Criteria
Medication Reconciliation at Admission
Priority for
Action
7.7
The team follows Accreditation Canada’s protocols and
definitions to collect and submit data on medication
reconciliation at admission.
The team does not have any unaddressed priority for
action flags based on their medication reconciliation at
admission indicator results.
7.7.1
7.7.2
The team reconciles medications with the client at referral or
transfer, and communicates information about the client’s
medications to the next provider of service at referral or
transfer to another setting, service, service provider, or level of
care within or outside the organization.
There is a demonstrated, formal process to reconcile
client medications at referral or transfer.
The process includes generating a comprehensive list of
all medications the client has been taking prior to referral
or transfer.
The process includes a timely comparison of the
prior-to-referral or prior-to-transfer medication list with the
list of new medications ordered at referral or transfer.
The process requires documentation that the two lists
have been compared; differences have been identified,
discussed, and resolved; and appropriate modifications to
the new medications have been made.
The process makes it clear that medication reconciliation
is a shared responsibility involving the client, nursing staff,
medical staff and pharmacists, as appropriate.
The organization has a documented plan to implement
throughout the organization, and before the next
accreditation survey, a medication reconciliation process
at referral and transfer.
11.3
11.3.1
11.3.2
11.3.3
11.3.4
11.3.5
11.3.6
Decision Support
Information, research and evidence, data, and technologies that support and facilitate
management and clinical decision-making.
Surveyor Comments
All charts reviewed showed evidence of regular progress notes for every MH client. The teams are
very concerned with maintaining clients' privacy and confidentiality.
There is evidence that information is provided to facilitate flow to providers on a need to know
basis, with the client's consent.
No Unmet Criteria for this Priority Process.
Detailed Accreditation Results
77
Accreditation Report
Impact on Outcomes
The identification and monitoring of process and outcome measures to evaluate and improve the
quality of services to clients and the impact on client outcomes.
Surveyor Comments
The teams are aware of risk issues associated with their work and client population. There is
evidence of planning around risk reduction for suicide prevention both in the design of their new
buildings and in the care and attention the staff pay to observation and safety proofing the client
environment.
The teams are collecting indicator data to reflect the strategic direction outlined in the Mental
Health Services Strategy report. A few of the indicators they are collecting include readmission
rates, wait times and average length of stay. They need to share this information with front line
staff.
The staff are aware of risk situations and have developed strategies to ensure safety for workers
that work alone in the community. They have instituted non violence crisis intervention (NVCI)
training with mental health workers.
Community Mental Health still needs to work on addressing the risk they have identified at the
PCH site's adult program and related to the shared waiting room. They have expressed concerns
that there are mixed populations that share the area which could potentially put some clients at
risk. Encouragement is offered to work with the child psychologist and the psychiatrists in that
area to develop solutions to address these risks.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Criteria
The team shares evaluation results with staff, clients, and
families.
Location
Priority for
Action
16.5
Obstetrics/Perinatal Care Services
Clinical Leadership
Providing leadership and overall goals and direction to the team of people providing services.
Surveyor Comments
The setting of annual goals and objectives and then measuring achievement of the goals is very
important in driving quality improvement.
The foundation at the Prince County Hospital (PCH) site is commended for being able to raise a
very large amount of money to provide up to date equipment for the organization.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
78
Detailed Accreditation Results
QMENTUM PROGRAM
Location
Criteria
The team proactively collects information about its clients and
the community.
1.1
The team uses the information it collects about clients and the
community to define the scope of its services and set priorities
when multiple service needs are identified.
1.2
The team’s scope of services is aligned with the organization
strategic plan.
1.3
The team collaborates with other services, programs, providers,
and organizations to identify, address, and coordinate services
across the continuum.
1.4
The team regularly reviews its services and makes changes as
needed.
1.5
The team works together to develop team goals and objectives.
2.1
The team’s goals and objectives for its obstetrics/perinatal care
services are measurable and specific.
2.2
Priority for
Action
Competency
Developing a highly competent interdisciplinary team with the knowledge, skills and abilities to
develop, manage, and deliver effective and efficient programs, services, and care.
Surveyor Comments
Performance reviews of the effectiveness of the team should be done on a regular basis.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Location
Criteria
The interdisciplinary team follows a formal process to regularly
evaluate its functioning, identify priorities for action, and make
improvements.
3.7
Team leaders regularly evaluate and document each team
member’s performance in an objective, interactive, and positive
way.
4.10
Priority for
Action
Detailed Accreditation Results
79
Accreditation Report
The team has a fair and objective process or program to
recognize team members for their contributions.
5.6
Episode of Care
Healthcare services provided for a health problem from the first encounter with a health care
provider through the completion of the last encounter related to that problem.
Surveyor Comments
The team at PCH is very close to full compliance with medication reconciliation on admission and
is encouraged to complete the journey.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Criteria
Medication Reconciliation at Admission.
The team follows Accreditation Canada’s protocols and
definitions to collect and submit data on medication
reconciliation at admission.
The team does not have any unaddressed priority for
action flags based on their medication reconciliation at
admission indicator results.
The team reconciles medications with the client at referral or
transfer, and communicates information about the client’s
medications to the next provider of service at referral or
transfer to another setting, service, service provider, or level of
care within or outside the organization.
80
Location
7.13
7.13.1
7.13.2
11.3
There is a demonstrated, formal process to reconcile
client medications at referral or transfer.
The process includes generating a single documented,
comprehensive list all medications the client has been
taking prior to referral or transfer.
11.3.1
The process requires documentation that differences
between the two lists have been identified, discussed, and
resolved, and that appropriate modifications to the new
medications have been made.
11.3.4
The organization has a documented plan to implement
throughout the organization, and before the next
accreditation survey, a medication reconciliation process
at referral and transfer.
11.3.6
Detailed Accreditation Results
11.3.2
Priority for
Action
QMENTUM PROGRAM
Following transition or end of service, the team contacts clients,
families, or referral organizations to evaluate the effectiveness
of the transition, and uses this information to improve its
transition and end of service planning.
11.5
Decision Support
Information, research and evidence, data, and technologies that support and facilitate
management and clinical decision-making.
Surveyor Comments
The team at PCH is commended for working together to develop an epidural service. It is hoped
that patients will be encouraged to avail themselves of the service.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Location
Criteria
The team reviews its guidelines to make sure they are
up-to-date and reflect current research and best practice
information.
Priority for
Action
15.2
Impact on Outcomes
The identification and monitoring of process and outcome measures to evaluate and improve the
quality of services to clients and the impact on client outcomes.
Surveyor Comments
The setting of written and measurable goals and objectives is an important step in developing
quality improvement.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Location
Criteria
The team identifies the resources it needs to achieve its goals
and objectives.
2.3
The team shares benchmark and best practice information with
its partners and other organizations.
15.5
The team implements verification processes and other checking
systems for high risk activities.
16.5
Priority for
Action
Detailed Accreditation Results
81
Accreditation Report
The team evaluates the verification processes and uses
information to make improvements.
16.5.3
The team identifies and monitors process and outcome measures
for its obstetrics/perinatal care services.
17.1
The team monitors clients and families’ perspectives the quality
of its obstetrics/perinatal care services.
17.2
The team compares its results with other similar interventions,
programs, or organizations.
17.3
The team uses the information it collects about the quality of its
services to identify successes and opportunities for
improvement, and makes improvements in a timely way.
17.4
The team shares evaluation results with staff, clients, and
families.
17.5
Rehabilitation Services
Clinical Leadership
Providing leadership and overall goals and direction to the team of people providing services.
Surveyor Comments
Rehabilitation services are well run programs at both the QEH and PCH sites, with teams of highly
trained dedicated staff that received high praise from all of the patients interviewed. The
Provincial Stroke Program operates out of the QEH site and rehabilitation services is an essential
part of that program. These staff were actively involved in the consultation, planning and
implementation of the program and are commended for their contributions to the success of this
province wide initiative.
The population of patients on the QEH rehabilitation unit is varied and consists of stroke,
orthopedic post operative patients, amputees, chronic neuromuscular, spinal cord and head
injury patients. The unit also had off service medicine patients. This variety of rehabilitation and
medical patients will provide challenges to staff being able to keep up their skills in all areas to
assure good quality patient care.
The rehabilitation services has worked with service providers, stakeholders and clients to develop
a province wide stroke program. Stroke patients are admitted to the Provincial Stroke Program to
ensure that they have access to the expertise of staff specializing in stroke care. They have
developed stroke protocols in emergency, acute stroke unit and rehabilitation. Patients are
transferred to the acute stroke unit from emergency and progress from there to rehabilitation
when they are medically stable and meet the criteria. There is an excellent in-hospital
continuum of care for this patient population.
The tracer was completed on a stroke patient admitted through the ED and transferred to ICU
prior to being admitted to the acute stroke unit and then on to rehabilitation. The admission
process was managed well and provided an excellent continuum of care.
82
patient care. All areas identified that the patient flow for the Provincial Stroke Program, as well
as other rehabilitation patients is working very well. The Provincial Stroke Program was used as
anAccreditation
example of service
review, which led to changes in practice that is now province wide. This
Detailed
Results
program ensures that there is consistency in the approach to stroke care in the province.
Team members are aware of community services and make use of these services in their
discharge planning. Patients verified that they were made aware of the community services they
QMENTUM PROGRAM
It was obvious that there had been good collaboration between the service to develop this seamless
approach to patient care. All areas identified that the patient flow for the Provincial Stroke Program,
as well as other rehabilitation patients is working very well. The Provincial Stroke Program was used
as an example of service review, which led to changes in practice that is now province wide. This
program ensures that there is consistency in the approach to stroke care in the province.
Team members are aware of community services and make use of these services in their
discharge planning. Patients verified that they were made aware of the community services they
could access prior to discharge. There is a process in place for outpatient physiotherapy services
to serve as a carry over from an inpatient discharge, if that service is required. Occupational
therapy and speech therapy outpatient services was not as readily available to patients that have
to access these services privately.
The team provides clinical placement opportunities for RNs, LPNs, PTs, OTs, speech therapy and
physicians. Every team member indicated that they have job descriptions, which provide role
clarity. The services are divided into two teams that provide services to the rehabilitation
patients. The staff felt that caseloads were evenly distributed and appropriate. The white board
was used effectively as a scheduler and as a communication board so that staff and visitors are
aware of the treatment schedule for rehabilitation services. Patients are informed of the use of
the white board and are asked if they agree to have their name put on the board.
Rehabilitation services has developed a working relationship with the Canadian Paraplegic
Association that has led to collaboration and improvements to patient care.
Areas for Improvement:
It is recommended that the team develop interdisciplinary team goals and objectives that are
measurable and have time lines, as a basis for continuous quality improvement initiatives.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Criteria
Location
The team works together to develop goals and objectives.
2.1
The team’s goals and objectives for rehabilitation services are
measurable and specific.
2.2
Priority for
Action
Competency
Developing a highly competent interdisciplinary team with the knowledge, skills and abilities to
develop, manage, and deliver effective and efficient programs, services, and care.
Surveyor Comments
There are two teams at the QEH site. These teams have representation from the service
providers involved in providing rehabilitation services. Team composition includes the physiatrist,
nurses, physiotherapists, occupational therapists, speech language pathologists, prosthetists,
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disciplines brings their unique skills to the team. The team members communicate easily
between disciplines and there is evidence of interdisciplinary planning of patient care.
There is evidence of every discipline completing separate assessments
andAccreditation
progress notes Results
in
Detailed
different areas of the chart. They are doing some reviews of functioning but it appears to be at a
discipline specific level and is not a formal process. Encouragement is offered to continue to
work on developing a high functioning interdisciplinary team. This would include interdisciplinary
charting, planning, evaluation of functioning and goal setting.
83
Accreditation Report
The patient population is divided between these two teams to ensure equitable distribution of caseloads.
Each of the disciplines brings their unique skills to the team. The team members communicate
easily between disciplines and there is evidence of interdisciplinary planning of patient care.
There is evidence of every discipline completing separate assessments and progress notes in
different areas of the chart. They are doing some reviews of functioning but it appears to be at a
discipline specific level and is not a formal process. Encouragement is offered to continue to
work on developing a high functioning interdisciplinary team. This would include interdisciplinary
charting, planning, evaluation of functioning and goal setting.
The team meets weekly to review the goals and objectives for every client/patient and to update
the team on patient's progress. This is one of the strengths of the two treatment teams in that
they have a process for including the patients in developing service goals and objectives. Plus,
they discuss and document patient goal attainment at their interdisciplinary rounds.
The unit manager and the manager of physical medicine services have annual processes for
checking to make sure that all staff have a current license to practice.
The nurse educator provides ongoing education on infusion pumps and provided a record of
nursing staff that have received training over the last year.
New nursing staff go through an extensive orientation process to the organization and the unit.
The allied health group have developed an orientation process for all new staff.
Educational opportunities are available for staff. Encouragement is offered to develop an
educational plan that incorporates individual staff needs identified through performance reviews
and team needs as identified through a team evaluation process.
The management team is encouraged to provide regular performance reviews for all staff, which
includes developmental plans. There was a varied response when asking staff if they had
received regular performance reviews. The implementation is inconsistent in that some staff had
a current review while others report no review for a number of years. It is recommended that the
team managers institute a process to complete performance reviews that identify development
needs on a regular basis.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Criteria
84
Location
The interdisciplinary team follows a formal process to regularly
evaluate its functioning, identify priorities for action, and make
improvements.
3.7
Team leaders regularly evaluate and document each team
member’s performance in an objective, interactive, and positive
way.
4.8
Detailed Accreditation Results
Priority for
Action
QMENTUM PROGRAM
Episode of Care
Healthcare services provided for a health problem from the first encounter with a health care
provider through
through the
the completion
completion of
of the
the last
last encounter
encounter related
related to
to that
that problem.
problem.
provider
Surveyor Comments
The staff are aware of the Ethics Committee but had not brought forward any ethics issues to
date. They felt they had the ability to discuss ethics issues at their rounds and team meetings.
They have used the Ethics Committee for approval of a research endeavour and had the project
approved.
The team was able to comment on an open, fair, and timely process for handling complaints but
need to make sure that all patients are aware of the process for bringing complaints forward.
Encouragement is offered to develop a written brochure to identify the complaints process so
that patients know how to submit a complaint. This brochure should be provided to patients
when admitted to the unit.
The rehabilitation team needs to develop a process to identify who will coordinate the patient's
care as soon as they enter the unit. The patients interviewed were not able to identify who was
responsible for coordinating their care, even after they had been on the unit for a time.
One of the strengths identified by stakeholders was the timely response to rehabilitation
referrals. Every patient is assessed for admission to the rehabilitation unit by the team's
physiatrist. After the consult, a decision is made as to whether the patient meets the criteria for
admission.
Staff indicate that there is no wait list for admission to rehabilitation.
Charting is done in hard copy and electronically, which creates challenges for obtaining a good
rounded picture of the patient. There is evidence of complete and timely assessments by all
providers.
Rehabilitation services is in the process of developing its medication reconciliation on admission.
The staff completes a Best Possible Medication History (BPMH) for each of the patients but have
yet to incorporate the full system. Full implementation is being planned and encouragement is
offered to continue to work toward full implementation.
The interdisciplinary team develops a comprehensive discharge plan for every patient that
includes involvement of the patient and family. Unfortunately, there is no formal process for
evaluating the effectiveness of their discharge planning. Patients will often come up to the
nursing station when they come back for their clinic appointment to let staff know how well they
are doing. There is also an opportunity for the outpatient staff that follow the patient to report
on how the patient is managing at home and in the community. They are strongly encouraged to
formalize the process. This will give them the chance to celebrate their successes and to improve
the process where needed.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Detailed Accreditation Results
85
Accreditation Report
Criteria
From their first contact with the organization or team, clients
and families are informed of the team member who is
responsible for coordinating their service, and told how to reach
that person.
6.2
The team reconciles the client’s medications upon admission to
the organization, with the involvement of the client, family or
caregiver.
7.4
There is a demonstrated, formal process to reconcile
client medications upon admission.
7.4.1
Depending on the model, the prescriber uses the BPMH
to create admission medication orders (proactive), OR, the
team makes a timely comparison of the BPMH against the
admission medication orders (retroactive).
The team documents that the BPMH and admission
medication orders have been reconciled; and appropriate
modifications to medications have been made where
necessary.
The process is a shared responsibility involving the client
and one or more health care practitioner(s), such as
nursing staff, medical staff, pharmacists, and pharmacy
technicians, as appropriate.
7.4.3
Medication Reconciliation at Admission
The team follows Accreditation Canada’s protocols and
definitions to collect and submit data on medication
reconciliation at admission.
The team does not have any unaddressed priority for
action flags based on their medication reconciliation at
admission indicator results.
7.4.4
7.4.5
7.5
7.5.1
7.5.2
The team educates clients and families about their rights, and
investigates and resolves any claims that these rights have been
violated.
8.7
The team reconciles medications with the client at referral or
transfer, and communicates information about the client’s
medications to the next provider of service at referral or
transfer to another setting, service, service provider, or level of
care within or outside the organization.
11.3
There is a demonstrated, formal process to reconcile
client medications at referral or transfer.
86
Location
Detailed Accreditation Results
11.3.1
Priority for
Action
QMENTUM PROGRAM
The process includes a timely comparison of the
prior-to-referral or prior-to-transfer medication list with the
list of new medications ordered at referral or transfer.
The process requires documentation that the two lists
have been compared; differences have been identified,
discussed, and resolved; and appropriate modifications to
the new medications have been made.
The process makes it clear that medication reconciliation
is a shared responsibility involving the client, nursing staff,
medical staff and pharmacists, as appropriate.
Following transition or end of service, the team contacts clients,
families, or referral organizations to evaluate the effectiveness
of the transition, and uses this information to improve its
transition and end of service planning.
11.3.3
11.3.4
11.3.5
11.5
Decision Support
Information, research and evidence, data, and technologies that support and facilitate
management and clinical decision-making.
Surveyor Comments
There is good evidence of regular updates to the patient's chart on patient progress and goal
attainment. The team has set up processes to meet with patients and family to discuss goals,
treatment plans and the coordination of information flow between providers, referrals to other
programs, services and other organizations. During the tracer, the referral unit staff spoke highly
of the transfer process, information and access provided to them by the rehabilitation program.
The team records a number of assessments electronically, such as fall prevention assessment,
nursing, medical, and allied health assessments. Progress notes are discipline specific and are
also recorded electronically. The team uses a hybrid chart where some information is recorded
on hard copy and some electronically. This presents a challenge as it is necessary to look at both
areas to obtain a true picture of the patient's progress.
Areas for Improvement:
The Provincial Stroke Program has developed clinical protocols/care plans and there is evidence
of these on the chart, but the staff do not consistently report on the care plan. They consider it
duplicated charting, as the care plan is not an electronic process. It is recommended that staff
document on the care plan, as this will be an excellent tool to measure consistency in care as a
quality improvement initiative.
No Unmet Criteria for this Priority Process.
Impact on Outcomes
The identification and monitoring of process and outcome measures to evaluate and improve the
quality of services to clients and the impact on client outcomes.
Detailed Accreditation Results
87
Accreditation Report
Surveyor Comments
The unit manager relies on the incident reports to identify risk issues on the unit. The manager
has a process to review trends and to discuss these at nursing staff meetings. This process needs
to be broadened to include the entire team for risk management. The front line staff were
unable to identify a formal process for identifying risks and developing action plans to reduce
risk. They feel that they address issues at rounds and team meetings and work to resolve issues
as they arise. This process is reactive. Encouragement is offered to formalize a proactive process
so that they can make sure that issues of risk are identified and reviewed, along with action
plans and time lines for resolutions.
The patients identified that the staff use two identifiers when providing services. They are
encouraged to continue to use two identifiers, as there can be a tendency to drop the two
identifiers when patients become familiar to the staff. This was voiced by the patients who
identified that initially, staff did check their arm bands and asked for their names but that this
was not necessarily sustained over time. Staff need to be mindful to continue the process so that
it establishes a habit of safety.
The team completes a functional independence measure (FIM) assessment on all clients and
reports the NRS data. The team completed a pilot project for the Canadian Institute for Health
Information (CIHI) and received very good feedback on their reporting and results. The team has
stopped receiving the comparison data for a time but there are plans in place to reincorporate
the practice. Encouragement is offered to implement the review of its comparative data against
benchmarks so that team members can evaluate the effectiveness of their outcomes against the
outcomes of their peers.
The team completes a Conley Falls Risk Assessment and identifies patients at risk for falls. The
team discusses safety issues at rounds and team meetings.
Areas for Improvement:
Family members commented that they had received a patient satisfaction survey. The unit
manager noted that she has received the compiled data and has provided the information at
nursing staff meetings. The manager is encouraged to make the information available to all team
members.
The team was aware of the incident reporting system and felt comfortable in reporting incidents
and that there was a culture of no blame associated with incident reporting. The staff were
unable to identify if they would do anything different in the case of a sentinel event. The unit
manager and the physical medicine manager are encouraged to review the process and
familiarize the staff with the concept of sentinel events. The unit manager commented that the
concept of recording near misses is being introduced. It is recommended that they continue to do
education and encourage staff to report near misses, as the staff interviewed reported that they
did not routinely report near misses.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
88
Detailed Accreditation Results
QMENTUM PROGRAM
Location
Criteria
The team informs and educates its clients and families in writing
and verbally about the client's and family’s role in promoting
safety.
15.4
Written and verbal information is provided to clients and
families about their role in promoting safety.
Staff uses written and verbal approaches to inform and
educate clients about their role in promoting safety.
Clients indicate that they have received written and verbal
communication about their role in promoting safety.
15.4.1
The team shares evaluation results with staff, clients, and
families.
Priority for
Action
15.4.2
15.4.3
16.5
Substance Abuse and Problem Gambling Services
Clinical Leadership
Providing leadership and overall goals and direction to the team of people providing services.
Surveyor Comments
The creation of measurable goals and objectives that align with the province's strategic priorities
need to be created and monitored. The program has been challenged to respond to changing
patterns of clients, including increased needs for youth services.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Location
Criteria
The team’s goals and objectives for its substance abuse and
problem gambling services are measurable and specific.
2.2
Team members have input on work and job design, including the
definition of roles and responsibilities, and case assignments,
where appropriate.
5.2
Priority for
Action
Competency
Developing a highly competent interdisciplinary team with the knowledge, skills and abilities to
develop, manage, and deliver effective and efficient programs, services, and care.
Surveyor Comments
Professional development is routinely available and performance reviews are done routinely in a
standard way. A review of medication administration at Talbot House is needed to make sure
properly credentialed staff are involved.
Detailed Accreditation Results
89
Accreditation Report
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Criteria
Location
Team members have position profiles that define roles,
responsibilities, and scope of practice.
3.2
The team has a fair and objective process to recognize team
members for their contributions.
5.7
Priority for
Action
Episode of Care
Healthcare services provided for a health problem from the first encounter with a health care
provider through the completion of the last encounter related to that problem.
Surveyor Comments
There may be value in having supervisors of programs share practices between sites to share
lessons learned. For example, the medication administration process at Lacey House has been
reviewed by the pharmacist whereas the process at the Talbot site has not, and could use
revision to support safer handling of medications.
Care is client focused and staff are able to relate well with clients as well as be respectful of
client desires for privacy.
The use of the Integrated Services Management Program (ISM) as the record enhances the ability
to transfer client information between services.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Criteria
The team identifies, and removes where possible, barriers that
prevent clients, families, service providers, and referring
organizations from accessing services.
6.1
Current and potential clients and their families can access
essential services 24 hours a day, seven days a week.
6.3
The team reconciles the client’s medications upon admission to
the organization, with the involvement of the client, family or
caregiver.
7.5
There is a demonstrated, formal process to reconcile
client medications upon admission.
90
Location
Detailed Accreditation Results
7.5.1
Priority for
Action
QMENTUM PROGRAM
The team generates a Best Possible Medication History
(BPMH) for the client upon admission.
Depending on the model, the prescriber uses the BPMH
to create admission medication orders (proactive), OR, the
team makes a timely comparison of the BPMH against the
admission medication orders (retroactive).
The team documents that the BPMH and admission
medication orders have been reconciled; and appropriate
modifications to medications have been made where
necessary.
The process is a shared responsibility involving the client
and one or more health care practitioner(s), such as
nursing staff, medical staff, pharmacists, and pharmacy
technicians, as appropriate.
Medication Reconciliation at Admission
7.5.2
7.5.3
7.5.4
7.5.5
7.6
The team follows Accreditation Canada’s protocols and
definitions to collect and submit data on medication
reconciliation at admission.
The team does not have any unaddressed priority for
action flags based on their medication reconciliation at
admission indicator results.
7.6.1
7.6.2
A qualified team member fills the prescription and dispenses the
medication in a timely and accurate way.
10.3
The team reconciles medications with the client at referral or
transfer, and communicates information about the client’s
medications to the next provider of service at referral or
transfer to another setting, service, service provider, or level of
care within or outside the organization.
11.3
There is a demonstrated, formal process to reconcile
client medications at referral or transfer.
The process includes generating a comprehensive list of
all medications the client has been taking prior to referral
or transfer.
The process includes a timely comparison of the
prior-to-referral or prior-to-transfer medication list with the
list of new medications ordered at referral or transfer.
The process requires documentation that the two lists
have been compared; differences have been identified,
discussed, and resolved; and appropriate modifications to
the new medications have been made.
The process makes it clear that medication reconciliation
is a shared responsibility involving the client, nursing staff,
medical staff and pharmacists, as appropriate.
11.3.1
11.3.2
11.3.3
11.3.4
11.3.5
Detailed Accreditation Results
91
Accreditation Report
The organization has a documented plan to implement
throughout the organization, and before the next
accreditation survey, a medication reconciliation process
at referral and transfer.
11.3.6
Decision Support
Information, research and evidence, data, and technologies that support and facilitate
management and clinical decision-making.
Surveyor Comments
Electronic charting enhances the ability to share information between services. Security is in
place to limit access as appropriate and as well, for tracking the access of records.
No Unmet Criteria for this Priority Process.
Impact on Outcomes
The identification and monitoring of process and outcome measures to evaluate and improve the
quality of services to clients and the impact on client outcomes.
Surveyor Comments
Members of the team work well together, with an excellent focus on client centred provision of
service.
There is a strong focus on client confidentiality and maintaining best practices.
A challenge to be met is to focus on creating goals and objectives with measurable outcomes,
measuring and reporting outcomes and using this information for continuous quality
improvement.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Criteria
92
Location
The team shares benchmark and best practice information with
its partners and other organizations.
14.5
The team identifies and monitors process and outcome measures
for its substance abuse and problem gambling services.
16.1
The team compares its results with other similar interventions,
programs, or organizations.
16.3
The team uses the information it collects about the quality of its
services to identify successes and opportunities for
improvement, and makes improvements in a timely way.
16.4
Detailed Accreditation Results
Priority for
Action
QMENTUM PROGRAM
The team shares evaluation results with staff, clients, and
families.
16.5
Surgical Procedures
Delivery of safe surgical care to clients, from preparation and the actual procedure in the
operating room, to the post-recovery area and discharge.
Surveyor Comments
Strengths:
Although the surgery department facility at the PCH is newer, both are well maintained, clean
and efficient. The flow processes for day surgery and day admits are very good. Staffing levels
within the admissions process were very adequate as they were in the ORs. Staffing on the
surgical care units was more problematic but still good for care delivery. Good access for
diagnostic services as well as excellent turnaround times. The medication reconciliation process
on admission is fully implemented at the PCH and partially implemented at the QEH. The care
processes post surgery are excellent at the client level. Client education pre and post is
excellent.
Areas for Improvement:
The surgery department has yet to become integrated. There are early indications of progress
with the focusing of procedures such as orthopedics at the QEH. As a part of the integration
process it is recommended that both OR and surgical care teams develop department wide goal
setting, including performance indicators and a method for periodic assessment of progress. Both
teams can take measures to enhance their function through implementing tools such as a team
functioning tool, safety briefings, and external benchmarking. It was apparent that while the
PACU at the Prince County Hospital was documenting in the CIS, the nurses were still writing vital
signs on small pieces of paper and inputting the data later. This could lead to errors. The RNs
should be encouraged to document the vital signs directly into the computer or the hospital
should invest in the technology to permit vital signs data to download directly from the devices.
The use of Safety Engineered Devices has been implemented across the system, however, the use
of non-safety needles was obvious in the ORs.
The table below indicates the specific criteria that require attention, based on the accreditation
review.
Location
Criteria
Priority for
Action
Operating Rooms
The interdisciplinary team follows a formal process to regularly
evaluate its functioning, identify priorities for action, and make
improvements.
1.8
Detailed Accreditation Results
93
Accreditation Report
The team leaders regularly evaluate and document each team
member’s performance in an objective, interactive, and positive
way.
2.8
Immediately prior to the procedure, the team conducts a
preoperative pause to confirm the client’s identity and nature,
site, and side of the procedure.
6.9
The team uses personal protective equipment according to the
manufacturers’ instructions.
9.1
The team carries out regular safety briefings to share
information about potential safety problems, reduce the risk of
error, and improve the service quality.
14.1
The team sets performance goals and objectives and measures
their achievement.
14.4
The team benchmarks or compares its results with other similar
interventions, programs, or organizations.
14.5
Surgical Care Services
The team works together to develop goals and objectives.
2.1
The team’s goals and objectives for its surgical care services are
measurable and specific.
2.2
The interdisciplinary team follows a formal process to regularly
evaluate its functioning, identify priorities for action, and make
improvements.
3.7
Team leaders regularly evaluate and document each team
member’s performance in an objective, interactive, and positive
way.
4.8
The team has a fair and objective process to recognize team
members for their contributions.
5.5
Medication Reconciliation at Admission
7.13
The team follows Accreditation Canada’s protocols and
definitions to collect and submit data on medication
reconciliation at admission.
94
Detailed Accreditation Results
7.13.1
QMENTUM PROGRAM
The team does not have any unaddressed priority for
action flags based on their medication reconciliation at
admission indicator results.
7.13.2
The team reconciles medications with the client at referral or
transfer, and communicates information about the client’s
medications to the next provider of service at referral or
transfer to another setting, service, service provider, or level of
care within or outside the organization.
There is a demonstrated, formal process to reconcile
client medications at referral or transfer.
The process includes generating a comprehensive list of
all medications the client has been taking prior to referral
or transfer.
The process includes a timely comparison of the
prior-to-referral or prior-to-transfer medication list with the
list of new medications ordered at referral or transfer.
The process requires documentation that the two lists
have been compared; differences have been identified,
discussed, and resolved; and appropriate modifications to
the new medications have been made.
The process makes it clear that medication reconciliation
is a shared responsibility involving the client, nursing staff,
medical staff and pharmacists, as appropriate.
The organization has a documented plan to implement
throughout the organization, and before the next
accreditation survey, a medication reconciliation process
at referral and transfer.
11.4
11.4.1
11.4.2
11.4.3
11.4.4
11.4.5
11.4.6
Following transition or end of service, the team contacts clients,
families, or referral organizations or teams to evaluate the
effectiveness of the transition, and uses this information to
improve its transition and end of service planning.
11.6
The team shares benchmark and best practice information with
its partners and other organizations.
14.5
Staff and service providers participate in regular safety briefings
to share information about potential safety problems, reduce
the risk of error, and improve the quality of service.
15.3
The team identifies and monitors process and outcome measures
for its surgical care services.
16.1
The team monitors clients’ perspectives on the quality of its
surgical care services.
16.2
Detailed Accreditation Results
95
Accreditation Report
96
The team compares its results with other similar interventions,
programs, or organizations.
16.3
The team shares evaluation results with staff, clients, and
families.
16.5
Detailed Accreditation Results
QMENTUM PROGRAM
Performance Measure Results
The following section provides an overview of the performance measures collected for the entire organization.
These measures consist of both instrument and indicator results, which are valuable components of evaluation
and quality improvement.
Instrument Results
The instruments are questionnaires completed by a representative sample of clients, staff, leadership and/or
other key stakeholders that provide important insight into critical aspects of the organization’s services. The
following tables summarize the organization’s results and highlight each item that requires attention. Results are
presented in three main areas: governance functioning, patient safety culture and worklife.
Performance Measures (Instruments and Indicators): Instrument Results
97
Accreditation Report
Patient Safety Culture Survey
The patient safety culture survey results provide valuable insight into staff perceptions of patient safety, as well
as an indication of areas of strength, areas of improvement, and a mechanism to monitor changes within the
organization.
Summary of Results
Number of survey respondents = 1161 respondents
A. Patient Safety: Activities to avoid, prevent, or
correct adverse outcomes which may result from
the delivery of health care
% Disagree
% Neutral
% Agree
Organization
Organization
Organization
1 Patient safety decisions are made at the proper
level by the most qualified people
9
14
77
2 Good communication flow exists up the chain of
command regarding patient safety issues
19
17
63
3 Reporting a patient safety problem will result in
negative repercussions for the person reporting it
79
11
10
4 Senior management has a clear picture of the risk
associated with patient care
20
20
60
5 My unit takes the time to identify and assess risks to
patients
6
12
82
6 My unit does a good job managing risks to ensure
patient safety
7
11
83
7 Senior management provides a climate that
promotes patient safety
11
18
70
8 Asking for help is a sign of incompetence
92
3
5
9 If I make a mistake that has significant
consequences and nobody notices, I do not tell
anyone about it
95
2
3
10 I am sure that if I report an incident to our reporting
system, it will not be used against me
18
17
65
11 I am less effective at work when I am fatigued
8
6
85
12 Senior management considers patient safety when
program changes are discussed
11
27
62
13 Personal problems can adversely affect my
performance
26
18
57
14 I will suffer negative consequences if I report a
patient safety problem
86
9
6
Used with permission from York University. All Rights Reserved.
98
Performance Measures (Instruments and Indicators): Instrument Results
Priority
for Action
QMENTUM PROGRAM
15 If I report a patient safety incident, I know that
management will act on it
12
22
66
16 I am rewarded for taking quick action to identify a
serious mistake
26
39
35
17 Loss of experienced personnel has negatively
affected my ability to provide high quality patient
care
41
26
34
18 I have enough time to complete patient care tasks
safely
26
22
52
19 I am not sure about the value of completing incident
reports
64
14
22
20 In the last year, I have witnessed a co-worker do
something that appeared to me to be unsafe for the
patient in order to save time
61
13
26
21 I am provided with adequate resources (personnel,
budget, and equipment) to provide safe patient care
31
22
46
22 I have made significant errors in my work that I
attribute to my own fatigue
83
9
8
23 I believe that health care error constitutes a real
and significant risk to the patients that we treat
12
16
72
24 I believe health care errors often go unreported
25
23
52
25 My organization effectively balances the need for
patient safety and the need for productivity
13
25
63
26 I work in an environment where patient safety is a
high priority
7
12
81
27 Staff are given feedback about changes put into
place based on incident reports
33
22
45
28 Individuals involved in patient safety incidents have
a quick and easy way to report what happened
19
22
60
29 My supervisor/manager says a good word when
he/she sees a job done according to established
patient safety procedures
21
24
55
30 My supervisor/manager seriously considers staff
suggestions for improving patient safety
11
18
71
31 Whenever pressure builds up, my
supervisor/manager wants us to work faster, even if
it means taking shortcuts
77
14
9
32 My supervisor/manager overlooks patient safety
problems that happen over and over
78
13
9
Used with permission from York University. All Rights Reserved.
Performance Measures (Instruments and Indicators): Instrument Results
99
Accreditation Report
33 On this unit, when an incident occurs, we think
about it carefully
8
18
74
34 On this unit, when people make mistakes, they ask
others about how they could have prevented it
14
22
65
35 On this unit, after an incident has occurred, we
think about how it came about and how to prevent
the same mistake in the future
8
13
79
36 On this unit, when an incident occurs, we analyze it
thoroughly
16
25
60
37 On this unit, it is difficult to discuss errors
65
21
15
38 On this unit, after an incident has occurred, we
think long and hard about how to correct it
13
24
62
B. These questions are about your perceptions of
overall patient safety
% Good/
Excellent
%
Acceptable
% Poor/
Failing
Organization
Organization
Organization
39 Please give your unit an overall grade on patient
safety
64
31
5
40 Please give the organization an overall grade on
patient safety
53
40
7
C. These questions are about what happens after a
Major Event
% Disagree
% Neutral
% Agree
Organization
Organization
Organization
41 Individuals involved in major events contribute to
the understanding and analysis of the event and the
generation of possible solutions
8
27
65
42 A formal process for disclosure of major events to
patients/families is followed and this process
includes support mechanisms for patients, family,
and care/service providers
12
35
53
43 Discussion around major events focuses mainly on
system-related issues, rather than focusing on the
individual(s) most responsible for the event
17
37
46
44 The patient and family are invited to be directly
involved in the entire process of understanding:
what happened following a major event and
generating solutions for reducing re-occurrence of
similar events
18
39
43
Used with permission from York University. All Rights Reserved.
100
Performance Measures (Instruments and Indicators): Instrument Results
Priority
for Action
Priority
for Action
QMENTUM PROGRAM
45 Things that are learned from major events are
communicated to staff on our unit using more than
one method (e.g. communication book, in-services,
unit rounds, emails) and / or at several times so all
staff hear about it
16
22
61
46 Changes are made to reduce re-occurrence of major
events
6
21
73
Performance Measures (Instruments and Indicators): Instrument Results
101
Accreditation Report
Indicator Results
Indicators collect data related to important aspects of patient safety and quality care. The tables in this section
show the indicator data that has been submitted by the organization.
Medication Reconciliation at Admission
Transition points in the care continuum are particularly prone to risk, and the communication of medication
information has been identified as a priority area for improving the safety of healthcare service delivery. This
performance measure will provide a practical guide for organizations as medication reconciliation is conducted
more widely throughout the organization.
Medication Reconciliation at Admission
Flag
102
Location
Team Name
(standard section)
Dates
(dd/mm/yyyy)
% Formal medication
reconciliation at
admission
GREEN
Beach Grove Home
Long Term Care (Long
Term Care Services)
01/01/2010
31/03/2010
90
YELLOW
Beach Grove Home
Long Term Care (Long
Term Care Services)
01/04/2010
30/06/2010
81
RED
Colville Manor
Long Term Care (Long
Term Care Services)
01/01/2010
31/03/2010
60
GREEN
Colville Manor
Long Term Care (Long
Term Care Services)
01/04/2010
30/06/2010
100
GREEN
Hillsborough Hospital
Long Term Care (Long
Term Care Services)
01/01/2010
31/03/2010
100
GREEN
Maplewood Manor
Long Term Care (Long
Term Care Services)
01/01/2010
31/03/2010
100
GREEN
Maplewood Manor
Long Term Care (Long
Term Care Services)
01/04/2010
30/06/2010
90
GREEN
Margaret Stewart Ellis
Home
Long Term Care (Long
Term Care Services)
01/01/2010
31/03/2010
100
GREEN
Margaret Stewart Ellis
Home
Long Term Care (Long
Term Care Services)
01/04/2010
30/06/2010
100
RED
Prince County Hospital
Medical Care (Medicine
Services)
01/04/2010
30/06/2010
60
RED
Prince County Hospital
Surgical Care (Surgical
Care Services)
01/04/2010
30/06/2010
56
Performance Measures (Instruments and Indicators): Indicator Results
QMENTUM PROGRAM
Medication Reconciliation at Admission
Flag
Location
Team Name
(standard section)
Dates
(dd/mm/yyyy)
% Formal medication
reconciliation at
admission
GREEN
Prince Edward Home
Long Term Care (Long
Term Care Services)
01/01/2010
31/03/2010
100
GREEN
Prince Edward Home
Long Term Care (Long
Term Care Services)
01/04/2010
30/06/2010
100
GREEN
Riverview Manor
Long Term Care (Long
Term Care Services)
01/01/2010
31/03/2010
100
GREEN
Riverview Manor
Long Term Care (Long
Term Care Services)
01/04/2010
30/06/2010
100
Souris Hospital
Medical Care (Medicine
Services)
01/01/2010
31/03/2010
41
GREEN
Summerset Manor
Long Term Care (Long
Term Care Services)
01/01/2010
31/03/2010
100
GREEN
Summerset Manor
Long Term Care (Long
Term Care Services)
01/04/2010
30/06/2010
100
GREEN
Wedgewood Manor
Long Term Care (Long
Term Care Services)
01/01/2010
31/03/2010
100
GREEN
Wedgewood Manor
Long Term Care (Long
Term Care Services)
01/04/2010
30/06/2010
100
RED
Threshold for Flags
RED:
< 75/100
YELLOW:
>= 75/100 AND < 90/100
GREEN:
>= 90/100
Performance Measures (Instruments and Indicators): Indicator Results
103
Accreditation Report
Surgical Site Infection
Post-surgical infection rate is a key outcome measure that reflects process interventions.
The thresholds for this performance indicator are currently in development. Performance ratings will be provided
when the thresholds are finalized.
Surgical Site Infection: Post-Surgical Infection - Hysterectomy
Flag
Location
Team Name
(standard section)
Dates
(dd/mm/yyyy)
% post-surgical
infections
Prince County Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2010
31/03/2010
0
Prince County Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2010
30/06/2010
3.7
The thresholds for this performance indicator are currently in development. Performance ratings will be provided
when the thresholds are finalized.
Surgical Site Infection: Post-Surgical Infection - Total Joint Arthroplasty
Flag
104
Location
Team Name
(standard section)
Dates
(dd/mm/yyyy)
% post-surgical
infections
Queen Elizabeth Hospital
(QEH)
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2010
31/03/2010
2.9
Queen Elizabeth Hospital
(QEH)
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2010
30/06/2010
0
Performance Measures (Instruments and Indicators): Indicator Results
QMENTUM PROGRAM
Surgical Site Infection
Timeliness of administering antibiotic prophylaxis is a universal process measure applicable to many surgical
procedures and with widely recognized benefits in reducing post-surgical infections in selected high risk
procedures.
Surgical Site Infection: Prophylactic Antibiotics - Hysterectomy
Flag
Location
Team Name
(standard section)
Dates
(dd/mm/yyyy)
% timely
administrations of
antibiotics
YELLOW
Prince County Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/10/2009
31/12/2009
82
GREEN
Prince County Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2010
31/03/2010
100
GREEN
Prince County Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2010
30/06/2010
100
Threshold for Flags
RED:
< 80/100
YELLOW:
>= 80/100 AND < 90/100
GREEN:
>= 90/100
Surgical Site Infection: Prophylactic Antibiotics - Total Joint Arthroplasty
Flag
Location
GREEN
Queen Elizabeth Hospital
(QEH)
GREEN
GREEN
Team Name
(standard section)
Dates
(dd/mm/yyyy)
% timely
administrations of
antibiotics
Infection Prevention &
Control (Infection
Prevention and Control)
01/10/2009
31/12/2009
100
Queen Elizabeth Hospital
(QEH)
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2010
31/03/2010
97
Queen Elizabeth Hospital
(QEH)
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2010
30/06/2010
96
Performance Measures (Instruments and Indicators): Indicator Results
105
Accreditation Report
Threshold for Flags
RED:
< 80/100
YELLOW:
>= 80/100 AND < 90/100
GREEN:
>= 90/100
106
Performance Measures (Instruments and Indicators): Indicator Results
QMENTUM PROGRAM
Health Care Associated Infection Rates
Health care associated C. difficile and MRSA infections represent a significant risk to the individuals receiving
care and are a substantial resource burden to organizations and the health care system. Measuring infection
control performance measures has the additional benefit of informing and shaping the staff's view of safety.
Evidence suggests that as staff become more aware of infection control rates and the evidence related to
infection control there is a change in behaviour to reduce the perceived risk.
Health Care-Associated MRSA & C. difficile - C. difficile
Flag
Location
Team Name
(standard section)
Dates
(dd/mm/yyyy)
# cases of infection /
10,000 patient days
GREEN
Beach Grove Home
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2010
31/03/2010
0
GREEN
Beach Grove Home
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2010
30/06/2010
0
GREEN
Colville Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2010
31/03/2010
0
GREEN
Colville Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2010
30/06/2010
0
GREEN
Community Hospital
O'Leary(CHO)
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2010
31/03/2010
0
GREEN
Community Hospital
O'Leary(CHO)
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2010
30/06/2010
0
GREEN
Hillsborough Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2010
31/03/2010
0
GREEN
Hillsborough Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2010
30/06/2010
0
GREEN
Kings County Memorial
Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2010
31/03/2010
0
Performance Measures (Instruments and Indicators): Indicator Results
107
Accreditation Report
Health Care-Associated MRSA & C. difficile - C. difficile
Flag
108
Location
Team Name
(standard section)
Dates
(dd/mm/yyyy)
# cases of infection /
10,000 patient days
GREEN
Kings County Memorial
Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2010
30/06/2010
0
GREEN
Maplewood Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2010
31/03/2010
0
GREEN
Maplewood Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2010
30/06/2010
0
GREEN
Prince County Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2010
31/03/2010
2.7
GREEN
Prince County Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2010
30/06/2010
0
GREEN
Prince Edward Home
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2010
31/03/2010
0
GREEN
Prince Edward Home
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2010
30/06/2010
0
GREEN
Queen Elizabeth Hospital
(QEH)
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2010
31/03/2010
0
GREEN
Queen Elizabeth Hospital
(QEH)
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2010
30/06/2010
0
GREEN
Riverview Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2010
31/03/2010
0
GREEN
Riverview Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2010
30/06/2010
0
Performance Measures (Instruments and Indicators): Indicator Results
QMENTUM PROGRAM
Health Care-Associated MRSA & C. difficile - C. difficile
Flag
Location
Team Name
(standard section)
Dates
(dd/mm/yyyy)
# cases of infection /
10,000 patient days
GREEN
Souris Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2010
31/03/2010
0
GREEN
Souris Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2010
30/06/2010
0
GREEN
Stewart Memorial
Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2009
30/06/2009
6.2
GREEN
Stewart Memorial
Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2010
31/03/2010
0
GREEN
Stewart Memorial
Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2010
30/06/2010
0
GREEN
Summerset Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2010
31/03/2010
0
GREEN
Summerset Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2010
30/06/2010
0
GREEN
Wedgewood Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2010
31/03/2010
0
GREEN
Wedgewood Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2010
30/06/2010
0
GREEN
Western Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2010
31/03/2010
0
GREEN
Western Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2010
30/06/2010
0
Performance Measures (Instruments and Indicators): Indicator Results
109
Accreditation Report
Threshold for Flags
RED:
> 80/10,000
YELLOW:
<= 80/10,000 AND > 60/10,000
GREEN:
<= 60/10,000
Health Care-Associated MRSA & C. difficile - MRSA
Flag
110
Location
Team Name
(standard section)
Dates
(dd/mm/yyyy)
# cases of infection +
colonization / 10,000
patient days
GREEN
Beach Grove Home
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2009
31/03/2009
1.7
GREEN
Beach Grove Home
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2009
30/06/2009
5.9
GREEN
Beach Grove Home
Infection Prevention &
Control (Infection
Prevention and Control)
01/07/2009
30/09/2009
5
GREEN
Beach Grove Home
Infection Prevention &
Control (Infection
Prevention and Control)
01/10/2009
31/12/2009
0
GREEN
Beach Grove Home
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2010
31/03/2010
1.7
GREEN
Beach Grove Home
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2010
30/06/2010
0.85
GREEN
Colville Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2009
31/03/2009
0
GREEN
Colville Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2009
30/06/2009
0
GREEN
Colville Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/07/2009
30/09/2009
0
GREEN
Colville Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/10/2009
31/12/2009
0
Performance Measures (Instruments and Indicators): Indicator Results
QMENTUM PROGRAM
Health Care-Associated MRSA & C. difficile - MRSA
Flag
Location
Team Name
(standard section)
Dates
(dd/mm/yyyy)
# cases of infection +
colonization / 10,000
patient days
GREEN
Colville Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2010
31/03/2010
0
GREEN
Colville Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2010
30/06/2010
0
GREEN
Community Hospital
O'Leary(CHO)
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2009
31/03/2009
0
GREEN
Community Hospital
O'Leary(CHO)
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2009
30/06/2009
0
GREEN
Community Hospital
O'Leary(CHO)
Infection Prevention &
Control (Infection
Prevention and Control)
01/07/2009
30/09/2009
0
GREEN
Community Hospital
O'Leary(CHO)
Infection Prevention &
Control (Infection
Prevention and Control)
01/10/2009
31/12/2009
0
GREEN
Community Hospital
O'Leary(CHO)
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2010
31/03/2010
0
GREEN
Community Hospital
O'Leary(CHO)
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2010
30/06/2010
0
GREEN
Hillsborough Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2009
31/03/2009
0
GREEN
Hillsborough Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2009
30/06/2009
0
GREEN
Hillsborough Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/07/2009
30/09/2009
0
Performance Measures (Instruments and Indicators): Indicator Results
111
Accreditation Report
Health Care-Associated MRSA & C. difficile - MRSA
Flag
112
Location
Team Name
(standard section)
Dates
(dd/mm/yyyy)
# cases of infection +
colonization / 10,000
patient days
GREEN
Hillsborough Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/10/2009
31/12/2009
0
GREEN
Hillsborough Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2010
31/03/2010
0
GREEN
Hillsborough Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2010
30/06/2010
0
GREEN
Kings County Memorial
Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2009
31/03/2009
4.1
GREEN
Kings County Memorial
Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2009
30/06/2009
4.4
GREEN
Kings County Memorial
Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/07/2009
30/09/2009
0
GREEN
Kings County Memorial
Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/10/2009
31/12/2009
0
GREEN
Kings County Memorial
Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2010
31/03/2010
0
GREEN
Kings County Memorial
Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2010
30/06/2010
0
GREEN
Maplewood Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2009
31/03/2009
0
GREEN
Maplewood Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2009
30/06/2009
0
Performance Measures (Instruments and Indicators): Indicator Results
QMENTUM PROGRAM
Health Care-Associated MRSA & C. difficile - MRSA
Flag
Location
Team Name
(standard section)
Dates
(dd/mm/yyyy)
# cases of infection +
colonization / 10,000
patient days
GREEN
Maplewood Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/07/2009
30/09/2009
0
GREEN
Maplewood Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/10/2009
31/12/2009
0
GREEN
Maplewood Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2010
31/03/2010
0
GREEN
Maplewood Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2010
30/06/2010
0
GREEN
Prince County Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2009
31/03/2009
3.8
GREEN
Prince County Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2009
30/06/2009
2.5
GREEN
Prince County Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/07/2009
30/09/2009
16
GREEN
Prince County Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/10/2009
31/12/2009
2.7
GREEN
Prince County Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2010
31/03/2010
8
GREEN
Prince County Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2010
30/06/2010
6.5
GREEN
Prince Edward Home
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2009
31/03/2009
0.91
Performance Measures (Instruments and Indicators): Indicator Results
113
Accreditation Report
Health Care-Associated MRSA & C. difficile - MRSA
Flag
114
Location
Team Name
(standard section)
Dates
(dd/mm/yyyy)
# cases of infection +
colonization / 10,000
patient days
GREEN
Prince Edward Home
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2009
30/06/2009
0.92
GREEN
Prince Edward Home
Infection Prevention &
Control (Infection
Prevention and Control)
01/07/2009
30/09/2009
4.6
GREEN
Prince Edward Home
Infection Prevention &
Control (Infection
Prevention and Control)
01/10/2009
31/12/2009
6.3
GREEN
Prince Edward Home
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2010
31/03/2010
0
GREEN
Prince Edward Home
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2010
30/06/2010
0.96
GREEN
Queen Elizabeth Hospital
(QEH)
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2009
31/03/2009
14
GREEN
Queen Elizabeth Hospital
(QEH)
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2009
30/06/2009
12
GREEN
Queen Elizabeth Hospital
(QEH)
Infection Prevention &
Control (Infection
Prevention and Control)
01/07/2009
30/09/2009
20
GREEN
Queen Elizabeth Hospital
(QEH)
Infection Prevention &
Control (Infection
Prevention and Control)
01/10/2009
31/12/2009
6.7
GREEN
Queen Elizabeth Hospital
(QEH)
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2010
31/03/2010
6.5
GREEN
Queen Elizabeth Hospital
(QEH)
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2010
30/06/2010
14
Performance Measures (Instruments and Indicators): Indicator Results
QMENTUM PROGRAM
Health Care-Associated MRSA & C. difficile - MRSA
Flag
Location
Team Name
(standard section)
Dates
(dd/mm/yyyy)
# cases of infection +
colonization / 10,000
patient days
GREEN
Riverview Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2009
31/03/2009
0
GREEN
Riverview Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2009
30/06/2009
0
GREEN
Riverview Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/07/2009
30/09/2009
0
GREEN
Riverview Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/10/2009
31/12/2009
0
GREEN
Riverview Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2010
31/03/2010
2.4
GREEN
Riverview Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2010
30/06/2010
0
GREEN
Souris Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2009
31/03/2009
0
GREEN
Souris Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2009
30/06/2009
0
GREEN
Souris Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/07/2009
30/09/2009
0
GREEN
Souris Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/10/2009
31/12/2009
0
GREEN
Souris Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2010
31/03/2010
0
Performance Measures (Instruments and Indicators): Indicator Results
115
Accreditation Report
Health Care-Associated MRSA & C. difficile - MRSA
Flag
116
Location
Team Name
(standard section)
Dates
(dd/mm/yyyy)
# cases of infection +
colonization / 10,000
patient days
GREEN
Souris Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2010
30/06/2010
0
GREEN
Stewart Memorial
Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2009
31/03/2009
0
GREEN
Stewart Memorial
Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/07/2009
30/09/2009
0
GREEN
Stewart Memorial
Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/10/2009
31/12/2009
0
GREEN
Stewart Memorial
Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2010
31/03/2010
0
GREEN
Stewart Memorial
Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2010
30/06/2010
0
GREEN
Summerset Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2009
31/03/2009
0
GREEN
Summerset Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2009
30/06/2009
0
GREEN
Summerset Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/07/2009
30/09/2009
0
GREEN
Summerset Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/10/2009
31/12/2009
0
GREEN
Summerset Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2010
31/03/2010
0
Performance Measures (Instruments and Indicators): Indicator Results
QMENTUM PROGRAM
Health Care-Associated MRSA & C. difficile - MRSA
Flag
Location
Team Name
(standard section)
Dates
(dd/mm/yyyy)
# cases of infection +
colonization / 10,000
patient days
GREEN
Summerset Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2010
30/06/2010
0
GREEN
Wedgewood Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2009
31/03/2009
0
GREEN
Wedgewood Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2009
30/06/2009
0
GREEN
Wedgewood Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/07/2009
30/09/2009
1.5
GREEN
Wedgewood Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/10/2009
31/12/2009
1.5
GREEN
Wedgewood Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2010
31/03/2010
0
GREEN
Wedgewood Manor
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2010
30/06/2010
1.5
GREEN
Western Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2009
31/03/2009
6.3
GREEN
Western Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2009
30/06/2009
5.9
GREEN
Western Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/07/2009
30/09/2009
6
GREEN
Western Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/10/2009
31/12/2009
11
Performance Measures (Instruments and Indicators): Indicator Results
117
Accreditation Report
Health Care-Associated MRSA & C. difficile - MRSA
Flag
Location
Team Name
(standard section)
Dates
(dd/mm/yyyy)
# cases of infection +
colonization / 10,000
patient days
GREEN
Western Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/01/2010
31/03/2010
0
GREEN
Western Hospital
Infection Prevention &
Control (Infection
Prevention and Control)
01/04/2010
30/06/2010
0
Threshold for Flags
RED:
> 80/10,000
YELLOW:
<= 80/10,000 AND > 60/10,000
GREEN:
<= 60/10,000
118
Performance Measures (Instruments and Indicators): Indicator Results
QMENTUM PROGRAM
Next Steps
Congratulations! You have just completed your Qmentum on-site survey visit. Please note the following check list
items that you need to attend to in the coming days and months.
We ask that you review this report within the next five days for errors in titles of names of services. This will
help ensure the report and our records are accurate. Once you have reviewed, please send your requested
changes to your Accreditation Specialist.
In 10 business days, a letter outlining your accreditation decision and requirements will be e-mailed to your
Chief Executive Officer. If revisions to the report were required, a copy of a revised report will be sent
along with that letter.
You are required to submit your quarterly reports on indicators on May 31st, every year. If you have any
questions regarding this submission, please contact your Accreditation Specialist.
Next Steps
119
Accreditation Report
Appendix A – Accreditation Decision Guidelines
Quality improvement continues to be a key principle of Accreditation Canada’s Qmentum program.
Accreditation Canada’s standards assess the quality of services provided by an organization and are
constructed around eight dimensions of quality:
1.
2.
3.
4.
5.
6.
7.
8.
Population focus
Accessibility
Safety
Worklife
Client-centred services
Continuity of services
Effectiveness
Efficiency
Each standard criterion is related to a quality dimension. Organizations participating in Accreditation
Canada’s Qmentum program are eligible for the recognition awards: Accreditation; Accreditation with
Condition (Report and/or Focused Visit) and Non-accreditation.
Under the Qmentum accreditation program, Accreditation Canada High Priority Criteria and Required
Organization Practices (ROPs) are the two main factors that are considered in determining the appropriate
recognition award.
Accreditation Canada High Priority Criteria
Accreditation Canada identifies high priority criteria by their alignment with several key areas:
•
•
•
•
Quality Improvement
Safety
Risk
Ethics
Required Organization Practices (ROPs)
A Required Organizational Practice is defined as an essential practice that organizations must have in
place to enhance patient/client safety and minimize risk. It is a specific requirement for healthcare
organizations in the accreditation program.
Based on the above, the three accreditation decisions for 2010 Qmentum surveys are:
120
Appendix A – Accreditation Decision Guidelines
QMENTUM PROGRAM
Option 1: Accreditation
An organization is eligible for full accreditation (with a resurvey in three years) if all of the
following criteria are met:
(a) 90% or more of high priority criteria met per standard section, AND
(b) Compliance with all of the Required Organizational Practices, AND
(c) Compliance with collection of all the performance measures,
If the organization is a CSSS, participating in the Joint Program with Conseil québecois d’agrément
(CQA) and Accreditation Canada, the following additional criteria are required, which are specific
CQA indicators relating to customer service and worklife:
(d) Compliance with ≥66.6% of Client Satisfaction Indicators AND
(e) Compliance with ≥66.6% of Employees Mobilization Indicators
Option 2: Accreditation with Condition: Report and/or Focused Visit
An organization will receive Accreditation with Condition: Report and/or Focused Visit if any of
following criteria is met:
(a) More than 10% and less than 30% of high priority criteria unmet in any standard section,
OR
(b) Non-compliance with any one of the Required Organizational Practices
OR
(c) Non-compliance with the collection of any one of the performance measures
If the organization is a CSSS, participating in the Joint Program with CQA and Accreditation Canada,
the following addition criteria apply:
(d) Compliance with less than 66.6% of Client Satisfaction Indicators,
OR
(e) Compliance with less than 66.6% of Employees Mobilization Indicators
The condition, i.e. submission of a report or focused visit; and timeframe, i.e. 6 months or 12 months; is
based upon the nature of the recommendations. If the organization is a CSSS, and their compliance with
the Client Satisfaction Indicators OR Employees Mobilization Indicators is less than 66.6%, they must
conduct the survey(s) again within 18 months following the onsite visit as a condition of accreditation.
Organizations are required to submit follow-up reports as a condition of maintaining accreditation status.
If a satisfactory report is not submitted within the required timeline, Accreditation Canada may grant a
one-time extension of 6 months, based on surveyor input, proof of progress, and a plan to meet the
conditions. Failure to comply with these requirements within the maximum allotted time extension will
result in removal of accreditation status, at the discretion of Accreditation Canada.
For organizations that fail to complete a satisfactory focused visit within the required timeline,
Accreditation Canada may grant a one-time extension of 6 months, based on surveyor input, proof of
progress and a plan to meet the conditions. Failure to comply with these requirements within the
maximum allotted time extension will result in removal of accreditation status, at the discretion of
Accreditation Canada.
Appendix A – Accreditation Decision Guidelines
121
Accreditation Report
Option 3: Non-accreditation
An organization will NOT be accredited if the following conditions exist:
(a) One or more ROPs not in place
AND
(b) 30% or more high priority criteria unmet in one or more standards sections
AND
(c) 20% or more criteria unmet overall for all standards applied to the organization
Should an organization wish to have their non-accreditation status reviewed within 6 months post survey,
they are required to complete a focused visit within 5 months. Organizations that fail to complete a
satisfactory focused visit within the required timeframe will maintain a non-accreditation status.
If the organization is a CSSS, and their compliance with the Client Satisfaction Indicators OR Employees
Mobilization Indicators is less than 66.6%, they must conduct the survey(s) again within 18 months
following the onsite visit as a condition of accreditation.
122
Appendix A – Accreditation Decision Guidelines