Accreditation Report

Transcription

1 St. Joseph's Health Centre Toronto, ON On-site survey dates: December 6, December 1, 215 Report issued: December 23, 215 Accredited by ISQua

2 About the St. Joseph's Health Centre (referred to in this report as the organization ) is participating in Accreditation Canada's Qmentum accreditation program. As part of this ongoing process of quality improvement, an on-site survey was conducted in December 215. Information from the on-site survey as well as other data obtained from the organization were used to produce this. Accreditation results are based on information provided by the organization. Accreditation Canada relies on the accuracy of this information to plan and conduct the on-site survey and produce the. Confidentiality This report is confidential and is provided by Accreditation Canada to the organization only. Accreditation Canada does not release the report to any other parties. In the interests of transparency and accountability, Accreditation Canada encourages the organization to disseminate its to staff, board members, clients, the community, and other stakeholders. Any alteration of this compromises the integrity of the accreditation process and is strictly prohibited. Accreditation Canada, 215

3 A Message from Accreditation Canada's President and CEO On behalf of Accreditation Canada's board and staff, I extend my sincerest congratulations to your board, your leadership team, and everyone at your organization on your participation in the Qmentum accreditation program. Qmentum is designed to integrate with your quality improvement program. By using Qmentum to support and enable your quality improvement activities, its full value is realized. This includes your accreditation decision, the final results from your recent on-site survey, and the instrument data that your organization has submitted. Please use the information in this report and in your online Quality Performance Roadmap to guide your quality improvement activities. Your Accreditation Specialist is available if you have questions or need guidance. Thank you for your leadership and for demonstrating your ongoing commitment to quality by integrating accreditation into your improvement program. We welcome your feedback about how we can continue to strengthen the program to ensure it remains relevant to you and your services. We look forward to our continued partnership. Sincerely, Wendy Nicklin President and Chief Executive Officer A Message from Accreditation Canada's President and CEO

4 Table of Contents 1. Executive Summary Accreditation Decision About the On-site Survey Overview by Quality Dimensions Overview by Standards Overview by Required Organizational Practices Summary of Surveyor Team Observations Detailed On-site Survey Results Priority Process Results for System-wide Standards Priority Process: Governance Priority Process: Planning and Service Design Priority Process: Resource Management Priority Process: Human Capital Priority Process: Integrated Quality Management Priority Process: Principle-based Care and Decision Making Priority Process: Communication Priority Process: Physical Environment Priority Process: Emergency Preparedness Priority Process: Patient Flow Priority Process: Medical Devices and Equipment Service Excellence Standards Results Service Excellence Standards Results Standards Set: Ambulatory Care Services - Direct Service Provision Standards Set: Biomedical Laboratory Services - Direct Service Provision Standards Set: Critical Care - Direct Service Provision Standards Set: Diagnostic Imaging Services - Direct Service Provision Standards Set: Emergency Department - Direct Service Provision Standards Set: Infection Prevention and Control Standards - Direct Service Provision Standards Set: Medication Management Standards - Direct Service Provision Standards Set: Medicine Services - Direct Service Provision Standards Set: Mental Health Services - Direct Service Provision Standards Set: Obstetrics Services - Direct Service Provision 48 Table of Contents i

5 Standards Set: Point-of-Care Testing - Direct Service Provision Standards Set: Primary Care Services - Direct Service Provision Standards Set: Transfusion Services - Direct Service Provision Priority Process: Surgical Procedures Instrument Results Governance Functioning Tool Canadian Patient Safety Culture Survey Tool: Community Based Version Worklife Pulse Client Experience Tool 63 Appendix A Qmentum 64 Appendix B Priority Processes 65 Table of Contents ii

6 Section 1 Executive Summary St. Joseph's Health Centre (referred to in this report as the organization ) is participating in Accreditation Canada's Qmentum accreditation program. Accreditation Canada is an independent, not-for-profit organization that sets standards for quality and safety in health care and accredits health organizations in Canada and around the world. As part of the Qmentum accreditation program, the organization has undergone a rigorous evaluation process. Following a comprehensive self-assessment, external peer surveyors conducted an on-site survey during which they assessed this organization's leadership, governance, clinical programs and services against Accreditation Canada requirements for quality and safety. These requirements include national standards of excellence; required safety practices to reduce potential harm; and questionnaires to assess the work environment, patient safety culture, governance functioning and client experience. Results from all of these components are included in this report and were considered in the accreditation decision. This report shows the results to date and is provided to guide the organization as it continues to incorporate the principles of accreditation and quality improvement into its programs, policies, and practices. The organization is commended on its commitment to using accreditation to improve the quality and safety of the services it offers to its clients and its community. 1.1 Accreditation Decision St. Joseph's Health Centre's accreditation decision is: Accredited with Exemplary Standing The organization has attained the highest level of performance, achieving excellence in meeting the requirements of the accreditation program. Executive Summary 1

7 1.2 About the On-site Survey On-site survey dates: December 6, 215 to December 1, 215 Location The following location was assessed during the on-site survey. 1 St. Joseph Health Centre Toronto Standards The following sets of standards were used to assess the organization's programs and services during the on-site survey. System-Wide Standards Leadership Governance Medication Management Standards Infection Prevention and Control Standards Service Excellence Standards Reprocessing and Sterilization of Reusable Medical Devices - Service Excellence Standards Primary Care Services - Service Excellence Standards Critical Care - Service Excellence Standards Point-of-Care Testing - Service Excellence Standards Ambulatory Care Services - Service Excellence Standards Diagnostic Imaging Services - Service Excellence Standards Medicine Services - Service Excellence Standards Obstetrics Services - Service Excellence Standards Mental Health Services - Service Excellence Standards Transfusion Services - Service Excellence Standards Biomedical Laboratory Services - Service Excellence Standards Perioperative Services and Invasive Procedures Standards - Service Excellence Standards Emergency Department - Service Excellence Standards Executive Summary 2

8 Instruments The organization administered: Governance Functioning Tool Canadian Patient Safety Culture Survey Tool: Community Based Version Worklife Pulse Client Experience Tool Executive Summary 3

9 1.3 Overview by Quality Dimensions Accreditation Canada defines quality in health care using eight dimensions that represent key service elements. Each criterion in the standards is associated with a quality dimension. This table shows the number of criteria related to each dimension that were rated as met, unmet, or not applicable. Quality Dimension Met Unmet N/A Total Population Focus (Work with my community to anticipate and meet our needs) Accessibility (Give me timely and equitable services) Safety (Keep me safe) Worklife (Take care of those who take care of me) Client-centred Services (Partner with me and my family in our care) Continuity of Services (Coordinate my care across the continuum) Appropriateness (Do the right thing to achieve the best results) Efficiency (Make the best use of resources) Total Executive Summary 4

10 1.4 Overview by Standards The Qmentum standards identify policies and practices that contribute to high quality, safe, and effectively managed care. Each standard has associated criteria that are used to measure the organization's compliance with the standard. System-wide standards address quality and safety at the organizational level in areas such as governance and leadership. Population-specific and service excellence standards address specific populations, sectors, and services. The standards used to assess an organization's programs are based on the type of services it provides. This table shows the sets of standards used to evaluate the organization's programs and services, and the number and percentage of criteria that were rated met, unmet, or not applicable during the on-site survey. Accreditation decisions are based on compliance with standards. Percent compliance is calculated to the decimal and not rounded. High Priority Criteria * Other Criteria Total Criteria (High Priority + Other) Standards Set Met Unmet N/A # (%) # (%) # Met Unmet N/A # (%) # (%) # Met Unmet N/A # (%) # (%) # Governance 42 (1.%) (.%) 32 (1.%) (.%) 74 (1.%) (.%) Leadership 46 (1.%) (.%) 85 (1.%) (.%) 131 (1.%) (.%) Infection Prevention and Control Standards 41 (1.%) (.%) 31 (1.%) (.%) 72 (1.%) (.%) Medication Management Standards 78 (1.%) (.%) 64 (1.%) (.%) 142 (1.%) (.%) Ambulatory Care Services 41 (97.6%) 1 (2.4%) 77 (1.%) (.%) 118 (99.2%) 1 (.8%) Biomedical Laboratory Services ** 71 (1.%) (.%) 13 (1.%) (.%) 174 (1.%) (.%) Critical Care 34 (1.%) (.%) 95 (1.%) (.%) 129 (1.%) (.%) Diagnostic Imaging Services 66 (98.5%) 1 (1.5%) 68 (1.%) (.%) 134 (99.3%) 1 (.7%) Emergency Department 47 (1.%) (.%) 79 (98.8%) 1 (1.3%) 126 (99.2%) 1 (.8%) Executive Summary 5

11 High Priority Criteria * Other Criteria Total Criteria (High Priority + Other) Standards Set Met Unmet N/A # (%) # (%) # Met Unmet N/A # (%) # (%) # Met Unmet N/A # (%) # (%) # Medicine Services 31 (1.%) (.%) 71 (1.%) (.%) 12 (1.%) (.%) Mental Health Services 36 (1.%) (.%) 88 (1.%) (.%) 124 (1.%) (.%) Obstetrics Services 64 (1.%) (.%) 8 (1.%) (.%) 144 (1.%) (.%) Perioperative Services and Invasive Procedures Standards 1 (1.%) (.%) 88 (1.%) (.%) 188 (1.%) (.%) Point-of-Care Testing ** 38 (1.%) (.%) 48 (1.%) (.%) 86 (1.%) (.%) Primary Care Services 37 (1.%) (.%) 69 (1.%) (.%) 16 (1.%) (.%) Reprocessing and Sterilization of Reusable Medical Devices 53 (1.%) (.%) 63 (1.%) (.%) 116 (1.%) (.%) Transfusion Services ** 75 (1.%) (.%) 67 (1.%) (.%) 142 (1.%) (.%) Total 9 (99.8%) 2 (.2%) 128 (99.9%) 1 (.1%) 218 (99.9%) 3 (.1%) * Does not includes ROP (Required Organizational Practices) ** Some criteria within this standards set were pre-rated based on the organization s accreditation through the Ontario Laboratory Accreditation Quality Management Program-Laboratory Services (QMP-LS). Executive Summary 6

12 1.5 Overview by Required Organizational Practices A Required Organizational Practice (ROP) is an essential practice that an organization must have in place to enhance client safety and minimize risk. Each ROP has associated tests for compliance, categorized as major and minor. All tests for compliance must be met for the ROP as a whole to be rated as met. This table shows the ratings of the applicable ROPs. Required Organizational Practice Overall rating Test for Compliance Rating Major Met Minor Met Patient Safety Goal Area: Safety Culture Accountability for Quality (Governance) Adverse Events Disclosure (Leadership) Adverse Events Reporting (Leadership) Client Safety Quarterly Reports (Leadership) Client Safety Related Prospective Analysis (Leadership) Met 4 of 4 2 of 2 Met 3 of 3 of Met 1 of 1 1 of 1 Met 1 of 1 2 of 2 Met 1 of 1 1 of 1 Patient Safety Goal Area: Communication Client And Family Role In Safety (Ambulatory Care Services) Client And Family Role In Safety (Critical Care) Client And Family Role In Safety (Diagnostic Imaging Services) Client And Family Role In Safety (Medicine Services) Client And Family Role In Safety (Mental Health Services) Client And Family Role In Safety (Obstetrics Services) Met 2 of 2 of Met 2 of 2 of Met 2 of 2 of Met 2 of 2 of Met 2 of 2 of Met 2 of 2 of Executive Summary 7

13 Required Organizational Practice Overall rating Test for Compliance Rating Major Met Minor Met Patient Safety Goal Area: Communication Client And Family Role In Safety (Perioperative Services and Invasive Procedures Standards) Dangerous Abbreviations (Medication Management Standards) Information Transfer (Ambulatory Care Services) Information Transfer (Critical Care) Information Transfer (Emergency Department) Information Transfer (Medicine Services) Information Transfer (Mental Health Services) Information Transfer (Obstetrics Services) Information Transfer (Perioperative Services and Invasive Procedures Standards) Medication reconciliation as a strategic priority (Leadership) Medication reconciliation at care transitions (Ambulatory Care Services) Medication reconciliation at care transitions (Critical Care) Medication reconciliation at care transitions (Emergency Department) Met 2 of 2 of Met 4 of 4 3 of 3 Met 2 of 2 of Met 2 of 2 of Met 2 of 2 of Met 2 of 2 of Met 2 of 2 of Met 2 of 2 of Met 2 of 2 of Met 4 of 4 2 of 2 Met 7 of 7 of Met 5 of 5 of Met 5 of 5 of Executive Summary 8

14 Required Organizational Practice Overall rating Test for Compliance Rating Major Met Minor Met Patient Safety Goal Area: Communication Medication reconciliation at care transitions (Medicine Services) Medication reconciliation at care transitions (Mental Health Services) Medication reconciliation at care transitions (Obstetrics Services) Medication reconciliation at care transitions (Perioperative Services and Invasive Procedures Standards) Safe Surgery Checklist (Obstetrics Services) Safe Surgery Checklist (Perioperative Services and Invasive Procedures Standards) Two Client Identifiers (Ambulatory Care Services) Two Client Identifiers (Biomedical Laboratory Services) Two Client Identifiers (Critical Care) Two Client Identifiers (Diagnostic Imaging Services) Two Client Identifiers (Emergency Department) Two Client Identifiers (Medicine Services) Two Client Identifiers (Mental Health Services) Met 5 of 5 of Met 5 of 5 of Met 5 of 5 of Met 5 of 5 of Met 3 of 3 2 of 2 Met 3 of 3 2 of 2 Met 1 of 1 of Met 1 of 1 of Met 1 of 1 of Met 1 of 1 of Met 1 of 1 of Met 1 of 1 of Met 1 of 1 of Executive Summary 9

15 Required Organizational Practice Overall rating Test for Compliance Rating Major Met Minor Met Patient Safety Goal Area: Communication Two Client Identifiers (Obstetrics Services) Two Client Identifiers (Perioperative Services and Invasive Procedures Standards) Two Client Identifiers (Point-of-Care Testing) Two Client Identifiers (Transfusion Services) Met 1 of 1 of Met 1 of 1 of Met 1 of 1 of Met 1 of 1 of Patient Safety Goal Area: Medication Use Antimicrobial Stewardship (Medication Management Standards) Concentrated Electrolytes (Medication Management Standards) Heparin Safety (Medication Management Standards) High-Alert Medications (Medication Management Standards) Infusion Pumps Training (Ambulatory Care Services) Infusion Pumps Training (Critical Care) Infusion Pumps Training (Emergency Department) Infusion Pumps Training (Medicine Services) Infusion Pumps Training (Mental Health Services) Infusion Pumps Training (Obstetrics Services) Met 4 of 4 1 of 1 Met 3 of 3 of Met 4 of 4 of Met 5 of 5 3 of 3 Met 1 of 1 of Met 1 of 1 of Met 1 of 1 of Met 1 of 1 of Met 1 of 1 of Met 1 of 1 of Executive Summary 1

16 Required Organizational Practice Overall rating Test for Compliance Rating Major Met Minor Met Patient Safety Goal Area: Medication Use Infusion Pumps Training (Perioperative Services and Invasive Procedures Standards) Narcotics Safety (Medication Management Standards) Met 1 of 1 of Met 3 of 3 of Patient Safety Goal Area: Worklife/Workforce Client Flow (Leadership) Client Safety Plan (Leadership) Client Safety: Education And Training (Leadership) Preventive Maintenance Program (Leadership) Workplace Violence Prevention (Leadership) Met 7 of 7 1 of 1 Met 2 of 2 2 of 2 Met 1 of 1 of Met 3 of 3 1 of 1 Met 5 of 5 3 of 3 Patient Safety Goal Area: Infection Control Hand-Hygiene Compliance (Infection Prevention and Control Standards) Hand-Hygiene Education and Training (Infection Prevention and Control Standards) Infection Rates (Infection Prevention and Control Standards) Met 1 of 1 2 of 2 Met 1 of 1 of Met 1 of 1 2 of 2 Patient Safety Goal Area: Risk Assessment Falls Prevention Strategy (Ambulatory Care Services) Met 3 of 3 2 of 2 Executive Summary 11

17 Required Organizational Practice Overall rating Test for Compliance Rating Major Met Minor Met Patient Safety Goal Area: Risk Assessment Falls Prevention Strategy (Diagnostic Imaging Services) Falls Prevention Strategy (Emergency Department) Falls Prevention Strategy (Medicine Services) Falls Prevention Strategy (Mental Health Services) Falls Prevention Strategy (Obstetrics Services) Falls Prevention Strategy (Perioperative Services and Invasive Procedures Standards) Pressure Ulcer Prevention (Critical Care) Pressure Ulcer Prevention (Medicine Services) Pressure Ulcer Prevention (Perioperative Services and Invasive Procedures Standards) Suicide Prevention (Mental Health Services) Venous Thromboembolism Prophylaxis (Critical Care) Venous Thromboembolism Prophylaxis (Medicine Services) Venous Thromboembolism Prophylaxis (Perioperative Services and Invasive Procedures Standards) Met 3 of 3 2 of 2 Met 3 of 3 2 of 2 Met 3 of 3 2 of 2 Met 3 of 3 2 of 2 Met 3 of 3 2 of 2 Met 3 of 3 2 of 2 Met 3 of 3 2 of 2 Met 3 of 3 2 of 2 Met 3 of 3 2 of 2 Met 5 of 5 of Met 3 of 3 2 of 2 Met 3 of 3 2 of 2 Met 3 of 3 2 of 2 Executive Summary 12

18 1.6 Summary of Surveyor Team Observations The surveyor team made the following observations about the organization's overall strengths, opportunities for improvement, and challenges. The organization, St. Joseph's Health Centre is commended on preparing for and participating in the Qmentum survey program. St. Joseph's Health Centre is a 4-bed hospital that serves more than 5, people per year. There are approximately 2,6 employees, 4 physicians and 3 volunteers. This organization is a teaching centre and supports approximately 6 medical trainees and 45 inter-professional students on an annual basis. This hospital has a history dating back to 1921 and to the Sisters of St. Joseph, and its infrastructure is outdated and requires redevelopment. This 87, square foot facility is landlocked and some best practices are challenging to meet for example, infection control practices and appropriate isolation rooms. In 212, part of the hospital building underwent redevelopment and staff members are proud of the end product. Although the physical structure of the hospital is old, the building is cared for and well-maintained. There is a Foundation that is diligent in working with the community to receive donations for capital and ongoing redevelopment project needs. Several committed donors have provided generous monetary contributions to this organization and its services. A new strategic plan was recently released. The organization was innovative in the creation of the strategic plan and it sought input from external partners, physicians and staff. The community was encouraged to engage in workshops and assist with the development of the: "Vision 2/2." The new plan identifies the need to build strong relationships with external partners and take an active role in the health and well-being of the community. As one staff member described it: "we are growing tentacles that will reach out and touch significant healthcare aspects of the community." Commendation is given for the work done to include patients and their families as partners in committee work, decision-making and health care delivery. The Community Engagement Council is considered an operational council and the members report directly to the chief executive officer (CEO). The board is selected with the use of a skills metrics. A selection committee is used to interview board candidates and to make sure the board members bring a diverse set of skill mixes. There are 19 board members and six board meetings per year. Board members are required to attend 75% of the board meetings. Board members appear as a dedicated group with an array of professional backgrounds and expertise. They provide clear direction to the organization. Every board member receives an annual meeting with the board chair and is provided with peer feedback. Learning needs and areas for development are discussed at this meeting. There are policies in place for length of time that board members serve, and number of members that leave the board at any one time. There has been a large turnover in the leadership team in the past five years. A new CEO and several key leadership positions have recently been hired. Quality and safety for patients, staff members and physicians is a key strategy for the leadership team. Developing leadership from within the organization is important, and there are several opportunities available to assist in the advancement of staff. The community partners have noticed a shift in the working relationship culture at St. Joseph's Health Centre, and offered some comments during the survey, and meeting with the surveyor team. Communication has greatly improved and there is now evidence of growing interest in external partners. There seems to be a more innovative approach by the senior team. To cite one partner: "I have noticed a shift from the work of the hospital behind insular walls to a shared interest in community and partnerships": To cite another: "the hospital is hearing our feedback and willing to do things differently." Partners feel the organization is willing to share responsibility and has moved away from an excuse-based system to a solution-based system. A representative from the Local Health Integrated Network (LHIN) noted that physician complaints to the LHIN leadership team Executive Summary 13

19 and members of parliament (MPPs) have stopped. This representative believes the physician's voice is being heard and a trusting relationship is developing between the hospital leadership team and the medical group. The community partners would like to consider sharing resources with St. Joseph's Health Centre, specifically, human resources (HR) and information technology (IT). There are strong partnerships and successful programs between the Toronto police and the Paramedic services and the hospital. The organization is encouraged to continue its work in the development of relationships. The community partners found this joint meeting most beneficial in that they got to meet and talk about common issues and goals. Quality and safety is a strategic priority for the organization. There is a quality improvement plan (QIP) which extends to approximately three years. There are seven key goals and the organization feels it takes an appreciative amount of time to achieve the selected target outcomes hence, the three-year plan. Each of the seven goals is identified as a problem statement, measured with current performance and analyzed, with improvements to practice or change and control where sustainability of the plan occurs. Again, the Community Engagement Council plays a key role in providing input to and assistance with the QIP. Note is made of the recently developed integrated risk management framework. The framework is being used to identify business, resource, compliance and strategy risk. Identified risks are presented to the board on a quarterly basis. There appears to be minimal recruitment issues. The turnover rate is 8.1% per year. The average retirement age is 62 years. Exit interviews are completed by , telephone or in person. Exit trends are reviewed and this information is given to the managers of the program. There are approximately 2,6 people working at St Joseph's Health Centre. The occupational health and safety (OHS) department has several programs which support staff. There are attendance support programs and modified/return to work programs. An employee assistance program (EAP) is available to physicians and staff. The organization has several staff functions, which are used to promote staff morale and retention. Long-service awards, barbecue days and holiday parties, and bike marathons are a sample of the 2 plus events that occur annually. Physicians have an Annual Clinic Day, and every year it attracts several hundred physicians and staff, and the day involves dinners, recognition awards and learner awards among other things. The wellness program includes a gym and a Pilates program for the staff. There is a Second Cup on site, which is open 24/7 for staff. St. Joseph's Health Centre has an ethicist available 24/7 hours and seven days per week. There is a well-defined ethical framework and the word "yoda" is associated with the framework. Yoda stands for: "You, Observe, Deliberate and Act". Staff members wear a card highlighting the steps to assist the process of working through an ethics issue. In speaking with physicians and staff, they appreciate the availability of this service and the ongoing support provided in dealing with ethics issues. In the period January 1 to October 31, 215, there have been 66 consults and 14 debriefs at St. Joseph's Health Centre. There is trending completed on the types of ethical cases. There is an ethics research committee which meets approximately 11 times per year. A community member sits on the committee, and this person is familiar with her role and ensures the rights, consent and safety of the patient is a focus of discussion. The agenda is circulated well in advance of the committee meeting so that members can read and be prepared for the meeting. There are approximately 35 new research submissions per year, and 7 ongoing research studies in process. The clinical services meet standards. Each of the programs is impressive and well managed. Staff members, physicians and the board are committed to the organization and to the community. Quality, safety and caring has been demonstrated in every aspect possible. This organization is well known in providing care to patients that are not able to pay for services and this is done without looking for recognition or rewards. Privacy in all areas of the hospital is an issue and requires review, with practice changes considered in all areas of the hospital such as waiting rooms. Executive Summary 14

20 Section 2 Detailed On-site Survey Results This section provides the detailed results of the on-site survey. When reviewing these results, it is important to review the service excellence and the system-wide results together, as they are complementary. Results are presented in two ways: first by priority process and then by standards sets. Accreditation Canada defines priority processes as critical areas and systems that have a significant impact on the quality and safety of care and services. Priority processes provide a different perspective from that offered by the standards, organizing the results into themes that cut across departments, services, and teams. For instance, the patient flow priority process includes criteria from a number of sets of standards that address various aspects of patient flow, from preventing infections to providing timely diagnostic or surgical services. This provides a comprehensive picture of how patients move through the organization and how services are delivered to them, regardless of the department they are in or the specific services they receive. During the on-site survey, surveyors rate compliance with the criteria, provide a rationale for their rating, and comment on each priority process. Priority process comments are shown in this report. The rationale for unmet criteria can be found in the organization's online Quality Performance Roadmap. See Appendix B for a list of priority processes. INTERPRETING THE TABLES IN THIS SECTION: The tables show all unmet criteria from each set of standards, identify high priority criteria (which include ROPs), and list surveyor comments related to each priority process. High priority criteria and ROP tests for compliance are identified by the following symbols: High priority criterion ROP MAJOR MINOR Required Organizational Practice Major ROP Test for Compliance Minor ROP Test for Compliance Detailed On-site Survey Results 15

21 2.1 Priority Process Results for System-wide Standards The results in this section are presented first by priority process and then by standards set. Some priority processes in this section also apply to the service excellence standards. Results of unmet criteria that also relate to services should be shared with the relevant team Priority Process: Governance Meeting the demands for excellence in governance practice. Surveyor comments on the priority process(es) The board membership is selected with the use of a skills metrics. A selection committee is used to interview board candidates and to ensure board members bring a diverse set of skill mixes. There are 19 board members and six board meetings per year. Board members are required to attend 75% of the board meetings. Every board member receives an annual meeting with the board chair and is provided with peer feedback. Learning needs and areas for development are discussed at this meeting. There are policies in place for the length of time board members can serve and also for the number of members that leave the board at any one time. Every board meeting is evaluated and members can submit their feedback forms for review. Changes to board agendas are made based on this feedback. The board has recently moved to a consent agenda and has found that this form of meeting allows more time for discussion on key issues and in-camera items. There is a roles and responsibility document for board members and this is reviewed annually. New board members are orientated and required to meet with key individuals, read the portal education materials, tour the hospital and attend retreats. There is a formal mentorship process for new board members. Numerous board members are elected to sit on sub-committees of the board such as for governance and quality. The members of the board appear engaged, enthused and invested in their work. There is commitment to the community being served. There are education opportunities provided for the board. Every board meeting begins with an education session and is based on the learning needs of the board. Most recently, the board started to tour various departments and programs to learn more about the care that patients receive and staff experiences. Board members may attend Ontario Hospital Association (OHA) education sessions if desired. Patient stories are becoming part of board learning and are seen as a valuable tool to help the board hear what patients are saying about the care they receive at St Joseph's Health Centre. The board is familiar with the ethics framework and has used it in the past for example, to recruit the current chief executive officer (CEO) and a physician. The board members provided input to the strategic plan. They encouraged the senior team to look broadly, and include the community in the Vision 2/2. This vision emphasizes external relationships and a proactive approach to the health and well-being of the community. The community was also actively involved in the Detailed On-site Survey Results 16

22 development of the strategic plan. Commendation is given for the amount of inclusiveness the organization sought and obtained in creating the strategic plan. Detailed On-site Survey Results 17

23 2.1.2 Priority Process: Planning and Service Design Developing and implementing infrastructure, programs, and services to meet the needs of the populations and communities served Surveyor comments on the priority process(es) St. Joseph's Health Centre has recently undergone some building redevelopment, and the newly developed space opened in 212. It is the hope that other areas of the hospital will be redeveloped so that best practices can be met for example, isolation rooms with sub-room entry points and more privacy for the patient. The hospital facility, which is 87, square feet, is landlocked and there is no ability to build new structures. Although old, the building is well-cared for and well-maintained. St. Joseph's Health Centre has moved from having a 'Rights and Responsibility' document to a Philosophy of Care document. This document is posted across the organization. The organization is currently working on three main development projects. It would like to increase the dialysis unit to a 24-chair unit and eventually to a 27-chair unit. This proposal currently rests with the ministry. St Joseph's Health Centre would also like to open a palliative unit in a 'focused' area and with approximately 1 beds. As well, the organization is working toward the development of a Learning Centre to provide ongoing educational and research support. There is also a master plan to assist with patient flow in the emergency department (ED). The community is informed of St. Joseph's Health Centre business and changes by way of the bi-annual newsletter entitled: "In the Community", the monthly newsletter, and the annual report. The leadership team is in touch with current media preferences and uses internal twitter or "chatter" and Facebook to provide information and education. The organization, including the Family Health Teams is currently preparing to support refugees from Syria. The organization is cognizant of change fatigue and does attempt to stage projects and new initiatives. Recently, an evening supervisor with on-call night responsibilities was introduced for the purpose of lessening managerial stress and increasing support for the front-line staff. In the development of the new strategic plan, the mission and values remain basically the same however, the vision is new and provides a broader community perspective and partnering with external providers. St. Joseph's Health Centre is a teaching organization and has proudly included this in its vision statement. Detailed On-site Survey Results 18

24 2.1.3 Priority Process: Resource Management Monitoring, administration, and integration of activities involved with the appropriate allocation and use of resources. Surveyor comments on the priority process(es) St. Joseph's Health Centre is in a surplus position. An external audit is completed twice yearly. Monthly financial status reports are presented to the board. There is a capital committee to which staff members submit equipment, and information technology requests and for redevelopment. These requests are prioritized and purchased based on the level of need and the decision of the committee. Biomedical and environmental services and infection control are involved in the purchase of equipment to ensure it meets standards from their professional perspective. There is an active Foundation along with numerous committed donors. The organization recognizes it is an area of monetary competition with other Toronto hospitals. For the newly opened redeveloped areas of the hospital, it was noted that the community was extremely generous and provided wonderful support so capital items could be purchased. There is a substantial contingency budget and any item below $25. can be purchased by the director or manager, without further senior leadership signatures. Products and equipment have been standardized and the hospital is connected to buying groups. The product evaluation committees assist with the choosing and purchasing of products and new equipment. Programs receive a funding envelope and are expected to provide services within that envelope. Every manager has a financial analyst for support. Operational reports are reviewed monthly. Detailed On-site Survey Results 19

25 2.1.4 Priority Process: Human Capital Developing the human resource capacity to deliver safe, high quality services Surveyor comments on the priority process(es) St. Joseph's Health Centre has a comprehensive interview process for new hires. Applicants are interviewed and scored by key stakeholders. Hospital and unit-specific orientation occurs. Learning plans are developed for those staff members that require additional learning support following or during their probationary period. Talent reviews are completed annually for all staff. A copy of the review is placed in the human resources (HR) department. Personnel files are locked and secured. Staff members are permitted to review their files upon request. The code of conduct and privacy forms are signed by physicians and staff. Prior to working at this hospital, back-checks are required of staff. There appears to be no recruitment issues. The turnover rate is 8.1% per year. The average retirement age is 62 years. Exit interviews are completed by , telephone or in person. Exit trends are reviewed and this information is given to the respective manager of the program. There are approximately 2,6 employees working at St Joseph's Health Centre. The occupational health and safety (OHS) department has several programs which support staff. There are attendance support programs and modified/return to work programs. An Employee Assistance Program (EAP) is available to physicians and staff, and us of the program is kept confidential. The organization has several staff functions, which are used to promote staff morale and retention. Long-service awards, barbecue days and holiday parties, and bike marathons are a sample of the 2 plus events that occur annually. Physicians have an Annual Clinic Day, and every year it attracts several hundred physicians and staff, and the day involves dinners, recognition awards and learner awards among other things. The wellness program includes a gym and a Pilates program for the staff. There is a Second Cup on site, which is open 24/7 for staff. There are three unions namely: Ontario Nurses Association (ONA), Canadian Union of Public Employees (CUPE) and SLIU (security). The leaders report good working relationships with labour-management groups. There are several regulated professional groups at St. Joseph's Health Centre that are not unionized. These staff members and the organization work closely together to address professional items. Fatigue, workload and stress are considered when reviewing staffing models. In areas where patient flow and acuity is high, a manager and assistant manager are hired to support the programs. The organization utilizes ministry initiatives such as: Late Career Nurse; New Graduate Initiative and Critical Care Education. Instead of completing the Worklife Pulse Tool the organization used an Employee and Physician Engagement tool. There was a 61% completion rate for staff, and 51% for the physicians. The results from this survey will be analyzed and used to improve the worklife of physicians and staff. There are dates set to re-survey the staff. Detailed On-site Survey Results 2

26 There is 24/7 security and this uses hospital employees. These staff members have received training in de-escalation techniques. In speaking directly with staff, there appears to be several safeguards in place for their protection. Detailed On-site Survey Results 21

27 2.1.5 Priority Process: Integrated Quality Management Using a proactive, systematic, and ongoing process to manage and integrate quality and achieve organizational goals and objectives Surveyor comments on the priority process(es) Quality and safety are a strategic priority for the organization. There is a quality improvement plan (QIP) which extends to approximately three years. There are seven goals and the organization feels it takes an appreciative amount of time to achieve the selected target outcomes hence, the three year plan. Each of the seven goals is identified as a problem statement, measured with current performance and analyzed, with improvements to practice or change and control and where sustainability of the plan occurs. The Community Engagement Council plays a key role in providing input to and assistance with the QIP. Adverse events are entered into Risk-pro. Upgrades to RL6 will occur in the near future. Trending of adverse events occurs with follow up. There is disclosure to the patient and family and where necessary, a secondary disclosure occurs for example, following a Quality of Care meeting. Case reviews are completed at the Quality Care committee. Open discussion occurs for each case, and input from a multitude of health care providers that sit at the table occurs. The physicians and staff members are commended for their openness and the desire to enhance the quality and safety of patient/family care using a transparent methodology, and in a safe environment. There are several client safety documents including: "Our Mutual Commitment" which focuses on the responsibilities of St. Joseph's Health Centre staff, physicians, volunteers, contract workers and also the patient, family member, care giver, visitor and surrogate decision makers. This document is posted across the organization. There is a handout pamphlet entitled: "Safety at St. Joseph's - Information for patients, families and care givers" and another: "Your safety is very important to us." Staff members have access to these pamphlets and are encouraged to become familiar with their contents. Patient comments are followed up within 48 hours of the complaint. Every complaint is resolved in a four-week period. The organization is working on a discharge follow-up telephone call program. There are more than 4 volunteers that work here, and the hiring processes for volunteers are identical to those for staff members in that health assessment records, privacy forms, orientation, hand hygiene and so on must be completed prior to commencing volunteer work. The organization is associated with the University of Toronto and other key education institutions and is involved in research. St. Joseph's Health Centre wishes to increase its research work soon. Research studies are approved by the Research Ethics Board. An integrated risk management framework was recently developed and is being used to identify business, resource, compliance and strategy risk. Identified risks are presented to the board on a quarterly basis. Detailed On-site Survey Results 22

28 2.1.6 Priority Process: Principle-based Care and Decision Making Identifying and decision making regarding ethical dilemmas and problems. Surveyor comments on the priority process(es) St. Joseph's Health Centre has an ethicist available 24/7 hours and seven days per week. They is a well-defined ethical framework and the word "yoda" is associated with the framework. Yoda stands for: "You, Observe, Deliberate and Act". Staff members wear a card highlighting the steps to assist the process of working through an ethics issue. In speaking with physicians and staff, they appreciate the availability of this service and the ongoing support provided in dealing with ethics issues. In the period January 1 to October 31, 215, there have been 66 consults and 14 debriefs at St. Joseph's Health Centre. There is trending completed on the types of ethical cases. There is an ethics research committee which meets approximately 11 times per year. A community member sits on the committee, and this person is familiar with her role and ensures the rights, consent and safety of the patient is a focus of discussion. The agenda is circulated well in advance of the committee meeting so that members can read and be prepared for the meeting. There are approximately 35 new research submissions per year, and 7 ongoing research studies in process. Most recently, an ethics research article has been developed by hospital staff. It has been published in the Nursing Ethics Journal. The article's title is: "Difficult healthcare transition: ethical analysis and policy recommendation for unrepresented patients." This article addressed a situation that occurred at the hospital and the ethicist felt the content would assist others. The staff members are working on a do not resuscitate (DNR) process review. The College of Physicians and Surgeons has recently adopted St. Joseph's Health Centre's Elder Abuse Policy. The organization provides an ethicist fellowship program and is recognized internationally for this program. The ethics program is commended for the innovative model of partnering and supporting approximately nine other facilities. Detailed On-site Survey Results 23

29 2.1.7 Priority Process: Communication Communicating effectively at all levels of the organization and with external stakeholders Surveyor comments on the priority process(es) The partners and clients perceptions of the quality of the health care received at St. Josephs Health Centre are positive. It is apparent the culture of St. Joseph s Health Centre has an ingrained philosophy toward strong and proactive efforts of communication and education. Patients and families feel well-informed and part of the family of St. Joseph's Health Centre. Open and transparent sharing of information of the changes internally and externally is appreciated by staff. An information system (IS) roadmap is aligned with the strategic directions to enable the corporate strategic priorities. The "Everyone Update" helps keep staff informed. The organization has proven to be a systems thinker, sharing information at conferences, community engagement sessions and via newsletters. The leaders at all levels are receptive to change and presenting information in different and innovative ways. Senior leadership is acutely focused on the end-goal of transparency, respect and quality care. The leadership invites staff members to participate in information giving/sharing by way of committee work, surveys and open dialogue. The organization actively utilizes Facebook, LinkedIn, Twitter and paper mediums, as well as the intranet and verbally to communicate internally and externally. Recently, new branding and marketing strategies have included the sharing of patient stories. Perhaps the organization could develop policy for management of the information. Senior leaders are aware they need to be more selective of data collection. They felt there is a need to streamline data collection to make decisions. Detailed On-site Survey Results 24

30 2.1.8 Priority Process: Physical Environment Providing appropriate and safe structures and facilities to achieve the organization's mission, vision, and goals Surveyor comments on the priority process(es) The organization meets applicable laws, regulations and codes. During renovations the organization meets all requirements for asbestos removal and the upgrade specifics for fire and staff safety. The building is clean and well maintained. There are back-up systems and generator for power outages. Maintenance and housekeeping staff members take pride in their roles and are connected with the clinical staff. It is noted the out-patient dialysis unit does not have a generator for power outages. The machines for dialysis can manage on battery for 45 minutes to enable patient to leave the machines. However in the past, with outages lasting several days, a generator would have facilitated continued care for patients over several shifts. The senior care ambulatory program and the out-patient laboratory collecting station are working in tight and cluttered spaces. Staff members can be heard talking to the Community Care Access Centre (CCAC) regarding patients needs, from the senior care ambulatory waiting room. Detailed On-site Survey Results 25

31 2.1.9 Priority Process: Emergency Preparedness Planning for and managing emergencies, disasters, or other aspects of public safety Surveyor comments on the priority process(es) The emergency preparedness and planning committee has a focused group of individuals representing a number of areas across the organization. The group represents infection prevention and control (IPAC), Plant Maintenance, Information Management, Communication, Emergency Department and the senior team. The group has created an impressive set of documents, processes and a crisis centre. The work around the recent PAN AM Games best reflects the preparatory work of the organization. A detailed plan called Plan Ahead for PAN AM was created, as St. Joseph's Health Centre was the closest hospital to the Games. Many partners collaborated in the plan. The planning focused on signage, alternate sites such as a tent in which to see patients, the procurement of equipment and supplies and the reality of having staff members coming to work in a high-traffic situation. The overall results were impressive and supported by such initiatives as Smart Commute. Another example of the work of the committee was the preparation for potential Ebola patients. There was extensive training in the use of Personal Protective Equipment, use of a designated room that had no other function and extensive patient screening. Issues such as fire drills, moving patients during a fire, and computer back-ups were discussed in detail. Overall, there is an excellent group for emergency preparedness, with strong leadership support. Detailed On-site Survey Results 26

32 2.1.1 Priority Process: Patient Flow Assessing the smooth and timely movement of clients and families through service settings Surveyor comments on the priority process(es) During the past few years St. Joseph's Health Centre has re-focused to deal with the reality of overcrowding in the emergency department (ED). Historically, there would often be twenty to thirty or more admitted patients camping out in the ED. The organization, from the top down, committed to moving the problem out of the ED and sharing it with the rest of the organization. Now, the number of patients in the ED is often single digits and if held, they are moved relatively quickly. To achieve this improvement it involved a number of parallel activities. First, the documentation process was changed to electronically documenting the utilization of all the departments and identifying any capacity. Secondly, staff members were allotted to the Access and Flow service to help departments with discharge and utilization of alternate spaces. Thirdly, the organization was supportive of the various departments' temporarily expanding to accommodate above their budgeted census. This third initiative was called: Take One, and departments would expand if they had additional space and could allot staffing to adequately support these patients. To support this process, daily bed meetings are held with department managers to collectively understand the challenge, and to offer support to expand. This process of temporarily expanding has been supported by a renewed effort from the Community Care Access Centre (CCAC), discharge planning and the most responsible physician (MRP). Another tool to support this effort is the DOT meetings. Twice weekly, discharge planning and the embedded CCAC staff members meet to review specific patients and review the processes in place to help with transfer or discharge. It is interesting to note that senior staff members such as the director and one of the managers attend. Also interesting to note is that the elective surgical program was supported and only used as a last resort to help decant patients from the ED. Overall however, the most impressive component of this initiative is the importance attached to it by senior management. Both the vice presidents of Medical and Clinical Services attended the on-site interview with the surveyor team and actively supported this work. The issue of ambulance download wait times has been reviewed. Historically, this was a challenge but generally, is less of an issue. Partially, this relates to the good working relationship between the paramedics and the nurse manager in the ED. Also, the organization has created the position of an Emergency Medical Services (EMS) off-load nurse. This role would focus on supporting the EMS patients and expedite and support the off-loading process. If not needed, the staff member would support other ED functions. The organization also focuses on the high-users of the ED services. If someone is identified as a frequent user, the person is often connected to a community case manager, especially if the patient has a mental health issue. Also, this mechanism has been used to identify patients that may be suitable for Health Links. Detailed On-site Survey Results 27

33 Priority Process: Medical Devices and Equipment Obtaining and maintaining machinery and technologies used to diagnose and treat health problems Surveyor comments on the priority process(es) The St. Joseph's Health Centre has developed an effective process to maintain and clean that various pieces of equipment used extensively across the organization. There is strong departmental leadership which is focused on ensuring that these staff members are prepared and able to deliver a quality service. It starts by fully utilizing the external guidance provided by the equipment manufacturers, and ensures that directions are fully incorporated into the department policies and procedures. There is strong support for ensuring that staff members are well-educated and fully trained in each process. It was interesting to note that the organization has raised the educational bar to include college level training. Also, the organization has designed a physical plant that allows for the easy flow of equipment, from dirty to clean and finally to sterilized. The physical plant is securely controlled and relies on separate elevators from the operating room (OR) suite to ensure adequate separation of dirty and clean equipment. The organization has fully utilized its space to accommodate a variety of equipment from surgical tools to endoscopes, to resuscitation crash carts. Each step of the process is carefully documented and supported by the various markers to indicate adequate sterilization. Staff members are well-supported and clearly committed to delivering safe equipment for the various procedures. It was also interesting to note that the department is an educational site for college students training in this discipline. The organization has developed a detailed preventive maintenance (PM) program supported by the engineering service. It has identified three classes of equipment that are serviced on an ongoing basis. More complex equipment is serviced by the manufacturer. Less complex equipment is jointly serviced by the manufacturer and the in-house engineering service after additional training. The least complex items are serviced in house, which has allowed for better utilization of staff. There is a detailed electronic monitoring program to ensure that all equipment undergoes a preventive maintenance step every year or less, and last year the service meet this goal more than 95% of the time. There is also another electronic program that allows for repair requests to be seen, categorized and responded to quickly. Also of note is that the service has pre-identified which engineer should be consulted for each piece of equipment. Since this is a teaching centre, students from Sheridan College can have placements in this service. What is most refreshing to the surveyor team is that both the reprocessing service and the engineering department are seen as essential and valued components in the delivery of quality patient care. Detailed On-site Survey Results 28

34 2.2 Service Excellence Standards Results The results in this section are grouped first by standards set and then by priority process. Priority processes specific to service excellence standards are: Clinical Leadership - Primary Care Providing leadership and overall goals and direction to the team of people providing services. Competency - Primary Care Developing a highly competent interdisciplinary team with the knowledge, skills and abilities to develop, manage, and deliver effective and efficient programs, services, and care. Decision Support - Primary Care Information, research and evidence, data, and technologies that support and facilitate management and clinical decision-making. Impact on Outcomes - Primary Care 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. Point-of-care Testing Services Using non-laboratory tests delivered at the point of care to determine the presence of health problems Primary Care Clinical Encounter Providing primary care in the clinical setting, including making primary care services accessible, completing the encounter, and coordinating services Clinical Leadership Providing leadership and overall goals and direction to the team of people providing services. Competency Developing a skilled, knowledgeable, interdisciplinary team that can manage and deliver effective programs and services Episode of Care Providing clients with coordinated services from their first encounter with a health care provider through their last contact related to their health issue Decision Support Using information, research, data, and technology to support management and clinical decision making Impact on Outcomes Identifying and monitoring process and outcome measures to evaluate and improve service quality and client outcomes Detailed On-site Survey Results 29

35 Medication Management Using interdisciplinary teams to manage the provision of medication to clients Organ and Tissue Donation Providing organ donation services for deceased donors and their families, including identifying potential donors, approaching families, and recovering organs Infection Prevention and Control Implementing measures to prevent and reduce the acquisition and transmission of infection among staff, service providers, clients, and families Surgical Procedures Delivering safe surgical care, including preoperative preparation, operating room procedures, postoperative recovery, and discharge Diagnostic Services: Imaging Ensuring the availability of diagnostic imaging services to assist medical professionals in diagnosing and monitoring health conditions Diagnostic Services: Laboratory Ensuring the availability of laboratory services to assist medical professionals in diagnosing and monitoring health conditions Transfusion Services Transfusion Services Standards Set: Ambulatory Care Services - Direct Service Provision Unmet Criteria High Priority Criteria Priority Process: Clinical Leadership Priority Process: Competency Priority Process: Episode of Care Priority Process: Decision Support 14.2 The team meets applicable legislation for protecting the privacy and confidentiality of client information. Detailed On-site Survey Results 3

36 Priority Process: Impact on Outcomes Surveyor comments on the priority process(es) Priority Process: Clinical Leadership Many out-patient clinical services (33) are provided by St Joseph's Health Centre. The team uses patient population demographics to determine community needs. For purposes of the accreditation survey the surveyor team toured the Seniors Care Program, the gastroenterology (GI) clinic and dialysis. The staff members demonstrated seamless care across the programs. The Regional Dialysis program has been approved by the Ontario Renal Network as a Regional Dialysis Service provider in order to help meet the overwhelming demand for kidney care and dialysis services in the Greater Toronto Area (GTA). The dialysis program offers both in and out-patient care to patients with kidney failure or at risk of kidney failure. The out-patient clinic is located off site. This clinic has a dynamic inter-professional team including a nephrologist, nurses, dietician, pharmacist, social worker, and more. The team works with the patient and their family with the goal of managing their health to delay the need for kidney replacement treatment (dialysis or kidney transplant) and to educate them on kidney replacement options if required. Family, with patient consent are involved in the dialysis and senior care program education. Priority Process: Competency Staff members in the clinics are friendly, courteous and respected by families and physicians. The interdisciplinary team members openly share their knowledge, skills and abilities to develop, manage, and deliver effective and efficient ambulatory programs, services and care. Competency checks are built into orientation and performance appraisals. Performance appraisals are completed regularly as per policy, every one or two years. Priority Process: Episode of Care Families are important members of the care team. They are encouraged, with patient permission, to take an active role in their loved one's care; to learn all they can and take part in the treatment plan. The staff members of the out-patient clinical services teams firmly believe and demonstrate good health care is always a team effort. Communication is shared between team members. All staff members respect each other s expertise. The ambulatory clinics have strong linkages with community partners for the care. Volunteers actively assist in the clinic environment. Wrist bands are not placed on ambulatory patients, and this could be an issue for the confused elderly when their names are called. Applying name bands on registration is suggested. Detailed On-site Survey Results 31

37 Priority Process: Decision Support The staff members and physicians are using information, research, data and technology to support management and clinical decision making. Priority Process: Impact on Outcomes The staff members have quality boards to display on the units and these are visible to physicians, patients and visitors. They strive to identify and monitor process and outcome measures to evaluate and improve service quality and client outcomes. Measurable client and family service goals are identified by way of patient conversations and plans of care are put into action. Detailed On-site Survey Results 32

38 2.2.2 Standards Set: Biomedical Laboratory Services - Direct Service Provision Unmet Criteria High Priority Criteria Priority Process: Diagnostic Services: Laboratory Surveyor comments on the priority process(es) Priority Process: Diagnostic Services: Laboratory During the survey a tour was conducted in the out-patient laboratory, blood bank, transfusion service, pathology, microbiology, and hematology. The out-patient laboratory waiting area is a distance from the out-patient lab-bloodletting station. The actual out-patient lab is small, crowded and noisy. Patients are separated by curtains. A stretcher bed is available for children or patients that feel faint. A Lazy Boy chair is used as the bariatric chair. Lab staff members are courteous and respectful despite the busy environment. Patients are surveyed for input regarding access or suggested improvements for services. Back-up systems are in place in the event of a power outage for the various laboratory services. The biochemistry laboratory is a tight but neat space however, it is a close working environment and could benefit from Lean strategies to assist staff members in having an easier work space. Pathology and microbiology have shower hoses located on the outer side of cupboards, with no floor drains if hoses were used as a shower. A sink is available for showering to cleanse eyes. It is suggested there be proper eye wash stations and floor drains or 'something' to catch the water in the event the shower nozzles are used, to prevent it from creating slip or water damage hazards. Detailed On-site Survey Results 33

39 2.2.3 Standards Set: Critical Care - Direct Service Provision Unmet Criteria High Priority Criteria Priority Process: Clinical Leadership Priority Process: Competency Priority Process: Episode of Care Priority Process: Decision Support Priority Process: Impact on Outcomes Priority Process: Organ and Tissue Donation Surveyor comments on the priority process(es) Priority Process: Clinical Leadership The critical care intensive care unit (ICU) is budgeted for 17 ICU beds but has the capacity for 2 beds. Seven of the beds are open-style beds with curtains to create privacy. Nine rooms are private rooms with sliding glass doors, and the remaining rooms are air flow controlled/isolation rooms. This is a busy unit that cares for patients that are critically ill. The ICU staff members are specially trained to administer critical care. Ongoing educational programs are offered. Patients are appreciative of the staff members for providing calm confident care. A specialty trained critical care response team (REACT RN) works out of the ICU on a 24/7 basis. Priority Process: Competency The unit is overseen by an intensive care unit (ICU) medical director and patient care manager. The ICU issues are reviewed and decision-making occurs via a Point of Care team, with a multidisciplinary membership. Families speak highly of the competent staff members that work successfully and efficiently caring for their patients. The interdisciplinary team meets twice daily to round on patients. Detailed On-site Survey Results 34

40 Priority Process: Episode of Care There are more than 9 patients per year admitted to the intensive care unit (ICU). The average length of stay (LOS) is 5.5 days. Several ICU rooms have capabilities for hemodialysis or continuous renal replacement therapy. There is a well-established multidisciplinary approach to care. Interdisciplinary rounds in the morning are at the nursing station. Noise is an issue for patients/ families and the rounding team. Perhaps a Plexiglas barrier could be erected to reduce sound from travelling. Priority Process: Decision Support Staff members are skilled and knowledgeable, participate in interdisciplinary team work and manage and deliver effective care. Priority Process: Impact on Outcomes The team works closely with area health care centres sharing ideas and outcomes, and this includes the University Healthcare Network (UHN), Trillium Gift of Life Network, St Michael's Hospital and the Sunnybrook and Mount Sinai hospitals. Priority Process: Organ and Tissue Donation There exists an excellent partnership with Trillium Gift of Life Network for organizing organ retrieval and donation opportunities. Detailed On-site Survey Results 35

41 2.2.4 Standards Set: Diagnostic Imaging Services - Direct Service Provision Unmet Criteria High Priority Criteria Priority Process: Diagnostic Services: Imaging 4.4 The client service area includes a space for screening clients which respects confidentiality issues prior to their diagnostic imaging examination. Surveyor comments on the priority process(es) Priority Process: Diagnostic Services: Imaging The diagnostic team members are extremely proud of their program and some of the service changes that have been made in the past five years. For example, a bedside peripherally inserted central catheter (PICC) program was introduced two years ago. One nurse was trained at the time and completes approximately 1 PICCs per year. A second nurse has been recently trained and there will soon be a third nurse trained to insert PICC's. The volume of PICC lines has increased considerably. By inserting PICC lines in the clinical setting, it has opened up a room in the diagnostic imaging (DI) department. This program has increased patient and staff satisfaction as patients do not need to be transported to DI and ongoing monitoring can occur at the bedside. This service was recently written about in the Hospital News. The DI program completes approximately 17, cases per year and currently has three computerized tomography (CT) machines and nine ultrasounds. This department's services were assessed by the ministry in 212. The hours of operation for this department have been considerably increased. As a result, case volumes have increased and wait times have decreased and are within wait time target limits. The number of "no shows" is below 5% and these cases are reviewed and trended. An intervention expansion submission is in progress and if accepted, two additional nurse recovery rooms and an obstetrics (OBS) breast centre will be added. Currently, patients that are being recovered or holding for transport back to the in-patient areas are in close proximity to the public waiting area. Patient flow does not appear to be an issue for this program. Each DI program has its own waiting area for example, Nuclear, CT, Mammography, Bone Density, and so on. There are numerous washrooms and change rooms and these are in close proximity to test areas. This department is well-lit, ventilated and clean. Equipment is maintained by on site bio medical staff, or by a service contract. This program has clearly defined and simplified the referral and requisition process. Referral requisitions are scanned into the patient electronic chart. If information is missing on the forms, then the form is sent back to the referral physician's office. The DI program has a user friendly computer system and staff members find it easy to retrieve and enter the information. The surgical pause is used in this department prior to, during and after a procedure. Radiologists read reports and in-patient areas may receive the results within 3 minutes. Referral physicians should get procedural results within seven days. There are some areas in this department where privacy could be improved. This program is encouraged to consider providing seating at the registration area. This would allow patients to sit and be at eye level to the clerical staff and also, ensure privacy with the transfer of personal information. Also, encouragement is offered to consider using a number system to keep patient names confidential thus, not being called out in Detailed On-site Survey Results 36