Accreditation Report

Transcription

1 Portage Montréal, QC On-site survey dates: June 16, June 21, 2013 Report issued: August 13, 2013 Accredited by ISQua

2 About the Portage (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 June 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, 2013

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 1.0 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 Required Organizational Practices Results Detailed On-site Survey Results Priority Process Results for System-wide Standards Priority Process: Planning and Service Design Priority Process: Governance 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 Standards Set: Customized Infection Prevention and Control Standards Set: Customized Managing Medications Standards Set: Substance Abuse and Problem Gambling Services Instrument Results Governance Functioning Tool Patient Safety Culture Tool Worklife Pulse Tool 36 Appendix A Qmentum 38 Appendix B Priority Processes 39 Table of Contents i

5 Section 1 Executive Summary Portage (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 Portage's accreditation decision is: Accredited (Report) The organization has succeeded in meeting the fundamental requirements of the accreditation program. Executive Summary 1

6 1.2 About the On-site Survey On-site survey dates: June 16, 2013 to June 21, 2013 Locations The following locations were assessed during the on-site survey. All sites and services offered by the organization are deemed accredited. 1 Centre d'accueil le Programme de Portage - Portage Lac Écho 2 Centre d'accueil le Programme de Portage - Portage Lionel-Groulx, programme TSTM 3 Centre d'accueil le Programme de Portage - Portage Québec 4 Centre d'accueil le Programme de Portage - Portage Square Richmond 5 Centre d'accueil le Programme de Portage - Portage St-Malachie 6 Centre d'accueil le Programme de Portage - Portage West-Island 7 Portage Program for Drug Dependencies - Portage Atlantic 8 Portage Program for Drug Dependencies - Portage British Columbia 9 Portage Program for Drug Dependencies - Portage Ontario Standards The following sets of standards were used to assess the organization's programs and services during the on-site survey. System-Wide Standards 1 2 Leadership Governance Service Excellence Standards Substance Abuse and Problem Gambling Services Customized Infection Prevention and Control Customized Managing Medications Instruments The organization administer: Governance Functioning Tool Patient Safety Culture Tool Worklife Pulse Tool Executive Summary 2

7 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 (Working with communities to anticipate and meet needs) Accessibility (Providing timely and equitable services) Safety (Keeping people safe) Worklife (Supporting wellness in the work environment) Client-centred Services (Putting clients and families first) Continuity of Services (Experiencing coordinated and seamless services) Effectiveness (Doing the right thing to achieve the best possible results) Efficiency (Making the best use of resources) Total Executive Summary 3

8 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 43 (97.7%) 1 (2.3%) 0 33 (97.1%) 1 (2.9%) 0 76 (97.4%) 2 (2.6%) 0 Leadership 42 (93.3%) 3 (6.7%) 1 78 (92.9%) 6 (7.1%) (93.0%) 9 (7.0%) 2 Customized Infection Prevention and Control 31 (93.9%) 2 (6.1%) 4 10 (90.9%) 1 (9.1%) 1 41 (93.2%) 3 (6.8%) 5 Customized Managing Medications 24 (100.0%) 0 (0.0%) 2 11 (100.0%) 0 (0.0%) 0 35 (100.0%) 0 (0.0%) 2 Substance Abuse and Problem Gambling Services 24 (92.3%) 2 (7.7%) 1 60 (84.5%) 11 (15.5%) 0 84 (86.6%) 13 (13.4%) 1 Total 164 (95.3%) 8 (4.7%) (91.0%) 19 (9.0%) (93.0%) 27 (7.0%) 10 * Does not includes ROP (Required Organizational Practices) Executive Summary 4

9 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 Adverse Events Disclosure (Leadership) Adverse Events Reporting (Leadership) Client Safety Quarterly Reports (Leadership) Client Safety Related Prospective Analysis (Leadership) Met 3 of 3 0 of 0 Met 1 of 1 1 of 1 Met 1 of 1 2 of 2 Unmet 0 of 1 0 of 1 Patient Safety Goal Area: Communication Client And Family Role In Safety (Substance Abuse and Problem Gambling Services) Dangerous Abbreviations (Customized Managing Medications) Information Transfer (Substance Abuse and Problem Gambling Services) Medication Reconciliation As An Organizational Priority (Leadership) Medication Reconciliation At Admission (Substance Abuse and Problem Gambling Services) Met 2 of 2 0 of 0 Met 4 of 4 3 of 3 Met 2 of 2 0 of 0 Met 4 of 4 0 of 0 Met 4 of 4 1 of 1 Executive Summary 5

10 Required Organizational Practice Overall rating Test for Compliance Rating Major Met Minor Met Patient Safety Goal Area: Communication Medication Reconciliation at Transfer or Discharge (Substance Abuse and Problem Gambling Services) Two Client Identifiers (Customized Managing Medications) Two Client Identifiers (Substance Abuse and Problem Gambling Services) Met 4 of 4 1 of 1 Met 1 of 1 0 of 0 Met 1 of 1 0 of 0 Patient Safety Goal Area: Worklife/Workforce Client Safety Plan (Leadership) Client Safety: Education And Training (Leadership) Preventive Maintenance Program (Leadership) Workplace Violence Prevention (Leadership) Met 2 of 2 2 of 2 Met 1 of 1 0 of 0 Met 3 of 3 1 of 1 Unmet 4 of 5 3 of 3 Patient Safety Goal Area: Infection Control Hand Hygiene Audit (Customized Infection Prevention and Control) Hand Hygiene Education And Training (Customized Infection Prevention and Control) Unmet 0 of 1 0 of 2 Met 2 of 2 0 of 0 Executive Summary 6

11 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. Portage is a bilingual non-profit organization offering a continuum of services to people with substance-abuse problems and concomitant disorders. Founded in 1970, Portage operates substance abuse rehabilitation centres in Quebec, Ontario, New Brunswick, and British Columbia. It provides residential and non-residential services. The clinical programs are designed for adults, mothers with children, and mentally ill chemical abusers. The organization is participating in its second accreditation cycle under the Qmentum program. Since its last accreditation survey in 2010, Portage has made efforts to respond to Accreditation Canada s recommendations, especially those related to safety and medication management. Consequently, the organization was well prepared for the recent Accreditation Canada survey at each of its eight sites. In some centres, young residents were involved in the tours, which enabled the surveyors to assess the physical environment and to receive a special presentation about the clinical program from members of the therapeutic community. Portage s Board of Directors consists of a group of people dedicated and committed to the organization and its strategic vision. The Chairman has held this position since 1970, and the Executive Director has been there since When board members are due for re-appointment, the organization is careful to ensure representation from various types of experts, and the continuing participation of experienced members on the board. The board of directors supervises the organization s strategic planning process. The strategic plan was recently adopted following consultations with internal and external bodies. The board is commended for an excellent analysis of the environment in which Portage works; the report clearly identifies the changes and new challenges that the organization had to take into account during the strategic planning process. The management team consists of representatives from each centre. The members of the management team are passionate about and dedicated to Portage and its program. Communication among the directors is frequent and provides a forum for sharing information and ensuring standardization in the program s implementation. Several partnerships have been established with community services and government bodies. Portage is encouraged to consolidate its cooperation with external partners to promote better continuity, seamlessness, and coordination of services. This is especially important before and after clients access Portage s services. In fact, the lack of effective relations in some situations reduces or prevents access to services, and resource utilization is not maximized. Portage has many dedicated, competent staff members who are responsive to clients needs. Staff members have access to training programs and the information required to safely provide care and services to clients. During the survey, the surveyors noted that interactions between the residents and staff members were respectful. Their clinical approach enables them to establish positive therapeutic relations with their clients. Procedures related to patient safety should be pursued. Dashboards to monitor certain worklife indicators need to be developed. Medication management, infection prevention and control, and emergency response measures are well organized and of a high quality. Regularly conducted surveys show that clients are extremely satisfied with the services Portage provides. The residents committees and the patients committees are actively involved in the centres. The members of these committees provide an important service by offering help to families, residents, and clients by handling, for example, dissatisfaction and complaints. The Complaints Commissioner is readily available to handle client complaints about the Quebec-based centres, and his reports are sent to the board of directors in Quebec. Executive Summary 7

12 Portage is encouraged to provide this type of impartial and independent mechanism for handling complaints in all centres and to forward resultant reports to the board of directors, so the reports can be made available as part of the quality improvement process. Numerous quality initiatives are conducted within Portage; however, they are not identified as such. Quality improvement initiatives are not always recognized, and information about the initiatives is not always communicated to the entire organization. (That said, some quality indicators have been identified and are monitored, such as client satisfaction.) Not every team at Portage has the same level of understanding of the components of an integrated quality improvement program. Developing an integrated quality improvement plan would result in more standardized and consistent implementation of the plan s components. Partial data about Portage s services are available. However, an integrated management framework for performance must be developed. It must identify performance outcome measures that could help the organization evaluate whether the expected outcomes are actually being achieved. Identifying clinical outcome indicators related to key clinical interventions would help determine the impact of each phase of the clinical program. The organization is encouraged to make clinical evidence about the programs and services available, and to update these data. Moreover, Portage is urged to partner with university researchers to benefit from their expertise, and to enable steps such as promoting the comparability of data. It is noteworthy that the organization and staff are dedicated to providing services that are truly going to help people. This was strongly indicated by some residents. Executive Summary 8

13 Section 2 Detailed Required Organizational Practices Results Each ROP is associated with one of the following patient safety goal areas: safety culture, communication, medication use, worklife/workforce, infection control, or risk assessment. This table shows each unmet ROP, the associated patient safety goal, and the set of standards where it appears. Unmet Required Organizational Practice Standards Set Patient Safety Goal Area: Safety Culture Client Safety Related Prospective Analysis The organization carries out at least one client safetyrelated prospective analysis and implements appropriate improvements. Leadership 15.9 Patient Safety Goal Area: Worklife/Workforce Workplace Violence Prevention The organization implements a comprehensive strategy to prevent workplace violence. Leadership 2.10 Patient Safety Goal Area: Infection Control Hand Hygiene Audit The organization evaluates its compliance with accepted hand-hygiene practices. Customized Infection Prevention and Control 4.4 Detailed Required Organizational Practices Results 9

14 Section 3 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 10

15 3.1 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: Planning and Service Design Developing and implementing infrastructure, programs, and services to meet the needs of the populations and communities served Unmet Criteria High Priority Criteria Standards Set: Leadership 5.1 The organization's leaders collect or have access to information about the community's health status, capacities, and health care needs. Surveyor comments on the priority process(es) The organization s leaders recently developed a national strategic plan with the participation of internal and external partners. Specific objectives were set out to ensure that the goals in the strategic plan are met. It is important to develop a communication plan to disseminate the goals and strategic objectives throughout the organization so that all teams objectives align with the strategic plan. It is also important to communicate the strategic plan to Portage s various partners working in the area of addictions. This might lead to a better understanding of the services provided by Portage and might help improve the referral pathway for clients. Because of the many changes that have occurred in the organization, several policies and procedures are available but have not yet been adopted. It is important that the policies and procedures on functions, activities, and key systems be recorded in writing, adopted, implemented, and distributed throughout the organization. Detailed On-site Survey Results 11

16 3.1.2 Priority Process: Governance Meeting the demands for excellence in governance practice. Unmet Criteria High Priority Criteria Standards Set: Governance 11.2 The governing body works with the CEO and the organization's leaders to develop an integrated quality improvement plan The governing body demonstrates a commitment to recognizing staff, service providers, volunteers, and students for their quality improvement work. Surveyor comments on the priority process(es) Portage s Board of Directors consists of a group of people dedicated and committed to the organization and its strategic vision. The Chairman has held this position since 1970, and the Executive Director has been there since Members of Portage s Board of Governors and Board of Directors are elected for one-year terms. When board members are due for re-appointment, the organization is careful to ensure representation from various types of experts, and the continuing participation of experienced members on the board. Both boards include representatives from Ontario, Atlantic Canada, British Columbia, and Quebec. The board members are very satisfied with their orientation program, and appreciate the visits to the various sites that make up Portage. The four regional committees (the regional boards) help the board of directors carry out its responsibilities. Ten permanent Portage committees also exist to help the board of directors. The mandate, structure, and operations of each committee are clearly identified; representation by the chairs of the regional boards on the various committees results in ongoing information sharing. A code of professional ethics and a code of conduct exists and applies to members of the boards, employees, placement students, and volunteers. The excellent review of governance that the board conducts each year is noteworthy. This review was recently expanded to include a policy on the role of the Chairman and the Executive Director, as well as succession planning for managers. The board of directors oversees the organization s strategic planning process. The strategic plan was recently adopted following extensive consultations with internal and external bodies. The board is commended for an excellent analysis of the environment in which Portage works; the report clearly identifies the changes and new challenges that the organization must take into account during the strategic planning process. A review of agendas from the board of directors meetings reveals the board s concern with having access to all the information necessary to fulfil its responsibilities. A program and watchdog committee presents information on safety and quality issues at the board s meetings. Detailed On-site Survey Results 12

17 3.1.3 Priority Process: Resource Management Monitoring, administration, and integration of activities involved with the appropriate allocation and use of resources. The organization has met all criteria for this priority process. Surveyor comments on the priority process(es) Financial resources are managed extremely carefully at all levels of the organization. Equipment replacement and the equipment procurement process are conducted bearing in mind client needs, safety, and support for service provision. A client-centred approach is evident in the organization s resource management. The budget planning process is very structured and forms part of the organization s regular planning cycle. The general guidelines are determined by the chair of the board of directors, the Executive Director, the Director of Administrative Services and the Controller. In conjunction with the Director of Administrative Services and the Comptroller, the directors and managers actively participate in preparing the annual budget. The finance committee studies the budgets and recommends when they should be submitted to the board of directors for adoption. The board of directors approves the budgets, financial reports, and capital projects following analysis and recommendation by the audit committee. The policy for the budget process was recently revised and adopted by the board of directors. This policy defines the entire budget planning and monitoring process for the year. All members of the management team very carefully monitor the use of the organization s resources. Every month, the directors receive a detailed report providing them with clear information on the use of hours and other expenses for their particular area. Several projects designed to improve client services and the service environment, were funded by very generous contributions from foundations. Detailed On-site Survey Results 13

18 3.1.4 Priority Process: Human Capital Developing the human resource capacity to deliver safe, high quality services Unmet Criteria High Priority Criteria Standards Set: Leadership The organization implements a comprehensive strategy to prevent workplace violence The organization conducts risk assessments to ascertain the risk of workplace violence. The organization's leaders identify and monitor process and outcome measures related to worklife and the work environment. The organization defines roles and responsibilities for client safety in writing. The organization's policies and procedures to monitor performance include how to deal with performance issues in an objective and fair way. ROP MAJOR Surveyor comments on the priority process(es) Human capital is very important for Portage, and by and large, it is clear that Portage takes care of its human capital and resolves relational conflicts with remarkable aptitude (with the same quality used in the field with clients) as situations arise. Procedures related to patient safety need to be reinforced, and dashboards for monitoring certain worklife indicators need to be developed, to enhance the supervision of existing quality objectives. Employees are monitored, supervised, and regularly evaluated; however, it seems that managers have difficulty making decisions when employees do not comply with regulations or have competency related problems or difficulties. Portage is strongly urged to finalize and update its organizational charts to more clearly establish the responsibilities of managers and employees in a way that reflects reality. Detailed On-site Survey Results 14

19 3.1.5 Priority Process: Integrated Quality Management Using a proactive, systematic, and ongoing process to manage and integrate quality and achieve organizational goals and objectives Unmet Criteria High Priority Criteria Standards Set: Leadership The organization's leaders, staff, service providers, volunteers, and students are recognized for their quality improvement work. The organization carries out at least one client safety-related prospective analysis and implements appropriate improvements At least one prospective analysis has been completed within the past year The organization uses information from the analysis to make improvements. The organization's leaders develop and implement an integrated quality improvement plan. ROP MAJOR MINOR Surveyor comments on the priority process(es) Since the last accreditation survey, the organization has made efforts to implement the necessary measures to comply with accreditation standards in the area of safety. A safety committee exists under the leadership of the Director of Administrative Services and consists of at least one representative from each centre. The committee meets four times per year to examine information on risk, health and safety management issues, and information assets. All incidents and accidents are reviewed, and quarterly reports are prepared for the watchdog committee and the board of directors. A safety report is prepared annually and includes an assessment of the objectives established in the previous year and the action plan for the coming year. The organization is to be commended for this initiative. The organization promotes a culture in which incidents, accidents, and common problems associated with resident and patient safety are reported and disclosed. A policy and process exist for disclosing accidents to residents and patients. The organization s teams do not all have the same level of understanding of the components of an integrated quality management program. Some quality indicators have been identified and are monitored, such as client satisfaction. The outcome measures that could help the organization determine whether the expected outcomes are actually being met still have to be identified. Identifying clinical outcome indicators related to key clinical interventions would help the team understand the impact of each phase of the clinical program. Numerous quality initiatives exist and are conducted by the organization. However, they are not identified as such. Recognition is not always given to these initiatives, and information on the initiatives is not always communicated to the entire organization. Developing an integrated quality improvement plan would result in more standardized and consistent implementation of the plan s components. Detailed On-site Survey Results 15

20 3.1.6 Priority Process: Principle-based Care and Decision Making Identifying and decision making regarding ethical dilemmas and problems. Unmet Criteria High Priority Criteria Standards Set: Leadership 1.10 The ethics framework includes a process for reviewing the ethical implications of research activities. Surveyor comments on the priority process(es) During the 2010 accreditation survey, the surveyors recommended to the management committee that a formal clinical ethics committee be established; this committee has been established through the central management committee whose agenda contains a standing item on ethical decision making. The management committee continues to support staff members grappling with clinical ethical issues and, if necessary, it consults an ethics specialist. However, it would be worth making this process better known to all staff members. Staff members can refer to the following documents about the organization s ethics and culture: Portage Ethics Framework (a professional ethics policy, procedure, and code of conduct for the board of directors, staff members, volunteers, and placement students), and the Portage Governance Review The mission, vision, and values expressed by Portage are primarily found in their intake and information documentation and are also reflected in the words and conduct of the professionals and support staff members who work with the clients. The organization s philosophy regarding recovery supports the various therapeutic methods made available to meet client needs. Portage also collaborates on evaluation research projects that do not require the approval of a research ethics committee, which is currently dissolved. The ethics committee will be established at a later date in preparation for future research projects. Detailed On-site Survey Results 16

21 3.1.7 Priority Process: Communication Communicating effectively at all levels of the organization and with external stakeholders The organization has met all criteria for this priority process. Surveyor comments on the priority process(es) The organization is deeply concerned about communication in all its forms. Two directors currently support the communications department, a communications committee has been established, a thematic schedule is used to plan and implement events that are often suitable for media publication, newsletters are issued to staff, access to social media is well thought out, and the Portage website is active (annual reports are located there). In addition focusing on media relations, Portage would certainly benefit from continuing to solidify its linkages with various governments and departments to increase coordination and agreements with existing public services. It should also use a research avenue to publicize its successes within a recognized university framework. Detailed On-site Survey Results 17

22 3.1.8 Priority Process: Physical Environment Providing appropriate and safe structures and facilities to achieve the organization's mission, vision, and goals The organization has met all criteria for this priority process. Surveyor comments on the priority process(es) This sector is clearly under control. The physical environment is well thought out, very pleasant (even inviting), and carefully planned based on client needs (except for the West Island location). The estimates are compared and the one that best meets an identified need is selected; software is being introduced to track maintenance that needs to be performed; several real estate projects are being studied very carefully to determine their feasibility. Detailed On-site Survey Results 18

23 3.1.9 Priority Process: Emergency Preparedness Planning for and managing emergencies, disasters, or other aspects of public safety The organization has met all criteria for this priority process. Surveyor comments on the priority process(es) The organization has developed and implemented emergency preparedness plans to ensure users safety. Evacuation drills are held regularly at various sites. Staff members ensure that all new residents are aware of the evacuation plans at the intake stage. Detailed On-site Survey Results 19

24 Priority Process: Patient Flow Assessing the smooth and timely movement of clients and families through service settings Unmet Criteria High Priority Criteria Standards Set: Leadership The organization's leaders use information about barriers to client flow to develop a strategy to build the organization's capacity to meet the demand for service and improve client flow throughout the organization. The organization evaluates the effectiveness and impact of the client flow strategy. Surveyor comments on the priority process(es) Patient flow is in place as soon as new residents are admitted. The main issues are barriers that exist before residents are admitted. At some sites, resident capacity was considerably higher than the number of residents actually living there. For example, at the Keremeos site in British Columbia, 17 residents were admitted to the program, although it has the capacity to take 42 residents in total. Many beds are therefore available to help other young people with drug problems in the British Columbia region but they remain vacant. This situation was explained as a problem extrinsic to Portage that has not yet been successfully resolved. It is strongly recommended that this obstacle be addressed with the appropriate external bodies, including local governments and regional health authorities, so that these sites can more effectively fulfill their mandate of taking in more adolescents and adults in need of support and assistance. Detailed On-site Survey Results 20

25 Priority Process: Medical Devices and Equipment Obtaining and maintaining machinery and technologies used to diagnose and treat health problems The organization has met all criteria for this priority process. Surveyor comments on the priority process(es) Portage is commended for the quality of this priority process. Detailed On-site Survey Results 21

26 3.2 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 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 Medication Management Using interdisciplinary teams to manage the provision of medication to clients Infection Prevention and Control Implementing measures to prevent and reduce the acquisition and transmission of infection among staff, service providers, clients, and families Standards Set: Customized Infection Prevention and Control Unmet Criteria High Priority Criteria Priority Process: Infection Prevention and Control The organization provides clients and families with information and education about preventing infections in a format that is easy to understand. Information provided to clients and families is documented in the client health record. 4.4 The organization evaluates its compliance with accepted hand-hygiene ROP practices. Detailed On-site Survey Results 22

27 The organization audits its compliance with hand hygiene practices The organization shares results from the audits with staff, service providers, and volunteers The organization uses the results of the audits to make improvements to its hand hygiene practices. The organization follows national and occupational health and safety guidelines on work restrictions for staff or volunteers with transmissible infections. MAJOR MINOR MINOR Surveyor comments on the priority process(es) Priority Process: Infection Prevention and Control With the arrival of a new nursing director, it will be easy for the organization to use targeted procedures to complete an already sustainable structure for infection prevention, especially because the nurses already provide exemplary monitoring and vigilance in the various centres. Detailed On-site Survey Results 23

28 3.2.2 Standards Set: Customized Managing Medications Unmet Criteria High Priority Criteria Priority Process: Medication Management The organization has met all criteria for this priority process. Surveyor comments on the priority process(es) Priority Process: Medication Management The organization does not have on-site pharmacies; it is served by the community's pharmacies. Various protocols are made available to staff members in order to appropriately manage the administration and distribution of medications as well as the risks. These include a health care manual and protocols, including a policy and procedure on medication management, a protocol on updating known medication reactions in patients, a protocol on medical emergency measures, medication reconciliation and the distribution of medications, a poster of the abbreviations to use for prescriptions and finally, the management of biomedical waste. Medications are dispensed using the Dispill system; the medication cart stays in the nurses' room. The double identification required for medication management is met. Staff members who distribute medication in the evening have access to the health care manual, which outlines clinical problems. The MAR indicates allergies and current or past adverse reactions of the patient. Training is planned for non-medical staff regarding the distribution of medications. With regard to the teaching provided to patients, information is recorded in the patient s file, and the nurse uses information brochures for this activity as needed. All criteria are met in the medication management standards; however, caution must be still be exercised, especially if there is staff turnover. Moreover, all sites must use the same form for medication reconciliation. Regarding medication-related incidents, based on the organization's analysis, failure to administer a medication was identified as an issue; an action plan has been developed to deal with this situation. Detailed On-site Survey Results 24

29 3.2.3 Standards Set: Substance Abuse and Problem Gambling Services Unmet Criteria High Priority Criteria Priority Process: Clinical Leadership The team collects information about its clients and the community. The team uses information it collects about clients and the community to define the scope of its services and set priorities when multiple service needs are identified. The team works together to develop goals and objectives. The team's goals and objectives for its substance abuse and problem gambling services are measurable and specific. Priority Process: Competency The organization provides sufficient workspace to support interdisciplinary team functioning and interaction. The interdisciplinary team follows a formal process to regularly evaluate its functioning, identify priorities for action, and make improvements. Priority Process: Episode of Care 8.10 The team responds to client and family complaints in an open, fair, and timely way. Priority Process: Decision Support The team has a process to access, review and select which evidence-based guidelines it will use. The team reviews its guidelines to make sure they are up-to-date and reflect current research and best practice information. The team's process includes seeking input from staff and service providers about the applicability of the guidelines and their ease of use. Priority Process: Impact on Outcomes The team shares benchmark and best practice information with its partners and other organizations. The team identifies and monitors process and outcome measures for its substance abuse and problem gambling services. The team compares its results with other similar interventions, programs, or organizations. Detailed On-site Survey Results 25

30 Surveyor comments on the priority process(es) Priority Process: Clinical Leadership Portage s clinical program has been formalized for many years. Steps are being taken to strengthen its processes and the uniformity between the various sites. For example, there are discussions between those in charge of admission (or reintegration) and nursing care; this is being done to improve the standardization of their respective programs and processes. The program is designed to provide continuity to support clients after a stay and during their return to a life that includes positive activities. This aspect of the program is a strength and should be continued and consolidated. Several collaboration mechanisms exist to ensure that service provision is complementary in terms of all of the services required by clients. For example, there are linkages with the Children s Hospital for the Mother and Child Program or the Adolescent Program, with the Douglas Mental Health University Institute for people with concomitant disorders, and childcare centres have integrated programming. This also results in work reintegration or schooling activities. At some sites, a basic operational plan with indicators has been developed or is in the process of being developed for the site s director and is aligned with Portage s strategic plan. Mandatory complementary processes require more specific development of clinical processes. For example, inspection or certification measures, such as those for the Elora site, which must already meet the requirements described in various Government of Ontario bodies reports (e.g., the Ministry of Children and Youth Services, Youth Justice Division compliance requirements 2012) already provide opportunities for the teams involvement in developing objectives, their implementation and evaluation. Portage is encouraged to involve the members of its local teams more directly and formally in defining services given the changing needs and issues among both adults and adolescents. Portage is also encouraged to complete the operational planning process with the teams. This has just been started as a result of the transparency desired by several departments [e.g., Mother and Child, MICA, Adolescents]. Portage is also encouraged to consolidate its cooperation with partners to promote better continuity and coordination of services, especially before and after accessing Portage s services, and particularly when people come from remote areas. Placement students and volunteers are accepted on a regular basis; this is a strategic way of recruiting staff members who can and want to work with this client group. Priority Process: Competency Portage delivers its services in a structured manner using a rigorous approach adopted by a multidisciplinary team whose members' roles are defined and evolve based on the treatment phase, with a view to maintaining continuity. For example, the admitting officer is there in the beginning and gradually becomes less involved, while the reintegration officer becomes increasingly involved over the course of the program. Detailed On-site Survey Results 26

31 The team members communication processes around the residents are clear and effective. They are continually adjusted as part of an improvement process. Significant attention is given to orientation and specific training (e.g., access to a degree in addiction treatment provided by the Université de Sherbrooke). This also results in periodic training based on client needs, which happens during the weekly and monthly meetings of group supervisory staff. Training in crisis intervention is also provided (OMEGA, NAPPI, ALPHA). Particular (and very significant) attention is given to individual and group supervision, as well as to staff performance appraisals and the identification of staff needs. This is noteworthy, and the teams are encouraged to continue this practice. The teams are encouraged to implement a structured process to evaluate their operations and thus make improvements, in order to evaluate them in more depth than the existing informal discussions during team meetings. Professional credentials, training (e.g., WHMIS, policies and procedures, safety, emergency procedures, including evacuation drills, CPR, violence management) and the annual evaluation of the staff members contributions were in the reviewed employee files. Staff members are very dedicated; they are invested in clients and the Portage organization. This is evident both in their actions and interactions. This also results in excellent availability (e.g., the person in charge of facility maintenance is available 24-7, as are some nurses and physicians). To foster a positive worklife balance with family or training obligations, work schedules are prepared to the satisfaction of employees. It was noted that there is no compulsory overtime for Portage s professionals. Priority Process: Episode of Care The clinical processes are implemented and designed to meet the needs of people who are admitted on a voluntary basis as part of a structured access, eligibility, and assessment process that can also provide the flexibility required to meet individual needs. Many examples provided by the teams (e.g., Mother and Child, MICA, West Island, etc.) are very good illustrations of this empathy and this necessity to bend the rules in order to serve people better. The orientation and integration with peer involvement are also evidence of this care and concern. The patient manual also illustrates the desire to provide comprehensive information. The time taken to explain it to residents also reflects this desire. All clients have their own treatment plan based on an assessment of the problem from a biopsychosocial perspective. This plan is signed by the client. Portage is encouraged to consider the systematic use of a suicide risk assessment matrix on admission. The development of the treatment plan, its regular review, and the involvement of the client and the client s loved ones throughout the process show the importance of the follow-up conducted with the person, including their progress as part of the therapeutic community. Special attention is paid to transition periods between the various phases, and adjustments may be made. The medication management procedure is clear and known. Detailed On-site Survey Results 27