Accreditation Report

Transcription

1 Jewish Rehabilitation Hospital Hôpital juif de réadaptation Laval, QC On-site survey dates: September 9, September 13, 2012 Report issued: November 13, 2012 Accredited by ISQua

2 About the Jewish Rehabilitation Hospital Hôpital juif de réadaptation (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 September 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. Any alteration of this compromises the integrity of the accreditation process and is strictly prohibited. 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. Accreditation Canada is a not-for-profit, independent organization that provides health services organizations with a rigorous and comprehensive accreditation process. We foster ongoing quality improvement based on evidence-based standards and external peer review. Accredited by the International Society for Quality in Health Care, Accreditation Canada has helped organizations strive for excellence for more than 50 years. Accreditation Canada, 2012

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 Jewish Rehabilitation Hospital Hôpital juif de réadaptation on your participation in the Qmentum accreditation program. Qmentum is designed to integrate with your quality improvement program. By using it 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 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: Acquired Brain Injury Services Standards Set: Biomedical Laboratory Services Standards Set: Diagnostic Imaging Services Standards Set: Infection Prevention and Control Standards Set: Laboratory and Blood Services Standards Set: Managing Medications Standards Set: Rehabilitation Services Instrument Results Governance Functioning Tool Patient Safety Culture Tool 46 Table of Contents i

5 4.3 Worklife Pulse Tool 48 Appendix A Qmentum 50 Appendix B Priority Processes 51 Table of Contents ii

6 Section 1 Executive Summary 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. Organizations that are accredited by Accreditation Canada undergo a rigorous evaluation process. Following a comprehensive self-assessment, trained surveyors from accredited health organizations conduct an on-site survey to evaluate the organization's performance against Accreditation Canada's standards of excellence. Jewish Rehabilitation Hospital Hôpital juif de réadaptation (referred to in this report as the organization ) is participating in Accreditation Canada's Qmentum accreditation program. This 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. Jewish Rehabilitation Hospital Hôpital juif de réadaptation 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 Jewish Rehabilitation Hospital Hôpital juif de réadaptation has earned the following accreditation decision. Accredited (Report) Executive Summary 1

7 1.2 About the On-site Survey On-site survey dates: September 9, 2012 to September 13, 2012 Location The following location was assessed during the on-site survey. 1 Jewish Rehabilitation Hospital / Hôpital juif de réadaptation 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 Governance Leadership Service Excellence Standards Managing Medications Reprocessing and Sterilization of Reusable Medical Devices Infection Prevention and Control Acquired Brain Injury Services Biomedical Laboratory Services Laboratory and Blood Services Rehabilitation Services Diagnostic Imaging Services Instruments The organization administer: Governance Functioning Tool Patient Safety Culture Tool Worklife Pulse Tool Executive Summary 2

8 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 lists the quality dimensions and shows how many of the criteria related to each dimension were rated as met, unmet, or not applicable during the on-site survey. 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

9 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 contribute to achieving the standard as a whole. System-wide standards address quality and safety at the organizational level in areas such as governance and leadership, while population-specific and service excellence standards address specific populations, sectors, and services. The sets of 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 (100.0%) 0 (0.0%) 0 32 (91.4%) 3 (8.6%) 0 75 (96.2%) 3 (3.8%) 0 Leadership 37 (88.1%) 5 (11.9%) 0 77 (88.5%) 10 (11.5%) (88.4%) 15 (11.6%) 0 Diagnostic Imaging Services 44 (86.3%) 7 (13.7%) (84.3%) 8 (15.7%) (85.3%) 15 (14.7%) 25 Infection Prevention and Control 33 (94.3%) 2 (5.7%) 6 35 (94.6%) 2 (5.4%) 5 68 (94.4%) 4 (5.6%) 11 Acquired Brain Injury Services 27 (100.0%) 0 (0.0%) 0 70 (92.1%) 6 (7.9%) 1 97 (94.2%) 6 (5.8%) 1 Biomedical Laboratory Services 9 (81.8%) 2 (18.2%) 5 31 (91.2%) 3 (8.8%) 2 40 (88.9%) 5 (11.1%) 7 Laboratory and Blood Services 61 (95.3%) 3 (4.7%) (94.4%) 4 (5.6%) (94.8%) 7 (5.2%) 41 Managing Medications 59 (88.1%) 8 (11.9%) 9 46 (92.0%) 4 (8.0%) (89.7%) 12 (10.3%) 11 Rehabilitation Services 26 (100.0%) 0 (0.0%) 0 66 (97.1%) 2 (2.9%) 1 92 (97.9%) 2 (2.1%) 1 Executive Summary 4

10 High Priority Criteria Other Criteria Total Criteria (High Priority + Other) Standards Set Met Unmet N/A # (%) # (%) # Met Unmet N/A # (%) # (%) # Met Unmet N/A # (%) # (%) # Reprocessing and Sterilization of Reusable Medical Devices 30 (85.7%) 5 (14.3%) 5 43 (76.8%) 13 (23.2%) 3 73 (80.2%) 18 (19.8%) 8 Total 369 (92.0%) 32 (8.0%) (90.3%) 55 (9.7%) (91.0%) 87 (9.0%) 105 Executive Summary 5

11 1.5 Overview by Required Organizational Practices In Qmentum, a Required Organizational Practice (ROP) is defined as 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 how the applicable ROPs were rated during the on-site survey. Required Organizational Practice Overall rating Test of Compliance Rating Major Met Minor Met Patient Safety Goal Area: Safety Culture Adverse Events Disclosure (Leadership) Adverse Events Reporting (Leadership) Client Safety As A Strategic Priority (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 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 (Acquired Brain Injury Services) Client And Family Role In Safety (Diagnostic Imaging Services ) Client And Family Role In Safety (Rehabilitation Services) Dangerous Abbreviations (Managing Medications) Information Transfer (Acquired Brain Injury Services) Met 2 of 2 0 of 0 Met 2 of 2 0 of 0 Met 2 of 2 0 of 0 Met 4 of 4 3 of 3 Met 2 of 2 0 of 0 Executive Summary 6

12 Required Organizational Practice Overall rating Test of Compliance Rating Major Met Minor Met Patient Safety Goal Area: Communication Information Transfer (Rehabilitation Services) Medication Reconciliation As An Organizational Priority (Leadership) Medication Reconciliation At Admission (Acquired Brain Injury Services) Medication Reconciliation At Admission (Rehabilitation Services) Medication Reconciliation at Transfer or Discharge (Acquired Brain Injury Services) Medication Reconciliation at Transfer or Discharge (Rehabilitation Services) Two Client Identifiers (Acquired Brain Injury Services) Two Client Identifiers (Diagnostic Imaging Services ) Two Client Identifiers (Managing Medications) Two Client Identifiers (Rehabilitation Services) Verification Processes For High-Risk Activities (Diagnostic Imaging Services ) Verification Processes For High-Risk Activities (Rehabilitation Services) Met 2 of 2 0 of 0 Unmet 3 of 12 0 of 0 Met 4 of 4 1 of 1 Met 4 of 4 1 of 1 Unmet 2 of 4 1 of 1 Unmet 2 of 4 1 of 1 Met 1 of 1 0 of 0 Met 1 of 1 0 of 0 Met 1 of 1 0 of 0 Met 1 of 1 0 of 0 Unmet 0 of 2 0 of 1 Unmet 2 of 2 0 of 1 Executive Summary 7

13 Required Organizational Practice Overall rating Test of Compliance Rating Major Met Minor Met Patient Safety Goal Area: Medication Use Concentrated Electrolytes (Managing Medications) Heparin Safety (Managing Medications) Infusion Pumps Training (Managing Medications) Infusion Pumps Training (Rehabilitation Services) Medication Concentrations (Managing Medications) Narcotics Safety (Managing Medications) Met 1 of 1 0 of 0 Met 4 of 4 0 of 0 Met 1 of 1 0 of 0 Met 1 of 1 0 of 0 Met 1 of 1 0 of 0 Met 3 of 3 0 of 0 Patient Safety Goal Area: Worklife/Workforce Client Safety Plan (Leadership) Client Safety: Education And Training (Leadership) Client Safety: Roles And Responsibilities (Leadership) Preventive Maintenance Program (Leadership) Workplace Violence Prevention (Leadership) Met 0 of 0 2 of 2 Met 1 of 1 0 of 0 Met 1 of 1 2 of 2 Unmet 2 of 3 0 of 1 Unmet 5 of 5 2 of 3 Patient Safety Goal Area: Infection Control Hand Hygiene Audit (Infection Prevention and Control) Hand Hygiene Education And Training (Infection Prevention and Control) Met 1 of 1 2 of 2 Met 2 of 2 0 of 0 Executive Summary 8

14 Required Organizational Practice Overall rating Test of Compliance Rating Major Met Minor Met Patient Safety Goal Area: Infection Control Infection Control Guidelines (Infection Prevention and Control) Infection Rates (Infection Prevention and Control) Influenza Vaccine (Infection Prevention and Control) Sterilization Processes (Infection Prevention and Control) Met 1 of 1 0 of 0 Met 1 of 1 3 of 3 Met 3 of 3 0 of 0 Met 1 of 1 1 of 1 Patient Safety Goal Area: Falls Prevention Falls Prevention Strategy (Acquired Brain Injury Services) Falls Prevention Strategy (Diagnostic Imaging Services ) Falls Prevention Strategy (Rehabilitation Services) Met 3 of 3 2 of 2 Met 3 of 3 2 of 2 Met 3 of 3 2 of 2 Executive Summary 9

15 1.6 Summary of Surveyor Team Observations During the on-site survey, the surveyor team made the following observations about the organization's overall strengths, opportunities for improvement, and challenges. After a period of consultation and reflection, the Jewish Rehabilitation Hospital (JRH) developed a strategic plan for 2012 to The plan demonstrates the engagement of each of the organization s members to continue offering quality services. The strategic plan development process included a revision of the JRH s mission statement, vision and values. The plan was recently adopted by the Board. The next step is approval by the l Agence de santé et des services sociaux of Laval. The JRH s ongoing commitment to striving for clinical excellence is remarkable at all levels. Also noteworthy is the organization s persistence in developing research and best practices, as well as in its objective to obtain the designation of University Institute and become a centre of excellence. The organization is committed to a human resources management perspective that is based on supporting the development of staff competencies to establish a quality work environment. Since Accreditation Canada s previous survey, the JRH has made efforts to meet Accreditation Canada s recommendations. The Board is made up of a group of individuals devoted and committed to the organization and its vision. The Board strongly supports the JRH s objective to become a recognized centre of excellence, a true University Institute, a regional centre for physical disability, and a centre with a supraregional mandate. The Board s by-laws are currently being revised to reflect the recent changes made to the Act respecting health services and social services. Now that the strategic plan has been adopted, it is important for the Board to assume its leadership by supporting the management team in its efforts to obtain the necessary approval to implement the plan; determine timeframes and responsibilities; attain strategic goals and objectives; ensure organizational performance; and ensure that there is a communication plan to promote the sharing of the strategic plan with internal and external partners. The JRH has developed a number of relationships with the community of Laval and in the Montreal region. The management team has many contacts with community partners and actively participates in Laval and Montreal s regional committees, which allows it to have an adequate comprehension of community needs. These different connections have led to the development of important partnerships and, consequently, should lead to improved service coordination and accessibility. Thanks to its consultations, the new strategic plan should allow for the clarification of the organization s mission and vision. It will also further improve the partnership with different organizations and increase accessibility to the services offered by the hospital. The Executive Committee is stable, passionate and devoted to the organization. It has the capacity to mobilize itself and the staff, as well as put in place the means required to concretely improve safety and the quality of care and services at the JRH. It must pursue its efforts to implement the integrated quality plan at all levels in the organization. The staff is dedicated and competent. The turnover rate is low, which particularly illustrates staff s appreciation of the quality of the work environment. A sense of belonging is present among staff. The organization employs a number of recognition strategies (study bursaries, research contributions, support, training, scheduling flexibility including flex time and part-time, etc.). Staff retention is significant. However, the high number of staff members over 55 years of age (approximately 20%) will require workforce planning and a human resources succession plan. Executive Summary 10

16 Recognition awards such as the Ministry of Health and Social Services Excellence Award Honourable Mention received for the traumatology program s sensibility activity conducted in high schools in the region demonstrate the excellence present in partnerships and services. Patients benefit directly from research activities thanks to the close link between the services offered and the research projects. A well established and structured process allows for the assessment of patients opinions on service satisfaction. Surveys conducted on a regular basis and post-program follow-ups clearly demonstrate clients high level of satisfaction. The local service quality and complaints commissioner is available for receiving and dealing with complaints. The commissioner s reports are regularly forwarded to the Board of Directors which ensures follow-up on the recommendations. Executive Summary 11

17 Section 2 Detailed Required Organizational Practices Results This section gives more information about unmet ROPs. It shows the patient safety goal area into which the ROP falls, the requirements of the ROP, and the set of standards where it can be found. The patient safety goal areas are safety culture, communication, medication use, worklife/workforce, infection control, and risk assessment. Unmet Required Organizational Practice Standards Set Patient Safety Goal Area: Communication Verification Processes For High-Risk Activities The team implements verification processes and other checking systems for high-risk activities. Diagnostic Imaging Services 15.8 Rehabilitation Services 15.5 Medication Reconciliation at Transfer or Discharge The team reconciles the client's medications with the involvement of the client, family or caregiver at transition points where medication orders are changed or rewritten (i.e. internal transfer, and/or discharge). Acquired Brain Injury Services 11.3 Rehabilitation Services 11.3 Medication Reconciliation As An Organizational Priority The organization reconciles clients' medications at admission, and transfer or discharge. Leadership 15.8 Patient Safety Goal Area: Worklife/Workforce Preventive Maintenance Program The organization's leaders implement an effective preventive maintenance program for medical devices, medical equipment, and medical technology. Leadership 9.7 Workplace Violence Prevention The organization implements a comprehensive strategy to prevent workplace violence. Leadership 2.10 Detailed Required Organizational Practices Results 12

18 Section 3 Detailed On-site Survey Results This section shows detailed on-site results. When reviewing these results, it is important to review the service excellence and the system-wide results together, as they are complementary. 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 considers criteria from different sets of standards that each 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 13

19 3.1 Priority Process Results for System-wide Standards The results in this section are categorized first by priority process and then by standards set. Some priority processes in this section also apply to the service excellence standards. Where there are unmet criteria that also relate to services, those results should be shared with the relevant team Priority Process: Planning and Service Design Developing and implementing the infrastructure, programs and service to meet the needs of the community and populations served. Unmet Criteria High Priority Criteria Standards Set: Leadership The organization's policies and procedures for all key functions, operations, and systems in the organization are documented, authorized, implemented, and up to date. The organization's leaders select management systems and tools to monitor and report on the implementation of operational plans. Surveyor comments on the priority process(es) The organization s leaders have recently developed the strategic plan for with much involvement from internal and external partners. The strategic plan development process included a revision of the Jewish Rehabilitation Hospital s mission statement, vision and values. Specific objectives were determined to make achieving the goals of the strategic plan possible. The new plan should provide guidelines for the JRH to realize its objective of preserving its unique identity all while consolidating its second line organizational mandate of focusing on specialized rehabilitation in physical health and physical disability for adult and pediatric clients. The last step is approval by the Laval Agency. Once the plan is approved, it is important that a communication plan be developed to communicate the strategic goals and objectives throughout the organization so that team, unit, and program objectives align with the strategic plan. The management team has many contacts with community resources and actively participates in Laval and Montreal s regional committees, which allows it to have an excellent comprehension of community needs. This knowledge is used effectively within the scope of services planning framework. These different connections have led to the development of important partnerships and consequently, improved service coordination and accessibility. Each administrator has developed and implemented an annual operational plan to support organizational plans and guide daily activities. The management team is aware of change management principles and uses this approach to ensure the implementation of changes in the organization is successful. The team in charge of reorganizing rehabilitation management deserves praise for having successfully managed this major change. Detailed On-site Survey Results 14

20 Because of the many changes that have occurred at the JRH, many policies and procedures must now be further developed or revised. It is important that policies and procedures related to key functions, activities, and systems be documented, authorized, implemented and updated. Detailed On-site Survey Results 15

21 3.1.2 Priority Process: Governance Unmet Criteria High Priority Criteria Standards Set: Governance The governing body works with the CEO to establish, implement, and evaluate a communication plan for the organization. The communication plan includes strategies to communicate key messages to staff, stakeholders, and the community The governing body regularly assesses its own functioning using the Governance Functioning Tool The governing body monitors its team functioning by administering the Governance Functioning Tool at least once every three years The governing body has taken action based on its most recent Governance Functioning Tool results. Surveyor comments on the priority process(es) MINOR MINOR The Board is made up of a group of individuals devoted and committed to the organization and its vision. The Board strongly supports the JRH s objective to become a recognized centre of excellence, a true University Institute, a regional centre for physical disability, and a centre with a supraregional mandate. Board meeting attendance is very high. Many members have held a seat on the Board for a number of years. There is a Foundation representative on the Hospital Board to ensure the Foundation Board and Hospital Board coordinate their activities. The Hospital Board s by-laws are currently being revised to reflect the recent changes made to the Act respecting health services and social services. Though its composition is defined in the Act, the Board could recruit new members to ensure that it includes members with certain competencies, others with experience, as well as representatives from the Jewish community. The Board is encouraged to offer to new members the option of participating in an orientation program to help them understand roles and responsibilities. The Board functions with seven internal committees, which allows it to receive the information necessary to continue to perform its functions. These committees include an Executive Committee, as well as Finance, Audit, Building and Maintenance, Vigilance and Quality, Priority and Planning, and Risk Management and Continuous Quality Improvement Committees. The local service quality and complaints commissioner is present at each Board meeting where he presents a statement of complaints received, the approach used to deal with these complaints, as well as the outcomes of each situation. The commissioner also prepares an annual report which he presents to the Board of Directors. Detailed On-site Survey Results 16

22 Now that the strategic plan has been developed, it is important for the Board to assume its leadership by providing advice to the management team in its efforts to obtain the necessary approval for the plan; to determine timeframes and responsibilities to attain strategic goals and objectives; and to ensure there is a communication plan to promote the sharing of the strategic plan with internal and external partners. Considering the organization ended the fiscal year with a deficit, and considering it projects another deficit for , it will be important for the Board to guide the Jewish Rehabilitation Hospital in a search for solutions so that the level of service quality can be maintained. Detailed On-site Survey Results 17

23 3.1.3 Priority Process: Resource Management Monitoring, administration, and integration of activities involved with the appropriate allocation and use of resources. Unmet Criteria High Priority Criteria Standards Set: Leadership 8.2 The organization's leaders prepare the annual operating and capital budgets according to the organization's financial policies and procedures. Surveyor comments on the priority process(es) All management team members pay very close attention to how the organization s resources are used. Each month, directors receive a clear and detailed report with data on time frames and expenditures in their particular area. A prospective analysis has identified vulnerable areas. Resource allocation adjustments are made according to a specific process so that resources go where they are most needed. The budget planning process is structured and is part of the regular planning cycle. Even though a detailed memo is sent to directors outlining the different steps required in the budget preparation cycle, formal policies and procedures related to budget preparation have not been developed. The Board of Directors receives monthly updates on resource allocation in the organization. The Board of Directors Finance Committee meets ten times a year and approves all budgets. The Jewish Rehabilitation Hospital (JRH) Foundation works closely with the Board of Directors and the management team when making resource allocation decisions. The Foundation s generous contributions allow for the financing of research and education activities, the purchasing of equipment and the realization of various projects. The JRH is commended for the interest it takes in identifying opportunities for improving the effective use of resources. The organization is encouraged to pursue its plans to establish a project support office that aims to help managers analyze the impact of resource allocation decisions. Detailed On-site Survey Results 18

24 3.1.4 Priority Process: Human Capital Developing the human resource capacity to deliver safe and high quality services to clients. Unmet Criteria High Priority Criteria Standards Set: Leadership The organization's leaders develop healthy workplace strategies to help staff and service providers manage their health. The organization implements a comprehensive strategy to prevent workplace violence The organization's leaders review quarterly reports of incidents of workplace violence and use this information to improve safety, reduce incidents of violence, and make improvements to the workplace violence prevention policy. The organization's leaders develop a confidential process for staff, service providers, and volunteers to bring forward complaints, concerns, and grievances. The organization monitors the quality of its worklife culture using the Worklife Pulse Tool The organization has taken action on the most recent Worklife Pulse Tool or «sondage sur la mobilisation du personnel» results. The organization's leaders establish a talent management plan that includes strategies for developing leadership capacity and capabilities within the organization. The organization's leaders ensure that position profiles for each position are developed and updated regularly. The organization's leaders regularly evaluate reporting relationships and leaders' span of control. The organization's leaders implement policies and procedures to monitor staff performance that align with the organization's mission, vision, and values. The organization's policies and procedures to monitor performance include how to deal with performance issues in an objective and fair way. ROP MINOR MINOR Surveyor comments on the priority process(es) The human resources management team ensures that it offers an open and accessible approach as well as good channels of communication. There are numerous policies with staff development as their goal: training, tuition fee reimbursement, bursaries for the freedom to conduct research activities, gym access, etc. Detailed On-site Survey Results 19

25 Policies on workplace violence, health and safety, and vaccination are defined and in place. Human resources data (dashboard) make it possible to follow the evolution of actions. Steps are taken to obtain Healthy Organization certification for the organization, which allows for a complete and integrated approach for improving quality worklife and the health of staff. The organization is encouraged to complete this process. It is also encouraged to develop and implement a human resources development plan for all employees, management included. Detailed On-site Survey Results 20

26 3.1.5 Priority Process: Integrated Quality Management Continuous, proactive and systematic process to understand, manage and communicate quality from a system-wide perspective to achieve goals and objectives. Unmet Criteria High Priority Criteria Standards Set: Leadership The organization reconciles clients' medications at admission, and transfer or discharge Medication reconciliation is implemented in one client service area at transfer or discharge There is a documented plan to implement medication reconciliation throughout the organization The plan includes locations and timelines for implementing medication reconciliation throughout the organization. The organization's leaders require, monitor, and support service, unit, or program areas to monitor their own process and outcome measures that align with the broader organizational strategic goals and objectives. Surveyor comments on the priority process(es) ROP MAJOR MAJOR MAJOR Since the previous accreditation on-site survey, considerable efforts have been made to put the necessary elements in place to meet the accreditation standards in the areas of quality improvement and risk management. The Risk Management and Quality Improvement Committee (under the leadership of two clinical directors) meets regularly, receives reports from a number of committees, and ensures follow-up on all necessary corrective measures. The leaders deserve praise for the excellent work they accomplish with limited resources. One of the Board of Directors priorities is to ensure the oversight of various quality and safety indicators. In fact, safety is central to one of the strategic priorities. A patient safety plan is developed and implemented, and an evaluation of problems related to safety is conducted. Quarterly patient safety reports are provided to the Board of Directors in the form of dashboards, on which specific activities and accomplishments supporting safety goals and objectives are identified. Board members endorse the activities being conducted and establish the follow-up required for the recommendations presented in the reports. Communication is open, as the organization promotes a culture of reporting incidents, accidents, and ongoing problems related to patient safety, as well as the full disclosure of all of these. There is a structured and transparent policy and process for disclosing accidents to patients and families. A support mechanism for patients, families and staff members concerned by such events is forthcoming. Detailed On-site Survey Results 21

27 Though many elements of an integrated quality improvement program are in place, an organizational quality improvement approach that includes the participation of all hospital departments and sectors has yet to be implemented. Detailed On-site Survey Results 22

28 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 1.7 The organization's leaders build the organization's capacity to use the ethics framework. Surveyor comments on the priority process(es) The organization encourages and promotes ethical reflection. Various methods are proposed: code of ethics, code of ethics for administrators, Clinical Ethics Committee, Research Ethics Committee, etc. Reports from the Clinical Ethics and Research Ethics Committees are presented to the Board of Directors annually. The Clinical Ethics Committee and clinical ethics consultant have a proactive approach for reaching clinicians. For example, they use team meetings and conferences during the lunch hour. The ethics consultant allows the organization to benefit from new methods, such as a new analytical framework for ethical dilemmas. The approval process for research projects is comprehensive. The organization is encouraged to formalize and disseminate an integrated and operational ethical framework. The framework should cover all aspects, including responsibilities, to ensure that all employees and volunteers have a better comprehension and knowledge of what is at stake when ethics are concerned. The organization is also encouraged to strengthen initial and ongoing ethics-related training and sensitization, and to pursue its efforts to reach all groups. The organization is also encouraged to ensure that Board members are kept up to date on the list of research projects underway that affect the organization s clients, as well as projects that have been completed or stopped. Detailed On-site Survey Results 23

29 3.1.7 Priority Process: Communication Communication among various layers of the organization, and with external stakeholders. Unmet Criteria High Priority Criteria Standards Set: Leadership The organization's leaders work with the governing body to develop and implement a communication plan to disseminate information to and receive information from internal and external stakeholders. The organization's leaders regularly assess the quality and usefulness of the organizations' data and information, and improve the organization's information systems. Surveyor comments on the priority process(es) There are various formal and informal processes for means of communication, which reach internally as much as externally. Strong communication alignments exist between the Board of Directors and the Foundation, as well as during different internal meetings (such as the annual meeting), either through partners or media (e.g., website, intercom, Facebook page). Communication plans for specific actions have been developed; for example, for changes to the rehabilitation program. Research and reference data are readily available through the library and its Health Sciences Information Centre. The Hospital developed a management plan for informational resources and associated responsibilities. The organization is encouraged to formalize its communication processes (organizational communication plan) and put formal evaluation mechanisms in place. The organization is also encouraged to evaluate data quality and conduct audits on access to clinical records. Detailed On-site Survey Results 24

30 3.1.8 Priority Process: Physical Environment Providing appropriate and safe structures and facilities to successfully carry out the mission, vision, and goals. The organization has met all criteria for this priority process. Surveyor comments on the priority process(es) The building is well maintained by a devoted team. The heating, ventilation and air conditioning systems are rigorously overseen. It would be good to computerize the data for the follow-up on services provided and the mechanisms used; this would simplify the task for service providers in terms of what the necessary requirements are. During the on-site survey, a renovation project was underway, which demonstrated the respect shown toward restricted access to areas under construction; the control of dangerous substances or equipment; as well as the hermetic isolation of renovation activities. There are good processes for signaling dangers and risks, and for the elimination of dangerous substances. There are back-up electricity and heating systems and restricted access sectors are well identified. The organization is conscious of environmental protection. The Hospital has received Canada s national environmental certification through the BOMA BEST program. A recycling process for paper, light bulbs, batteries, and cooking oil is in place. Separate collection recycling is present throughout the Hospital. Rules for tobacco use in public spaces are properly enforced. Bicycle parking areas for staff are available, which promotes a healthy lifestyle and reduces emissions. The organization has also opted for an ecological approach by using geothermal heating and air conditioning. Detailed On-site Survey Results 25

31 3.1.9 Priority Process: Emergency Preparedness Dealing with emergencies and other aspects of public safety. The organization has met all criteria for this priority process. Surveyor comments on the priority process(es) All policies and procedures concerning disasters or other events related to public health can be found in the Emergency Measures Plan manual. Clearly defined roles and responsibilities can also be found in the manual. Staff members carry an ID card with the list of emergency colour codes on the back. Simplified guides on emergency measures in the form of cardex files are distributed and posted throughout the Hospital. The Emergency Preparedness Planning Committee is active and meets on a quarterly basis. The Committee has evaluated real-life events and put corrective measures in place as needed. Practical exercises on elements of the emergency preparedness plan are regularly carried out during the different shifts. Staff members are satisfied when they witness the safety these tests provide them with, in preparation of potential disasters or emergencies. Training sessions with the goal of improving the competencies required to implement, respect, and execute the emergency preparedness plan are offered to all staff, yet few employees attend. We encourage the organization to make these sessions mandatory, as much for new employees as for long-time staff. Detailed On-site Survey Results 26

32 Priority Process: Patient Flow Smooth and timely movement of clients and their families through appropriate service and care settings. The organization has met all criteria for this priority process. Surveyor comments on the priority process(es) Patient flow processes are structured, known, and followed. Patient flow is centralized, save for the component related to admissibility. Significant efforts were put toward meeting Ministry targets and clearing the waiting list. Delays beyond Ministry standards do however exist for children. Resource reallocation, with a better definition of specialized services taken into account, has allowed the organization to respect access plan standards for disabled adults. The organization is encouraged to determine and apply measures to reduce access delays for children s services. Detailed On-site Survey Results 27

33 Priority Process: Medical Devices and Equipment Machinery and technologies designed to aid in the diagnosis and treatment of healthcare problems. Unmet Criteria High Priority Criteria Standards Set: Diagnostic Imaging Services 8.1 The individual responsible for the overall coordination of reprocessing and sterilization activities within the organization reviews and approves the team's set up and policies and procedures for cleaning and reprocessing. Standards Set: Leadership 9.7 The organization's leaders implement an effective preventive maintenance program for medical devices, medical equipment, and medical technology There is a preventive maintenance program in place for all medical devices, medical equipment, and medical technology The organization's leaders have a process to evaluate the effectiveness of the preventive maintenance program. Standards Set: Reprocessing and Sterilization of Reusable Medical Devices ROP MAJOR MINOR The organization designates a trained and competent individual with the accountability for coordinating all reprocessing and sterilization activities across the organization, including those performed outside the medical device reprocessing department. The designated person reports directly to the organization's senior management or the executive office. The medical device reprocessing department is designed to prevent cross-contamination of sterilized and contaminated devices or equipment, isolate incompatible activities, and clearly separate different work areas. The organization regulates the air quality, ventilation, temperature, and relative humidity, and lighting in decontamination, reprocessing, and storage areas. The organization selects materials for the floors, walls, ceilings, fixtures, pipes, and work surfaces that limit contamination, promote ease of washing and decontamination, and will not shed particles or fibres. The team tracks changes to policies, SOPs, standards of practice, and manufacturers' instructions using a document control procedure. The medical device reprocessing department's hand hygiene facilities are equipped with faucets supplied with foot-, wrist-, or knee-operated handles, or electric eye controls. Detailed On-site Survey Results 28

34 The team follows a detailed dress code while in the clean reprocessing area that addresses clothing, hair, jewelry, artificial fingernails of any form, and covered footwear. The team regularly conducts workplace assessments of its medical device reprocessing department for ergonomics and occupational health and safety (OHS). The medical device reprocessing department has an appropriate area for the storage of sterilized medical devices. The organization limits and monitors access to the storage area to appropriate team members. When cleaning the sterile storage area, staff members minimize the amount of air turbulence and excess moisture. For each recall, the team issues a written, complete notification to all areas of the organization that use reprocessed medical devices that identifies the items to be recalled and the actions needed to recall the items. The team issues a complete and written report of all recalls The team follows a policy to retain recall orders and reports in its files As part of the quality management system, the team engages in an annual review of reprocessing and sterilization activities, with formal reports provided to the organization's senior management. The team verifies and documents the quality of reprocessing services provided in other areas, or by contracted services or subsidiaries. The team leaders review the quality management system regularly. Surveyor comments on the priority process(es) The organization does not have its own biomedical engineering services team, but it is associated with the Hôpital du Sacré-Coeur s Biomedical Engineering Group which addresses the need. The organization is encouraged to develop a process for the purchase, control, and maintenance of medical instruments and devices. Each of these practices should be included in policies and procedures in order to standardize the process. There is no integrated and transversal preventative maintenance system in place for medical instruments; as a result, certain services, due to the burdensome nature of the task, are not able to ensure adherence to preventive maintenance plans and processes, nor evaluate the program s effectiveness. It would be good to put the management of the preventive maintenance program for all of the organization s medical devices or instruments under one entity. Detailed On-site Survey Results 29

35 Reprocessing and the responsibility for it is divided by program/service, among Nursing units, Physiotherapy and Occupational Therapy (rehabilitation) services, Pediatrics with their area for toys, and material for the Evaluation, Development and Professional Reintegration Program (PÉDIP). It would be good to have the global coordination of reprocessing and sterilization activities in the organization as one responsibility, to standardize the policies and procedures and their application with regard to quality management throughout the organization. At present, the reprocessing and sterilization department is not designed to meet the standards. A major renovation to the department is planned for 2013 and the invitation to tender will occur September 15, The realization of this project will smooth out the current, uneven state of things. Despite the difficult working conditions in the sterilization department, team members are devoted and show consideration for clients. It would be good to consider more appropriate spaces other than the reprocessing area for the disposal of solutions, vials, and other medical supplies belonging to the pharmacy. Laboratory services stores hundreds of sampling tubes and other supplies here. The organization is encouraged to move these supplies to appropriate areas. The department manager should explore the possibility of implementing a structured program for managing quality and measuring effectiveness. Detailed On-site Survey Results 30