Accreditation Report. Prepared for: St. Mary's General Hospital, Kitchener. Kitchener, ON. On-site Survey Dates: February 13, February 17, 2011

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1 Accreditation Report Prepared for: St. Mary's General Hospital, Kitchener Kitchener, ON On-site Survey Dates: February 13, February 17, 2011 March 22, 2011 Accredited by ISQua

2 Accreditation Report About this Report The results of this accreditation survey are documented in the attached report, which was prepared by Accreditation Canada at the request of St. Mary's General Hospital, Kitchener. This report is based on information obtained from the organization. Accreditation Canada relies on the accuracy of this information to conduct the survey and to prepare the report. The contents of this report is subject to review by Accreditation Canada. Any alteration of this report would compromise the integrity of the accreditation process and is strictly prohibited. Confidentiality This Report is confidential and is provided by Accreditation Canada to St. Mary's General Hospital, Kitchener only. Accreditation Canada does not release the Report to any other parties. In the interests of transparency, Accreditation Canada encourages the dissemination of the information in this Report to staff, board members, clients, the community, and other stakeholders. Accreditation Canada, 2011

3 QMENTUM PROGRAM Table of Contents About the Accreditation Report... ii Accreditation Summary... 1 Surveyor s Commentary... 2 Organization's Commentary... 5 Overview by Quality Dimension... 6 Overview by Standard Section... 7 Overview by Required Organizational Practices (ROPs)... 8 Detailed Accreditation Results... 9 Performance Measure Results Instrument Results Indicator Results Appendix A Accreditation Decision Guidelines Table of Contents i

4 Accreditation Report About the Accreditation Report The accreditation report describes the findings of the organization's accreditation survey. It is Accreditation Canada's intention that the comments and identified areas for improvement in this report will support the organization to continue to improve quality of care and services it provides to its clients and community. Legend A number of symbols are used throughout the report. Please refer to the legend below for a description of these symbols. Items marked with a GREEN flag reflect areas that have not been flagged for improvements. Evidence of action taken is not required for these areas. Items marked with a YELLOW flag indicate areas where some improvement is required. The team is required to submit evidence of action taken for each item with a yellow flag. Items marked with a RED flag indicate areas where substantial improvement is required. The team is required to submit evidence of action taken for each item with a red flag. Leading Practices are noteworthy practices carried out by the organization and tied to the standards. Whereas strengths are recognized for what they contribute to the organization, leading practices are notable for what they could contribute to the field. Items marked with an arrow indicate a high risk criterion. ii About the Accreditation Report

5 QMENTUM PROGRAM Accreditation Summary St. Mary's General Hospital, Kitchener This section of the report provides a summary of the survey visit and the status of the accreditation decision. On-site survey dates February 13 to 17, 2011 Report Issue Date: March 22, 2011 Accreditation Decision Accreditation with Condition (Report) Locations The following locations were visited during this survey visit: 1 Main Hospital Site Service areas The following service areas were visited during this survey visit: 1 Ambulatory Care 2 Community Health Services 3 Diagnostic Imaging 4 Emergency Department 5 Intensive Care Unit/Critical Care 6 Laboratory 7 Medicine 8 Operating Room 9 Rehabilitation 10 Sterilization and Reprocessing of Medical Equipment 11 Surgical Care Accreditation Summary 1

6 Accreditation Report Surveyor s Commentary The following global comments regarding the survey visit are provided: St. Mary's General Hospital is part of the St Joseph's Healthcare System operated out of Hamilton. The CEO and President roles are split. Dr. Kevin Smith is the CEO for the system and Don Shilton is the President for this site. Mr. Shilton was appointed to the position of President in the fall of 2010 and is accountable to the CEO for the System. The Board of Trustees provides input into the performance appraisal for Mr. Shilton, which is completed by Dr. Smith. St. Mary's General Hospital has a current Mission, Vision, Strategic Directions and Goals with measurable outcomes. Patient safety, quality and risk management are firmly embedded in the Vision and Strategic Directions of the organization. The corporate Strategic Plan is utilized to guide decision making. The organization has adopted a program management framework. The clinical programs including cardiac, chest, emergency, medicine and surgery, as well as the support departments, have defined strategic directions and goals that align well with the Corporate Strategic Plan. The corporate and program/department Quality Improvement (QI) programs flow from the Strategic Directions. The balanced scorecard methodology has been utilized since 2006 to report on the QI program at both the corporate and program level. There is an openness at all levels of the organization to examine current processes and systems and make improvements. There is also a strong emphasis on patient safety and quality at the Board level. The Board of Trustees identified a need to become better informed about changing health care needs and future trends in health care delivery. A strategy is being developed to address this need. Clinical and professional staff and physicians are committed to providing compassionate care and advancing a culture of safety. The staff in the support departments understand their role in supporting the work of the clinical departments to deliver excellent, safe and quality care. Over the past two to three years the organization has enjoyed many successes Utilizing webcast technology, quality reports are shared with the Board Quality Committee prior to the meeting so that the focus at the meeting is in-depth reflective discussion rather than information sharing. Recently the LEAN methodology was introduced to support the Strategic Directions, especially those relating to quality and patient safety. The LEAN methodology has been implemented on three units (Chest, Cardiac Cath Lab and ED) with an enthusiastic response from staff. There is enhanced visibility of senior management within all departments since the initiation of the walkabouts to learn more about quality and safety improvement opportunities from patients and staff. Several process improvement initiatives which have been implemented with success include the introduction of the Safe Surgical Checklist, implementation of the Best Possible Medication History on all units, the introduction of the regional 24/7 Code STEMI program, the development of a disclosure policy for adverse events and the development of a Code of Conduct policy for staff and physicians. The identification of the Chest Centre of Excellence and the Level 1 Thoracic Surgery Centre designation by Cancer Care Ontario in addition to the strong emphasis on clinical pharmacy to support patient care are examples of other successful initiatives. Other noteworthy events include the decrease in the Hospital Standardized Mortality Ratio (HSMR) from 76 in to 61 (YTD) in as well as the Foundation's success in exceeding their fundraising target by more than $1 million. 2 Surveyor s Commentary

7 QMENTUM PROGRAM St. Mary's patients and staff benefit from the significant presence and role of volunteers. St. Mary's also supports health care learners and is a designated site for the provision of medical education. More than 400 students come to St. Mary's for clinical experience. Every patient interviewed by the surveyors reported satisfaction with the care provided and spoke very highly of staff. They particularly highlighted the caring and respectful approach utilized by all staff. The NRC Picker Patient Satisfaction survey results also indicate overall satisfaction with the care and services provided by St. Mary's. Feedback from staff indicates a significant and positive shift within the organization in the past six months since the appointment of the new President. They describe communication as "more open" with a strong emphasis on staff empowerment (utilizing LEAN methodology), change management and quality and safety. The sharing of quality, utilization and LEAN related data throughout the organization on public bulletin boards is an indication of the open transparent style of communication that St. Mary's embraces. The recently implemented GEMBA rounds which involve the senior team and directors are described as very informative regarding the "real issues and concerns" for staff. Through observation and dialogue, the surveyors concluded that the management team appears to enjoy good collegial relationships with the senior team. Effort is made to keep managers and directors informed about the outcomes of the monthly Board meeting through the management meeting which occurs the day following the Board meeting. Information from the public Board meeting is also posted on the public website for all staff and the public to view. Members of the governing body identify a strong and trusting relationship with the President and his team. Various members of the senior team serve as resources to specific Board committees and this has enhanced the interface and communication between Board members and senior leadership. The physicians report good working relationships with the hospital. They indicated they "like working at St. Mary's". They feel they are kept well informed and that senior leadership "listens". Community partners report positive relationships with St. Mary's. All readily identify collaborative initiatives between their organization and St. Mary's. St. Mary's is described as a "good partner". They "welcome opportunities" and "step up to the plate" to support patient/community needs. Participants identified the proactive media relations approach they jointly used to convey positive messaging about all healthcare organizations and service delivery challenges such as wait times in the emergency departments. They describe the communication style used by St. Mary's as "open". Participants conveyed that St. Mary's supports learning for all providers. They indicated that collaboration with other organizations occurs at all levels of the organization. For example, the hospitals, with the support of the LHIN, recently developed a plan to transfer the adult Cystic Fibrosis clinic from Grand River Hospital to St. Mary's. Participants identified possible opportunities for collaborative and innovative planning including utilizing the concepts and lessons learned from the STEMI program to provide pre-hospital assessment in the community for patients with other acute needs and possibly avoiding transfer to the hospital emergency department for assessment. Other opportunities for collaboration include a regional model for medical manpower to support medical imaging and a regional model for the delivery of comprehensive rehabilitation services. Participants expressed confidence that St. Mary's would continue in their tradition of being "a willing partner" to these types of opportunities. Other areas of strength include an excellent relationships with community partners, a well developed ethics framework and a robust disclosure process, a designation as the regional cardiac centre which assists in recruitment of professional staff and enhances fund raising opportunities and a state of the art SPD and reprocessing facility to support the delivery of safe clinical care and infection prevention initiatives. The surveyors identified two possible leading practices: a nurse led outreach team to support Nursing Homes and avoid ED admissions and the implementation of real time information to facilitate patient flow and improve the patient experience using the Daily Access Reporting Tool (DART) and MARY. The organization is encouraged to document these potentially leading practices for external sharing and publication. Further information is available from the organization. Surveyor s Commentary 3

8 Accreditation Report No areas of significant risk were identified by the surveyors. The organization embraces change and continuous improvement and is encouraged to address the following areas for improvement. Clinical opportunities include improving the process for the transfer of clinical information at internal patient transfer points, the development of a VTE prophylaxis protocol and strengthening the medication management process at patient discharge. Opportunities relating to timely access to clinical services and information include a review of the MRI referral and results reporting processes and exploring how the IT systems at Grand River and St. Mary's could enable more timely sharing of clinical information to aid clinical decision making (i.e., emergency and clinic visits to the other hospital). Physical facilities related opportunities include addressing the lack of adequate space in the clinical areas located in the older sections of the building (which results in excessive clutter in the hallways and challenges in assuring that fire safety and infection prevention and control standards are consistently met) and a review of whether the Pharmacy Department will continue to meet Code relating to venting of the fume hoods. Opportunities relating to supporting staff include the development of a comprehensive Human Resource Strategic People Plan which aligns with the Strategic Directions and ensuring security systems address staff and patient safety needs for both off-site and in- hospital locations. This includes a review of the Security Services contract to ensure that it is responsive to today's needs for staff and patient safety. Other opportunities for improvement include developing a plan to ensure there are adequate resources to support ethics as the demand for this service increases and developing systems to assure privacy of data being stored on portable devices such as USB keys. Challenges being experienced by St. Mary's include ongoing fiscal challenges and uncertainty about future funding. They also experience over capacity of inpatients on some days, increasing volumes in the Emergency Department and the related challenges of managing patient flow and ALC patients. Other challenges include assuring good infection control standards in an aging facility, becoming an effective, sustainable organization utilizing LEAN methodology, greater integration between the laboratory and diagnostic imaging IT systems to support timely clinical decision making and advancing the capital redevelopment planning process with the Ministry of Health and Long Term Care. 4 Surveyor s Commentary

9 QMENTUM PROGRAM Organization's Commentary The following comments were provided to Accreditation Canada post survey. St. Mary's General Hospital was pleased to be surveyed under Accreditation Canada's QMENTUM program for the second time this past February. During the three days of our on-site Accreditation Survey, the surveyors visited virtually every area of the hospital, meeting with over 200 staff, physicians and volunteers as well as many patients and their families. Our Surveyors confirmed many of our perceived strengths, including: our new Mission, Vision, Strategic Directions and Goals, with Measurable Outcomes, openness within the organization at all levels to examine current processes and system and make improvements, benefits from the significant presence of our volunteers, and excellent relationships with our community partners as well as patients and their families. The report also highlights many successes achieved since the last Accrediation onsite in 2008, including: implementation of the Best Possible Medication History on all units, the introduction of our regional 24/7 Code STEMI program, our adverse event disclosure policy, our Code of Conduct Policy for staff and physicians, our Chest Centre of Excellence and Level 1 Thoracic Surgery Centre and our strong emphasis on clinical pharmacy to support patient care. The report also highlighted challenges including: ongoing fiscal challenges (given funding uncertainty, increasing demand and the management of patient flow), physical plant opportunities and infection control challenges in an aging facility, as well as the opportunity to develop a strategic HR plan. In the coming days and weeks we will be focusing our attention on the 4 unmet criteria highlighted in the report. We will be working towards submitting evidence of our compliance with these criteria into the Accreditation portal for the July 17th deadline, in order to have our accreditation decision changed. In the months until our next Accreditation, we will be using the opportunities for improvement highlighted in the final report to guide improvement projects alongside our LEAN initiatives to improve quality and patient safety at St. Mary s. Organization's Commentary 5

10 Accreditation Report Overview by Quality Dimension The following table provides an overview of the organization s results by quality dimension. The first column lists the quality dimensions used. The second, third and fourth columns indicate the number of criteria rated as met, unmet or not applicable. The final column lists the total number of criteria for each quality dimension. Quality Dimension Met Unmet N/A Total Population Focus (Working with communities to anticipate and meet needs) 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 Overview by Quality Dimension

11 QMENTUM PROGRAM Overview by Standard Section The following table provides an overview of the organization by standard section. The first column lists the standard section used. The second, third and fourth columns indicate the number of criteria rated as met, unmet or not applicable. The final column lists the total number of criteria for that standard section. Standard Section Met Unmet N/A Total Sustainable Governance Effective Organization Infection Prevention and Control Ambulatory Care Services Biomedical Laboratory Services Blood Bank and Transfusion Services Community Health Services Critical Care Diagnostic Imaging Services Emergency Department Laboratory and Blood Services Managing Medications Medicine Services Operating Rooms Reprocessing and Sterilization of Reusable Medical Devices Surgical Care Services Total Overview by Standard Section 7

12 Accreditation Report Overview by Required Organizational Practices (ROPs) Based on the accreditation review, the table highlights each ROP that requires attention and its location in the standards. Criteria Diagnostic Imaging Services 14.6 Managing Medications 10.2 Medicine Services 7.4 Medicine Services 11.3 Surgical Care Services 7.7 Required Organizational Practices The team informs and educates its clients and families in writing and verbally about the client and family s role in promoting safety. The organization has identified and implemented a list of abbreviations, symbols, and dose designations that are not to be used in the organization. The team identifies medical and surgical clients at risk of venous thromboembolism (DVT and PE) and provides appropriate thromboprophylaxis. The team reconciles medications with the client at referral or transfer, and communicates information about the client s medications to the next provider of service at referral or transfer to another setting, service, service provider, or level of care within or outside the organization..the team identifies medical and surgical clients at risk of venous thromboembolism (DVT and PE) and provides appropriate thromboprophylaxis. 8 Overview by Required Organizational Practices (ROPs)

13 QMENTUM PROGRAM Detailed Accreditation Results System-Wide Processes and Infrastructure This part of the report speaks to the processes and infrastructure needed to support service delivery. In the regional context, this part of the report also highlights the consistency of the implementation and coordination of these processes across the entire system. Some specific areas that are evaluated include: integrated quality management, planning and service design, resource allocation, and communication across the organization. Findings Following the survey, once the organization has the opportunity to address the unresolved criteria and provide evidence of action taken, the results will be updated to show that they have been addressed. Planning and Service Design Developing and implementing the infrastructure, programs and service to meet the needs of the community and populations served. The organization has recently completed a renewal process for the Vision and Mission statements which involved broad consultation with both internal and external stakeholders. Four Strategic Directions have been identified, as well as annual goals and measurable indicators for each direction. The Balanced Scorecard was revised guided by input from the Board Quality Committee. The indicators align with the Strategic Directions and Goals. The Board has received the first report utilizing this new Scorecard format and is very satisfied with the result. Program areas have completed programmatic strategic directions and goals which align with the corporate Strategic Directions. Measurable indicators are in place and monitored regularly at the Program Operations and Quality Committees. All members of the leadership team, medical directors and physician leads have electronic access to pertinent clinical data, in real time and retrospectively, through the innovative internally developed DART and MARY web based systems. These systems have been shared with organizations and the response has been so positive to the applications that a Business Development strategy has been developed to market the DART and MARY tools which support day to day operational decision making and program planning. This third party business venture will be operational within the next few months. Recently the organization has initiated LEAN strategies on two trailblazer units and has plans to roll this out to the remainder of the organization by summer This strategy is being utilized to assist with ongoing operational planning and continuous improvement. To date more than 100 innovations/improvement initiatives have been identified. The organization has a goal of 1000 in the first year of LEAN. They are encouraged to manage tracking of the improvements so it does not become an overwhelming project. Many of the current approaches have been revised in the past year. Therefore it is imperative that the organization ensure ongoing attention to these new approaches to ensure sustainability (i.e., GEMBA, LEAN, balanced scorecard, use of DART and MARY). In addition, given the amount of change occurring within the organization, sustained attention to supporting staff to manage change is encouraged. Detailed Accreditation Results 9

14 Accreditation Report No Unmet Criteria for this Priority Process. Resource Management Monitoring, administration, and integration of activities involved with the appropriate allocation and use of resources. The process for the development and ongoing monitoring of the annual operational budget has been enhanced to include monthly departmental reports, which are provided to the managers along with other pertinent utilization data. The four Strategic Directions of the organization are utilized to guide fiscal decision making. Case costing will be implemented in spring 2011 and will assist in ongoing monitoring and informed decision making. The finance department has developed a process to attribute OHIP adjustments to the specific departments and this has improved reimbursement recoveries. The capital equipment planning and approval process was recently revised to include sign off by all affected departments (i.e., physical facilities).the Foundation participates on the capital planning committee and report this is beneficial for fundraising efforts. The organization is encouraged to ensure the current capital equipment process aligns with the updated Strategic Directions. The organization reports that the finance policies and procedures have been reviewed and updated as needed, especially relating to procurement and capital equipment planning processes. The organization is encouraged to review and update as necessary the Board of Trustees finance related policies to ensure they reflect any changes made to the finance policies of the hospital. Physician impact analysis is completed for new medical staff. A follow-up review to determine the actual impact approximately one year after the physician appointment is encouraged. No Unmet Criteria for this Priority Process. Human Capital Developing the human resource capacity to deliver safe and high quality services to clients. The Board of Trustees utilizes a skills matrix to ensure the right mix of experience on the Board. There is a lot of community interest in serving on the Board. When there are more suitable candidates for the vacant positions than available positions, candidates are invited to serve on Board committees as community representatives. This approach nurtures the continued interest of prospective Board members until a position becomes available on the Board. The Board evaluates its' collective performance at each meeting. Evaluation of individual members performance is done informally and the Chair follows up with that individual as needed. The orientation program for new members occurs annually. The number of elected Board members was recently modified and the policy regarding term lengths was also revised. The organization is committed to supporting staff in their pursuit of professional growth and development to the limit of available resources. Staff appreciate the support they receive. 10 Detailed Accreditation Results

15 QMENTUM PROGRAM Seeking any and all opportunities to support staff professional growth and development is encouraged. Staff report overall satisfaction with SMGH as an employer and the low turnover rate attests to staff satisfaction. The organization has not completed a staff survey since 2009 and 2010 when the Accreditation Canada Worklife Pulse and Patient Safety Culture Surveys were used. The organization is encouraged to proceed with their plan to conduct a comprehensive staff survey in the spring of 2011 and to utilize the results to guide planning relating to ensuring a positive workplace culture. Many staff report that they have received a performance appraisal within the past year, however the human resource files examined did not support that the completion rate meets the desired target. Most files contained appraisals completed within the past 2 years, not annually as the current policy states. The organization is encouraged to continue working towards improved compliance with their existing standard and/or perhaps consider a revision to the existing policy regarding frequency of completing PA's for good performing long standing staff members from annual to biannual. With the recent release of the new Vision and Strategic Directions, there is an excellent opportunity for the HR department to develop a comprehensive multi- year Strategic People Plan which aligns the Strategic Directions and especially focuses on "Our People". The Strategic People Plan should include, at a minimum, the long term health human resource plan including recruitment, retention and succession planning, a comprehensive rewards and recognition program, plan for investing in your people to support their ongoing professional growth and development and managing change. Currently the Human Resources Department monitors a standard set of outcome measures such as sick time, turnover and grievance rates.these indicators should be enhanced to include meaningful outcome measures tied to each strategy identified within the plan. The People Plan would guide planning and decision making regarding supporting "your people". Although recruitment tools are in place, they do not align with the new Vision and Strategic Directions. There is an opportunity to explore the use of a behaviourally based recruitment selection tool to assist in recruiting people who are committed to supporting the Vision and Mission of St Mary's. Some work has been done to identify future health human resource needs at a departmental level. This work should be completed for all departments and be incorporated into a comprehensive Strategic People Plan. The identification of future recruitment needs will enable leadership to proactively plan future recruitment, support succession planning and perhaps avoid some long delays in filling difficult to fill positions. The organization is encouraged to review the policy for frequency of completing performance appraisals and also to streamline the tool for all staff and especially Allied Health staff to achieve the greatest compliance level possible. The table below indicates the specific criteria that require attention, based on the accreditation review. Criteria Location Priority for Action Effective Organization The organization s leaders regularly evaluate reporting relationships and managers span of control Detailed Accreditation Results 11

16 Accreditation Report Integrated Quality Management Continuous, proactive and systematic process to understand, manage and communicate quality from a system-wide perspective to achieve goals and objectives. At both the corporate and program/department levels the organization has robust processes for identifying, measuring and communicating the quality improvement initiatives and outcomes as well as patient safety and risk management. It is suggested that patient safety be broadened to include staff safety and that indicators for staff safety be developed and included in the Balanced Scorecard. The quality program is well integrated with the Strategic Plan, Vision and Mission and Strategic Directions. As the quality, safety and risk programs have evolved, indicators have been added or revised. The Balanced Scorecard approach continues to be used and refined. The organization is commended for implementing the safety officer position. Although there is a formal and well designed disclosure process, the organization is encouraged to ensure that documentation of quality of care reviews including final disposition is included in their record keeping. Patient records reviewed by surveyors did not consistently include a notation that disclosure occurred or the patient/family response. In addition the final note/summary of the actions taken and outcomes of follow-up was not consistently observed in the incident record keeping system. Greater recognition of staff and volunteers for their contributions to the quality improvement program is encouraged. It is occurring in the LEAN departments but not consistently in other departments. No Unmet Criteria for this Priority Process. Principle Based Care and Decision Making Identifying and decision making regarding ethical dilemmas and problems. The ethics framework is an integral part of St. Mary's General Hospital. As a member of the St. Joseph's Healthcare System, the organization is reviewing and renewing the ethics framework to align with the growing needs caused by increased demand and complexity. Three recent ethics problems were discussed and traced. The first case was a hospital perception of futility versus a cultural need for continuing active care. The ethics program recommended that, in keeping with the ethical framework, the wishes of the family be respected. The second area of discussion was staff debriefing following difficult clinical problems. The discussion included the use of the Employee Assistance Program and the measures used to manage disruptive physician behaviour. The third issue was withdrawal of care. In all cases, staff were educated and involved in the process. The processes to address ethical issues include local management for well understood issues and educational rounds to highlight ethical issues. Issues that have been dealt with recently include ethical considerations of Alternate Levels of Care, the ethics of marginal populations and Advance Directives. Ethics support is available 24/7 and the ethicist attends rounds in ICU weekly. An annual conference is undertaken by the ethics committee. Ethics rounds are held monthly and are well attended. The clinical ethical committee meets quarterly. 12 Detailed Accreditation Results

17 QMENTUM PROGRAM Research ethics is done in conjunction with two other regional hospitals and is known as the Tri-Hospital Research Ethics Board. The committee chair is an ethicist and a wide range of disciplines are represented. A formal application procedure is used. The Research Ethics Board reviews consents, impact of research on the hospitals and local adverse events. Major ethical challenges include resource allocation in an environment of increased ethical issues and rising expectations of patients, families and staff. This will become increasingly acute as the needs of long-term care patients and those with chronic illness are increasingly prevalent in the medical needs of the community. Additional issues include early discharge versus compassion and conflict resolution. There are two issues that should be addressed immediately. At present there is no physician member on the Clinical Ethics Committee. Medical input would strengthen the committee. A physician with an interest in Clinical Ethics should be identified to become a member of the committee.the second issue is a privacy issue. Confidential information should be encrypted and access should be by encryption key only. It is important for the organization to ensure that confidential information does not leave the hospital. Also, devices that contain information such as USB keys should not leave the hospital, but should be encrypted in case of loss. Computers with patient information should be locked to the desks. The table below indicates the specific criteria that require attention, based on the accreditation review. Criteria Location Priority for Action Effective Organization The organization s leaders build the organization s capacity to apply the ethics framework by encouraging the governing body, leaders, staff, and service providers to develop and enhance their ethics-related knowledge. 5.8 Communication Communication among various layers of the organization, and with external stakeholders. The organization has developed a Communication Plan to enhance external communication and media relationships. Indicators have been identified to monitor progress. There are many internal communications tools utilized including Suture Line and Grapevine (newsletters with different foci), , the intranet, the well attended General Staff meetings which the president holds quarterly, the GEMBA rounds, the monthly management meeting which is held on the day following the Board of Trustees meeting where information from the Board meeting is shared, communication boards throughout the departments and the organization and the dedicated LEAN information boards. All staff have access to the Intranet. Many staff report that is the most beneficial communication tool for them. The organization is encouraged to evaluate the effectiveness of their internal strategies and focus on those which staff identify as most helpful. The Information Management systems are developed and provide timely and meaningful data to support decision making. Feedback from discussions with end users indicate satisfaction with the overall level of service and response time. A five-year information management plan has been drafted which identifies new, existing and replacement capital needs. It has not yet been approved. Detailed Accreditation Results 13

18 Accreditation Report The Communications Department and the Foundation work closely to maximize the work of each, avoid duplication of effort and effectively utilize limited resources to advance a positive image of St. Mary's both externally and internally. There is a plan to redesign the intranet and a joint request for quote (RFQ) has been issued to support internal communication. The Foundation has been very successful in their annual fundraising campaign and they attribute this to the overall community satisfaction with services delivered by SMGH. Both the organization and the Foundation receive positive patient/family feedback regularly. Both areas identified an opportunity to further share this positive feedback internally with staff and departments identified. The organization is encouraged to identify a mechanism to evaluate the effectiveness of the communication plan and the strategies used and utilize these results to further enhance their communication efforts focusing on those tools and strategies which staff report as most effective for them. The organization is encouraged to prioritize the needs identified in the Information Management plan to enable IT and Decision Support to continue to provide/advance the level of support they provide to the various internal stakeholders. No Unmet Criteria for this Priority Process. Physical Environment Providing appropriate and safe structures and facilities to successfully carry out the mission, vision, and goals. Existing physical space varies from recently redeveloped and built to sorely in need of redevelopment. The 5th floor medical inpatient unit is cluttered, lacks storage space and space for health professionals to document. For instance, a section of a multi-purpose patient/family lounge is used for storage of extra patient beds and also by the OT staff as office space for documentation. Wallpaper in inpatient care areas is targeted for removal which is a positive move towards a "clean" environment. As the 2010 Master Planning document states, the inpatient units are "deficient in all respects to support expectations for infection prevention and control, accessibility, privacy, family centered care and teaching". It is recommended that planning to update inpatient units such as the 5th floor medical unit proceed as a priority. An annual amount of $250,000 is allocated for in-house refresh and renovation. Submissions are invited and triaged annually. The 8th floor is currently vacant and is being considered for optimal utilization, likely as a non patient care area. The Engineering Services department is aware of the hospital's location in a residential community and seeks ways in which to minimize its environmental impact. For instance, an environmentally friendly salt substitute is used for ice control during winter. There is a new Code Grey policy which has been developed and is in the process of being implemented. Code Grey directs response to planned or unplanned loss of infrastructure. Infrastructure was specifically targeted for redevelopment and modernization during the past major capital project. As a result, the physical plant enjoys many modern mechanical systems. Engineering Services will assume responsibility for Hospital Security including management of the security service contracts. This responsibility will be transferred from the HR program. 14 Detailed Accreditation Results

19 QMENTUM PROGRAM Engineering services respond to patient and staff safety incidents in an appropriate manner which extends to the prevention of like future incidents. An example is a recent code yellow which identified the need to secure doorways opening from stairwells. The engineering service is aligned with the emergency management team and takes pride in contributing to creating a safe environment for staff and patients. Key performance indicators have been developed over the past year as part of the new (CMMS) maintenance connection system. It is recommended that indicators be finalized and that yellow/red flags be addressed. The table below indicates the specific criteria that require attention, based on the accreditation review. Criteria Location Priority for Action Effective Organization The organization s physical space meets applicable laws, regulations, and codes Emergency Preparedness Dealing with emergencies and other aspects of public safety. Maintaining Disaster Codes policies and protocol work is ongoing. The Code Orange protocol is in the process of being revised. A Code Grey protocol has been developed and a roll out plan has been identified. The Code Yellow protocol will be reviewed and revised as a result of the learning from a recent actual Code Yellow event. Fire drills are held monthly. A mock Code Green was held since the last accreditation survey. Documentation arising from mock codes and real events is comprehensive and includes recommendations for change to policy or systems and processes. These incident debriefing documents are useful in ongoing quality improvements. Code White is an area of concern for the organization. The role of security services within this facility is more so that of a "commissionaire" rather than security which would participate in a Code White situation. Staff are evaluating documentation of incidents of aggression. Recommendations for a change in security services have been forwarded to senior management. Code fairs are held at least annually and volunteers are welcome to attend. Emergency preparedness education is also available in orientation, classroom environments and on e-learning systems. E-learning systems also provide hand hygiene, WHMIS, violence in the workplace training and more. Links with other area hospitals and municipalities are maintained for emergency planning and mock disaster events. Some staff have been trained on web based emergency operations centre software. The occupational health and safety committee has an annual work plan and includes off-site program space in annual inspections including the homes of transcription staff. Detailed Accreditation Results 15

20 Accreditation Report No Unmet Criteria for this Priority Process. Patient Flow Smooth and timely movement of clients and their families through appropriate service and care settings. St. Mary's General Hospital has undertaken a number of initiatives designed to improve patient flow. These initiatives include "bullet" rounds on each nursing unit that include the whole interdisciplinary team. The team identifies patients ready for discharge and the steps needed to move other patients efficiently towards discharge. A bed meeting is held each day at 1000 AM conducted by the bed coordinator and attended by representatives from each area in the hospital. The goal is to have patients discharged by 1100 AM and the secondary goal is A second bed meeting is held if necessary. Key personnel have access to the DART system, an application designed by the IT department that enables staff to review data points that will drive clinical decision making. DART is updated at 4:00 AM each day. St. Mary's has also developed a program called MARY, a Blackberry application that alerts staff to the number of patients in the emergency department, the number of admitted patients in the emergency department, the number of isolated patients and the availability of beds. There are a number of challenges to efficient patient flow. Occupancy is well in excess of 100% most days. The targets for time of discharge, although not particularly stringent, are not met very frequently. Bottlenecks are present at all levels of the organization. Alternate Level of Care (ALC) is a significant problem with 24 ALC patients admitted on the day of the survey. Another problem is the number of patients in isolation; there were 28 patients in isolation on the day of the survey. A thorough review of the discharge process using the LEAN methodology adopted by the hospital should be undertaken. The table below indicates the specific criteria that require attention, based on the accreditation review. Criteria Location Priority for Action Emergency Department The team collaborates with its partners to provide access to the full spectrum of emergency services. The team has strategies in place to effectively manage overcrowding and surges in the Emergency Department Medical Devices and Equipment Machinery and technologies designed to aid in the diagnosis and treatment of healthcare problems. 16 Detailed Accreditation Results

21 QMENTUM PROGRAM The Sterilization and Processing Department of St. Mary's General Hospital moved to new and state of the art facility three years ago. The Department has about 25 employees who work in the three major areas: decontamination, reprocessing and endoscopy. All new recent employees have obtained certificates in processing and sterilization and several are pursuing additional qualifications. All new staff undergo an extensive orientation that includes one-on-one mentoring in the major areas and in the standard operating procedures. Staff are dedicated, hard working and very much part of the team that plays an integral role in effective patient care. The leaders of the SPD department continually stress to the staff the importance of their role in good clinical care. The staff are proud of their role in the hospital. The main strength of the program is the continuing education programs for the staff. All new processes and instruments are "taught" to all the employees in the staff, so that all are able to function with new equipment very quickly. An educator works closely with the staff on a weekly basis, at least. Also, the leadership of SPD has developed an on-line and ongoing education program for staff that includes an annual updating requirement. The program is password protected, but the clinical leadership personnel can access the individual results to ensure that staff update on an annual basis. The online program for each individual employee also includes modules for WHMIS and other organization wide initiatives. Staff are fully supportive of the continuous learning and updating opportunity. The SPD Department maintains accurate logs of sterile processes and are confident that if a recall or recheck was required that they would be able to provide the organization with the information that is needed. Members of the team understand the quality initiatives that are underway and periodically are able to make suggestions re: new initiatives. The processing equipment is covered by service contracts which include online monitoring by the equipment provider. This has resulted in several early interventions that significantly reduced down time for the equipment. The biomedical Department is a small department that has an important and increasing role in the hospital, given the proliferation of medical devices and the increasing reliance on the devices. Major equipment is usually covered by service contracts, but the Biomedical Department is familiar with the equipment and troubleshoots before calling the supplier. Biomedical Department ensures that the terms of the service contracts, particularly with respect to preventative maintenance are carried out. All other equipment is identified by bar code and preventative maintenance is tracked and done in the department. The department is involved in patient incident reviews as they pertain to equipment. An area for improvement for the Biomedical Department is to take a more active role in the education programs for clinical staff. Much of the inservice and orientation is done by suppliers, with which in many cases they have an excellent relationship. However, there are aspects of education and surveillance that could be improved by participation in the education program. A specific example is wider publicity for the "go green" campaign to prevent deep discharge of IV infusion pump batteries. A tracer done in the ICU revealed that one of six IV infusion pumps was not plugged in, thereby exposing it to deep discharge conditions that lead to decreased reliability of the device. Another area for improvement is to more effectively use the relatively new system of identifying and taking out of service any device that fails. The system then automatically produces a work order for biomedical and action is undertaken. This system although available remains underused. Procurement of medical devices is driven by a capital replacement committee that reviews all requests and prioritizes within the scope of the strategic priorities and the funds available. A separate process which is similar in construct is available for funds allocated by the Foundation. Detailed Accreditation Results 17

22 Accreditation Report All items over $100,000 require a request for purchase review and are ultimately referred to the St. Joseph's purchasing group. Standardization is done both within the hospital and within the St.Joseph's buying group. There is no equipment that has been obtained using leasing arrangements or borrowed funds. The organization works closely with the Ministry for expensive new initiatives or expensive upgrades like new cardiac cath suites. No Unmet Criteria for this Priority Process. Direct Service Provision This part of the report provides information on the delivery of high quality, safe services. Some specific areas that are evaluated include: the episode of care, medication management, infection control, and medical devices and equipment. Findings Following the survey, once the organization has the opportunity to address the unresolved criteria and provide evidence of action taken, the results will be updated to show that they have been addressed. Ambulatory Care Services Clinical Leadership Providing leadership and overall goals and direction to the team of people providing services. The Ambulatory Care program includes cardiac rehabilitation, COPD clinic, diabetes clinic, rheumatology, medical day care, pre-surgery, post operative follow-up, heart function, cardiac device assessment and follow-up, eye clinic and the geriatric assessment clinics. Clinics are offered in a shared space at the hospital and off-site (cardiac rehab, diabetes, COPD and Solutions (weight management) ). There is good collaboration between the ED, inpatient areas and the clinics to enable timely referrals and access. Wait times are monitored informally for most programs; patients are triaged by the clinical teams and as a result wait times are within acceptable limits. Collaboration also occurs between programs across the region (i.e. cardiac rehab) so that patients can access services closer to their home if they wish and if a program exists. Planning for clinics is needs based. Goals, objectives and outcome indicators are in place for each program which are shared with the respective clinical program. The clinics utilize a multidisciplinary approach to service delivery. Students and volunteers are used through the ambulatory clinics to support the patient and enable staff. Assuring staff safety at the off-site clinic after hours should be addressed. No Unmet Criteria for this Priority Process. Competency Developing a highly competent interdisciplinary team with the knowledge, skills and abilities to develop, manage, and deliver effective and efficient programs, services, and care. 18 Detailed Accreditation Results