Accreditation Report

Transcription

1 Interior Health Authority Kelowna, BC On-site survey dates: September 23, September 28, 2012 Report issued: April 2, 2013 Accredited by ISQua

2 About the Interior Health Authority (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. Confidentiality This report is confidential and is provided by Accreditation Canada to the organization only. Accreditation Canada does not release the report to any other parties. In the interests of transparency and accountability, Accreditation Canada encourages the organization to disseminate its to staff, board members, clients, the community, and other stakeholders. Any alteration of this compromises the integrity of the accreditation process and is strictly prohibited. Accreditation Canada, 2013

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

4 Table of Contents 1.0 Executive Summary Accreditation Decision About the On-site Survey Overview by Quality Dimensions Overview by Standards Overview by Required Organizational Practices Summary of Surveyor Team Observations Detailed Required Organizational Practices Results Detailed On-site Survey Results Priority Process Results for System-wide Standards Priority Process: Planning and Service Design Priority Process: Governance Priority Process: Resource Management Priority Process: Human Capital Priority Process: Integrated Quality Management Priority Process: Principle-based Care and Decision Making Priority Process: Communication Priority Process: Physical Environment Priority Process: Emergency Preparedness Priority Process: Patient Flow Priority Process: Medical Devices and Equipment Priority Process Results for Population-specific Standards Standards Set: Child and Youth Populations Standards Set: Mental Health Populations Standards Set: Public Health Services Service Excellence Standards Results Standards Set: Ambulatory Care Services Standards Set: Ambulatory Systemic Cancer Therapy Services Standards Set: Community-Based Mental Health Services and Supports Standards Standards Set: Critical Care Standards Set: Emergency Department Standards Set: Home Care Services 73 Table of Contents i

5 3.3.7 Standards Set: Infection Prevention and Control Standards Set: Long-Term Care Services Standards Set: Managing Medications Standards Set: Medicine Services Standards Set: Mental Health Services Standards Set: Obstetrics Services Standards Set: Rehabilitation Services Priority Process: Surgical Procedures Instrument Results Governance Functioning Tool Patient Safety Culture Tool Worklife Pulse Tool Client Experience Tool Organization's Commentary 117 Appendix A Qmentum 120 Appendix B Priority Processes 121 Table of Contents ii

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

7 1.2 About the On-site Survey On-site survey dates: September 23, 2012 to September 28, 2012 Locations The following locations were assessed during the on-site survey. All sites and services offered by the organization are deemed accredited Mile House District Hospital 2 Boundary Hospital and Community Care Centre 3 Cara Centre 4 Cranbrook Health Centre 5 East Kootenay Regional Hospital 6 Hardy View Lodge 7 Kelowna General Hospital 8 Kelowna Health Centre, Ellis Street 9 Kimberley Special Care Home 10 Kirschner Road 11 Kootenay Boundary Regional Hospital 12 Kootenay Lake Hospital 13 McKinney Place 14 Noric House 15 Oliver Health Centre 16 Parkview Place, Enderby 17 Penticton Health Centre 18 Penticton Integrated Health Centre 19 Penticton Regional Hospital 20 Reid's Corner 21 Royal Inland Hospital 22 Salmon Arm Health Centre 23 Shuswap Lake Hospital 24 South Okanagan General Hospital 25 Three Links Manor 26 Trinity Care Centre 27 Vernon Jubilee Hospital Standards The following sets of standards were used to assess the organization's programs and services during the on-site survey. Executive Summary 2

8 System-Wide Standards 1 Governance 2 Leadership Population-specific Standards 3 Child and Youth Populations 4 Mental Health Populations 5 Public Health Services Service Excellence Standards 6 Managing Medications 7 Operating Rooms 8 Reprocessing and Sterilization of Reusable Medical Devices 9 Surgical Care Services 10 Critical Care 11 Emergency Department 12 Infection Prevention and Control 13 Home Care Services 14 Ambulatory Care Services 15 Long-Term Care Services 16 Medicine Services 17 Rehabilitation Services 18 Mental Health Services 19 Community-Based Mental Health Services and Supports Standards 20 Ambulatory Systemic Cancer Therapy Services 21 Obstetrics Services Instruments The organization administer: Governance Functioning Tool Patient Safety Culture Tool Worklife Pulse Tool Client Experience Tool Executive Summary 3

9 1.3 Overview by Quality Dimensions Accreditation Canada defines quality in health care using eight dimensions that represent key service elements. Each criterion in the standards is associated with a quality dimension. This table shows the number of criteria related to each dimension that were rated as met, unmet, or not applicable. Quality Dimension Met Unmet N/A Total Population Focus (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 4

10 1.4 Overview by Standards The Qmentum standards identify policies and practices that contribute to high quality, safe, and effectively managed care. Each standard has associated criteria that are used to measure the organization's compliance with the standard. System-wide standards address quality and safety at the organizational level in areas such as governance and leadership. Population-specific and service excellence standards address specific populations, sectors, and services. The standards used to assess an organization's programs are based on the type of services it provides. This table shows the sets of standards used to evaluate the organization's programs and services, and the number and percentage of criteria that were rated met, unmet, or not applicable during the on-site survey. Accreditation decisions are based on compliance with standards. Percent compliance is calculated to the decimal and not rounded. High Priority Criteria * Other Criteria Total Criteria (High Priority + Other) Standards Set Met Unmet N/A # (%) # (%) # Met Unmet N/A # (%) # (%) # Met Unmet N/A # (%) # (%) # Governance 43 (100.0%) 0 (0.0%) 0 32 (91.4%) 3 (8.6%) 0 75 (96.2%) 3 (3.8%) 0 Leadership 32 (76.2%) 10 (23.8%) 0 69 (79.3%) 18 (20.7%) (78.3%) 28 (21.7%) 0 Child and Youth Populations 4 (100.0%) 0 (0.0%) 0 24 (85.7%) 4 (14.3%) 1 28 (87.5%) 4 (12.5%) 1 Mental Health Populations 2 (50.0%) 2 (50.0%) 0 24 (68.6%) 11 (31.4%) 0 26 (66.7%) 13 (33.3%) 0 Public Health Services 38 (80.9%) 9 (19.1%) 0 44 (64.7%) 24 (35.3%) 0 82 (71.3%) 33 (28.7%) 0 Ambulatory Systemic Cancer Therapy Services 44 (100.0%) 0 (0.0%) 1 77 (78.6%) 21 (21.4%) (85.2%) 21 (14.8%) 1 Obstetrics Services 60 (100.0%) 0 (0.0%) 2 69 (92.0%) 6 (8.0%) (95.6%) 6 (4.4%) 3 Infection Prevention and Control 47 (95.9%) 2 (4.1%) 2 39 (90.7%) 4 (9.3%) 3 86 (93.5%) 6 (6.5%) 5 Ambulatory Care Services 28 (90.3%) 3 (9.7%) 6 65 (92.9%) 5 (7.1%) 6 93 (92.1%) 8 (7.9%) 12 Executive Summary 5

11 High Priority Criteria * Other Criteria Total Criteria (High Priority + Other) Standards Set Met Unmet N/A # (%) # (%) # Met Unmet N/A # (%) # (%) # Met Unmet N/A # (%) # (%) # Community-Based Mental Health Services and Supports Standards 15 (93.8%) 1 (6.3%) (92.0%) 9 (8.0%) (92.2%) 10 (7.8%) 1 Critical Care 29 (100.0%) 0 (0.0%) 0 83 (90.2%) 9 (9.8%) (92.6%) 9 (7.4%) 2 Emergency Department 27 (87.1%) 4 (12.9%) 0 90 (94.7%) 5 (5.3%) (92.9%) 9 (7.1%) 1 Home Care Services 40 (100.0%) 0 (0.0%) 0 44 (84.6%) 8 (15.4%) 2 84 (91.3%) 8 (8.7%) 2 Long-Term Care Services 23 (100.0%) 0 (0.0%) 0 71 (98.6%) 1 (1.4%) 1 94 (98.9%) 1 (1.1%) 1 Managing Medications 57 (76.0%) 18 (24.0%) 1 41 (78.8%) 11 (21.2%) 0 98 (77.2%) 29 (22.8%) 1 Medicine Services 25 (96.2%) 1 (3.8%) 0 65 (94.2%) 4 (5.8%) 1 90 (94.7%) 5 (5.3%) 1 Mental Health Services 29 (96.7%) 1 (3.3%) 0 59 (83.1%) 12 (16.9%) 1 88 (87.1%) 13 (12.9%) 1 Operating Rooms 68 (98.6%) 1 (1.4%) 0 29 (96.7%) 1 (3.3%) 0 97 (98.0%) 2 (2.0%) 0 Rehabilitation Services 25 (96.2%) 1 (3.8%) 0 58 (85.3%) 10 (14.7%) 1 83 (88.3%) 11 (11.7%) 1 Reprocessing and Sterilization of Reusable Medical Devices 39 (100.0%) 0 (0.0%) 1 54 (94.7%) 3 (5.3%) 2 93 (96.9%) 3 (3.1%) 3 Surgical Care Services 29 (100.0%) 0 (0.0%) 0 65 (100.0%) 0 (0.0%) 1 94 (100.0%) 0 (0.0%) 1 Total 704 (93.0%) 53 (7.0%) (87.7%) 169 (12.3%) (89.6%) 222 (10.4%) 37 * Does not includes ROP (Required Organizational Practices) Executive Summary 6

12 1.5 Overview by Required Organizational Practices A Required Organizational Practice (ROP) is an essential practice that an organization must have in place to enhance client safety and minimize risk. Each ROP has associated tests for compliance, categorized as major and minor. All tests for compliance must be met for the ROP as a whole to be rated as met. This table shows the ratings of the applicable ROPs. Required Organizational Practice Overall rating Test for Compliance Rating Major Met Minor Met Patient Safety Goal Area: Safety Culture 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 (Ambulatory Care Services) Client And Family Role In Safety (Ambulatory Systemic Cancer Therapy Services) Client And Family Role In Safety (Community-Based Mental Health Services and Supports Standards) Client And Family Role In Safety (Critical Care) Client And Family Role In Safety (Home Care Services) Met 2 of 2 0 of 0 Met 2 of 2 0 of 0 Met 2 of 2 0 of 0 Unmet 1 of 2 0 of 0 Met 2 of 2 0 of 0 Executive Summary 7

13 Required Organizational Practice Overall rating Test for Compliance Rating Major Met Minor Met Patient Safety Goal Area: Communication Client And Family Role In Safety (Long-Term Care Services) Client And Family Role In Safety (Medicine Services) Client And Family Role In Safety (Mental Health Services) Client And Family Role In Safety (Obstetrics Services) Client And Family Role In Safety (Rehabilitation Services) Client And Family Role In Safety (Surgical Care Services) Dangerous Abbreviations (Managing Medications) Information Transfer (Ambulatory Care Services) Information Transfer (Ambulatory Systemic Cancer Therapy Services) Information Transfer (Community-Based Mental Health Services and Supports Standards) Information Transfer (Critical Care) Information Transfer (Emergency Department) Information Transfer (Home Care Services) Information Transfer (Long-Term Care Services) Met 2 of 2 0 of 0 Met 2 of 2 0 of 0 Met 2 of 2 0 of 0 Met 2 of 2 0 of 0 Met 2 of 2 0 of 0 Met 2 of 2 0 of 0 Unmet 4 of 4 1 of 3 Met 2 of 2 0 of 0 Met 2 of 2 0 of 0 Met 2 of 2 0 of 0 Met 2 of 2 0 of 0 Met 2 of 2 0 of 0 Met 2 of 2 0 of 0 Met 2 of 2 0 of 0 Executive Summary 8

14 Required Organizational Practice Overall rating Test for Compliance Rating Major Met Minor Met Patient Safety Goal Area: Communication Information Transfer (Medicine Services) Information Transfer (Mental Health Services) Information Transfer (Obstetrics Services) Information Transfer (Rehabilitation Services) Information Transfer (Surgical Care Services) Medication Reconciliation As An Organizational Priority (Leadership) Medication Reconciliation At Admission (Ambulatory Care Services) Medication Reconciliation At Admission (Ambulatory Systemic Cancer Therapy Services) Medication Reconciliation At Admission (Community-Based Mental Health Services and Supports Standards) Medication Reconciliation At Admission (Critical Care) Medication Reconciliation At Admission (Emergency Department) Medication Reconciliation At Admission (Home Care Services) Medication Reconciliation At Admission (Long-Term Care Services) Medication Reconciliation At Admission (Medicine Services) Met 2 of 2 0 of 0 Met 2 of 2 0 of 0 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 0 of 0 Met 5 of 5 2 of 2 Unmet 4 of 5 1 of 2 Met 4 of 4 1 of 1 Met 4 of 4 1 of 1 Met 4 of 4 1 of 1 Unmet 0 of 4 0 of 1 Met 4 of 4 1 of 1 Met 4 of 4 1 of 1 Executive Summary 9

15 Required Organizational Practice Overall rating Test for Compliance Rating Major Met Minor Met Patient Safety Goal Area: Communication Medication Reconciliation At Admission (Mental Health Services) Medication Reconciliation At Admission (Obstetrics Services) Medication Reconciliation At Admission (Rehabilitation Services) Medication Reconciliation At Admission (Surgical Care Services) Medication Reconciliation at Transfer or Discharge (Ambulatory Systemic Cancer Therapy Services) Medication Reconciliation at Transfer or Discharge (Community-Based Mental Health Services and Supports Standards) Medication Reconciliation at Transfer or Discharge (Critical Care) Medication Reconciliation at Transfer or Discharge (Emergency Department) Medication Reconciliation at Transfer or Discharge (Home Care Services) Medication Reconciliation at Transfer or Discharge (Long-Term Care Services) Medication Reconciliation at Transfer or Discharge (Medicine Services) Met 4 of 4 1 of 1 Met 4 of 4 1 of 1 Unmet 1 of 4 1 of 1 Met 4 of 4 1 of 1 Unmet 0 of 4 0 of 1 Met 3 of 3 2 of 2 Unmet 1 of 4 0 of 1 Met 4 of 4 1 of 1 Unmet 0 of 3 0 of 2 Met 4 of 4 1 of 1 Met 4 of 4 1 of 1 Executive Summary 10

16 Required Organizational Practice Overall rating Test for Compliance Rating Major Met Minor Met Patient Safety Goal Area: Communication Medication Reconciliation at Transfer or Discharge (Mental Health Services) Medication Reconciliation at Transfer or Discharge (Obstetrics Services) Medication Reconciliation at Transfer or Discharge (Rehabilitation Services) Medication Reconciliation at Transfer or Discharge (Surgical Care Services) Surgical Checklist (Obstetrics Services) Surgical Checklist (Operating Rooms) Two Client Identifiers (Ambulatory Care Services) Two Client Identifiers (Ambulatory Systemic Cancer Therapy Services) Two Client Identifiers (Critical Care) Two Client Identifiers (Emergency Department) Two Client Identifiers (Home Care Services) Two Client Identifiers (Long-Term Care Services) Two Client Identifiers (Managing Medications) Met 4 of 4 1 of 1 Unmet 0 of 4 0 of 1 Unmet 0 of 4 0 of 1 Met 4 of 4 1 of 1 Unmet 1 of 3 0 of 2 Met 3 of 3 2 of 2 Met 1 of 1 0 of 0 Met 1 of 1 0 of 0 Met 1 of 1 0 of 0 Unmet 0 of 1 0 of 0 Met 1 of 1 0 of 0 Met 1 of 1 0 of 0 Unmet 0 of 1 0 of 0 Executive Summary 11

17 Required Organizational Practice Overall rating Test for Compliance Rating Major Met Minor Met Patient Safety Goal Area: Communication Two Client Identifiers (Medicine Services) Two Client Identifiers (Mental Health Services) Two Client Identifiers (Obstetrics Services) Two Client Identifiers (Operating Rooms) Two Client Identifiers (Rehabilitation Services) Two Client Identifiers (Surgical Care Services) Verification Processes For High-Risk Activities (Ambulatory Care Services) Verification Processes For High-Risk Activities (Ambulatory Systemic Cancer Therapy Services) Verification Processes For High-Risk Activities (Community-Based Mental Health Services and Supports Standards) Verification Processes For High-Risk Activities (Critical Care) Verification Processes For High-Risk Activities (Long-Term Care Services) Verification Processes For High-Risk Activities (Medicine Services) 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 Met 1 of 1 0 of 0 Met 1 of 1 0 of 0 Met 2 of 2 1 of 1 Met 2 of 2 1 of 1 Met 2 of 2 1 of 1 Met 2 of 2 1 of 1 Met 2 of 2 1 of 1 Met 2 of 2 1 of 1 Executive Summary 12

18 Required Organizational Practice Overall rating Test for Compliance Rating Major Met Minor Met Patient Safety Goal Area: Communication Verification Processes For High-Risk Activities (Mental Health Services) Verification Processes For High-Risk Activities (Obstetrics Services) Verification Processes For High-Risk Activities (Rehabilitation Services) Verification Processes For High-Risk Activities (Surgical Care Services) Met 2 of 2 1 of 1 Met 2 of 2 1 of 1 Unmet 0 of 2 0 of 1 Met 2 of 2 1 of 1 Patient Safety Goal Area: Medication Use Concentrated Electrolytes (Managing Medications) Heparin Safety (Managing Medications) Infusion Pumps Training (Ambulatory Care Services) Infusion Pumps Training (Ambulatory Systemic Cancer Therapy Services) Infusion Pumps Training (Critical Care) Infusion Pumps Training (Emergency Department) Infusion Pumps Training (Home Care Services) Infusion Pumps Training (Long-Term Care Services) 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 Unmet 0 of 1 0 of 0 Met 1 of 1 0 of 0 Unmet 0 of 1 0 of 0 Unmet 0 of 1 0 of 0 Executive Summary 13

19 Required Organizational Practice Overall rating Test for Compliance Rating Major Met Minor Met Patient Safety Goal Area: Medication Use Infusion Pumps Training (Managing Medications) Infusion Pumps Training (Medicine Services) Infusion Pumps Training (Obstetrics Services) Infusion Pumps Training (Operating Rooms) Infusion Pumps Training (Rehabilitation Services) Infusion Pumps Training (Surgical Care Services) Medication Concentrations (Managing Medications) Narcotics Safety (Managing Medications) 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 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 Met 3 of 3 1 of 1 Met 5 of 5 3 of 3 Executive Summary 14

20 Required Organizational Practice Overall rating Test for Compliance Rating Major Met Minor Met Patient Safety Goal Area: Infection Control Hand Hygiene Audit (Infection Prevention and Control) Hand Hygiene Education And Training (Infection Prevention and Control) Infection Control Guidelines (Infection Prevention and Control) Infection Rates (Infection Prevention and Control) Influenza Vaccine (Infection Prevention and Control) Pneumococcal Vaccine (Long-Term Care Services) Sterilization Processes (Infection Prevention and Control) Met 1 of 1 2 of 2 Met 2 of 2 0 of 0 Met 1 of 1 0 of 0 Unmet 1 of 1 2 of 3 Met 3 of 3 0 of 0 Met 2 of 2 0 of 0 Met 1 of 1 1 of 1 Patient Safety Goal Area: Falls Prevention Falls Prevention Strategy (Ambulatory Care Services) Falls Prevention Strategy (Ambulatory Systemic Cancer Therapy Services) Falls Prevention Strategy (Home Care Services) Falls Prevention Strategy (Long-Term Care Services) Falls Prevention Strategy (Medicine Services) Falls Prevention Strategy (Mental Health Services) Falls Prevention Strategy (Obstetrics Services) Met 3 of 3 2 of 2 Unmet 0 of 3 0 of 2 Met 3 of 3 2 of 2 Met 3 of 3 2 of 2 Met 3 of 3 2 of 2 Met 3 of 3 2 of 2 Met 3 of 3 2 of 2 Executive Summary 15

21 Required Organizational Practice Overall rating Test for Compliance Rating Major Met Minor Met Patient Safety Goal Area: Falls Prevention Falls Prevention Strategy (Rehabilitation Services) Falls Prevention Strategy (Surgical Care Services) Met 3 of 3 2 of 2 Met 3 of 3 2 of 2 Patient Safety Goal Area: Risk Assessment Home Safety Risk Assessment (Home Care Services) Pressure Ulcer Prevention (Long-Term Care Services) Suicide Prevention (Community-Based Mental Health Services and Supports Standards) Suicide Prevention (Mental Health Services) Venous Thromboembolism Prophylaxis (Critical Care) Venous Thromboembolism Prophylaxis (Medicine Services) Venous Thromboembolism Prophylaxis (Surgical Care Services) Met 3 of 3 2 of 2 Met 3 of 3 2 of 2 Met 5 of 5 0 of 0 Met 5 of 5 0 of 0 Unmet 3 of 3 1 of 2 Met 3 of 3 2 of 2 Met 3 of 3 2 of 2 Executive Summary 16

22 1.6 Summary of Surveyor Team Observations The surveyor team made the following observations about the organization's overall strengths, opportunities for improvement, and challenges. The organization, Interior Health Authority is commended on preparing for and participating in the Qmentum survey process. There is a strong commitment from individual board members to the vision and mission of Interior Health Authority (IHA). There is an effective governance structure providing oversight on financial, quality management and patient safety. There is commitment to improving board effectiveness. The board is encouraged to create an opportunity for the senior Medical Health Officer to regularly report to the quality and safety committee of the board on Population Health issues and their statutory responsibilities. The mechanism could be similar to that for the internal auditor, and one of the first reports needs to be a comprehensive community health needs assessment with recommendations for action. This need was identified in the previous accreditation survey and more recently by the Provincial Health Officer. Interior Health Authority is recognized for its effective collaboration with Aboriginal communities and the newly established First Nations Health Authority. There are regular visits by the CEO and Board chair to the communities served by Interior Health, these visits focus on issues related to local facilities and services rather than community health status. A Community Engagement Strategy has been developed and IHA is encouraged to adopt this more formal community consultation and engagement strategy with communities around population health improvement and health services plans. The organization is also encouraged when it reviews its community health needs assessment to identify opportunities to address inequities in health status and health services. There is evidence of the impact of the new and energetic leadership. The chief executive officer (CEO) is committed to effective communication across all levels of the organization. There are effective processes and procedures for linking the strategic plan and priorities to operating plans and follow-up reporting/monitoring. The organization's leadership and commitment extends beyond healthcare, as shown by its commitment to minimize the organization's impact on the environment. The organization received the provincial Climate Action Secretariat award in There has been a concerted effort by medical and administrative leadership in developing and coordinating standardized and best operational practices across the IHA. Interior Health Authority's performance monitoring tool has been recognized by an award. The organization is encouraged to continue to expand access to the tool. The organization is encouraged to complete the roll out of the new structure which is, allied health and to make adjustments to address emerging issues. There is an opportunity for senior leadership to address work-life balance for front-line managers. This is a significant issue that links to recruitment and retention. The leadership team is encouraged to follow up on the recommendations of the internal auditor for a multi-year strategic plan for emergency preparedness. The plan needs to address consistency across the region and be inclusive of key community partners. The leadership team is encouraged to ensure that the new congestion strategies are effective in addressing over capacity issues in the long term. Executive Summary 17

23 The staff culture for the most part is good. Staff members support one another and are interested in participating in quality improvement activities. There is a culture of safety and learning. There are comprehensive human resources (HR) and communications plans. There is a comprehensive electronic information system that supports HR activities and streamlines processes and timelines. Online learning provides access to a wide range of education and development tools for staff and managers. There is concerted effort around team development and in responding to the Gallup results. The organization needs to look at how to address the fact performance appraisals are not being carried out regularly in many areas. There is also a need to recognize that staff are fatigued and becoming overwhelmed by the amount of new information, initiatives and guidelines and protocols. The IHA is encouraged to look at how its organizational development capacity can help respond to this change-fatigue that staff feel. The implementation of the patient safety learning system and medication reconciliation has had a significant positive impact on the delivery of safe and effective care. Implementation of the upgrades to the medi-tech system by Connex is a key initiative. The development of the HART transport teams facilitates transfer of patients from rural emergency departments (EDs) to regional centres. There has been standardization of equipment such as infusion pumps across the authority. The standardization process has included human factors analysis, which will help create a safer work/care environment for patients and staff. Staff members identified benefits from the regional networks that have been established and there exists opportunity to expand the networks to include other areas. There is also an opportunity to expand and standardize prevention programs such as for falls and pressure sores. The roll-out of the hand-hygiene program across the IHA also holds significant potential benefits. There is effective use of patient-view volunteers to incorporate the patient perspective in program and service planning. This commitment to including the patient perspective is also reflected in the wide variety of patient and family councils across various services. There is public participation on the ethics committees. There exists an opportunity to explore the feasibility of the patient follow-up at 24 hours and seven days post discharge, which is occurring at some sites and has proven effective in preventing readmissions. The IHA is encouraged to sustain its commitment to patient-centred care. Executive Summary 18

24 Section 2 Detailed Required Organizational Practices Results Each ROP is associated with one of the following patient safety goal areas: safety culture, communication, medication use, worklife/workforce, infection control, or risk assessment. This table shows each unmet ROP, the associated patient safety goal, and the set of standards where it appears. Unmet Required Organizational Practice Standards Set Patient Safety Goal Area: Communication Client And Family Role In Safety The team informs and educates clients and families in writing and verbally about the client and family's role in promoting safety. Critical Care 16.3 Verification Processes For High-Risk Activities The team implements verification processes and other checking systems for high-risk activities. Rehabilitation Services 15.5 Medication Reconciliation At Admission The team reconciles the client's medications upon admission to the organization, with the involvement of the client, family or caregiver. Ambulatory Systemic Cancer Therapy Services 9.14 Home Care Services 6.7 Rehabilitation Services 7.4 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). Obstetrics Services 12.3 Ambulatory Systemic Cancer Therapy Services 16.3 Home Care Services 11.2 Rehabilitation Services 11.3 Critical Care 12.5 Two Client Identifiers The team uses at least two client identifiers before administering medications. Emergency Department 10.4 Managing Medications 18.3 Dangerous Abbreviations The organization has identified and implemented a list of abbreviations, symbols, and dose designations that are not to be used in the organization. Managing Medications 10.2 Surgical Checklist The team uses a safe surgery checklist to confirm safety steps are completed for a surgical procedure. Obstetrics Services 9.9 Detailed Required Organizational Practices Results 19

25 Unmet Required Organizational Practice Standards Set Patient Safety Goal Area: Medication Use Infusion Pumps Training Staff and service providers receive ongoing, effective training for service providers on all infusion pumps. Critical Care 4.4 Long-Term Care Services 4.5 Home Care Services 4.6 Patient Safety Goal Area: Infection Control Infection Rates The organization tracks infection rates; analyzes the information to identify clusters, outbreaks, and trends; and shares this information throughout the organization. Infection Prevention and Control 1.2 Patient Safety Goal Area: Falls Prevention Falls Prevention Strategy The team implements and evaluates a falls prevention strategy to minimize client injury from falls. Ambulatory Systemic Cancer Therapy Services 21.2 Patient Safety Goal Area: Risk Assessment Venous Thromboembolism Prophylaxis The team identifies medical and surgical clients at risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) and provides appropriate thromboprophylaxis. Critical Care 7.5 Detailed Required Organizational Practices Results 20

26 Section 3 Detailed On-site Survey Results This section provides the detailed results of the on-site survey. When reviewing these results, it is important to review the service excellence and the system-wide results together, as they are complementary. Results are presented in two ways: first by priority process and then by standards sets. Accreditation Canada defines priority processes as critical areas and systems that have a significant impact on the quality and safety of care and services. Priority processes provide a different perspective from that offered by the standards, organizing the results into themes that cut across departments, services, and teams. For instance, the patient flow priority process includes criteria from a number of sets of standards that address various aspects of patient flow, from preventing infections to providing timely diagnostic or surgical services. This provides a comprehensive picture of how patients move through the organization and how services are delivered to them, regardless of the department they are in or the specific services they receive. During the on-site survey, surveyors rate compliance with the criteria, provide a rationale for their rating, and comment on each priority process. Priority process comments are shown in this report. The rationale for unmet criteria can be found in the organization's online Quality Performance Roadmap. See Appendix B for a list of priority processes. INTERPRETING THE TABLES IN THIS SECTION: The tables show all unmet criteria from each set of standards, identify high priority criteria (which include ROPs), and list surveyor comments related to each priority process. High priority criteria and ROP tests for compliance are identified by the following symbols: High priority criterion ROP MAJOR MINOR Required Organizational Practice Major ROP Test for Compliance Minor ROP Test for Compliance Detailed On-site Survey Results 21

27 3.1 Priority Process Results for System-wide Standards The results in this section are presented first by priority process and then by standards set. Some priority processes in this section also apply to the service excellence standards. Results of unmet criteria that also relate to services should be shared with the relevant team Priority Process: Planning and Service Design Developing and implementing infrastructure, programs, and services to meet the needs of the populations and communities served Unmet Criteria High Priority Criteria Standards Set: Leadership 4.3 The organization's leaders engage the community when planning services When developing the organization's vision and strategic plan, the organization's leaders incorporate the needs of the community and priorities set by government and other stakeholders. The organization's leaders share the mission, vision, and values with staff, service providers, clients and families, and stakeholders. The organization's leaders report on the organization's progress toward achieving the strategic goals and objectives to internal and external stakeholders and the governing body where applicable. The organization's leaders collect or have access to information about the community's health status, capacities, and health care needs. The organization's leaders share the information about the community with the governing body, staff and service providers, and stakeholders, including other organizations, clients, and families. The organization's structures and services or program areas are designed, implemented, and adjusted as required to support service delivery and achievement of the operational plans. The organization's leaders develop the community partnerships needed to efficiently and effectively deliver and coordinate services. The organization's leaders support and participate in ongoing community initiatives to promote health and prevent disease. Detailed On-site Survey Results 22

28 Standards Set: Public Health Services The organization carries out a complete community health assessment every three years. The organization reviews the community health assessment every year and updates it as necessary. The organization compares its health assessment data to data from other jurisdictions. The organization shares the results of the most recent community health assessment with key stakeholders and the general population using a variety of methods. The organization analyzes surveillance data to assess its impacts on community programs, relevant laws and regulations, and the community health assessment. The organization develops relevant partnerships needed to address community health needs. The organization's partners reflect the community's diversity The organization engages partners and relevant stakeholders in developing and implementing a community health improvement plan. The organization has a documented process to work with partners to establish priorities. The organization establishes a strategy and a timeline for involving different partners at different stages in community health improvement efforts. The organization and partners develop a communication strategy based on evidence, best practices, research, and the community health assessment. With its partners, the organization tailors the communication strategy to meet the needs of different target audiences and community groups. The organization and partners communicate essential public health information at multiple levels using appropriate language and different media. The organization regularly assesses the effectiveness of its communication strategy and uses this information to make improvements. The organization links with partners to coordinate and integrate services. 7.2 The organization acts as an advocate for healthy public policy in the community. Detailed On-site Survey Results 23

29 The organization involves and engages the community in the design of its services. The organization designs its services to target the health inequities and barriers to access identified in the community health assessment. The organization conducts a workforce assessment at least every three years to determine the capacity of its workforce and volunteers to meet community health needs. The organization develops and implements a plan to address workforce gaps. At least every three years, the organization evaluates the outcomes and impacts of its public health programs and services. Surveyor comments on the priority process(es) The CEO uses a variety of tools including face-to-face walk-abouts to communicate with staff and key stakeholders. There is strong support for the ethics framework. Although a community engagement framework has been developed, there is not a formal structured process for engaging with the community in the planning of services. Encouragement is offered to incorporate into the organization's formal planning structure, a formal approach to community engagement around population health improvement and the health services plan. Interior Health Authority is encouraged to complete a comprehensive community health needs assessment, with recommendations to provide a base for development of the population health improvement and health services plans. The planning processes link to the strategic plan, with the development of the operational and budget plan as well as identification of the outcome measures that will be monitored. There is a process to refresh plans annually in accordance with the directives received from the Ministry of Health. Managers have an opportunity to provide input to the planning process. Interior Health Authority has identified resources to assist with organizational change and design with the provision of consultation support as well as via i-learn modules and workshops. Consultants familiar with Lean process improvement are available to assist programs and services. For service planning initiatives, the IHA utilizes patient view volunteers. These individuals actively participate in service planning processes to ensure that planning is driven from the patients' perspective. Interior Health Authority is encouraged to increase its epidemiological capacity to improve its surveillance and health intelligence activities relative to its statutory responsibilities under the Public Health Act. Detailed On-site Survey Results 24

30 3.1.2 Priority Process: Governance Unmet Criteria High Priority Criteria Standards Set: Governance The governing body identifies and has access to the information it needs to support decision making. When developing or updating the mission statement, the governing body and the organization's leaders seek input from organization staff and stakeholders, including partners and clients. The governing body regularly consults with and encourages feedback from stakeholders and the community about the organization and its services. Surveyor comments on the priority process(es) The Ministry of Health specifies the roles and responsibilities of the Interior Health Authority. The Board Resourcing and Development Office of the government of BC is responsible for the appointment process and the code of conduct for appointees. The appointment process includes the appointment of the chair by the Minister of Health. Although the final decision and authority on appointments rests with the minister, the board regularly reviews its membership and identifies its needs for new members. The board chair communicates to the minister the board's recommendations for renewal of its membership. The appointment is for a three-year term with the opportunity for renewal. The board has established standing committees that are responsible for key functional areas such as finance and audit, quality and patient safety, governance and human resources, and stakeholder relations. All members of the board can attend the sub-committees although only appointed members may vote on committee matters. The board was involved in the review of the vision and mission. The development of the strategic directions was somewhat more challenging as the Ministry of Health specified the priorities and the board and senior leadership team worked to ensure alignment of the organization's priorities with the ministerial directives. There was one area of tension related to the ministry's focus on targets for hips, knees and cataracts. The senior leadership with the support of the board identified that the organization would not commit to meeting these targets because of the adverse impact that focusing resources on hips and knees would have on other priority health issues of the IHA. The ability to engage with clients on the updating of the mission statement was not possible. The board has access to information to support its decision-making in a number of its areas of responsibility. However, there is a major gap in that the board does not have a recent comprehensive population health needs assessment for IHA to allow a full understanding of the health determinants that are contributing to the lower life expectancy of 80.4 years, compared to other health authorities in British Columbia. The individual community profiles while useful for local engagement and discussion, do not fully replace the need for a comprehensive needs assessment to help guide the board in its decision making. Detailed On-site Survey Results 25

31 The board has implemented a system of electronically distributing the information for board meetings and has recently implemented a secure site on the IHA's internal website for board members' use. Good use is made of telephone and video conferences as well as face-to-face meetings to link board members and IHA staff members. The board has an established process for annual evaluation of the chief executive officer (CEO), based on mutually agreed performance objectives. All board members have an opportunity to provide input to the evaluation. Succession has been identified as a significant risk issue by the board and the CEO is required to provide regular updates on succession plans for all members of the senior leadership team. The board audit committee meets with the external auditor on a regular basis and at a minimum of three times a year to review the proposed audit plan and preliminary audit findings and the final audit report. In addition, the board also meets with and approves the work plan for the internal auditor. Recent internal audits have looked at the organization's regulatory responsibilities for protection of water systems, which was a source of political tension with some communities and the organization's emergency preparedness. There is evidence of the organization taking action or developing plans to take action on the recommendations of the internal audits. The board has identified depletion of its reserves. This was required to be able to initiate recent major capital projects in Kelowna and Vernon and constitutes as a major risk as it significantly constrains the board's ability to respond to emergent issues that may occur. Currently, the board is using any annual surpluses that may occur to rebuild their reserves. The second major financial risk identified is the projected shortfall in capital funding for building and capital equipment replacement. This is an issue for all health authorities in BC and they are working jointly with the Ministry of Health on a long-term strategy to address it. They are concerned that the shifting of capital to support high-profile capital projects has resulted in significant reduction in capital expenditures for equipment, information technology and other required capital facility projects. The board chair and CEO along with the appropriate board member for the geographical area tour each of the 59 communities served by IHA every year. There is a structured visit where they meet with physicians, IHA staff, Foundation and Auxiliaries, and tour IHA facilities and meet with local elected officials. This provides an opportunity to hear what the local concerns are and to communicate IHA's plans. Board members are also expected to met regularly with key individuals and groups in their geographical area to ensure that IHA has a good sense of the community's issues and concerns. The board is encouraged to consider establishing a similar formal process for engaging with communities on the Ministry of Health's initiatives for healthy schools and communities. Board members participate in recognition events for long-term service employees. Annually, the board members review their own performance, the chair's performance and the board's performance. Two changes in their functioning that came from their most recent evaluation were to consolidate committee and board meetings to be held over a two day period. This was done to be more effective with use of time and expenditures and also allowed board members to attend any of the committees in which they were interested. Detailed On-site Survey Results 26

32 3.1.3 Priority Process: Resource Management Monitoring, administering, and integrating activities related to the allocation and use of resources Unmet Criteria High Priority Criteria Standards Set: Leadership 8.4 The organization's leaders gather input from external and internal stakeholders to make resource allocation decisions. Surveyor comments on the priority process(es) There are established processes for operational and capital budgeting that link to the strategic plan, which occur as part of the regular planning cycle. Overall direction on the priorities and available funding is provided by the Ministry of Health. This direction is reflected both in the strategic plan and in the budget planning cycle. For new managers, there are a number of modules on the IHA's i-learn site that cover the financial essentials for which a new manager is expected to be competent. As well, each area is supported by a business analyst who is able to provide support on finance and budget related issues. There is input via the regional hospital districts, foundations and auxiliaries on the capital spending priorities, as a portion of the capital funding comes from the hospital districts. The processes include engagement with clinical leaders to understand their priorities. There is concern that the focus in recent years of capital expenditures on major capital building projects has compounded to the point that risks exist with capital equipment, information systems and other physical facilities. As well, in order to initiate capital projects, the organization has had to utilize its reserves, creating potential future risks. The organization is using program-based marginal analysis to identify areas for dis-investment and investment. It has expanded the use of a tool developed for capital expenditures for use in prioritizing operational expenditures. The organization is encouraged to review how population health status impact and reduction of health inequities is reflected and weighted in the prioritization process particularly given the limited opportunity to consult more broadly on allocation decisions. Detailed On-site Survey Results 27

33 3.1.4 Priority Process: Human Capital Developing the human resource capacity to deliver safe, high quality services Unmet Criteria High Priority Criteria Standards Set: Leadership The organization's leaders support leaders throughout the organization to develop their capabilities to promote a safe and healthy work environment. The organization's leaders monitor staff and service providers' fatigue and stress levels and work to reduce safety risks associated with fatigue and stress. The organization's leaders use a staffing process that is evidence-based and makes appropriate use of individual skills, education, and knowledge The organization's leaders implement policies and procedures to monitor staff performance that align with the organization's mission, vision, and values. Surveyor comments on the priority process(es) One of the organization's four strategic directions is to: "Cultivate an Engaged Workforce and a Healthy Workplace." The organization's initiatives in achievement of this goal include tactics to improve work attendance, implementing IHA-wide engagement and wellness strategy and enhancing leadership capability. The HR plan does indicate the intent in 2012/13 to offer managers workshops on work-life balance. In addition to offering this type of direct support to managers, the senior leadership team is encouraged to look at how it can better manage strategic initiatives and priorities to avoid excessive workload expectations and ensure that they are supporting an appropriate work-life balance. Interior Health Authority participates in the Gallup Poll survey as an alternative to the Worklife Pulse Tool. It recently conducted its first Gallup survey in March 2011 and had the highest level of participation of any health authority in BC. The survey identified that significant concerns in the areas the questions covered included whether staff knew what is expected of them at work and whether they have the materials and equipment that they require. The results of the poll were provided to managers along with tools and coaching for them to present the results to their staff and to develop action plans for the key areas of concerns identified by a manager's staff. Action plans have been developed by more than 97 percent of managers. In interviews with managers, some have identified that although plans have been developed that workload issues including the identification of new strategic priorities by their senior leadership have prevented them from following up on the plans. Concern was also expressed by other managers and in some cases their staff, about the workload expectations. In at least one case, this has resulted in a manager leaving their management position to take a staff position. Detailed On-site Survey Results 28

34 The organization has a dedicated program with two full-time equivalents (FTEs) and dedicated funding of $750,000 for the violence prevention program. Local occupational health and safety committees are involved in the risk assessments. The risk assessments also include a review of the physical facilities and grounds. Interior Health Authority is working with other health authorities to examine how reporting of incidents of violence involving staff and patients can be streamlined. Currently, it requires duplicate reports to be filed in the occupational health and safety system and in the patient safety learning system. This has led to delays in reporting in one of the systems from time to time. Detailed On-site Survey Results 29

35 3.1.5 Priority Process: Integrated Quality Management Using a proactive, systematic, and ongoing process to manage and integrate quality and achieve organizational goals and objectives Unmet Criteria High Priority Criteria Standards Set: Leadership As part of the integrated risk management approach, the organization's leaders develop contingency plans. The organization's leaders disseminate the risk management approach and contingency plans 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. The organization's leaders communicate the results of quality improvement activities broadly, as appropriate. Surveyor comments on the priority process(es) There is clear commitment to quality management and patient safety at the board and senior management team level. There is the commitment of significant resources to support integrated quality management. Staff members at most sites showed a commitment to quality and safety. The i-learn site provides resources for staff and managers. There is a strong team to support quality management across the organization. Implementation of medication reconciliation is proceeding across Interior Health Authority. As it is implemented by different programs and services, IHA is encouraged to review the specific medication reconciliation process used to determine that it accurately reflects the best possible medication history (BPMH). This will be important to avoid potential propagation of errors that in turn, erode the benefits of medication reconciliation. Interior Health Authority is encouraged to continue its collaborative efforts in quality improvement with the Ministry of Health and other health authorities and in its engagement with physicians. Efforts at strengthening disclosure capacity across the organizations should continue. Consideration should be given to more formal evaluation of how well quality improvement activities have been implemented across the various programs and sites. Detailed On-site Survey Results 30

36 3.1.6 Priority Process: Principle-based Care and Decision Making Identifying and making decisions about ethical dilemmas and problems The organization has met all criteria for this priority process. Surveyor comments on the priority process(es) Policies governing clinical ethics and research ethics have been in place since 2005 and are regularly reviewed. Recently, the senior executive approved implementation of an integrated model with an integrated ethics council to incorporate clinical and research ethics. Council membership is currently being selected and includes representation from quality, risk, finance and evaluation. Identification of an executive lead is also currently underway. The integrated model includes a decision-making model and has been designed, based on a review of leading practices across the country. The research ethics board (REB) has been operational since The REB reviews research proposals, provides education and consultation to researchers and monitors trends. The board provides reports to the medical advisory committee twice per year and has a liaison member from the governance board. The chair of the REB also chairs the provincial BC ethics harmonization initiative which is working toward greater collaboration between research ethics bodies and reducing duplication for multi-region and multi-sectoral research. The REB works in collaboration with the University of British Columbia (UBC) research ethics body. The REB is cognizant that new medical school seats will increase research activity over the next two years and has entered an agreement with UBC for ethical review of family medicine resident research projects to reduce duplication. The board of directors and senior executive team use the organizational values as an ethical lens and guide when making administrative and resource allocation issues. The organizational values were established in 2006 and are reviewed and validated by the board annually. The board expressed its commitment to do what is right. Clinical ethics is guided by an IHA clinical ethics committee and six local clinical ethics committees. Chairs of the six local committees are included in the membership of the health authority-wide committee. The IHA clinical ethics committee provides standardization across the province and takes the lead on capacity building by way of education. An annual ethics week is held including education sessions based on trending and informal needs analysis. In addition, the region hosted a national conference on ethics and provided resources for attendance by representatives of the six local committees which then spread their acquired knowledge locally. The six local committees provide clinical ethics consultation on request by clinicians. Ethics consultations are escalated to the region- wide committee if particularly complex or have regional or provincial implications. One example given was a consultation over the use of medicinal marijuana in residential care settings where smoking policies and other policies were incongruent with the resident need. Consultations can take place within 24 hours either in person or via teleconference based on the level of urgency identified by the clinician. The local clinical ethics committees also strive to build front-line capacity for ethical decision-making and recognizing an ethical dilemma. Examples were observed in residential care in which the local manager had independently and effectively used ethics consultation methodology with her team regarding decisions for a resident wishing to live at risk for choking. Detailed On-site Survey Results 31

37 The clinical ethics committees are cognizant that membership is primarily stable and experienced. Strategies for attracting new members from a succession planning and 'sustainability' perspective are encouraged. The organization has access to qualified clinical ethicists via contracts. A budget is designated for ethicist consultation and is adjusted as necessary to ensure that financing is not a barrier to accessing the ethicist when needed. Consideration is currently being given to acquiring a dedicated ethicist for the IHA. While the chairs of the six local committees work collaboratively, the team is encouraged to consider additional mechanisms to make the learning and experience of one local committee more readily available to the others. The team is currently considering appropriate methodologies for documentation of clinical ethics consultation both on the clinical record and administratively, including the potential for a central repository of consultations. Detailed On-site Survey Results 32

38 3.1.7 Priority Process: Communication Communicating effectively at all levels of the organization and with external stakeholders Unmet Criteria High Priority Criteria Standards Set: Leadership 7.5 The organization's leaders seek input from stakeholders on a regular basis to evaluate the effectiveness of their relationships with them. Surveyor comments on the priority process(es) There is a communications plan for 2011/12 to 2013/14 and it was updated in September, Its strategic objectives include strengthening internal communications and keeping government, municipalities, stakeholders and the public informed of changes in health services. Objectives also include developing effective strategies for IHA annual priorities, developing strategies for health promotion and strengthening government relations. For community engagement, communications is in more of an advisory role. The perspective is that each of the managers is responsible for engaging their respective community. A resource document on community engagement is available. The focus is to have the community managers responsible for discussing with their local community. The internal website has been redesigned, with the intent to make it more interactive to increase staff engagement. A policy has been developed that provides a framework for staff around the use of social media. Two hundred and fifty people have been trained in the appropriate use of social media via an electronic learning module. It is expected that social media is built into every communication plan. Other communication tools to support staff include Sharepoint communications sites for teams and the clinical practices website. Communications is actively involved in support of the Gallup Poll. There are well-established policies for responding to media inquiries and for every issue it is assessed for who is the best spokesperson. Support is provided to coach the person that does the interview and to monitor the interview. Media training is provided. If there are service changes such as temporary suspension of services, there is a formal process for announcing service changes. Tweets are issued after the media release has occurred. Interior Health Authority is exploring the possibly of a blog. One model under consideration is that of Vancouver Coastal Health Authority, which has an executive blog that it shares. Note is made of the leadership link, which is a quarterly conference call with the CEO since 2006 and it has been evaluated. People wanted more options for asking questions. Detailed On-site Survey Results 33

39 The organization uses patient voice volunteers as a mechanism for ensuring that the patient s perspective is included in service planning. Impact BC is the contact to identify potential contacts. It is a network of trained volunteers. A patient voice volunteer described their experience with the shared care committee to look at improvements in the referral processes from general practitioners (GPs). The work has also resulted in the development of a patient tool for patients to manage their own care. The IHA has been proactive about including the patient s perspective in their service planning activities. With the diabetes strategy there are three to four persons that represent the patient perspective. The patient voice volunteer indicated seeing their own words in the document and being taken seriously. In fact, the mission statement was rewritten from the patients' perspective. The patient went from the bottom of the document to the top and content changed from a passive voice to an active voice. Further, it was commented by a client that IHA does not toot its own horn enough and that often, people are surprised about IHA initiatives. Detailed On-site Survey Results 34

40 3.1.8 Priority Process: Physical Environment Providing appropriate and safe structures and facilities to achieve the organization's mission, vision, and goals The organization has met all criteria for this priority process. Surveyor comments on the priority process(es) Interior Health Authority demonstrates a commitment to maintain a safe and comfortable physical environment for those who receive services and/or work in the physical spaces. The scope and variety of services offered in both new and modern buildings and the constraints of old or outdated infrastructure, and often operating side by side with shared mechanical systems, make this an ongoing challenge for the organization. There is evidence of significant capital investment across IHA, with numerous infrastructure projects recently completed, currently in progress and/or planned for future implementation. The organization is commended on the completion of the major projects at Kelowna, Vernon and Nelson. Proposals have been submitted for further renovation and site improvements to address aging infrastructure and increased service demands on many sites across the region. There is a well-defined capital planning process in place. Resources for capital investment are limited and the organization has entered into effective 'P3' partnerships as a means for moving forward with several major capital initiatives. Lack of space in patient care areas, especially in the four bed areas in the older facilities/units, creates challenges for safety in provision of clinical care. This is further compounded by working at an overcapacity status at many of these sites. Cramped space in patient bathrooms in these rooms create hazards for patients that need assistance to ambulate and the staff that assist them. A shortage of storage space was noted across sites and service areas resulting in having organized clutter in hallways, creating a potential risk for patients and staff working in these areas. Managers and staff are aware of the safety risks associated with these space challenges and work together to maximize comfort and safety for everyone within these constraints. Pharmacy space at many sites was identified as inadequate, leading to ongoing challenges in providing safe and appropriate medication management. Lean projects have been utilized in some areas for example, in the laboratory at Cranbrook, to reorganize workspaces to maximize efficiency and effectiveness in the use of available space. In Vernon and Nelson, issues were identified with a lack of signage regarding the changes in how the public were to enter newly renovated buildings. Managers are aware of the risks and potential safety and these will be addressed. The smoking policy is not enforced consistently across the region and at some sites such as at Shuswap, patients regularly go outside the hospital and on hospital grounds to smoke. At sites where security is provided, this is done by a contracted service. Hours of coverage range from 24/7 to none. Processes are in place where there is no security on site to ensure that access to the buildings is appropriately restricted. Swipe cards are widely used to control access to both exterior and interior doors. Detailed On-site Survey Results 35

41 Code white teams are in place and there is training provided for management of aggressive behaviour. Fire safety training is conducted across the organization and full tests are conducted regularly at some sites. Fire drills are not consistently performed during off hours. Follow-up debriefing of staff post drill is not consistent in Vernon. There was a small fire at the Kelowna General Hospital during the on-site survey. Staff members on the unit responded quickly and appropriately. A review of the situation is underway and the organization is encouraged to use this as a learning opportunity for staff across the site and region to reinforce their fire training. It was noted that young volunteers in the gift shop were uncertain about how to respond. There is a comprehensive project planning approach for construction and renovation projects. This includes involvement of infection control from the beginning of the project and inclusion of appropriate stakeholders during the project. Staff indicated that for the most part, their input was sought and heard. There was evidence of compliance to infection control standards during construction during site tours. Attention is paid to scheduling and staging projects for minimizing impact on care delivery. Interior Health Authority is commended for its ongoing leadership and commitment to 'environmental sustainability'. This has been recognized nationally with the Energy and Environmental Stewardship award from the Canadian College of Health Leaders in 2011 and provincially, with the Climate Action Secretariat award in There are numerous energy conservation initiatives across the organization, including solar thermal hot water heating, geothermal heating and cooling and the use of a fleet of green vehicles. There is a commitment to achieving LEED standards for all new construction. Detailed On-site Survey Results 36

42 3.1.9 Priority Process: Emergency Preparedness Planning for and managing emergencies, disasters, or other aspects of public safety Unmet Criteria High Priority Criteria Standards Set: Emergency Department 2.5 The team has an emergency preparedness plan and is trained and equipped to manage disasters and emergencies. Standards Set: Infection Prevention and Control 14.6 The organization coordinates its planning for pandemics and outbreaks with its overall planning for disasters and emergencies. Standards Set: Leadership The organization's leaders develop, implement, and evaluate an all-hazard disaster and emergency response plan to address the risk of disasters and emergencies. The organization's leaders align the organization's all-hazard disaster and emergency response plan with those of partner organizations and local, regional, and provincial governments. The organization's leaders provide access to education to support the all-hazard disaster and emergency response plan. The organization's leaders regularly test the organization's all-hazard disaster and emergency response plans with drills and exercises to evaluate the state of response preparedness. The organization's leaders use the results from post-drill analysis and debriefings to review and revise if necessary its all-hazard disaster and emergency response plans and procedures. The organization's leaders develop and implement an incident management system to direct and coordinate actions and operations during and after disasters and emergencies. The organization's leaders develop and implement an emergency communication plan. The organization's leaders develop and implement a business continuity plan to continue critical operations during and following a disaster or emergency. The business continuity plan addresses back-up systems for essential utilities and systems during and following emergency situations. Detailed On-site Survey Results 37

43 Standards Set: Public Health Services The plan is developed with partners from all levels and sectors, and is aligned with the provincial or territorial emergency response and preparedness plans. The emergency response plan defines the roles, functions, and responsibilities of the organization and its partners in an emergency, and identifies a clear chain of command. The plan identifies the conditions that trigger implementation of the plan The plan clearly outlines protocols for emergency responses The organization annually tests the plan using one or more simulations The organization, with its partners, reviews and revises the plan at least every two years, and more often if necessary. Surveyor comments on the priority process(es) Emergency management has developed a number of tools to help support managers in the development of their emergency response plans for their respective facilities. The provision of a common template has allowed for standardization of the code response across Interior Health Authority. These tools are available on the internal website. Emergency preparedness uses Sharepoint for documentation during an incident and afterwards for debriefing. The IHA recently participated in a multi-agency plan involving the Kelowna Regional Airport. This provided an opportunity to test the mass casualty plan for the Kelowna General Hospital, as well as response by Public Health to concerns about contamination arising from the incident. While there is a strong and effective working relationship with the city of Kelowna and the surrounding communities on emergency preparedness and response, there is a need for IHA to develop similar relationships with other community groups across all its region. There is a need for Emergency Management (EM), Senior MHO Office and Health Protection to discuss roles, responsibilities and accountabilities. A number of the tools and resources that have been developed focus on the development of site based plans. The Emergency Management team is focused on working with sites and facilities. The team is encouraged to identify its role in supporting the development of emergency response plans for community based services and contracted facilities. Gaps in emergency response planning were also identified in the review carried out by the Internal Auditor of IH's emergency response capability. Encouragement is offered to continue to take action on the recommendations of the internal audit of the emergency preparedness capacity that was carried out. Detailed On-site Survey Results 38

44 Priority Process: Patient Flow Assessing the smooth and timely movement of clients and families through service settings Unmet Criteria High Priority Criteria Standards Set: Emergency Department The team collaborates with its partners to provide access to the full spectrum of emergency services. The team quickly recognizes overcrowding in the Emergency Department and follows protocols to move clients elsewhere within the organization. Surveyor comments on the priority process(es) The organization has initiated several processes to address challenges to patient flow. A BC ambulance decision-making committee reviews ambulance delays, financial implications and alternatives to barriers for efficient transport and transfer. The acute care partnership committees (ACPC) involving all levels of staff collaborate on the management of patients and processes to support effective bed management. There are individual ACPCs in Kamloops, Vernon, Kelowna and Penticton. This process in conjunction with congestion monitoring involving the eight largest hospitals with 3-hourly updating of bed occupancy, over capacity huddles, ALC scorecards and daily patient flow meetings have proven successful in some facilities such as Penticton but less so in others such as Kelowna. Community and residential contacts work effectively with acute care services to identify patients for transfer and facilitate the same. Residential assessors come into the Penticton hospital to complete assessment to support streamlined transfers Barriers that complicate transfers to residential care homes include restrictions in admission hours, and coordination of physician orders. The appointment of a "doctor of the day" has made the discharge process more effective. These initiatives are commended and have effectively assisted in the efficient management of beds in South Okanagan. It will be important that the learning from this process be shared and assimilated by other centres for equal effect. Despite the obvious tracking and problem-solving being used to address and facilitate an effective patient flow strategy, there are varying degrees of success in some facilities. It is apparent that efforts in Kelowna need to be increased so that the impact on the ED can be resolved. Information is shared from ED to the bed mapping coordinators so that the organization is aware of impending admissions. A CQI initiative is to commence soon (September 28). This is an access and flow improvement project involving all partners and will utilize process mapping to determine barriers to successful patient flow and to address same. Detailed On-site Survey Results 39

45 Priority Process: Medical Devices and Equipment Obtaining and maintaining machinery and technologies used to diagnose and treat health problems Unmet Criteria High Priority Criteria Standards Set: Operating Rooms 13.6 The team verifies that surgical equipment or medical devices returned to the operating room following repair or replacement are clearly marked with the date and a signed notice describing the maintenance or purchase. Standards Set: Reprocessing and Sterilization of Reusable Medical Devices The organization regulates the air quality, ventilation, temperature, and relative humidity, and lighting in decontamination, reprocessing, and storage areas. The medical device reprocessing department is equipped with hand hygiene facilities at entrances to and exits from the reprocessing areas, including personnel support areas. Staff members have access to the supplies needed to support proper hand hygiene, including properly supplied and functioning soap and towel dispensers or waterless, alcohol-based hand rubs in the working environment. Surveyor comments on the priority process(es) The creation, structure and evolution of the medical device reprocessing (MDR) network have focused appropriate attention on a high- risk area of the organization. Biomedical, plant services and infection prevention and control (IPAC) representatives on the organization's MDR network agreed the process for prioritizing medical devices and equipment is clear and smooth at the site specific and regional levels with input from front-line users. The process ensures that potential gaps in areas such as training end-users, servicing, infection control, cleaning and physical renovations are addressed prior to purchase. Biomedical staff have a system to assess servicing costs for new medical devices and equipment that objectively helps determine whether or not the preventive maintenance (PM) and repairs can be efficiently done in-house and if not, or the human resources are unavailable in IHA, a service agreement is arranged with an external provider. Plant services, biomedical staff members and managers monitor the age of medical devices and equipment and assist in making decisions about replacing equipment. Utilization reviews on equipment such as ventilators and dialysis machines such as hours of use are closely monitored. The PM program for identified medical devices and equipment is automated at Kelowna, Vernon, Penticton, and Shuswap hospitals, which were the sites visited during the survey. There are audits done to determine whether or not scheduled PMs are being done in a timely way. Detailed On-site Survey Results 40

46 The patient safety learning system (PSLS) is used to communicate device failures and staff are familiar with the system. In Vernon and Kelowna, a coloured sticker is used and left in departments to indicate the response to a work order or complete a work order. The form has the work order number on it and a telephone number to call should the manager want to call plant services for follow-up. Using the PSLS system and online resource, the safety alert, there is an expectation that follow-up is noted thus, completing the loop and ensuring the issue has been followed up and resolved. However, not every site has this mechanism of communication and follow-up. Some sites relied on verbal communication with the person in the department at the time the device was being returned. At Kelowna, Vernon, Penticton and Shuswap Hospital - Salmon Arm, contaminated instruments were transported in closed containers or bins and in closed carts. The carts were either covered, or had a waterproof cover that is wiped down after every transport. The plan is to replace the carts with covers, with contained stainless steel carts. At Vernon, the MDR department uses a clear plastic cart cover to enclose its clean delivery cart when delivering to the ER, ICU and non-or areas. It is cleaned with Everyday Disinfectant and affords clear line of sight for the person delivering the trays/instruments. The MDR network has a comprehensive quality assurance plan, written in 2009 and reviewed in The network supports re-processing staff by providing education such as MDR refresher courses for staff whose original certification is older than five years as well as supporting specialty. All staff members working in MDRs must have certification in re-processing and sterilization. There has been interest and good uptake of Canadian Standards Association (CSA) certification with 17 to date and a plan to offer up to 80 more spots for certification in the coming year). Staff members that have demonstrated an initiative to gain CSA certification would be good candidates for mentoring and buddying new staff. The MDR network has also developed a regional template for identifying tray contents and appropriate cleaning and sterilization of instruments and devices. This is being rolled out across the authority, with a longer term plan to automate these procedures thus, making updates and standardization easier to manage. There is a clear process across the organization for receiving, inventorying, checking/calibrating in-servicing and delivering new devices and equipment. The organization is encouraged to continue its work on competency assurance among MDR workers to ensure annual competency evaluations are done for MDR staff members. There is value in standardizing orientation and inservices/education by way of checklists and written outlines, particularly if a variety of staff members are carrying out this function. While records are kept on names of employees that attend inservices and education, it is difficult to determine without extensive manual effort who has not attended training. It is recommended that the organization look at electronic tracking of education that clearly identifies who has and who has not attended inservices and especially education that is considered mandatory. At one site namely, Kelowna the MDR in OR is undergoing renovation and MDR staff were not aware of where the eye wash station was located. In areas where renovation or changes are in progress staff members require updated information on safety and high-risk procedures. As renovation plans proceed to expand activity such as surgery that impacts MDRs, the organization is encouraged to analyze traffic and work flow patterns as well as capacity. There was concern expressed at Kelowna and Vernon hospitals that additional ORs will put major pressure on current MDR space and storage. A recent review of work flow done at Vernon MDR may offer alternatives and require changes to the way work is currently done. Detailed On-site Survey Results 41

47 At Shuswap Hospital, the MDR work area counters need replacement. In Penticton, the dirty and clean carts are transported in the public elevators. Space limitations and age of some facilities are having an impact on ability to meet standards. Further work on standardizing OR instrumentation for example, orthopedics in Trail is to be encouraged. Detailed On-site Survey Results 42

48 3.2 Priority Process Results for Population-specific Standards The results in this section are grouped first by standards set and then by priority process. Priority processes specific to population-specific standards are: Chronic Disease Management Integrating and coordinating services across the continuum of care for populations with chronic conditions Population Health and Wellness Promoting and protecting the health of the populations and communities served through leadership, partnership, and innovation Standards Set: Child and Youth Populations Unmet Criteria High Priority Criteria Priority Process: Population Health and Wellness The organization seeks input from the children, youth, and families it serves to identify service needs. The organization uses the clinical information system to generate regular reports about performance and adherence to guidelines, and to improve services and processes. The organization monitors and validates the quality of data in the clinical information system. The organization obtains feedback from clients about their perspectives on the quality of its services for children, youth, and families. Surveyor comments on the priority process(es) Priority Process: Population Health and Wellness The staff team members are professional, competent, caring and resilient. The program leadership strives to improve quality and to focus on outcomes. Based on the new Ministry directions for programming, adaptations to the IH context will further enhance inter-sectoral collaborations to lead to better health. There is a need for further development of innovative methods for seeking client (and staff) input and for in-depth program measurement, monitoring and evaluation. The team is encouraged to continue to gain a deeper understanding of the barriers for accessing services for vulnerable populations, with a focus on building overall health equity. Detailed On-site Survey Results 43

49 3.2.2 Standards Set: Mental Health Populations Unmet Criteria High Priority Criteria Priority Process: Chronic Disease Management The organization collects information about the service needs of mental health populations in the community. The organization uses the information it collects to classify populations according to the need for programs and services. The organization sets measurable and specific goals and objectives for its services for mental health populations. The organization collaborates with community partners to provide health promotion and illness prevention services for populations with or at risk for mental illness. The organization encourages and participates in community action to promote health, prevent disease, and support the community to manage its own health. The organization shares benchmark and best practice information with its partners and other organizations. The organization uses the clinical information system to establish service priorities by classifying clients according to condition and other factors such as co-morbid conditions. The organization uses the information system to generate regular reports about performance and adherence to guidelines, and to improve services and processes. The organization identifies and monitors performance measures for mental health services. The organization obtains feedback from clients about their perspectives on the quality of its services for mental health populations. The organization has regular consultations with its partners to collect information, identify gaps in the continuum of care, and make improvements to services for mental health populations. The organization compares its results with other similar interventions, programs, or organizations. The organization shares information about its successes and opportunities for improvement, improvements made, and future plans with staff, service providers, clients, and families. Detailed On-site Survey Results 44

50 Surveyor comments on the priority process(es) Priority Process: Chronic Disease Management Over the past two years, the MH/AOD service providers indicated they are experiencing a growing disconnect in planning between the providers of Mental Health services in the community, acute and tertiary care systems. Although through the introduction of the automated record, providers indicated client information moves more consistently and transparently between these systems. It should be noted the integration of services between MH/AOD, Primary Health and Home Care has been strengthened. Throughout the survey, staff indicated access to expertise and services between these programs has improved and there is a recognition many of the Mental Health clients usually require services from more than one provider. Community staff can discuss complex cases as a team and provide services which are more appropriate and timely to these clients than they did before. There is a perception by the community partners and staff that there is no short and long term plan for Mental Health/ Alcohol and other Drugs in the region. They indicated they have not been involved in any planning activities and they are not aware of a strategic plan for Mental Health and Alcohol and other Drugs by the IH, other than the provincial governments plan entitled "Healthy Minds, Healthy People, A Ten-Year Plan to Address Mental Health and Substance Use in British Columbia." Partners and staff also indicated that communication from the senior management on Mental Health expectations, objectives and activities appeared to be focused on acute care issues only. There are activities for health promotion and prevention directed at mental health centred around print and television media. Given the demographics and technology changes taking place, the IH may want to examine opportunities in social media, as that appears to be where more individuals are seeking information about their health and available services in their community. Detailed On-site Survey Results 45

51 3.2.3 Standards Set: Public Health Services Unmet Criteria High Priority Criteria Priority Process: Population Health and Wellness The organization's health promotion activities are based on priorities identified in the community health assessment and population health improvement plan. The organization regularly assesses the impacts of its health promotion activities on the intended outcomes. The organization's injury prevention activities are based on priorities identified in the community health assessment. The organization has a process to maintain continuity of operations and restore time-critical services. When evaluating its services, the team involves clients, families, and other organizations. The organization uses its evaluation results to develop a quality improvement plan. Surveyor comments on the priority process(es) Priority Process: Population Health and Wellness The staff team members are professional, competent, caring and resilient. The program leadership strives to improve quality and to focus on outcomes. There are longstanding and diverse partnerships with community agencies, including a growing connection with First Nations' Communities. The team is encouraged to publish a Senior Medical Health Officer's Health Status Report, with recommendations for action, to further inform health system and community planning. There was little evidence that the Medical Health Officers, as community medicine specialists, are utilized to reorient health care services toward prevention of illness and promotion of health. It is needed to undertake an internal review of Health Protection due to the recent reallocation of resources and the growing demands (e.g. 212 new facilities). Staff also noted that access to pool fleet vehicles is negatively impacting productivity for demand/complaint work that cannot be pre-scheduled. The team is encouraged to further develop innovative methods for seeking client (and staff) input and for in-depth program measurement, monitoring and evaluation. Detailed On-site Survey Results 46

52 3.3 Service Excellence Standards Results The results in this section are grouped first by standards set and then by priority process. Priority processes specific to service excellence standards are: Episode of Care - Ambulatory Systemic Cancer Therapy Healthcare services provided for a health problem from the first encounter with a health care provider through the completion of the last encounter related to that problem. Clinical Leadership Providing leadership and direction to teams providing services Competency Developing a skilled, knowledgeable, interdisciplinary team that can manage and deliver effective programs and services Episode of Care Providing clients with coordinated services from their first encounter with a health care provider through their last contact related to their health issue Decision Support Using information, research, data, and technology to support management and clinical decision making Impact on Outcomes Identifying and monitoring process and outcome measures to evaluate and improve service quality and client outcomes Medication Management Using interdisciplinary teams to manage the provision of medication to clients Organ Donation Providing organ donation services for deceased donors and their families, including identifying potential donors, approaching families, and recovering organs Infection Prevention and Control Implementing measures to prevent and reduce the acquisition and transmission of infection among staff, service providers, clients, and families Surgical Procedures Delivering safe surgical care, including preoperative preparation, operating room procedures, postoperative recovery, and discharge Standards Set: Ambulatory Care Services Unmet Criteria High Priority Criteria Detailed On-site Survey Results 47

53 Priority Process: Clinical Leadership Priority Process: Competency The organization has met all criteria for this priority process. 4.9 Team leaders regularly evaluate and document each team member's performance in an objective, interactive, and positive way. Priority Process: Episode of Care The team receives clients at the service area in a manner that respects their privacy and confidentiality. The team monitors and works to reduce the number of clients who fail to present at scheduled appointments. The team updates the client's service plan and shares the information in a timely way with the client's other service providers, in accordance with privacy legislation. The team tells clients and families what to expect during transition or end of service. Following transition or end of service, the team contacts clients, families, or referral organizations to evaluate the effectiveness of the transition, and uses this information to improve its transition and end of service planning. Priority Process: Decision Support 14.2 The team meets applicable legislation for protecting the privacy and confidentiality of client information. Priority Process: Impact on Outcomes 17.7 The team follows the organization's policy and process to disclose adverse events to clients and families. Surveyor comments on the priority process(es) Priority Process: Clinical Leadership The renal program has recently undergone a senior leadership change, and the director and medical director were appointed less than one year ago. This, coupled with the organization's structural change to a full program management model for all of IHA will provide opportunities for both staff and patients to improve patient care. The team acknowledges this transition has been challenging however, the rewards are evident in terms of consistency of practice, better program planning and overall organization of the work load. Staff engagement plans have been enacted, and the increased visibility of the local leadership is appreciated. The renal program is a complicated program to deliver from a service model perspective because of the numerous sites where services are delivered with relatively low patient volumes. Economies of scale can not be realized because of this service delivery model however, the delivery of services close to the patients is necessary to provide quality and patient-centred care. Detailed On-site Survey Results 48

54 It is suggested that the leadership review the management model for the East Kootenays, as the span of control for the in-scope manager who services the sites is large. It includes community dialysis units, chronic kidney disease clinics, transplant and home programs, which makes it too large to service both the needs of the staff and patients adequately. Because of the size of the geographic area that requires coverage, the current in-scope manager is often 'crisis' managing, spending a large majority of her time ensuring appropriate staffing at each of the sites to ensure consistent service to the patients. This is complicated by the current vacancy in the patient care coordinator position for the in-site unit. During the episode of care at both East Kootenay Regional Hospital and Kootenay Boundary Regional Hospital considerable frustration was expressed with the current processes in the staffing office. Many examples were cited regarding lack of consistent and timely filling of staff vacancies, multiple levels of paperwork and general lack of trust in the system. In both the renal and medicine programs the mangers choose to call their own staff to fill vacancies due to the currently strained relationship. It is suggested that work flow analysis and process improvement work be continued to reduce the frustration and potentially, reduce the number of overtime shifts. From the sites that were visited there does not appear to be any access problems for patients to receive the desired form of dialysis. There appears to be sufficient capacity for haemodialysis. Kamloops was identified as an area of reduced access however, there will soon be a community dialysis centre opening in north Kamloops, which will enhance care. Kelowna General Hospital has identified the need to develop a policy to assist with the decision to dialyse patients who travel for short periods, from other centres both within and outside of British Columbia. This will assist other facilities of the program to ensure safe patient care. The organization is encouraged to review the span of control for managers who cover several sites, along with the challenges facing the renal program. The organization is commended for the roll-out of the 'save the vein' bracelet program, and from talking with patients and staff it has been very well received. Priority Process: Competency The renal program held an education event in the last year whereby the staff travelled to a central location to receive training. This was well-received by the staff and the organization is encouraged to undertake this type of event regularly. It is evident that there are different models of care at each of the sites visited, and no standardized approach. All of the staff members approached identified that there was an appropriate amount of educational opportunities available and that education was indeed supported. Priority Process: Episode of Care Episodes of care were carried out at the East Kootenay Regional Hospital, Kootenay Boundary Regional Hospital, Kelowna General Hospital and Royal Inland Hospital. The care provided is of high standard and patient experiences are reported as favourable. Detailed On-site Survey Results 49

55 The leadership team is encouraged to review the care model along the continuum for the plan of care. It was observed that there is a lack of consistency in terms of patient access to professionals to assist with the plan of care for the patients. Specifically, observations were made in four areas. First, hemodialysis patients at East Kootenay Regional Hospital and Grand Forks have access via telehealth to both social work and dietician coverage. The team reports that this is infrequently utilized by the patients. Second, the chronic kidney disease clinic (CKD) patients at East Kootenay Regional Hospital have in-person access to a dietician and social worker but their services are not available to the 'Hemo' patients. Third, the nephrologists are only accessible via teleheath to patients at East Kootenay Regional Hospital. The team reported that this is a new occurrence, and no in-person visits have occurred during the last 18 months to two years. Fourth, transplant and home dialysis patients are required to travel from Cranbrook to Trail for in-person follow-up by the nurse and nephrologists and no telehealth is utilized. It is understandable that there is significant utilization of telehealth due to the size of the region and distances that need to be travelled. However, there appears to be no standard as to how teleheath is used and in what situation and that in-person care would be more acceptable. Most notably, is the lack of in person nephrologists coverage and lack of continuity for patients' transition from the chronic kidney disease (CKD) clinic to dialysis. It is suggested that a standard be developed as to the number of in-person visits versus telehealth. There appears to be different models of clinic delivery at the sites visited. At Kootenay Boundary, the staff informed the surveyor that the multidisciplinary team meets with the patient together to evaluate the plan and determine the plan of care. At the other CKD clinics visited, care is delivered by having the patient travel from practitioner to practitioner. Kelowna does attempt to identify the patient goals using a "clinic visit questionnaire", with inconsistent results. The organization may consider conducting either patient focused groups or surveys to gain the patient perspective and develop a standard for the delivery of care and improved communication. At Royal Inland Hospital social issues about the patients are not documented but are known by the staff and a small number of people who see every patient. This may be an area that the organization would choose to review to ensure consistency across the region, as well as to ensure appropriate communication. There is a lack of consistency as to the forms used at some of the sites. Kelowna General Hospital uses a different flow sheet from the East Kootenays flow sheet. It is acknowledged that work is underway to standardize the report. In addition, the Provincial Renal Program is working on standardized care maps, which will enhance the care for the renal population. The renal program will be undertaking several projects to enhance the patient experience. Most notably, Rutland and Vernon will be piloting an innovative project titled "Involved Care" to promote independence and the implementation of advanced care planning. Priority Process: Decision Support There are numerous indicators and information provided to the renal program to aid in both day-to-day decision-making and overall program planning. The indicators include those of the BC Renal Agency, IHA performance dashboard and the renal health record named PROMIS. In particular, the organization is complimented on achieving a 38 percent home haemodialysis start rate. Detailed On-site Survey Results 50

56 Program-specific indicators to aid service delivery may be considered. For example, it was expressed at all of the sites visited that vascular access is sometimes difficult to attain in a timely manner. However, there is no benchmark identified from time of referral to achieving the required procedure. At Kelowna General Hospital in particular, the team meets with the surgeons when the list becomes a concern. The renal program is encouraged to develop a benchmark to measure the indicator and develop processes when to achieve the desired outcome. Likewise, workload indicators for allied health in particular may be considered. Priority Process: Impact on Outcomes The BC Renal agency identifies a number of indicators to be monitored that impact patient outcomes. The outcomes evaluated span the continuum of care. It is evident that there is a culture of safety from the interviews conducted with staff and management. Regular discussions occur with staff to address specific safety issues and there is utilization of the patient safety and reporting system. There is evidence of follow up of the occurrences reported by the patient care coordinator and managers. The staff members felt they could bring issues forward and they would be addressed. There is some need identified to improve the disclosure of error to patients. One area of concern for this patient population is the long distances that must be travelled regularly to attain service within the renal program on a regular basis. The social workers all report that they spend the majority of their time associated with finding support for travel and accommodation. The renal program is currently focusing all of their efforts on the treatment of kidney disease. The plans reviewed from IHA do not appear to address providing methods or strategies to reduce the onset of renal disease. There does not appear to be any links to other chronic disease populations such as diabetes or hypertension patients. Some of the sites have taken part in community events to increase their knowledge of renal disease however, this is sporadic and not part of a strategic plan. This may be an area of consideration for future planning efforts. Detailed On-site Survey Results 51

57 3.3.2 Standards Set: Ambulatory Systemic Cancer Therapy Services Unmet Criteria High Priority Criteria Priority Process: Episode of Care - Ambulatory Systemic Cancer Therapy 9.14 When medication therapy is a significant component of care, the team ROP reconciles the client's medications with the involvement of the client, family or caregiver at the beginning of service. Reconciliation should be repeated periodically as appropriate for the client or population receiving services The team provides documented rationale for the selection of target clients or populations to receive formal medication reconciliation The process is a shared responsibility involving the client and one or more health care practitioner(s), such as nursing staff, medical staff, pharmacists, and pharmacy technicians, as appropriate. The team uses standardized clinical measures to assess the client's symptoms. MAJOR MINOR 16.2 The team works with other teams, services, and organizations to determine the client's appropriate placement and develop a comprehensive follow-up plan The team reconciles the client's medications with the involvement of the ROP client, family, or caregiver at interfaces of care where the client is a risk of medication discrepancies (transfer, discharge), when medication therapy is a significant component of care. Reconciliation should be repeated periodically as appropriate for the client or population receiving services The team provides documented rationale for the selection of target clients or populations to receive formal medication reconciliation, and the risk points during service delivery where reconciliation will be conducted There is a demonstrated, formal process to reconcile client medications at interfaces of care where the client is at risk of medication discrepancies (transfer, discharge), and periodically as appropriate for the client or population receiving services The team documents any changes to the medications list (i.e. medications that have been discontinued, altered, or prescribed) Upon transfer or discharge, the team provides clients and their providers of care (e.g. family physician, next provider of care) with a copy of the up-to-date medications list and clear information about the changes. MAJOR MAJOR MAJOR MAJOR Detailed On-site Survey Results 52

58 The process is a shared responsibility involving the client or family, and one or more health care practitioner(s), such as nursing staff, medical staff, and pharmacy staff, as appropriate. Following transition, the team has a process to regularly evaluate the effectiveness of the transition, and uses this information to improve its transition planning. MINOR Priority Process: Clinical Leadership The team uses the information it collects about clients and the community to define the scope of its services and to set priorities when multiple service needs are identified. The team's scope of services is aligned with the organization's strategic direction. The team regularly reviews its services and makes changes based on changing priorities as needed. Team members work together to develop goals and objectives that are measurable and specific to the delivery of ambulatory systemic cancer therapy services. The team identifies the resources needed to effectively deliver ambulatory systemic cancer therapy services. The team leaders advocate to senior management on the team's behalf for the resources needed to achieve the goals and objectives. The team has sufficient space to accommodate its clients and to provide safe and effective services. The team has sufficient staff to accommodate clients and meet workload demands. The organization assigns team members to meet workload demands in a fair and equitable manner. Priority Process: Competency Team members are provided with opportunities to develop skills to improve the interdisciplinary approach and overall team functioning. Sufficient workspace is available to support team functioning and interaction. The team evaluates its functioning at least annually, identifies priorities for action based upon the evaluation, and makes improvements. Team leaders regularly evaluate and document each team member's performance and competency in an objective, interactive, and constructive way. Detailed On-site Survey Results 53

59 Priority Process: Decision Support Priority Process: Impact on Outcomes The organization has met all criteria for this priority process The team implements and evaluates a falls prevention strategy to minimize ROP client injury from falls The team implements a falls prevention strategy. MAJOR The strategy identifies the populations at risk for falls. MAJOR The strategy addresses the specific needs of the populations at risk for falls The team establishes measures to evaluate the falls prevention strategy on an ongoing basis The team uses the evaluation information to make improvements to its falls prevention strategy. The team identifies and monitors process and outcome measures for its ambulatory systemic cancer therapy services. The team monitors clients' perspectives on the quality of its ambulatory systemic cancer therapy services. The team compares its results with other similar interventions, programs, or organizations. The team uses the information it collects about the quality of its services to identify successes and opportunities for improvement, and makes improvements in a timely way. The team shares evaluation results with staff, clients, and families. MAJOR MINOR MINOR Priority Process: Medication Management The organization has met all criteria for this priority process. Surveyor comments on the priority process(es) Priority Process: Episode of Care - Ambulatory Systemic Cancer Therapy Documentation of informed consent is usually contained in the oncologist consultation and assessment notes. Child and youth populations are generally not cared for in the ambulatory oncology program; however, if there is a need to care for this patient group, a process is available. Treatment care plans are carefully documented in the oncologist consultation and assessment notes and changes to treatment plans are contained in the progress notes. Detailed On-site Survey Results 54

60 There is variability across the region relative to the comprehensiveness of the care plan, which is largely dependent on the availability of other professionals such as nutrition and social work. However, the clinical care plan and protocols are comprehensive. All services demonstrated evidence that clients are provide with strategies to prevent, and manage symptoms specific to cancer therapies; however, there is variability in the methods of documentation. Oncologists document changes and adjustments to the care plan. Generally, the clients do not requests to bring their own medications. Patient education is well done at all sites and includes one-on-one teaching, videos and written materials. Documentation is not always included in the clinical record. Not all sites have psychosocial support available; however, patients receive support from nursing staff. Priority Process: Clinical Leadership Information on cancer incidence, prevalence, mortality and clinical outcomes is available from the British Columbia Cancer Agency (BCCA). The cancer agency provides feedback on workload volumes to the various cancer sites. The team collects pertinent information on operational issues such as wait times for treatment, falls, incidents, and other things. Facilities are expanding, based on the increased volume of patients, but there is no overall plan for meeting future needs The process of providing input on work and job design by team members is not consistent across the region. Team leaders regularly evaluate the effectiveness of nursing staff and use the information to make improvements. The team has specific measures in place to avoid excessive consecutive hours of work and fatigue applicable only to nursing staff. The organization is in the process of standardizing infusion pumps across the region. All cancer sites are delivering systemic therapy in accordance clinical standard and medical practice guidelines as set by the BCCA and additionally, BCCA provides volumes based funding that covers drugs and 50 percent funding to cover staffing costs. The hospital based cancer centres are required by BCCA to meet ministry wait time benchmarks, deliver treatment in accordance with standard clinical protocols, and completion of certification in chemotherapy administration by nurses and report workload statistics. The BCCA is not involved in operational issues of the hospital-based cancer centres. The employees are highly energetic, dedicated and compassionate and caring. This finding was confirmed by twenty-one patients that were interviewed. Feedback from these twenty-one patients and numerous family members on the quality of care, attitude of staff and patient education and support was overwhelmingly positive. Nursing staff are certified for chemotherapy administration with the BCCA. The BCCA requires nurse completion of annual continuing education activities. Attendance at provincial and regional oncology conference is an expectation, as are contributions to the development of patient educational tools, journal writing, and so on. Nurses are certified on the use of infusion pump. All certifications and educational activities are documented in the personnel record. Detailed On-site Survey Results 55

61 Physicians are qualified in oncology and the community oncology program is attended by general practitioners (GPs) that are required to complete a seven-week course in oncology with BCCA. Patient education is well done at all sites and includes one on one teaching, videos, and written materials. Documentation in the clinical record is not always completed and was inconsistent across the region. Good relationships exist with community physicians, BCCA, and palliative care services. Priority Process: Competency The interdisciplinary approach to deliver ambulatory systemic cancer therapy services is not consistent across the region. Priority Process: Decision Support There are space constraints which are compromising patient privacy and confidentiality. Priority Process: Impact on Outcomes There is not a formal fall prevention strategy in place for ambulatory systemic treatment services. The nursing assessment does identify patients who are at risk however, there is a lack of consistency across the services related to the completion of nursing assessments. Priority Process: Medication Management Pharmacy services provided by 100 Mile District Hospital were reviewed with the pharmacist and two pharmacy technicians. The pharmacy provides dispensing services for the ED, a 16-bed acute care service, and chemotherapy admixtures for satellite systemic treatment for ambulatory and inpatients. The pharmacist plays an integral role in the systemic treatment program, in that the pharmacist receives the systemic treatment protocol from the referring cancer centre in Kamloops, Kelowna or Vancouver. The pharmacist checks the protocol with the most recent protocol update on the BCCA s website for completeness and accuracy. The pharmacist schedules the patient treatment and notifies the patient on the date and provides the patient with basic information. The physician is notified by the pharmacist for the completion of the pre-print chemotherapy orders. Medication reconciliation is completed by the pharmacist using the medication listing from PharmaNet. Chemotherapy orders are checked against the medication listing for possible drug interactions. Interactions are discussed with the physician. Findings are recorded on the pharmacy checklist and filed in the pharmacy department. The pharmacist is involved in patient education and provides educational sessions for nursing staff on adverse reactions of medications. The health centre uses a pyxis drug dispensing system on the nursing units. High-dose heparin formats are not used and only single units are available. Likewise, only single and low dose narcotic products are available. No sample medication products are used. This health centre followed organizational policies for managing shortages during the Sandoz crisis. Overall, pharmacy space is adequate for the volume of activity to service both the acute and long term patients. The ante-room for the preparation of admixtures for chemotherapy is somewhat undersized however, the staff indicate that it is currently adequate for patient volumes. Patient volumes are increasing and there may be a requirement in the near future to increase the space. Detailed On-site Survey Results 56

62 The pharmacy department at 100 Mile House requires a refrigerator, with appropriate temperature controls and designed for the storage of medications. Currently, it is using a household refrigerator. Detailed On-site Survey Results 57

63 3.3.3 Standards Set: Community-Based Mental Health Services and Supports Standards Unmet Criteria High Priority Criteria Priority Process: Clinical Leadership The organization collects information about the individuals, families, and community it serves. The organization uses the information it collects about the individuals, families, and community it serves to define the scope of services and supports, and to set priorities when multiple service needs are identified. The organization makes information about service needs and identified priorities available to the public. The organization's goals and objectives are based on the needs of the community it serves. The organization's goals and objectives are specific and measurable. Priority Process: Competency 5.7 The organization has processes in place to assist staff and service providers to resolve conflicts. Priority Process: Episode of Care The team has a process to obtain informed consent from the individual and/or family before delivering services or supports and on an ongoing basis, which includes determining the individual's and/or family's capacity to provide informed consent. Following a transition or at the end of service, the team contacts individuals, families, and referring organizations to evaluate the effectiveness of the transition, and uses this information to improve its transition and end-of-service planning. Priority Process: Decision Support Priority Process: Impact on Outcomes The organization has met all criteria for this priority process The organization shares benchmark and leading practice information with its partners and other organizations. The team compares its results with other similar interventions, programs, or organizations. Detailed On-site Survey Results 58

64 Surveyor comments on the priority process(es) Priority Process: Clinical Leadership The organization has numerous advisory groups, at different levels of involvement regionally, working with the mental health (MH) and ambulatory (AOD) staff members to assist in the identification of needs. The discussion within the advisory structure identifies local needs and focuses on local issues which are critical to the IHA achieving its program objectives for mental health and substance abuse clients. The emphasis of these initiatives appears to be targeted to specific client issues identified by these groups, which are more reactive to specific cases or situations, rather than being proactive based on a comprehensive community needs assessment. Some communities identified they have a good handle on the issues in their area and how the IHA is shifting resources to meet these needs. This appears to be driven locally in areas where the physicians who are at the front-line delivery service are also part of the regional MH leadership. The operational or annual plans of MH are based on the objectives defined by the organization's strategic plan, which in turn are based on goals of the ministry's strategic directions. There are minimal modifications to the plan based on specific community needs. In essence, the plan appears to be top down with little input from the front-line staff as to its applicability to the actual needs of the presenting clients. In discussions with the community partners there is a wide range of experience with MH and AOD staff, as well as management across the IHA. This appears to be driven more by relationships than strategic communication. Therefore, some partners express a level of satisfaction with their communication and others indicate they have had minimal contact with the IHA service providers. Priority Process: Competency A major challenge for some of the remote areas is being able to attract and retain qualified staff. The reorganization of some management positions has further compounded this issue, as there is the opportunity for uncertainty and job security. The surveyor team met numerous staff in middle management positions that had only been in their positions for less than a year. Most of the staff interviewed expressed a high appreciation for the support they received during their orientation, and education and ongoing training needs to ensure they felt part of IHA. The policy of the IHA is to complete a performance appraisal for staff every three years. In speaking with the regional supervisors most indicated they were conducting this annually, as they stated staff need feedback on their skills and direction on where they need to improve. The staff members see this as supporting their efforts as the organization is going that extra mile for them. They acknowledged the local support for their efforts. All areas conduct an annual appreciation activity to acknowledge staff and recognize their accomplishments. Priority Process: Episode of Care A noted strength of the MH and AOD program is how the staff provide treatment services to their clients. The IT system Connex provides MH and AOD staff with a comprehensive system for recording client activity. The chart is completely automated and other than the initial referral and consent forms, the new chart is paperless. Using the Connex system ensures that documentation is completed; information is readily accessible to those who are approved to see the record; progress notes are concise and up to date; medication reconciliation is a dynamic process; the care plan is easily accessed and up to date; client issues are noted and readily available and all test results are accessible. Another benefit of Connex is when a client is transferred to an acute program from the community or vice versa, the client's information is immediately accessible to the new service. Privacy is protected with IT policy and procedures, and access to specific client information is controlled by staff profiles. Detailed On-site Survey Results 59

65 Some areas within the region utilize clinical supervision to support their counselling staff. This gives counsellors another avenue to seek expertise for those difficult cases. The team is encouraged to consider this for all areas within its portfolio. The organization has produced a pamphlet entitled: "Concerned about quality of care? Let us know." which is distributed to every client and participating family member. The steps for addressing any concerns are explained and discussed with all clients on their first visit. This ensures clients are well-aware of what to expect. There was an opportunity to speak directly to a cross-section of clients, some from the long-term program and some from the short program. Every one of them expressed that they clearly understood their specific care plan and felt they were the driver in the management of their care. They indicated they worked with the counsellor to identify their specific short and long term goals. The clients also understood if they felt they were not receiving the service they expected, or they were unhappy with the treatment they were receiving from staff, there was an avenue for them to raise their concerns. An area for improvement is how the program deals with client consents. Every MH office appears to approach this differently. The management indicated the organization utilizes an implied consent principle. If a client appears at an IHA mental health facility, they are seeking help and implying they are giving their consent to services. Other offices require a signed consent before beginning treatment. Some have the form signed before the client sees a counsellor, and some with a counsellor. Some clients receive an explanation of the form before signing and others are requested to read and sign it. Three different consent forms were noted in the offices visited. This can be a major concern in litigation where a client claims being harmed. It is important the organization have a standard consent form, a process for having the document signed and document the consistent process in a policy. The literature indicates the earlier the intervention, the better the likelihood of a positive outcome. Most of the offices visited exhibited this principle. Intake was immediate upon presentation and some form of treatment or intervention began immediately upon the initial visit. Waiting times could be measured in minutes not days. At Trail, the intake assessment is completed on the day the client presents themselves, and the next visit is usually a month later. They also handle their AOD admissions differently. A review should be conducted and steps taken to ensure a consistent approach across the region for intake, assessment and the initiation of treatment. Priority Process: Decision Support A noted strength of the organization is in its utilization of technology. The IHA makes good use of the automated records in managing the activities of their clients. They are moving towards using the system to generate statistics which can be used to assist them in developing their operational plans and in reporting performance indicators. It is important that they see these initiatives as a priority so they can quantitatively show the value of their services. The IHA also has conducted research activities to enhance their understanding and support of leading practices. They need to be encouraged to continue this work as the MH and AOD community requires validation that different treatment models can be used to achieve positive client outcomes. Detailed On-site Survey Results 60

66 Priority Process: Impact on Outcomes The organization has a structured safety risk program and which all areas of the mental health program utilize. Feedback is shared with staff members. Detailed On-site Survey Results 61

67 3.3.4 Standards Set: Critical Care Unmet Criteria High Priority Criteria Priority Process: Clinical Leadership 10.4 The team has access to a service environment that promotes the comfort and well-being of the client. Priority Process: Competency 3.8 The organization provides sufficient workspace to support interdisciplinary team functioning and interaction. 4.4 Staff and service providers receive ongoing, effective training on infusion ROP pumps There is documented evidence of ongoing, effective training on infusion pumps. Team leaders regularly evaluate and document each team member's performance in an objective, interactive, and positive way. Priority Process: Episode of Care MAJOR 7.5 The team identifies medical and surgical clients at risk of venous ROP thromboembolism (deep vein thrombosis and pulmonary embolism) and provides appropriate thromboprophylaxis The team establishes measures for appropriate thromboprophylaxis, audits implementation of appropriate thromboprophylaxis, and uses this information to make improvements to their services. The team uses standardized clinical measures to evaluate the client's pain on a continuous basis. MINOR 10.8 The team follows a protocol when conducting a daily interruption in sedation The team reconciles the client's medications with the involvement of the ROP client, family or caregiver at transition points where medication orders are changed or rewritten (i.e. internal transfer, and/or discharge) There is a demonstrated, formal process to reconcile client medications at transition points where medication orders are changed or rewritten (i.e. internal transfer, and/or discharge) The team documents that the BPMH, the active medication orders, and the transfer or discharge medication orders have been reconciled; and appropriate modifications to medications have been made where necessary. MAJOR MAJOR Detailed On-site Survey Results 62

68 Depending on the transition point, an up-to-date medication list is retained in the client record (internal transfer), OR, the team generates a Best Possible Medication Discharge Plan (BPMDP) that is communicated to the client, community-based physician or service provider, and community pharmacy, as appropriate (discharge) The process is a shared responsibility involving the client or family, and one or more health care practitioner(s), such as nursing staff, medical staff, and pharmacy staff, as appropriate. Following transition or end of service, the team contacts clients, families, or referral organizations to evaluate the effectiveness of the transition, and uses this information to improve its transition and end of service planning. MAJOR MINOR Priority Process: Decision Support Priority Process: Impact on Outcomes The organization has met all criteria for this priority process The team informs and educates clients and families in writing and verbally about the client and family's role in promoting safety. ROP The team provides written and verbal information to clients and families about their role in promoting safety. MAJOR 17.1 The team identifies and monitors process and outcome measures for its critical care services The team monitors clients' perspectives on the quality of its critical care services. The team shares evaluation results with staff, clients, and families. Priority Process: Organ Donation The organization has met all criteria for this priority process. Surveyor comments on the priority process(es) Priority Process: Clinical Leadership Since the previous survey, a regional critical care network has been established. The network is co-led by a network director and the IHA medical director for critical care. The network team is engaged and all members have indicated that positive and collaborative relationships have developed across the authority. This has been a tremendous support to all teams. A draft strategic regional work plan has been developed. The team has identified best practices for authority-wide development and spread across the sites. The team has had many successes with the development of regional standards and protocols. For example, the critical care record for documentation, venous thrombo embolism (VTE) protocol and sedation protocol. The team is engaged and encouraged to maintain the momentum to continue implementation of work-plan priorities. Detailed On-site Survey Results 63

69 The regional network is working on building system capacity to provide information related to clients served, with the implementation of critical care information systems. Two sites have joined the BC critical care database and begun collecting data. The implementation of this authority-wide would be an asset in the reporting of indicators and the organization is encouraged to expand the information system across the region. Two of the intensive care (ICU) units in the organization have recently been renovated and both sites have been recommended for an award. This is commendable. Input to design and functionality by all members is evident in the excellent planning and implementation of services. Most sites have appropriate space for critical care however, the East Kootenay Hospital should be considered a priority for redesign when capital funding is available. The space is restricted and patient confidentiality and privacy is a concern. Priority Process: Competency The teams indicated that staffing levels were appropriate however, some sites and particularly the rural areas are challenged with recruitment of nurses. The implementation of the high acuity response teams (HART) has been an asset and the regional network is exploring further opportunities to develop critical outreach capacity. All sites have interdisciplinary teams to provide care. Staff members indicated there are many opportunities for continuing education and leadership support for participation in education. The clinical educators provide valuable support to the team. The orientation program has been revised and staff indicate it meets their needs. A new pump training has been implemented. Teams at all sites visited have processes in place for ongoing training for infusion pumps however, not all nurses have documented their completion of the training to date. This should be a priority for follow up. Staff indicated that managers provide informal feedback on their performance however, none of the staff interviewed had received a formal written performance evaluation. Feedback is important to staff members and managers are encouraged to complete appraisals on a timely basis. Managers did indicate that completing performance evaluations is a priority and acknowledge that this is an opportunity for improvement. Managers also indicated that performance appraisal at the management level is more consistent. Priority Process: Episode of Care Patients/families interviewed indicated overwhelming satisfaction with the service, noting the high degree of professionalism of the staff and commitment to patient needs. Families felt included in the care process. A new patient satisfaction survey has commenced and the network is currently reviewing the process for uptake of the survey and ongoing feedback of the results. The units are a combination of both open and closed units and the regional network indicated the model will be further evaluated and evolved to best meet the needs of the patients. All units have intensivists or internal medicine specialists available to provide medical care. Detailed On-site Survey Results 64

70 The regional network has been working on the development and implementation of standardized protocols and roll-out has begun or is scheduled to begin over the coming months. The VTE protocol is one example that is scheduled for October The team is commended for the vast amount of work they have completed in the standardization and development of protocols and policies and with this momentum, they should continue with the implementation of their work plan priorities The use of standardized tools for pain assessment and daily interruption of sedation was inconsistent across the region but with the implementation the new standardized protocols, this should be resolved. The regional network has identified this as an area for improvement and is encouraged to move forward with this process. Medication reconciliation at admission has been implemented at all sites and the team should now move to reconciliation on transfer and discharge. The transportation of critically ill patients in the region has been noted as an ongoing issue and the leadership team has identified this as a challenge. Opportunities for improvement need to continue to be explored. The HART team has been recognized as a valuable asset to the team and supports the rapid response process internal to the facility and supports the external transport of the patients From a patient flow perspective, most sites are managing well however, the Kelowna Hospital reports issues with access to inpatient beds for transfer of their patients. The team has identified this as a concern and is working with other site teams and the regional network to identify solutions. This should be a priority for follow up. Priority Process: Decision Support The orientation program was reviewed and staff members believe it is complete and prepares them well for their work. Continuing education is available for staff to keep updated on equipment and technology. Access to online education is available and staff participation is good. A new standardized record for documentation for clinical care has been developed and implemented. Staff feedback on the new record is positive. The team has been building on best practice with the implementation of new guidelines for adult sedation and glycemic control. Access to information for decision-making has been identified as a need and the organization is encouraged to implement a critical care information system. The network team has identified this as a priority in their work plan. Priority Process: Impact on Outcomes The critical care regional network is commended for the work it is doing in the standardization of policies and protocols. The network has started to develop performance indicators for benchmarking however, this is limited due to the availability of critical care data and an information system. The regional network team has this as a priority and is encouraged to continue its work. Although the regional network has established priorities, site teams are encouraged to set specific goals and objectives, establish benchmarks and measure their progress. The patient safety learning system (PSLS) is being widely used for staff members to report events. The organization is encouraged to provide more follow-up feedback to the teams at the site level on any trends, and lessons learned. Detailed On-site Survey Results 65

71 There are pamphlets available about the patient's role in safety however, all patients interviewed were not aware of the information. All teams are encouraged to discuss and provide this information in writing to all patient and families consistently. The network team has just developed and implemented a patient satisfaction survey but results are not available. This information will be valuable, providing information for improvement. The results should be shared with staff and patients and families. Priority Process: Organ Donation The team indicates that organ donor policies and processes are effective and staff members have opportunity to participate in ongoing education in this area. Detailed On-site Survey Results 66

72 3.3.5 Standards Set: Emergency Department Unmet Criteria High Priority Criteria Priority Process: Clinical Leadership 2.9 The team has the workspace needed to deliver effective services in the Emergency Department. Priority Process: Competency The interdisciplinary team follows a formal process to regularly evaluate its functioning, identify priorities for action, and make improvements. Team leaders regularly evaluate and document each team member's performance in an objective, interactive, and positive way. Priority Process: Episode of Care 7.8 After the initial triage assessment, the team advises clients who are waiting for service to return to triage if their condition changes. Priority Process: Decision Support Priority Process: Impact on Outcomes The organization has met all criteria for this priority process The team uses at least two client identifiers before providing any service or procedure. ROP The team uses at least two client identifiers before providing any service or procedure. MAJOR 16.1 The team identifies and monitors process and outcome measures for its Emergency Department services. Priority Process: Organ Donation 9.12 The most qualified team member follows a written process when approaching families about organ and tissue donation. Surveyor comments on the priority process(es) Priority Process: Clinical Leadership The emergency and trauma services network has established significant strategies and processes to support standardization in clinical programs, education and indicator measurement. High acuity response teams (HART) have been established to facilitate transport of patients from rural areas to regional centres. A consistent emergency assessment and treatment form has been established and implemented in all sites with the exception of Vernon. Encouragement is offered that this final site be included in the regional roll-out for Detailed On-site Survey Results 67

73 consistency of practice and information tracking. The leadership in the emergency and trauma portfolio is commended for its organized strategic planning. As new appointments are made to senior positions, it is anticipated that the influence to ensure consistency of practice and management of appropriate emergency services will be realized. An excellent score card system tracks indicators and includes congestion monitoring and alternate level of care (ALC) to provide timely information regarding admissions and ED flow. Some EDs utilize volunteers to assist in navigation of patients across the region. This effort appears to be effective in supporting patient information. In most EDs the staff morale and supportive culture are good. However, In Kelowna the patient flow issues have resulted in increased stress levels for staff, with increasing staff turnover and illness. Some of the newer ED building and renovation, has provided an excellent environment for patient management. Input to the design plan for the Vernon ED from staff apparently was not always considered and an example of the resulting less than efficient change to the ED is the circuitous hallway for ambulance transport. Each of the larger EDs uses an electronic bed board, which assists in tracking patients. South Okanagan General Hospital Emergency Department: This site has an average of 15,000 visits to the ED every year. There is sole physician coverage 24 hours per day. The volume of patients coming to the ED in the past year has decreased somewhat as the IHA has successfully recruited family physicians who are more available for same-day appointments for their patients. The electronic bed board has been installed but not yet activated, as this will be done when the Connex system is activated in November this year. An initiative that commenced several months ago and known as the access flow team, included a complete flow study of the patient activities and several recommendations were made, including the placement of the registration clerk. Currently, patients presenting at the ED must then walk if they are ambulatory, down two long corridors to be registered and then walk back down to the ED to hand their form to the receiving nurse. Included in the flow study, was the wait times for the patient to be seen by the physician after registration and also the wait time for an inpatient bed to be allocated once the decision to admit had been made. Focus groups were held with the staff and physicians, and also with the community partners and from the discussion, several recommendations were presented. Many of these have received action and a plan is in process for the rest. Since action has been taken on many of the recommendations, the ED has seen a decrease in the number of patients and faster movement to a residential facility for the inpatients, freeing up space for admissions. The ED is also seeing seven percent fewer ALC patients. The data collected showed that there is minimal wait time from registration to the time seen by the physician, and also no wait time for an inpatient beds. This is due to the physical capacity on the inpatient unit, which is funded for 18 beds but has the capacity to admit 25. The issue of having only one RN on the night shift has been investigated by a joint team of management and union and they are hopeful that an additional nurse will be funded for the future. The facility works very closely with the ambulance services and with the RCMP, as both respond quickly when there is an issue in the unit. There is a pilot project in effect for the emergency visit discharge form which provides information on the treatment and follow up required of a visit to the ED. This is mainly for confused patients or patients who are in residential homes. There is also a fast track process with nursing initiating orders to speed up the service in the ED and the practice is based on the guidelines set by the Ottawa model. Interior Health Grand Forks- Emergency Operations Centre (EOC): There is excellent leadership and an engaged team. The team triages patients using the Canadian triage acuity scale (CTAS). The department is well-organized from a patient flow perspective and well-equipped to manage emergency care. This includes a trauma room, emergency OR, and isolation room. Consideration should be given to improving the registration area to provide easier access for wheelchair clients and ergonomics for staff members. The team indicated it is conducting audits related to CTAS scores and ED wait Detailed On-site Survey Results 68

74 times but on an inconsistent basis. The team is encouraged to develop performance indicators for monitoring. As part of the regional network plan, the team indicates it is implementing a number of initiatives for example VTE, hot stroke and falls prevention however, the process for these is just underway. The organization should continue to support the implementation of these protocols. Staff members are maintaining competencies with a high participation rate in many continuing education and certification programs like advanced cardiac life support (ACLS), and trauma nursing critical care (TNCC). The foundation has been active in supporting capital equipment acquisition. The team completes medication reconciliation on admission. Although there are patient safety information pamphlets available all staff need to provide this information to patients and families consistently. Priority Process: Competency There has been a concerted effort to provide uniform orientation to ED for new recruits in all ED centres. Rural educators provide ongoing inservices. Simulation programs are offered and staff attendance is good. In a teleconference attended by representatives from rural facilities across the region, ED managers suggested an opportunity to provide staff with experiences in the regional ED centre to share expertise, practice skills and establish relationships. Consistent competency requirements have been established and the region has designated funding in support of this. New decision support IV pumps are being introduced to the region and inservice in this regard is in place. Several of the larger centre EDs have flow nurse positions to support the triage nurse in facilitating enhanced patient flow in the ED. There is a 'New to ED RN' training program with core competency description and a nursing orientation checklist. A trauma outreach program exists and rural managers express appreciation for the rural medicine simulation program. The trauma nursing core course (TNCC) and emergency nursing pediatrics course (ENPC) are offered. It was suggested that the role of rural nurse educators be expanded and that a pool of casual nurses that could float between facilities be established to relieve staff and facilitate educational-offering-participation. It was also suggested that HART training could be implemented in smaller centres to increase the number of transport nurses. Kootenay Boundary Regional Hospital,Trail: The ED team functions effectively, team members participate in continuing education to maintain their competencies. They have access to a number of online education programs and maintain the appropriate certifications. Staff are appreciative of the education support however, noted that they would like to receive more education leave to participate. The team has developed and implemented, with the support of the clinical educator, a new RN program that provides an opportunity for RNs in other program areas to develop skills in ED nursing. This initiative provides an opportunity for RNs to explore other practice areas and is assisting with workload issues in the department. Priority Process: Episode of Care Although most EDs are able to effectively manage the patient load presenting in their departments, it is important to monitor the number of patients who are leaving without being seen, again this is specifically in Kelowna. From a risk and liability perspective, this issue needs to be addressed. There is evidence that the coordination of patient transport with BC Ambulance - BC Bedline service, particularly in the rural areas requires attention. Recently, there has been a change in dispatch which has further compromised effective transport. It was suggested that criteria for escort be reviewed to facilitate more timely transfer without the requirement for RN coverage. Detailed On-site Survey Results 69

75 100 Mile House - Emergency Department: This is a small, well-organized and productive department. The patient volume has increased by about 11,000 visits per year. This consists of a stable number of booked visits around 1700 per year, and a slightly declining number of approximately 9000 unscheduled visits. The decline is attributed to the recent establishment of walk-in clinics in each of the three family practice groups in 100 Mile House. Of the 13 physicians in practice in 100 Mile House, 10 participate in coverage of the ED. This coverage also constitutes the night and weekend coverage of each of the practices of all the physicians in the town. One physician is assigned to the ED, each 24 hours. Nursing coverage consists of the two nurses on the day shift and one nurse overnight. Additional assistance can be obtained if necessary from the nurses for the inpatient acute services. One of the ED nurses also provides the service of chemotherapy for cancer. Such treatments are scheduled to usually be done on Thursdays. There is no social worker and that is a significant deficiency for this department and all of care in 100 Mile House. Most patients are of the acuity CTAS 1 or 2. For acutely ill patients the task of staff in the ED is to stabilize patients and arrange for their transfer elsewhere. There is available both fixed wing aircraft and a helicopter. Support for transport is reportedly quite good. Patients presenting with chest pain and possible myocardial infarction would be assessed locally and if there is no significant cardiovascular instability, could be treated with thrombolysis. Patients with suspected stroke are transferred because of the need for imaging studies of the brain and a neurologist or internist to supervise thrombolysis. Patients present at the main entrance of the health care facility for which there is good signage, to be assessed. Triage is done by the nurse for the ED although streaming is not done, but is carried out in IHA's larger facilities. For continuing competence the physicians and nurses take the ACLS courses and CARE, which is a modification of a trauma course suitable for small centres. There is a visit for continuing professional development purposes of a simulation session about once per year. Staff members would prefer more frequent opportunity for simulation. Equipment is adequate and this seemed to be well-maintained and well-located. The staff wish to have a small portable ultrasound machine as part of the assessment of trauma patients. It was noted that such a machine would also be a useful support of their obstetrical program for such things as determining placental localization and fetal-lay and presentation. Any issues concerning the ED are managed via referral by the nursing staff to the medical advisory committee. Medication reconciliation is done on arrival for all patients and is done again to constitute admission medication orders if transfer to the unit is to be done. About eight percent of patients presenting to the ED are actually admitted to the hospital. Occasionally there is a delay in admission because the acute care beds are full. It is noted that of the 16 acute care beds up to half of them are frequently occupied with patients awaiting alternate levels of care. At this hospital the staff members cope with this fairly well. They may call for assistance from nurses in the inpatient are and/or clear patients from that area and/or use a bed in the chronic care facility which is on the second floor. Thus, the delay in admitting patients does not interfere with providing timely access to care for other patients presenting to the ED. Identified problems include occasional delay in transport and the need for more support for mental health care. Both the physician and nurses interviewed are proud of the fact that they have sustained service without interruption for all the people in the community and have done so for about 30 years. Patients spoken to were unanimous in saying that the nurses are fantastic. Detailed On-site Survey Results 70

76 Priority Process: Decision Support A number of protocols and guidelines have been adopted recently and are being well-received by staff members and one example is the rattlesnake protocol. The clinical record is manually updated but the documentation appears complete. An impressive IT system provides online access to protocols, educational offerings and intranet access. This system appears to be well-utilized by staff members. New IV pumps with decision assist support are being implemented and staff training is in place. A discussion with representatives from rural EDs indicates a need for the HART team to educate as well as transfer. Consistent processes for communicating new information are required to address apparent variability in the effectiveness of information sharing. All centres requested consistent and timely advice regarding the unavailability of the HART team for service so that centres could action a plan B. Priority Process: Impact on Outcomes In reviewing the utilization of the ED service in Penticton it is apparent that some services such as ENT, medicine and surgery may be using ED as an outpatient service for clinical interventions that may more appropriately be managed in the physicians' office. A review of the ED utilization of service may be helpful to rationalize appropriate use of resources. The ED in Oliver is commended for effectively incorporating a palliative care program with palliative care nurses to decrease palliative patients in the ED. Also, this site has incorporated pre-admission screening by physicians, a pain management strategy and use of hospitalists to decrease the LOS. Three focus groups have been identified by BC Health to target action in an attempt to reduce ED visits and the groups are COPD patients, frail elderly and mental health and substance abuse clients. A doctor of the day initiative has been established in Penticton, which utilizes a designated physician to visit a resident in the home to manage issues with a resulting 48 percent decrease in ED visits. The ED in Kamloops has initiated a streaming process using their rapid assessment unit. A clinical decision unit is also in place for holding patients for admission. In Kamloops, the turn around times for laboratory results is increasing and staff suggested that implementing point-of-care testing might address these delays. In Vernon, a holding unit adjacent to the ED is staffed with nurses that appear to have varying competency levels and completion of orientation to the site. As a result, there appears to be increased errors particularly in medication administration. Efforts to facilitate improved patient flow, with decreasing necessity to use holding beds and more consistent staff members may help to address this issue. The decontamination unit in Vernon is exemplary. This is a well-established area and training of staff in the decontamination process is well done. Detailed On-site Survey Results 71

77 In Kelowna, the VTE prophylaxis protocol compliance is 65 percent. Efforts continue to increase education for the staff to improve results. Colour-coded folders are used to identify patients for specific treatments. This is an effective method of communicating priorities and required interventions. Nurse initiated diagnostic orders are being used to improve flow for patients. To ensure that nurses are being used most effectively in the ED, it is suggested that clerical support be adequately provided and not reduced. There is an obvious need to address the use of ED beds to hold patients. On nights, an LPN provides care for patients who are to be admitted. The CTAS 2 patients wait in the waiting room without adequate observation. There is a need to actively intervene in the patient flow process to decant ED patients more effectively to enable the ED service to be appropriately used. Kootenay Boundary Regional Hospital-Trail: Patient flow regarding access to inpatient beds is a concern to staff at times however, data related to the frequency and time/day was not available to the staff. Staff members acknowledged that there is a protocol currently being developed to address overcapacity. The organization is encouraged to share data with staff around volumes of patient visits and wait times to identify opportunities for improvements. The team completes medication reconciliation on admission. In all centres, staff members appear conversant with incident reporting and the importance of timely disclosure. Priority Process: Organ Donation Staff members advise that an organ donation policy is being developed. At this time, staff assess patients and refer to the ICU for follow-up with the provincial organ donation program. Detailed On-site Survey Results 72

78 3.3.6 Standards Set: Home Care Services Unmet Criteria High Priority Criteria Priority Process: Clinical Leadership The organization's goals and objectives are measurable and specific. The organization identifies the resources needed to achieve its goals and objectives. Priority Process: Competency 4.6 Staff and service providers receive ongoing, effective training for service ROP providers on all infusion pumps There is documented evidence of ongoing, effective staff training on infusion pumps. The organization regularly evaluates and documents each staff member's performance in an objective, interactive, and positive way. Priority Process: Episode of Care MAJOR 2.1 The organization uses a team approach to develop its goals and objectives. 6.7 The team reconciles the client's medication at the beginning of service with ROP the involvement of the client and family or caregiver when medication is a component of care There is a demonstrated, formal process to reconcile client medications at each visit if medications have been discontinued, altered or changed The team generates a Best Possible Medication History (BPMH) at the beginning of service when medication management is a component of care The team conducts a timely comparison of the BPMH with medications prescribed, ordered, dispensed, or administered during service The team communicates the BPMH and discrepancies requiring resolution to the appropriate health care provider, and documents actions taken in the client record The process is a shared responsibility involving the client and one or more health care practitioner(s), such as nursing staff, medical staff, pharmacists, and pharmacy technicians, as appropriate. MAJOR MAJOR MAJOR MAJOR MINOR Detailed On-site Survey Results 73

79 11.2 The team reconciles the client's medications at interfaces of care where the client is at risk for medication discrepancies (circle of care, discharge) with ROP the involvement of the client and family or caregiver when medication management is a component of care, or as deemed appropriate through clinician assessment There is a demonstrated, formal process to reconcile client MAJOR medications at interfaces of care where the client is at risk of medication discrepancies (circle of care, discharge) The team updates the client's medication list following each MAJOR clinician consultation or visit to a health care practitioner within the client's circle of care The team provides the client with a copy of the up-to-date MINOR medication list, clear information about the changes, and educates the client to share the list when encountering providers in the client's circle of care Upon notification that a client has been transferred or MAJOR discharged, the community care organization communicates the most recent medication list to the next provider of care The process is a shared responsibility involving the client or family, and one or more health care practitioner(s), such as nursing staff, medical staff, and pharmacy staff, as appropriate. MINOR Priority Process: Decision Support Priority Process: Impact on Outcomes The organization has met all criteria for this priority process The organization follows a formal process to regularly evaluate the functioning of the team annually, identify priorities for action, and make improvements. The organization identifies and monitors process and outcome measures for its services. The organization uses the information it collects about the quality of its services to identify successes and opportunities for improvement, and makes identified improvements in a timely way. The organization shares evaluation results with staff, clients, and families. Surveyor comments on the priority process(es) Priority Process: Clinical Leadership The home and community care program accesses a variety of resources to collect and use information to inform service provision. This allows for a broad standardization of services, in keeping with the one IHA philosophy while also supporting unique community needs. There is a flow from the organization's overall strategic vision and service plan, notably in the areas of shifting care to the community and strengthening integrating of community-based services, chronic disease prevention and management, end of life strategy and alternate level of care (ALC) initiatives. Detailed On-site Survey Results 74

80 Considerable effort has been made to fully integrate services. This has proven successful to date, and is evidenced in the common language around integration, the well-established team and multidisciplinary collaboration vehicles, including case conferences and leadership team meetings. This has led to enhanced confidence in their colleague's role, increased accountability to the team and provided a common vision that places the client at the centre of their work. The team continually challenges itself to provide service in a way that is best for the client. The program and operations model is viewed positively at all levels in the team, as is the division of family practice partnership. The home and community care program team is well-informed of its community partners and communicates these resources to clients and their families. Information about these resources is carefully tailored for every client, based on their initial contact with the service and in an ongoing manner as care needs evolve. The team is diligent in avoiding duplication of these external services and seeks rather to augment services for their clients. Good relationships with First Nations communities and private residential care homes are noted to ensure clients' continuum of care needs are met. There are high level goals and strategies based on the service plan. Teams in many communities also have goals which they are working towards and regularly review these as a team. Specific and measurable objectives and the resources needed to achieve them are not in place. The team is encouraged to formalize this work, which will both provide increased clarity and allow a measure of success for team accomplishments. Team members are well-supported to deliver quality services. Examples include the safety-line-lone-worker system, education and training opportunities and input to care processes. Home and community care information is provided to clients in a variety of ways. The team has a good referral process with physicians, other IHA services and external partners. Clients can obtain information via a centralized telephone line, the IHA website and from pamphlets, posters and brochures. The intake package information is tailored to every client to ensure they are aware of the supports the program offers. A standardized safety risk assessment tool (HARP) has been in place for many years and provides detailed information regarding the risks identified in the client home, mitigation strategies and any ongoing restrictions put in place to ensure staff entering the home do so in a safe manner. This is a priority assessment, which the team diligently completes. Staff members are encouraged to report safety issues. In discussion with the team, several examples and follow-up actions to resolve the issues were provided. The team is commended for its responsiveness in this area. Priority Process: Competency The home and community care program supports ongoing education and ensures competency of their staff. Team members indicate that they are provided with learning opportunities via several venues including i-learn modules, on- and off-site educational sessions, and a variety of regular rounds and case conferences. Orientation for new staff occurs. Initial and ongoing training related to specific care needs is completed. The knowledge coordinators are well placed to meet team members' learning needs. Infusion pump use is sporadic across the services and provided by the home and community care program. These pumps are more frequently used in the ambulatory treatment clinics. Initial infusion pump training is provided and team members receive certification of same. From discussions with staff members, ongoing training is not formally provided, and there is an expectation that infusion pump use be reviewed independently. Detailed On-site Survey Results 75

81 Team member contributions are recognized in a variety of creative ways by the managers and peer-to-peer. The team is encouraged to share and implement these ideas more broadly. Staffing strategies are reviewed and improvements and efficiencies are made where possible. In certain circumstances, where able, staffing resources are shared geographically owing to service fluctuations. Staff members span program/service boundaries to provide continuity of care, and service is provided to First Nations community clients, as appropriate. As noted, the team has well-established processes to identify and manage risks to both clients and staff. Diligence in this area is commendable. Priority Process: Episode of Care The home and community care program has broad overarching goals and strategies that relate to the region's service plan. A more refined process with measurable objectives was not evident. The team is encouraged to formalize this work. The team membership includes many disciplines and has access to a wide variety of specialists. The enthusiasm for their work and dedication to their clients is most evident. There is an interdisciplinary team approach to providing client service. The team is commended for the attention and resources it has invested to foster and achieve this outcome. The team has instituted a variety of venues to promote integration and collaboration of service. Case conferences, rounds, multidisciplinary care reviews and leadership meetings are but a few examples that evidence this approach. The team is encouraged to review mechanisms for collegial support in the adult day program. Staff members at all levels are aware of their supports and appreciate the timely response to their queries. Students and volunteers are active team members. The team actively lives the organization's Home is Best philosophy. The team strives to ensure that clients and families can easily access service. Education is provided to both internal and external partners to promote a clear understanding of the supports and services available in the program. Work is ongoing around equity of service across the region. There are several mechanisms to ensure responsiveness of service. At all sites, staff indicate that medication reconciliation is not in place at this time. There is a regional plan to implement medication reconciliation in all service areas of the IHA. Staff members currently complete a medication profile and at this time, it does not include all over the counter and herbal/holistic agents. Clients are provided with both oral and written information regarding the services that will be provided to them. Education is provided to both the client and family as appropriate. Ongoing dialogue occurs relative to service needs. Client consent is implied as service provision is voluntary. Client wishes related to refusal of service at any point, for any duration of time, is respected. Client rights and the IHA complaints/concern processes are reviewed with clients. Those clients interviewed had a clear understanding of who to contact and how to handle concerns they or their family may have regarding their care. Ethics issues are frequently discussed at case reviews or team meetings. The home and community care program has referred cases to the regional ethics committee for review. A standardized home safety risk assessment (HARP) is completed for all clients. Staff members view this as an essential assessment, which is given first priority. A falls prevention program (SAILS) has been implemented. Detailed On-site Survey Results 76

82 The assessment and ongoing prevention strategies are a multidisciplinary responsibility. Home care acquired non-surgical infections are not monitored in the region at this time. The team has a robust wound management process and ensures clients are referred and receive treatment as needed. The Pixalere system provides excellent documentation and communication of wound management. Links to infection prevention and control (IPAC) have been identified as lacking, in large part due to resource issues. The provincial patient safety learning system (PSLS) is used to report incidents of all types. Data are tracked and reported. A comprehensive plan of care is developed for every client. There are well-defined processes to communicate the plan to all team members. Care plans are regularly reviewed by the team and changes are made based on client need. Several documentation templates and forms have been standardized and are in use. The team is encouraged to continue with these standardization efforts. The team is also encouraged to review their medication documentation practice. The lack of having a medication administration record (MAR) increases the client risk. There are processes in place to delegate medication-related tasks and all staff are aware of their role in this area. Transition of care in the program and to other service areas such as acute care and residential care is client focused. The team works collaboratively to ensure that all required information is provided during transition to both care providers and the client and family. Return to service transition is reviewed. Elder outreach teams, Aboriginal patient navigators, hospital transition nurses and others provide valuable input to ensure smooth transition of care. The client experience processes are a provincial initiative. Results from previous surveys were not reviewed. The patient voices network has been used to provide input to new initiatives and this has been seen as positive. The team is encouraged to seek other ways to obtain client feedback. Priority Process: Decision Support Client information is collected, stored and transported in a safe manner. Clients are informed about the IHA's responsibilities related to personal information via a written pamphlet received upon admission to the program. This is an excellent resource that also provides information about the clients' rights in this area. Select pieces of the program records are electronic and accessible to the entire team. Other records are manual or not able to be shared due to incompatible technology and IM/IT systems. These barriers have been identified and work, both regionally and provincially is underway to streamline these processes. The program/operation model currently in place supports the team's ability to select evidence informed practices which reflect new and emerging knowledge in the areas of home and community care. The multidisciplinary team approach also fosters this process. Priority Process: Impact on Outcomes The team regularly shares information about potential safety problems and risks via team meetings, case conferences and discussions with managers. Incidents are reported via the provincial PSLS. At a local level, medication incidents are reviewed to determine if additional home supports are needed for example, moving from medication reminders for clients to providing medication assistance. Detailed On-site Survey Results 77

83 Client information is shared electronically, orally and in writing. Team members share information formally and informally. In several communities, home and community care teams are in close proximity with acute care, residential care, physician clinics and other service providers. This co-location was viewed positively and greatly enhanced team relationships and communication. At the corporate level, utilization indicators for community integrated health services are monitored and reported to the ministry. The team is encouraged to continue this work and develop indicators and benchmarks which will assist in evaluating the process and service outcomes for their clients. Also encouraged is to work in partnership to develop cross-sector indicators. Examples may include indicators related to access to residential care, acute care readmissions, ED use, pain management and client satisfaction. Informal evaluation of local initiatives occurs. New initiatives have an evaluation component built in, but in many cases this may be premature as many initiatives are just underway. The home and community care team indicate that formal program evaluation based on indicator and other available data is not in place at this time. With the recent organizational restructuring and integration initiatives the team is poised to begin this work. Detailed On-site Survey Results 78

84 3.3.7 Standards Set: Infection Prevention and Control Unmet Criteria High Priority Criteria Priority Process: Infection Prevention and Control 1.2 The organization tracks infection rates; analyzes the information to identify clusters, outbreaks, and trends; and shares this information throughout the ROP organization Staff and service providers are aware of the infection rates and recommendations from outbreak reviews. MINOR 1.6 The organization shares trends in infections and significant findings with other organizations, public health agencies, and the community The organization offers IPAC education and training to partners, other organizations, and the community. The team follows specific procedures to handle, clean, and disinfect mobile client equipment. The staff member soaks, flushes, and cleans each device in a timely way to remove inorganic and organic matter on the device. All endoscope reprocessing areas are equipped with separate clean and decontamination work areas as well as storage, dedicated plumbing and drains, and proper air ventilation. Surveyor comments on the priority process(es) Priority Process: Infection Prevention and Control The organization's infection prevention and control (IPAC) team is well-supported clinically and administratively. The IPACs are knowledgeable and dedicated health care professionals who work well as a team and as individuals, covering IPAC concerns in IHA's acute care and residential care facilities. The recently added support of an epidemiologist, the leadership of a medical director eminently qualified in infectious diseases and IPAC and the leadership of the corporate director of IPAC lends additional strength to the IPAC team. The IPACs make good use of the technology available to them regarding laboratory reports, patient infection status, daily summaries of inpatients on precautions, surveillance, and other timely information. The team responds promptly to current IPAC events for example, a serious novel virus infection currently being reported by the Centre for Disease Control triggered a memo from IPAC outlining a protocol to screen patients with the intent of alerting clinicians to the potential of a new infection. The team participates in public education targeted at children and parents on the subject of appropriate use of antibiotics. They use a variety of written documentation in the form of pamphlets to describe proper glove use, precaution protocols, and so on. Detailed On-site Survey Results 79

85 The online IPAC manual is comprehensive and current with good references noted at the end of every policy/procedure. The 2010 policies are currently being reviewed. The IPACs do regular audits on their respective facility areas of responsibility and develop action plans to address gaps. They follow up with managers and staff responsible for addressing the deficiencies and document and report responses to their plans. The IPAC team meets monthly. Every third month there are face-to-face meetings and the remainder of the time, meetings are by teleconference. Regional standardization of housekeeping procedures in a coil bound water-resistant booklet reinforces the standard approach to cleaning specific areas. Housekeeping is encouraged to continue the work and roll-out of the booklet to all front-line staff. There is good communication with the Communicable Diseases Department of Public Health regarding residential or acute care outbreaks, as this impacts home care services, community bathing programs, and others. The IPAC program has community care plans for specified infection control issues, as well as hand washing, and antibiotic resistant organism management, which are available on the IHA internal website. These are targeted at staff and community clients. Community staff have been provided with education related to hand hygiene and have the necessary supplies to ensure compliance while providing service in the community. The IPAC indicates that tuberculosis (TB) is well-managed by a multidisciplinary council and the TB staff screening program is a current focus of attention. The use of a standardized checklist for orienting new staff is a worthwhile regional initiative to promote standardization of optimal cleaning procedures. Buddying and mentoring of new staff should be assigned to experienced staff members who are committed to providing standardized and consistent training. There is no formal education or orientation for community staff relative to food handling and light meal preparation in the home. There are some processes in place such as dating prepared foods prior to refrigerating. Community staff identify potential infections, consult physicians, and wound management resources as appropriate and ensure clients receive needed treatment. There is however, a lack of interface with the IPAC program on home-acquired infections. The community and IPAC programs recognize there is an opportunity to improve collaboration, especially given the more invasive care now being provided in the home via peripherally inserted central catheter (PICC) lines, ports and computer aided design (CAD) pumps. Hand-hygiene audits are not currently being done in community services or in the facility MDR areas surveyed. The MDR network representatives acknowledge its focus has been in areas where there is a patient interface. Progress has been made in improving compliance. General reports are available on site compliance and posted by main elevators in the facilities visited. The IPACs are involved in the development of the policy and procedures involving aseptic procedures, and also attend wound rounds. The accountability and procedures for cleaning mobile medical equipment varies from site to site. Some sites use a tag system to identify clean or dirty equipment. At some sites there is an unwritten but generally known practice of leaving clean or dirty equipment in a specific area. It is important that staff working in a unit or at a site know what the protocols are with respect to who is responsible for cleaning specific equipment, what it should be cleaned with and when. In some cases a tracking record of when a piece of equipment was cleaned may also be appropriate and is in use in some locations. In all cases, the procedures should be written down and accessible to staff. Detailed On-site Survey Results 80

86 Although staff members interviewed were not always aware of their unit or site's infection rates they did know that their manager, coordinator or the IPAC would know and that if there was a problem they were confident they would be advised. Linen is handled appropriately in most facilities visited however, it is recommended that laundry personnel at Shuswap Lake General Hospital cover their clean linen when it is being transported in the building. In some older facilities, space constraints do not allow for optimal separation of dirty and clean areas. At Three Links Manor in Kelowna there is a personal laundry in the basement where there is only a counter separating the dirty linen from the clean linen. Workflow has been optimized to work within the limitations of this space. Detailed On-site Survey Results 81

87 3.3.8 Standards Set: Long-Term Care Services Unmet Criteria High Priority Criteria Priority Process: Clinical Leadership Priority Process: Competency The organization has met all criteria for this priority process. 4.5 Staff and service providers receive effective training on infusion pumps. ROP There is documented evidence of effective training on infusion pumps. Each team member's performance is regularly evaluated and documented in an objective, interactive, and positive way. MAJOR Priority Process: Episode of Care The organization has met all criteria for this priority process. Priority Process: Decision Support The organization has met all criteria for this priority process. Priority Process: Impact on Outcomes The organization has met all criteria for this priority process. Surveyor comments on the priority process(es) Priority Process: Clinical Leadership A restructuring of the residential care program took place in 2010 to better align with Key Results Areas required by the Ministry of Health. The program reports to the vice president (VP) of residential care and chief financial officer (CFO), and the structure has an operational arm and a program planning arm. Approximately 50 percent of facilities are operated directly by IHA and 50 percent are operated by private operators on a contractual basis. The organization is in the process of developing a residential care physician leadership group consisting of three leaders. Board members shared examples of receiving regular quality and safety reports including reports on falls and falls prevention. As a result, the board encouraged the purchase of hip protectors and other equipment, and then monitored subsequent reports for improvement. The organization has a wealth of client data available via the resident assessment instrument (RAI), as well as local community data which is the local health area profile that is used for planning purposes. The organization makes good use of client specific RAI reports. Service and program planning is driven by resident needs and guided by the organization's strategic plan, goals and objectives. A recent ombudspersons' report and seniors action plan of February 2012 guides service planning. A bed allocation planning model is used and staffing ratios are standardized across the authority. Detailed On-site Survey Results 82

88 An ALC steering committee is in place and meets monthly to address the flow between the various components of the continuum of care, with particular attention to the acute care residential care flow. Students and volunteers are used regularly and support service provision. Responsibility for management of volunteers is defined at every facility and an orientation checklist is in place. The policy and protocol relating to pneumococcal vaccination is readily available online in a decision tree/flow chart format. Compliance with the policy is monitored by the quality reviews. The policy is built on the premise that all residential care residents are at risk for pneumococcal disease. Gallup poll staff survey results are available and used. A number of team building and team development activities have been initiated as a result of these results. Hand-hygiene products are available in most areas and use is encouraged however, the team is encouraged to move forward with the implementation of a formal hand-hygiene program, including carrying out audits for residential care in a timely manner. Priority Process: Competency Reporting relationships for allied health professionals varies across the IHA region, with some professionals reporting to local management and others reporting to discipline-specific leadership outside the local facility. The organization is in a transition period in terms of leadership structure for allied health professionals, and is encouraged to establish a working structure in a timely manner. It is evident that some disciplines, such as recreation have been without adequate professional practice leadership for considerable time. Various mechanisms exist to facilitate interdisciplinary team development and cohesion. One facility is using a daily stand-up meeting format, which is a 15-minute maximum huddle of all available staff members used as a communication vehicle and an area to identify safety issues and concerns. Residential care is encouraged to consider such locally developed practices for universal implementation at all facilities. Regular evaluation and consideration of team functioning and opportunities for improvement are assessed via the regular quality reviews. A number of initiatives to improve team functioning based on the quality review results are in place. Appropriate orientation programs are in place and typically include a buddy system orientation guided by an orientation checklist. Orientation includes quality and safety and the appropriate use of equipment. Variability exists in the use of infusion therapies across facilities, with some regularly providing infusion and others avoiding infusion whenever possible. Infusion pumps are available at all facilities visited. Staff training is again inconsistent with only one visited site providing evidence of annual infusion pump training. Others report that just-in-time infusion pump training is available online for staff. A wealth of educational material is available for self-learning via the IHA's internal website. Performance evaluation occurs every three years according to organizational policy however, not all employees have received their most recent evaluation of performance within the prescribed time frame. Detailed On-site Survey Results 83

89 The organization has undergone a project to standardize staffing ratios across facilities, based on leading practices. The team has recognized that changes to the local LPN training program from a one-year to two-year program may have an impact on the availability of LPN resources temporarily, and is encouraged to consider mitigating strategies for that time period. Priority Process: Episode of Care Evidence of a resident-first approach to care delivery is abundant. Staff members readily display a sense of pride in their environment and their work. In addition to the care plan with goals and objectives generated by RAI, the use of 'my day' care plans is evident in all residential care facilities. The team is commended for its commitment to using the 'my day' sheets which outline important aspects of care, risks such as falls risk or behavioural risk including precipitating factors and mitigation strategies, and resident likes, dislikes and preferences. It is evident that 'my day' plans are regularly updated. The team produces a comprehensive medical record for every resident that includes all regular assessments, plans and progress. There is consistent evidence however, that components of the record are routinely incomplete. In particular, it is noteworthy that the majority of charts reviewed displayed incomplete documentation of the admission checklist, which is a document that guides activity and assessment for the first 21 days of stay and incomplete follow-up on the effectiveness of PRN medications. In addition, a number of documents requiring physician signatures, such as medication reconciliation discrepancies and no cardiopulmonary resuscitation (no-cpr) forms are incomplete. The organization is encouraged to put in place a redundant double check system whereby incomplete or outstanding documentation can be identified and rectified in a timely manner. Medication administration is typically conducted in the open areas of the facility. All teams are encouraged to consider mechanisms to minimize the possibility of the medication nurse becoming distracted while preparing and administering medications. Those facilities using open trolleys for medication administration, rather than lockable medication carts are encouraged to review the safety implications of that practice immediately. Policies and procedures are in place to guide resident self-medication administration and use of resident own medications or supplements. The preparation of medications by pharmacy differs somewhat from site to site, depending on preparation by IHA pharmacies and private pharmacies. The team is encouraged to review current practices to identify and broadly implement those identified as the best practice from a resident safety perspective. The organization is encouraged to do a review of medication storage practices in residential care facilities to ensure that the storage of narcotics and controlled substances is fully compliant with legislation and regulation. The team is commended for its commitment to building capacity for addressing ethics issues. A local clinical ethics committee is available for consultation and support. At one site, local management has been able to take acquired knowledge and apply it independently to ethically charged issues such as resident choice to live at risk for example, choking hazard and the use of PRN medications for disruptive behaviour. There is a variety of food preparation methods in place, from home cooked in the facility to centrally prepared and reheated. Residents and families consistently report a pleasant dining experience. Resident preferences are respected and accommodated. Detailed On-site Survey Results 84

90 Residential care facilities support pet visitation and on-site animals. The team is encouraged to ensure that IHA policies in this regard are known and followed at all sites, as implementation of the policy is currently inconsistent. Standardized assessment tools are in place for areas of resident risk, such as falls and pressure ulcers. There is clear evidence that the tools are consistently used. Priority Process: Decision Support Those facilities which continue to display resident names and room numbers at the main public entrance are encouraged to review the appropriateness of that practice. The team produces a comprehensive medical record for every resident that includes all regular assessments, plans and progress. There is consistent evidence however, that components of the record are routinely incomplete. In particular, it is noteworthy that the majority of charts reviewed displayed incomplete documentation of the admission checklist, which is a document that guides activity and assessment over the first 21 days of stay and incomplete follow-up on the effectiveness of PRN medications. In addition, a number of documents requiring physician signatures, such a medication reconciliation discrepancies and No-CPR forms are incomplete. The organization is encouraged to put in place a redundant double check system whereby incomplete or outstanding documentation can be identified and rectified in a timely way. Educators are developing evidence-based clinical practice guidelines, some of which are complete and others in development. Examples include admission protocols, medication reconciliation, care of the deceased, bowel protocols, delirium protocols and team conferencing. Priority Process: Impact on Outcomes The team is commended for its use of photographs as a patient identifier, in addition to familiar recognition supplemented by verification by a regular staff member when needed. Clear photographs, regularly updated as a resident's appearance changes are affixed to the medication cassette and the medication administration record (MAR). While all areas have meetings and mechanisms that facilitate discussion of safety issues, a regular team huddle dedicated to safety issues such as safety rounds should be considered. The team is commended for its relatively recent adoption of the purple dot strategy for assessment and identification of residents at risk of aggressive behaviour as a universal strategy for all facilities following the successful pilot. The organization is commended on its routine use of the residential quality review self-assessment tool. This comprehensive review includes review of the physical plant and culture, team functioning, resident population profiles, resources, assessment, care planning and intervention activities, and required organizational practices. There is good evidence that the data produced by the quality reviews is used to identify and prioritize areas for improvement. A large number of local initiatives are underway or complete as a result and it is evident that local staff and managers have taken ownership of the results and take pride in their improvement accomplishments. The team is encouraged to consider mechanisms to spread the acquired knowledge and improvement initiatives more widely for the benefit of all IHA residential care facilities. The quality review process is a leading practice now being targeted for other regions of the province. Detailed On-site Survey Results 85

91 Program evaluation is conducted using the IHA framework for evaluation. The extensive IHA online dashboard supports program evaluation and ongoing monitoring. There is a wealth of data available via the RAI at the resident, unit, site and regional level. The team monitors resident and family perspectives primarily via informal and anecdotal mechanisms. The team is encouraged to move forward with its plans for conducting resident and family surveys and for expanding its use of resident and family councils to all facilities. Specific residential care facilities have partnered with researchers from the University of Alberta on SCOPE projects, which are designed to improve resident experience using RAI data to inform change and interventions. These front-line driven and owned initiatives have already proven successful in improving dining room behaviours and reducing agitation and wandering. Detailed On-site Survey Results 86

92 3.3.9 Standards Set: Managing Medications Unmet Criteria High Priority Criteria Priority Process: Medication Management Pharmacists and pharmacy staff are part of the organization's interdisciplinary team. Staff and service providers who participate in the medication use process have access to internal or external training related to the medication use process. The organization educates staff and service providers about adverse drug events (ADEs). The organization orients staff and service providers to the medication use process before they are permitted to work independently. The organization, including community-based organizations, follows written criteria for adding medications to and removing medications from the formulary. Staff and service providers have access to the formulary, and are made aware of which medications are included and excluded from the list. The organization has a process to systematically and regularly review the formulary and update safety or efficacy information accordingly. Medication storage areas are clean and orderly. Medication storage areas are equipped with sufficient lighting. Medications are stored in secure areas accessible only by authorized staff. Medication storage conditions protect the stability of medications. Medications for client service areas are stocked in ready-to-use formats, where available. Medications for client service areas are stored in labelled, unit dose packaging. The organization has a policy and process to manage medications brought into the organization by clients and families. The organization securely stores cytotoxic agents in a segregated area with adequate ventilation. Detailed On-site Survey Results 87

93 10.1 Prescribing professionals write or electronically enter complete medication orders, reorders, or reassessments upon admission, end of service, or transfer to another level of care The organization has identified and implemented a list of abbreviations, ROP symbols, and dose designations that are not to be used in the organization The organization educates staff about the list at orientation and when changes are made to the list The organization audits compliance with the Do Not Use List and implements process changes based on identified issues. The organization develops and follows a policy to maintain accurate allergy information in each client medication history. MINOR MINOR The pharmacy and other service providers accept verbal orders for medication only in emergencies. The pharmacy and other service providers accept telephone orders for medication only in emergencies. The organization has a policy for the acceptability of medication orders. The organization provides quiet work areas where medication orders are written, transcribed, and entered into computer systems. The organization provides workspace to pharmacy staff to support safe and effective preparation of medications. Pharmacy staff compound sterile medications and intraveneous admixtures in the pharmacy using aseptic technique and appropriate safety materials and equipment. The pharmacy uses an externally-vented biohazard hood for cytotoxic products. At the start of service, service providers educate clients and families about how to take an active role in ensuring medication prescribed for them is administered safely The team uses at least two client identifiers before administering ROP medications The team uses at least two client identifiers before administering medications. Service providers refer to the client's medication administration record each time medication is administered. MAJOR Service providers seek an independent double check before administering high-alert/high-risk medications. The organization establishes an interdisciplinary group to investigate adverse drug events and review adverse event summary reports to support learning within the organization. Detailed On-site Survey Results 88

94 21.9 The organization provides staff and service providers with regular feedback about adverse drug events, hazardous situations, and risk reduction strategies that are being implemented. Surveyor comments on the priority process(es) Priority Process: Medication Management A framework for pre-printed order forms has been created and approved by the pharmacy and therapeutics committee (P&T). This was recently rolled out with the VTE prophylaxis pre-printed order. The pre-printed order forms have a significant impact on standardizing medication therapy prescribing and use by embedding evidence-based practice guidelines. The organization is encouraged to continue to roll out pre-printed orders but to do so in a manner that would support review and approval, as well as have the appropriate project coordination and support to manage these pre-printed orders. Doing so will guide the significant move in transitioning to computerized physician order entry (CPOE) at a near future date. The organization is commended on its implementation of smart infusion devices. The organization has committed substantial time and effort, including human factors engineering assessment to the selection, standardization, and implementation of smart infusion devices across the region so as to facilitate medication safety with high risk/ high alert medications using decision support software. The organization is encouraged to continue to roll out the wireless infrastructure in all IHA facilities so as to facilitate numerous initiatives, among which is the ability to gather quality improvement analytics and reports on medication errors averted, with the smart infusion devices being implemented. Detailed On-site Survey Results 89

95 Standards Set: Medicine Services Unmet Criteria High Priority Criteria Priority Process: Clinical Leadership Priority Process: Competency The organization has met all criteria for this priority process The interdisciplinary team follows a formal process to regularly evaluate its functioning, identify priorities for action, and make improvements. Team leaders regularly evaluate and document each team member's performance in an objective, interactive, and positive way. Priority Process: Episode of Care The organization has met all criteria for this priority process. Priority Process: Decision Support The organization has met all criteria for this priority process. Priority Process: Impact on Outcomes The team shares benchmark and best practice information with its partners and other organizations. Staff and service providers participate in regular safety briefings to share information about potential safety problems, reduce the risk of error, and improve the quality of service. The team compares its results with other similar interventions, programs, or organizations. Surveyor comments on the priority process(es) Priority Process: Clinical Leadership South Okanagan General Hospital Medicine Program: There are 18 funded beds for medical/surgical patients, all on one unit. Although most patients are medical, they have a physical capacity of 25 beds therefore, are able to go over capacity. Monitoring and telemetry is available at four of the beds in that one unit and the unit is staffed with one patient care coordinator, one RN, two LPNs and two PCAs. The ratio of nurse to patient is 1-6 or 1-7, which is quite high for the care that is required for these patients. Detailed On-site Survey Results 90

96 The facility is staffed by family physicians, and 16 have admitting privileges and of those 16, some also work in the ED. On the day shift, each of the family physician is responsible for covering his/her own patient and in the off-hours, the emergency physician covers the inpatient acute care unit. There is access to a second call roster of physicians that can be on site within 20 minutes if the need arises. This second call list is accessed once or twice a month. For more acute cases, there is access to the HART team that will arrive for transport and there is also access to specialized physicians from Kelowna for trauma. The catchment covers a large area, but a small population. It is noted that the volume of patients that access is much larger than the actual population because of workers coming here in the summer and the snowbirds who come in the winter. These two patient groups are complex because the summer workers usually do not have family physicians and the snowbirds tend to be elderly and many have chronic diseases. The residential population of Oliver has the highest age of the Okanagan valley so they too have multiple needs. Another aspect of the population is the high number of East Indians, Portuguese and Natives. They are actively working with the civic leaders of each group to educate about health issues, such as diet and tuberculosis and they have also recently made presentations on advance directives at the Seniors Centre. There is a good working relationship with community partners such as the nursing homes, the rest homes, the RCMP, the Hospice Society, and Public Health. An excellent example of the general hospital and the community partners working together is the weekly meeting every Wednesday morning to review the discharge planning needs of every patient on the unit. In attendance is the patient care coordinator, and the community social worker, OT and PT, and the palliative care nurse, and the acute care social worker, OT and PT, and the residential care patient care coordinator. They have seen a marked decrease in the length of stay since this initiative started two years ago, and also fewer repeat admissions. There is a process called Pathway to Home which includes a short-stay for recovery at the McKinney Centre for convalescence or palliative care. There are criteria for admission to the centre and good collaboration and communication by the teams involved. There is an electronic patient record with physician order entry in Oliver, and the only area that is not yet automated is the ED, which is to be automated in the near future. Medication reconciliation is initiated by the admitting physician in the ED and then finalized by the pharmacist within 24 hours of admission. Recruitment of clinical staff is a challenge and there are many positions that have only one incumbent, such as the pharmacist and the palliative care nurse, and coverage on their days off can be a challenge. However, there is a process in place to cover the absences but it frequently means having to juggle workloads. Performance appraisals do not appear to be a priority at any of the centres, except for Oliver, where the surveyor was informed that the clinical staff had asked to have a formal review with their manager, and about 50 percent are now done. The team approach to the care is highly evident at this site. Priority Process: Competency Kelowna General Hospital Medicine Program: There are two tertiary sites in the IHA and Kelowna Hospital is one of the two. It has 127 beds located on four different units. The units themselves are set up in pods that specialize in oncology, respirology, gastro-intestinal, detoxification, general medicine, alternate level of care, and renal. There is a 10-bed medical teaching unit and the physicians are two Intensivists and one general internal medicine physician. There are 24 FTE hospitalists that staff the units. Admissions are 75 percent from the ED and 25 percent direct admits. There are 176 GPs in the community, although only 64 are active in the hospital and of those, they mostly do obstetrics. Detailed On-site Survey Results 91

97 The problem of overcapacity in the hospital, with patients being admitted to beds in the corridors, has led to the initiative of creating better flow of patients throughout the system. In the two months since the initiative began, the staff are seeing a big difference in that now, 72 percent of discharges occur by 1100 hours, with a peak of admissions at 60 percent between 1100 and 1500 hours, whereas before, the peak of admissions was between 2200 and 2300 hours. The peaks of discharges and admissions are now closer together, with an eight-hour difference in just two months. Just this month, the hospital opened a 24-bed ALC unit with the following admission criteria that flow in from acute care in that they have to have a plan of care in place, and they have to have the geriatric syndrome assessment completed. The unit is covered by hospitalists, although a few of the patients are covered by their family physician. In setting up this unit, a steering committee, which involved several community and residential partners, looked at population health data, looked at the resources that would be required and then developed the admission criteria. They involved the different unions in this project and developed an engagement strategy and ensured that the initiative was in line with the executive strategic priorities. As the majority of the medical admissions are from the ED, the medicine program is heavily involved in the patient flow across the hospital. There is a bed meeting every morning and the patient care coordinator participates actively in those meetings. A plan-do-study-act (PDSA) cycle occurs every week to see how the program is doing. The target wait time for a bed for an ED patient is 10 hours and currently, this is at 11.6 hours. A good initiative, of introducing patient and family centred care to the organization with a steering committee of administrators, physicians, clinical staff members, and patients and family members is leading the implementation of this initiative. Another good initiative is a telephone call to the patients 24 hours post discharge and again seven days post discharge, combined with enhanced links to the community. The entire region supports students in many forms, be they clinical or high school, as well as numerous volunteers. Priority Process: Episode of Care Vernon Jubilee Hospital Medicine program: The hospital is divided into two medical units, which include eight telemetry beds and a medical short-stay pod. There are 12 ALC beds which are currently at over-capacity with 18 patients. The staff have created an overflow area for medical patients with eight beds next to the ED and those patients are for the ones whose LOS averages two to three days. Because of the over-capacity issue, there is a daily meeting at 0900 hours, with the managers only and then with the front-line leaders (PCCs) at 1000 hours to expedite the flow of patients. If there is no movement, the trigger is to the chief of staff and the directors. As with the other health centres in the region, the orientation program is standardized and comprehensive, and it is also tailored to every employee in order to meet their needs. Some of the learning is via modules on the computer, some are with an educator in the classroom and finally, with a preceptor on the designated unit. On a consistent basis, the incident and near misses are reported in the patient safety learning system (PSLS) in all the centres. Follow-ups are done and reports for trending are examined by the leadership. Disclosure education has been done with the physicians. Safety briefings are not done in Vernon and it is recommended that staff get into the habit of spending two to three minutes at the beginning of each shift to highlight areas of special concern that day. Detailed On-site Survey Results 92

98 Priority Process: Decision Support Penticton Regional Hospital Medicine Program: There exists quite a large catchment area with a population of about 70,000 residents but the patient base is augmented throughout the year with the workers in the summer and the seekers of warmth in the winter. There are two medical units with 27 and 18 beds respectively and with telemetry capacity. They are consistently in overcapacity and for that reason have set up an overflow unit next to the ED and one overflow bed has been allocated to each of the inpatient units. There are daily huddles with the community leaders in order to ease the overcapacity. The hospital received the BC Patient Safety and Quality Council award in 2009 for its falls prevention program, and the outline of this program has been used to develop the falls program across the region. There is clear evidence of teamwork and respect for colleagues at this hospital and a pride in the work that is performed here. They clearly appreciate the regional approach to policies and agree that standardization across the region will benefit the patients and in fact, they would welcome even more networking and collaboration. Priority Process: Impact on Outcomes Kootenay Boundary Regional Hospital - Trail: The Kootenay Boundary Regional Hospital is a 30-bed unit. It is evident that there is a high-functioning interdisciplinary team on the unit. The staff recognize the need to improve patient flow and support IHA by repatriating patients in a timely way from the larger facilities. The site states that they receive quarterly data regarding performance, including LOS; however, it is evident that their utilization to inform decision-making and planning is limited at the front-line manager level. The organization is encouraged to provide where possible, benchmark data for different case mix groups to better identify opportunities for improvement to improve the patient s length of stay. Since the new program structure was introduced, the medicine program staff report that they feel isolated and a lack of progress to improve services. They report that medicine is not identified as a program. AtKootenay Boundary Regional Hospital the care of the palliative patient requires some attention. In particular, focused teaching about the needs of the palliative patient and their family and development of palliative care rooms to create a more patient/family focused environment is encouraged. Detailed On-site Survey Results 93

99 Standards Set: Mental Health Services Unmet Criteria High Priority Criteria Priority Process: Clinical Leadership The team collects information about its clients and the community. The team uses the information it collects about clients and the community to define the scope of its services and set priorities when multiple service needs are identified. The team works together to develop goals and objectives. The team's goals and objectives for its mental health services are measurable and specific. Priority Process: Competency The organization encourages all team members to develop skills to improve the interdisciplinary approach and overall team functioning. The organization provides sufficient workspace to support interdisciplinary team functioning and interaction. The interdisciplinary team follows a formal process to regularly evaluate its functioning, identify priorities for action, and make improvements. The team monitors and meets each team member's ongoing education, training, and development needs. Team leaders regularly evaluate and document each team member's performance in an objective, interactive, and positive way. The team has a fair and objective process to recognize team members for their contributions. Priority Process: Episode of Care Priority Process: Decision Support The organization has met all criteria for this priority process The organization has a process to select evidence-based guidelines for mental health populations. Priority Process: Impact on Outcomes 2.3 The team identifies the resources needed to achieve its goals and objectives. Detailed On-site Survey Results 94

100 14.5 The team shares benchmark and best practice information against its partners and other organizations. Surveyor comments on the priority process(es) Priority Process: Clinical Leadership The mental health program does not have a specific program plan to guide current and future service delivery options. Rather, there is focus on the broader priorities/directions, as established by IHA as whole. In this regard, there is alignment at a high level with the organization's overall strategic direction. It was also noted that with recent restructuring elements of the program, specifically community health, mental health has developed longer term plans. However, this was done without involvement of, or collaboration with the facility-based mental health services. The program is particularly strong in the relationships between its various service modalities namely, community mental health, acute care inpatient and tertiary residential. At all sites visited, this strong working relationship was in evidence and was further confirmed in consultation with other members of the surveyor team. This relationship has remained strong even as the organizational reporting structure for mental health has undergone change. This commitment to maintaining service relationships and seeing an individual patient for the full extent of their service requirements is commendable. There is concern however, as to whether this strong service relationship can be maintained without supporting infrastructure such as a network for mental health. A number of sites supported student placement for example, medical and nursing students and volunteer involvement in their programming. Particularly noteworthy, was the involvement of a number of current/former health clients on various units and in various roles. Priority Process: Competency In all sites visited, there was evidence of a high degree of exemplary teamwork. The MH program is commended for strong team work and an evident commitment to working together for the benefit of the patient. Challenges were recognized with recent new management hires and orientation to the service and continued work on implementing the new MH organizational structure. However, all staff and medical staff that were talked with spoke highly of their colleagues in the respective sites. Orientation programs at all sites appeared to be robust and included good mentoring and support efforts on the part of existing staff. New staff members felt supported in their introduction to the MH program. There was limited use of infusion pumps on the MH units visited. This has been by intent. It was noted that there have been exceptions to this design and that necessary training has been pursued as required, or support from medical units obtained as necessary. Across the sites visited, a strong commitment was apparent for maintaining staff safety and continuously educating staff on how to prevent and manage any episodes of workplace violence, with code white response and exercises. This effort/emphasis is noteworthy and commendable. Priority Process: Episode of Care All clients interviewed were highly complimentary of staff and medical staff supporting patient care. Clients noted that in all cases they felt safe, informed and involved in their care planning and transition to community or other care options as circumstances dictated. Detailed On-site Survey Results 95

101 In the client charts reviewed and where indicated, there was documented evidence of suicide risk assessment. There was also evidence of updates to status as the clients' care journey progressed during their stay in a program. Evidence was seen of patients being informed about their legal rights and about how to file/process complaints about care as required. It was evident from a records review, discussion with staff, and by confirmation with fellow surveyor team members that transfer of information between community, acute hospital, and tertiary level services was well-managed. The team is commended for its work on dealing with transport issues and specifically for the work on sedation/transport protocols. The team is encouraged to share/publish its work at the appropriate time to the benefit of other jurisdictions facing similar challenges. Priority Process: Decision Support Patient records that were reviewed are comprehensive and accurate. Limited evidence was presented as to any formal/structured means to keep abreast of best practices in MH services. There were some comparisons drawn between IHA sites for example, the MH patient satisfaction survey. There are greater opportunities and requirements to consider mechanisms by which the service in its entirety can benefit from access to external research, information and data. Priority Process: Impact on Outcomes In the absence of program-specific/program-wide goals and objectives, there is no ability to systematically/rigorously identify resources needed to achieve such. There is some information that was made available such as inpatient bed capacity per 100,000 population that if used in establishing program plans, could be quite powerful in setting direction for the program. The MH program demonstrated particular strength to the surveyor in identifying and reducing risk to team members in the delivery of patient care services. In particular, there was strong emphasis on preventing/managing incidents of workplace violence. Just as important and commendable in this regard was the demonstrated commitment to the minimal use of restraints. Client records contained evidence of the established falls prevention strategy. Moreover, specific and graduated responses to individual patient circumstances were initiated versus blanket/global responses. The MH program is commended for the excellent work in the use of two client identifiers. Excellent examples of this were in evidence at Harbour House and in other settings, such as Penticton clients were able to note how staff had used two means to identify patients before providing any intervention/medication. Detailed On-site Survey Results 96

102 It is evident from discussion with a variety of staff and medical staff, patients/clients and a review of organizational documents/patient records that there is a strong commitment to patient-centred care. However, there is limited formal/structured means in place at this time to consistently and objectively evaluate this performance. In addition, there is limited to almost no means of sharing information on quality of service provided either with staff of the MH program or with patients/families receiving service. This is an area deserving of effort, as it would serve to both recognize and further motivate staff effort and further assure patients/families of the quality of service they are receiving. Detailed On-site Survey Results 97

103 Standards Set: Obstetrics Services Unmet Criteria High Priority Criteria Priority Process: Clinical Leadership 2.8 The team has access to the supplies and equipment needed to deliver obstetrics services. Priority Process: Competency The organization provides sufficient workspace to support interdisciplinary team functioning and interaction. The team orients new team members about their roles and responsibilities, the team goals and objectives, and the organization as a whole. Team leaders evaluate and document each team member's performance in an objective, interactive, and positive way. The team has a fair and objective process or program to recognize team members for their contributions. Priority Process: Episode of Care 9.9 The team uses a safe surgery checklist to confirm safety steps are ROP completed for a surgical procedure The team uses the checklist for every surgical procedure in the operating room The team has developed a process for ongoing monitoring of compliance with the checklist The team evaluates the use of the checklist and shares results with staff and service providers The team uses results of the evaluation to improve the implementation of and expand the use of the checklist. MAJOR MAJOR MINOR MINOR 12.3 The team reconciles the client's medications with the involvement of the ROP client, family or caregiver at transition points where medication orders are changed or rewritten (i.e. internal transfer, and/or discharge) There is a demonstrated, formal process to reconcile client medications at transition points where medication orders are changed or rewritten (i.e. internal transfer, and/or discharge) Depending on the model, the prescriber uses the Best Possible Medication History (BPMH) and the active medication orders to generate transfer or discharge medication orders (proactive), OR, the team makes a timely comparison of the BPMH, the active medication orders, and the transfer or discharge medication orders (retroactive). MAJOR MAJOR Detailed On-site Survey Results 98

104 The team documents that the BPMH, the active medication orders, and the transfer or discharge medication orders have been reconciled; and appropriate modifications to medications have been made where necessary Depending on the transition point, an up-to-date medication list is retained in the client record (internal transfer), OR, the team generates a Best Possible Medication Discharge Plan (BPMDP) that is communicated to the client, community-based physician or service provider, and community pharmacy, as appropriate (discharge) The process is a shared responsibility involving the client or family, and one or more health care practitioner(s), such as nursing staff, medical staff, and pharmacy staff, as appropriate. Following transition or end of service, the team contacts clients, families, or referral organizations to evaluate the effectiveness of the transition, and uses this information to improve its transition and end-of-service planning. MAJOR MAJOR MINOR Priority Process: Decision Support The organization has met all criteria for this priority process. Priority Process: Impact on Outcomes The organization has met all criteria for this priority process. Surveyor comments on the priority process(es) Priority Process: Clinical Leadership The perinatal and child health network is well-developed and appears to be effective. It has joint administrative and medical leadership and these individuals are energetic and thoughtful. They appear to be widely respected. The multidisciplinary groups at each of the sites consider the services that they can pride and should provide and give consideration to what can be sustained. They are aware of and use the resources of the other IHA sites. Priority Process: Competency Within the larger facilities the practice volume contributes to maintaining competence since staff have not been in the habit of the conducting multidisciplinary drills to rehearse and enhance the ability to deal with emergencies and maintain their ability at obstetrical skills. The advent of the MORE OB program offers the opportunity to correct this deficiency. In the smaller centres with low volumes there is an even greater need for the use of simulation and other means to maintain competence. In addition, consideration may be given to having enough teams of staff from small centres attend briefly at a larger and high-volume centre for the purpose of multiple repetitions of cesarean section skills. This way, staff can maintain their competence. Consideration must be given to some means to back-fill in the smaller units when staff members attend for continuing professional development at a larger facility of IHA. Detailed On-site Survey Results 99

105 Priority Process: Episode of Care Interior health Authority has established a prenatal registration program wherein all women may make known their pregnancies and can be directed to the applicable and appropriate resources available in their vicinity. This is a highly commendable development that facilitates access. A specific consent form addresses the circumstance when care, such as the ability to do a cesarean section, may or may not be present in smaller units. Thus, women may be appropriately informed and can make the choice they wish for the site at which they would receive their care. In Kamloops the organization has established a quite desirable program called Little Roots for the care of the mother and infant in circumstances of substance use and methadone consumption by the mother. The needs of the Aboriginal population, who are a substantial portion of those for whom care is provided at certain sites, will be enhanced by Aboriginal doulas. Within lha there are aboriginal navigators. These individuals are quite valuable for those receiving obstetrics and perinatal care. There is variable access to a service for vaginal delivery for breech presentation. Current evidence suggests that appropriately selected women should be offered vaginal breech delivery. This is available in Vernon but not available in Kelowna. The IHA system needs to devise methods to not only increase practice according to current evidence but also to permit women the choice of care at facilities other than their own if that evidence-based care is not available in their home community. The cesarean section rates are high in IHA as in all of British Columbia but are commendably somewhat lower in Vernon. Contributing to the high cesarean section rate is the low frequency of offering trial of labour to women with previous cesarean sections. When a trial of labour is offered, vaginal delivery is often achieved but the frequency of offering a trial of labour is low. Vernon is maintaining a low induction rate, which probably contributes to their lower cesarean section rate than elsewhere in the region. Priority Process: Decision Support The team receives valuable input to and provision of standardized guidelines and documentation material from the BC perinatal program. The team will receive further valuable input as IHA adopts and disseminates the MORE OB program. Local individual efforts are made by groups to devise policies and pre-printed orders but these tend to be site specific. Difficulty and some frustration is encountered with the attempt to have these accepted across the region in all of its facilities. The perinatal registration system will engage women with the healthcare system early in their pregnancies. Priority Process: Impact on Outcomes There is a fall prevention strategy to specifically address the needs of pregnant women including those who had an epidural anesthetic and for the care of babies. This is specifically addressed to the population served and is highly applicable to their needs. Critical events are recognized, reported and used as part of the patient learning system. However, there may be deficiencies as there are long delays before feedback is given to those who reported. Detailed On-site Survey Results 100

106 There is some information in the form of the recording of the opinion of the patients and families about services provided but this is not regularly and systematically collected. Available to this team is information comparing sites within IHA services. There is also the great advantage of comparisons available from the BC perinatal health program. This can permit the selection of peer facilities elsewhere in British Columbia. Detailed On-site Survey Results 101

107 Standards Set: Rehabilitation Services Unmet Criteria High Priority Criteria Priority Process: Clinical Leadership The team regularly reviews its services and makes changes as needed. The team's goals and objectives for rehabilitation services are measurable and specific. Priority Process: Competency The organization provides sufficient workspace to support interdisciplinary team functioning and interaction. The interdisciplinary team follows a formal process to regularly evaluate its functioning, identify priorities for action, and make improvements. Team leaders regularly evaluate and document each team member's performance in an objective, interactive, and positive way. Priority Process: Episode of Care 7.4 The team reconciles the client's medications upon admission to the ROP organization, with the involvement of the client, family or caregiver The team generates a Best Possible Medication History (BPMH) for the client upon admission Depending on the model, the prescriber uses the BPMH to create admission medication orders (proactive), OR, the team makes a timely comparison of the BPMH against the admission medication orders (retroactive) The team documents that the BPMH and admission medication orders have been reconciled; and appropriate modifications to medications have been made where necessary. The team uses standardized clinical measures to evaluate the client's pain. MAJOR MAJOR MAJOR 11.3 The team reconciles the client's medications with the involvement of the ROP client, family or caregiver at transition points where medication orders are changed or rewritten (i.e. internal transfer, and/or discharge) There is a demonstrated, formal process to reconcile client medications at transition points where medication orders are changed or rewritten (i.e. internal transfer, and/or discharge). MAJOR Detailed On-site Survey Results 102

108 Depending on the model, the prescriber uses the Best Possible Medication History (BPMH) and the active medication orders to generate transfer or discharge medication orders (proactive), OR, the team makes a timely comparison of the BPMH, the active medication orders, and the transfer or discharge medication orders (retroactive) The team documents that the BPMH, the active medication orders, and the transfer or discharge medication orders have been reconciled; and appropriate modifications to medications have been made where necessary Depending on the transition point, an up-to-date medication list is retained in the client record (internal transfer), OR, the team generates a Best Possible Medication Discharge Plan (BPMDP) that is communicated to the client, community-based physician or service provider, and community pharmacy, as appropriate (discharge) The process is a shared responsibility involving the client or family, and one or more health care practitioner(s), such as nursing staff, medical staff, and pharmacy staff, as appropriate. Following transition or end of service, the team contacts clients, families, or referral organizations to evaluate the effectiveness of the transition, and uses this information to improve its transition and end of service planning. MAJOR MAJOR MAJOR MINOR Priority Process: Decision Support 14.1 The organization has a process to select evidence-based guidelines for rehabilitation services. Priority Process: Impact on Outcomes 15.5 The team implements verification processes and other checking systems for ROP high-risk activities The team identifies high-risk activities. MAJOR The team develops and implements verification processes for high-risk activities The team evaluates the verification processes and uses information to make improvements. The team monitors clients' perspectives on the quality of its rehabilitation services. The team compares its results with other similar interventions, programs, or organizations. The team shares evaluation results with staff, clients, and families. MAJOR MINOR Detailed On-site Survey Results 103