Accreditation Report. Quality Improvement Plan & Benchmarking Data. Prepared for Erie St. Clair Community Care Access Centre

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2 Report Quality Improvement Plan & Benchmarking Data Prepared for Erie St. Clair Community Care Access Centre

3 Decision Three-Year Expiration: June 2015 Organization Erie St. Clair Community Care Access Centre () 712 Richmond Street, Box 306 Chatham, ON N7M 5K4 Canada Organizational Leadership Betty Kuchta, B.A, LL.B., Chief Executive Officer Melanie Bucek, M.S.W., Quality Improvement Manager Glenda Maillioux, CGA, Senior Director, Corporate Services Survey Dates June 27-29, 2012 Survey Team Blair Philippi, Administrative Surveyor Brent Selman, Program Surveyor Avanthi Goddard, B.B.A. Hon., Dip Adult Ed., Program Surveyor Programs/Services Surveyed Home and Community Services Services Management Network with Access Centre Governance Standards Applied 1 Erie St. Clair Community Care Access Centre Report

4 Programs/Services by Location Erie St. Clair Community Care Access Centre 712 Richmond Street, Box 306 Chatham, ON N7M 5K4 Canada Home and Community Services Services Management Network with Access Centre Governance Standards Applied -Windsor Site 5415 Tecumseh Road East, 2nd Floor Windsor, ON N8T 1C5 Canada Home and Community Services -Sarnia Site 1150 Pontiac Drive Sarnia, ON N7T 7H9 Canada Home and Community Services Erie St. Clair Community Care Access Centre Report 2

5 Survey Summary Areas of Strength Erie St. Clair Community Care Access Centre () has strengths in many areas. is a high-performing health service provider dedicated to improving the quality of life of persons served in the area it serves. The board, senior leadership, and staff show an immense loyalty and commitment to putting the person served first. Programs are designed and delivered based on best practices and identified population and geographic needs. Examples include the Geriatric Rapid Response Team and Palliative Care Consultation Team (PCCT). has been recognized both locally and provincially for its success in these programs and others at the organization. has undergone immense change since its beginnings in the late 1990s., after amalgamation, worked diligently to integrate operations and develop a model of care that is reflective of the needs of the community. This organization benefits tremendously from the experience of the CEO in the community and her longevity in this position. has excellent legal and regulatory policies and processes to support its business functions to operate a large organization across multiple sites. Procurement guidelines and the monitoring of performance of health service providers completed in a proactive fashion and the quarterly meetings and joint agendas are appreciated by agencies outside the organization. The organization also credits its success due to its involvement with the Ontario Association of Community Care Access Centres as this collaborative relationship enables provincial program development and planned implementation. Governance oversight and accountability are evident in the approach and trust the board has in the CEO. Board members are actively engaged and are aware of their role and continue to seek opportunities to identify strategic needs and resources for the benefit of the community in the Erie St. Clair Local Health Integration Network (LHIN) region. The culture is warm and inviting. People work collaboratively in a safe and positive environment in Chatham, Sarnia, and Windsor. Human resource and health and safety policies are very well done, and front-line staff appreciates the support and ongoing communications to improve their work lives. Further, staff members shared that the is their employer of choice, and the best decision they made was to come work here. Senior management and the CEO are to be commended for building that supportive culture over time. In these challenging and stressful times, the organization continues to support staff every day. The PCCT and the Geriatric Rapid Response Team programs provide professional, specialized resources both to persons served and other service providers in the network. The programs have been initiated to address the unique health needs of the region, and has responded to its community in a proactive manner using a coordinated approach of specialized services that is unique to community care. There is a dedicated team assistant role for the programs to ensure consistency in approach and provide a common contact for the service providers and persons served. The team members for both programs are cognizant of the risk that the persons served have to deal with and have a well-developed on-call system within the specialized services. 3 Erie St. Clair Community Care Access Centre Report

6 Areas for Improvement should seek improvement in the following areas. The organization should engage stakeholders (persons served and contracted health service providers) in the development of its strategic planning by providing opportunities for them to give input regarding its strengths and opportunities. The organization should conduct a more comprehensive analysis of its accessibility issues that includes providing opportunities for persons served, personnel, and other stakeholders to give input to assist in the identification of barriers and take into consideration any accessibility needs that may hinder full and effective participation on an equal basis with others. All identified barriers should be included in s accessibility plan that addresses action for the removal of barriers and time lines for their removal. should prepare an accessibility status report that includes progress made in the removal of identified barriers and areas for improvement. The accessibility plan was recently implemented; however, the organization should ensure that it prepares the status report on an annual basis moving forward. Decision Erie St. Clair Community Care Access Centre has earned a Three-Year. On balance, the organization has many strengths as demonstrated by its high level of conformance to the CARF standards, while simultaneously recognizing the areas for improvement. has sound practices in business processes and policies that support operations and program delivery. Staff is engaged and values the emphasis that management places on human resources and health safety, information management, and information technology. Governance oversight is strategic, and board members seek information about the outcomes of service delivery for persons served in the region. As a business services network providing aging services to its population, the organization has worked closely with its network of providers, reaching and benefiting thousands of seniors. Its mission is evidenced throughout the network and echoed by persons served who are the beneficiaries of an incredibly strong coordination of services. Although some areas for improvement have been identified, it is apparent that the organization is actively working toward meeting all standards and should continue the efforts in place. Erie St. Clair Community Care Access Centre Report 4

7 Exemplary Conformance Section 2. Care Process for the Persons Served A. Program/Service Structure The PCCT is a unique program with a focus to improve access to quality palliative care for persons served in their preferred setting where possible. The team is composed of a variety of healthcare professionals, including nurse practitioners, resource nurses, an occupational therapist, a social worker, a local physician, and other allied health professionals. The key to the success of the team is the role of the nurse practitioners who have specialized competencies around the issues like the type of cancer that persons served are living with, the pain management techniques and medications required to manage the pain, and the medical resources available in the region. The case management and coordination of a specialized medical need such as this is unique. They are able to respond in a timely manner and to navigate the system for their persons served. Statistics from the past year highlight some of the positive impacts achieved by the PCCT. Between April 1 and October 31, 2010, the PCCT made it possible for 85 percent of end-of-life persons served in Sarnia to die in the home, a significant role of the team that persons served note as a priority. Similarly, part of the PCCT s function is to avoid emergency room visits for palliative persons served, 286 of which were avoided between April 1 and October 31. This is an amazing program focused on the person served and adds a benefit to the congested local hospitals. The program also addresses the specific health needs of the population of the region and has been recognized by its peers, funders, and government leaders as being unique, innovative, and effective. Consultation Section 1. ASPIRE to Excellence G. Risk Management It is suggested that develop a system to roll up risk data specific to persons served in a simple, meaningful way. is encouraged to undertake a process for defining the criteria of risk that are consistent across the network, and this information could be used during emergencies. Another purpose of this report is to create suitable action plans and make decisions in real time. A format that is easy to understand for staff could be made to link existing plans and process in performance improvement, accessibility, and financial monitoring. I. Human Resources has highly engaged staff members who are dedicated and loyal to the organization, and leadership is encouraged to continue to communicate its person-centred approach to staff members and how they can live these values every day. 5 Erie St. Clair Community Care Access Centre Report

8 The following consultation applies to the Services Management Network program area. Section 2. Network Administration B. Administration Structure and Accountability is encouraged to work closely with contracted health service providers to review any planned changes to service based on financial constraints. The organization has developed a comprehensive plan to address current financial pressures and might consider developing a detailed communication strategy to outline any impacts to care of persons served. Consultation does not indicate non-conformance to standards, but is offered as a suggestion for further quality improvement. Erie St. Clair Community Care Access Centre Report 6

9 Standards Conformance This section of the Report displays the specific reasons for any partial or non-conformance to standards identified as a result of the survey. The standards listed in this section are addressed in the organization s Quality Improvement Plan, which can be accessed at customerconnect.carf.org. Below are the possible reasons for partial or non-conformance to standards, along with an explanation of why each reason is cited. To receive the information contained in this section in an alternate format, please contact editing@carf.org. Reason for partial or non-conformance All components not addressed Credentials inadequate Data or information necessary to address conformance not collected and/or evaluated Documentation inadequate Effort not comprehensive Financial ratio calculation below the median Forms inadequate Frequency inadequate Information not communicated understandably Involvement by appropriate person(s) inadequate Noncompliance with law, regulation, or other rule Policy/plan/procedure/practice not consistently implemented Policy/plan/procedure/practice not developed Policy/plan/procedure/practice not implemented Policy/plan/procedure/practice recently implemented Training inadequate Evidence of conformance inadequate Is cited: When a standard element requires more than one item, at least one item (but not all) is not in full conformance. When a standard element requires that an individual possess a specific credential or level of credential, the specific credential is not possessed, or the credential possessed is below the specified level. When the issue addressed by the standard element has not been considered and, consequently, the information necessary to address conformance has not been collected and/or evaluated in connection with the issue addressed. When a standard element requires documentation or that documentation contain specific information, the documentation either does not exist or does not contain the specific information. When a standard element requires an activity to occur, the performance of the activity is insufficient to address the full scope of the activity. When the standard element rating is based on the calculation of a specific financial ratio, such ratio is below the 50 th percentile. When a standard element requires use of a specific form or that the form contain specific information, the form is not used or does not contain the specific information. When a standard element requires that an activity occur with a specific frequency or some unspecified regularity, the performance of the activity does not occur, occurs less frequently than required, or occurs less frequently than appropriate if regularity unspecified. When a standard element requires that information be shared with certain persons, the information is either not shared or not shared in a manner that allows for comprehension by the recipient. When a standard element requires the involvement of certain persons, those persons are either not involved or not involved in a sufficient manner. When a standard element requires compliance with a legal requirement or a process for achieving legal compliance, sufficient evidence of compliance or the compliance process is not demonstrated. When a standard element requires a policy/plan/procedure/practice, it exists but the actual performance does not occur with sufficient regularity to be deemed standard operating procedure. When a standard element requires a policy/plan/procedure/practice, it is not in existence. When a standard element requires a policy/plan/procedure/practice, it exists but there is no actual performance. When a standard element requires a policy/plan/procedure/practice, it exists but the actual performance has not been in place for sufficient time to establish a track record. When a standard element requires that certain training occur, it either does not occur or does not occur with sufficient regularity to be deemed standard operating procedure. When the requirement of a standard element is not satisfied, or is inconsistently satisfied and no other reasons apply. 7 Erie St. Clair Community Care Access Centre Report

10 Standard Number Standard Text Reasons for Partial or Non-conformance All components not addressed Credentials inadequate Data or information necessary to address conformance not collected and/or evaluated Documentation inadequate Effort not comprehensive Financial ratio calculation below median Forms inadequate Frequency inadequate Information not communicated understandably Involvement by appropriate person(s) inadequate Noncompliance with law, regulation, or other rule Policy/plan/procedure/practice not consistently implemented Policy/plan/procedure/practice not developed Policy/plan/procedure/practice not implemented Policy/plan/procedure/practice recently implemented Training inadequate Evidence of conformance inadequate 1.C.2.a.(2) 1.C.2.a.(3) 1.L.1.a.(1) A written strategic plan: Is developed with input from: Personnel. A written strategic plan: Is developed with input from: Other stakeholders. The organization's leadership: Assesses the accessibility needs of the: Persons served. 1.L.1.b.(9)(a) The organization's leadership: Implements an ongoing process for identification of barriers in the following areas: Any other barrier identified by the: Persons served. 1.L.1.b.(9)(b) The organization's leadership: Implements an ongoing process for identification of barriers in the following areas: Any other barrier identified by the: Personnel. 1.L.1.b.(9)(c) The organization's leadership: Implements an ongoing process for identification of barriers in the following areas: Any other barrier identified by the: Other stakeholders. 1.L.3.a. 1.L.3.c.(1) An accessibility status report: Is prepared annually. An accessibility status report: Includes: Progress made in the removal of identified barriers. 1.L.3.c.(2) An accessibility status report: Includes: Areas needing improvement. Standards from the 2011 Business and Services Management Standards Manual were also applied during this survey. The following reflects the application of those standards. 5.D.4.a.(1) Unannounced tests of all emergency procedures: Are conducted at least annually: On each shift. 5.D.4.a.(2) Unannounced tests of all emergency procedures: Are conducted at least annually: At each location. 5.D.4.b. Unannounced tests of all emergency procedures: Include complete actual or simulated physical evacuation drills. 5.D.4.c. Unannounced tests of all emergency procedures: Are analyzed for performance improvement. 5.D.4.d. Unannounced tests of all emergency procedures: Result in improvement of or affirm satisfactory current practice. 5.D.4.e. 5.D.7.a. Unannounced tests of all emergency procedures: Are evidenced in writing. A written analysis of all critical incidents is provided to or conducted by the leadership: At least annually. 5.D.7.b.(1) A written analysis of all critical incidents is provided to or conducted by the leadership: That addresses: Causes. Erie St. Clair Community Care Access Centre Report 8

11 Standard Number Standard Text Reasons for Partial or Non-conformance 5.D.7.b.(2) 5.D.7.b.(3) A written analysis of all critical incidents is provided to or conducted by the leadership: That addresses: Trends. A written analysis of all critical incidents is provided to or conducted by the leadership: That addresses: Actions for improvement. All components not addressed Credentials inadequate Data or information necessary to address conformance not collected and/or evaluated Documentation inadequate Effort not comprehensive Financial ratio calculation below median Forms inadequate Frequency inadequate Information not communicated understandably Involvement by appropriate person(s) inadequate Noncompliance with law, regulation, or other rule Policy/plan/procedure/practice not consistently implemented Policy/plan/procedure/practice not developed Policy/plan/procedure/practice not implemented Policy/plan/procedure/practice recently implemented Training inadequate Evidence of conformance inadequate 5.D.7.b.(4) 5.D.7.b.(5) 5.D.7.b.(6) A written analysis of all critical incidents is provided to or conducted by the leadership: That addresses: Results of performance improvement plans. A written analysis of all critical incidents is provided to or conducted by the leadership: That addresses: Necessary education and training of personnel. A written analysis of all critical incidents is provided to or conducted by the leadership: That addresses: Prevention of recurrence. 5.D.7.b.(7) 5.D.7.b.(8) A written analysis of all critical incidents is provided to or conducted by the leadership: That addresses: Internal reporting requirements. A written analysis of all critical incidents is provided to or conducted by the leadership: That addresses: External reporting requirements. 9 Erie St. Clair Community Care Access Centre Report

12 Benchmarking This section of the Report benchmarks your organization s conformance to standards. By comparing strengths and areas for improvement with various comparator groups, benchmarking encourages your organization to improve effectiveness, efficiency, satisfaction, and access. This information should also stimulate discussions among stakeholders focused on better meeting the needs and preferences of the persons served. In addition, benchmarking: Encourages a culture of continuous evaluation and improvement. Accelerates understanding of and agreement on areas for improvement. Helps prioritize improvement opportunities. Shifts internal thinking toward a focus on outcomes. Provides a reference to increase performance expectations. Motivates your team to work collaboratively to surpass benchmarks. This report provides benchmarks (mean % of conformance) for each section of the ASPIRE to Excellence quality framework. * When available, benchmark comparison groups include: All surveyed organizations. All surveyed organizations in the same primary CARF customer service unit. Surveyed organizations with the same ownership type. Surveyed organizations in the same geographic region. Surveyed organizations with similar number of persons served annually. Surveyed organizations with similar staff size. In addition, standards conformance for each organization undergoing resurvey is benchmarked against its previous survey in all standards areas. Benchmark Comparison Groups Primary area of accreditation: Aging Services (AS) Ownership type: Other Geographic region: Canada - ON Staff size (FTEs): Persons served annually: 5,000+ To receive the information contained in this section in an alternate format, please contact editing@carf.org. * Excluding Governance and Strategic Integrated Planning. Erie St. Clair Community Care Access Centre Report 10

13 All surveyed organizations A: Assess the Environment Leadership CARF Three-Year CARF One-Year 90.6% 98.6% Nonaccreditation 75.7% P: Persons Served and Other Stakeholders - Obtain Input Input from Stakeholders CARF Three-Year CARF One-Year Nonaccreditation 50.2% 83.6% 99.6% 11 Erie St. Clair Community Care Access Centre Report

14 All surveyed organizations continued Legal Requirements CARF Three-Year CARF One-Year Nonaccreditation 99.3% 92.3% 83.6% Financial Planning and Management CARF Three-Year CARF One-Year Nonaccreditation 72.3% 91.0% 99.1% Erie St. Clair Community Care Access Centre Report 12

15 All surveyed organizations continued Risk Management CARF Three-Year CARF One-Year 79.5% 97.1% Nonaccreditation 59.4% Health and Safety CARF Three-Year CARF One-Year 85.0% 96.5% Nonaccreditation 70.0% 13 Erie St. Clair Community Care Access Centre Report

16 All surveyed organizations continued Human Resources CARF Three-Year CARF One-Year Nonaccreditation 97.4% 90.0% 78.9% Technology CARF Three-Year CARF One-Year 78.3% 98.4% Nonaccreditation 53.1% Erie St. Clair Community Care Access Centre Report 14

17 All surveyed organizations continued Rights of Persons Served CARF Three-Year CARF One-Year Nonaccreditation 98.2% 93.0% 86.6% 83.3% Accessibility CARF Three-Year CARF One-Year 68.2% 95.3% Nonaccreditation 46.0% 15 Erie St. Clair Community Care Access Centre Report

18 All surveyed organizations continued R: Review Results Information Management and Measurement CARF Three-Year CARF One-Year Nonaccreditation 35.5% 62.7% 96.9% E: Effect Change Performance Improvement CARF Three-Year CARF One-Year Nonaccreditation 18.0% 44.9% 94.2% Erie St. Clair Community Care Access Centre Report 16

19 Other benchmarks A: Assess the Environment Leadership Aging Services Other Ownership Type Ontario 100 to 499 FTEs 97.7% 97.0% 98.1% 98.7% 5,000+ Persons Served 98.8% P: Persons Served and Other Stakeholders - Obtain Input Input from Stakeholders Aging Services Other Ownership Type Ontario 100 to 499 FTEs 5,000+ Persons Served 99.0% 95.5% 97.9% 99.8% 17 Erie St. Clair Community Care Access Centre Report

20 Other benchmarks continued Legal Requirements Aging Services Other Ownership Type Ontario 100 to 499 FTEs 5,000+ Persons Served 97.7% 97.8% 98.6% 99.3% 99.5% Financial Planning and Management Aging Services Other Ownership Type Ontario 100 to 499 FTEs 5,000+ Persons Served 98.1% 98.5% 97.9% 99.3% 99.7% Erie St. Clair Community Care Access Centre Report 18

21 Other benchmarks continued Risk Management Aging Services Other Ownership Type Ontario 100 to 499 FTEs 95.7% 92.3% 96.2% 97.2% 5,000+ Persons Served 96.6% Health and Safety Aging Services Other Ownership Type Ontario 100 to 499 FTEs 97.0% 94.1% 90.1% 96.8% 5,000+ Persons Served 95.4% 19 Erie St. Clair Community Care Access Centre Report

22 Other benchmarks continued Human Resources Aging Services Other Ownership Type Ontario 100 to 499 FTEs 95.6% 95.6% 95.0% 97.8% 5,000+ Persons Served 97.0% Technology Aging Services Other Ownership Type Ontario 100 to 499 FTEs 94.2% 95.5% 94.8% 98.6% 5,000+ Persons Served 98.9% Erie St. Clair Community Care Access Centre Report 20

23 Other benchmarks continued Rights of Persons Served Aging Services Other Ownership Type Ontario 100 to 499 FTEs 5,000+ Persons Served 97.4% 97.7% 96.5% 97.9% 97.8% 83.3% Accessibility Aging Services Other Ownership Type Ontario 100 to 499 FTEs 91.6% 92.5% 91.2% 95.4% 5,000+ Persons Served 95.0% 21 Erie St. Clair Community Care Access Centre Report

24 Other benchmarks continued R: Review Results Information Measurement and Management Aging Services Other Ownership Type Ontario 100 to 499 FTEs 5,000+ Persons Served 97.2% 92.2% 96.5% 97.7% 97.6% E: Effect Change Performance Improvement Aging Services Other Ownership Type Ontario 100 to 499 FTEs 5,000+ Persons Served 86.4% 96.1% 94.0% 95.9% 95.6% Erie St. Clair Community Care Access Centre Report 22

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