Accreditation Report

Religious Hospitallers of Saint Joseph of the Hotel Dieu of Kingston Kingston, ON On-site survey dates: September 13, 215 - September 17, 215 Report issued: October 1, 215 Accredited by ISQua

About the Religious Hospitallers of Saint Joseph of the Hotel Dieu of Kingston (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 215. Information from the on-site survey as well as other data obtained from the organization were used to produce this Accreditation Report. 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, 215

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

Table of Contents 1. Executive Summary 1 1.1 Accreditation Decision 1 1.2 About the On-site Survey 2 1.3 Overview by Quality Dimensions 3 1.4 Overview by Standards 4 1.5 Overview by Required Organizational Practices 6 1.6 Summary of Surveyor Team Observations 1 2. Detailed Required Organizational Practices Results 11 3. Detailed On-site Survey Results 12 3.1 Priority Process Results for System-wide Standards 13 3.1.1 Priority Process: Governance 13 3.1.2 Priority Process: Planning and Service Design 14 3.1.3 Priority Process: Resource Management 15 3.1.4 Priority Process: Human Capital 16 3.1.5 Priority Process: Integrated Quality Management 17 3.1.6 Priority Process: Principle-based Care and Decision Making 18 3.1.7 Priority Process: Communication 19 3.1.8 Priority Process: Physical Environment 2 3.1.9 Priority Process: Emergency Preparedness 21 3.1.1 Priority Process: Patient Flow 22 3.1.11 Priority Process: Medical Devices and Equipment 23 3.2 Service Excellence Standards Results 24 3.2.1 Standards Set: Ambulatory Care Services 25 3.2.2 Standards Set: Diagnostic Imaging Services 27 3.2.3 Standards Set: Emergency Department 28 3.2.4 Standards Set: Infection Prevention and Control Standards 3 3.2.5 Standards Set: Medication Management Standards 31 3.2.6 Standards Set: Mental Health Services 32 3.2.7 Standards Set: Point-of-Care Testing 34 3.2.8 Priority Process: Surgical Procedures 35 4. Instrument Results 36 4.1 Governance Functioning Tool 36 Table of Contents i

4.2 Canadian Patient Safety Culture Survey Tool: Community Based Version 4 4.3 Worklife Pulse 42 4.4 Client Experience Tool 43 5. Organization's Commentary 44 Appendix A Qmentum 45 Appendix B Priority Processes 46 Table of Contents ii

Section 1 Executive Summary Religious Hospitallers of Saint Joseph of the Hotel Dieu of Kingston (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 Religious Hospitallers of Saint Joseph of the Hotel Dieu of Kingston's accreditation decision is: Accredited with Exemplary Standing The organization has attained the highest level of performance, achieving excellence in meeting the requirements of the accreditation program. Executive Summary 1

1.2 About the On-site Survey On-site survey dates: September 13, 215 to September 17, 215 Location The following location was assessed during the on-site survey. 1 Hotel Dieu Hospital Standards The following sets of standards were used to assess the organization's programs and services during the on-site survey. System-Wide Standards 1 Leadership 2 Governance 3 Medication Management Standards 4 Infection Prevention and Control Standards Service Excellence Standards 5 6 7 8 9 1 11 Reprocessing and Sterilization of Reusable Medical Devices Point-of-Care Testing Ambulatory Care Services Diagnostic Imaging Services Mental Health Services Perioperative Services and Invasive Procedures Standards Emergency Department Instruments The organization administered: 1 2 3 4 Governance Functioning Tool Canadian Patient Safety Culture Survey Tool: Community Based Version Worklife Pulse Client Experience Tool Executive Summary 2

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 (Work with my community to anticipate and meet our needs) 43 43 Accessibility (Give me timely and equitable services) 48 5 53 Safety (Keep me safe) 45 2 28 435 Worklife (Take care of those who take care of me) 97 97 Client-centred Services (Partner with me and my family in our care) 92 1 5 98 Continuity of Services (Coordinate my care across the continuum) 34 1 35 Appropriateness (Do the right thing to achieve the best results) 535 22 557 Efficiency (Make the best use of resources) 41 6 47 Total 1295 3 67 1365 Executive Summary 3

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 42 (1.%) (.%) 32 (1.%) (.%) 74 (1.%) (.%) Leadership 46 (1.%) (.%) 85 (1.%) (.%) 131 (1.%) (.%) Infection Prevention and Control Standards 39 (1.%) (.%) 2 29 (1.%) (.%) 2 68 (1.%) (.%) 4 Medication Management Standards 77 (1.%) (.%) 1 57 (1.%) (.%) 7 134 (1.%) (.%) 8 Ambulatory Care Services 34 (1.%) (.%) 8 71 (1.%) (.%) 6 15 (1.%) (.%) 14 Diagnostic Imaging Services 65 (98.5%) 1 (1.5%) 1 67 (1.%) (.%) 1 132 (99.2%) 1 (.8%) 2 Emergency Department 42 (1.%) (.%) 5 67 (1.%) (.%) 13 19 (1.%) (.%) 18 Mental Health Services 33 (1.%) (.%) 3 84 (1.%) (.%) 4 117 (1.%) (.%) 7 Perioperative Services and Invasive Procedures Standards 1 (1.%) (.%) 84 (1.%) (.%) 4 184 (1.%) (.%) 4 Executive Summary 4

High Priority Criteria * Other Criteria Total Criteria (High Priority + Other) Standards Set Met Unmet N/A # (%) # (%) # Met Unmet N/A # (%) # (%) # Met Unmet N/A # (%) # (%) # Point-of-Care Testing ** 38 (1.%) (.%) 48 (1.%) (.%) 86 (1.%) (.%) Reprocessing and Sterilization of Reusable Medical Devices 5 (1.%) (.%) 3 61 (1.%) (.%) 2 111 (1.%) (.%) 5 Total 566 (99.8%) 1 (.2%) 23 685 (1.%) (.%) 39 1251 (99.9%) 1 (.1%) 62 * Does not includes ROP (Required Organizational Practices) ** Some criteria within this standards set were pre-rated based on the organization s accreditation through the Ontario Laboratory Accreditation Quality Management Program-Laboratory Services (QMP-LS). Executive Summary 5

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 Accountability for Quality (Governance) Adverse Events Disclosure (Leadership) Adverse Events Reporting (Leadership) Client Safety Quarterly Reports (Leadership) Client Safety Related Prospective Analysis (Leadership) Met 4 of 4 2 of 2 Met 3 of 3 of 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 (Diagnostic Imaging Services) Client And Family Role In Safety (Mental Health Services) Client And Family Role In Safety (Perioperative Services and Invasive Procedures Standards) Dangerous Abbreviations (Medication Management Standards) Information Transfer (Ambulatory Care Services) Met 2 of 2 of Met 2 of 2 of Met 2 of 2 of Met 2 of 2 of Met 4 of 4 3 of 3 Met 2 of 2 of Executive Summary 6

Required Organizational Practice Overall rating Test for Compliance Rating Major Met Minor Met Patient Safety Goal Area: Communication Information Transfer (Emergency Department) Information Transfer (Mental Health Services) Information Transfer (Perioperative Services and Invasive Procedures Standards) Medication reconciliation as a strategic priority (Leadership) Medication reconciliation at care transitions (Ambulatory Care Services) Medication reconciliation at care transitions (Emergency Department) Medication reconciliation at care transitions (Mental Health Services) Medication reconciliation at care transitions (Perioperative Services and Invasive Procedures Standards) Safe Surgery Checklist (Perioperative Services and Invasive Procedures Standards) Two Client Identifiers (Ambulatory Care Services) Two Client Identifiers (Diagnostic Imaging Services) Two Client Identifiers (Emergency Department) Met 2 of 2 of Met 2 of 2 of Met 2 of 2 of Met 4 of 4 2 of 2 Met 7 of 7 of Unmet of 5 of Met 5 of 5 of Unmet of 5 of Met 3 of 3 2 of 2 Met 1 of 1 of Met 1 of 1 of Met 1 of 1 of Executive Summary 7

Required Organizational Practice Overall rating Test for Compliance Rating Major Met Minor Met Patient Safety Goal Area: Communication Two Client Identifiers (Mental Health Services) Two Client Identifiers (Perioperative Services and Invasive Procedures Standards) Two Client Identifiers (Point-of-Care Testing) Met 1 of 1 of Met 1 of 1 of Met 1 of 1 of Patient Safety Goal Area: Medication Use Concentrated Electrolytes (Medication Management Standards) Heparin Safety (Medication Management Standards) High-Alert Medications (Medication Management Standards) Infusion Pumps Training (Emergency Department) Infusion Pumps Training (Perioperative Services and Invasive Procedures Standards) Met 3 of 3 of Met 4 of 4 of Met 5 of 5 3 of 3 Met 1 of 1 of Met 1 of 1 of Patient Safety Goal Area: Worklife/Workforce Client Safety Plan (Leadership) Client Safety: Education And Training (Leadership) Preventive Maintenance Program (Leadership) Workplace Violence Prevention (Leadership) Met 2 of 2 2 of 2 Met 1 of 1 of Met 3 of 3 1 of 1 Met 5 of 5 3 of 3 Executive Summary 8

Required Organizational Practice Overall rating Test for Compliance Rating Major Met Minor Met Patient Safety Goal Area: Infection Control Hand-Hygiene Compliance (Infection Prevention and Control Standards) Hand-Hygiene Education and Training (Infection Prevention and Control Standards) Infection Rates (Infection Prevention and Control Standards) Met 1 of 1 2 of 2 Met 1 of 1 of Met 1 of 1 2 of 2 Patient Safety Goal Area: Risk Assessment Falls Prevention Strategy (Ambulatory Care Services) Falls Prevention Strategy (Diagnostic Imaging Services) Falls Prevention Strategy (Emergency Department) Falls Prevention Strategy (Mental Health Services) Falls Prevention Strategy (Perioperative Services and Invasive Procedures Standards) Pressure Ulcer Prevention (Perioperative Services and Invasive Procedures Standards) Suicide Prevention (Mental Health Services) Venous Thromboembolism Prophylaxis (Perioperative Services and Invasive Procedures Standards) 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 Met 3 of 3 2 of 2 Met 5 of 5 of Met 3 of 3 2 of 2 Executive Summary 9

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, Religious Hospitallers of Saint Joseph of the Hotel Dieu of Kingston (Hotel Dieu) is commended on preparing for and participating in the Qmentum survey program. The organization has an experienced and committed board of directors. The ethical decision-making process aligns with the faith-based history of the organization. The organization has engaged in the Healthcare Tomorrow process with the aim of improving healthcare to the community it serves. The community partners very much endorse the organization as a visionary, collaborative and caring provider of health care. Hotel Dieu is seen as a responsive and committed participant in the healthcare community. Staff members are supportive of the commitment demonstrated by the leadership team. The presence and visibility of senior leaders, directors and managers in the patient care areas are truly committed to the work of the organization. Staff members exhibit low turn-over rates, low absenteeism rates and high staff satisfaction rates. This speaks to an organization where staff members feel valued and appreciated. Patient services at Hotel Dieu are innovative, creative and respond to the needs of the community. Services are adjusted or expanded according to demonstrated need. Patient surveys demonstrate a high level of satisfaction with the services received. Staff and management readily make changes when this is indicated. The organization is justly proud of its research activities. Research is done in many fields and is often ground breaking in nature. In a challenging fiscal climate the organization has successfully balanced its budget for the past several years and anticipates the same for this year. Given that the Hotel Dieu facility is an old building, staff members are recognized for maintaining a remarkable level of cleanliness. The senior team is planning to replace an aging Information technology infrastructure and will work with other providers to accomplish this on a regional basis. Healthcare Tomorrow is seen as representing an opportunity for better service to the community, and staff members are at the forefront of this change process. As with all organizations there are challenges to face. For Hotel Dieu, the aging buildings and physical plants require constant maintenance. The challenges associated with demographic changes in the community lead to increasing difficulties in discharging patients causing back-ups to the system. In-patient beds at the Kingston General Hospital (KGH) receive admissions from the Hotel Dieu Urgent Care Centre. Executive Summary 1

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 Medication reconciliation at care transitions With the involvement of the client, family, or caregivers (as appropriate), the team initiates medication reconciliation for clients with a decision to admit and a target group of clients without a decision to admit who are at risk for potential adverse drug events (organizational policy specifies when medication reconciliation is initiated for clients without a decision to admit). Perioperative Services and Invasive Procedures Standards 8.4 Emergency Department 9.3 Detailed Required Organizational Practices Results 11

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 12

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. 3.1.1 Priority Process: Governance Meeting the demands for excellence in governance practice. Surveyor comments on the priority process(es) The Local Health Integrated Network's region-wide initiative: "Healthcare Tomorrow" has yet to determine the future look of health care in the southeast region. The organization continues to define what the Hotel Dieu Hospital does and states: "We will achieve excellence and innovation in academic ambulatory health care and deliver excellent care and an excellent experience for all patients and families." Detailed On-site Survey Results 13

3.1.2 Priority Process: Planning and Service Design Developing and implementing infrastructure, programs, and services to meet the needs of the populations and communities served Surveyor comments on the priority process(es) The organization has developed a strong leadership team that demonstrate initiative, commitment and enthusiasm for the work that it does. The staff members live the values of the organization and support the mission, vision and strategic directions. Patients and clients report feeling supported, engaged and cared for by the team. Detailed On-site Survey Results 14

3.1.3 Priority Process: Resource Management Monitoring, administration, and integration of activities involved with the appropriate allocation and use of resources. Surveyor comments on the priority process(es) The organization has demonstrated fiscal responsibility for the past several years. The finance leadership and staff members work diligently to monitor and report and manage the budget. They do this by engaging leadership at all levels, as well as physicians and staff. This is not an easy job to accomplish in times of fiscal restraint. Detailed On-site Survey Results 15

3.1.4 Priority Process: Human Capital Developing the human resource capacity to deliver safe, high quality services Surveyor comments on the priority process(es) The organization is commended for living its values. Staff members, volunteers and service providers report a high level of satisfaction with their worklife, the culture of the organization and the leadership and supervision. Staff members report that they like to come to work and that they feel appreciated and supported. Detailed On-site Survey Results 16

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 Surveyor comments on the priority process(es) There are no specific comments identified. Detailed On-site Survey Results 17

3.1.6 Priority Process: Principle-based Care and Decision Making Identifying and decision making regarding ethical dilemmas and problems. Surveyor comments on the priority process(es) The organization is commended for embracing a strong faith-based ethical framework which is clearly evident across the organization. Universally, comments were made about the quality of care provided and the sense that the people in this organization care for each other and look after one another. Detailed On-site Survey Results 18

3.1.7 Priority Process: Communication Communicating effectively at all levels of the organization and with external stakeholders Surveyor comments on the priority process(es) Insofar as communication, there is an active, professional team representing multiple aspects of information management. Data and information are carefully handled both internally and externally, extending to the public and to partners in health care provision. Detailed On-site Survey Results 19

3.1.8 Priority Process: Physical Environment Providing appropriate and safe structures and facilities to achieve the organization's mission, vision, and goals Surveyor comments on the priority process(es) The physical space meets applicable laws, regulations and codes. However, much of the Hotel Dieu facility is quite old and in many cases, the space has been re-purposed for different uses. This represents a challenge for the environmental services team and for the hospital staff. The organization is fully aware of the need to provide utilities back-up systems and these are in place. It is noted that a recent fire in the boiler room was managed appropriately, and sufficient redundancies are in place to allow for ongoing functioning. Detailed On-site Survey Results 2

3.1.9 Priority Process: Emergency Preparedness Planning for and managing emergencies, disasters, or other aspects of public safety Surveyor comments on the priority process(es) No specific comments are identified. Detailed On-site Survey Results 21

3.1.1 Priority Process: Patient Flow Assessing the smooth and timely movement of clients and families through service settings Surveyor comments on the priority process(es) The essence of the work of this team is forming partnerships (Health Links) with other providers to improve care to patients with complex and chronic health challenges. In particular, the team provides a coordinating role, supporting patients to allow them to better control their health problems. Protocols have been developed to assist clients/patients that need to access care. Sometimes this includes access to in-patient beds; more often it involves the redirection of patients from an acute care setting to a chronic disease management environment. Many of these high use/high cost patients have multiple comorbidities, including mental health issues. Often, these patients require multiple contacts with the health care system where communication and coordination is key to efficiency and patient satisfaction. The team is currently conducting a pilot to address that complex needs of patients that lack a primary care provider. The team has found ways to assist with care coordination and has worked closely with Health Links and Health Care Connect to link the unattached clients with a family doctor. Detailed On-site Survey Results 22

3.1.11 Priority Process: Medical Devices and Equipment Obtaining and maintaining machinery and technologies used to diagnose and treat health problems Surveyor comments on the priority process(es) There is a comprehensive process for reprocessing devices and equipment. This is managed by certified staff members that work in a well-ventilated, well-stocked area. Some of the equipment is maintained by the manufacturers under contract, and this works well. The remainder of the equipment is maintained by the bio-medical engineering staff, and this works particularly well. A full preventive maintenance process is in place, complete with appropriate tracking. An extensive process is in place for the acquisition of new devices or equipment. Detailed On-site Survey Results 23

3.2 Service Excellence Standards Results The results in this section are grouped first by standards set and then by priority process. Priority processes specific to service excellence standards are: Point-of-care Testing Services Using non-laboratory tests delivered at the point of care to determine the presence of health problems Clinical Leadership Providing leadership and overall goals and direction to the team of people providing services. Competency Developing a skilled, knowledgeable, interdisciplinary team that can manage and deliver effective programs and services Episode of Care Providing clients with coordinated services from their first encounter with a health care provider through their last contact related to their health issue Decision Support Using information, research, data, and technology to support management and clinical decision making Impact on Outcomes Identifying and monitoring process and outcome measures to evaluate and improve service quality and client outcomes Medication Management Using interdisciplinary teams to manage the provision of medication to clients Organ and Tissue 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 Diagnostic Services: Imaging Ensuring the availability of diagnostic imaging services to assist medical professionals in diagnosing and monitoring health conditions Detailed On-site Survey Results 24

3.2.1 Standards Set: Ambulatory Care Services Unmet Criteria High Priority Criteria Priority Process: Clinical Leadership Priority Process: Competency Priority Process: Episode of Care Priority Process: Decision Support Priority Process: Impact on Outcomes Surveyor comments on the priority process(es) Priority Process: Clinical Leadership Some programs are expanding. These changes have occurred in response to community needs that were previously unmet. The leadership team is supportive of meeting community needs when feasible and actively pursues opportunities to apply for appropriate funding. Staffing and job design are being evaluated to ensure they support the clinical programs. Priority Process: Competency An orientation process is in place for new staff members. Existing staff members may apply ffor funding for educational endeavours. In addition, the organization supports several e-learning opportunities for staff. Detailed On-site Survey Results 25

Priority Process: Episode of Care Several areas of the ambulatory care program were visited during the on-site survey. While there is some variability in approach each of those areas visited demonstrated standardized processes and procedures. In dermatology the service has identified the common diagnoses that are referred to the program and has standardized approaches to managing these. A brief visit was made to the neurology program and again, there is streamlining of the approaches and the diagnoses are appropriately directed to the sub-specialty clinics. The bariatric clinic has highly structured processes and procedures beginning with criteria for intake and throughout the whole program, leading to medical treatment or to surgery and post-operative care. A brief and fascinating visit was made to the pain management service. Here, patients can benefit from a novel approach thus providing great relief to people that badly need this relief. In addition, more commonly used processes are also in place using a standardized registration and patient management approach. The Mohs clinic is offering a streamlined, single location service to patients with skin cancer. Priority Process: Decision Support The information management (IM) system supports the work of the clinics. Research protocols are approved by Queen s University Health Sciences and Affiliated Teaching Hospitals Research Ethics Board, the overseeing body, and these all meets the ethical requirements of the organization. Priority Process: Impact on Outcomes There were several examples of indicators and data collection. In the bariatric clinic, there was extensive and detailed data collection for bariatric outcomes of the care. The Mohs clinic can monitor outcomes by direct pathological examinations of excised specimens. Patients give direct and almost immediate feedback in the pain clinic regarding the outcome of the intervention offered. Detailed On-site Survey Results 26

3.2.2 Standards Set: Diagnostic Imaging Services Unmet Criteria High Priority Criteria Priority Process: Diagnostic Services: Imaging 4.4 The client service area includes a space for screening clients which respects confidentiality issues prior to their diagnostic imaging examination. Surveyor comments on the priority process(es) Priority Process: Diagnostic Services: Imaging The diagnostic imaging department (DI) is a busy service. Patient flow is well-managed throughout a maze of hallways and corridors. The staff members work as a united team and patients report a high rate of satisfaction with the services provided. Detailed On-site Survey Results 27

3.2.3 Standards Set: Emergency Department Unmet Criteria High Priority Criteria Priority Process: Clinical Leadership Priority Process: Competency Priority Process: Episode of Care 9.3 With the involvement of the client, family, or caregivers (as appropriate), the team initiates medication reconciliation for clients with a decision to ROP admit and a target group of clients without a decision to admit who are at risk for potential adverse drug events (organizational policy specifies when medication reconciliation is initiated for clients without a decision to admit). 9.3.1 The team initiates medication reconciliation for all clients MAJOR with a decision to admit. A Best Possible Medication History (BPMH) is generated and documented with the involvement of the client, family, or caregiver. The medication reconciliation process may begin in the emergency department and be completed in the receiving inpatient unit. 9.3.2 The organization identifies criteria for a target group of MAJOR non-admitted clients who are eligible for medication reconciliation and documents the rationale for choosing those criteria. 9.3.3 When medications are adjusted for non-admitted clients in the MAJOR target group, the team generates and documents the BPMH with the involvement of the client, family, or caregiver. 9.3.4 For non-admitted clients in the target group, the team MAJOR communicates medication changes to the primary health care provider. 9.3.5 For non-admitted clients identified as requiring medication reconciliation, the team provides the client and the next care provider (e.g., primary care provider, community pharmacist, home care services) with a complete list of medications the client is taking. MAJOR Priority Process: Decision Support Priority Process: Impact on Outcomes Detailed On-site Survey Results 28

Priority Process: Organ and Tissue Donation Surveyor comments on the priority process(es) Priority Process: Clinical Leadership The emergency department (ED) information system has proved to be a treasure trove of data and information. This has allowed the urgent care centre (UCC) to collect specific and measurable data for almost every aspect of the work done. In addition, it has greatly improved the transfer of information to primary care health providers after their patients had been seen in the UCC. Priority Process: Competency Orientation programs are in place for new staff members. New and existing staff members can avail themselves of educational opportunities which are supported by the organization. Priority Process: Episode of Care The processes for patient assessment and treatment in the urgent care centre (UCC) are in place. As this is not an emergency department (ED) per se, ambulances do not deliver patients to this care area. Some patients are transferred from the UCC to the ED at Kingston General Hospital. Information transfer is seamless as the same information system is available in real time at both sites. Priority Process: Decision Support The emergency department information system (ED IS) has greatly improved the ability of team members to access information and to make decisions about patient care. Evidence-based protocols are in use. Priority Process: Impact on Outcomes Both quantitative and qualitative outcomes are measured in the department. Priority Process: Organ and Tissue Donation Given that Hotel Dieu has an urgency care centre, and is not considered an emergency department these standards for organ and tissue donation do not apply. Detailed On-site Survey Results 29

3.2.4 Standards Set: Infection Prevention and Control Standards Unmet Criteria High Priority Criteria Priority Process: Infection Prevention and Control Surveyor comments on the priority process(es) Priority Process: Infection Prevention and Control The organization has a competent, professional team doing excellent work in the area of infection prevention and control. Appropriate supports and back-ups are in place, and appropriate processes are in use. Outcomes analyses are reassuringly good. The physical space is remarkably clean. Detailed On-site Survey Results 3

3.2.5 Standards Set: Medication Management Standards Unmet Criteria High Priority Criteria Priority Process: Medication Management Surveyor comments on the priority process(es) Priority Process: Medication Management Medication reconciliation is fully implemented in the Child and Adolescent mental health program. Detailed On-site Survey Results 31

3.2.6 Standards Set: Mental Health Services Unmet Criteria High Priority Criteria Priority Process: Clinical Leadership Priority Process: Competency Priority Process: Episode of Care Priority Process: Decision Support Priority Process: Impact on Outcomes Surveyor comments on the priority process(es) Priority Process: Clinical Leadership The leadership team of the child and adolescent mental health urgent consult clinic as well as the staff members and physicians have enabled this program to provide much needed services to the adolescent youth served by Hotel Dieu. Priority Process: Competency The team members are highly motivated, and report that they: "love their jobs and the opportunity to work at the Hotel Dieu. The team is excited about piloting new programs and initiatives. Team members are engaged with the community and the school boards. Priority Process: Episode of Care Adolescent clients attend the program on an out-patient basis. The team provides care in a compassionate, caring manner and exhibits the patient-centred values of the organization. Detailed On-site Survey Results 32

Priority Process: Decision Support The team is excited about the pilot project that is currently in the process of being developed. The team will be show-casing a poster presentation and publishing an article on "Cyber Bullying". The poster is titled Adolescent Urgent Psychiatric Consult Clinic: Prevalence and Clinical Characteristics of Cyber-bullying victimization and it will be presented at the Annual Canadian Association of Child and Adolescent Psychiatry (CACAP) Conference on October 5, 215 in Quebec City. The team is in the process of trying to get the research results published in a social work journal. The team s research shows that cyber-bullied youth have a higher rate of admission and suicidal ideation than traditionally bullied or non-bullied youth; one of the outcomes was that ER doctors should make a point to ask about bullying victimization, especially cyber-bullying. The results of an earlier study from two years ago: Bullying victimization (being bullied) among adolescents referred for urgent psychiatric consult: prevalence and association with suicidality is being published in the Canadian Journal of Psychiatry next month. Priority Process: Impact on Outcomes The adolescent mental health team has reached out to the community, particularly the school boards. Training of school staff to triage children that may require services is provided by one of the team psychiatrists. A teaching model to raise awareness of mental health issues and de-stigmatize mental illness has been developed and incorporated into the curriculum in the public school boards of the region. Gym teachers take the lead role. The team is commended for their forward thinking and visionary approach to identifying opportunities to increase and enhance services. Detailed On-site Survey Results 33

3.2.7 Standards Set: Point-of-Care Testing Unmet Criteria High Priority Criteria Priority Process: Point-of-care Testing Services Surveyor comments on the priority process(es) Priority Process: Point-of-care Testing Services The point-of-care testing (POCT) team has a pre-analytics staff member that spends a portion of his time reviewing incidents and assuring that quality improvements are ongoing. The POCT is a contracted service from the Kingston General Hospital (KGH). There is a POCT multidisciplinary advisory committee whose members meet four or five times per year, or as necessary. This committee oversees the delivery of POCT and defines the scope of the services. The system is mostly automated and is effective and efficient. Staff members and physicians report a high level of satisfaction with the service. Detailed On-site Survey Results 34

3.2.8 Priority Process: Surgical Procedures Delivering safe surgical care, including preoperative preparation, operating room procedures, postoperative recovery, and discharge Unmet Criteria High Priority Criteria Standards Set: Perioperative Services and Invasive Procedures Standards 8.4 With the involvement of the client, family, or caregiver (as appropriate), the team generates a Best Possible Medication History (BPMH) and uses it to ROP reconcile client medications at transitions of care. 8.4.1 Upon or prior to admission, the team generates and MAJOR documents a Best Possible Medication History (BPMH), with the involvement of the client, family, or caregiver (and others, as appropriate). 8.4.2 The team uses the BPMH to generate admission medication MAJOR orders OR compares the Best Possible Medication History (BPMH) with current medication orders and identifies, resolves, and documents any medication discrepancies. 8.4.3 A current medication list is retained in the client record. MAJOR 8.4.4 The prescriber uses the Best Possible Medication History (BPMH) and the current medication orders to generate transfer or discharge medication orders. 8.4.5 The team provides the client, community-based health care provider, and community pharmacy (as appropriate) with a complete list of medications the client should be taking following discharge. Surveyor comments on the priority process(es) MAJOR MAJOR There is a professional, multidisciplinary team in place. A wide range of surgical services is provided, and many of these are using a standardized evidence-based care map process. All aspects of the care process have been examined and improved where possible. Ongoing modifications are done on a regular basis. The team develops and implements annual goals and objectives. Detailed On-site Survey Results 35

Section 4 Instrument Results As part of Qmentum, organizations administer instruments. Qmentum includes three instruments (or questionnaires) that measure governance functioning, patient safety culture, and quality of worklife. They are completed by a representative sample of clients, staff, senior leaders, board members, and other stakeholders. 4.1 Governance Functioning Tool The Governance Functioning Tool enables members of the governing body to assess board structures and processes, provide their perceptions and opinions, and identify priorities for action. It does this by asking questions about: Board composition and membership Scope of authority (roles and responsibilities) Meeting processes Evaluation of performance Accreditation Canada provided the organization with detailed results from its Governance Functioning Tool prior to the on-site survey through the client organization portal. The organization then had the opportunity to address challenging areas. Data collection period: November 16, 214 to November 3, 214 Number of responses: 11 Governance Functioning Tool Results % Disagree % Neutral % Agree Organization Organization Organization %Agree * Canadian Average 1 We regularly review, understand, and ensure compliance with applicable laws, legislation and regulations. 2 Governance policies and procedures that define our role and responsibilities are well-documented and consistently followed. 3 We have sub-committees that have clearly-defined roles and responsibilities. 4 Our roles and responsibilities are clearly identified and distinguished from those delegated to the CEO and/or senior management. We do not become overly involved in management issues. 5 We each receive orientation that helps us to understand the organization and its issues, and supports high-quality decisionmaking. 9 91 93 1 95 1 97 1 95 1 92 Instrument Results 36

% Disagree % Neutral % Agree Organization Organization Organization %Agree * Canadian Average 6 Disagreements are viewed as a search for solutions rather than a win/lose. 7 Our meetings are held frequently enough to make sure we are able to make timely decisions. 8 Individual members understand and carry out their legal duties, roles and responsibilities, including sub-committee work (as applicable). 9 Members come to meetings prepared to engage in meaningful discussion and thoughtful decision-making. 1 Our governance processes make sure that everyone participates in decision-making. 11 Individual members are actively involved in policy-making and strategic planning. 12 The composition of our governing body contributes to high governance and leadership performance. 13 Our governing body s dynamics enable group dialogue and discussion. Individual members ask for and listen to one another s ideas and input. 14 Our ongoing education and professional development is encouraged. 15 Working relationships among individual members and committees are positive. 16 We have a process to set bylaws and corporate policies. 17 Our bylaws and corporate policies cover confidentiality and conflict of interest. 18 We formally evaluate our own performance on a regular basis. 19 We benchmark our performance against other similar organizations and/or national standards. 2 Contributions of individual members are reviewed regularly. 1 95 1 98 1 96 22 78 94 1 94 11 89 89 1 93 1 96 1 88 1 97 1 95 1 97 13 88 82 11 89 72 22 78 64 Instrument Results 37

% Disagree % Neutral % Agree Organization Organization Organization %Agree * Canadian Average 21 As a team, we regularly review how we function together and how our governance processes could be improved. 22 There is a process for improving individual effectiveness when non-performance is an issue. 23 We regularly identify areas for improvement and engage in our own quality improvement activities. 24 As a governing body, we annually release a formal statement of our achievements that is shared with the organization s staff as well as external partners and the community. 25 As individual members, we receive adequate feedback about our contribution to the governing body. 26 Our chair has clear roles and responsibilities and runs the governing body effectively. 27 We receive ongoing education on how to interpret information on quality and patient safety performance. 28 As a governing body, we oversee the development of the organization's strategic plan. 29 As a governing body, we hear stories about clients that experienced harm during care. 3 The performance measures we track as a governing body give us a good understanding of organizational performance. 31 We actively recruit, recommend and/or select new members based on needs for particular skills, background, and experience. 32 We have explicit criteria to recruit and select new members. 33 Our renewal cycle is appropriately managed to ensure continuity on the governing body. 1 9 81 22 78 64 1 8 1 9 84 25 75 69 1 96 11 89 84 1 95 11 11 78 85 1 92 1 9 87 13 88 84 11 89 9 Instrument Results 38

% Disagree % Neutral % Agree Organization Organization Organization %Agree * Canadian Average 34 The composition of our governing body allows us to meet stakeholder and community needs. 35 Clear written policies define term lengths and limits for individual members, as well as compensation. 36 We review our own structure, including size and subcommittee structure. 1 94 11 89 94 14 86 89 37 We have a process to elect or appoint our chair. 1 95 *Canadian average: Percentage of Accreditation Canada client organizations that completed the instrument from July to December, 214 and agreed with the instrument items. Instrument Results 39

4.2 Canadian Patient Safety Culture Survey Tool: Community Based Version Organizational culture is widely recognized as a significant driver in changing behavior and expectations in order to increase safety within organizations. A key step in this process is the ability to measure the presence and degree of safety culture. This is why Accreditation Canada provides organizations with the Patient Safety Culture Tool, an evidence-informed questionnaire that provides insight into staff perceptions of patient safety. This tool gives organizations an overall patient safety grade and measures a number of dimensions of patient safety culture. Results from the Patient Safety Culture Tool allow the organization to identify strengths and areas for improvement in a number of areas related to patient safety and worklife. Accreditation Canada provided the organization with detailed results from its Patient Safety Culture Tool prior to the on-site survey through the client organization portal. The organization then had the opportunity to address areas for improvement. During the on-site survey, surveyors reviewed progress made in those areas. Data collection period: July 14, 214 to November 16, 214 Minimum responses rate (based on the number of eligible employees): 152 Number of responses: 197 Instrument Results 4