Hamilton Niagara Haldimand Brant Community Care Access Centre %UDQWIRUG, ON On-site survey dates: March 18, 2012 - March 22, 2012 Report issued: April 13, 2012 Accredited by ISQua
About the Hamilton Niagara Haldimand Brant Community Care Access Centre (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 March 2012. Information from the on-site survey as well as other data obtained from the organization were used to produce this. Accreditation results are based on information provided by the organization. Accreditation Canada relies on the accuracy of this information to plan and conduct the on-site survey and produce the. Any alteration of this compromises the integrity of the accreditation process and is strictly prohibited. Confidentiality This report is confidential and is provided by Accreditation Canada to the organization only. Accreditation Canada does not release the report to any other parties. In the interests of transparency and accountability, Accreditation Canada encourages the organization to disseminate its to staff, board members, clients, the community, and other stakeholders. Accreditation Canada is a not-for-profit, independent organization that provides health services organizations with a rigorous and comprehensive accreditation process. We foster ongoing quality improvement based on evidence-based standards and external peer review. Accredited by the International Society for Quality in Health Care, Accreditation Canada has helped organizations strive for excellence for more than 50 years. Accreditation Canada, 2012
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 Hamilton Niagara Haldimand Brant Community Care Access Centre on your participation in the Qmentum accreditation program. Qmentum is designed to integrate with your quality improvement program. By using it to support and enable your quality improvement activities, its full value is realized. This includes your accreditation decision, the final results from your recent on-site survey, and instrument data that your organization has submitted. Please use the information in this report and in your online Quality Performance Roadmap to guide your quality improvement activities. Your Accreditation Specialist is available if you have questions or need guidance. Thank you for your leadership and for demonstrating your ongoing commitment to quality by integrating accreditation into your improvement program. We welcome your feedback about how we can continue to strengthen the program to ensure it remains relevant to you and your services. We look forward to our continued partnership. Sincerely, Wendy Nicklin President and Chief Executive Officer A Message from Accreditation Canada's President and CEO
Table of Contents 1.0 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 5 1.6 Summary of Surveyor Team Observations 7 2.0 Detailed On-site Survey Results 10 2.1 Priority Process Results for System-wide Standards 11 2.1.1 Priority Process: Planning and Service Design 11 2.1.2 Priority Process: Resource Management 13 2.1.3 Priority Process: Human Capital 14 2.1.4 Priority Process: Integrated Quality Management 15 2.1.5 Priority Process: Principle-based Care and Decision Making 16 2.1.6 Priority Process: Communication 17 2.1.7 Priority Process: Physical Environment 18 2.1.8 Priority Process: Emergency Preparedness 19 2.1.9 Priority Process: Medical Devices and Equipment 20 2.2 Service Excellence Standards Results 21 2.2.1 Standards Set: Case Management Services 21 2.2.2 Standards Set: Customized Infection Prevention and Control 25 3.0 Instrument Results 27 3.1 Governance Functioning Tool 27 3.2 Patient Safety Culture Tool 31 3.3 Worklife Pulse Tool 33 4.0 Organization's Commentary 35 Appendix A Qmentum 36 Appendix B Priority Processes 37 Table of Contents i
Section 1 Executive Summary Accreditation Canada is an independent, not-for-profit organization that sets standards for quality and safety in health care and accredits health organizations in Canada and around the world. Organizations that are accredited by Accreditation Canada undergo a rigorous evaluation process. Following a comprehensive self-assessment, trained surveyors from accredited health organizations conduct an on-site survey to evaluate the organization's performance against Accreditation Canada's standards of excellence. Hamilton Niagara Haldimand Brant Community Care Access Centre (referred to in this report as the organization ) is participating in Accreditation Canada's Qmentum accreditation program. This Accreditation 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. Hamilton Niagara Haldimand Brant Community Care Access Centre 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 Hamilton Niagara Haldimand Brant Community Care Access Centre has earned the following accreditation decision. Accredited with Exemplary Standing Executive Summary 1
1.2 About the On-site Survey On-site survey dates: March 18, 2012 to March 22, 2012 Locations The following locations were assessed during the on-site survey. All sites and services offered by the organization are deemed accredited. 1 HNHB CCAC Brant Branch/Head Office 2 HNHB CCAC Burlington Branch HNHB CCAC Hamilton Branch HNHB CCAC Niagara Branch 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 Sustainable Governance 2 Effective Organization Service Excellence Standards 3 4 Case Management Services Customized Infection Prevention and Control Instruments The organization administer: 1 2 3 Governance Functioning Tool Patient Safety Culture Tool Worklife Pulse 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 lists the quality dimensions and shows how many of the criteria related to each dimension were rated as met, unmet, or not applicable during the on-site survey. Quality Dimension Met Unmet N/A Total Population Focus (Working with communities to anticipate and meet needs) 32 0 0 32 Accessibility (Providing timely and equitable services) 13 0 0 13 Safety (Keeping people safe) 58 0 11 69 Worklife (Supporting wellness in the work environment) 36 0 0 36 Client-centred Services (Putting clients and families first) 21 0 1 22 Continuity of Services (Experiencing coordinated and seamless services) 6 0 0 6 Effectiveness (Doing the right thing to achieve the best possible results) 142 0 4 146 Efficiency (Making the best use of resources) 20 0 0 20 Total 328 0 16 344 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 contribute to achieving the standard as a whole. System-wide standards address quality and safety at the organizational level in areas such as governance and leadership, while population-specific and service excellence standards address specific populations, sectors, and services. The sets of standards used to assess an organization s programs are based on the type of services it provides. This table shows the sets of standards used to evaluate the organization s programs and services, and the number and percentage of criteria that were rated met, unmet, or not applicable during the on-site survey. High Priority Criteria * Other Criteria Total Criteria (High Priority + Other) Standards Set Met Unmet N/A # (%) # (%) # Met Unmet N/A # (%) # (%) # Met Unmet N/A # (%) # (%) # Sustainable Governance Effective Organization Customized Infection Prevention and Control Case Management Services Total 23 (100%) 0 (0%) 0 68 (100%) 0 (0%) 0 91 (100%) 0 (0%) 0 56 (100%) 0 (0%) 1 47 (100%) 0 (0%) 2 103 (100%) 0 (0%) 3 24 (100%) 0 (0%) 9 8 (100%) 0 (0%) 1 32 (100%) 0 (0%) 10 30 (100%) 0 (0%) 0 72 (100%) 0 (0%) 3 102 (100%) 0 (0%) 3 133 (100%) 0 (0%) 10 195 (100%) 0 (0%) 6 328 (100%) 0 (0%) 16 * includes ROP Executive Summary 4
1.5 Overview by Required Organizational Practices In Qmentum, a Required Organizational Practice (ROP) is defined as an essential practice that an organization must have in place to enhance client safety and minimize risk. Each ROP has associated tests for compliance, categorized as major and minor. All tests for compliance must be met for the ROP as a whole to be rated as met. This table shows how the applicable ROPs were rated during the on-site survey. Required Organizational Practice Overall rating Test of Compliance Rating Major Met Minor Met Patient Safety Goal Area: Safety Culture Adverse Events Disclosure (Effective Organization) Adverse Events Reporting (Effective Organization) Client Safety As A Strategic Priority (Effective Organization) Client Safety Quarterly Reports (Effective Organization) Client Safety Related Prospective Analysis (Effective Organization) 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 (Case Management Services) Information Transfer (Case Management Services) Medication Reconciliation As An Organizational Priority (Effective Organization) Medication Reconciliation At Admission (Case Management Services) Medication Reconciliation at Transfer or Discharge (Case Management Services) Met 2 of 2 0 of 0 Met 2 of 2 0 of 0 Met 4 of 4 0 of 0 Met 4 of 4 1 of 1 Met 3 of 3 2 of 2 Executive Summary 5
Required Organizational Practice Overall rating Test of Compliance Rating Major Met Minor Met Patient Safety Goal Area: Worklife/Workforce Client Safety Plan (Effective Organization) Client Safety: Education And Training (Effective Organization) Client Safety: Roles And Responsibilities (Effective Organization) Workplace Violence Prevention (Effective Organization) Met 0 of 0 2 of 2 Met 1 of 1 0 of 0 Met 1 of 1 2 of 2 Met 5 of 5 3 of 3 Patient Safety Goal Area: Infection Control Hand Hygiene Audit (Customized Infection Prevention and Control) Hand Hygiene Education And Training (Customized Infection Prevention and Control) Infection Control Guidelines (Customized 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 Patient Safety Goal Area: Risk Assessment Home Safety Risk Assessment (Case Management Services) Met 3 of 3 2 of 2 Executive Summary 6
1.6 Summary of Surveyor Team Observations During the on-site survey, the surveyor team made the following observations about the organization's overall strengths, opportunities for improvement, and challenges. The organization, Hamilton Niagara Haldimand Brant Community Care Access Centre (HNHB CCAC) is commended on preparing for and participating in the Qmentum survey process. The Board of Directors has demonstrated commitment to providing equitable access, individualized care coordination and quality health care for the diverse communities. The governing body (Board) reviews regular reports on financial performance and coordinates its review on utilization management, risk management and safety. There exists a Board committee established to monitor quality and safety. The mission and vision are reviewed and endorsed by all CCACs. Values are affirmed by all communities. The strategic directions endorsed by the Board focus on client experience, accountability and transparency, strategic partnerships and passionate and inspired staff. The talented leadership team, led by the visionary chief executive officer (CEO) has developed strategic and operational plans that are outlined within the accountability framework. Decision Support provides support to the Board, Executives and Management in assessing performance at strategic, tactical, and operational levels and also for evidence-based decision-making. The organization has turned data into information by way of: analysis of financial, utilization, demographic and clinical information to provide recommendations for improvements to maximize and support client care in a fair, equitable, and cost-effective manner; development of scorecards, dashboards and other tools to monitor and report information internally and externally; provision of internal expertise in performance management, indicator development and evaluation; and, collaboration with the Local Health Integrated Network (LHIN) and provincial stakeholders to maximize opportunities for integrated decision support. The HNHB CCAC is committed to advancing its own sustainability and supporting the sustainability of the broader health system. This organization brings the rigor of a Project Management Office (PMO) and the principles of a Lean/Six Sigma program to its operations via the Continuous Improvement (CI) team. The PMO oversees project identification, concept development, resources, gaiting, risk monitoring and escalation processes, implementation and evaluation. It also supports project leads across the organization, and applies best practices in project management to key components of the Corporate Work Plan. Partnerships with community and external stakeholders are vitally important to the success of the organizational goals. The organization's community partners describe this high performing CCAC as an open, forward-thinking, innovative, sharing and engaging organization that shows willingness to take on challenges. Leadership is demonstrated in all levels of the organization. In 2009, HNHB CCAC became the first CCAC to earn the designation of: "Registered Nurses Association Ontario (RNAO) Spotlight Organization", and is still the only CCAC to have achieved this status. The organization is proud of the work it has done to ensure that staff are aware of and adhering to a high standard of care for clients. The HNHB CCAC creates a workplace culture that supports its strategic direction, while fostering a Learning Organization that is continuously striving to improve. Human Resources (HR) is responsible for recruitment and retention, which includes hiring all staff externally and internally via the icims (Internet Collaborative Information Management System), a leading practices recruitment software, as well as new hire orientation and exit interviews. Organizational Development coordinates follow-up on Employee Engagement surveys, including the identification and implementation of action plans to address areas of concern, and does this by working closely with the transformation monitoring Group (TMG). Members of this group represent all departments, branches and levels of HNHB CCAC, and act as internal ambassadors by liaising between management and staff in action planning. Executive Summary 7
The provision of quality client care is a key priority for the HNHB CCAC. The organization has identified the Client Experience, considering both quality and safety, as one of their strategic directions, and commitment and success in this area is evident across the organization. Both clients and family members express a high level of satisfaction with service delivery. They recognize and appreciate the efforts made by service provider agencies to have consistency in staffing, resulting in improved continuity in care. Case managers are found to be resourceful in assisting clients to meet their unique needs. Efforts by the organization and staff to work collaboratively with community partners to develop and deliver care plans are greatly appreciated. This is especially evident in the Palliative Care program. The partnership between the hospice and CCAC is viewed positively in meeting the needs of palliative care clients. The introduction of new approaches to care, such as the Nursing Care Centres for ambulatory clients has been well received by clients and has resulted in more efficient and effective service delivery. New initiatives such as Home First and Transitional Services have had a positive impact within the broader healthcare system. The CCAC actively seeks feedback from clients regarding the services they have received. For the past several years, the organization has participated in a provincial initiative, engaging a third party to conduct client satisfaction surveys. The survey encompasses the CCAC, service providers and overall service delivery. The Client Safety and Quality committee reviews the results and action plans are developed based on the feedback. All information is shared with staff via staff forums and the intranet. The Board also receives this information via established reporting structures. The organization s commitment and success in this area is evident when considering that results from the client satisfaction survey reveal that 93% of clients indicated a willingness to recommend. This exceeds the provincial average. In addition, the organization has met or exceeded 10 provincial key performance indicators (KPIs) related to client care and performance. The organization utilizes an Event Management system to track all client incidents, complaints and compliments. This system has established follow up and reporting protocols to ensure that all events are reviewed, action plans developed and outcomes communicated. In conversations with clients and family members, they convey an overall satisfaction with services and interactions with the HNHB CCAC. They also indicate comfort in bringing forward any issues or concerns. The organization is receptive and responsive in addressing these situations. The caring and genuine interest in the well-being of the clients, evident in interactions with the CCAC staff, is very reassuring for both clients and their families. As with any organization there are challenges to face. The HNHB CCAC will need to develop a robust staff recruitment plan as a result of impending staff shortages due to an aging workforce. Pace of change and direction at times are not within organizational control, hence it is important to stay as a nimble organization and proactively address risks. Given there is a scarcity of resources, it is important to clearly delineate what the organization can do and direct those clients to the appropriate services offered by other community partners when it outside the scope of service delivery in this organization. Clients with increased acuity and complexity in home care cases will continue to require high intensity of resources. There is also a need for improved care transitions and linkages with primary care. The organization has demonstrated many successful outcomes from its initiatives to improve patient flow and seek reduction in alternate level of care (ALC). However, the limitation of amount of services that can be provided, availability of various community supports and services such as accommodation in LTC homes, and availability of health care professionals such as pediatric speech language therapists are some of the challenges identified. Difficulty in predicting timing of funding hence planning with partners remains a challenge for example, base versus one time funding timing. Additionally, allocation and accountability for scarce resources remain a challenge. As a result, home care wait lists and service restrictions will become the norm. The organization will continue to experience financial pressures. Challenges exist relative to service delivery due to an aging population with increasing complex health care needs, combined with efforts to meet these needs Executive Summary 8
while experiencing financial uncertainty. There is also increased demand for community services without a corresponding increase in funding. An aging workforce and the organization's ability to maintain a qualified and stable workforce is an additional pressure. There exists an opportunity to improve client services, with efforts to ensure a more consistent application of policies that ultimately affect service decisions across all sites. Executive Summary 9
Section 2 Detailed On-site Survey Results This section shows detailed on-site results. When reviewing these results, it is important to review the service excellence and the system-wide results together, as they are complementary. Accreditation Canada defines priority processes as critical areas and systems that have a significant impact on the quality and safety of care and services. Priority processes provide a different perspective from that offered by the standards, organizing the results into themes that cut across departments, services, and teams. For instance, the patient flow priority process considers criteria from different sets of standards that each address various aspects of patient flow, from preventing infections to providing timely diagnostic or surgical services. This provides a comprehensive picture of how patients move through the organization and how services are delivered to them, regardless of the department they are in or the specific services they receive. During the on-site survey, surveyors rate compliance with the criteria, provide a rationale for their rating, and comment on each priority process. Priority process comments are shown in this report. The rationale for unmet criteria can be found in the organization's online Quality Performance Roadmap. See Appendix B for a list of priority processes. INTERPRETING THE TABLES IN THIS SECTION: The tables show all unmet criteria from each set of standards, identify high priority criteria (which include ROPs), and list surveyor comments related to each priority process. High priority criteria and ROP tests for compliance are identified by the following symbols: High priority criterion ROP MAJOR MINOR Required Organizational Practice Major ROP Test for Compliance Minor ROP Test for Compliance Detailed On-site Survey Results 10
2.1 Priority Process Results for System-wide Standards The results in this section are categorized first by priority process and then by standards set. Some priority processes in this section also apply to the service excellence standards. Where there are unmet criteria that also relate to services, those results should be shared with the relevant team. 2.1.1 Priority Process: Planning and Service Design Developing and implementing the infrastructure, programs and service to meet the needs of the community and populations served. The organization has met all criteria for this priority process. Surveyor comments on the priority process(es) The Hamilton Niagara Haldimand Brant (HNHB) CCAC accountability framework is identified to define and measure and manage accountability based on strategic directions. The Corporate Work Plan is subsequently developed. This organization also focuses on continuous improvement, with Lean/Six Sigma development of internal capacity. In 2009, HNHB CCAC became the first CCAC to earn the designation of being an RNAO Best Practice Spotlight Organization, and is still the only CCAC to have achieved this status. The organization is proud of the work it has done to ensure that staff are aware of and adhering to a high standard of care for clients. The mission and vision are common and affirmed across all 14 CCAC sites however, the values reflect the local community's belief. The Board of Directors is governed by bylaws. An annual board retreat provides opportunity to review past strategic objectives and develop new ones. Metrics are identified to track the progress made. The LHIN and provincial directions tend to drive priorities and set targets. Monthly and quarterly reporting is provided to LHINs. There is a balanced scorecard approach to performance measurement. The organization has a policy driven board and 4 sub board committees have been established. Board orientation is provided for new members. This is a skill based board whose members are very committed to quality client services. The HNHB CCAC, which is the largest by budget among all CCACs is made up of 5 predecessor CCACs, with Hamilton Niagara and Brant in their entirety, 90% of Haldimand Norfolk and 45% of Halton. A harmonization process took place to amalgamate the 5 former CCACs into one. Nine collective agreements were consolidated into two. The People, Development & Innovation, Finance, Strategy, Quality and Performance Management functions are centralized in Hamilton. Certain client services specialties are located in every branch. Other client services specialties are centralized and managed from a central branch. Renovations were undertaken in 4 of 5 branches to facilitate redesigned work processes. A new telephone system and client database system were put in place. Currently, it is difficult to predict timing of funding, and planning with partners around base versus one time funding timing. Another challenge concerns allocation and accountability for scarce resources, and support is Detailed On-site Survey Results 11
given to the plan to continue to develop cost saving strategies, increase work efficiency and prioritize care needs. There is an identified need to develop a robust staff recruitment plan as a result of impending staff shortage due to an aging workforce. Pace of change and direction at times are not within organizational control, hence it is important to stay as a nimble organization, proactively addressing risks. Detailed On-site Survey Results 12
2.1.2 Priority Process: Resource Management Monitoring, administration, and integration of activities involved with the appropriate allocation and use of resources. The organization has met all criteria for this priority process. Surveyor comments on the priority process(es) The Board Finance and Audit sub committee reviews and makes recommendations to approve resource allocation decisions. The organization assesses the following factors when allocating resources: maximum impacts; interdependency; impact across all 5 former CCACs; and, cost savings. Financial Analysis and Reporting is used to assist management in making critical financial decisions and to ensure that all quarterly and annual financial and statistical reporting requirements of the Ministry of Health and Long-Term Care (MOHLTC) and the LHIN are met. Budget and Forecast Management includes annual preparation and monthly monitoring of financial budgets to identify variances and enable appropriate action to be taken. The Resource Allocation Model (RAM) is a financial tool used to help monitor and control client service spending. There is good communication between Finance and Client Services to ensure that fluctuation in funding is minimized and stable client services are provided. Budget preparation is based on elements such as volume of services, case management model, centralization of medical equipment to realize cost savings and realignment of case loads. Finance develops financial policies and procedures to document, communicate and promote adherence to internal controls. Detailed On-site Survey Results 13
2.1.3 Priority Process: Human Capital Developing the human resource capacity to deliver safe and high quality services to clients. The organization has met all criteria for this priority process. Surveyor comments on the priority process(es) Human Resources (HR) is responsible for recruitment and retention, which includes hiring all staff externally and internally via the icims (Internet Collaborative Information Management System), as well as new hire orientation and exit interviews. The icimis is a leading practices recruitment software program. The HNHB CCAC participates in a Benefits consortium of eight CCACs with an external party, which negotiates with the benefits providers. Leave Management is responsible for staff scheduling, short-term leaves of absence including disability, and long-term leaves including disability and an Attendance Management program. A learning culture is promoted by developing, delivering and/or outsourcing appropriate development programs and tools. These are based on a Talent Management and LEADS Leadership Framework for: performance review and goal-setting; an on line learning management system (LMS), a skills inventory and succession planning. Organizational Development coordinates follow-up on Employee Engagement Surveys, including the identification and implementation of action plans to address areas of concern. It does so by working closely with the Transformation Monitoring group (TMG). Members of this group represent all departments, branches and levels of HNHB CCAC, and acts as internal ambassadors by liaising between management and staff in action planning. Oversight is provided to the Total Well-being committee that researches, recommends and facilitates workplace programs to promote the health and wellness of HNHB CCAC staff. A centralized Joint Health and Safety committee (JHSC) and the 5 branch JHSCs made up of both management and bargaining unit members meets regularly to identify and address issues, promote training, review reports, conduct inspections and perform investigations. Personnel files are scanned and stored electronically. While there is a good process in place to enhance the efficiency of the recruitment process, there is a still a significant number of vacancies to be filled. The organization is encouraged to develop a robust recruitment plan to fill these vacant positions. Based on the Worklife Pulse survey results, the organization is encouraged in its plan to address the areas of workload, trust and involvement in decision making and then communicate back to staff, with the follow up action plans. Detailed On-site Survey Results 14
2.1.4 Priority Process: Integrated Quality Management Continuous, proactive and systematic process to understand, manage and communicate quality from a system-wide perspective to achieve goals and objectives. The organization has met all criteria for this priority process. Surveyor comments on the priority process(es) The organization's Quality, Risk and Client Safety Framework was developed provincially by the CCAC Risk Management committee and endorsed by the CEO Council. This guides the organization's approach to quality, risk and client safety. The framework identifies key elements and enablers that must be in place to achieve and sustain safe and quality care. Strategic and operational plans are in place. There exists a Quality and Safety Strategic Plan and Annual Plan. Committee structures include the Quality and Safety committee (Board) and the Quality and Client Safety committee (staff). Accountabilities are assigned at all levels across the HNHB CCAC Accountability Framework and include corporate work plan and operational plans, policies and procedures, leadership characteristics, position descriptions of board and staff, performance review systems, client safety roles and responsibilities. There is focus on the voice of customers, client safety reviews, client safety dialogues and disclosure of harm to clients. The organization promotes a safety environment for client safety/risk reporting and a just culture. Debriefing meetings take place following incidents in which the Incident Management Plan is activated. The HNHB CCAC promotes the use of leading practices such as the Registered Nurses Association of Ontario (RNAO) Best Practices and celebrates learning. It promotes and supports the use of Lean/Six Sigma continuous improvement methodology. Client Event Management trends and follow up activities are presented at Client Services Branch meetings and Service Provider meetings. Client safety stories are shared at all board meetings, and shared with staff via the Client Safety Newsflash and with service providers at their discipline-specific meetings. There are board and staff education sessions related to quality and client safety. A full day of client safety orientation is provided to new CCAC staff. Quality and safety updates are standing agenda items for the All Staff Forums and the All Service Provider meetings. Resources are posted on the Client Safety, Quality and Risk section of the HNHB CCAC intranet and internet. Client Event Management system tracking, trending and root cause analysis (RCA) are used to manage risk. A corporate risk assessment and monthly organizational risk assessment are conducted on an annual basis. Risk mitigation strategies and controls are identified. The resource utilization management tool named Resource Allocation Model (RAM) is used to assist case managers and CCAC managers to monitor utilization hours/dollars against budget. While there are many initiatives to promote patient flow, the organization is encouraged in its plan to provide time for staff to understand the impacts of all these initiatives and translate new knowledge into their practice. Detailed On-site Survey Results 15
2.1.5 Priority Process: Principle-based Care and Decision Making Identifying and decision making regarding ethical dilemmas and problems. The organization has met all criteria for this priority process. Surveyor comments on the priority process(es) The HNHB CCAC is commended for their work in developing the: "SOLVE Ethical Decision-Making Toolkit and Framework", which facilitates a common approach across the organization when dealing with conflict and ethics issues. This toolkit was developed utilizing ethical principles and community values, as well as information from the Toronto Community Ethics Network. Consideration was also given to the various professional colleges to ensure compliance with their Codes of Ethics. The toolkit includes a Code of Ethics for Client Services, the SOLVE ethical-decision making framework and worksheet which guides staff through the process. During the roll out of the SOLVE framework, mandatory staff educational sessions were provided which included test scenarios to apply the framework and a post quiz to ensure staffs' understanding of all elements of the framework. Pocket guides were provided to all staff to ensure access to the framework and guiding principles during their day-to-day work. The ethics framework is utilized in specific challenging client situations, to guide service provision decisions in complex cases and has been built into the policies and procedures for case conferences. In addition, the final step includes debrief and evaluation of the situation, identification of lessons learned and communication of this information to staff. This approach has resulted in a high level of comfort and competence among staff members in applying the ethics framework and addressing ethical situations. The organization has access to an external ethicist and utilizes this resource as necessary. The HNHB CCAC is encouraged to follow through with their plans to participate in the development of a LHIN Regional Ethics Network. The HNHB CCAC is actively involved in several research initiatives and clearly is a leader amongst their peers in this regard. An agreement is in place with the University of Waterloo for the use of RAI-HC data, exploring how this information can be utilized to advance client care. This partnership has lead to an invitation to the HNHB CCAC to present at the upcoming International Inter-RAI Conference. The CCAC has also participated in research projects with other academic centres including the University of Toronto, McMaster University and the University of Guelph. A Research policy is in place to guide this activity and it includes criteria for participation. This policy adheres to International, National and Provincial Research Standards. Consideration is given as to whether the knowledge generated will result in improved care and service, as well as to benefit the wider healthcare system. All proposals must have Research Ethics Board (REB) approval, be consistent with the organizations' strategic directions and subscribe to their identified ethical principles. Research proposals undergo an initial pre-screening, followed by a more in depth review to ensure compliance with the organization's policy. Detailed On-site Survey Results 16
2.1.6 Priority Process: Communication Communication among various layers of the organization, and with external stakeholders. The organization has met all criteria for this priority process. Surveyor comments on the priority process(es) There is a Communications Plan in place to support brand, reputation and relationships of organization. The business priorities are to profile the role of HNHB CCAC in supporting people to come home from hospital, to remain living independently at home, and assisting in the transition to other levels of care when living at home is not possible. The plan also highlights the CCAC brand themes of: Quality, Caring, Knowledge/Expertise; and, Connections for stakeholders including clients and caregivers, staff, service providers, community agencies, health sector partners, media and elected officials. Communication objectives have been identified to support HNHB CCAC strategic directions. Key objectives include building community awareness of the CCAC's role and services, positioning as a strong organization focused on excellence, accountability and transparency, maintaining and enhancing existing external relationships, forging new ones and positioning as an open and communicative organization. The organization is encouraged in its plan to adopt user friendly software programs to allow better information flow. This includes the need to maximize the benefits of technology to standardize processes in order to streamline process steps, number of players, controls and approvals. Encouragement is offered to provide sufficient training and support to staff as part of the advance planning when introducing new technology, including end-user consultation. The organization needs to foster an open, two-way communication via team meetings, one-on-one meetings between managers and employees and prompt responses to queries. Detailed On-site Survey Results 17
2.1.7 Priority Process: Physical Environment Providing appropriate and safe structures and facilities to successfully carry out the mission, vision, and goals. The organization has met all criteria for this priority process. Surveyor comments on the priority process(es) The HNHB CCAC is a large organization operating out of 39 locations and includes 5 major offices, 10 nursing care centres and a large number of hospital sites. The five branch offices visited were found to be clean, had well-lit work environments with consideration being given to providing ample work space, access to supplies and staff lunchrooms. Each of the 5 office locations offers a dedicated fitness area for use by CCAC staff. All office sites are kept secure by controlled access that requires double entry outside of usual business hours. Back up generators are located in the main office sites to ensure continuity of service during power outages and recycling programs are in place. The physical space meets all applicable laws, regulations and codes. The CCAC has contracts with several vendors for heating ventilation and air conditioning (HVAC), shredding, fire extinguishers, office equipment and office cleaning. A request for proposal (RFP) process is used to identify and select vendors and service agreements are developed with enhanced quality checks in place. Quarterly reviews of these service agreements are conducted to address any issues/concerns and to ensure vendors are meeting all expectations. The organization's commitment to providing a safe work environment is evident with the development of an Occupational Health and Safety Policy Statement, and access to first aid stations and materials safety data sheets (MSDS) in the office areas. This commitment was further demonstrated during a situation with mould at one of the 5 office locations. In an effort to ensure the safety and security of staff during the cleanup process, legislative requirements related to isolating the area were not only met, but exceeded. An additional level of verification was carried out to ensure workers involved possessed the required level of certification for this work. The communication to staff during the process ensured their comfort and understanding of steps being taken to address the issue. The Ministry of Labour was on site to verify compliance with all requirements and the situation was resolved without the need to issue any Ministry of Labour work orders. The CCAC is commended for the commitment and success in providing safe, functional and comfortable working environments for all of the staff. Detailed On-site Survey Results 18
2.1.8 Priority Process: Emergency Preparedness Dealing with emergencies and other aspects of public safety. The organization has met all criteria for this priority process. Surveyor comments on the priority process(es) The HNHB CCAC has adopted the Incident Management system that is used by the MOHLTC and provides the framework for their approach in planning and dealing with emergency situations. This system is used along with a comprehensive Pandemic Plan to reduce the vulnerability of CCAC staff and clients when emergencies occur and it allows them to respond promptly and efficiently to these situations. The Pandemic Plan identifies phases and levels of preparedness and the activities required relative to these levels. It also details roles and responsibilities and time frames for completion of the various steps in the process. Flow sheets are included to ensure compliance and completeness when the plan is implemented. The management team participates in a review of the Business Continuity Plan semi-annually, utilizing mock scenarios to test understanding with the established processes. All management staff are included in an annual review. Management staff feel these sessions are extremely beneficial for their understanding and comfort in dealing with emergency situations. Back up systems are in place to ensure the CCAC's ability to continue to provide service when power outages occur. There is a clear process in place for utilizing the high level message component of the telephone system and it is used to communicate urgent messages to staff during unexpected situations. The CCAC uses data generated in the RAI-HC to assist in the identification of vulnerable clients and uses this information in prioritizing service provision during emergency situations. Fire drills are conducted quarterly and are followed by a debriefing session to evaluate the event and develop action plans moving forward. These are posted on the intranet and are accessible by all staff. The regular inspections, testing and maintenance of all fire safety and emergency equipment occur to reduce the risk from fire and ensure staffs' ability to respond appropriately. The HNHB CCAC has engaged in a Mutual Assistance Agreement with the Mississauga-Halton CCAC. This agreement provides a framework for how assistance could be requested in unexpected situations. Consultation with staff and unions was carried out during the development process and with legal counsel prior to finalization of the agreement. This is the only Mutual Assistance Agreement amongst the CCACs in the province and is now being considered by the Ontario Association of Community Care Access Centres (OACCAC) as a province-wide initiative. The Emergency plans that have been developed and implemented by the HNHB CCAC have proven effective in managing incidents, both internal and external which affect the normal operations of the organization. The fire safety plan could be enhanced with the addition of a simulated fire extinguisher exercise. Detailed On-site Survey Results 19
2.1.9 Priority Process: Medical Devices and Equipment Machinery and technologies designed to aid in the diagnosis and treatment of healthcare problems. The organization has met all criteria for this priority process. Surveyor comments on the priority process(es) The CCAC does not have a direct role in the provision of medical equipment. This service is provided by contracted vendors that are responsible for the inspection, cleaning, maintenance, delivery and pick up of equipment required by clients. As a part of this role, the contracted vendors are required to maintain written records of ongoing maintenance and inspection of all equipment. These records are provided to the CCAC upon request. Evaluation of the vendors' Preventive Maintenance (PM) program is included with the CCAC Quarterly Performance Review Process. In addition, the Client Event Management reporting system is used by the HNHB CCAC to monitor adverse events and near misses related to client equipment. All incidents are reviewed, with follow up action taken as required. Detailed On-site Survey Results 20
2.2 Service Excellence Standards Results The results in this section are categorized first by standards set and then by priority process. Priority processes specific to service excellence standards are: Clinical Leadership Providing leadership and overall goals and direction to the team of people providing services. Competency Developing a highly competent interdisciplinary team with the knowledge, skills and abilities to develop, manage, and deliver effective and efficient programs, services, and care. Episode of Care 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. Decision Support Information, research and evidence, data, and technologies that support and facilitate management and clinical decision-making. Impact on Outcomes The identification and monitoring of process and outcome measures to evaluate and improve the quality of services to clients and the impact on client outcomes. Infection Prevention and Control Measures practiced by healthcare personnel in healthcare facilities to decrease transmission and acquisition of infectious agents. 2.2.1 Standards Set: Case Management Services Unmet Criteria High Priority Criteria Priority Process: Clinical Leadership The organization has met all criteria for this priority process. Priority Process: Competency The organization has met all criteria for this priority process. 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. Detailed On-site Survey Results 21
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 HNHB CCAC is congratulated for their commitment to the provision of high quality client care within the context of their Vision and Values. As a result, the organization has positioned itself as a leader within the community health sector. By way of innovation and responsiveness, the organization is able to meet the changing health care needs of the community. Examples of this innovation include collaboration and partnership with family health teams (FHTs) and also with a group of family physicians and a Community Health Centre (CHC). The collaboration and partnership with FHTs has resulted in enhanced communication between the CCAC and primary care, which has improved coordination of client care and has lead to the development of excellent working relationships with this sector. In the Community Frailty Pilot Project, the CCAC is working with a group of family physicians and a Community Health Centre to identify frail clients that may be at risk for hospitalization. A screening tool is used to assess needs and trigger a referral to the CCAC. There is evidence of a strong team focus across the organization, as staff members work collaboratively to provide service. The leadership team is viewed as being extremely supportive and responsive when concerns are identified. Staff members feel valued and appreciate opportunities to have input to their roles and workload. The use of the Champion model has proven successful in the rollout and implementation of new initiatives and programs. A number of staff recognition practices are in place including the Annual Service Awards event, the recognition of project work during staff forums and the "Celebrating our Successes" during staff meetings. Priority Process: Competency The CCAC is fortunate to a have highly skilled and diverse workforce, and has been successful in creatively positioning staff in the organization to enable them to utilize their skills and achieve maximize benefit within an inter-professional approach. A learning culture is promoted by developing and delivering appropriate education programs for staff at all levels. Access to the Independent Learning Resource on the CCAC intranet has greatly enhanced staffs' ability to receive both mandatory and optional training. Individual learning goals are established during the performance review process and opportunities are sought to meet these goals. Staff appreciate the importance placed on their ongoing education and development by the organization. In effort to assist new staff members to succeed in their new roles, the organization has recently increased the orientation plan for Client Services from four to six weeks. The CCAC has undergone significant change over the past 5 years, which has had an impact on the workload and expectations placed on staff. Although the organization is sensitive to this and has provided supports where possible, it is suggested that this continue to be kept in the forefront, undertaking environmental scans so that the full impact can be identified and action plans developed to minimize same. Detailed On-site Survey Results 22