Executive Summary Jewish Rehabilitation Hospital Hôpital juif de réadaptation Laval, QC On-site survey dates: September 9, 2012 - September 13, 2012 Report issued: November 13, 2012 Accredited by ISQua
About the Jewish Rehabilitation Hospital Hôpital juif de réadaptation (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 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 Jewish Rehabilitation Hospital Hôpital juif de réadaptation 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 Executive Summary is part of the, but can also be used as a stand-alone document to inform stakeholders. It shows your accreditation decision and highlights some of your accreditation activities and on-site survey results. 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 6 1.6 Summary of Surveyor Team Observations 10 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. Jewish Rehabilitation Hospital Hôpital juif de réadaptation (referred to in this report as the organization ) is participating in Accreditation Canada's Qmentum accreditation program. This 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. Jewish Rehabilitation Hospital Hôpital juif de réadaptation 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 Jewish Rehabilitation Hospital Hôpital juif de réadaptation has earned the following accreditation decision. Accredited (Report) Executive Summary 1
1.2 About the On-site Survey On-site survey dates: September 9, 2012 to September 13, 2012 Location The following location was assessed during the on-site survey. 1 Jewish Rehabilitation Hospital / Hôpital juif de réadaptation 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 2 Governance Leadership Service Excellence Standards 3 4 5 6 7 8 9 10 Managing Medications Reprocessing and Sterilization of Reusable Medical Devices Infection Prevention and Control Acquired Brain Injury Services Biomedical Laboratory Services Laboratory and Blood Services Rehabilitation Services Diagnostic Imaging Services 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) 31 3 1 35 Accessibility (Providing timely and equitable services) 44 3 1 48 Safety (Keeping people safe) 236 26 43 305 Worklife (Supporting wellness in the work environment) 68 10 1 79 Client-centred Services (Putting clients and families first) 54 3 1 58 Continuity of Services (Experiencing coordinated and seamless services) 21 0 0 21 Effectiveness (Doing the right thing to achieve the best possible results) 416 47 55 518 Efficiency (Making the best use of resources) 44 2 3 49 Total 914 94 105 1113 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. Accreditation decisions are based on compliance with standards. Percent compliance is calculated to the decimal and not rounded. High Priority Criteria Other Criteria Total Criteria (High Priority + Other) Standards Set Met Unmet N/A # (%) # (%) # Met Unmet N/A # (%) # (%) # Met Unmet N/A # (%) # (%) # Governance 43 (100.0%) 0 (0.0%) 0 32 (91.4%) 3 (8.6%) 0 75 (96.2%) 3 (3.8%) 0 Leadership 37 (88.1%) 5 (11.9%) 0 77 (88.5%) 10 (11.5%) 0 114 (88.4%) 15 (11.6%) 0 Diagnostic Imaging Services 44 (86.3%) 7 (13.7%) 15 43 (84.3%) 8 (15.7%) 10 87 (85.3%) 15 (14.7%) 25 Infection Prevention and Control 33 (94.3%) 2 (5.7%) 6 35 (94.6%) 2 (5.4%) 5 68 (94.4%) 4 (5.6%) 11 Acquired Brain Injury Services 27 (100.0%) 0 (0.0%) 0 70 (92.1%) 6 (7.9%) 1 97 (94.2%) 6 (5.8%) 1 Biomedical Laboratory Services 9 (81.8%) 2 (18.2%) 5 31 (91.2%) 3 (8.8%) 2 40 (88.9%) 5 (11.1%) 7 Laboratory and Blood Services 61 (95.3%) 3 (4.7%) 17 67 (94.4%) 4 (5.6%) 24 128 (94.8%) 7 (5.2%) 41 Managing Medications 59 (88.1%) 8 (11.9%) 9 46 (92.0%) 4 (8.0%) 2 105 (89.7%) 12 (10.3%) 11 Rehabilitation Services 26 (100.0%) 0 (0.0%) 0 66 (97.1%) 2 (2.9%) 1 92 (97.9%) 2 (2.1%) 1 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 # (%) # (%) # Reprocessing and Sterilization of Reusable Medical Devices 30 (85.7%) 5 (14.3%) 5 43 (76.8%) 13 (23.2%) 3 73 (80.2%) 18 (19.8%) 8 Total 369 (92.0%) 32 (8.0%) 57 510 (90.3%) 55 (9.7%) 48 879 (91.0%) 87 (9.0%) 105 Executive Summary 5
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 Adverse Events Reporting Client Safety As A Strategic Priority Client Safety Quarterly Reports Client Safety Related Prospective Analysis 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 (Acquired Brain Injury Services) Client And Family Role In Safety (Diagnostic Imaging Services ) Client And Family Role In Safety Dangerous Abbreviations (Managing Medications) Information Transfer (Acquired Brain Injury Services) Met 2 of 2 0 of 0 Met 2 of 2 0 of 0 Met 2 of 2 0 of 0 Met 4 of 4 3 of 3 Met 2 of 2 0 of 0 Executive Summary 6
Required Organizational Practice Overall rating Test of Compliance Rating Major Met Minor Met Patient Safety Goal Area: Communication Information Transfer Medication Reconciliation As An Organizational Priority Medication Reconciliation At Admission (Acquired Brain Injury Services) Medication Reconciliation At Admission Medication Reconciliation at Transfer or Discharge (Acquired Brain Injury Services) Medication Reconciliation at Transfer or Discharge Two Client Identifiers (Acquired Brain Injury Services) Two Client Identifiers (Diagnostic Imaging Services ) Two Client Identifiers (Managing Medications) Two Client Identifiers Verification Processes For High-Risk Activities (Diagnostic Imaging Services ) Verification Processes For High-Risk Activities Met 2 of 2 0 of 0 Unmet 3 of 12 0 of 0 Met 4 of 4 1 of 1 Met 4 of 4 1 of 1 Unmet 2 of 4 1 of 1 Unmet 2 of 4 1 of 1 Unmet 0 of 2 0 of 1 Unmet 2 of 2 0 of 1 Executive Summary 7
Required Organizational Practice Overall rating Test of Compliance Rating Major Met Minor Met Patient Safety Goal Area: Medication Use Concentrated Electrolytes (Managing Medications) Heparin Safety (Managing Medications) Infusion Pumps Training (Managing Medications) Infusion Pumps Training Medication Concentrations (Managing Medications) Narcotics Safety (Managing Medications) Met 4 of 4 0 of 0 Met 3 of 3 0 of 0 Patient Safety Goal Area: Worklife/Workforce Client Safety Plan Client Safety: Education And Training Client Safety: Roles And Responsibilities Preventive Maintenance Program Workplace Violence Prevention Met 0 of 0 2 of 2 Met 1 of 1 2 of 2 Unmet 2 of 3 0 of 1 Unmet 5 of 5 2 of 3 Patient Safety Goal Area: Infection Control Hand Hygiene Audit (Infection Prevention and Control) Hand Hygiene Education And Training (Infection Prevention and Control) Met 1 of 1 2 of 2 Met 2 of 2 0 of 0 Executive Summary 8
Required Organizational Practice Overall rating Test of Compliance Rating Major Met Minor Met Patient Safety Goal Area: Infection Control Infection Control Guidelines (Infection Prevention and Control) Infection Rates (Infection Prevention and Control) Influenza Vaccine (Infection Prevention and Control) Sterilization Processes (Infection Prevention and Control) Met 1 of 1 3 of 3 Met 3 of 3 0 of 0 Met 1 of 1 1 of 1 Patient Safety Goal Area: Falls Prevention Falls Prevention Strategy (Acquired Brain Injury Services) Falls Prevention Strategy (Diagnostic Imaging Services ) Falls Prevention Strategy Met 3 of 3 2 of 2 Met 3 of 3 2 of 2 Met 3 of 3 2 of 2 Executive Summary 9
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. After a period of consultation and reflection, the Jewish Rehabilitation Hospital (JRH) developed a strategic plan for 2012 to 2015. The plan demonstrates the engagement of each of the organization s members to continue offering quality services. The strategic plan development process included a revision of the JRH s mission statement, vision and values. The plan was recently adopted by the Board. The next step is approval by the l Agence de santé et des services sociaux of Laval. The JRH s ongoing commitment to striving for clinical excellence is remarkable at all levels. Also noteworthy is the organization s persistence in developing research and best practices, as well as in its objective to obtain the designation of University Institute and become a centre of excellence. The organization is committed to a human resources management perspective that is based on supporting the development of staff competencies to establish a quality work environment. Since Accreditation Canada s previous survey, the JRH has made efforts to meet Accreditation Canada s recommendations. The Board is made up of a group of individuals devoted and committed to the organization and its vision. The Board strongly supports the JRH s objective to become a recognized centre of excellence, a true University Institute, a regional centre for physical disability, and a centre with a supraregional mandate. The Board s by-laws are currently being revised to reflect the recent changes made to the Act respecting health services and social services. Now that the strategic plan has been adopted, it is important for the Board to assume its leadership by supporting the management team in its efforts to obtain the necessary approval to implement the plan; determine timeframes and responsibilities; attain strategic goals and objectives; ensure organizational performance; and ensure that there is a communication plan to promote the sharing of the strategic plan with internal and external partners. The JRH has developed a number of relationships with the community of Laval and in the Montreal region. The management team has many contacts with community partners and actively participates in Laval and Montreal s regional committees, which allows it to have an adequate comprehension of community needs. These different connections have led to the development of important partnerships and, consequently, should lead to improved service coordination and accessibility. Thanks to its consultations, the new strategic plan should allow for the clarification of the organization s mission and vision. It will also further improve the partnership with different organizations and increase accessibility to the services offered by the hospital. The Executive Committee is stable, passionate and devoted to the organization. It has the capacity to mobilize itself and the staff, as well as put in place the means required to concretely improve safety and the quality of care and services at the JRH. It must pursue its efforts to implement the integrated quality plan at all levels in the organization. The staff is dedicated and competent. The turnover rate is low, which particularly illustrates staff s appreciation of the quality of the work environment. A sense of belonging is present among staff. The organization employs a number of recognition strategies (study bursaries, research contributions, support, training, scheduling flexibility including flex time and part-time, etc.). Staff retention is significant. However, the high number of staff members over 55 years of age (approximately 20%) will require workforce planning and a human resources succession plan. Executive Summary 10
Recognition awards such as the Ministry of Health and Social Services Excellence Award Honourable Mention received for the traumatology program s sensibility activity conducted in high schools in the region demonstrate the excellence present in partnerships and services. Patients benefit directly from research activities thanks to the close link between the services offered and the research projects. A well established and structured process allows for the assessment of patients opinions on service satisfaction. Surveys conducted on a regular basis and post-program follow-ups clearly demonstrate clients high level of satisfaction. The local service quality and complaints commissioner is available for receiving and dealing with complaints. The commissioner s reports are regularly forwarded to the Board of Directors which ensures follow-up on the recommendations. Executive Summary 11