Page 1 of 5 Ongwanada ORGANIZATIONAL CLIENT SAFETY PLAN 2011-2012 Purpose The purpose of the Client Safety Plan is to formally establish a mechanism to identify actual or potential safety risks and develop corrective measures to address those risks. Ongwanada recognizes the importance of establishing a safety awareness culture and dedicates available resources to the identification or events that may contribute to an unsafe environment. The Plan is consistent with Ongwanada's Strategic Plan, Vision and Mission and encompasses Accreditation Canada's Required Organizational Practice 6.2 and Standards. Our goal is to be proactive in our approaches to reduce or eliminate safety risk to our clients. This is done through ongoing monitoring efforts to identify potential or actual risk. Further, systems have been designed to collect, review and analyze data to identify trends should an untoward event occur and implement corrective measures to prevent a reoccurrence. The Plan encourages the involvement of staff, providers, clients and visitors in identification of safety risk and in the recognition of potential/real unsafe areas, as well as in the implementation of processes to provide for the overall safety of clients/staff/providers and consumers. This shall be accomplished through the effective reduction of medical/healthcare errors and other factors that could contribute to unintended adverse outcomes through the management of the physical environment, and the implementation of Safety, Risk management, and Security programs. The Continuous Quality Improvement and Risk Management Annual Plan also addresses Client Safety activities in the Quarterly Continuous Quality Improvement and Quarterly Risk Management Reports, e.g. client incidents, medication incident rates, client restraints. The 2011 Annual Plan for Client Safety (Prospective Analysis) will be developed in detail and will be included as Appendix I. Lead Person: Reviewed by: Distributed to: (Karen Menzies-Turner) Senior Management Group, Continuous Quality Improvement Committee, Accreditation Committee, Prospective Analysis Task Force Department Heads & Supervisors
1.0 Develop and implement and Annual Organizational Client Safety Plan for 2010-2011 2011-2012 CLIENT SAFETY PLAN Item/Steps Responsibility Actions Timelines Evaluation Tool Outcome Obtain approval from Annually in the Senior April Management Group 2.0 Client Support Plan Process (Policy # 05-05-01*) 3.0 Client and Parental Concerns and Complaints (Policy # 05-03-07*) Services Supervisor (M. Slade) Epidemiologist (H. Oullette-Kuntz) Board Executive Committee Each client and family member will be provided with an opportunity to participate in their Support Plan Conference to develop client safety goals. Distribute a Family Satisfaction Survey to the families of all Residential Clients. Address specific complaints/concerns as required. Annually for each client Biannually Annual Support Plan Audit and Support Plan Satisfaction Survey (Policy # 05-05-01) January Family Satisfaction Survey Report (Biannually) Report as a Serious Occurrence to the Ministry (as required) To be approved by the Senior Management group To be reviewed by the CQI Committee and Accreditation Committee Report to be presented to the Senior Management Group, CQI Committee and Client Care Committee Report of the Survey of Parents/Guardian of Community Residence Clients to be presented to the Client Care Committee with outcomes published in the Fall 2011 edition of the Horizon. 4.0 Client Representative /Client Concerns (Policy # 05-03-25) 5.0 Alleged Abuse of Clients (Policy #01-04-02) Co-ordinator, Services (B. Bentley) \ Specific concerns addressed by Client Representative/, as required A review of this policy occurs on an annual basis to ensure it continues to address the prevention, identification, reporting and promotion of zero tolerance of abuse. A record of this review including any changes made are maintained by the Co-Chairs of the Alleged Abuse Inquiry Team. As required Annually Client Representative Role (Policy # 05-03-25) CQI Quarterly Risk Management Report April Review and evaluation of the policy related to Abuse of Clients as per the following: Annual Policy & Procedure Reviews (Policy # 01-03-10) Mandatory Education Programs/Tracking of Mandatory Education Programs - Policy 02-02-12 Risk Management Report to be presented by the to the Board of Governors on a quarterly basis. Recommendations related to the Client Representative Role are to be implement. Report and recommendations to be presented to the Board of Governors
2011-2012 CLIENT SAFETY PLAN Item/Steps Responsibility Actions Timelines Evaluation Tool Outcome Ongwanada ensures that annual education and awareness building on client safety and abuse prevention and to employees/ volunteers/home Share Providers/Board members through presentations and/or review of policies Annually Volunteer Services - Policy # 05-09-01 Board Orientation / Training 6.0 Client Training (Policy # 05-02-08 *) (Policy # 05-02-31 *) (Policy # 01-04-02) Senior Management Group Initial education and awareness building on abuse prevention and to clients/nearest relatives upon first receiving services. Ongwanada ensures that annual education and awareness building on client safety and abuse prevention and to clients through presentations and/or review of policies, e.g. Keeping Me Safe Ongoing Identified at Support Plan Meeting Client Orientation Checklist (Policy # 05-03-06 - Introduction of a New Residential / Home Share/ Treatment Home Client for Admission) and Client Rights Policy # 05-03- 01 Evaluation component addressed in final report of Keeping Me Safe Program Increased client awareness of client safety including identifying, reporting and preventing abuse. The evaluation report and recommendations is to be provided to the Senior Management Group. A report is to be presented to the Client Care Committee *Policies are identified in Policy # 01-03-10 Annual Policy and Procedure Review and are reviewed by staff on an annual basis.
2011-2012 CLIENT SAFETY PLAN Items/Steps Responsibility Actions Timelines Evaluation Tool Outcome 7.0 Client Safety and Supervision Policy # 05-07-03 *) 8.0 Client Safety Policy (Policy # 05-02-41 *) 9.0 Identify specific needs for population at risk for falls (Policy # 05-03-38 *) Coordinator, Vocational & Community Services (R. Dillon) Services Supervisor (M. Slade) Each client will be assigned a Client Safety & Supervision level Policy to be reviewed and revised, as necessary in June 2012 Develop and implement a policy on falls prevention and management program. (Policy # 05-02-41) Semi-annual April & October Policy Reviewed as required C.Q.I. Quarterly Reports Annual Evaluation Review of semiannual Supervision List Policy # 05-07-03 Client Safety discussed at client's Support Plan, departmental meetings and Community Residence/Day program planning days Evaluation completed from data on the Client/Visitor Incidents Reports Quarterly data is contained in the CQI Quarterly Report A report with recommendations is to be presented to Vocational Services and (April and October 2011) Recommendations/revisions are to be implemented as identified. The lists are distributed all key areas (April & October 2011) Annual Organizational Patient Safety Plan to be developed and approved by the Senior Management Group. The Annual Organizational Client Safety Plan is to be presented to the Client Care Committee and Department Heads and Supervisors. An annual evaluation report is to be presented to the Senior Management Group and results shared with the Department Heads/Supervisors *Policies are identified in Policy # 01-03-10 Annual Policy and Procedure Review and are reviewed by staff on an annual basis.
10.0 Search & Rescue (Policy # 05-02-04 a & b*) 2011-2012 CLIENT SAFETY PLAN Items/Steps Responsibility Actions Timelines Evaluation Tool Outcome Annual Annual Search and Rescue Drill conducted in September 2010. Required Organizational Practice 6.6 - Prospective Analysis on Search & Rescue Process completed Report developed with recommendations and presented to the Senior Management Group Page 5 of 5 Results of the Search & Rescue Drill are to be presented to the Senior Management Group and shared with the Department heads/supervisors. An article related to the results is to be published in the Source. 11.0 Locked/Secured and Alarmed Areas (Policy # 05-02-35 *) 12.0 Prospective Analysis (See Appendix I) Every client area will be reviewed to determine if specific areas/ supplies are to be locked/secured. Ongwanada will carry out one (1) client safety related prospective analysis per year and implement appropriate improvements. Semi-annual Annually Missing Person is a type of Serious Occurrence reported to the Ministry. 2010-2 2009-0 2008-2 2007-1 2006-1 Statistics maintained since 1995 Serious Occurrence must be reported to MCSS e.g. concern re: physical safety standard 2010-0 2009-0 2008-0 2007-0 2006-0 Results of the Prospective Analysis are provided in the Task Force final report which ensures the activities outlined in the Terms of reference have been completed. The Serious Occurrence Reporting Procedure - 2011 annual Summary and Analysis Report is shared with the CQI Committee and reflected in the Quarterly CQI report. Report with recommendations is to be presented to the Senior Management Group semi-annually (May 11 & Nov 11) and the Locked/Secured and Alarmed Areas Semi-Annual Collated report is to be distributed to all key stakeholders. The Final Report and recommendations of the Prospective Analysis Task Force is to be presented to the Senior Management Group. A presentation of the Task Force findings will be presented to the Client Care Committee.