Stroke Distinction Report. Lakeridge Health Oshawa. Oshawa, ON. On-site Survey Dates: October 26, October 29, PDF Free Download

Stroke Distinction Report Lakeridge Health Oshawa Oshawa, ON On-site Survey Dates: October 26, 2015 - October 29, 2015 Report Issued: November 12, 2015

About the Distinction Report Lakeridge Health Oshawa (referred to in this report as the organization ) is participating in the Accreditation Canada Distinction program. As part of this ongoing process of quality improvement, an on-site survey was conducted. Information from the on-site survey as well as other data obtained from the organization were used to produce this Distinction Report. On-site survey 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 Distinction Report. 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 Distinction Report to staff, board members, clients, the community, and other stakeholders. Any alteration of this Distinction Report compromises the integrity of the process and is strictly prohibited. Accreditation Canada, 2015

A Message from the Accreditation Canada CEO On behalf of Accreditation Canada, I extend my congratulations to Lakeridge Health Oshawa on your participation in a program that recognizes organizations that demonstrate clinical excellence and an outstanding commitment to leadership. I hope you find the Distinction process to be an interesting and informative experience, and that it is providing valuable information that you are using to plan your quality and safety initiatives. This Distinction Report shows your decision, as well as final results from your recent on-site survey. I encourage you to use the information in this report to guide your ongoing 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 Distinction into your quality 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. Sincerely, Wendy Nicklin President and Chief Executive Officer Accreditation Canada

Table of Contents 1 Introduction 1 2 Executive Summary 2 2.1 Distinction Decision 2 2.2 On-Site Survey Information 3 2.3 Overview of Results 4 2.4 Summary of Evaluator Team Observations 5 3 Distinction Standards 6 3 Distinction Standards 6 3.1 Standards Set: Acute Stroke Services 7 3.2 Standards Set: Inpatient Stroke Rehabilitation Services 14 4 Distinction Protocols 21 5 Performance Indicators 24 5.1 Standards Set: Acute Stroke Services 24 5.2 Standards Set: Inpatient Stroke Rehabilitation Services 24 5.3 Standards Set: Optional 24 6 Client and Family Education 28 7 Excellence and Innovation 30 8 Next Steps 32 i

1. Introduction The Accreditation Canada Distinction program recognizes organizations that demonstrate clinical excellence and an outstanding commitment to leadership in a specific field of expertise. The program is developed in close consultation with key stakeholders and content experts to reflect detailed practices and the most up-to-date evidence. It offers rigorous and highly specialized standards of excellence, in-depth performance indicators and protocols, and an on-site survey by expert evaluators with extensive practical experience in the field. The program includes an on-site survey every four years. The Distinction program includes the following key components: Standards: Distinction standards are based on the latest research and evidence related to excellence in the field. Protocols: Distinction requires the use of evidence-based protocols to promote a consistent approach to care and increase effectiveness and efficiency. Indicators: A key component of the Distinction program is the requirement to submit data on a regular basis and meet performance thresholds on a core set of performance indicators. Client and Family Education: Client, family and caregiver education and self-management support are integral parts of stroke care that should be addressed at all stages across the continuum of stroke care for both adult and pediatric clients. Education is an ongoing and vital part of the recovery process for stroke, which must reach the survivor, family members and caregivers. Excellence and Innovation: Distinction clients must demonstrate implementation of a project or initiative that aligns with best practice guidelines, utilizes the latest knowledge, and integrates evidence to enhance the quality of care. 1

2. Executive Summary Lakeridge Health Oshawa (referred to in this report as the organization ) is participating in the Accreditation Canada Distinction program. Accreditation Canada is an independent, not-for-profit organization that sets standards for quality and safety in health care and accredits health organizations across Canada. As part of the Distinction program, Lakeridge Health Oshawa has undergone a rigorous evaluation process. External peer evaluators conducted an on-site survey during which they assessed the organization's programs and services. Results are included in this report and were considered in the Distinction decision. Please see Appendix A for a copy of the Decision Guidelines. This report shows the results to date and is provided to guide the organization as it continues to incorporate the principles of Distinction and quality improvement into its programs and services. Lakeridge Health Oshawa is commended on its commitment to using Distinction to improve the quality and safety of the services it offers to its clients and its community. 2.1 Distinction Decision Accreditation Canada is very pleased to recognize Lakeridge Health Oshawa for earning Distinction in Stroke Services for the following locations and services: Acute Stroke Services Inpatient Stroke Rehabilitation Services 2

2.2 On-Site Survey Information On-Site Survey Dates October 26, 2015 to October 29, 2015 Location The following location was assessed during the on-site survey. 1 3

2.3 Overview of Results The following is an overview of the organization s results for each component of the Distinction program. Component Achivement Met Unmet Total % Standards Acute Stroke Services 102 0 102 100.0 Inpatient Stroke Rehabilitation Services 87 0 87 100.0 Distinction Protocol 20 0 20 100.0 Indicator 11 2 13 84.6 Distinction Education 8 0 8 100.0 Distinction Excellence and Innovation Lakeridge Health Stroke Prevention Clinic 5 0 5 100.0 4

2.4 Summary of Evaluator Team Observations The evaluator team made the following observations about the organization s overall strengths, opportunities for improvement and challenges. The organization, Lakeridge Health Oshawa, is commended on preparing for and participating in Accreditation Canada's Stroke Distinction Program. Lakeridge Health Oshawa's stroke program is wonderful evidence that a busy community hospital can reach the highest standards of care and compete with university-based, academic institutions. This program has strong leadership, superb multidisciplinary staff members and excellent physician support. The organization's senior management deserves credit for its support of the program and recognition of its excellence. The team meets virtually all of Accreditation Canada's Stroke Distinction standards. Patient satisfaction is excellent. Constant re-evaluation of services is well-established. Research activity is increasing. Team morale is at a high level. The core stroke standards are met and exceeded in many cases and the team continues to expand its search for new and better ways to provide care. The community partners' meeting with the surveyor team was very positive with the partners expressing a high degree of satisfaction with the program and its interaction with the community. Educational opportunities for staff members are readily available. Patient and family education are intense. Nearly all transient ischemic attack (TIA) patients and discharged stroke patients are followed in the Stroke Prevention Clinic which interacts well with community services and family physicians. There is every effort made to ensure that patients and their families receive any help they need following discharge. The overall quality of care provided by the stroke team is among the best this surveyor team has seen. The team continues to learn and advance practice and now needs to increase its community education activities. Despite a concerted effort to raise awareness of stroke in the community, there is still work to be done. Patients continue to arrive in the emergency department (ED) too late to be considered for thrombolytic therapy (tpa). This is a nation-wide problem and joint efforts between the health care organizations, stroke teams and The Heart and Stoke Foundation of Canada are encouraged. The team meets the mission and vision of Lakeridge Health Oshawa and exceeds its expectations. The organization's mission of: "Excellence - every moment, every day" is truly met every day. The team also meets the mission's standard of providing seamless care to every patient in all of its services. The organization of this survey by the team leadership was exceptional. Everything was covered and the team members were eager to discuss their work with the surveyors. Even though they were extremely busy, the stroke team members wished to have the opportunity to express their love of their work to the surveyor team. The stroke team members talked excitedly about their passion for their work and their high satisfaction with their work. The organization's leadership has recognized the stroke team for its excellent care and has supported the team at every turn. 5

3. Distinction Standards The Distinction standards identify policies and practices that contribute to high quality, safe, and effectively managed care in a specific area of expertise. Each standard is followed by a number of criteria that are statements about the activities required to achieve the standard. High priority criteria are foundational requirements for delivering safe and quality services and are identified by a red exclamation mark in the standards. During the on-site survey, the evaluators assessed the organization s compliance with each section of the standards, and provided the following results. The following tables indicate the criteria in the standards that were rated unmet during the on-site survey. As part of ongoing quality improvement, the organization is encouraged to address these criteria. High Priority Criteria Other Crietria All Criteria Standards Set Met Unmet N/A # (%) # (%) # Met Unmet N/A # (%) # (%) # Met Unmet N/A # (%) # (%) # Acute Stroke Services Lakeridge Health Oshawa 25 (100.0%) 0 (0.0%) 0 77 (100.0%) 0 (0.0%) 0 102 (100.0%) 0 (0.0%) 0 Inpatient Stroke Rehabilitation Services Lakeridge Health Oshawa 20 (100.0%) 0 (0.0%) 0 67 (100.0%) 0 (0.0%) 0 87 (100.0%) 0 (0.0%) 0 Total 45 (100.0%) 0 (0.0%) 0 144 (100.0%) 0 (0.0%) 0 189 (100.0%) 0 (0.0%) 0 6

3.1 Standards Set: Acute Stroke Services 3.1.1 Clinical Leadership for Stroke Providing leadership and overall goals and direction to the team providing stroke services. The organization has met all criteria for this priority process. The evaluators provided the following overall comments for this section: The population served and the risks in hard-to-reach populations are discussed at the Stroke Council. Efforts to provide service to hard-to-reach populations are discussed at this venue. The leadership of the stroke program is outstanding. All core requirements for the Stoke Distinction Program are regularly reviewed and updated. In addition, the team has selected other criteria to follow and has established its own high standards in examining these criteria. The team is extremely cohesive and members work as a truly multidisciplinary team. Team members are eager to describe their enjoyment of their work and their colleagues. Team members were eager to talk of their challenges and satisfaction as members of the team. During the survey, a team meeting was observed where patient decisions were made. All team members participated actively in these discussions and contributed to team decisions. This was a wonderful process to observe. Stroke patients are provided care on an integrated stroke unit (ISU) throughout their hospital stay. Initially, acute care is provided on this unit, and the patients graduate to rehabilitation care on the same unit. The same professional team follows the patient from acute to rehabilitation care, which means team members may be caring for both acute patients and rehabilitation patients on the same unit. A family indicated high satisfaction with this model because the patient was not transferred between units during periods when confusion and cognitive impairment were prominent. The telehealth program is used primarily to provide support for patients at other sites in the region. All patients in the region that would benefit from this integrated approach to care are moved to this site, which is the District Stoke Centre. The pathway via the emergency department (ED) for acute stroke patients is well developed and minimizes time to computerized tomography (CT) and potential thrombolytic therapy (tpa) injection. Emergency Medical Services are integrated into the care team and understand their responsibility for bring stroke patients to this District Stroke Centre without delay. The community partner meeting was exhilarating. This group is extremely happy with the role that Lakeridge Health Oshawa is providing for acute and rehabilitation care and is supportive of the leadership of that program. The team is actively involved with community education programs. Awareness of the FAST diagnostic nomogram is spread by way of community meetings, school visits and other public venues. Despite great efforts to raise community awareness, the team 7

recognizes that there is still much teaching to be done to increase awareness and early referral to the program. 8

Episode of Care: Acute Stroke Services Acute stroke services provided for hyperacute and acute phases, from the onset of signs and symptoms to completion of initial assessment and management in the Emergency Department (ED), until the client is stable and able to begin participation in rehabilitation and proceeding to an alternate level of care. The organization has met all criteria for this priority process. The evaluators provided the following overall comments for this section: Emergency Medical Services (EMS) is integrated into the emergency department (ED) response to an acute stroke. Protocols for EMS indicate common stroke presentations and provide protocols which call for bypass of non-stroke hospitals and delivery of the patient to the District Stroke Centre at Lakeridge Health Oshawa. Few patients are taken to other facilities although a few may be if the symptoms of their stroke are greater than 24 hours in duration. The EMS team recognizes the need for immediate transport to the centre, with minimal efforts to treat at the pick-up site. The Code Stroke has been developed for both ED patients and in-patients. There is a Stroke Box where all necessary documents for stroke patients including CT requisition are available in the ED and in the Critical Care Unit (CrCU). The Code Stroke team consists of designated nurses and physicians that they immediately attend the patient in the ED or the hospital unit where stroke is suspected. Radiology is warned of a potential Code Stroke arriving by ambulance and the CT requisition is hand delivered to radiology. A CT scan is immediately made available for the stroke patient and the radiologist responsible is immediately notified. After CT, the radiologist provides a verbal report to the leader of the Code Stroke team and assists in the decision as whether to provide thrombolytic therapy (tpa) or not. Patients that receive tpa receive the drug in the ED and then are sent to CrCU for a minimum of 24 hours. This process appears to run smoothly. Door to injection times are reported to the team after each tpa patient admission. A dysphagia screening is completed by trained staff soon after the patient is admitted. When there is any concern, the nurse will request a follow-up assessment by a speech-language pathologist. If the patient requires neurosurgical care, arrangements are immediately made for transfer of the patient to a Toronto hospital (1/2 hour by ambulance). All transient ischemic attack (TIA) patients that are not admitted are referred to the Stroke Prevention Clinic for further work-up and assessment. The patient's visit and future plans for investigation are documented and provided to the patient and family. All stroke patients are treated on an integrated stroke unit (ISU) where both acute and rehabilitation care are provided. Nutritional status is assessed on request for consultation by a dietitian that is attached to the team. There is a full-time pharmacist who is a member of the team. Social work is provided on a regular basis but is not a full-time member of the team. The falls preventions status is determined for every patient and redone if there is any change in the patient's condition. All falls are recorded and investigated. Trending information is provided to all members of the team. Cognitive function and mood change are regularly evaluated, and referrals are made to the appropriate disciplines when indicated. 10

Patient and family education begins on admission to the hospital. There is a focus on learning to "live with stroke". Patients and family members are trained in the care of the stroke patient. There is evidence of active emotional support for patients and family members. Education about stroke prevention is provided to both patients and care givers. The team provides information on how to manage co-morbidities associated with increased risk of secondary stroke. It was observed during the survey that patients and families receive extensive information before discharge and are encouraged to attend the stroke out-patient clinic. The family and patient were observed receiving information on expected continuing improvement and goal setting. The document "Durham Region Community Resource Guide for Individuals Living with Stroke and their Caregivers" provides patients and families with extensive information on the services provided by community partners. This document is comprehensive and simple to use. All community partners participated in the development of this document which is extremely professional and complete. All participants in the development of this document should be congratulated. The transfer process at discharge appears to be seamless. The CrCU staff members respond to in-house code stroke calls with the same team that does CrCU outreach on the units. The expectations for care of these patients are the same as for patients arriving in the ED. A Code Stroke Box is available in the CrCU and is carried to the patient's bedside. The CT service responds exactly the same way to these patients as to patients in the ED. The Stroke Prevention Clinic sees every discharged patient with a diagnosis of TIA and discharged from the ED and nearly all patients discharged from the in-patient unit that have suffered a stroke. There is strong emphasis on education of patients in how they can prevent a future stroke. Patient satisfaction with the clinic is assessed and is noted as high. 11

3.2 Standards Set: Inpatient Stroke Rehabilitation Services 3.2.1 Clinical Leadership for Stroke Providing leadership and overall goals and direction to the team providing stroke services. The organization has met all criteria for this priority process. The evaluators provided the following overall comments for this section: Lakeridge Health Oshawa's inpatient stroke rehabilitation demonstrates strong and committed clinical leadership and has the characteristics of a high-functioning team. The team is connected to the Durham community and committed to meeting the needs for education, support and care in the community it services. The team has developed and uses its Stroke Distinction metrics scorecard. There is high morale within the team and members are proud of the work that has been accomplished. Comprehensive stroke education packages have been developed for multiple hospital departments such as the Integrated Stroke Unit, the Stroke Prevention Clinic, and the Stroke/TIA/MNDS emergency department. Education packages are continually assessed and adjusted so that they meet the needs of the patients and care givers. The team has successfully implemented the Canadian Best Practice Guidelines in stroke care and built the stroke program around evidence-based practices. The team has implemented sustainability strategies into the program. The team has produced an informative video to introduce the members of the team to their role, and this has been well received. The team collaborates with many community groups to collect information to inform its services. The team members recognize that they are now receiving many younger patients, and work to ensure that the patient goals are discussed and respected and reflected in the inter-professional plan of care. Neurologists are accessible for consultation via the Ontario Telehealth Network (OTN). There is a clinical ethicist available to assist both patients and their families and staff members to successfully manage ethical dilemmas. There is an opportunity to seek out opportunities to publish the inter-professional team's journey in building an evidence-based stoke program based on the Canadian Best Practice Guidelines. As leaders in stroke care, it is suggested that sharing the team's successes, challenges and opportunities would encourage other organizations to adopt best practices at their organizations. The integrated stroke unit (ISU) collects indicators and monitors these closely. All the data on core acute and rehabilitation indicators are gathered and closely monitored monthly and reviewed by the inter-professional stroke team. There is use of the continuous quality board to share indicators for falls and for medication errors in an easy-to-understand way. Care coordination for the inter-professional team is undertaken by a dedicated and effective patient care specialist that works closely with patients and their families to ensure that their needs are met. 14

The unit is organized and the patient rooms are spacious and have large windows, accessible bathrooms and space for equipment storage of walkers, canes, and wheelchairs in the rooms. There is a large dining room with a television where patients and their families are encouraged to enjoy their meals and visit with visitors. There is a private sitting area with seating options and it has the educational videos showing on a loop via a computer. Additionally, there are several quiet and well-equipped areas allocated for therapies (gyms) and patients and their families report that they enjoy their therapies and appreciate that they are located in close proximity to their unit and room. The team has long-standing, collaborative relationships with community partners, and has developed the: "Durham Region Community Resource Guide for Individuals Living with Stroke and their Caregivers." Community Partners including the Community Care Access Centre (CCAC), March of Dimes, Helpline, University of Ontario Institute of Technology, Stroke Survivor & Caregiver Oshawa Support Group and Peers Fostering Hope, and Emergency Medical Services (EMS) highly complimented the Lakeridge Stroke team for bringing them together to develop initiatives to meet the needs of stroke survivors in the Durham region. The process included peer visiting, providing education and sharing their experience as a stroke survivor. Nurses on the stroke unit also provide education and consultation (swallowing screenings) to other units in the hospital, upon request. The District Stroke Centre has also provided education to community groups including local high schools and feels that this has increased public knowledge of the early signs of stroke. Within the Lakeridge Health organization, many departments/programs work co-operatively to provide care and services for patients and families. The emergency department, the stroke prevention program, diagnostic imaging, and critical care quality and information management are all involved in this regard. It is suggested that co-design with patients and their families and stakeholders for the development of new processes, policies and education would provide an excellent opportunity to ensure that future initiatives are patient and family centred and address priority issues for patients and their families. Encouragement is offered to consider completing the sustainability assessment available from the National Health Service in the United Kingdom. This sustainability assessment can be completed online. 15

Competency for Stroke Developing a highly competent interdisciplinary stroke team with the knowledge, skill, and ability to develop, manage, and deliver effective and efficient stroke services. The organization has met all criteria for this priority process. The evaluators provided the following overall comments for this section: The inter-professional team has adopted and implemented the Canadian Best Practice Recommendations for Stroke Care. The Most Responsible Practitioner is defined. There is a process for notifying computerized tomography (CT) which offers 24/7 CT coverage, and the laboratory, and the overhead Code Stroke page using Ext 611. Nurses that work on the Integrated Stroke Unit (ISU) have completed online modules on stroke, attend stroke conferences and have received training in completing swallowing screenings. Nurses are asked to perform the swallowing screening on other units in the hospital thus, providing access to an important screening, and will refer the patient to a speech-language pathologist if required. The inter-professional team has also produced excellent teaching videos for their patients and their families to increase their competence and confidence in self-management. These videos are available on a continuous loop via a computer for patients and families to view, and on the hospital television, and access is also possible from the Lakeridge Health website. There is a high level of professional commitment by all members of the team and they are proud of the care and services they provide. They have full access to an ethicist that provides excellent support to the team and works closely with patients and their families to help them adjust to their life following a stroke. Education is provided using a blended learning approach of in-person and e-learning modules. Stroke education is also provided by way of the: "Passport to Safety" whereby staff members are encouraged to first visit several posters, which are stamped when they receive their passport. Staff members report they enjoy this opportunity to learn in a fun and engaging environment. Staff performance appraisals are completed bi-annually and provide important information to plan and implement learning opportunities to meet learning needs. 16

Episode of Care: Inpatient Stroke Rehabilitation Services Stroke inpatient rehabilitation services from the first encounter with a rehabilitation health care provider through the completion of the last encounter related to stroke. The organization has met all criteria for this priority process. The evaluators provided the following overall comments for this section: Lakeridge Health Oshawa has a strong inter-professional admission process that follows the Canadian Best Practice Guidelines for Stroke using evidence-based assessment tools. The process is comprehensive and provides an excellent baseline to assess progress throughout the patient's in-patient stay. Appropriate referrals are made related to the outcomes of the assessments. The admission process is streamlined with patients admitted as soon as possible following their emergency visit. The team monitors this transition closely and patients and families report a positive admission transition experience that was smooth and they had full confidence in the care they were receiving. There is a central equipment program that ensures that patients have their equipment needs met immediately and they can use Lakeridge Health equipment regardless of where they are in the organization. Patients and families report this to be an excellent policy and say it relieves the patient and family of worrying about equipment at the beginning of their admission. A transfer of accountability form is completed for all new admissions received from the emergency department (ED). Education is provided by all team members to meet individual needs and where necessary, it is coordinated by the patient care specialist. Education is customized to meet individual needs to where ever the patient and care giver are in their journey. There are also active peer support programs for patients and their families. The inter-professional team works together to meet patient and care giver needs, and education related to community services is provided. The inter-professional team uses evidence-based clinical pathways in both the acute and rehab programs. The inter-professional team is involved with the patients and their families in planning their discharge and has an excellent rounds process two times per week to discuss patient progress and barriers to discharge. Team discharge plans are developed considering patient and family goals and ensure communication with the patients and families. Patient referrals and assistance with meeting needs are completed and copies are provided to patients and their families. Rehabilitation plans are documented and entered into the Meditech system where the assessments, documentation and plans of care can be viewed by all team members. White boards are completed in every room and these highlight patient goals and progress. The expected discharge location and discharge date is also clearly written. The integrated stroke unit (ISU) provides both acute and rehabilitation stroke care and the model is working well. Staff members express that they work to their full scope of practice and have multiple opportunities for continuing education. The team hosts a discharge planning meeting prior to the discharge with the patient and care givers, and provides information about the next steps and referrals that have been made on their behalf. Resources from the Heart and Stroke Foundation are also shared. Referrals are 17

made as appropriate for follow up at the Stroke Prevention Clinic, including the completion of an accessible parking pass if required. Bi-weekly inter-professional team huddles are held where the rehabilitation progress, discharge plans and any barriers to discharge are reviewed and it can include team brainstorming. A large board is used to communicate patient information, including estimated discharge date, discharge destination, Alpha-Functional Independence Measure (Alpha-FIM) score, rehabilitation stay, activity level, continence level, physiotherapy, occupational therapy, speech-language therapy, rehabilitative social work and stroke discharge manager, discharge needs and progress in activities of daily living and independent activities of daily living. The Community Care Access Centre is also present for the huddles to ensure integration of hospital-to-home continuity. Huddles have proven to be proactive and effective in communicating patient and family issues amongst team members. The patient care specialist coordinates the huddles and ensures follow-up on the issues raised. The Morse fall scale is completed on admission and depending on the results, high-risk patients are identified to reduce the risk factors identified. The sharing of the clinical pathways with interested patients and their families may help to increase their understanding related to their length of stay on the specialized unit. The team has worked with the community partners to create a wonderful resource guide (Durham Region Community Resource Guide for Individuals Living with Stroke and their Caregivers). The information is excellent and there is an opportunity to provide a short summary of what each of the resources can provide for the patient and care giver to allow patients and care givers to understand resources that will meet individual needs. It is suggested that peer support could be used to review the resource guide prior to discharge and could offer insight and guidance in fully utilizing the resource guide. There is monitoring of the goal of delivering a minimum of one hour of direct therapy to each relevant core therapy at a minimum of five days a week and it includes working on strategies to meet this goal. 18

Decision Support for Stroke Stroke information, research and evidence, data, and technologies that support and facilitate management and clinical decision making. The organization has met all criteria for this priority process. The evaluators provided the following overall comments for this section: The team has built specific screens into the Meditech system to document and provide information related to the care, assessments, education and therapy that the patient is receiving. Lakeridge Health Oshawa is transparent in sharing the results of their indicator monitoring and uses a team approach to develop initiatives and action plans to resolve gaps. Lakeridge Health Oshawa uses a hybrid chart which includes paper documentation and an electronic patient chart (Meditech) and meets legislative requirements for protecting privacy and integrity of information. All inter-professional team members have access to all documentation available on the Meditech system. This system also allows for specific reports to be used to provide information that informs the team on system performance. 19

Impact on Outcomes for Stroke The identification, collection, and monitoring of process and outcome measures to evaluate and improve the quality of stroke services to clients and the impact on client outcomes. The organization has met all criteria for this priority process. The evaluators provided the following overall comments for this section: The Lakeridge Health Oshawa stroke team reviews utilization data and has adopted the indicators for Stroke Distinction as their core indicators. Attention is paid to indicators outside of the threshold and the team meets to determine how to meet the thresholds. This is a high-functioning inter-professional team that collaborates to make improvements in all areas of care and services for acute care and rehabilitation. The team benchmarks performance and works closely with many other departments including information management, diagnostic imaging, quality, emergency, critical care and out-patient clinics. The data collected is transparent and shared with all staff. The key indicators are posted on the unit s continuous quality board. The team has developed a stroke distinction scorecard that is updated and the information is trended and used to initiate improvement initiatives. The addition of patient stories to complement the indicators and data would prove valuable to assist with knowledge translation. Also, this would add a compelling element to the data collected. Sharing the patient experience adds relevance to the data and allows knowledge users the ability to see the relevance of the trending and the actions the team has taken. It also involves patients and their families to become active partners in the initiatives when they can understand how they can contribute to actions leading to improved outcomes. 20

4. Distinction Protocols Implementing protocols ensures that services are delivered in a consistent manner across the organization. Protocols can be in the form of Clinical Practice Guidelines (CPGs), algorithms or checklists. The Distinction standards cover the protocols that need to be in place to ensure safe and quality services across the care continuum. Accreditation Canada highlighted a list of high-risk protocols from the standards that were evaluated using the following criteria during the on-site visit: Acute Stroke Services Protocol Met / Unmet The team contributes to ongoing education for EMS providers about assessment and management of suspected stroke clients at the pick-up site and during transport. The team has protocols and memorandums of understanding with EMS providers for direct transport to stroke centres, bypass of smaller centres, use of air ambulance services, and screening tools for suspected stroke clients. The team has protocols with EMS providers to receive pre-notification of suspected acute stroke clients in transit. The ED and stroke team initiate stroke protocols when stroke pre-notification is received from EMS so that suspected stroke clients are received efficiently from EMS personnel when they arrive. The stroke team or ED personnel follow established protocols for clients with suspected acute stroke to undergo brain imaging immediately upon arrival to hospital. The acute stroke team or ED staff evaluate stroke clients to determine their eligibility for treatment with tpa using the current criteria in the Canadian Best Practice Recommendations for Stroke Care. 21

The acute stroke team screens and documents the client's swallowing ability using a simple valid and reliable bedside testing protocol as part of their initial assessment, and prior to initiating oral intake of medications, fluids, or food. The acute stroke team administers at least 160 mg of acetylsalicylic acid (ASA) to all acute adult stroke clients after brain imaging has ruled out intracranial hemorrhage. The stroke team assesses the client's stroke rehabilitation needs within the first 48 hours after admission. The team implements and evaluates a falls prevention strategy specific to stroke clients to minimize the risk of falls in this population. The team has established protocols to assess and manage diabetes in clients admitted following a stroke. The team uses formal referral criteria to identify stroke clients who are ready for inpatient rehabilitation, and makes a referral for inpatient rehabilitation services. The acute stroke team or ED staff administer tpa in accordance with the current Canadian best practice guidelines for tpa with respect to mode of administration, dosage, and infusion time. NEW FOR 2015 SURVEYS: The team assesses each client's risk for developing a pressure ulcer and implements interventions to prevent pressure ulcer development. 22

Acute Stroke Services The evaluators provided the following overall comments for this section: The organization has a newly developed education program designed specifically for EMS which will becomes mandatory in the near future. This is an excellent program that should make a great impact. There is a plan to evaluate its success once in place. The EMS providers were able to access the stroke protocol immediately and share it with the surveyor. EMS notifies the hospital ED of potential acute stroke patients before arriving at the hospital. The ED and radiology teams immediately prepare for the arrival of the patient and notify the stroke team of the impending arrival. CT is provided to appropriate patients immediately and the radiologist reports the findings to the stroke team leader. A decision as whether tpa is appropriate for the patient is made and the patient either receives tpa in the ED or is transferred to the CrCU or ISU, depending upon patient stability. Patients chosen to receive tpa are transferred to the CrCU for at least 24 hours. A swallowing screening is done by a trained staff member before a decision on type of nutrition is decided. A follow-up swallowing assessment can be made by consulting speech-language pathology. Antiplatelet medications are provided in the ED. Assessment for risk of developing pressure ulcers is completed for each patient. Co-morbidities are managed in a proactive fashion. 23

5. Performance Indicators The following section provides a list of the performance indicators collected in the Distinction program. Overall performance is based on data submitted by the organization for each indicator. A key component of the Distinction program is the requirement to submit data on a regular basis and meet thresholds on a core set of performance indicators. Organizations are also expected to report on additional indicators chosen from a list of optional indicators. For optional indicators there are no thresholds to be met. This table shows the organization s indicator results. 5.1 Standards Set: Acute Stroke Services Performance Indicators Reported Data Threshold Met Core 1. Stroke / TIA mortality rates 2.6 % 2. Proportion of ischemic stroke clients who receive acute thrombolytic therapy 14.4 % 3. Time to administration of acute thrombolytic agent 61.3 % 4a.Proportion of clients treated on dedicated stroke unit 84.3 % 5. Length of stay in an acute care hospital setting for clients admitted following an acute stroke event 4.5 days 6. Readmission to acute care for stroke related causes 2.2 % 24

Performance Indicators Reported Data Threshold Met Core 7. Proportion of acute stroke clients discharged to inpatient rehabilitation 38.2 % 8. Proportion of acute ischemic stroke and TIA clients prescribed antithrombotic therapy 70.6 % 9. Proportion of clients with initial dysphagia screening at admission 41.4 % 5.2 Standards Set: Inpatient Stroke Rehabilitation Services Performance Indicators Reported Data Threshold Met Core 1a. Proportion of clients treated on dedicated stroke unit 96.1 % 2. Length of stay in an inpatient rehabilitation setting for clients admitted following an acute stroke event 16.0 days 3. Proportion of acute ischemic stroke and TIA clients prescribed antithrombotic therapy 97.3 % 25

Performance Indicators Reported Data Threshold Met Optional 4. Proportion of clients with initial dysphagia screening at admission 88.9 % 5.3 Standards Set: Optional Performance Indicators Reported Data Threshold Met Optional 2. Proportion of acute stroke and TIA clients who receive brain CT or MRI within 24 93.4 % N/A 4. Proportion of inpatients with stroke that experience complications during inpatient stay: including pneumonia, venous thrombo-embolism, gastrointestinal bleed, secondary cerebral hemorrhage, pressure ulcers, urinary tract infection 1.7 % N/A 8. Median number of days from stroke onset to admission to inpatient rehabilitation 4.0 days N/A 9. Change in functional status from time of admission to an inpatient rehabilitation unit for stroke clients to the time of discharge, based on a standardized measurement tool score 18.5 points N/A 26

Performance Indicators Reported Data Threshold Met Optional 11. Proportion of stroke clients with documentation to indicate screening for vascular cognitive impairment was performed either informally or using a formal assessment tool in the acute care or rehabilitation setting following an acute stroke event 58.1 % N/A 27

6. Client and Family Education Client, family and caregiver education is an integral part of stroke care that should be addressed at all stages across the continuum of stroke care. In order to achieve Stroke Services Distinction, the following targets for providing client and family education that is an integrated component of stroke care and is consistently documented must be met. Requirements Met / Unmet Client education is an integrated component of stroke care delivery. Client educational materials are available and accessible on the ward (e.g., posters, display boards, booklets given to clients, etc). Client educational materials are available in a variety of languages appropriate to the client population mix. Client educational materials are available in formats for that are appropriate for persons with special communicative needs. In interviews with clients and family members during tracers, clients report receiving education regarding their stroke, recovery, and self-management from the healthcare professionals that care for them. Target: 4/4 There is consistent documentation in the client medical record that client and family education has been provided. A standardized tool (e.g. checklist) is used to document components of education provided to ensure all critical elements are addressed prior to client discharge. There is a consistent location in the client chart for documentation of education provided. Each healthcare profession involved in the client's care documents the education provided within the discipline notes or common progress notes. The specific content addressed during an educational session (e.g., skills taught and demonstrated, discharge preparation, etc) is documented. Target: 2/4 The organization s project or initiative meet the requirements for client and family education. The evaluators provided the following comments. 28

Client and family educational material is readily available on the ISU. Materials are provided to patients and families on admission and discharge. Staff are active in reinforcing educational information and assuring that there is understanding. Materials are available for patients with aphasia and a number of staff have aphasia communication training. Patients and families interviewed by the surveyors indicated their satisfaction with the educational efforts made by staff and the availability of written material. The team is constantly upgrading their educational material. 29

7. Excellence and Innovation Organizations must demonstrate implementation of at least one project or initiative that aligns with best practice guidelines, utilizes the latest knowledge, and integrates evidence to enhance the quality of care. The organization s project or initiative was evaluated against the following criteria during the on-site visit: 30

Lakeridge Health Stroke Prevention Clinic The stroke project or initiative is evidence based, e.g. aligned with accreditation standards and current Canadian Best Practice Recommendations for Stroke. The stroke project or initiative adds to the overall quality of stroke services within the facility or the region. The stroke project or initiative includes a completed evaluation, and measures sustainability of the project or initiative. The stroke project or initiative communicates findings within the organization and externally. The stroke project or initiative is notable for what it could contribute to the delivery of stroke services. The organization s project or initiative meet the requirements for excellence and innovation. The evaluators provided the following comments. In preparation for this innovation project, the team performed a six month review of all stroke prevention clinic activities with special emphasis on wait times and patient satisfaction. This was directed as a process improvement exercise with emphasis on improving metrics aligned with Canadian Best Practices. This study was also aligned with standards already in place for the stroke program at Lakeridge Health Oshawa. Obstructive sleep apnea was added as an area to review. Depression and cognitive screening were also investigated. Strategies to reduce wait times for first visit have been introduced. A revised referral form was developed to coincide with best practice recommendations. Collaboration with diagnostic imaging improved more timely completion of testing. The project is a continuous quality improvement exercise. Initially it was planned to continue for only one year but the results have been so exciting that data collection has been continued and ongoing process improvements are being considered. Patient satisfaction scores have been very high for the stroke prevention clinic. All findings are shared with team members, hospital staff, family and physicians, and the community is provided with the data about the improvements. An abstract was presented at the 2014 Canadian Stroke Congress in Vancouver and was very well received. The information was also presented in Toronto. The team was awarded a President's Moment of Excellent Award. The number of patients receiving early assessment, diagnostic imaging, and education about stroke prevention has increased tremendously and patient satisfaction has improved. As an added (but unexpected) benefit, cost per patient has been reduced. 31

Stroke Distinction Report. Lakeridge Health Oshawa. Oshawa, ON. On-site Survey Dates: October 26, October 29, 2015